Commentary. 1: The right to refuse treatment.

The author suggests that by providing ventilators (or other equipment) with a mechanism which would automatically switch them off, (thus allowing the patient to die without the intervention of another human being switching the machine off) doctors would somehow be spared the moral dilemma and responsibility of acceding to a patient's request for a life-support system to be withdrawn. This "legalistic" moral position is apparently consistent with the author's discussion in relation to acts of omission or commission. Moral responsibility is taken by a clinician acceding to a patient's request to allow him/her to die, whether taken as agreement not to commence life support or to terminate provision of care which requires continuous maintenance and supervision from medical and paramedical staff. According to the author's premises, while it would not be ethical to switch off a ventilator it would be ethical, after receiving a request to terminate life support by ventilation, to cease maintaining the patient on the ventilator. This would allow, for example, the endotracheal tube to become blocked with secretions and the patient to die a lingering and painful death over a period of hours, days or weeks. I agree with the author, that acts of omission and commission may sometimes be morally indistinguishable but they are, I imagine, legally pragmatic. If failure adequately to care for a patient on a ventilator resulted in his or her untimely death, this would, by an act of omission, be manslaughter. According to the argument of the author attaching somebody to a machine which would automatically switch itself off would be ethical, yet as a planned act of commission could be deemed to be murder. The legal distinction between acts of omission and