Prevention and treatment of postasphyxial, i.e. hypoxic-ischemic, brain damage can be considered at various levels or stages of the process. The first approach is based on epidemiological studies, which typically allow the delineation of risk factors for cerebral damage. By trying to eliminate or reduce such factors, one may influence the incidence of the disorder. At the second stage, the actual pathogenetic mechanisms, e.g. hypoxia or hypotension, leading to brain damage may be preventable or treatable. Finally, limiting the extent of the lesion immediately after the event may be possible.

The first consideration must be an agreed-upon definition of asphyxia. We cannot determine outcome of a condition if some observers are referring to apples and others to pears. Asphyxia is a pathophysiological event comprising both hypoperfusion and hypoxia, and these events result in compromise at a cellular level with the production of metabolic acids. This can be due to a wide number of insults, but a complication of the birth process is the most important cause. Asphyxia is not like intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), as these are conditions that can be diagnosed with a reasonable degree of precision with imaging techniques.

In this review I shall discuss the prognostic value of the clinical neurological examination, the EEG (and the various methods of recording it), evoked responses, and Doppler ultrasound measurements of cerebral blood velocity. Imaging modalities (ultrasound, CT, MRI) will be dealt with elsewhere under discussion of their diagnostic value.

Infants who require intensive care are at considerable risk of death or long-term neurodevelopmental disability. Therefore, noninvasive methods have been sought for assessing the structure and function of the brain in the immediate newborn period. The major aims are to investigate the prevalence and mechanisms of brain-damaging lesions, to test preventive strategies and treatment, and to assign the prognosis of the infants. Several methods have proved their worth, e.g., ultrasound imaging, electroencephalography, including the testing of evoked potentials, and Doppler ultrasonography for measuring flow velocity in intracerebral vessels.

Neurodevelopmental follow-up has an important role in perinatal management and research. The value of individual studies depends on the quality of the planning, the data collected, and the interpretation of the findings. Interpretation, in particular, has caused many problems; these have usually arisen because of a failure to understand the nature of the data and what they mean. Follow-up studies are labor intensive and, therefore, very expensive. If they are to continue, there must be a full understanding of their strengths and weaknesses by those who plan them, carry them out, and — above all, by those who analyze and interpret them.

Modern neonatal medicine raises a series of fundamental ethical questions. In the confrontation with these and in attempting to solve them, basic concepts concerning human life and death should be discussed. On what values do we base our practice? Terms such as human, right to life, sanctity of life, equality, and justice should all be considered with reference to the sick newborn baby. Leading Anglo-American contemporary philosophers who deal with such concepts have a tendency to link them to the autonomy of the individual. Is this a fruitful approach when dealing with ethical questions in neonatal medicine? In the following, I will exemplify this to elucidate the problem.

Treatment decisions in the delivery room and neonatal intensive care unit are often life-and-death decisions. In a true Hippocratic spirit of “do no harm,” the guiding principle should be the long-term outlook for the infant and the family. This is usually, but not always, determined by the prospects of normal or near normal mental development versus incapacitating injury.

The United States, unlike most European countries, has had substantial legal, regulatory, and legislative activity concerning treatment decisions for newborns. This activity began as a result of the highly publicized “Baby Doe” case, in which parents of a child born in 1982 with Down syndrome and esophageal atresia refused consent for surgery, and the Indiana state courts refused to intervene (1). Initially, the Department of Health and Human Services promulgated a series of “Baby Doe” regulations intended to prohibit nontreatment. The regulations were at all times invoking the theory that it is discriminatory to fail to provide treatment to a handicapped infant if such treatment would be provided to a child without such handicap (2). This theory worked well for the department's paradigm case, where the handicap was one such as Down syndrome, and there was an associated physical defect that could be corrected and that would be treated were the infant of normal mental capacity. But a nondiscrimination theory here is extremely rigid: it appeared that even devastating levels of handicap— indeed, even the most extreme “handicap” of unconsciousness — would be irrelevant to treatment decisions.

Over a number of centuries, philosophers, theologians, and other scientists have debated upon what is meant by a living person. The reverse — i.e., what is meant by a dead person — has not been considered so difficult to define. The questions of when life begins and when death takes place, and of what criteria should be applied in these connections, involve several difficult considerations — ethical, practical, and legal.

An economic evaluation of a health care program seeks to investigate the relative costs and consequences of alternative strategies in health care by examining the values of the resources used and weighing them against the values of the outcomes. Because resources are finite, there are choices to be made about how best to use them. Thus, the concept of the value of resources that is applied in an economic evaluation is that of opportunity cost: since resources are finite, deploying them in one way means that a benefit is foregone in not having them available to pursue the best alternative. An economic evaluation of a health care program fundamentally is an exercise about choices, not simply about money.

For several reasons, the question posed by the title of this article cannot be answered in simple terms of monetary values or quality of life. The main reason is that it is impossible to define the concept “handicapped” in a clearcut manner. The definition of handicap will change with time and place and with “the eyes of the beholder,” whether he or she is a family member, relative, employer, administrator, or a representative, politically or otherwise of the society.

Health care providers are increasingly concerned about the rising costs of the total health care system, which is now approaching 10–12% of the gross national product (GNP). The long-term decrease in birth rates and the prolonged mean length of life of the population shifts the age pyramid to older ages, bringing a higher demand for health care at increasing costs. Another explanation for the rising health care expenditure is the application of modern medical technologies in the treatment of the terminally or critically ill at any age. It has been estimated that 1 of every 7 health care dollars is now consumed by patients who are within 6 months of the end of their lives (5).