End-of-life decision before and after birth: changing ethical considerations.

Despite the dramatic improvement in the outcome of somatically handicapped neonates, vexing ethical issues remain. In which fetuses would termination be indicated? In which neonates are the malformations so serious that surgery and intensive care should not be initiated (withholding or not starting treatment)? Conversely, in which neonates should the initiated treatment be stopped (withdrawal of treatment)? These questions pose huge medical, legal, ethical, moral, and financial problems for doctors, lawyers, ethicists, and families. Fetuses and neonates with congenital anomalies can be divided into 6 groups: 1, those who have the potential for total recovery; 2, those with anomalies that would allow for a nearly normal life; 3, those with malformations requiring permanent supervision and/or medical care; 4, those with somatic rest defect and subnormal mental development; 5, those with serious somatic and mental damage; and 6, those with anomalies that are incompatible with life. The decision making should be tailored to each of these groups. The pediatric surgeon, besides taking into consideration the quantity and quality of the rescued life, should lower the anxiety of the parents, should follow the morals of a civilized society, should act according to the law, and finally, should convince himself to be a solution to a problem and not to be a cause of any.