Limits of viability: dilemmas, decisions, and decision makers

Decision-making about treatments for neonates at the threshold of viability is a complex process that must involve physicians, other health-care professionals, and families. Parents and families bring personal, ideological, cultural, and religious beliefs into their relationship with health-care professionals that have the potential to conflict with professional perceptions of good medical care and the interests of the patient. Neonatologists often find themselves criticized for overtreatment of these extremely premature infants. Yet, from the perspective of the health-care provider, perceived obligations in the face of an uncertain outcome, parental wishes as well as perceptions about legal mandates are often cited as the reasons for the provision of such extraordinary care. Recent reductions in perinatal mortality for premature infants born at the cusp of viability, in conjunction with emerging data on the substantial short- and long-term morbidities experienced by infants born between 23-25 weeks' gestation, have engendered a serious debate about professional and parental obligations in the face of extreme uncertainty. The fundamental questions are who ought to be permitted, under the present circumstances of rapidly evolving technologies and innovative therapies, to decide the best interests of the child, and how to achieve consensus regarding treatment goals when the outcome is uncertain and there are divergent views with regard to the infant's best interests. As survival for these infants increases and morbidity remains a significant likelihood, physicians must be cognizant of the power of their technology to impose undesired burdens on these infants. A reasonable, and reasoned, approach for these vulnerable infants requires collaborative decision making incorporating professional recommendations, with an openness, trust and willingness to work with parents to ascertain the best interests of an individual infant. Understanding of and respect for the differing views of the moral obligations of perinatal specialists and families can aid neonatal professionals in resolving interdisciplinary and physician-family conflicts as well as facilitating resolution of neonatal ethical dilemmas.