In December, 2013, the Canadian Medical Association (CMA) Board of
Directors decided to shape the debate and law concerning euthanasia and
assisted suicide and revisit CMA policy opposing physician participation in
the procedures. By the summer of 2014 it was clear that the overwhelming
majority of physicians supported the existing policy. However, it appears
that the Board decided the policy should be changed before the Supreme Court
of Canada decided the case of Carter v. Canada.
The Board sponsored an ostensibly neutral resolution affirming support
for the right of physicians to follow their conscience in deciding whether
or not to provide euthanasia/assisted suicide if the law changed. The
resolution was overwhelmingly approved. Unnoticed at the time was
that the resolution was not conditional upon eligibility criteria, such as
decision-making capacity or terminal illness.
The CMA intervention at the Supreme Court of Canada in the Carter
case emphasized that existing CMA policy against euthanasia and
assisted suicide would be changed to reflect the resolution. It conveyed the message that the Association would support
physicians who decided to participate in euthanasia or assisted
suicide no matter how broadly the Court or legislatures might cast the rules
governing the procedures.
The Board reversed CMA policy about two months before the Court ruled. It
formally approved physician assisted suicide and euthanasia, subject only to legal
constraints. The policy did not exclude minors, the incompetent or the
mentally ill, nor did it limit euthanasia and assisted suicide to the
terminally ill or those with uncontrollable pain. It classified both as "end
of life care," promising support for patient access to the procedures should
they be legalized. Support for physicians refusing to participate in
euthanasia or assisted suicide was qualified by the statement that there
should be no "undue delay" in providing them. Implicit in all of this was a
new ethical paradigm: that in some circumstances, physicians have a
professional obligation to kill patients or to help them kill themselves.
The new policy effectively wrote a blank cheque for the Supreme Court of
Canada to legalize euthanasia and physician assisted suicide on any terms
acceptable to the judges. After the Court struck down the law CMA
officials expressed concern about the criteria set by the Court. It was
implied that the Supreme Court was to blame for anxiety and profound
discomfort among Canadian physicians because it had imposed upon them an
obligation to kill, contrary to centuries of medical ethics and practice.
However, the concerns voiced by CMA officials after the Carter
ruling existed when the CMA intervened in the case, and the CMA did not
raise them then. In fact, the Supreme Court gave legal effect to a policy
the CMA had already adopted, and the criteria the Court set for the
procedures were actually more restrictive than anything the CMA had
proposed. The Court cannot be blamed because CMA leaders were ill-prepared
to deal with the consequences of a ruling entirely consistent with their own
policy.
The consequences fell most heavily upon physicians who refused, for
reasons of conscience, to provide euthanasia and assisted suicide or to
collaborate in providing the services by referral or other means. Since Carter, the debate in Canada has been largely about whether or under
what circumstances physicians and institutions should be allowed to refuse
to provide or facilitate the services. While it is generally agreed
that physicians should not be compelled to personally provide them,
there are strident demands that physicians unwilling to kill their patients
or help them commit suicide should be forced to refer patients to someone
who will.
This review demonstrates that the CMA Board of Directors focus in 2014
was on the role physicians would play in providing euthanasia and assisted
suicide should the law change. The Board knew that the overwhelming majority
of Canadian physicians would refuse to participate in euthanasia or assisted
suicide. The fundamental conflict presented by imposing an
obligation to kill upon unwilling physicians was foreseeable and had been
foreseen by CMA officials. Attacks upon physician freedom of conscience,
particularly with respect to referral, were predictable.
However, the Board failed to consider physician freedom of conscience in
relation to assisted suicide and euthanasia except the extent that it could
be used to further its policy goals. As a result, after
the Carter ruling, CMA officials were quite unprepared to mount a
cogent, articulate and persuasive defence of physician freedom of
conscience, especially in relation to referral. They discovered that state
authorities and the public were often unreceptive and even hostile to
physicians unwilling to arrange for patients to be killed by someone else.
Negotiating at a significant disadvantage of their own making, they were
desperate to find a policy "acceptable to the regulators" and to objecting
physicians whose fundamental freedoms they had rashly jeopardized.
The CMA has since produced a strong defence of physician freedom of
conscience in relation to referral for euthanasia and assisted suicide, and
sound protection of conscience provisions have been incorporated into a
revised CMA policy on the procedures. However, by the time these statements
appeared, objecting physicians were on the defensive in a treacherous and
even hostile environment, compelled to launch an expensive constitutional
challenge to defend fundamental freedoms of conscience and religion. The
outcome of that case will determine if they will be able to continue to
practise medicine if they refuse to collaborate in killing their patients.
The World Medical Association (WMA) national
medical associations are free to decide to change their policies on
physician participation in euthanasia or assisted suicide. This review
demonstrates that they should not follow the example of the Canadian Medical
Association if they wish to safeguard the fundamental freedoms of physicians
and health care workers.
INTRODUCTION
PART I PRELIMINARIES TO
CARTER
- Canadian Medical Association (CMA) General Council
(August, 2013)
- CMA Board decides to shape the
debate and the law (October, 2013)
- CMA Board revises euthanasia and assisted suicide policy (December, 2013)
- CMA studies euthanasia & assisted suicide
(January-June, 2014)
- CMA announces plan to intervene in
Carter v. Canada
(April, 2014)
- CMA applies for intervener status in
Carter v.
Canada (June, 2014)
- CMA Board resolution on euthanasia and assisted
suicide (June-July, 2014)
- CMA General Council (August, 2014)
- CMA officials comment (August-September, 2014)
- CMA intervention in
Carter v. Canada
(August-October, 2014)
- CMA Board approves euthanasia and assisted suicide (December, 2014)
- Effects of the policy change
PART II CMA ON FREEDOM OF CONSCIENCE AFTER
CARTER
CONCLUSION
The Canadian Medical Association (CMA) and Royal Dutch Medical
Association (RDMA) are attempting to convince the World Medical Association
(WMA) to drop its opposition to euthanasia and assisted suicide.1
It appears that the CMA is recommending its own management of the
controversial subject as a progressive model that should be followed by the
WMA and other national associations.2
Since legalization of physician assisted suicide and euthanasia has
potentially serious implications for freedom of conscience among health care
workers, decisions by the WMA and its constituent members should be informed
by a critical review of the CMA's approach to changes in policy and law.
This review considers the CMA's approach to euthanasia and assisted suicide
only in relation to its impact on physician freedom of conscience.
Part I focuses on the period from August, 2013 to
December, 2014. During this time, the CMA Board of Directors actively
engaged in a process leading to reversal of CMA policy against physician
participation in euthanasia and assisted suicide and affirmation of the
procedures as legitimate forms of end-of-life medical care. The
transition from opposition to affirmation was facilitated by the acceptance
of an ostensibly neutral resolution on physician participation in euthanasia
and assisted suicide. Part I briefly considers the CMA's intervention
in the landmark case of Carter v. Canada, and concludes with a
consideration of the broad effects of the policy change and intervention in
relation to the outcome of the case and the consequences for objecting
physicians.
Part II begins on the eve of the Supreme Court of Canada decision in Carter in February, 2015 and concludes in the fall of 2015 with the
approval of the CMA's draft framework for providing euthanasia and assisted
suicide. It describes the response of the CMA Board to attacks on
physician freedom of conscience in the maelstrom unleashed by the Carter
decision, particularly in relation to the critical and controversial issue
of referral. It also documents attempts by CMA officials to shape a policy
on physician freedom of conscience that would accommodate the
expectations of medical regulators. Part
II concludes with a postcript on current CMA policy and the position of
objecting physicians.
In June, 2012, in the case of Carter v. Canada
(Attorney General), a judge of the Supreme Court of British Columbia
struck down the absolute criminal prohibition of physician assisted suicide
and physician administered euthanasia, suspending the ruling for one year to
give governments the opportunity to implement the decision.3
When the CMA Annual General Council convened in
August, 2013, an appeal of the Carter decision was in progress, and
a euthanasia bill had been introduced in the Quebec legislature. Delegates
were presented with a motion from the Quebec Medical Association that the
CMA should ask "all relevant levels of government to conduct a large-scale
public consultation to consider the recognition of medical aid in dying as
appropriate end-of-life care."4
A contentious debate followed, centred on the wording of the
motion and the definition of terms, and the motion was defeated. Instead,
delegates voted "to refer the issue to the CMA Board for future
deliberation." The outgoing chair of the medical ethics committee said that
the vote reflected "deep divisions within the medical community."4
Another motion called for the CMA to replace the
term "physician-assisted suicide" with "physician-assisted death" in all its
official documents. According to a Globe and Mail report, this motion also
generated a "passionate debate."
"Suicide is an unhappy word," said John O'Brien-Bell
of Surrey, B.C., a past CMA president. "Assisting suicide is also illegal."
Lawrence Erlick of Scarborough, Ont., tried to find a compromise, suggesting
the unwieldy term "patient-requested medically assisted death." Robin
Saunders, chair of the CMA ethics committee, would have none of it. "Let's
call a spade a spade: It's euthanasia," he said.
Delegates voted to have the CMA Board review the issue and make a
decision.5
However, delegates did pass the following motion:
36. The Canadian Medical Association supports the
right of any physician to exercise conscientious objection when faced with a
request for medical aid in dying. (DM 5-22).6
In October, 2013, the BC Court of Appeal reversed
the Carter trial court ruling.7 The Court of Appeal quoted the CMA policy against physician
participation in euthanasia and assisted suicide, setting it beside the
policies of other associations, as the trial judge did, to make the point
that the evidence at trial "did not demonstrate a clear consensus of public
or learned opinion on the wisdom of permitting physician-assisted suicide."8 It was generally understood that the
case would be appealed to the Supreme Court of Canada.
The CMA Board held a retreat the same
month, apparently for the purpose of deciding upon a course of action
concerning euthanasia and physician assisted suicide. In describing the
"dilemma" faced by the Board, Dr. Blackmer noted that polls had demonstrated
that the large majority of physicians were opposed to euthanasia and
assisted suicide, but the public was increasingly in favour of the
procedures. Consistent with the position of the majority of physicians, CMA
policy was against both. According to CMA Vice-President Dr. Jeff Blackmer, the choice faced by the
Board was to leave the policies unchanged, or "play a more active role in
representing its membership." The Board opted to become involved in what Dr.
Blackmer called the "national conversation." It meant to shape the debate
and law concerning euthanasia and assisted suicide, and authorized "a substantial
budget and significant internal resources" for that purpose.2
CMA President Chris Simpson later explained, "We realized that this was
something that society needs us to lead on."9
The great majority of CMA members opposed
legalization of euthanasia and assisted suicide, but, in representing CMA
members in the "conversation," the Board appears to have decided to include
both majority and minority perspectives. This was challenging but
worthwhile, and need not have had any adverse effects on physician freedom
of conscience.
However, by the summer of 2014, it appears that the Board's
plan to shape the debate and the law had evolved into a plan to overturn CMA
policy against the procedures, notwithstanding the opposition of
the majority of physicians, apparently because it had concluded that euthanasia and/or
assisted suicide should be legalized in at least some cases. According to Dr. Chris Simpson, then CMA
President, the Board decided that there was no consensus on the procedures,
and "There can't be a one-size-fits-all. We have to have the ability to fit
everybody's legitimate concerns and aspirations here."10
Belief that the Carter case would result
in legalization of the procedures also seems
to have contributed to the Board's plan to change CMA policy.11,12
The
Board wanted to ensure not only that the CMA would be involved in writing and implementing
a new law,13,14,15,16
but would
be in the vanguard of what would be a momentous change.17,18,19,20
That meant being on the right side of history if, as widely expected,
the Supreme Court ruled that the law should be changed.21,22 However, that also meant achieving a major policy change
at the General Council in August, as the next opportunity to do so would not
come for another year.
Beginning in June, 2014, with a General Council two
months away and a Supreme Court hearing expected in the fall, the Board put into
action what
was probably a still evolving plan, without reflecting adequately
upon the effects of their actions on medical practice and the fundamental
freedoms of physicians. As a result, they were surprised by elements of
the Supreme Court ruling and ill-prepared to respond, especially to challenges
to physician freedom of conscience.
In December, 2013, the CMA Board approved changes
to Association policy on euthanasia and assisted suicide.23 The update,
published in 2014, introduced new terminology and reiterated the
Association's opposition to the procedures. Three statements in the policy
are of particular interest:
A change in the legal status of these practices in
Canada would represent a major shift in social policy and behaviour. For the
medical profession to support such a change and subsequently participate in
these practices, a fundamental reconsideration of traditional medical ethics
would be required. (p. 2, emphasis added)
Physicians, other health professionals, academics,
interest groups, the media, legislators and the judiciary are all deeply
divided about the advisability of changing the current legal prohibition of
euthanasia and assisted suicide. Because of the controversial nature of
these practices, their undeniable importance to physicians and their
unpredictable effects on the practice of medicine, these issues must be
approached cautiously and deliberately by the profession and society. (p. 2)
The CMA recognizes that it is the prerogative of
society to decide whether the laws dealing with euthanasia and assisted
suicide should be changed. The CMA wishes to contribute the perspective of
the medical profession to the examination of the legal, social and ethical
issues. (p. 3)
There was no reference to the resolution passed by the Annual General
Council in 2013 asserting "the right of any physician to exercise
conscientious objection when faced with a request for medical aid in dying," but this would have been
premature. Assisted suicide or euthanasia were still illegal, and the
Association's position still stated that physicians should not participate in either.
During 2014, pursuing the direction given by the
Board the previous October, CMA officials quietly studied the
provision of physician assisted suicide and euthanasia in Oregon,
Washington, Montana, Vermont and New Mexico, Netherlands, Belgium and
Switzerland.12 It also held five town hall meetings
across Canada in the first half of the year, ending on 27 May in
Mississauga. With respect to euthanasia and assisted suicide, the
report about the meetings noted that "the public often had diametrically
opposed views,"24 was divided on whether or not
the procedures should be legalized,25 and stated that
the potential impact of legalization on the medical profession "should be
carefully considered and studied further."26
Six meetings were also held with physicians across
the country, and a website was maintained for physician-only comment from
February to the end of May. The report of the consultation stated that the
meetings and on-line responses were characterized by "diametrically opposed
views" on euthanasia and assisted suicide.27 The
majority of CMA members participating opposed physician involvement in the
procedures,28 (71.5% of an on-line poll29),
while "[a] significant minority" (25.8% of poll respondents29)
believed that the policy "should at least be reviewed if not revised to
support some form of physician-assisted dying."28.
A
majority of about 66% in the recent Irish abortion referendum has been
described as "overwhelming,"30 a "landslide"31 and "decisive."32
By this standard, a larger-than-overwhelming majority of Canadian physicians
opposed a change in CMA policy. No one has suggested that the referendum
result left the Irish government doubtful about its mandate. However, the CMA
consultation report - finalized at about the time the Board seems to have launched its
plan to change CMA policy - stated that the
Association "was
not given a clear cut mandate on future activity dealing with the sensitive
area of euthanasia and physician-assisted dying."28
The month before the town hall meetings ended, CMA
President Dr. Louis Hugo Francescutti and Dr. Jeff Blackmer announced that
the Association would intervene in the Supreme Court of Canada in the Carter case.
. . . the CMA will be seeking intervener status before
the Court, not to offer a polarizing "pro" or "con" view on an already
divisive issue - our policy is clear and speaks for itself - but to share a
narrative of insights on the physician's perspective. The goal would be to
provide the Court with a deeper understanding and appreciation of the
findings from the CMA's dialogue on end-of-life care, the spectrum of
options and the current CMA policy perspective. We would also highlight the
challenges posed to physicians' understanding of their traditional roles if
the Court were to change the law.33
Dr. Blackmer and Francescutti also claimed that the 2013 Annual General
Council rejected the motion calling for national consultation "to regard
medical aid in dying as appropriate care" because "medical aid in dying"
had never, until that point, been properly defined." This substantially
understated the significant differences that were evident to those observing
the proceedings. They did, however, make the following observations:
One person's
right is another person's obligation, and sometimes great burden. And in
this case, a patient's right to assisted dying becomes the physician's
obligation to take that patient's life.
We have heard from many of our members that this
prospect makes them not only uncomfortable but downright terrified. . .
. . .only a tiny minority of patients at the end of
their lives request access to medical aid in dying. Until we can provide
access to palliative care to all Canadians who need it, this is where the
focus of our attention should remain . . .
33
Given the concern expressed by Dr. Blackmer and
Dr. Francescutti in April, 2014 about imposing an obligation to kill upon
physicians, and the ramifications of doing so, one would expect this to have
been a constant concern of the CMA Board with respect to the
legalization of euthanasia and assisted suicide. However, it does not seem to have been considered again. The failure to attend to this issue
left most physicians unaware of its significance, and of the significance of
the policy direction taken by the CMA Board from June, 2014.
In June, 2014, the CMA applied for leave to
intervene at the Supreme Court of Canada in Carter v. Canada. The
application was supported by an affidavit by Dr. Chris Simpson,
president-elect.13 Quoting then CMA
policy, he emphasized deep divisions of opinion among physicians, other
health professionals, academics, interest groups, the media, legislators and
the judiciary (para. 23).
With reference to physicians, Dr. Simpson observed that a 2011
survey indicated that only 16% of Canadian physicians would provide
euthanasia or assisted suicide, while 44% would refuse (para. 33). He noted
that it was clear that the public was divided on the issue (para. 38, 39d).
While drawing attention to the strong opposition
of Quebec palliative care physicians to the province's proposed euthanasia
law, as well as doubts expressed by some family physicians, Dr. Simpson
nonetheless noted that physicians had "worked through and continue to assess
the appropriate ethical perspectives" of euthanasia, and that both the
Quebec Medical Association and Collège des médecins du Québec supported the
legislation (para. 44).
In describing then current CMA policy, Dr. Simpson
drew the court's attention to worries about a "slippery slope." However, he made
special note that a Royal Society panel of experts had concluded
that there was "no basis to these arguments." (para. 29)
The affidavit acknowledged but downplayed then
CMA policy against physician participation in euthanasia and
assisted suicide, stating that it was "not a certainty nor is it perpetually
frozen in time" (para. 28):
. . .while the policy states that the CMA is opposed
to physician-assisted death "Canadian physicians should not participate in
euthanasia or assisted suicide"), it frames it as a societal issue and
envisages the possibility of change, as informed by a dialogue between
physicians, patients and the legislatures. . .(para. 25)
Consistent with statements made two months earlier by Dr. Blackmer and
Dr. Francescutti, Dr. Simpson stated that a CMA intervention would not offer "a
black and white perspective" (para. 57), which "would be a disservice to the
issues and the Court," since, he wrote, "Such a perspective does not exist,"
adding, "The CMA's current policy is not static and can change (para. 58,
emphasis added).
The affidavit also envisaged a key role for
physicians should the law be changed:
If the law changes, physicians will be key players in
any assisted death regime. They will play two critical roles. First, they
will have to determine whether an individual patient's wish to be assisted
in dying meets the threshold. Second, they will have to prescribe the agents
leading to death, and to provide the patient with bedside care through the
process leading to death. Plainly, assisted death, if sanctioned by law, has
no prospect of implementation unless physicians in sufficient numbers across
the country are persuaded that the sanctioned regime is ethical, practical,
and in accordance with existing medical standards. . . (para. 56)
Nothing in the affidavit suggested that
the CMA would oppose legalization of physician
assisted suicide and euthanasia, and it did not state that the CMA would support
it. However, it clearly implied that, should the court legalize the
procedures, the Association would likely change its policy, and that
physicians would be "key players" whose cooperation would be needed to make
assisted suicide and euthanasia available.
During 2014 there was continual discussion of
physician assisted suicide and euthanasia by the CMA Board. CMA
Board member Dr. Ewan Affleck proposed that the Board sponsor a resolution
at the August Annual General Council. What he later told the Northern News
Service suggests that this probably occurred in June.
"CMA applied for intervener status with the Supreme
Court," said Affleck.
"That was some of the urgency in developing our
position, we knew the Supreme Court was moving forward and we wished to have
a clear position."33
At that point, the CMA's position was clear; the
Association opposed physician participation in euthanasia and assisted
suicide. If Dr. Affleck and others on the Board included in his "we" wanted
a "clear position," they must have wanted something different. Dr. Affleck, who described himself as
"passionate
about the issue of end-of-life choices" because of personal experiences,
explained what happened.
"We had been discussing this issue at length at the
level of the board for a good long while because it is an important issue,"
said Affleck.
"We had a lot of debates and then I sat down and wrote
a proposal for a motion and then took it back to the board as a board member
and it was quite uniformly well accepted."34
The resolution proposed by Dr. Affleck stated:
The Canadian Medical Association supports the right of
all physicians, within the bounds of existing legislation, to follow their
conscience when deciding whether to provide medical aid in dying as defined
in CMA's policy on euthanasia and assisted suicide.35
The Board thus agreed that the CMA should support
physicians who participate in assisted suicide and euthanasia as well as
those who refuse to do so, but this could hardly be considered a "clear
position" when read in conjunction with existing CMA policy. The Board's support for the
resolution conflicted with CMA policy against
physician participation.
However, the resolution had to be accompanied by a
supporting rationale, which, according to CMA rules, is the means
by which the General Council gives policy guidance and direction to the
Board.36 Thus, as the sponsor of the resolution, the
Board wrote - or at least approved in advance - the kind of guidance
it wanted to use to resolve the apparent conflict.
The rationale for the motion noted the "polarizing
nature" of the subject reflected in divisions among the public and CMA
members. It argued that unanimity among Association members seemed unlikely,
and that those supporting and those opposing assisted suicide and euthanasia
could marshal "just moral and ethical arguments" to support their respective
positions. While the wording of the motion seemed to suggest the
adoption of a laissez-faire position
concerning participation by individual physicians, the rationale went much
further, asserting that the current prohibition "may adversely impact
patients with terminal conditions and unremitting suffering from obtaining
compassionate care."
Implicit in CMA's mission statement, helping
physicians care for patients is the centrality of the patient in the mandate
of Canadian physicians.
CMA's current policy on euthanasia and assisted
suicide suggests that Canadian physicians should not participate in assisted
death. This poses a dilemma for CMA, as it could be suggested that a
prohibition on physician-assisted death bars physicians from providing a
service desired by some patients to alleviate pain and suffering.35
The CMA Code of Ethics, it was argued,
"implies the paramount importance of honouring the will of the patient in
determining the course of therapy they receive, including end-of-life
therapy."
Given that evidence supports that there are competent
Canadians with terminal illness who seek the services of physicians to
assist them with dying, how then can Canadian physicians justify withholding
a service against the will of a patient?35
Rhetorical questions are meant to elicit expected answers. The answer
obviously expected by the Board in this case was that the CMA
could not justify refusing assisted suicide and euthanasia to competent
patients who are terminally ill and want to kill themselves or have a
physician kill them.
This strongly suggests that, at least by June, 2014,
the Board had come to believe that CMA should formally approve physician
participation in assisted suicide and euthanasia, in order, as Dr. Simpson
said, accommodate "everybody's legitimate concerns and aspirations."10
However, they did not put this to the General Council. Instead,
the resolution they sponsored was ostensibly limited to the exercise of freedom of
conscience, supported by an appeal to adopt a policy of neutrality:
Rather than choosing to prohibit or approve
physician-assisted death, CMA will best serve Canadians seeking quality
health care by highlighting that physicians may follow their conscience when
deciding whether to participate within the bounds of existing law.35
(Emphasis added)
Consistent with the conclusion about the Board's opinion, the appeal to neutrality included the decidedly
non-neutral view that physician assisted suicide and euthanasia could be
considered "quality health care" in at least some circumstances.
Briefing materials were prepared for the CMA Board and delegates to the Annual General Council. The materials included relevant
resolutions passed at the 2013 Annual General Council, an outline of the
town hall meetings held in 2014 and a
backgrounder for the strategy session on Care at the End of Life (Appendix
2).37 The 2013 resolution that physicians had a right to
conscientious objection was listed with eight other resolutions passed at
the same time (p. A2-1). It was not included in the summary
of CMA policy that followed.
Key elements of the then current CMA policy on
euthanasia and assisted suicide were partially reproduced, the redaction of
one of which is noteworthy:
For the medical profession to [*support such a change
and subsequently*] . . . participate in these practices, a fundamental
reconsideration of traditional medical ethics would be required." [*Replaced
by elipsis*](p. A2-2)
If
even supporting legalization of euthanasia and assisted suicide would
require "a fundamental reconsideration of traditional medical ethics," one
would expect that a briefing note to delegates would have directed their
attention to that point rather than away from it,
especially since the Board planned to ask them to support a change in policy
conducive to legalization.
The backgrounder reported that the CMA had
applied for leave to intervene in the Carter
case. It posed five strategic questions to focus the discussion. Three
referred to euthanasia and assisted suicide; the last presumed a "need for euthanasia and assisted
suicide."
3) Should the CMA revise its current policy on
euthanasia and assisted suicide?
4) If the law is changed in Canada to make euthanasia
or assisted suicide legal how should the medical profession respond?
5) If access to palliative care services was
universal, would it eliminate the need for euthanasia and assisted suicide?(p. A2-4)
[Emphasis added]
Included in the backgrounder was "Schedule 'A'",
which outlined patient eligibility, process, and physician obligations
respecting euthanasia/assisted suicide in jurisdictions where the
procedures are legal. It stated that objecting physicians in Washington, Vermont, Oregon, Belgium,
and Luxembourg "have a duty to transfer patient care to another physician
who can fulfil the request." (p. A2-7)This was erroneous and misleading: erroneous,
because the law in Vermont said nothing of the sort;38 misleading, because it
could be taken to mean that the objecting physician has a duty to initiate
the transfer to a willing colleague. This was not required in any of the
jurisdictions listed. All that was required is that objecting physicians
transfer the patient's medical records as requested by the patient.39,40,41,42
The resolution proposed by
Dr. Affleck was seconded by outgoing CMA President Dr. Francescutti:
The Canadian Medical Association supports the right of
all physicians, within the bounds of existing legislation, to follow their
conscience when deciding whether to provide medical aid in dying as defined
in CMA's policy on euthanasia and assisted suicide. (DM 5-6)35
It was argued on the floor that "current
policy on euthanasia and physician-assisted suicide does not sufficiently
reflect the broad spectrum of opinions on the matter held by Canadian
physicians," since it prohibited physician participation in euthanasia and
assisted suicide. In contrast, the most recent survey of Canadian physicians
found almost 45% of physicians supported legalizing assisted suicide, about
36% favoured legalization of euthanasia, and almost 27% were willing to be
involved with providing assisted suicide if the acts were legalized.43
Of course, the survey results also revealed that
55% of physicians surveyed were against legalizing assisted suicide, 64%
against legalizing euthanasia, and 73% were unwilling to be involved with
assisted suicide, but it appears that those citing the statistics preferred
to accentuate the positive rather than the negative. It also appears that
the numbers of those willing or unwilling to provide euthanasia, if
available, were not reported. Again, evaluating the returns using the
standard applied to the Irish abortion referendum, an overwhelming majority
of physicians remained opposed to euthanasia and assisted suicide.
Nonetheless, this approach offered some strategic advantage in
view of the possibility that the Supreme Court might strike down the law, especially if the Association
maintained its policy against physician participation in the procedures. In that case, the resolution would have left willing
physicians free to apply the law without putting them in conflict with CMA
policy. It offered the Association as a whole and individual members a way
to agree to disagree, at least until the policy could be revisited if the
law changed.
On the face of it, the 2014 resolution did no
more than affirm the 2013 resolution supporting physicians who refuse to
participate in euthanasia, while adding the promise of support for physicians
wanting to do so. In the event that the procedures were legalized, the
resolution appeared to commit the CMA to impartially defend both groups -
nothing more. Dr. Blackmer later explained the resolution as "the other
side" of conscientious objection: "almost conscientious permission."44 Even delegates opposed to euthanasia and assisted
suicide would probably have been swayed by such considerations. On the other
hand, voting against the resolution would have been a vote against physician
freedom of conscience that would arguably have nullified the 2013 resolution
in support of a right to conscientious objection. In view of all of this, it is not surprising
that the outcome of the vote was 91% in favour of the resolution.
Professor Margaret Somerville, initially
satisfied with the resolution, later changed her mind:
The CMA's motion, as worded and subsequently
interpreted, placed its voting members in an untenable situation. Their only
options were to vote either for protection of conscience and for euthanasia
or against both. The possibility of voting for freedom of conscience and
against euthanasia, as I believe most would, was eliminated.45
Unnoticed at the time was the fact that the CMA's
promise to support physicians providing legal euthanasia and assisted
suicide was unlimited. It was not conditional upon patients having to
meet certain criteria to qualify, such as decision-making capacity or having
a terminal illness.
A CMA report of the meeting noted that a "straw
vote" showed 70% of delegates believed that the CMA should revise its policy
on euthanasia and assisted suicide, and "78% felt universal access to
palliative care services would not eliminate the need for euthanasia and
physician-assisted death."43 These votes were obviously in response to
"strategic questions" 3 and 5 posed to the delegates in their briefing
material.
It is difficult to verify the validity of the "straw votes" as a
reflection of the views of the entire CMA membership because of the contrary
views expressed during the earlier extensive physician consultations and the
bias evident in the information supplied to delegates. Especially important, one cannot determine whether the desire for
policy change expressed in response to Strategic Question 3 indicated
approval of euthanasia and assisted suicide or a preference for a policy of
neutrality - as urged by those supporting the Board resolution.
Two days after the vote, the CMA Board confirmed the resolution on freedom of conscience in relation to
assisted suicide and euthanasia.46 The confirmation of the resolution left the
prohibition against physician participation untouched. Some commentators - Professor Somerville among
them - initially believed that the resolution was an affirmation of
physician freedom of conscience rather than an expression of support for
physician participation in assisted suicide and euthanasia. In fact, that is exactly what Dr. Jeff Blackmer
told The Catholic Register.
". . .It (the new policy) doesn't say we favour a
change in the law," said Dr. Jeff Blackmer, the CMA's executive director of
ethics.
The CMA stance opposing euthanasia remains in place.
"Our position is still that Canadian physicians should
not participate in euthanasia or assisted suicide," Blackmer said.47
Dr. Blackmer maintained the distinction in another
interview:
"One of the options would have been to say our policy
is unchanged. We could say ethics trumps the law."
He noted that in Belgium, where euthanasia was
legalized in 2002, the Belgian Medical Association continues to discourage
physician participation in the practice.44
CMA President Dr. Chris Simpson also took this
approach during an interview in the first week of September.
Simpson said he is in full agreement with Affleck -
that the CMA not taking a stance one way or the other on doctor-assisted
deaths by passing the motion, but only allowing Canadian physicians to
follow their conscience.
"What we are doing is protecting doctors and allowing
them to follow their conscience on this issue," he said.
Simpson said if a doctor does not believe in helping a
patient end their life, they shouldn't have to and shouldn't be forced by
law to do so.48
With respect to euthanasia and assisted suicide,
he noted that some commentator had described the resolution as "a softening
of the CMA's stance on doctor-assisted death."
"I prefer to think of it as a tightening of
definitions when it comes to doctors and their role around end of life care.
This is a very complex, controversial issue for doctors and the public at
large."
"The CMA had to be careful in its use of terminology
in finalizing Affleck's motion."48
This response is noteworthy for three reasons. First: that Dr. Simpson
preferred to describe what
happened as "a tightening of definitions" did not amount to a denial that
softening had occurred or was occurring. Indeed, in November, 2014, looking back on the adoption
of the resolution, he called it "a sea change"9
- not just a "tightening of definitions."48
Second: the term "medical aid in dying" - the
only specialized term used in the text of Dr. Affleck's motion - had been
defined in CMA policy six months before he brought the motion to the Board.
His motion involved no "tightening of definitions." Third: what Dr. Simpson described as being
"careful in its use of terminology in finalizing Affleck's motion" must have
been a reference to the care taken in drafting the supporting rationale,
since the text of the motion introduced no new terminology and changed no
definitions.
Comments by Dr. Simpson in an earlier interview
provide more insight into his thinking. He expressed sympathy for physicians
concerned by the prospect that euthanasia and assisted suicide might be
legalized.
Most doctors aren't opposed to the notion of patients
being able to choose how and when they die, "but they're uncomfortable with
the role they're being asked to play," Simpson said.
"That discomfort comes a lot from this uncertainty: Am
I going to be compelled to do it if I don't want to do it? Am I going to be
asked to make decisions that I'm really uncomfortable with?"49
However, referring to some kinds of cancer and
diseases that cause "uncontrollable pain" and suffering that cannot be
alleviated by even the best palliative care, he said, "[W]e would all agree
that if we were in that situation we would be looking for potentially other
solutions"49 - an obvious if euphemistic reference to death by lethal
injection or assisted suicide.
Dr. Simpson's claim that "we would all agree" to
such solutions contradicted the CMA's repeated
acknowledgement that there was no agreement about the acceptability
of euthanasia and assisted suicide. However, it was consistent with the
views he expressed in the application to intervene in Carter, as
well as the
arguments in favour of euthanasia and assisted suicide offered by the CMA
Board in supporting Dr. Affleck's motion.
More significant was his response to the
suggestion that someone other than physicians should provide euthanasia and
assisted suicide. He said, "I don't think we want to be reneging on our
responsibilities to serve our patients."49 This could be understood to
support the view that, in some circumstances, physicians have a legal or
professional obligation to kill a patient or to help a patient kill himself.
As outgoing CMA President, Board member and seconder of Dr. Affleck's
motion, Dr. Louis Francescutti was well placed to anticipate what the CMA
Board would do. The conclusion that CMA Board supported physician
participation in euthanasia and assisted suicide is supported by a comment he made just after Dr. Affleck's motion was accepted by
the General Council. He noted that the CMA's official policy had not
changed, but "it's only a matter of time."50
The CMA factum for its intervention in Carter
was filed a week after
the end of the Annual General Council.51 Counsel for the
Association Harry Underwood made an oral submission during the Supreme Court of Canada
hearing in mid-October, 2014, making clear that the Association was not
arguing for or against the legalization of assisted suicide or euthanasia.52
He explained that physicians had been
historically barred from providing euthanasia and assisted suicide because
of ethical considerations, notably a physician's obligation "to secure
patient well-being."
But the concept of patient well-being is capable of an
interpretation which encompasses the patient's right to choose death, where
the alternative is certain suffering, a choice which is also supported by
the concept of patient autonomy. Thus, going back to first principles, the
two approaches are each possible.53
He went on to say that the profession was divided
between these approaches, "each defensible on the basis of established
medical ethical considerations and compassion." In light of this, he
said, referring to the resolution passed at the General Council in August,
the Association had decided that physicians "who can square their
participation with their own consciences" could provide euthanasia and
assisted suicide, "without overriding the consciences" of objecting
physicians. He told the Court that CMA policy would be changed to
reflect this.54
This reinforced statements in the
CMA factum:
The CMA's policies are not meant to mandate a standard
of care for members or to override an individual physician's conscience.
(para. 9)
It is acknowledged that just moral and ethical
arguments form the basis of arguments that both support and deny assisted
death. The CMA accepts that, in the face of such diverse opinion, based on
individuals' consciences, it would not be appropriate for it to seek to
impose or advocate for a single standard for the medical profession. (para.
16)
"As long as such practices remain illegal," the
factum stated, "the CMA believes that physicians should not participate in
medical aid in dying," but, should the law change, "the CMA would
support its members who elect to follow their conscience."(para. 3)
This promise was unconditional. Consistent with the
resolution sponsored by the Board in August, the
factum and oral submission conveyed the message that the Association would
support physicians who decided to participate in legal euthanasia or
assisted suicide, no matter how broadly the Court or legislatures might cast
the rules governing the procedures. The CMA offered no suggestions
concerning criteria for eligibility should the law be changed, but did tell
the Court that it seemed wrong to deny assisted suicide and euthanasia to
"grievously ill" (not terminally ill) patients simply because palliative
care is unavailable (para. 20).
In the last half of his presentation, Mr.
Underwood addressed practical concerns raised by the legalization of
physician assisted suicide and euthanasia. Notably absent from his list of
concerns was the fact that, as late as August, the great majority of
physicians were opposed to the procedures. However, he had earlier
insisted that the law should protect both objecting and non-objecting physicians,55
a point also made in the factum (para. 28).
[N]o physician should be compelled to participate in
or provide medical aid in dying to a patient, either at all, because the
physician conscientiously objects . . . or in individual cases, in which the
physician makes a clinical assessment that the patient's decision is
contrary to the patient's best interests. Notably, no jurisdiction
that has legalized medical aid in dying compels physician participation.
(para. 27)
The distinction made in the factum (but not in the oral
submission) between participation and provision is important. In this
context, "participation" is a broader term that would seem to include
referral. The CMA was well aware of longstanding and increasingly
strident demands that physicians be compelled to refer for morally contested
services like abortion.56 The
Association was also well aware that Jocelyn Downie, one of the leading
advocates for compulsory referral for abortion, had joined other experts in
recommending mandatory referral for euthanasia and assisted suicide;the
CMA President had cited their report57
in his affidavit. Downie was, in fact,
live-tweeting from the Supreme Court during the hearing.58
However, rather than directing the court's attention to this problem, the
CMA factum suggested vaguely that the Court could "indicate that a
practicable legislative regime for medical aid in dying must legally protect
those physicians who choose to provide this new intervention to their
patients, as well as those who do not." (para. 28) Worse, it advised the
Court that, if a physician declines to participate, "every jurisdiction that
has legalized medical aid in dying has adopted a process for eligible
patients to be transferred to a participating physician."(para. 27) Here the
factum cited the erroneous and misleading "Schedule A" prepared for the
August AGM, which could be understood to require objecting physicians to
collaborate in delivering the services.
Having watched the hearing, Udo Schuklenk, one of
Downie's fellow experts, criticized the joint intervention by the Protection
of Conscience Project, Faith and Freedom Alliance and Catholic Civil Rights
League because it argued against forcing objecting physicians to refer for
euthanasia and assisted suicide.58 He
did not mention the CMA submission.
In December, 2014, while the country awaited the
decision of the Supreme Court in Carter, the CMA Board approved a change
in Association policy on euthanasia and assisted suicide, renaming it
"Euthanasia and Assisted Death."59 When the revised policy was published, the CMA issued a statement
that it "and other changes to the CMA's approach to end-of-life care issues
. . . codify resolutions adopted by delegates at the association's annual
meeting in August."60
This was misleading. The revised policy did codify the resolution that
urged the Association to support for physicians who "follow their
conscience." Recall, however, that the resolution was not presented as an
approval of euthanasia and assisted suicide, but as a position of neutrality
concerning physician participation in the practices, a distinction
emphasized by both the CMA Director of Ethics and the CMA President shortly
after the General Council.
Instead, the revised policy formally approved
physician assisted suicide and euthanasia, subject to legal constraints,
classifying both practices as "end of life care."
There are rare occasions where patients have such a
degree of suffering, even with access to palliative and end of life care,
that they request medical aid in dying. In such a case, and within legal
constraints, medical aid in dying may be appropriate. The CMA supports
patients' access to the full spectrum of end of life care that is legal in
Canada.59
Once more, this affirmation was unconditional.
The
CMA Board promised to ensure patient access to "the full
spectrum" of end-of-life care, including euthanasia and assisted suicide, no matter what the
criteria might be. The policy did not exclude minors, the incompetent or
the mentally ill, nor did it limit euthanasia and assisted suicide to the terminally
ill or those with uncontrollable pain. It referred only to "patients"
and "the suffering of persons with incurable diseases." Thus, the
Board committed the Association to
support euthanasia and assisted suicide not only for competent adults, but
for any patient group and for any reason approved by the courts or
legislatures.
As noted above,
the previous policy included a grave warning: For the
medical profession to support such a change and subsequently participate in
these practices, a fundamental reconsideration of traditional medical ethics
would be required. Not having attempted such an exercise, the Board
simply deleted the statement. It also deleted a number of cautionary
statements and references to concerns found in the earlier version.
Delegates had neither been presented with nor had
they approved a resolution to this effect at the Annual General Council.
However, by approving the resolution supporting the right of physicians to
act according to their conscience, the delegates implicitly approved the
accompanying rationale that, having been carefully drafted by the Board,
could be understood to authorize the changes. In bringing about the change
of policy in this manner, the Board may have been following long-established
practices acceptable to the members of the Association. It might, in
addition, cite the "straw votes" at the General Council and the absence of general protest as evidence of
support for their reversal of CMA policy.
The CMA Board decided to lead
society and shape the debate and law on assisted suicide and euthanasia. They convinced delegates at the General
Council to approve an ostensibly neutral policy that favoured provision of
the procedures, which was widely seen as an overwhelming change.
In its application to intervene in Carter, the Board assured the
Supreme Court of Canada that CMA policy against euthanasia and assisted
suicide was "not a certainty" nor "perpetually frozen in time," that it was
"not static and can change," and reaffirmed this in its intervention. It
suggested no limits to circumstances under which euthanasia and assisted
suicide might be provided, but did tell the Court that it seemed wrong to
refuse to provide the services simply because palliative care was
unavailable. Finally, it implied that the Court could count on the
cooperation of the Association, no matter what their ruling might be.
Finally, the Board reversed CMA policy against physician
participation, deleting
statements of concern that might have impeded legalization, and unconditionally approved euthanasia and assisted suicide as
legitimate forms of medical treatment that should be provided "without undue
delay"to persons suffering from incurable diseases - should the law change.
It published the new policy while the Court was considering its ruling in
Carter, probably with a reasonable expectation that the Court would
consider it in its decision - which it did.
By doing all of this, the CMA Board
effectively wrote a blank cheque for the Supreme Court of
Canada to legalize euthanasia and physician assisted suicide on any terms
acceptable to the judges, assured that the Association would accept and
cooperate with legalization on whatever terms the Court set.
By formally approving physician assisted suicide and euthanasia rather
than adopting a neutral position, and by committing the CMA to support
patients's access to physician assisted suicide and euthanasia under
conditions set by law, the Board implicitly agreed that, in some
circumstances, physicians have a professional obligation to kill patients or
to help them kill themselves.
Further, by classifying euthanasia and assisted suicide as "end of life
care," the Board made participation in euthanasia and assisted suicide
normative for the medical profession. This effectively mandated a standard
of care for its members, something the Association had told the Supreme
Court the CMA did not mean to do.
The new policy also imposed a single ethical standard upon the entire
profession, something the CMA had told the Supreme Court would be
inappropriate. Once
legalized, euthanasia and assisted suicide became therapeutic medical
services.61,62 Refusing
the services in the
circumstances set out by law became an
exception to professional obligations requiring justification or
excuse. This is why, since Carter, the debate in Canada has
been largely
about whether or under what circumstances physicians and
institutions should be allowed to refuse to
provide or facilitate homicide and suicide.
It also explains
an important caveat the Board added to the 2014 policy's reference to freedom
of conscience:
A physician should not be compelled to participate in
medical aid in dying should it be become legalized. However, there
should be no undue delay in the provision of end of life care, including
medical aid in dying.59
Notice that, apart from mere legality, the policy placed no
limits on criteria for euthanasia and assisted suicide, and no limits on
what non-objecting physicians might agree to do, but
implied that freedom of conscience for objecting physicians could be limited
in order to ensure timely patient access to the services.
All of the preceding effects of changing CMA
policy against euthanasia and assisted suicide might have been foreseen by
the CMA Board had it not been so intent upon changing it within
the time frame imposed by the Carter case. Its lack of
foresight began to become evident on the eve of Supreme Court decision in
Carter.
Just before the ruling, CMA President Dr. Chris
Simpson said there was "a lot of moral angst" among physicians15
about what conditions or kinds of illness would justify the procedures14,18
what kind of suffering - physical, psychological or both - should make
someone eligible,18 and how terminal
illness should be defined.14 Among his other questions:
should assisted suicide and euthanasia be offered only to competent adults,
or also to the mentally ill, or clinically depressed18
or those with dementia?14 Should substitute decision
makers be able to ask for euthanasia or assisted suicide on behalf of
someone unable to do so?14,15,18
Just after the ruling, Dr. Simpson said that he had
not anticipated that the judges would permit euthanasia and assisted suicide
for any "grievous and irremediable medical condition" rather than terminal
illness.61 Dr. Blackmer acknowledged that physicians who
were willing to provide euthanasia in cases of terminal illness might be
less willing to do so for suffering caused by other medical conditions.63
A few days later, Dr. Blackmer expressed concern
about the eligibility criteria set by the Court. Blindess is "irremediable,"
he noted, and
said that the Carter decision would probably allow euthanasia and assisted
suicide for chronic depression and spinal
cord injuries.
My feeling is that there would be much more
support for a tighter framework in terms of requiring that the patient be
terminal. This is not to minimize in any way the suffering of people who do
not have a terminal illness, it is just that for a lot of doctors, this
opens too many doors and generates too many questions. . . My conversations
with doctors to date indicate more of a comfort level with tight
parameters.64
However, he believed that the CMA "might have very little ability" to
influence how the Carter criteria would be developed64 -
something the CMA Board might usefully have considered when planning
its intervention and before embarking upon its plan to change CMA
policy.
Dr. Blackmer also complained that the term
"grievous" is entirely subjective and "is not a technical medical term."64
Expanding upon this a few months later, he referred to "some angst and
discomfort" among physicians about the breadth of the Carter criteria.
"I've now given dozens or hundreds of presentations on
this and every time I speak about it and I ask doctors, ‘Look, have any of
you ever told a patient that you're really sorry but their condition is
grievous?' Of course, no one ever has," Blackmer said. "No doctor in
Canadian history, I don't think, has ever told a patient that they're
suffering from a ‘grievous" condition. So none of us know what that means."65
All of these complaints are
astonishing. Neither the CMA's factum nor its oral submission
at the Supreme Court of Canada suggested that assisted suicide or euthanasia
should be limited to patients with terminal illnesses, nor, in its
intervention, did the CMA suggest any criteria whatever as relevant for the
purpose of determining eligibility for the procedures. The revised
policy, Euthanasia and Physician Assisted Death, did not exclude minors, the
incompetent or the mentally ill as candidates for assisted suicide or
euthanasia, nor did it limit its application to the terminally ill or those
with uncontrollable pain. It referred directly only to "patients" and "the
suffering of persons with incurable diseases."
The question put to the courts by the plaintiffs from the
very beginning in 2011 was never about terminal illness, but about "grievous
and irremediable illness."66 The term was defined in the
trial court ruling, where it was used extensively,67 and
it appeared again in the first sentence of the appellants' factum filed in
the Supreme Court of Canada.68 Finally, the CMA factum,
"reviewed and approved by several senior CMA elected officials,"45 stated
that it seemed wrong to deny assisted suicide and euthanasia to "grievously
ill" patients just because palliative care is unavailable (emphasis
added)69 - yet Dr. Blackmer later
claimed that "none of us know what that means."67
In sum, all of the concerns voiced by Dr.
Simpson and Dr. Blackmer after the Carter ruling existed when the CMA
intervened in the case, but the CMA Board did not raise them.
Instead, it worked steadily to remove or minimize obstacles that
might have impeded legalization of physician assisted suicide and
euthanasia. The legal criteria set for euthanasia
and physician assisted suicide by the Supreme Court of Canada were actually
more restrictive than anything the CMA had proposed in its intervention or
included in its new policy.
Arguably, the CMA Board contributed
substantially to the legalization of physician suicide and euthanasia on the
broad terms set by the Court, and so were themselves, in large measure,
responsible for the "angst and discomfort" and profound unease of
Canadian physicians following the ruling.
Notes
1.
Murphy S. World Medical
Association urged to change policy against euthanasia, assisted suicide:
Canadian & Royal Dutch Medical Association want censure dropped.
Protection of Conscience Project, 13 February, 2018.
2. Blackmer J.
Assisted
Dying and the Work of the Canadian Medical Association. World
Medical Ass J. 2017 Oct; 63(3):6-9 (Accessed 2018 Sep 10).
3.
Carter v. Canada (Attorney General)
2012 BCSC 886 [Carter-BCSC] (Accessed
2018 Sep 10).
4. Eggertson L.
CMA delegates defer call
for national discussion of medically assisted death. CMAJ, September
17, 2013, 185 (13) E623-624
(Accessed 2018 Sep 10).
5.
Picard A.
Fears prevail during CMA
policy debate on euthanasia. Globe and Mail, 21 August, 2014
(Accessed 2018 Sep 10).
6.
Canadian Medical Association.
Resolutions Adopted,146th Annual Meeting of the Canadian Medical
Association (19-21 August 2013 - Calgary, AB)
(Accessed 2018 Sep 10).
7.
Carter v. Canada (Attorney General)
2013 BCCA 435 [Carter-BCCA]
(Accessed
2018 Sep 10).
8.
Carter-BCCA, para. 248.
9. Martin S.
The story behind the CMA's overwhelming change on assisted death. The Globe and Mail, 6 November, 2014
(Accessed 2018 Sep 10).
10. Geddes J.
Interview: The CMA's
president on assisted dying: Dr. Chris Simpson calls for a process to
set new rules. Macleans, 6 February, 2015
(Accessed 2018 Sep 10). Full transcript by Protection of Conscience Project
[Geddes Full Transcript],
lines 16-22.
11. Dr. Chris Simpson (CMA President): "I was not
surprised, we were not surprised. Perhaps the unanimous decision was a
little bit of a surprise. But, at the CMA, we've been, we've been preparing
for this eventuality for the last year and a half or two years."
Geddes Full Transcript, lines 4-7.
12. Dr. Blackmer: "I think we're
looking at the possibility that the court will refer this back to the
lawmakers . . . They could suggest some framework from the bench that we
might want to be in a position to comment on fairly quickly. . . We're
preparing for all eventualities. . ." Kirkey S.
Canadian doctors preparing
for 'all eventualities' in case top court strikes down ban on assisted
suicide. National Post, 21 December, 2014
(Accessed 2018 Sep 10).
13. In the Supreme Court of Canada (On Appeal from the
Court of Appeal of British Columbia)
Affidavit of Dr.
Chris Simpson, Motion for Leave to Intervene by the Canadian Medical
Association (5 June, 2014) [Simpson Affidavit] para. 56
(Accessed 2018 Sep 10).
14. "Should the justices rule the law on assisted death
and euthanasia is unconstitutional and needs amendment, 'we feel pretty
strongly that we want to be at the table' to help draft a new law and
guidelines for physicians and patients, CMA president Dr. Chris Simpson said
Thursday." Ubelacker S.
Doctors ready for Supreme Court
decision on assisted suicide. CTV News, 5 February, 2015
(Accessed 2018 Sep 10).
15. Dr. Chris Simpson (CMA President): "We'll be very
interested in having a lot of input into the operational details." Grant
K.
Canadian doctors drafting new rules in case doors open to assisted
suicide. Globe and Mail, 5 February, 2015
(Accessed 2018 Sep 10).
16. "President Dr. Chris Simpson said the CMA
believes it must play a key role in helping to draft the legislation that is
needed to make physician-assisted dying available." Branswell H.
Canadian MDs, many hesitant about assisted death, assessing Supreme Court
ruling. Times Colonist, 6 February, 2018 (Accessed 2018 Sep 10).
17. Dr. Chris Simpson (CMA President): "Now that the
decision has come down, we want to really take a leadership role in helping
to craft the legislation and the rules and regulation around it." Hume J.
Supreme Court strikes down ban on assisted suicide. Toronto Sun,
6 February, 2015
(Accessed 2018 Sep 10).
18. Dr. Chris Simpson (CMA President): "[W]e're going
to need to hit the ground running if we want to lead and do this well."
Kirkey S.
Helping suffering patients die may be doctor's most humane
option, Canadian Medical Association says. National Post, 4 February, 2015
(Accessed 2018 Sep 10).
19. Dr. Chris Simpson (CMA President): "[T]hat's
exactly what we'll be seeking: is some mechanism for, for us to have a
prominent role in the, in the crafting of the new rules and regulations and,
and legislation."
Geddes Full Transcript, lines 150-152.
20. "The CMA is well positioned to continue to play a
leadership role in the debate around end-of-life care in Canada," said
Simpson. Rich P.
CMA positioned to take lead role in crafting new
regulations. Canadian Medical Association, 6 February, 2018
(Accessed 2018 Sep 10).
21. Dr. Chris Simpson (CMA President): "This will be
really historic for Canada, and we really want to make sure we get it
right." Stone L.
'Historic' assisted suicide ruling could
make Parliament draft new laws. Global News, 6 February, 2015 (Accessed
22018 Sep 10).
22. Dr. Chris Simpson (CMA President): "It's a really
historic moment and I'm very mindful of, of the role that physicians have to
play and . . . I'm really, really proud of how the CMA has handled this over
the last two or three years."
Geddes Full Transcript, lines 160-162.
23. Canadian Medical Association.
CMA
Policy: Euthanasia and Assisted Suicide (Update 2014). (Accessed
2019 Feb 03).
24. Canadian Medical Association.
End-of-Life Care: A National Dialogue (June, 2014) [CMA Public
Consultation] p. 1
(Accessed 2018 Sep 10).
25.
CMA Public Consultation, p. 1,
17.
26.
CMA Public Consultation, p.
17.
27.
Canadian Medical Association.
End-of-Life Care: A National Dialogue. CMA Member Consultation Report
(July, 2014) [CMA Member Consultation] p.
9 (Accessed 2018 Sep 10).
28.
CMA Member Consultation, p. 2.
29.
CMA Member Consultation, p.
11.
30.
Henley J.
Irish abortion referendum: yes wins
with 66.4% – as it happened. The Guardian, 26 May, 2018
(Accessed 2018 Sep 10).
31. McDonald H, Graham-Harrison E, Baker S.
Ireland
votes by landslide to legalise abortion. The Guardian, 26 May, 2018
(Accessed 2018 Sep 10).
32. Booth W, Stanley-Becker I.
Ireland votes to overturn its abortion ban,
'culmination of a quiet revolution,' prime minister says. The
Washington Post, 26 May, 2018
(Accessed 2018 Sep 10).
33. Blackmer J, Francescutti LH. Canadian Medical
Association Perspectives on End-of-Life in Canada. HealthcarePapers 2014
April; 14(1):17-20 doi:10.12927/hcpap.2014.23966.
34. Anselmi E.
Yk doc key in assisted
suicide ruling: Dr. Ewan Affleck instrumental in penning resolution
considered by Supreme Court. Northern News Service, 13 February, 2015
(Accessed 2018 Sep 10).
35. Ca Canadian Medical Association.
147th
General Council Delegates' Motions: End-of-Life Care: Motion DM 5-6
(Accessed 2018 Sep 10).
36.; Canadian Medical Association.
General
Council Motions - 2014 Procedures and Guidelines: Motion Development, p.
2, point 6
(Accessed 2018 Sep 10).
37. Canadian Medical Association. Reports to the
General Council. CMA 147th Annual General Meeting, August 17-20, 2014.
Appendix 2 -Care at the End of Life (Backgrounder - Strategic Session 2)
A2-1 to A2-8
(Accessed 2018 Sep 10).
38. Vermont Statutes Title 18: Health,
Chapter 113:
An
act relating to patient choice and control at end of life (Accessed
2018 Sep 10).
39. Belgium: "At the request of
the patient or the person taken in confidence, the physician who refuses to
perform euthanasia must communicate the patient's medical record to the
physician designated by the patient or person taken in confidence."
The Belgian
Act on Euthanasia (2002) Chapter VI: Special Provisions, Section 14.
Protection of Conscience Project.
40. Luxembourg: "A physician who refuses to comply
with a request for euthanasia or assisted suicide is required, at the
request of the patient or support person, to communicate the patient's
medical record to the doctor appointed by him or by the support person."
Legislation Regulating Palliative Care, Euthanasia and Assisted Suicide,
Art. 15.
Protection of Conscience Project.
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