Background: Among the many neonatal ethical problems, the one which neonatologists are faced with on a regular basis involves the issue of selective non-treatment, that is, clinical decisions made after the birth of a liveborn infant to either withhold or withdraw treatment in certain clinical situations.

Data sources: Original data from national surveys performed in Australia and the Neonatal Intensive Care Unit (NICU) at Monash Medical Centre (MMC) were reported. The policy underlying clinical practice of selective non-treatment at MMC was reviewed and compared to that reported from other NICUs in both developed and developing countries.

Results: If doctors believe that the infant has little prospect for intact survival, their management would be suboptimal and they create a self-fulfilling prophecy. A policy establishing criteria for initiating life-sustaining treatment must be developed with proper consideration of the cultural, social and economic factors operating in the developed or developing country. There are infants whose subsequent clinical course after initiation of neonatal intensive care will indicate that further curative efforts are futile or lack compensating benefit. A policy establishing criteria for withdrawing lifesustaining treatment must also be developed to allow the appropriate use of palliative care in these instances. The clinical situations in which selective non-treatment is taking place in the neonatal intensive care unit are: (1) when death is considered to be inevitable whatever treatment is provided; (2) even when death is not inevitable, there is a significantly high risk of severe physical and mental disability should the infant survive; and (3) when survival with moderate disability is possible, but the infant is likely to experience ongoing pain and suffering, repeated hospitalization and invasive treatment, and early death in childhood.

Conclusions: The principles underlining clinical practice should be the same for developed and developing countries. However, compared to developed countries, communications between the medical and nursing staff and the parents are less adequate in developing countries. Less medical paternalism and more informed parental involvement are encouraged in developing countries in addressing ethical and moral dilemmas in neonates.