When Requests for Non-Beneficial Treatment Confront Standards of Care: Time to Update Ethical Considerations

PurposeThe widely accepted position that clinicians are not obligated to provide interventions that are considered to be outside standards of care requires a "deeper dive" and in some cases, a revision. Relying solely on standards of care may be inadequate given the complexity of modern medical practice, which aims to improve quality through personalization and precision, and the reality that healthcare professionals do not always reach consensus on what constitutes standards of care under certain circumstances.Despite the increasing emphasis on evidence-based medicine expected to contribute to established standards of care practices, only about 10% of current medical practice is supported by high-level evidence. Intensive Care Unit (ICU) clinicians are often exhorted by patients and their surrogates to administer treatments or interventions that they deem to be outside accepted standards of care given the patients' clinical status. These clinicians and their teams must balance respect for patient autonomy with their duty to maximize the benefits and minimize the risks of the proposed intervention or treatment.Clinicians and ethicists can become entangled in conflicting ethical principles, uncertain of which to prioritize, and may rely on standards of care to guide both clinical and ethical decisions. However, standards of care are not as definitive as they may appear; they contain ambiguities and uncertainties. As illustrated by three anonymized cases, physicians must often go beyond guideline recommendations. They must critically evaluate and thoughtfully consider the intervention's applicability to the specific patient, balancing its potential benefits and harms, and negotiating a shared path forward, even if it falls outside established norms.