Patients write DNR orders to avoid a vegetative state or an otherwise low-quality life, which they fear will follow resuscitation, but policy makers are concerned that DNR orders hasten death, especially for vulnerable subgroups. Both patients and policy makers would be well informed by knowing how often and for whom obeying a DNR order will cause the early termination of life and how often those terminated lives would have been high quality.

There are two ways to learn about the causal effects of DNR orders: an observational study, such as performed by Shepardson et al. (1999) and a randomized clinical trial (RCT). At the end of our discussion, we consider an alternative to both an observational study and a traditional RCT that involves random assignment, yet may be both ethical and more policy relevant than a traditional RCT.

When treatment evaluation does not benefit from any random assignment, observational study methods must be used to assess treatment effects. Here, the authors use propensity score methods and conclude that a patient's choice to write a DNR order on average hastens death. At first glance, it may seem strange to use formal quantitative methods to evaluate this question. After all, can forbidding “resuscitation to preserve life” do anything but hasten death? However, the authors' give their attention to assessing the magnitude of the effect, which has far more policy relevance than the more mundane question of assessing statistical significance.