The concept of extracorporeal device-based therapy for providing organ support is not new. The ventricular assist device (VAD), used to support refractory heart failure, is comparable to ECMO in that it can provide significant circulatory support, and ECMO may serve as a bridge to VAD therapy. However, in patients with refractory respiratory failure, no destination device option currently exists, meaning that patients receiving ECMO support are necessarily confined to the ICU. Circumstances may arise when a patient receiving ECMO is unable to be bridged to recovery, transplant, or destination device therapy, yet the patient is capable of surviving with ongoing ECMO support. Such an ethically challenging and emotionally charged situation is sometimes referred to as a “bridge to nowhere,” with obvious implications for the patient, his or her family, the caregivers, the hospital, and the health-care system. Addressing the ethical issues that accompany ECMO becomes even more essential as the medical community has seen a significant expansion in case volume, due in part to the ease with which it can be initiated.1 Despite its increased use, data regarding its efficacy are limited. The strongest evidence supporting ECMO for respiratory failure comes from the randomized controlled trial Efficacy and Economic Assessment of Conventional Ventilatory Support Versus Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR), which evaluated the use of venovenous ECMO for severe hypoxemic respiratory failure.8 Although one may conclude that referral to an ECMO-capable center improves survival over conventional management at non-ECMO centers, methodological flaws limit the interpretation of this trial. Other evidence supporting the use of venovenous ECMO is limited to randomized trials with outdated technology or observational studies,9‐14 with propensity analyses demonstrating mixed results.3,15,16 The data for venoarterial ECMO for ECPR, cardiac failure, and bridge to transplantation are even more limited.4,5,7,17‐20 The use of resource-intensive technology in the absence of data that establish a clear benefit raises ethical issues and, to some degree, requires a societal judgment on the acceptable use of expensive, unproven interventions. This issue is mitigated to some degree by the context in which ECMO is applied. For hypoxemic respiratory failure, it remains a salvage therapy for those unable to be managed with conventional support, with a multicenter randomized controlled trial currently underway to better define its role (ECMO to Rescue Lung Injury in Severe ARDS [EOLIA]).21 In cases where ECMO serves as a bridge to lung transplantation, randomized trials of ECMO vs invasive mechanical ventilation are difficult to design because of the inevitability of death in those patients in whom ECMO is believed to be the only salvage option.22 We are, therefore, left with observational studies that have inherent limitations in determining efficacy, although such studies have recently demonstrated improved posttransplant outcomes with ECMO as bridging therapy.23,24 Ultimately, more data, including cost-benefit analyses, are needed before the medical community and governing bodies that regulate health-care systems will know how to best implement this technology. In the meantime, its judicious use should be based on the medical facts of each case, with careful consideration of the existing evidence and the available resources.