Physicians and relatives facing end-of-life decisions in intensive care: ethical insights from a comparison of French and American models

BACKGROUND: Decisions to limit life-sustaining treatment (LST) in intensive care frequently generate ethical tensions between physicians and patients' relatives. Although France and the United States both emphasize respect for patient autonomy, their decisional frameworks allocate different roles to physicians and surrogates, raising questions about how these models shape ethical practice. The aim of this study was to compare French and American approaches to LST decision-making to identify shared ethical difficulties in physician-relative interactions beyond framework differences. METHODS: Qualitative comparative analysis combining a review of decisional frameworks with semi-structured interviews of intensivists and ethicists in France and the United States. Data were analyzed thematically. RESULTS: Three recurrent ethical issues emerged across both contexts. First, while patient autonomy remains a central normative reference, its implementation is limited by the scarcity, ambiguity, and contextual inadequacy of advance directives, as well as uncertainties in interpreting patients' wishes through relatives. Second, irrespective of formal decision-making authority, physicians report a strong sense of moral responsibility grounded in medical expertise and professional integrity, often associated with moral distress when asked to provide treatments perceived as non-beneficial. Third, conflicts with relatives commonly arise from value-based disagreements regarding proportionality of care and perceived medical futility. CONCLUSION: Despite contrasting legal models - physician-led decision-making in France and surrogate-led decision-making in the United States - ethical tensions surrounding LST decisions appear largely similar. These findings suggest that procedural frameworks alone are insufficient to address the moral complexity of end-of-life decision-making, underscoring the need to strengthen ethical deliberation, and recognition of shared moral responsibility between physicians and relatives.