Portal de Periódicos da CAPES

Changes in Forgoing Life-Sustaining Treatments in the United States: Concern for the Future

1996; Elsevier BV; Volume: 71; Issue: 5 Linguagem: Inglês

10.4065/71.5.512

1942-5546

Charles L. Sprung, Leonid A. Eidelman, Reuven Pizov,

Palliative Care and End-of-Life Issues

The past 4 decades have witnessed major advances in medicine and technology that have led to a substantial increase in life expectancy. Unfortunately, with the many successes, failures have also occurred, including situations in which mechanically ventilated patients with severe disabilities remain alive in hospitals or other institutions. Throughout these years, the attitudes of physicians, the law, and society have changed. In addition, alterations have occurred in the forgoing of life-sustaining treatments. This commentary focuses on the more recent changes in physician beliefs and actions that have led many people to voice considerable concern about the future. Initial Critical-Care Techniques.—During the 1950s, mechanical ventilation was first used during a poliomyelitis epidemic, 1Engström C-G Treatment of severe cases of respiratory paralysis by the Engström universal respirator.BMJ. 1954; 2: 666-669Crossref PubMed Scopus (42) Google Scholar and in 1956, Zoll and associates2Zoll PM Linenthal AJ Gibson W Paul MH Norman LR Termination of ventricular fibrillation in man by externally applied electric countershock.N Engl J Med. 1956; 254: 727-732Crossref PubMed Scopus (282) Google Scholar described the termination of ventricular fibrillation by applying external countershock. By 1960, external cardiac massage was demonstrated,3Kouwenhoven WB Jude JR Knickerbocker GG Closed-chest cardiac massage.JAMA. 1960; 173: 1064-1067Crossref PubMed Scopus (1337) Google Scholar and during the 1960s, intensive-care units (ICUs) were being established.4Hilberman M The evolution of intensive care units.Crit Care Med. 1975; 3: 159-165Crossref PubMed Scopus (61) Google Scholar These new techniques, which now are routine, revolutionized the care of critically ill patients. Physicians were able to interrupt and occasionally reverse the dying process. Their primary goal was to prevent death, which was considered a failure of medicine. This perspective was consistent with the Western ethical system that proclaimed the infinite worth of a human being. This was also a time of seemingly unlimited resources. Changes in Critical-Care Medicine Related to Court Decisions.—The Quinlan case in 19765In the matter of Karen Quinlan, 70 NJ 10, 355 A2d 647 (1976)Google Scholar can be cited as the true beginning of changes in the practice of medicine. For the first time, a court decided an issue that had previously been decided by the medical profession. In addition, the public became interested in a medical-ethical issue. Of more importance, this was the first decision that allowed the removal of a ventilator from a patient who was not brain dead and who physicians thought would die if the ventilator was removed.5In the matter of Karen Quinlan, 70 NJ 10, 355 A2d 647 (1976)Google Scholar The treating physicians and several experts believed that the removal of the ventilator in such a case was a deviation from medical practices, standards, and traditions.5In the matter of Karen Quinlan, 70 NJ 10, 355 A2d 647 (1976)Google Scholar In 1983, 73&x0025; of physicians believed that intravenously administered fluids should be provided to a comatose, terminally ill patient with no hope of recovery.6Micetich KC Steinecker PH Thomasma DC Are intravenous fluids morally required for a dying patient?.Arch Intern Med. 1983; 143: 975-978Crossref PubMed Scopus (72) Google Scholar Intravenous fluids seemed to differ from other medical therapies and seemed to be a treatment that physicians had difficulty in discontinuing. The removal of intravenous fluids and nutrition was such a gross deviation from ethical and legal standards that in 1983 two physicians who had discontinued fluids and nutrition to a comatose, severely brain-damaged patient with little hope of recovery were prosecuted for murder.7Barber v Superior Court, 195 Cal Rptr 484, 147 Cal App 3d 1006 (1983)Google Scholar During the 15 years after the Quinlan decision, courts throughout the United States proclaimed the patient's right to refuse life-sustaining treatments. This right was given to competent patients and to comatose patients through a surrogate and included the refusal of therapies ranging from ventilators to nutrition.8Satz v Perlmutter, 362 So2d 1960, aff'd 379 So2d 359 (Fla 1978)Google Scholar, 9Brophy v New England Sinai Hospital Inc, 497 NE2d 626 (Mass 1986)Google Scholar, 10Bouvia v Superior Court, 225 Cal Rptr 297 (Cal App 2d Dist, 1986)Google Scholar, 11Cruzan v Director, Missouri Department of Health, 110 SCt 2841 (1990)Google Scholar One judge even recognized the patient's right to die with assistance.10Bouvia v Superior Court, 225 Cal Rptr 297 (Cal App 2d Dist, 1986)Google Scholar In addition, natural death acts were enacted in several states that allowed the withholding or withdrawal of life-sustaining procedures or treatments in patients with a terminal illness.12President's Commission for the Study of Ethical Problems in Medicine and Biomédical and Behavioral Research Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. US Government Printing Office, Washington (DC)1983: 141-145Google Scholar The courts9Brophy v New England Sinai Hospital Inc, 497 NE2d 626 (Mass 1986)Google Scholar and the President's Commission12b concluded that permitting the withdrawal of therapies was important because, if such action was not allowed and medical interventions had to be continued, physicians would be discouraged from attempting treatments, and premature decisions allowing patients to die would occur. Despite the previous medical standard that terminally ill and comatose patients should receive fluids and nutrition, many physicians have changed their beliefs throughout the years. Many of the court decisions quoted the Council on Ethical and Judicial Affairs of the American Medical Association that “it is not unethical to discontinue all means of life prolonging medical treatment for patients in irreversible comas.”13Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association—1986: Withholding or Withdrawing Life-Prolonging Medical Treatment. American Medical Association, Chicago1986Google Scholar Nutrition and hydration were included among the life-sustaining therapies. Some argued that allowing the withdrawal of life-prolonging therapies was a dangerous precedent and the beginning of a “slippery slope” that might lead to active euthanasia in the United States.14Sprung CL Changing attitudes and practices in forgoing life-sustaining treatments.JAMA. 1990; 263: 2211-2215Crossref PubMed Scopus (74) Google Scholar These pronouncements were refuted by the fact that the court decisions were based on the patient's autonomous right to refuse life-sustaining treatments.15Sananman M Road to euthanasia or right to refuse care? [letter].JAMA. 1990; 264: 1809Crossref PubMed Google Scholar No one would ever deny life-sustaining treatments to a patient or family surrogate who wanted such treatment to be continued. Changes in Physician Attitudes and Practices.—Further changes in attitudes and practices have occurred in American medicine. Physicians have traditionally been the advocate for their patients.16Levinsky NG The doctor's master.N Engl J Med. 1984; 311: 1573-1575Crossref PubMed Scopus (191) Google Scholar The physician's primary responsibility and duties center on the best interests of their individual patients, without regard to costs or societal considerations.16Levinsky NG The doctor's master.N Engl J Med. 1984; 311: 1573-1575Crossref PubMed Scopus (191) Google Scholar Physician autonomy has decreased because more physicians have become salaried employees rather than independent practitioners.17Starr P The Social Transformation of American Medicine. Basic Books, New York1982: 420-429Google Scholar This situation has certainly been accentuated with the growth of health maintenance organizations (HMOs) and managed care.18Rodwin MA Conflicts in managed care.N Engl J Med. 1995; 332: 604-607Crossref PubMed Scopus (118) Google Scholar At the same time, health-care spending in the United States has increased to more than 14&x0025; of its gross national product.19Chalfin DB Fein AM Critical care medicine in managed competition and a managed care environment.New Horiz. 1994; 2: 275-282PubMed Google Scholar A large amount of such expenditures is used for critically ill patients, many of whom will not survive their illness.20Office of Technology Assessment Intensive care units (ICUs): clinical outcomes, costs, and decisionmaking. US Government Printing Office, Washington (DC)1984Google Scholar During the past few years, physicians have become more concerned with societal needs than with their individual patient needs. 16Levinsky NG The doctor's master.N Engl J Med. 1984; 311: 1573-1575Crossref PubMed Scopus (191) Google Scholar21Luce JM The changing physician-patient relationship in critical care medicine under health care reform.Am J Respir Crit Care Med. 1994; 150: 266-270Crossref PubMed Scopus (9) Google Scholar Health-care reform has emphasized cost containment and universal access, and physicians have stressed distributive justice and proportional advocacy. 21Luce JM The changing physician-patient relationship in critical care medicine under health care reform.Am J Respir Crit Care Med. 1994; 150: 266-270Crossref PubMed Scopus (9) Google Scholar Most physicians do what is best for their patients. Recently, however, they have been told not to do everything that is in the best interests of their patient but rather to do as much as is reasonable.21Luce JM The changing physician-patient relationship in critical care medicine under health care reform.Am J Respir Crit Care Med. 1994; 150: 266-270Crossref PubMed Scopus (9) Google Scholar During the past 2 decades, physician practices of forgoing life-sustaining treatments have also changed. Twenty years ago, most patients died in critical-care units only after physicians performed cardiopulmonary resuscitation (CPR). The frequency of terminal care decisions in ICUs has increased dramatically during the past decade.22Koch KA Rodeffer HD Wears RL Changing patterns of terminal care management in an intensive care unit.Crit Care Med. 1994; 22: 233-243Crossref PubMed Scopus (93) Google Scholar The forgoing of treatments includes withholding and withdrawing CPR, intubation, mechanical ventilation, vasopressors, supplemental oxygen, positive end-expiratory pressure, blood transfusions, diagnostic and therapeutic procedures including dialysis and surgical intervention, antibiotics, antiarrhythmic drugs, nutrition, and fluids.23Smedira NG Evans BH Grais LS Cohen NH Lo B Cooke M et al.Withholding and withdrawal of support from the critically ill.N Engl J Med. 1990; 322: 309-315Crossref PubMed Scopus (432) Google Scholar24Faber-Langendoen K Bartels DM Process of forgoing life-sustaining treatment in a university hospital: an empirical study.Crit Care Med. 1992; 20: 570-577Crossref PubMed Scopus (123) Google Scholar Increases have occurred not only in do-not-resuscitate (DNR) decisions but also in other limitations and withdrawals of therapies.22Koch KA Rodeffer HD Wears RL Changing patterns of terminal care management in an intensive care unit.Crit Care Med. 1994; 22: 233-243Crossref PubMed Scopus (93) Google Scholar Up to 79&x0025; of deaths in the ICU have been shown to occur after the forgoing of life-prolonging therapies.22Koch KA Rodeffer HD Wears RL Changing patterns of terminal care management in an intensive care unit.Crit Care Med. 1994; 22: 233-243Crossref PubMed Scopus (93) Google Scholar Treatments such as CPR, which initially were mandatory in all patients in the ICU, have become optional and have ultimately become unavailable for some patients.25Callahan D On feeding the dying.Hastings Cent Rep. 1983; 13: 22PubMed Google Scholar These decisions to forgo life-sustaining treatments are usually implemented only after consensus exists between the physician and nursing staff and the patient and family.23Smedira NG Evans BH Grais LS Cohen NH Lo B Cooke M et al.Withholding and withdrawal of support from the critically ill.N Engl J Med. 1990; 322: 309-315Crossref PubMed Scopus (432) Google Scholar Unfortunately, in some circumstances, patient values are less important than would be expected.26Orentlicher D The illusion of patient choice in end-of-life decisions.JAMA. 1992; 267: 2101-2104Crossref PubMed Scopus (68) Google Scholar For end-of-life decisions, physician values may be more decisive than patient values.26Orentlicher D The illusion of patient choice in end-of-life decisions.JAMA. 1992; 267: 2101-2104Crossref PubMed Scopus (68) Google Scholar Patient and family preferences are respected when physicians agree with these decisions, but they may not be respected when physicians disagree.26Orentlicher D The illusion of patient choice in end-of-life decisions.JAMA. 1992; 267: 2101-2104Crossref PubMed Scopus (68) Google Scholar Physicians almost always decide when forgoing therapy is an issue for a patient; requests are infrequently initiated by a patient or the family.23Smedira NG Evans BH Grais LS Cohen NH Lo B Cooke M et al.Withholding and withdrawal of support from the critically ill.N Engl J Med. 1990; 322: 309-315Crossref PubMed Scopus (432) Google Scholar Physicians' values predominate for several reasons.26Orentlicher D The illusion of patient choice in end-of-life decisions.JAMA. 1992; 267: 2101-2104Crossref PubMed Scopus (68) Google Scholar Physicians are unaware of patient preferences because patients who have decision-making capacity when they are admitted are typically incompetent when they are in the ICU. Despite physicians being incorrect about patient preferences for resuscitation27Uhlmann RF Pearlman RA Cain KC Physicians' and spouses' predictions of elderly patients' resuscitation preferences.JGerontol. 1988; 43: M115-M121Crossref Scopus (394) Google Scholar and continued life,28Danis M Southerland LI Garrett JM Smith JL Hielema F Pickard CG et al.A prospective study of advance directives for life-sustaining care.N Engl J Med. 1991; 324: 882-888Crossref PubMed Scopus (411) Google Scholar they often present information based on their own views and preferences, which alters patient decisions.29Murphy DJ Burrows D Santilli S Kemp AW Tenner S Kreling B et al.The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.N Engl J Med. 1994; 330: 545-549Crossref PubMed Scopus (475) Google Scholar They may make the decision themselves because they believe the patient or the family cannot understand the medical complexity of the situation or because they believe it is a medical decision.26Orentlicher D The illusion of patient choice in end-of-life decisions.JAMA. 1992; 267: 2101-2104Crossref PubMed Scopus (68) Google Scholar Physicians may simply override the patient-family decision because they disagree.28Danis M Southerland LI Garrett JM Smith JL Hielema F Pickard CG et al.A prospective study of advance directives for life-sustaining care.N Engl J Med. 1991; 324: 882-888Crossref PubMed Scopus (411) Google Scholar In addition, physicians may be unwilling to provide treatment that they believe is medically futile or inappropriate.26Orentlicher D The illusion of patient choice in end-of-life decisions.JAMA. 1992; 267: 2101-2104Crossref PubMed Scopus (68) Google Scholar30Luce JM Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists.Crit Care Med. 1995; 23: 760-766Crossref PubMed Scopus (97) Google Scholar Furthermore, they have biases relative to the forgoing of life support that may be contrary to the goals of patients.31Christakis NA Asch DA Biases in how physicians choose to withdraw life support.Lancet. 1993; 342: 642-646Abstract PubMed Scopus (171) Google Scholar Physicians prefer to withdraw therapy supporting organs that fail because of natural rather than iatrogenic causes, to withdraw recently instituted rather than long-term treatment, to withdraw therapy resulting in immediate rather than delayed death, and to withdraw treatment resulting in delayed rather than immediate death when diagnostic uncer-tainty exists.31Christakis NA Asch DA Biases in how physicians choose to withdraw life support.Lancet. 1993; 342: 642-646Abstract PubMed Scopus (171) Google Scholar Although many end-of-life decisions have been framed in medical terms such as “futility,”30Luce JM Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists.Crit Care Med. 1995; 23: 760-766Crossref PubMed Scopus (97) Google Scholar32Truog RD Brett AS Frader J The problem with futility.N Engl J Med. 1992; 326: 1560-1564Crossref PubMed Scopus (362) Google Scholar33Sprung CL Eidelman LA Steinberg A Is the physician's duty to the individual patient or to society? [editorial].Crit Care Med. 1995; 23: 618-620Crossref PubMed Scopus (19) Google Scholar they are often subjective and ethical determinations. Decisions to continue or to discontinue therapies are often based on soft scientific information, and medical uncertainty abounds.” In fact, when several physicians are responsible for the care of critically ill patients, they frequently disagree about the patient's prognosis.34Poses RM Bekes C Copare FJ Scott WE The answer to “What are my chances, doctor?” depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.Crit Care Med. 1989; 17: 827-833Crossref PubMed Scopus (88) Google Scholar The patient's concept of life and its quality and benefit are as correct as that of the physician.” Physicians should avoid confusing value judgments with medical indications for therapy. Unfortunately, the warnings of critics are being fulfilled. Abuses occur when futility is inconsistently applied and expanded.32Truog RD Brett AS Frader J The problem with futility.N Engl J Med. 1992; 326: 1560-1564Crossref PubMed Scopus (362) Google Scholar Curtis and colleagues” demonstrated that many physicians' definition of futility includes interventions that might be considered medically reasonable. Of 75 patients, physicians deemed CPR to be futile in 32&x0025; despite the probability that survival was 5&x0025; or greater and in 20&x0025; when the survival probability was 10&x0025; or greater. Physicians did not agree when CPR was futile, and disturbingly I CPR was more likely to be considered futile if the patient was not white.” Stating that treatments such as CPR, which have a survival probability of 5 to 10&x0025;, are useless is clearly unacceptable. In addition, qualitative futility was determined for 61 patients, and quality of life was discussed with only 65&x0025; of the 40 competent patients.35Curtis JR Park DR Krone MR Pearlman RA Use of the medical futility rationale in do-not-attempt-resuscitation orders.JAMA. 1995; 273: 124-128Crossref PubMed Scopus (133) Google Scholar Physicians have also used CPR inequitably in patients with different diseases that have similar prognoses.36Wächter RM Luce JM Hearst N Lo B Decisions about resuscitation: inequities among patients with different diseases but similar prognoses.Ann Intern Med. 1989; 111: 525-532Crossref PubMed Scopus (197) Google Scholar DNR orders were written for 52&x0025; of patients with the acquired immunodeficiency syndrome (AIDS) and for 47&x0025; of patients with cancer but only for 16&x0025; of patients with cirrhosis and 5&x0025; of patients with congestive heart failure, all of which have similar prognoses.36Wächter RM Luce JM Hearst N Lo B Decisions about resuscitation: inequities among patients with different diseases but similar prognoses.Ann Intern Med. 1989; 111: 525-532Crossref PubMed Scopus (197) Google Scholar Asch and coworkers37Asch DA Hansen-Flaschen J Lanken PN Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes.Am J Respir Crit Care Med. 1995; 151: 288-292Crossref PubMed Scopus (220) Google Scholar showed that 34&x0025; of physicians continue life-sustaining treatments despite patient or surrogate wishes for discontinuation and that 82&x0025; unilaterally forgo therapies they believe are futile. Some of these decisions are made without the knowledge or consent of the patient or surrogate, and some are made despite their objection.37Asch DA Hansen-Flaschen J Lanken PN Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes.Am J Respir Crit Care Med. 1995; 151: 288-292Crossref PubMed Scopus (220) Google Scholar Patient self-determination and a right to die have been altered into a “duty to die,” even against patient and surro-gate wishes.16Levinsky NG The doctor's master.N Engl J Med. 1984; 311: 1573-1575Crossref PubMed Scopus (191) Google Scholar38Sprung CL, Eidelman LA, Steinberg A. The evolution of the patient's right to die into a duty to die [submitted for publication]Google Scholar This situation was exemplified in the case of Wang lie, an elderly female patient with respiratory failure who was in a persistent vegetative state (PVS).39Miles SH Informed demand for “non-beneficial” medical treatment.N Engl J Med. 1991; 325: 512-515Crossref PubMed Scopus (118) Google Scholar The physicians concluded that the ventilator was “non-beneficial,” and they sought court assistance in appointing a guardian who would agree with the removal of the ventilator.39Miles SH Informed demand for “non-beneficial” medical treatment.N Engl J Med. 1991; 325: 512-515Crossref PubMed Scopus (118) Google Scholar They took such action despite the fact that Wanglie' s husband believed that his wife experienced no suffering and that she would consider a ventilator, which was sustaining her life, to be a benefit.39Miles SH Informed demand for “non-beneficial” medical treatment.N Engl J Med. 1991; 325: 512-515Crossref PubMed Scopus (118) Google Scholar Some medical and legal experts have recommended that patients in a PVS be considered dead.40Schaffner KF Snyder JV Abramson NS Bar-Joseph G D'Alecy LG Edgren E et al.Philosophical, ethical, and legal aspects of resuscitation medicine. III. Discussion.Crit Care Med. 1988; 16: 1069-1076Crossref PubMed Scopus (12) Google Scholar Discrimination against elderly persons has surfaced, and age has been proposed as a standard for terminating treatment.41Callahan D Terminating treatment: age as a standard.Hastings Cent Rep. 1987; 17: 21-25PubMed Google Scholar An attitude that certain types of patients have a “life not worthy to be lived”42Alexander L Medical science under dictatorship.N Engl J Med. 1949; 241: 39-47Crossref PubMed Scopus (204) Google Scholar is becoming more acceptable. Changes in Society.—In conjunction with these changes in physician actions, societal outlook has been altered. Active euthanasia is performed in approximately 2,000 to 10,000 patients a year in the Netherlands.43de Wächter MA Active euthanasia in the Netherlands.JAMA. 1989; 262: 3316-3319Crossref PubMed Scopus (62) Google Scholar Active euthanasia is also occurring in other European countries.44Vincent JL European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire.Intensive Care Med. 1990; 16: 256-264Crossref PubMed Scopus (152) Google Scholar Despite strict guidelines for the practice of euthanasia in the Netherlands, including a request by a patient with an unbearable illness beyond recovery and a confirmation of the diagnosis and prognosis,43de Wächter MA Active euthanasia in the Netherlands.JAMA. 1989; 262: 3316-3319Crossref PubMed Scopus (62) Google Scholar a certain percentage of patients who do not fulfill these criteria undergo euthanasia.45van der Wal G Dillmann RJ Euthanasia in the Netherlands.BMJ. 1994; 308: 1346-1349Crossref PubMed Scopus (73) Google Scholar The physician decides when hastening death is appropriate; involuntary euthanasia has been performed in patients who have not requested it, and many of these cases have not been reported.43de Wächter MA Active euthanasia in the Netherlands.JAMA. 1989; 262: 3316-3319Crossref PubMed Scopus (62) Google Scholar45van der Wal G Dillmann RJ Euthanasia in the Netherlands.BMJ. 1994; 308: 1346-1349Crossref PubMed Scopus (73) Google Scholar The American Medical Association has condemned mercy killing as “contrary to the most fundamental measures of human value and worth.” Nevertheless, how long will American physicians be able to avoid active euthanasia when the public and many physicians believe it is best for patients and society? Active euthanasia is evolving in the United States. Americans fear that dying will be prolonged by medical technology and that they will have no control over what will happen to them. Prominent physicians have stated that physician assistance in the rational suicide of a terminally ill patient is not immoral.46Wanzer SH Federman DD Adelstein SJ Cassel CK Cassem EH Cranford RE et al.The physician's responsibility toward hopelessly ill patients: a second look.N Engl J Med. 1989; 320: 844-849Crossref PubMed Scopus (338) Google Scholar During the November 1994 elections, Oregon became the first state to give immunity to physicians who prescribe medication to be used by a terminally ill patient to commit suicide.47Alpers A Lo B Physician-assisted suicide in Oregon: a bold experiment.JAMA. 1995; 274: 483-487Crossref PubMed Scopus (54) Google Scholar Public opinion polls show that many Americans favor physician-assisted suicide and active euthanasia.48Giving death a hand: rending issue.New York Times. 1990 Jun 14; A6Google Scholar A case of active euthanasia has been reported,49It's over, Debbie.JAMA. 1989; 259: 272Google Scholar and many of the 6,000 daily deaths in the United States are in some way planned or assisted indirectly.48Giving death a hand: rending issue.New York Times. 1990 Jun 14; A6Google Scholar Distinction Between Withholding and Withdrawing Treatment.- Despite the fact that may ethicists and the President's Commission have stated that no moral differences exist between withholding and withdrawing life-sustaining treatments.12b many health-care professionals are still more uncomfortable withdrawing than withholding therapies.44Vincent JL European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire.Intensive Care Med. 1990; 16: 256-264Crossref PubMed Scopus (152) Google Scholar50Society of Critical Care Medicine Ethics Committee Attitudes of critical care medicine professionals concerning forgoing life-sustaining treatments.Crit Care Med. 1992; 20: 320-326Crossref PubMed Scopus (107) Google Scholar Biblical ethics, the historic foundation of the Western Judeo-Christian moral code, consider every human life to have infinite value. Withholding life-prolonging therapy is, in general, allowed, whereas withdrawing therapy that leads to death is prohibited and considered murder.51Rosner F Modern Medicine and Jewish Ethics. Yeshiva University Press, New York1986: 189-207Google Scholar This code may seem archaic to many American and European physicians, but Israeli physicians consider the withdrawal of life-sustaining treatments, which shortens a patient's life, to be unethical and illegal. Israeli physicians would never hesitate to initiate therapy in a critically ill patient even though treatments cannot be withdrawn. Pain relief is always a primary concern. Beauchamp52Beauchamp TL A reply to Rachels on active and passive euthanasia.in: Beauchamp TL Walters L Contemporary Issues in Bioethics. 2nd ed. Wadsworth Publishing, Belmont (CA)1982: 316-323Google Scholar provided reasons for preserving the distinction between active and passive euthanasia. One reason involves two groups of patients whose condition is wrongly diagnosed as hopeless: the first group will survive even if a treatment is ceased (to allow a natural death), and the second will survive only if the treatment is not ceased.52Beauchamp TL A reply to Rachels on active and passive euthanasia.in: Beauchamp TL Walters L Contemporary Issues in Bioethics. 2nd ed. Wadsworth Publishing, Belmont (CA)1982: 316-323Google Scholar If only passive euthanasia (withdrawing therapy) were allowed, then allowing death would lead to the loss of patients in the second group only, whereas if active euthanasia were allowed, at least some patients in the first group would be “needlessly lost.52Beauchamp TL A reply to Rachels on active and passive euthanasia.in: Beauchamp TL Walters L Contemporary Issues in Bioethics. 2nd ed. Wadsworth Publishing, Belmont (CA)1982: 316-323Google Scholar We believe that this argument should also pertain to the distinction between withholding and with-drawing therapy. For example, in a patient thought to need or receiving mechanical ventilation, if only withholding were allowed, patients in both the first and second groups would survive; however, if withdrawing were also allowed, only patients in the first group would survive, and patients in the second group would be needlessly lost. Therefore, the consequence of withholding and not withdrawing life-sustaining treatments would save some lives that could not be saved if both withholding and withdrawing were allowed. As in the distinction between active and passive euthanasia, the number of such cases is likely to be small, and it is not a decisive reason because counterbalancing grounds may exist that favor withdrawing of treatment.52Beauchamp TL A reply to Rachels on active and passive euthanasia.in: Beauchamp TL Walters L Contemporary Issues in Bioethics. 2nd ed. Wadsworth Publishing, Belmont (CA)1982: 316-323Google Scholar It is, however, a reason favoring only withholding that is morally relevant and should be considered.52Beauchamp TL A reply to Rachels on active and passive euthanasia.in: Beauchamp TL Walters L Contemporary Issues in Bioethics. 2nd ed. Wadsworth Publishing, Belmont (CA)1982: 316-323Google Scholar A physician recently described to us a patient who belonged to an HMO who had therapy withdrawn because of respiratory, renal, and hepatic dysfunction that was not particularly severe but who had an 80% mortality based on an APACHE II (acute physiology and chronic health evaluation) score (a severity of illness score that predicts mortality in the ICU).53Knaus WA Draper EA Wagner DP Zimmerman JE APACHE II: a severity of disease classification system.Crit Care Med. 1985; 13: 818-829Crossref PubMed Scopus (13355) Google Scholar The physician was extremely disturbed inasmuch as he believed that most intensivists would have continued treatment in this patient. As previously noted, DNR decisions are being made unilaterally by physicians. One wonders how many other decisions to forgo care are also being made unilaterally or with patient or surrogate consent based on physician values but without appropriate guidelines. This may be another reason to allow withholding of but not withdrawal of life-saving therapies. Current Practices.-In a new generation of physicians who have not experienced the evolution of changes in forgoing life-sustaining treatments, many do not know that a time existed when life-prolonging therapies could not be withdrawn. Today, practically all intensivists have withheld or withdrawn life-sustaining interventions based on the expectation of the patient's death, and most do so frequently throughout the course of a year.37Asch DA Hansen-Flaschen J Lanken PN Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes.Am J Respir Crit Care Med. 1995; 151: 288-292Crossref PubMed Scopus (220) Google Scholar Physicians are “struck” by the gravity of forgoing life-sustaining therapies and experience considerable anguish the first time they forgo treatments.54Edwards MJ Tolle SW Disconnecting a ventilator at the request of a patient who knows he will then die: the doctor's anguish.Ann Intern Med. 1992; 117: 254-256Crossref PubMed Scopus (63) Google Scholar They have feelings of accusations that they, not the disease, are killing the patient.54Edwards MJ Tolle SW Disconnecting a ventilator at the request of a patient who knows he will then die: the doctor's anguish.Ann Intern Med. 1992; 117: 254-256Crossref PubMed Scopus (63) Google Scholar After a while, however, forgoing these therapies is done frequently, becomes commonplace, and is associated with less anxiety. To a certain extent, some physicians may have lost the great respect they once had for the sanctity of life. Future Implications.-Although physicians and families may believe that they know what is best for the patient, occurrences in the future may not be based on what the patient, family, or physician wants for the patient. The arguments between advocates for patient autonomy versus those for medical professionalism will soon become meaningless. Insurance companies and managed care plans will decide what treatments are beneficial and what are futile based on what they determine is reimbursable. What the patient, family, or physician knows is best will not matter, even if they agree. Therefore, physicians must learn from past mistakes of inactivity to ensure that they do not recur. Medicine must not wait for the courts or insurance agencies with different agendas to decide what is best for patients. Physicians, despite their disagreements, must become proactive, band together, and define specific guidelines. Safeguards against inconsistency and disregard for patient values34Poses RM Bekes C Copare FJ Scott WE The answer to “What are my chances, doctor?” depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.Crit Care Med. 1989; 17: 827-833Crossref PubMed Scopus (88) Google Scholar must be developed. Many areas exist in which consensus can be obtained. For the vast majority of patients, most physicians and families will agree which patients are entitled to complete care and which are not. Even in the gray areas in which disagreements may occur, consensus may be obtained for coverage for some acceptable period or until the family and physician agree. If physicians would develop scientifically and ethically based guidelines for the forgoing life-sustaining treatments, public trust in physicians would be greater. Epilogue.-Our perspective will probably not be accepted by most American physicians. They might say that this is a conservative Jewish viewpoint from Israel. Nevertheless, many Jewish and even Christian patients and families in the United States agree with our opinions, and physicians should be aware of beliefs that differ from their own. addition, the authors are well aware of American medical practices. The senior author practiced medicine in the United States for 15 years before recently immigrating to Israel. He was the chairman of the Ethics Committee and a member of the Council of the Society of Critical Care Medicine for several years. The other authors have also received training in the United States. Whatever reservations readers may have about this commentary, the facts cannot be disputed. Progressive changes have occurred in American medical practices. We do not want to proselytize but rather offer a different approach that might be considered. If our article instills in physicians more caution and a greater respect for the sanctity of life, then we will have achieved our goal.