Table 1 Case description and arguments presented

Situation A: A previously healthy 72-year-old woman is brought to the emergency room in a deep coma for what is believed to be a stroke with a right-sided hemiphlegia. In order to conduct a CT scan and to secure respiratory function, it is necessary to intubate and mechanically ventilate the patient. The CT scan shows a large haemorrhage in the left central part of the brain. A surgical evacuation in this delicate area is considered undesirable. However, without neurosurgery, intracranial pressure will probably increase, and a herniation of the brain will occur. Accordingly, without treatment, the patient is presumed fated to die within a few days.

In favour of surgery:

• Surgery should be performed because it is the first task of health care to safe lives

• A neurosurgeon refers to experience from a successful case 2 years ago; thus, the surgery should be performed.

• Surgery should be performed because otherwise it might be interpreted as a kind of euthanasia

• Surgery should be performed because a son has asked the doctor to do everything to save his mother's life

Against surgery:

• Surgery should be avoided because the patient's quality of life would be greatly reduced

• Surgery should be avoided because of the age of the patient

• Surgery should be avoided because of the cost and uncertain result

• Surgery should be avoided because of the patient's wish not to end up in a persistent vegetative state

Situation B: Neurosurgery has been performed and the patient is transferred to the intensive care unit. After 2 days the patient is still on the ventilator, no improvement has been observed and the patient is still deeply unconscious. After 10 days a new CT scan is conducted, which indicates that a large area of the brain is incarcerated. The patient is no longer able to breathe without a ventilator, and the physicians discuss whether to continue the treatment

In favour of continuation of ventilation:

• Ventilator treatment should be continued because discontinuing it might be perceived as a kind of euthanasia

• The patient's son is strongly against discontinuing ventilator treatment, thus, treatment should be continued

Against continuation of ventilation:

• The treatment should be discontinued because it only prolongs the dying process

• The treatment should be discontinued because it is in accordance with the wishes of the patient

Situation C: The physicians have now decided to withdraw ventilator treatment and inform the relatives. After 12 hours of breathing unaided, the patient develops convulsions and forced breathing. The condition looks painful and stressful. In order to alleviate the patient's symptom, morphine and tranquillizers may be provided. However, these drugs might also affect the respiratory centre in the brain and accordingly hasten death

In favour of morphine and tranquillizers:

• Tranquillizers and morphine should be provided in order to keep the patient free from symptoms even though they might hasten death

• Tranquillizers and morphine should be provided in order to shorten the dying process

Against morphine and tranquillizers:

• Tranquillizers and morphine should be provided but without risking acceleration of death

• Tranquillizers and morphine should not be provided if the purpose is to hasten the dying process