V Yu

One major ethical dilemma in neonatal medicine which neonatologists have to face on a regular basis involves the issue of selective non-treatment, that is, having to make clinical decisions after the birth of a live infant to withhold or to withdraw neonatal intensive care in selected circumstances. One example is following the birth of an extremely low birthweight or preterm infant of borderline viability. Although the outcome of these preterm infants has improved significantly over the last decade, many such live births are often left to die at birth because resuscitation or neonatal intensive care is withheld. If doctors believe that the infant has little prospect for intact survival, their management is suboptimal, thus a self-fulfilling prophecy is created by their inaction. A policy that establishes the criteria for initiating life-sustaining treatment must be developed in every institution, with proper consideration of the ethical issues relevant to the community which it serves, taking into consideration its available resources. Even after successful resuscitation and admission to the neonatal intensive care unit, there are some infants whose subsequent clinical course after initiation of neonatal intensive care will indicate that further curative efforts are futile or lack compensating benefit. A policy that establishes the criteria for withdrawing life-sustaining treatment must be developed, to allow the appropriate use of palliative care in these instances. Clinical situations in which selective non-treatment is taking place in the neonatal intensive care unit are: (1) when death is considered to be inevitable whatever treatment is provided, (2) when death is not inevitable but there is a significantly high risk of severe physical and mental disability should the infant survive, and (3) when survival with moderate disability is possible, but the infant is likely to experience ongoing pain and suffering, repeated hospitalization and invasive treatment, and early death in childhood. In the decision-making process of selective non-treatment, less medical paternalism and more informed parental involvement are encouraged. This process is built on trust between the neonatal staff and parents, and requires time, information, honesty and empathy. The good neonatologist must possess the qualities of extreme responsibility, extraordinary sensitivity and heroic compassion.