The dilemma of good clinical practice in the study of compromised standards of care

Four ethical issues loom over the study by Lieberman and colleagues--the absence of informed consent, the study being non-interventional in situations that typically call for life-saving interventions, the bias involved in doctors that study their own problematic practice and monopoly over intensive care unit triage, and ageism. We learn that the Israeli doctors in this study never make no-treatment decisions regarding patients in need of mechanical ventilation. They are complicit with botched standards of care for these patients, however, accepting without much doubt an ethos of scarce resources and poor managerial habits. The main two practical lessons to be taken from this study are that, for patients in need of mechanical ventilation, compromised care is better than a policy of intubation only when the intensive care unit is available, and that vigorous efforts are needed in order to extirpate ageism.