Obliged to Kill

The Assault on Medical Conscience

The Weekly Standard
Reproduced with permission

Wesley J. Smith*

A court in Ontario, Canada, has ruled that a patient’s desire to be euthanized trumps a doctor’s conscientious objection. Doctors there now face the cruel choice between complicity in what they consider a grievous wrong – killing a sick or disabled patient – and the very real prospect of legal or professional sanction.

A little background: In 2015, the Supreme Court of Canada conjured a right to lethal-injection euthanasia for anyone with a medically diagnosable condition that causes irremediable suffering – as defined by the patient. No matter if palliative interventions could significantly reduce painful symptoms, if the patient would rather die, it’s the patient’s right to be killed. Parliament then kowtowed to the court and legalized euthanasia across Canada. Since each province administers the country’s socialized single-payer health-care system within its bounds, each provincial parliament also passed laws to accommodate euthanasia’s legalization.

Not surprisingly, that raised the thorny question of what is often called “medical conscience,” most acutely for Christian doctors as well as those who take seriously the Hippocratic oath, which prohibits doctors from participating in a patient’s suicide. These conscientious objectors demanded the right not to kill patients or to be obliged to “refer” patients to a doctor who will. Most provinces accommodated dissenting doctors by creating lists of practitioners willing to participate in what is euphemistically termed MAID (medical assistance in dying).

But Ontario refused that accommodation. Instead, its euthanasia law requires physicians asked by a legally qualified patient either to do the deed personally or make an “effective referral” to a “non-objecting available and accessible physician, nurse practitioner, or agency .  .  . in a timely manner.”

A group of physicians sued to be exempted from the requirement, arguing rightly that the euthanize-or-refer requirement is a violation of their Charter-protected right (akin to a constitutional right) to “freedom of conscience and religion.”

Unfortunately, the reviewing court acknowledged that while forced referral does indeed “infringe the rights of religious freedom .  .  . guaranteed under the Charter,” this enumerated right must nonetheless take a back seat to the court-invented right of “equitable access to such medical services as are legally available in Ontario,” which the court deemed a “natural corollary of the right of each individual to life, liberty, and the security of the person.” Penumbras, meet emanations.

And if physicians don’t want to commit what they consider a cardinal sin, being complicit in a homicide? The court bluntly ruled: “It would appear that, for these [objecting] physicians, the principal, if not the only, means of addressing their concerns would be a change in the nature of their practice if they intend to continue practicing medicine in Ontario.” In other words, a Catholic oncologist with years of advanced training and experience should stop treating cancer patients and become a podiatrist. (An appeal is expected.)

This isn’t just about Canada. Powerful political and professional forces are pushing to impose the same policy here. The ACLU has repeatedly sued Catholic hospitals for refusing to violate the church’s moral teaching around issues such as abortion and sterilization. Prominent bioethicists have argued in the world’s most prestigious medical and bioethical professional journals that doctors have no right to refuse to provide lawful but morally contentious medical procedures unless they procure another doctor willing to do as requested. Indeed, the eminent doctor and ethicist Ezekiel Emanuel argued in a coauthored piece published by the New England Journal of Medicine that every physician is ethically required to participate in a patient’s legal medical request if the service is not controversial among the professional establishment—explicitly including abortion. If doctors don’t like it? Ezekiel was as blunt as the Canadian court:

Health care professionals who are unwilling to accept these limits have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession.

For now, federal law generally supports medical conscience by prohibiting medical employers from discriminating against professionals who refuse to participate in abortion and other controversial medical services. But the law requires administrative enforcement in disputes rather than permitting an individual cause of action in civil court. That has been a problem in recent years. The Obama administration, clearly hostile to the free exercise of religion in the context of health care, was not viewed by pro-life and orthodox Christian doctors as a reliable or enthusiastic upholder of medical conscience.

The Trump administration has been changing course to actively support medical conscience. The Department of Health and Human Services recently announced the formation of a new Conscience and Religious Freedom Division in the HHS Office for Civil Rights, which would shift emphasis toward rigorous defense of medical conscience rights.

Critics have objected belligerently. The New York Times editorialized that the new emphasis could lead to “grim consequences” for patients—including, ludicrously, the denial by religious doctors of “breast exams or pap smears.”

The American College of Obstetricians and Gynecologists joined the Physicians for Reproductive Health to decry the creation of the new office – which, remember, is merely dedicated to improving the enforcement of existing law – warning darkly that the proposal “could embolden some providers and institutions to discriminate against patients based on the patient’s health care decisions.”

The Massachusetts Medical Society joined the fearmongering chorus, opining that the new office could allow doctors to shirk their “responsibility to heal the sick.” Not to be outdone in the paranoia department, People for the American Way worried the new office might mean that “other staff like translators also refuse to serve patients, which could heighten disparities in health care for non-English-speaking patients.”

The Ontario court ruling is a harbinger of our public policy future. Judging by the apocalyptic reaction against the formation of the Conscience and Religious Freedom Division, powerful domestic social and political forces want to do here what the Ontario court ruling – if it sticks on appeal – could do in that province: drive pro-life, orthodox Christian, and other conscience-driven doctors, nurses, and medical professionals from their current positions in our health-care system.

Wesley J. Smith is a senior fellow at the Discovery Institute’s Center on Human Exceptionalism and a consultant to the Patients Rights Council.

Canadian court tells doctors they must refer for euthanasia

Will they be hounded out of their profession?


Michael Cook

For years bioethicists of a utilitarian cast have argued that conscientious objection has no place in medicine. Now Canadian courts are beginning to put their stamp of approval on the extinction of doctors’ right to refuse to kill their patients.

The Superior Court of Justice Division Court of Ontario ruled this week that if doctors are unwilling to perform legal actions, they should find another job.

A group of five doctors and three professional organizations were contesting a policy issued by Ontario’s medical regulator, the College of Physicians and Surgeons of Ontario (CPSO), arguing it infringed their right to freedom of religion and conscience under Canada’s Charter of Rights and Freedoms.

However, Justice Herman J. Wilton-Siegel wrote on behalf of a three-member panel:

“the applicants do not have a common law right or a property right to practise medicine, much less a constitutionally protected right.

“Those who enjoy the benefits of a licence to practise a regulated profession must expect to be subject to regulatory requirements that focus on the public interest, rather than the interests of the professionals themselves.”

At issue is the policy of “effective referral”. A doctor who objects to participating in euthanasia cannot be forced to do it. But he is expected to pass the patient to another doctor who will. The CPSO argues that effective referral is necessary “to protect the public, prevent harm to patients and facilitate access to care for patients in our multicultural, multifaith society, by guiding all physicians on how to uphold their professional and ethical obligations of non-abandonment and of patient-centred care within the context of Ontario’s public health-care system.”

Without the policy of effective referral, equitable access would be “compromised or sacrificed, in a variety of circumstances, more often than not involving vulnerable members of our society at the time of requesting services,” Justice Herman Wilton-Siegel wrote. People in remote communities might request euthanasia. If their doctor refused, they might suffer needlessly and taxpayers would have to foot the bill to subsidise the refusnik’s conscience.

It is remarkable how closely Justice Wilton-Siegel’s text hews to the arguments of bioethicists who have been chipping away at the right to conscientious objection for years.

In 2005 American legal scholar Alta Charo described conscientious objection as “an unfettered  right to personal autonomy while holding monopolistic control over a public good … an abuse of the public trust—all  the worse if it is not in fact a personal act of conscience but, rather, an attempt at cultural conquest’.

In 2006 Oxford’s Julian Savulescu argued in the BMJ that “when conscientious objection compromises the quality, efficiency, or equitable delivery of a service, it should not be tolerated”.

More recently, Canadian bioethicist Udo Schuklenk and a colleague contended in the BMJ that

“If at any given time a doctor is unable to continue practicing due to their—ultimately arbitrary—conscience views, nothing would stop them from leaving the profession and taking up a different vocation. This happens across industries and professions very frequently. Professionals can be expected to take responsibility for the voluntary choices they make.”

Responding to the ruling, Larry Worthen, executive director of the Christian Medical and Dental Society of Canada, said: “We heard from our members and other doctors with conscientious objections over and over again that they felt referral made them complicit and that they wouldn’t be able to live with themselves or stay in the profession if effective referral is still required.”

The case is sure to be appealed, but if the doctors championing conscientious objection fail, the consequences will be dire.

Throughout Canada, doctors would be required to refer for euthanasia. If they refuse, they will be hounded out of their profession, or, at best, shunted into specialties where the question will not arise, like pathology or dermatology.

This ruling shows how quickly tolerance vanishes after euthanasia has been legalised. In the Carter decision which legalised it, Canada’s Supreme Court explicitly stated that legalizing euthanasia did not entail a duty on the part of physicians to provide it. Now, however, 18 months and more than a thousand death after legalisation, conscientious objection is at risk.

It also shows how vulnerable religious-based arguments can be. The plaintiffs contended that referring patients violated their right to religious freedom. While this is true, is this the main ground for conscientious objection? As several doctors pointed out in the Canadian Medical Association Journal last year, “Insofar as all refusals of therapy are ultimately justified by the ethical belief that the goal of therapy is to provide benefit and avoid harm, all treatment refusals are matters of conscience.”

This article is published by Michael Cook and MercatorNet under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to MercatorNet. Commercial media must contact MercatorNet for permission and fees.

Ontario court rules doctors who oppose assisted death must refer patients

The Globe and Mail

Sean Fine

In the first Canadian test of conscience rights for doctors who oppose assisted death, an Ontario court has upheld regulations requiring the objectors to refer their patients to physicians willing to perform the procedure.

Groups representing 4,700 Christian doctors had challenged Ontario’s regulations requiring the referrals, saying that making such a referral was morally equivalent to participating in an assisted death.

But Ontario’s Divisional Court said the referral rule was a reasonable limit on doctors’ freedom of religion because it protects vulnerable patients from harm. And those patients, it said, have a constitutional right to equitable access to publicly funded health care.

Without the policy of “effective referral,” equitable access would be “compromised or sacrificed, in a variety of circumstances, more often than not involving vulnerable members of our society at the time of requesting services,” Justice Herman Wilton-Siegel wrote in the 3-0 ruling on Wednesday. . . [Full text]

The Alarming Trend Of Bullying Hospitals And Hospices Into Assisted Suicide

Huffington Post

Reproduced with permission

Dr. Will Johnston

Canadians who are sick and suicidal can now be put to death under various medicalized and government-approved protocols, following court and legislative victories by euthanasia activists. These activists are now turning their considerable talents to a coercive makeover of the palliative hospice movement by demanding that hospices founded on a promise to never deliberately hasten death should provide a death

Before they got their way in the Canadian Supreme Court, the public posture of euthanasia advocates was one of caution, reassurance and limitation of objectives. After their victory, partisans of the medical killing movement have become impatient with individuals or institutions who want no part in suicide and euthanasia. Activists recommend expanding access to include all the people who were strategically excluded from the plan that had been sold to the public: children, people with chronic nonfatal conditions, the physically disabled, the cognitively disabled, psychiatric patients.

Now, even changing the location of a patient requesting suicide — from a euthanasia-free hospital or hospice, to one that does offer it — is being protested as a cruel imposition. In doing so, the death-seeking person is set up as a victim, and the hospital or hospice is portrayed as a victimizer. Never mind that hospital wards routinely transport people in complete comfort to procedures like X-rays or scopes, or to another location to continue care.

The implications of this are dire. Many hospices serve patients who want nothing to do with assisted suicide, and there will be much harm done by forcing it into their midst. Every community in this country has the resources to provide a distinct euthanasia-free space. That distinct space and its staff could be specialized and uncoerced into death-hastening.

The unpleasant alternative was demonstrated by the recent “sneak attack” on Louis Brier Hospital, a Jewish retirement home in Vancouver. This was the work of euthanasia activist Ellen Wiebe, idolized by like-minded columnists for her aggressive death-providing practice. Rather than arrange a simple transfer — perhaps to the home of one of the suicidal father’s daughters — the patient was killed by Dr. Wiebe against the firm policy of a facility with an understandable aversion to euthanasia.

As Louis Brier’s director protested, “We have a lot of Holocaust survivors. To have a doctor sneak in and kill someone without telling anyone. They’re going to feel like they’re at risk when you learn someone was sneaking in and killing someone.”

What Dr. Wiebe was doing by giving the finger to Louis Brier is a form of ethical bullying, masquerading as an altruistic claim that her client should come first and trump other people’s rights about the kind of place they want to live in.

Wanting Dr. Wiebe to kill you is a tragedy, not an emergency. It is a personal preference, sadly now provided by the Canadian health-care system, but without any judicial or parliamentary authorization to force others to accept involuntary proximity to your actions. It is also, increasingly, about people who are not dying, except in Dr. Wiebe’s elastic interpretation, but about those who have lost meaning and hope. What they get from the euthanasia provider amounts to a heartless endorsement of the hopelessness of their situation, cloaked in the language of autonomy.

Rather than look for a win-win compromise over this issue, the board of Fraser Health Authority, a large B.C. hospital system, has imposed euthanasia provision in all its palliative hospices. This edict, totally uncalled for by provincial or federal guidelines, caused the high-profile resignation of Palliative Care Medical Director Dr. Neil Hilliard.

Meanwhile, our governments are, in Dr. Hilliard’s words, “guilty by neglect” of a “palliative care access gap,” and your sick family member who seeks care, not death, may not find it “equitable or timely.”

Forcing hospices to betray their no-kill founding principles will not close that gap, it will just torpedo the 40-year struggle to convince often-fearful patients that palliative hospices are not about hastening death.

Fraser Health and any other misled health bureaucracies across Canada should back down. Don’t bully hospices as though there are no fair alternatives. Don’t bully Catholic hospitals, founded on a reverence for life long before the public purse got involved.

Doctors, advocacy groups address proposed law protecting those who object to assisted dying

CBC News

Holly Caruk

Dr. Frank Ewert wants protection from having to help a patient die — but Dying with Dignity Canada doesn’t want that to happen at the cost of patients receiving full access to end-of-life options.

“When I started back a number of years ago and vowed to follow the Hippocratic oath, I meant it. It was very profound to me, it resonated with my core beliefs, that I would always respect life, that I would do nothing to harm a patient,” Ewert told a legislative committee on Monday evening. . . [Full text]


Is there any difference between euthanasia and palliated starvation?


Xavier Symons

While euthanasia and assisted suicide are currently illegal in most countries, the practice of voluntarily stopping eating and drinking (VSED) is seen by some as an ethically and legally permissible alternative. VSED refers to seriously-ill patients refusing to eat and drink for a sustained period of time with the intention of bringing about their own death.

Yet a new paper published in BMC Medicine argues that VSED is ethically indistinguishable from assisted suicide, and should be subject to the same legal regulations as more salient cases of assistance in dying.

The paper, lead-authored by Ralf J. Jox of the Institute for Ethics, History and Theory of Medicine at the University of Munich, argues that “supporting patients who embark on VSED amounts to assistance in suicide, at least in some instances, depending on the kind of support and its relation to the patient’s intention”.

While VSED does not involve an invasive or aggressive act like many other means of suicide, the authors write that “VSED should [nevertheless] be considered as a form of suicide, as there is both an intention to bring about death and an omission that directly causes this effect”. Doctors who assist patients in VSED — by encouraging them, or promising pain-relief if VSED is undertaken — are potentially instrumental in the deaths of the patients, as the suicide would not occur without them, and they share the patient’s intention of inducing death.

The authors of the paper conclude that the same legal prescriptions or regulations that apply to physician assisted suicide should also apply to VSED.

“[We] maintain… that future ethical discussions on assisted suicide require consideration of medically supported VSED, and vice versa…Thus, the widely held position by palliative care societies, professional bodies of physicians, legal scholars, and ethicists to disapprove of assisted suicide but approve of and even promote medically supported VSED appears inconsistent”.

This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.


Accessed 2017-08-11


Critics call bill aimed to protect health workers unwilling to offer assisted death ‘one-sided’

CBC: The Current

Interviewer/host: Piya Chattopadhyay


VOICE 1: Bill 34 is being introduced by the Manitoba government to protect conscience rights for health care professionals, so that health care providers would not be required to participate in assisted suicide.

VOICE 2: While I cannot participate in assisted suicide for a couple of reasons. The first is I made a vow as a medical student 40 years ago that I wouldn’t kill patients, okay? And I’m not willing to cross that line.

PC: It has been less than 18 months now since medically assisted dying became legal in Canada. And health care workers are still adapting to that paradigm change. We just heard part of a video produced by the Coalition for Health Care and Conscience. It’s a national umbrella organization of religious groups, and as you heard it is lobbying for Bill 34 a proposed piece of legislation in Manitoba that was drafted to help health care workers with conscientious objections to helping end patients’ lives. Here’s Manitoba’s health minister Kelvin Goertzen. . . [Full episode transcript]



Policy on medically assisted dying in works

Brantford Expositor

Michael-Allan Marion

A policy on handling requests for medically assisted dying is being prepared for the John Noble Home.

The home’s committee of management this week got a staff report on the drafting of a formal policy on managing medical assistance in dying, or MAID, requests, which is now required in long-term care homes by federal law.

The draft could be presented to the committee for review as early as next month and will be referred to the city’s legal department for comment.

Jennifer Miller, administrator for the home for the aged on Mount Pleasant Street, said that, so far, there have been no MAID requests from residents. . . [Full text]


Canadian doctors face questions over assisted suicide, euthanasia for minors

” . . .conscientious objection in Canada, unfortunately, hangs by a thread . . .”

The Catholic Register

Catholic News Agency

Ottawa – Only one year after assisted suicide and voluntary euthanasia became legal for adults in Canada, a new study is showing that some of the country’s pediatricians are being faced with questions about the practices for minors.

The study, which surveyed 1,050 doctors and was published by the Canadian Paediatric Society, found that more than ten percent of Canadian pediatricians have had conversations with parents or minors about the option of assisted suicide or euthanasia for terminal patients under the age of 18. . . [Full text]

Proposed legislation to protect health professionals who object to assisted dying called ‘one-sided’

Dying with Dignity Canada says Bill 34 doesn’t protect patients’ rights to access assisted dying

CBC news

Holly Caruk

A bill that would protect Manitoba health professionals’ rights to refuse assisted dying services and protect them from reprisals is being called redundant and one-sided.

Bill 34, which was introduced in May and hasn’t yet reached a second reading in the House, would ensure health professionals cannot be compelled to go against their own religious or ethical beliefs when it comes to providing medical assistance in dying (MAID) services.

It would also ban any professional regulatory body from requiring members to participate in medically assisted deaths, which were made legal by the Supreme Court in 2015. . . [Full text]