In a recent article in CHEST (February 2005),1Tonelli illustrated the ethical issues surrounding the participation of critically ill patients in decisions about ICU withdrawal, arguing that the focus on conflicting ethical principles of autonomy and beneficence is inadequate, and suggesting instead the usefulness of examining the unique clinical circumstances compared to paradigm cases. This offers little moral guidance. Our experience with children ventilated and given high dose steroids during an acute deterioration in their severe end-stage lung disease, for which they were listed for lung transplant, is that recovery is rare and ICU withdrawal often occurs. Usually, these patients are adolescents, who, as English Law deems them competent to assent to medical decisions yet not to decline them, cannot actively participate in end-of-life discussions. Ethical questions about waking these patients to tell them death is imminent, allowing them opportunities to say goodbye, invariably occur. Currently, the views of the ICU team, the ethics committee, and the families concur. Waking is inappropriate due to the factors mentioned by Tonelli, especially because of the potential emotional and physical distress. Such paternalism, a term that was invented for children, conflicts with increasing calls for adolescent participation in complex health areas.2 A more robust ethical basis for our view must be developed.