Withholding and withdrawing life-sustaining treatment: the necessity of discrepancies in ethical reasoning

Observations can be proposed regarding the study by Rydvall and Lynöe [1]. The use of standardised questionnaires in the general population measures the intention of the persons interviewed but not the reality of reasoning in a concrete clinical situation.

Most studies report that factors such as proxy comprehension and symptoms of anxiety or depression are major determinants of medical end-of-life decisions [2]. A study of the general population's wishes requires the use of random sampling; but before asking the population how they would react in theoretical situations, it seems important to first evaluate their knowledge. In a survey including 8,000 residents in France [3], only 28% chose the correct definition of the intensive care unit. The population's answer reflects social need regarding an efficacious medical system of which the aim is to protect and save human life.

The objective of a consensus between physicians and the general population should not be considered an ethical shield: the consensus in itself has no ethical value. As discussion permits best decision-making, the existence of discrepancies between physicians and the general population is reassuring. There is no one good or bad decision or answer because, in practice, two different but valid decisions may be taken for the same case. Determinants of a decision to forgo life-sustaining treatments are not objective, are always context related, and remain independently associated with death after adjusting for comorbidities and severity at intensive care unit admission [4]. The results of studies focusing on end-of-life intentions depend on factors such as social coverage, medical culture (including intensive care unit admission policy), evolution of medical theories, practices and techniques, clinicians' experience and values, and the psychological and relational context of patient and proxies.