I was disappointed by the recent article by Waisel and Truog [1]. Although the authors noted that "unlike all other therapies, one had to get consent to withhold [cardiopulmonary resuscitation] CPR," they did not pursue this idea. Cardiopulmonary resuscitation was devised for sudden unexpected deaths. It is not obvious that the routine application of CPR represents either good medicine or good ethics. Like most physicians, I have seen patients with terminal illnesses routinely resuscitated at great emotional cost, eventually proving nothing more than the house officer's truism, "If you can't keep them alive when they are alive, you can't keep them alive when they are dead."

In trying to reach a value-free conclusion (as if value judgments should always be avoided), the authors have fallen into the greater trap of assuming that providing CPR as a "default setting" is a value-free judgment. It isn't. It assumes that without explicit evidence, anyone would obviously want to be resuscitated rather than be allowed to die. That itself is a huge value judgment and does not reflect the real world. Further, it leads to a logically absurd medical ethic in which physicians are allowed to withhold therapies that are seen as irrelevant and inappropriate. However, when death occurs as a logical consequence of this approach, an obligation exists to perform CPR unless CPR has been explicitly refused. Why? Some patients are not comfortable with making explicit decisions about CPR even though they are content to accept that they are being made "comfortable" or that "everything reasonable will be done."

I personally have no problem with discussing plans with families to reach a consensus. However, I cannot accept that unilateral do-not-resuscitate policies are flawed simply because they involve value judgments. Has medicine abrogated the right to make value judgments, and, if so, to whom? Insurance companies? Hospital administrators? The real issue to consider is whether a moral or scientific basis supports the conclusion that CPR should automatically be provided in all cases when neither consent nor refusal has been stated. In my opinion, that position is not justified.