Many think that medical treatment for children is altogether different from that for adults. On the one hand, pediatrics seems to be about maintaining inherent good health through disease prevention, such as immunizations. On the other hand, we think of the obvious, even miraculous, advances in therapies for some childhood cancers (especially the most common, acute lymphocytic leukemia) and for disorders of the prematurely born. Unfortunately, pediatrics also has a less optimistic side. Some congenital anomalies, genetic disorders, and malignancies have not yet yielded to the press of modern medical science. Current technology and medical skill are unable to provide a reliably good outcome for very small preterm infants, certainly those born at 22 weeks of gestation or earlier, and a varying proportion of those born up to 26 weeks of gestation. The scourges of accidental injury, severe physical abuse, and AIDS continue to provide both enormous challenges and a depressing reminder of the limits of treatment.

Two features distinguish the futility confrontation in pediatrics faced by health care providers and the public from the confrontation in the rest of medicine. These are (1) our deeply held belief and hope that childhood should be different and that children should not die before some imaginary natural life span and (2) medical uncertainty in pediatrics, that is, the difficulty in predicting eventual outcomes, especially those pertaining to neurodevelopment. With these thoughts in mind, some issues in the debate over futile treatment in pediatrics are discussed.