Advances in pharmacology and technology have pushed back the limits of viability to 23−24 weeks of gestation at the expense of an increasing number of survivors with disabilities. Treatment of these extremely preterm infants should be based on a thorough determination of diagnosis and prognosis, followed by decision-making on the basis of futility of treatment or quality-of-life issues and the counselling of parents. This paper reviews the survival rates and outcome of infants under 26 weeks of gestation born in Europe and the rest of the world, and discusses the role of parents and the influence of condition at birth, gender and birth weight on ethical decision-making on behalf of these infants. Dutch guidelines on the treatment of extremely preterm infants at birth are presented to assist clinicians facing the challenging ethical, moral, legal and emotional dilemmas that surround this hot topic in perinatology.