The newborn intensive care unit (NICU) is a common setting for difficult ethical challenges, often involving life-and-death decisions. These may include withholding treatment such as resuscitation, mechanical ventilation, or surgery, or withdrawing life-sustaining medical treatment such as mechanical ventilation and artificial nutrition and hydration. Such decisions are frequently faced because of the high morbidity and mortality of some conditions commonly encountered in this setting, such as extreme prematurity, perinatal asphyxia, and major congenital anomalies.

Who should decide when a treatment should be withheld or withdrawn? Ideally, decisions are made by the parents, providers, and nurses working together, but what is to be done when they disagree?

On what basis should decisions be made? Ideally, a careful ethical analysis is carried out, based on solid clinical and prognostic data and the values of those involved in making the decision. In reality, data are often very vague and values are often not shared in common, but a decision must nevertheless be reached.

Such critical ethical decisions may be more common in the NICU than in other pediatric settings, but they are certainly not unique to the NICU. Nonetheless, is there something unique about ethical problems encountered with this patient population? For example, is borderline viability based on extreme prematurity a unique situation in pediatrics, or is it analogous to other problems sometimes encountered in the care of older children?

Are clinicians more willing to withdraw or withhold life-sustaining treatment for this patient population than for others in pediatrics or adult medicine? If so, is this justified?