De facto gatekeeping and informed consent in intensive care.

Medical decision-making is based on the doctrine of informed consent which is, in turn, based on autonomy, which represents one of four pillars of medical ethics, the others being beneficence, non-malfeasance and social justice. Decision-making in intensive care with respect to the withdrawal of treatment, in particular ventilator therapy, is often extremely difficult for patients or their relatives and they would rather not make any decision other than to insist on the maintenance of therapy in spite of sound, reasonable medical advice that such therapy is of no value to the patient. Aside from issues of a dignified death, this is likely to be to the detriment of other patients who might be refused admission to intensive care and thus is counter to the dictates of social justice. Under these circumstances, there would appear to be a need to give authority to the reasonable medical decision to discontinue resuscitation.