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We don’t need unilateral DNRs: taking informed non-dissent one step further
  1. Diego Real de Asúa1,2,
  2. Katarina Lee3,4,
  3. Peter Koch5,
  4. Inmaculada de Melo-Martín6,
  5. Trevor Bibler7,8
  1. 1 Department of Internal Medicine, Hospital Universitario de la Princesa, Madrid, Spain
  2. 2 Division of Medical Ethics, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
  3. 3 Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
  4. 4 Health Care Ethics Service, St. Boniface Hospital, Winnipeg, Manitoba, Canada
  5. 5 Department of Philosophy, Villanova University, Villanova, Pennsylvania, USA
  6. 6 Department of Public Health, Weill Cornell Medical College, New York, New York, USA
  7. 7 Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
  8. 8 Ethics Consultation Service, Houston Methodist Hospital, Houston, Texas, USA
  1. Correspondence to Dr Diego Real de Asúa, Department of Internal Medicine, Hospital Universitario de la Princesa, Diego de León 62, 28006 Madrid, Spain ; diego.realdeasua{at}


Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges.

  • clinical ethics
  • end-of-life
  • ethics committees/consultation

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  • Contributors DRdA, KL, PK, IMdM and TB developed the original idea and drafted the initial version of the manuscript. DRA, IMM and TB revised the manuscript and made additional contributions. IMM and TB supervised the process.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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