Two of the most poignant decisions in pediatrics concern disagreements between physicians and families over imperiled newborns. When can the family demand more life-sustaining treatment (LST) than physicians want to provide? When can it properly ask for less? The author looks at these questions from the point of view of decision theory, and first argues that insofar as the family acts in the child’s best interest, its choices cannot be constrained, and that the maximax and minimax strategies are equally in the child’s best interest. He then proposes a guideline according to which the family can demand LST if it is physiologically possible to preserve a life the child can be expected to welcome, and refuse such treatment if it causes suffering that is “more than can be borne” even if an uncompromised life is expected to emerge.

Managing a healthcare situation in accordance with the best interests of a child can be challenging for both parents and healthcare professionals. These challenges take different forms as the child grows and develops physically, emotionally, and cognitively. In this article I argue that a child’s best interests cannot be construed in terms of a narrow conception of human beings as isolated, self-contained biological organisms, in which “health” and “illness” are understood in terms of physiological function and dysfunction. Such an approach overlooks the wider context in which the child grows into and comes to dwell in the world, continually enacting her life within her community. The health of a child is intimately connected to the ways in which she is involved in the world, through active and rewarding engagement with significant others. That embeddedness implies that acting in her best interests calls for others to nurture and integrate her into a sustainable human community so that she is supported appropriately throughout all the contingencies and vagaries of life that impact on her health.