Ethics Opinions

Physicians should engage patients whose capacity is impaired in decisions involving their own care to the greatest extent possible, including when the patient has previously designated a surrogate to make decisions on his or her behalf.

Decisions not to initiate care or to discontinue an intervention can be emotionally wrenching for the parents of a seriously ill newborn. Physicians should help parents, families, and fellow professionals understand that there is no ethical difference between withholding and withdrawing treatment, when an intervention no longer helps to achieve the goals of care or promote the quality of life.

Although often thought of primarily for terminally ill patients or those with chronic medical conditions, advance care planning is valuable for everyone, in order to ensure that their own values, goals, and preferences will inform care decisions when they cannot speak for themselves. Physicians should routinely engage their patients in advance care planning but should be sensitive to each patient’s individual situation and preferences when broaching this topic.

A patient who has decision-making capacity appropriate to the decision at hand has the right to decline or halt any medical intervention even when that decision is expected to lead to his or her death, When a patient lacks appropriate capacity, the patient’s surrogate may halt or decline any intervention. There is no ethical difference between withholding and withdrawing treatment. When an intervention no longer helps to achieve the patient’s goals for care or desired quality of life, it is ethically appropriate for physicians to withdraw it.

Orders not to attempt resuscitation (DNAR orders) direct the health care team to withhold resuscitative measures in accord with a patient’s wishes. Physicians should address the potential need for resuscitation early in the patient’s course of care, while the patient has decision-making capacity, and should encourage the patient to include his or her chosen surrogate in the conversation.

Physicians are not required to offer or to provide interventions that, in their best medical judgment, cannot reasonably be expected to yield the intended clinical benefit or achieve agreed-on goals for care. Respecting patient autonomy does not mean that patients should receive specific interventions simply because they (or their surrogates) request them.

Organ transplantation is unique in that it involves two patients, donor and recipient, both of whose interests must be protected. Concern for the patient should always take precedence over advancing scientific knowledge.

Physicians have a responsibility to contribute their expertise to developing resource allocation policies that are fair and that safeguard the welfare of patients.