AM, an eighty-year-old woman, is brought by ambulance to emergency room after an apparent suicide attempt. She was discovered by her neighbors, who have tried to look after her since her husband died three years ago. They became concerned when she did not answer her phone, and when they went to investigate, they found her unconscious on floor next to an empty bottle of sleeping pills. A suicide note was left on dining room table. Alarmed, neighbors called paramedic service, which resulted in AM's being placed on a breathing tube to assist her respiration. In her suicide note AM requested that authorities contact her oldest friend, SK, who would make burial plans. SK was summoned to hospital When told of suicide attempt and AM's still uncertain condition, SK informed physicians that AM had completed an advance directive years before, which gave SK durable power of attorney for health care decisions. SK told emergency room staff that AM had made a rational decision to commit suicide. She reported that AM felt that she had lived a full life and that she feared growing infirmity and memory loss. AM had told her friend that she wanted to die while she was still healthy and fit. Days before, she played a full round of golf at her country dub and then celebrated her eightieth birthday over dinner with some friends. A call to patient's long-time physician confirmed that AM had been in excellent health. Dr. T reported that except for mild osteoarthritis, patient was fit. The physician also volunteered that a month ago, AM visited his office to say goodbye. Dr. T did not feel that patient was depressed at that time and believed her to be completely rational. He suggested psychiatric evaluation, but patient refused this referral. The matter was not pursued further. Citing patient's preferences not to receive extraordinary medical care, her legal status as patient's health care decisionmaker, and her obligation to be true to her friend's wishes, SK requests that AM be taken off ventilator. The physicians in emergency room are hesitant to accede to SK's request. They are uncomfortable and feel that removing ventilator would be akin to assisted suicide. Is removal of AM's ventilator assisted suicide? Or is it a withdrawal of life-sustaining therapy consistent with patient's prior wishes? Any judgment about propriety of removing ventilator will be informed by measure of responsibility owed to AM. Standing at her bedside, we must ask ourselves, Who is responsible for tragedy before us? An emergency room physician could properly note that he was not responsible for causal chain of events leading to her presence there. It is not physician-assisted suicide because he neither intended that AM take her own life nor provided her with means to do so. Although this line of argument logically points away from viewing removal of ventilator as assisted suicide, extubating this patient remains intuitively different from other sorts of cases in which life-sustaining therapy is withdrawn. Even though we generally accept that removal of a ventilator does not cause death but lets nature take its course, we would have lingering reservations if patient's life could be saved and care was not already futile. In that narrow context, removal of ventilator symbolically could be seen as completing a suicide attempt and thus adding insult to injury. If Am's prognosis is good then AM cannot succeed in taking her own life without involvement of a physician willing to withhold potentially lifesaving therapy. Imagine AM waking up and pulling at her endotracheal tube. Here nature is not likely to take its course. The clinical context then puts one's theoretical commitment to patient self-determination to test. Steven Miles has described physician-assisted suicide as a crucible formed by the essential and difficult intimacy with dying patient. …