We are grateful to Drs. Edwards and Tolle, two caring, competent physicians who wrote of their anguish in disconnecting a fully competent, ventilator-dependent patient from the ventilator at the patient's request [1]. Their courageous and candid presentation has given us much cause for thought, reflection, and some consternation.

What are the limits of patient autonomy? The patient did not appear to suffer from a terminal illness except for ventilatory insufficiency of neuromuscular cause. After a week of intense and time-consuming consideration, the physicians were satisfied that their patient wished to die rather than be ventilator-dependent. How was this decision made? It is relatively easy to present material to gently guide patients or their health care proxies along the pathways of our own biases. Did this particular patient know that there are many patients with neuromuscular disorders (for example, quadriplegics) who live chronically on ventilators in which an uncuffed endotracheal tube allows for speaking during expiration? These patients often live at home and are cared for by family members after a period of training. Would meeting some of these patients have lifted the patient out of his depression? Depression and suicide ideation are not uncommon in the initial phases of rehabilitation after a serious illness. How does one decide that a request for withdrawal of life support constitutes a "durable request of a mentally competent, well-informed patient?" How long is durable? It is the common experience of psychiatrists that many mentally competent, even "well-informed" patients who have attempted suicide feel quite different about ending their lives after appropriate treatment.

When does terminating a nonterminally ill patient's life support become routine? Edwards and Tolle [1] tell us that the "disconnection" was scheduled to occur at a certain time. If these disconnects become more frequent, do we risk the danger of lessening the thought and consideration given to any particular case? Could not the next logical step be to administer heavy sedation and concentrated potassium chloride just before the patient is to be disconnected? Why do physicians need to be involved at all? Disconnecting a patient from a ventilator is comparatively easy and does not require any particular expertise. An appropriate "discontinue ventilation" order, with all the requisite forms and signatures, could make the matter of ending life a part of hospital practice with no more emotional content than the writing of an antibiotic order.

What is the effect on the physician of withdrawal of life support in these circumstances? This [1] issue has received little attention in the ethical literature and may be the most bothersome of all. We are members of a profession whose credo has been "above all do no harm". The original oath of Hippocrates stated "I will give no deadly medicine if asked, nor suggest any such counsel ..." [2]. Since antiquity, we and the public we serve have defined us as sustainers of life and comfort. Thus, the effect on the physician who deliberately terminates life must be profound, as Edwards and Tolle testified. Might the practice be limited to only those physicians who are "tough enough to take it"? Although Edwards and Tolle are adamant that they no longer experience any anxiety, it is an axiom of psychotherapy that the unconscious mind may experience feelings of which the conscious self is not aware.