Principles and Practice of Mechanical Ventilation > Chapter 66. The Ethics of Withholding and Withdrawing Mechanical Ventilation Élie Azoulay

Fundamental Issues of Ethics

"The field of bioethics, born in the late 1960s, rests on four fundamental ethical principles (beneficence, nonmaleficence, autonomy, and distributive justice) and describes a spectrum of patient-physician relationship styles ranging from paternalism to autonomy (Fig. 66-1).¹⁶ The four fundamental ethical principles guide decisions in the ICU management of dying patients and their families. Patients are discussed here and families later on in this chapter. Regarding beneficence and nonmaleficence, I will discuss studies that address the specific needs and expectations of dying patients. I will then briefly contrast paternalism and autonomy, and I will argue that the long-standing controversy opposing these two models should give way to emphasis on the shared decision-making model. I will also discuss the principle of double-effect accepted by the U.S. Supreme Court, Society of Critical Care Medicine (SCCM) recommendations, and international consensus in the support of the use of sedation and analgesia to relieve symptoms, provided death is not intended, although it may be foreseen.^17–20 The unresolved debate regarding the relative merits of terminal extubation and terminal weaning for taking dying patients off the ventilator will be mentioned. Regarding justice, I will do my utmost to convince the reader that cost considerations are irrelevant to DFLST...."