Ethical dilemmas in extreme prematurity: recent answers; more questions Umberto Simeoni a, * , Mariella Vendemmia a , Alina Rizzotti a , Marc Gamerre b a Department of Neonatology, La Timone University Hospital, 264 rue Saint-Pierre, 13385 Marseille, France b Department of Obstetrics and Gynaecology, La Conception University Hospital, Marseille, France Abstract Advances in perinatal care allow survival of more extremely premature infants, but the implementation and continuation of intensive care may itself constitute an ethical dilemma, given the limited chances of intact survival among the patients most at risk. This paper discusses several key issues raised by the options that are under general consideration with reference to births of infants at the threshold of viability, in particular: the implications of making a distinction between extreme prematurity and other general medical situations that may involve decisions on ending support; the concrete nature of the restrictions on therapy in such patients interactions and the need for feedback between parents, medical staff and society. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Ethics; Infant; Premature; Extremely low birth weight Recent years have been marked by major progress in perinatal and neonatal care, which has allowed a consider- able increase in the survival rates among extremely premature infants. However, a high incidence of cerebral palsy and other major sequelae is still observed in survivors, while long-term follow-up reveals a high frequency of so- called minor complications that may impinge more than previously thought on their quality of life. The feeling that limits need to be set for the initiation and the continuation of intensive care in extremely premature infants is shared widely both among the medical community and among the public, although it translates differently in different countries and cultures. Traditional questions on limits of viability have usually been given traditional answers in terms of patient groupings based on gestational age or birth weight, who should or should not receive life support, this decided on the basis of mortality rates and of long-term follow-up data. Data from large, well- conducted multicentre studies in various countries or from neonatal networks, including cohorts of patients born at between 22 and 25 weeks of gestation in the mid-1990s, are now available [1–4]. Panel guidelines therefore commonly recommend providing intensive care to patients born at 24 or 25 weeks of gestational age or later. Meanwhile, an active debate is in progress on the subject of preterm births occurring between 22 and 24 weeks of gestational age, decision making usually being considered dependent on parental choice or consent. Fetal indications for caesarean section between 24 and 26 weeks of gestation are even more controversial. Decision making is generally presented as relying on both doctors and parents, but the parental choice on whether their infant should be resuscitated at birth and/or provided with intensive life support is considered determinant [5]. In this connection, the objectives of follow-up studies are currently described as aimed at improving information to parents. The aim of the present paper is to discuss several key ethical issues that are implicit in the current options proposed for premature patients born at the threshold of viability, for their parents and for society. www.elsevier.com/locate/ejogrb European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S33–S36 * Corresponding author. Tel.: +33 4 91 386 717; fax: +33 4 91 384 899. E-mail address: umberto.simeoni@ap-hm.fr (U. Simeoni). 0301-2115/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2004.07.016