When should you resuscitate babies born prematurely?

IN 2006, the Nuffield Council on Bioethics produced its report on critical care decisions in foetal and neonatal evidence. Part of the report was designed to clarify the appropriate way of dealing with premature babies. As medicine progresses, increasingly it offers the possibility of rescuing babies who would otherwise have died - ie, those born at very early gestational stages.

Evidence considered by the committee led it to the conclusion that the likelihood of survival of babies born at a gestational age that borders viability - in their estimate, this is 25 weeks and six days - was small and even less if the baby is born before 22 weeks.

Nonetheless, the primary recommendation of the committee was that, where a child shows signs of life, it should be examined by an experienced paediatrician, but the report also concedes that, in some cases, aggressive treatment should not be instituted. When the chances of survival, or of survival without major disability, are small and when the treatment would be painful and excessively burdensome, then there is no obligation to treat. When the baby is extremely premature, following review by the paediatrician, resuscitation should not be attempted.

The recommendations have been criticised from a number of perspectives. First, it is argued, every effort should be made to prolong life: babies are entitled to appropriate treatment and should not be discarded because, for example, they are disabled.

Most people would agree with this, but it must be borne in mind that the key word here is "appropriate". We do not insist adults are subjected to invasive and burdensome treatment in every medical case; might this not also be extended to very young babies?

Second, it has been suggested that failing to offer treatment is discriminatory against people with disabilities. Too much prejudice already exists for us to be sure that quality of life decisions are based on sound medical judgment and not on the basis of assumptions made about the likely quality of life with disability. As always, this is an important concern, but not every disability is compatible with life, far less with a life of experienced quality.

Finally, and from a very different perspective, some argued the committee had lost a valuable opportunity to endorse neonaticide - to allow, as has occurred in the Netherlands, the active termination of these very young babies' lives.

It is likely this report will remain controversial. It deals with the most vulnerable members of our society and its recommendations may result in the death of some of them. However, it is also important to note that the committee did its very best to resolve these extremely difficult questions by focusing on the burdens for the child that would follow often unpleasant treatment, which would probably not result in a positive outcome, and by recognising the importance of the views of families.

Perhaps most importantly, the committee endorsed the view that withdrawing treatment once it was begun and recognised as futile should be seen as morally equivalent to not instituting it in the first place. This means that there is no disincentive to attempting treatment and that is surely to be welcomed. If a trial of treatment fails, doctors can then withdraw it without fear of criminal or other liability.

This is an extraordinarily difficult area. Even the most firm adherents to the principle of the sanctity of all human life will probably recognise there are some situations where prolonging life is merely prolonging an existence characterised by suffering and possibly pain.

The gravity of decision-making in this area mandates the development of clear guidance and the best possible practice. Whether that is what is offered by this report remains to be seen, but it has been broadly welcomed in medical circles.