Ethical challenges in medical decision-making in ICU settings during the COVID-19 pandemic in China

This article presents a case-based ethical analysis of a critically ill COVID-19 patient in an ICU in mainland China, focusing on the conflict between a previously expressed refusal of life-sustaining treatment and subsequent family and institutional pressures. Rather than empirically studying medical workers, the analysis uses the case of Mr. Wang, an 85-year-old patient who refused extracorporeal membrane oxygenation during a documented lucid interval, to examine how autonomy, beneficence, nonmaleficence, and justice should be interpreted in a concrete clinical context. Mr. Wang initially refused treatment and expressed a wish to leave scarce medical resources to younger patients. After his condition deteriorated and he developed delirium, his family requested aggressive treatment, creating tension between his prior wishes, surrogate decision-making, scarce ICU resources, and institutional pressure. The analysis suggests that a competent refusal should carry substantial ethical weight, but that respect for autonomy also requires attention to authenticity and external pressures, including financial vulnerability, family expectations, and cultural obligations. This case highlights the need for structured documentation, family communication, and ethics consultation in similar ICU decisions. The central conceptual claim is that respect for patient autonomy requires evaluation of both decision-making capacity and the authenticity of the patient’s expressed preferences; capacity alone is insufficient to establish that a treatment refusal is fully autonomous.