The use of extracorporeal membrane oxygenation Q4 (ECMO) as a temporary bridge to recovery, transplant, or durable device implantation is widely accepted. Major unease remains for patients already receiving ECMO who are progressing in ways that preclude recovery, transplantation, or device implantation. A substantial number of clinicians argue that when a patient no longer qualifies for recovery, transplantation, or device, ECMO should be withdrawn, even over patient or authorized decision-maker objection. In this article, we assess ethical arguments for this unilateral withdrawal position, make counterarguments in opposition to unilateral withdrawal, and offer practical suggestions for resolving conflicts. We critique 4 ethical rationales for unilaterally discontinuing ECMO: (1) the original design and purpose of ECMO;
(2) medically inappropriate treatment; (3) the equivalency thesis, which states that because withholding is permissible, so is withdrawing; and (4) resources, expense, and distributive justice. In addition, we review legal issues and outline practical steps for conflict resolution.