Commentary: neonatal viability in the 1990s: held hostage by technology.

The emergence of new obstetrical and neonatal technologies, as well as more aggressive clinical management, has significantly improved the survival of extremely low birth weight (ELBW) infants. This development has heightened concerns about the limits of viability. ELBW infants, weighing less than 1,000 grams and no larger than the palm of one’s hand, are often described as “miracles” of late twentieth century technology. Improved survivability of ELBW infants has provided opportunities for long-term follow-up. Information on their physical and emotional development contributes to developing standards of practice regarding their care. Problems associated with the treatment of ELBW infants raise questions about interventions that might be considered medically futile. In recent years, the concept of medical futility and its application in clinical practice has been the subject of considerable controversy and debate.1–4 Definitions of medical futility are conceptually ambiguous. Broad distinctions have been made between quantitative and qualitative forms of medical futility and statistical indicators for determining futility have been proposed. However, precise application of these models to clinical practice is problematic because of the sometimes unpredictable nature of an infant’s response to therapy, variability in physicians’ management styles, and the ethos of different neonatal intensive care units (NICUs). Earlier investigations have addressed the complex issues that characterize medical futility in NICUs.5–7 To date, however, there has been limited discussion of medical futility in relation to the treatment of ELBW infants. The current capability of NICUs to promote survivability of these infants sustains a healthcare environment in which health providers, newborns, and their families are often held hostage to biomedical technology. In this paper, we address the impact of scientific technology on the survivability of ELBW infants. Specific criteria are outlined for determining medical futility for these critically ill infants. Ethical dilemmas are pervasive in the complex and difficult process of decisionmaking. We argue that it is vitally important for healthcare providers to maintain a strong and dynamic relationship with parents and families in forging a consensus for treatment.