title: International variations in application of the best-interest standard across the age spectrum.
abstract: Ethically and legally, assertions that resuscitation is in a patient's best interest should be inversely correlated with willingness to forego intensive care (and accept comfort care) at the surrogate's request. Previous single country studies have demonstrated a relative devaluation of neonates when compared with other critically ill patients.
  
  
  
  In this international study, physicians in Argentina, Australia, Canada, Ireland, The Netherlands, Norway and the United States were presented with eight hypothetical vignettes of incompetent critically ill patients of different ages. They were asked to make assessments about best interest, respect for surrogate autonomy and to rank the patients in a triage scenario.
  
  
  
  In total, 2237 physicians responded (average response rate 61%). In all countries and scenarios, participants did not accept to withhold resuscitation if they estimated it was in the patient's best interest, except for scenarios involving neonates. Young children (other than neonates) were given high priority for resuscitation, regardless of existing disability. For neonates, surrogate autonomy outweighed assessment of best interest. In all countries, a 2-month-old-infant with meningitis and a multiply disabled 7-year old were resuscitated first in the triage scenario, with more variable ranking of the two neonates, which were ranked below patients with considerably worse prognosis.
  
  
  
  The value placed on the life of newborns is less than that expected according to predicted clinical outcomes and current legal and ethical theory relative to best interests. Value assessments on the basis of age, disability and prognosis appear to transcend culture, politics and religion in this domain.
authors.affiliation: Department of Pediatrics and Communicable Diseases, 8-621 Mott C&W Hospital, University of Michigan School of Medicine, Ann Arbor, MI, USA.
authors.forename: N
authors.initials: N
authors.lastname: Laventhal
authors.affiliation: Department of Pediatrics, University Medical Center Groningen, University of Groningen, The Netherlands.
authors.forename: A A E
authors.initials: AAE
authors.lastname: Verhagen
authors.affiliation: Oslo University Hospital, Department of Neonatology, Division of Child and Adolescent, Clinical Ethics, Oslo, Norway.|University of Oslo, Institute of Clinical Medicine, Faculty of Medicine, Oslo, Norway.
authors.forename: T W R
authors.initials: TWR
authors.lastname: Hansen
authors.affiliation: INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland.
authors.forename: E
authors.initials: E
authors.lastname: Dempsey
authors.affiliation: The Royal Women's Hospital, Melbourne, VIC, Australia.|The University of Melbourne, Parkville, Melbourne, VIC, Australia.
authors.forename: P G
authors.initials: PG
authors.lastname: Davis
authors.affiliation: Department of Maternal and Child Health Hospital Universitario Austral-Universidad Austral, Buenos Aires, Argentina.
authors.forename: G A
authors.initials: GA
authors.lastname: Musante
authors.affiliation: Rosalind Franklin University Chicago Medical School, Chicago, IL, USA.
authors.forename: A
authors.initials: A
authors.lastname: Wiles
authors.affiliation: Department of Pediatrics, University of Chicago, Chicago, IL, USA.
authors.forename: W
authors.initials: W
authors.lastname: Meadow
authors.affiliation: Department of Pediatrics and Department of Clinical ethics, University of Montreal, Monreal, QC, Canada.|Department of Neonatology, Clinical Ethics Unit, CHU Sainte-Justine, Montreal, QC, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Janvier
mesh_terms: D000367:Age Factors; D000066491:Clinical Decision-Making / Q000941:ethics* / Q000379:methods*; D016638:Critical Illness / Q000628:therapy*; D054521:Cultural Competency; D004185:Disability Evaluation; D006801:Humans; D007391:International Cooperation; D008020:Life Support Care / Q000379:methods; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011379:Prognosis; D011795:Surveys and Questionnaires