Introduction

The retrospectoscope is usually a pleasure to use. After someone else's case turns out badly, simply direct the retrospectoscope at the original clinical events and explain calmly how you would have made better decisions, resulting in a better outcome. In the case of Baby Girl M, it is plain that aggressive management from the moment of birth would have avoided the awkward six hours in which she received comfort care only, but that is not the whole story. In fact, it is my thankless duty to assert that aggressive care was inappropriate at any time, and that optimal management would have resulted, not in survival, but in her prompt and intended death. That did not happen, and I am pleased for Baby Girl M herself, who is doing well, but her good outcome does not vindicate her initial management. To understand how she should have been managed, we must begin with the issues raised by infants who are born at the margin of viability.

This essay reviews the determination of viability, moves on to the legal doctrines that influence care decisions, discusses the way these issues illuminate the case of Baby Girl M, and concludes with recommendations for a process designed to lead to better decisions.

Shades of viability

An infant's chance of survival gradually increases with gestational age, so the limit of viability is blurred rather than distinct.