determinations of “futility” as defined by the Baby Doe Rules, potentially even more controversial. S. Van McCrary / Neonatology and the specter of the law 73 These international data may suggest that trends in some developed countries are moving toward aggressive treatment for extremely preterm infants regardless of gestational age and that higher survival rates (if not an artifact of flawed methods) indicate a divergence of neonatology practice according to national, regional, or even local cultures. Individual countries and cultures may be going their own ways when determining treatment thresholds. Contrary to the general trend toward uniformity in medical standards of care, in neonatology the opposite of standardization may be occurring. This counter-standardization according to geographic and cultural variables has been noted by John Lantos as one of the emerging challenges of both research and practice in neonatology (a concept I first heard from Dr. Lantos during a plenary session at the 20th Annual Bioethics Summer Retreat in Santa Rosa, California, June, 2008). It appears likely that this also accounts for the position of the International Liaison Committee on Resuscitation that its guidelines on neonatal resuscitation “... must be interpreted according to current regional outcomes and societal principles” [28]. I will now turn to a summary of research findings on physicians’ legal defensiveness and knowledge of law. 4. Research on physicians’ legal defensiveness and knowledge of medical law Our research group has defined legal defensiveness as the aggregate of factors encompassing physicians’ perceptions and practices regarding abatement of lifesustaining treatment, including medical, ethical, legal, social, psychological, and spiritual factors [29]. Some research issues that prompted these studies include: the prevalence of legal defensiveness among physicians treating critically ill adults; the adequacy of physicians’ knowledge of relevant laws; whether accuracy of physicians’ legal knowledge is associated with sources of legal knowledge; whether physicians think that law forces them to alter their practice patterns; whether improved knowledge of law may diminish legal defensiveness; and whether legal defensiveness, in the broadest sense, affects physicians’ assessments of medical futility in ways that have an impact of patients’ and families’ ability to exercise self-determination in end-of-life decisions. Briefly, our methods included a 67-item questionnaire assessing physicians’ responses in the categories of medical law, medical futility, and physician anxiety regarding dying patients. The instrument included a 10-item quiz designed to measure objectively some important substantive laws relating to end-of-life medical treatment. In response, we received 301 usable questionnaires from faculty and house staff who were actively practicing internal medicine, oncology, and surgery in tertiary care medical centers around the state of Texas. Six items from the instrument were found to be significantly intercorrelated in measuring general legal defensiveness and they were combined into a composite score– the “LD6 scale.” Results on this scale form the basis of our measure of legal defensiveness. Additional details about methodology can be found in our work published previously [29–31]. Our findings in this population indicate that approximately 25 percent of responding physicians reported an extreme level of legal defensiveness as measured by the LD6 scale (see Fig. 1) [29]. Further, extreme legal defensiveness was substantially lower among physicians 1) who treated a large number of terminally ill patients, 2) who had more years of clinical experience, 3) who reported that they felt “adequately trained to deal with dying patients,” and 4) oncologists, as compared with other internists and surgeons. Regarding knowledge of medical law the mean score on the quiz was 53.9 percent, indicating that the average physician answered about half the questions correctly. The source of physicians’ legal knowledge was also found to be important – those respondents who reported receiving none of their information about law from other physicians were twice as likely to get a high score on the law quiz as were those who reported receiving at least some of their information about law from their physician colleagues. A very interesting finding was that those physicians who demonstrated better knowledge of relevant law (by scoring 70 percent or better on the quiz) were significantly less likely to report extreme legal defensiveness. These findings enabled us to construct a logistic regression model estimating the effects of these (and other) factors on the probability of extreme legal defensiveness. Using this model, the most defensive group would be early-career, non-oncologist physicians who had treated relatively few terminally ill patients, who said they did not feel adequately trained to deal with dying patients, and who scored below 70 percent on the law quiz. We repeated the major elements of this study in Denmark several years later and compared the results to those from the United States [32]. Our findings indicate that the Danish physicians sampled demonstrated significantly better knowledge of Danish laws relevant to their practice, and that they reported significantly lower levels of legal defensiveness. These findings are