Area 1: Intention in Clinical End-of-Life Practices
The concept of “intention” has long been used in end-of-life care in relation to the ethics of physician actions that may inadvertently lead to the hastening of a patient’s death. The frequently referenced doctrine of double effect (DDE) argues that merely “foreseeing” a hastened death as a result of clinical actions is permissible, while directly “intending” the death of a patient is impermissible (McIntyre 2018). In 2016, the government of Canada passed federal legislation that allowed eligible Canadian adults to request medical assistance in dying (MAID) for intractable illness, dividing the medical community over the ethical validity of this practice and its role in medicine. In 2019, the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians released a joint call to action, asserting that MAID is not a part of palliative care on the grounds of a crucial difference in intention between other accepted palliative practices (such as terminal sedation (TS) and withdrawal of life-sustaining treatment (WLT) (CHPCA 2019). Physicians on this side of the debate state that the intention to hasten the death of a patient inherent in the practice of MAID is outside of the scope of the physician’s role and violates the principle of non-maleficence. Conversely, many Canadian MAID providers contradict these claims on the grounds that, in both MAID and TS/WLT, the primary intention is to provide comfort and relieve suffering, upholding the principle of beneficence and patient autonomy (Goligher et al. 2017). This impasse may reflect a conceptual disparity in physicians’ understanding of “intention” and its application to broad professional standards and individual clinical scenarios.
Area 1 aims to generate mutual understanding within the Canadian palliative care community by integrating theoretical and empirical approaches to “intention”.
Phase 1:
Literature Reviews
Goal : Disambiguate the concept of “intention” in bioethical discourses through critical literature reviews and conceptual analysis.
Differing understandings of intention and foresight may lead to blurred definitions of palliative practices and physician moral and emotional distress. For example, sedation that maintains continuous and deep unconsciousness or is used in combination with the withdrawal of life-sustaining treatment (WLT) is sometimes suspected to be a form of ‘slow’ euthanasia, towing the line between accepted palliative practice and euthanasia (Douglas et al. 2008). To ensure the effective and ethically conscious provision of palliative care, confusion regarding intention in end-of-life practices must be addressed. Through careful consideration of prominent theoretical and empirical research on this topic, the nature of the intentions involved in MAID and traditional palliative care practices and the utility of examining intention in end-of-life care will be investigated. Ultimately, the literature reviews aim to weigh in and provide clarity on the question of whether MAID should be included within the gamut of palliative care.
Phase 2:
Semi-structured Interviews
Goal : Observe and interpret the lived experience of Canadian physicians and nurse practitioners who engage in end-of-life healthcare practice.
Interviews will capture the features of physician experience most relevant to the role of “intention” in physician self-understanding and decision-making concerning practices that lead to patient death. The balanced understanding of “intention” resulting from the integration of careful philosophical analysis with the lived experience of medical professionals engaged in end-of-life practice will help both a stalemated bioethical debate and a divided medical profession.
Phase 3:
Research Integration
Goal : Integrate research findings to mutually inform theoretical and empirical discourses concerning intention and clinical end-of-life practices.
Findings from the literature reviews on the empirical and theoretical considerations of “intention” and foresight in end-of-life care practices will be combined with qualitative results from the interviews with physicians. Our conceptual work will help empirical researchers better operationalize the term “intention,” and our empirical work will inform ongoing theoretical discussions. The results will also be of interest to interdisciplinary researchers as an example of how philosophical and social scientific research can be fruitfully linked.
Phase 4:
Guidelines to Inform Solutions
Goal : Generate and disseminate conceptual resources to advance conversation and generate mutual understanding.
Clarifying how “intention” is viewed by Canadian end-of-life practitioners and within the bioethical literature will help health care practitioners navigate debates concerning MAID and palliative care. Ensuring that all sides understand each other is the first step toward a healthier, less polarizing conversation.
Our Collaborators
In addition to our main researchers the following people will be close collaborators for Area 1;
Dr. James Downar
Critical Care and Palliative Care Physician
James Downar graduated from McGill Medical School and completed residency training in Internal Medicine, Critical Care and Palliative Care at the University of Toronto. He has a Master’s degree in Bioethics from the Joint Centre for Bioethics at the University of Toronto. He is Professor and Head of the Division of Palliative Care at the University of Ottawa, where he holds a Clinical Research Chair in Palliative and End of Life Care. He is the co-chair of the Pan-Canadian Palliative Care Research Collaborative and the Secretary of the Canadian Critical Care Society. In 2021 he received the Award of Excellence from the Ontario Medical Association’s Section on Palliative Medicine. His research interests include communication, decision-making and suffering for seriously ill patients; bereavement; Palliative Care for the Critically Ill; and Palliative Care for Non-cancer Illnesses.
Dr. Ewan Goligher
Critical Care Medicine Professor
Ewan Goligher MD, PhD is an Assistant Professor in the Interdepartmental Division of Critical Care Medicine at the University of Toronto and a Scientist at the Toronto General Hospital Research Institute. His research program in clinical respiratory physiology focuses on characterizing the mechanisms and impact of injury to the lung and diaphragm during mechanical ventilation. He is co-chair of the international PRACTICAL adaptive platform trial in acute hypoxemic respiratory failure. He also writes on the ethics of assisted death and the role of physician conscience in end-of-life care practices.
Reference List
Canadian Hospice Palliative Care Association. (2019). Hospice Palliative Care and Medical Assistance in Dying (MAiD) Position Statement. Retrieved May 29, 2023, from https://www.chpca.ca/wp-content/uploads/2020/11/CHPCA-Position-Statement_MAiD_June2019-5.pdf.
Douglas, Charles et al. “Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia.” Bioethics, vol. 22,7 (2008): 388-96. doi:10.1111/j.1467-8519.2008.00661.x
Goligher, Ewan C et al. “Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues.” Critical care medicine, vol. 45,2 (2017): 149-155. doi:10.1097/CCM.0000000000001818.
McIntyre, A. (2018, December 24). Doctrine of Double Effect. Stanford Encyclopedia of Philosophy. https://plato.stanford.edu/entries/double-effect/