Abstract

Central to the purpose of perinatal medicine and neonatal care are three clinical aims: to save the lives of infants with treatable conditions, to minimize needless suffering and indignity, and to maximize the quality of life in survivors. The report of The Nuffield Council on Bioethics on "Critical Care Decisions in Fetal and Neonatal Medicine" and the policy statement of the American Academy of Pediatrics (AAP) on "Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns" remind us of the difficulties, both ethical and clinical, in trying to achieve these goals for infants born at the threshold of viability.

This paper explores the key factors in decision making in this area: Who decides on whether or not to initiate aggressive treatment? Who determines when to stop? What standards, if any, should guide such choices? Whose view prevails when there is a conflict over treatment between the physician and the parents?