Effective patient-clinician communication and shared decision making are key components of patient-centered care. These components require that informed, activated. This report on end-of-life decision-making in Canada was produced by an international expert panel and commissioned by the Royal Society of Canada.

Effective patient-clinician communication and shared decision making are key components of patient-centered care. These components require that informed, activated. This report on end-of-life decision-making in Canada was produced by an international expert panel and commissioned by the Royal Society of Canada.

The Report by the Royal Society of Canada Expert Panel on End- of- Life Decision- Making. We need now to address two distinct types of arguments. The first denies the conclusion that has just been argued for, claiming that the prima facie moral right that we have just argued for does not exist.

The least ambitious such argument attempts to block the inference that many have made between the widely accepted claim that competent adults have the right to refuse medical treatment, or to have medical treatment interrupted once it has been started, even when it seems clear that abstaining from medical treatment will result in death, and the claim that competent individuals should have the right to choose assisted death. Indeed, some have argued that once one accepts the former practice, there is no moral ground for refusing the second. The argument against this view appeals to a pair of related distinctions, between intending a consequence and (merely) foreseeing it, and between doing and allowing. The argument is the least ambitious because while it establishes, if successful, that we cannot merely piggyback the moral acceptability of assisted death on that of the right to refuse treatment or to have it withdrawn, it does not tell us why assisted death is wrong.

Two further families of argument will then be considered that attempt to establish exactly that point. One such argument affirms the importance of autonomy, but argues that there are certain acts that autonomous choosers should never choose. The second holds that there are values that trump autonomy. We will in particular be focussing on the dignity- based argument against the prima facie right to choose assisted death, because dignity is a value that is quite regularly cited by the Supreme Court as central to the Canadian constitutional order.

The second set of arguments claims that though the prima facie moral right may very well exist, countervailing considerations exist that require that we abstain from giving legal expression to it. These arguments are paradigmatically expressed as . No Inference from the Right to Refuse Treatment to the Right to Assisted Death. The Panel will be reviewing in what follows a number of influential conceptual frameworks frequently invoked in discussions on end- of- life decision- making.

These concepts do not necessarily have a bearing on the autonomy based analysis offered in this Report. Some have been included merely to ensure that the review of influential conceptual frameworks is reasonably comprehensive. If healthcare professionals not only can, but must, adhere to the wishes of a patient who no longer wishes to be treated, does it not stand to reason that they should also be permitted to assist that patient in dying? Those who deny this logical implication must drive a hard conceptual and moral line between action and omission. They must claim that it is worse to bring about a person's death than it is to omit an act so as to prevent a person's death.

They must also defend the view that there is a moral distinction between killing and simply letting die. Finally, they must hold that an individual is not morally responsible for the bad ends that they merely foresee will result from an action, but that they do not intend to occur. Do these distinctions withstand critical scrutiny?

The Acts and Omissions Doctrine (AOD) holds, essentially, that there is a moral difference between actively killing a patient and omitting to keep a patient alive when one could have acted, at a reasonable cost to oneself, to produce that same outcome. This view holds that omitting to keep, for instance, a terminally ill patient alive who does not wish to be kept alive is sometimes less – or not at all – morally objectionable than actively killing a terminally ill patient who requests active assistance in his or her dying. Robert Young offers a possible rationale for this point of view in more abstract terms: Those who conceive of morality exclusively, or a least predominantly, within a traditional (deontological) framework claim, that doing something harmful is intrinsically morally wrong – that is, is morally wrong in itself, regardless of any good consequences it may produce.

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By contrast, when something similarly harmful is allowed to happen, a lesser intrinsic wrong is thought to be involved . Those who think acts of killing are intrinsically worse . What they insist, however, is that even in medical settings, where such extrinsic features are not normally present, it is intrinsically worse to do something harmful than to allow something harmful to occur.

This latter view has been criticized as conceptually indefensible by numerous scholars. Jonathan Glover argues that the AOD relies on accepting the claim ? If one were to compare actions and omissions using the same criteria, it becomes apparent that none of these arguments succeed. For instance, it is not necessarily the case that an omission to act is less likely than an action to guarantee a particular outcome. Similarly, it is not necessarily true that someone who omits to act is less causally connected to a particular outcome than someone who acted to achieve that same outcome. All of these suppositions depend upon the particularities of each case. There may very well be situations in which these differences are reversed, for example that an omission will more readily contribute to a particular outcome than an action.

Imagine, on the one hand, that an individual omits to remove a baby from a shallow pond in which he or she may drown. In this case, that individual's omission has a clearly identifiable victim. Imagine, on the other hand, that an individual throws water balloons into a crowded room, knowing that they will damage the clothes of some people in the room, but not knowing which one. Indeed, for any reason provided by Glover to indicate why people might think that there are features about acting that impart greater responsibility than omitting to act, it is possible to construct cases with the opposite conclusion. The distinction between action and omission falls apart. Both can be brought about by the same intention: that of bringing about a state of the world in which a patient will be dead rather than alive.

Omissions can sometimes result not from intention, but from negligence. Though there are cases of people who have neglected to do something less responsible than had they intended and planned to do that thing (less responsible, but not completely exempt from responsibility), this is not the case when the omission is deliberate, as in the case where one passes by the baby drowning in the shallow pond, deliberates about whether or not to rescue it, and decides not to. Intending to omit to do something, with the intention of bringing about a consequence, seems not to have any of the features that would make an individual less likely to ascribe moral responsibility to certain omissions than to actions. It is because intending to omit in order to bring about a result does not seem, morally, very different from intending to act in order to bring about that same result, that the AOD does not seem to have much relevance to end- of- life decision- making in clinical contexts. Indeed, though negligence does occur in clinical contexts, the types of cases considered in this Report are ones in which healthcare professionals omit to treat their patients in full knowledge that doing so might hasten their deaths (after having consulted with their patients about the course of action that they desire).

The Panel analyzed whether, when both intention and outcome are held constant, there is something morally relevant that distinguishes action and inaction. The Panel asserts that there is not, and that attribution of responsibility must occur on a case- by- case basis, rather than on the basis of a conceptual distinction between doing and allowing, or between killing and letting die. Another avenue that has been proposed to account for both the moral acceptability of current medical practice (for example, withholding treatment, use of potentially life- shortening analgesics and sedatives) and the moral condemnation of medically- assisted death, is the invocation of the doctrine of double effect (DDE) and the associated intention- foresight distinction (IFD). Before analysing the tenability of the DDE, the Panel notes that in daily medical practice there is usually no need to invoke this doctrine to justify the use of palliative measures by a physician. In most cases, the dosages of drugs used are carefully modulated in such a way that no life- shortening effect needs to be assumed. Moreover, patients in severe pain can tolerate drug dosages that would quickly kill people who are not suffering pain. And even the reverse could happen as drug administration for pain control can itself prolong life rather than hasten death.

In all such cases, physicians are not hastening the death of their patient so there is no need to invoke DDE to justify such treatment. However, things are different when patients do die quickly after the administration of drugs and certainly when physicians administer sharply increasing dosages of pain medication with the clear knowledge that this administration is likely or even certain to hasten the patient's death.

Here the DDE is sometimes invoked to justify the life- shortening effect of the intervention by the physician. The Panel analyses now whether the doctrine can be successfully used for that purpose. The DDE and the IFD distinguish between the intended outcome of predictable (or foreseeable) actions and outcomes and those actions and outcomes that are not intended. Consider a healthcare professional who decides to prescribe a life- shortening amount of pain- killing medicine; a sanctity- of- life doctrine- supporting observer subscribing to the DDE would want to know whether the healthcare professional was intent on shortening the patient's life or whether he or she was intent on relieving the patient's suffering.