Some of the most difficult issues in spinal cord injury (SCI) medicine occur when existential questions arise, for example, when is life with SCI not worth living? As a static, nonprogressive disability, high levels of SCI are usually compatible with a long lifespan—even when a ventilator is required to sustain life. As a form of life-sustaining treatment, a ventilator—like any other medical treatment—can be freely chosen or rejected by a competent patient. But what are the minimum standards for competency (or decision-making capacity), and how much does a new patient need to know about life with SCI to make a fully informed decision? For a patient who has lived with SCI for a while and now despairs due to a lack of options or social supports, is a decision to be removed from a ventilator an act of authentic autonomy or a forced choice due to social injustices? This article explores these issues in some depth and offers SCI health care professionals some suggestions for helping patients navigate these difficult and lonely waters.
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