Physician freedom of conscience in Alberta
Project commentary
Sean Murphy*
Full Text
Abstract
From 1991 to 2008 the College of Physicians and Surgeons of Alberta (CPSA) policy on abortion provided the framework for accommodating patients seeking morally contested services and physicians unwilling to provide them for reasons of conscience. The policy required physicians to provide patients with information necessary to enable informed medical decision-making, but did not require them to provide contested services or to facilitate them by referral or other means.
The CPSA Registrar promised that this would not change when Standards of Practice were adopted in 2009. However, from the outset, he offered mixed messages about referral by objecting physicians. The Alberta Medical Association elected to accept his assurance that physicians would not be obliged to facilitate procedures to which they objected for reasons of conscience. However, by 2014 media were reporting that CPSA policy required objecting physicians to make such referrals, and the CPSA published an ethics commentary to the same effect.
In 2015, without the approval of College Council, a CPSA official expressed strong support for a policy of mandatory effective referral in a formal submission to another state regulator. At least one CPSA staffer was reportedly telling Alberta physicians that CPSA policy required effective referral, and the College Registrar openly advocated effective referral for euthanasia and assisted suicide. These developments directly contradicted the assurance he have given the medical profession in 2009.
The overwhelming majority of respondents to the 2016 consultation about conscientious objection opposed requiring effective referral by objecting physicians, and the standard does not require it. However, the document is essentially the same as the 2009 version, and has been cited on various occasions as requiring physicians to refer patients for services to which they object — without contradiction by the College. Accommodation of objecting physicians is further complicated by differences between two practice standards, Conscientious Objection and Medical Assistance in Dying.
While there appear to have been no complaints about non-compliance, and the Alberta model has been praised by freedom of conscience advocates, this is probably in spite of existing policies and tendentious interpretation of those policies by CPSA officials.
If accommodation of physician freedom of conscience in Alberta is currently satisfactory, it is probably because tolerance is encouraged by individuals in key positions within government and the health professions, and because the relatively few physicians who refuse to refer patients for morally contested services treat patients respectfully, discuss their concerns and options and provide them with contact information for Alberta Health Link.
TABLE OF CONTENTS
Abstract
CMA Code of Ethics and Professionalism
College of Physicians and Surgeons of Alberta (CPSA) Policies
Effect of the policies
Summary
CMA Code of Ethics and Professionalism
The Code of Ethics and Professionalism of the Canadian Medical Association (CMA) has been formally adopted by the CPSA and provides a useful introduction to discussion of CPSA policies.1 The Code includes the following provisions concerning physicians' exercise of freedom of conscience:
3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your duty of non-abandonment to the patient by always acknowledging and responding to the patient's medical concerns and requests whatever your moral commitments may be.
4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or practice of any medical procedure or intervention as it pertains to the patient's needs or requests.2
The CMA's understanding of the duty of non-abandonment and obligation to respond to patients' concerns and requests is articulated in the Association's policy on EAS, Medical Assistance in Dying:
a. The CMA believes that physicians are not obligated to fulfill a patient's request for assistance in dying but that all physicians are obligated to respond to a patient's request. This means that physicians who choose not to provide or otherwise participate in assistance in dying are:
i. not required to provide it, or to otherwise participate in it, or to refer the patient to a physician or a medical administrator who will provide assistance in dying to the patient [emphasis added]; but
ii. are still required to fulfill their duty of non-abandonment by responding to a patient's request for assistance in dying.
There should be no discrimination against a physician who chooses not to provide or otherwise participate in assistance in dying.
b. The CMA believes that physicians are obligated to respond to a patient's request for assistance in dying in a timely fashion. This means that physicians are obligated to, regardless of their beliefs:
i. provide the patient with complete information on all options available, including assistance in dying;
ii. advise the patient on how to access any separate central information, counselling and referral service; and
iii. transfer care of the patient to another physician or another institution, if the patient requests it, for the assessment and treatment of the patient's medical condition and exploration of relevant options. . . 3
The CMA's Medical Assistance in Dying explicitly acknowledges that moral/ethical issues are not confined solely to the act of lethal injection or assistance in suicide: providing, otherwise participating and referring a patient to an EAS provider are all recognized as morally/ethically charged acts.
Further, in explaining how physicians should respond to a patient, the policy makes an important distinction between providing information necessary to enable informed medical decision-making (required) and providing or facilitating a morally contested service (not required). Objecting physicians are normally willing to inform patients of their views, discuss options and provide information, and, upon request, to transfer care and medical records to a physician chosen by the patient. These expectations are not problematic for most objecting physicians.
On the other hand, many objectors determined to avoid complicity in killing patients insist that the "separate information, counselling and referral service" NOT be a service dedicated to providing EAS, or, at least, that they are not required to provide contact information for an EAS service.
The approach taken by the CMA in the Code of Ethics and Professionalism combined with Medical Assistance in Dying provides the basic elements of an adequate protection of conscience policy that could be applied to any morally contested service.
College of Physicians and Surgeons of Alberta (CPSA) Policies
Background
Canada: 1969 – 1999
Attempts to compel health care workers and institutions to provide or facilitate morally contested procedures began in Canada soon after the reform of the abortion law in 1969 and increased after 1988, when the Supreme Court struck down all legal restrictions on the procedure. It has been generally agreed that objecting physicians should not be forced to personally perform abortions, but in the 1990's they faced increasing pressure to connect patients directly with abortion providers by referral or other means. Some physicians opposed to abortion were willing to do so, but others refused because they believed that referral made them morally complicit in the procedure. This is a reasonable position acknowledged even by academics who would compel them to refer. By the late 1990's the issue of referral had become the characteristic flashpoint of all disputes about forcing unwilling health care workers to participate in abortion and other morally contested procedures.
Alberta: 1999 – 2008
In 1999 a CPSA councillor asserted that objecting physicians "should refer the patient appropriately and provide all the necessary information and opportunities available" (emphasis added). College policy at the time required only that physicians provide pregnant women with "information or assistance to enable them to make informed decisions on all available options . . . including terminations."4
The implication that providing both referral and information was required was promptly rejected by Canadian Physicians for Life (CPFL). "In plain English," the Secretary Treasurer said, "independent medical professionals have no duty to refer anyone to anyone when the referral would violate the conscience and the good medical judgement of the professional."5
In this regard, the CPSA explained its policy to the Protection of Conscience Project as one of ensuring informed consent, indicating that formal or informal referral pertained to directing patients to physicians "more able to provide full information."6
Two years later, rejecting a claim by Planned Parenthood Alberta, CPFL stated, "Our correspondence with Alberta College of Physicians and Surgeons registrar, Dr. Ohlhauser, states clearly that physicians do not have a professional obligation to refer a patient for an abortion."7
In short, Alberta physicians were obliged to provide information necessary to enable informed medical decision making, were expected to refer or direct patients to other physicians to provide such information if need be, but were not required to refer patients to someone who would provide an abortion. This was the status of the issue when the CPSA began to develop standards of practice in 2008.
Alberta, 2009: mixed message from the CPSA Registrar
As the College neared completion of the standards the following year, Registrar Dr. Trevor Theman observed that the provisions concerning abortion had attracted considerable attention.
Most respondents take exception with the draft, believing that the College will require physicians to refer patients for termination of pregnancy, or at the very least to be compliant in arranging a patient's abortion, contrary to the physician's personal beliefs. This is not true. . .
A Standard of Practice on this subject will not change the obligations of physicians that have been accepted by this College since 1991. The words are a little different, but the intent is not, as the principles underlying the standard have not changed over the past 20 years (emphasis in original).8
Had Dr. Theman stopped there he would have laid to rest the concerns expressed by most of the respondents to the draft standards. However, in further discussion of the importance of providing information to patients, he stated that when physicians' "personal values would influence the recommendation or practice of any medical procedure" (as in the case of abortion) they were obliged "to refer the patient to another physician or resource that will provide the patient with all available medical options so that the patient can make an informed choice "(emphasis added). He also included his personal view of the subject:
[T]he issue here is not the physician's individual moral beliefs or conscience. As a physician, and a medical professional, you must first consider the well-being of your patients (Code of Ethics #1). You must also, as professionals, resolve conflicts of interest in the best interest of patients (Code of Ethics #11).9
The dismissal of physicians' moral beliefs and conscience as irrelevant to medical practice was a considered position. Eight years earlier he had insisted that, "In determining the right thing to do, the patient's values take primacy over [physicians'] personal values and morals," and "to act professionally, [physicians] must keep the patient's interests (which include the patient's values and morals) as paramount to our own"(emphasis added).10
Dr. Theman's setting aside of conscience and reference to someone who would provide "all available options" rather than information about options overshadowed his earlier promise that no physician would be obliged to refer for or arrange for an abortion. The article generated more concern and confusion, as a result of which the Project Administrator wrote to him seeking clarification.
In subsequent correspondence, clarification was not forthcoming. In discussing the new standard, Moral or Religious Beliefs Affecting Medical Care, Dr. Theman agreed that physicians were obliged to provide information necessary to enable informed medical decision making.11 However, he did not reiterate his promise that objecting physicians would not be required to refer or arrange for an abortion. Further, when explicitly asked to confirm that objectors would not be required to help patients "obtain an abortion (or assisted suicide, euthanasia, etc) by helping a patient to find someone willing to provide these procedures"12 he declined to answer.13
The Administrator copied the correspondence to the Alberta Medical Association (AMA) and others likely to have an interest in the issue. "[I]t is the position of the Project", he wrote, " that a regulatory authority that is either unable or unwilling to explain its own Standards of Practice is not in a legal or ethical position to compel physicians to refer for abortion or other controversial procedures."14 The AMA recognized the problem, describing the standard as "somewhat obtuse and [failing] to clearly define the intent of this section. The Association had previously expressed its concern in a letter and in a presentation to the College Council:
. . . in dealing with medical matters of conscience, a physician whose moral or religious beliefs prevent him/her from offering or participating in a medical or surgical service must however, inform the patient of the availability of the service and possible alternatives for seeking this option. Such a physician should not be coerced into active participation in the delivery of such a service.
. . .In our view, the statement by the Registrar in the Messenger of April 2009 which states that the Standard of Practice on this matter does not change the obligations of physicians as expressed in previous College policy, does make clear that, while there is an obligation to inform patients of alternatives, there is no obligation to participate in the process. While we would be happier if the Standard was clear on this issue, we accept the explanation of the Registrar that the Standard does embody the views the AMA has expressed to the College on this issue.15
Alberta, 2014 – 2015: CPSA officials contradict longstanding policy
In 2014, a Calgary physician was criticized publicly for having posted a notice that she did not prescribe oral contraceptives. In reporting on the case, CTV News stated:
According to the College of Physicians and Surgeons of Alberta, doctors must communicate clearly and promptly if there is a service that he or she will not provide. And when moral or religious beliefs prevent access to care, the doctor must refer that patient to another physician or resource where they can receive the requested service.16
Dr. Theman did not deny the CTV News explanation of College policy. Citing Moral or Religious Beliefs Affecting Medical Care, he noted that the physician had altered her sign "giving prospective patients specific information as to where (and from whom) they receive information about birth control, including, if appropriate, a prescription for oral contraceptive pills"(emphasis added).17 It seems that he was satisfied that the physician had complied with the policy. However, it is not clear that he would have been satisfied had the physician declined to provide specific contact information for contraceptive providers.
Two months later, Assistant Registrar Dr. Own Heisler reflected on Dr. Theman's discussion of the case. Dr. Heisler stated that the standard Moral or Religious Beliefs Affecting Medical Care required objecting physicians to direct patients "to another physician who is able to provide timely values-appropriate care."18 This was consistent with the CTV News explanation of CPSA policy, consistent with Dr. Theman having declined to confirm that the standard would not be used in this fashion, but contradicted Dr. Theman's 2009 assurance that physicians would not be required to refer for abortion.
A more significant development occurred the following year. The College of Physicians and Surgeons of Ontario (CPSO) was finalizing its policy, Professional Obligations and Human Rights, the most contentious element of which was a requirement that objecting physicians provide an "effective referral" for services they decline to provide. This was defined as "a referral made in good faith, to a non-objecting, available, and accessible physician, or other health-care provider, or agency."19
An official acting on behalf of the CPSA filed a submission with the CPSO in February, 2015, stating that the College "strongly supported" the policy.20 This flatly contradicted the Registrar's 2009 promise that the longstanding CPSA policy on referral would not be changed.
Council President stonewalls
The signature of the responsible CPSA official had been removed from the copy of the submission posted by the CPSO. The Project Administrator wrote to the President of the CPSA College Council:
I would like to know whether the CPSA letter dated 19 February, 2015, expressing strong support for Professional Obligations and Human Rights reflects the position of the College of Physicians and Surgeons of Alberta as approved by College Council, or if it reflects the opinion of a College official that was not approved by College Council prior to its submission.21
The College Council President stonewalled repeated requests by the Project for an answer to this enquiry.22
Alerted by the Project to this development, the President of the Alberta Medical Association replied that the AMA was not aware that Moral or Religious Beliefs Affecting Medical Care was scheduled for review or revision, nor aware that College policy on referral by objecting physicians had changed. He agreed that such a change "would be a dramatic change in position."23
Alberta, 2015: CPSA officials advocate mandatory effective referral
Meanwhile, the Project Administrator received information from reliable sources that at least one College staffer was telling Alberta physicians that the College already had an effective referral policy set out in Moral or Religious Beliefs Affecting Medical Care. Further, information indicated that the submission to the CPSO had not been approved by College Council. Those responsible were said to believe that Moral or Religious Beliefs Affecting Medical Care was essentially the same as the CPSO policy, so Council approval was not required.
In August, 2015, speaking at the CMA Annual General Council, Dr. Theman insisted that physicians unwilling to kill their patients were ethically obliged to refer them to someone who would. "Patient rights trump our rights," he said, affirming the views he had expressed in 2001. "Patient needs trump our needs."24
Three months later the expert provincial-territorial panel of which Dr. Theman was a member unanimously recommended that objecting physicians be forced to actively enable homicide or suicide by providing referrals, arranging direct transfers or enlisting or arranging the enlistment of patients in an EAS delivery system.25
Conscientious Objection (2016)
Moral or Religious Beliefs Affecting Medical Care was reviewed in 2015/2016. Only 31 of 645 respondents to the consultation supported a mandatory effective referral requirement. The rest — including four of six stakeholders — were opposed to the measure.26 The text of Conscientious Objection as approved is virtually identical to the earlier version of the standard.27
It is possible to adopt the AMA position (citing the Registrar's definitive promise in 2009)28 that Conscientious Objection continues traditional CPSA policy, so that physicians must "inform patients of alternatives" but are not obliged "to participate in the process" by referral or other means. This would be consistent with the CMA Code of Ethics and Professionalism (as further informed by its policy Medical Assistance in Dying: see above).
However, recall that College officials apparently attempted to overturn longstanding CPSA policy and impose a policy of effective referral under cover of what is essentially the text of Conscientious Objection. This raises concerns about the CPSA's initial response to a 2019 bill to protect freedom of conscience for Alberta health care workers. The College said the bill was
unnecessary.
According to a statement from spokesperson Andrea Garland, "the college has not experienced push back from Alberta physicians around the Standard of Practice," which requires physicians to refer patients to another doctor who can give them the services they need (emphasis added).29
It is not clear if the italicized passage is an accurate or inaccurate paraphrase of an explanation offered by Garland or the product of the reporter's personal review of the policy. At the least, this indicates continuing difficulties with the interpretation of the document.
Medical Assistance in Dying (2016)
It would have been possible to apply Conscientious Objection to euthanasia and assisted suicide, and that appears to have been the CPSA's intention. The College Council originally approved Medical Assistance in Dying on 27 May, 2016, before the federal government passed Bill C-14 to formally legalize euthanasia and assisted suicide. The standard as first approved was clearly directed only to physicians willing to participate in the procedures.30
However, on 10 June, the day Bill C-14 passed the House of Commons, the government of Alberta directly intervened by issuing an Order in Council under the Health Professions Act to amend Medical Assistance in Dying.31 The Order was apparently intended to replicate the Criminal Code provisions, with five added paragraphs (3 to 7) setting out requirements specific to Alberta. However, the Order omitted the Code's requirement for a 10 day reflection period (s. 241.2(3)g). College Council had no power to amend a defective Order in Council, but could not publish a standard of practice inconsistent with the criminal law.
The conundrum was resolved by publishing the present standard (backdated to 1 June, without reference to a subsequent revision), omitting all but the five Alberta-specific paragraphs of the Order. However, it retains the original opening paragraph directing that written requests for euthanasia or assisted suicide must be received, considered and fulfilled "in accordance with legislation." This ensured the standard conformed with the law without drawing attention to the government's defective amendment.
Medical Assistance in Dying is a chimerical document, largely an Order in Council published by the College as a medical standard of practice.32 Its direction to objecting physicians is convoluted, and it differs from that provided by Conscientious Objection. It requires different responses from physicians to a patient "inquiry" about euthanasia or assisted suicide and a patient's oral or written "request" for the services.
In response to an "inquiry" the physician must provide the inquirer with "contact information for the Alberta Health Services Medical Assistance in Dying Care Coordination Service" (AMCCS) "without delay" (para. 3). The inquirer is responsible for making contact with AMCCS.
Faced with a "request," physicians must ensure the patient has "reasonable access" to AMCCS "without delay" (para. 4).
What counts as “reasonable access”?
It might include providing contact information, or providing other information sufficient to allow the patient to contact AMCCS, so that the patient — not the physician — is responsible for making contact. However, the vague formulation enables College officials to pressure physicians into directly connecting patients to AMCCS or making the connection on their behalf. On the other hand, it enables objecting physicians to adopt a different interpretation and refuse.
Why would objecting physicians refuse?
They might refuse because the AMCCS (sometimes also identified simply as the Care Coordination Service33) is primarily an EAS delivery service, notwithstanding its obligation to provide information about and facilitate access to "all end of life care options."34,35 Its web pages are almost exclusively devoted to euthanasia and assisted suicide and related issues.
Some objecting physicians are unwilling to help market EAS services, and so refuse to provide contact information for AMCCS in response to an "inquiry." They would also be unwilling to make an effective referral to AMCCS or actively help a patient to connect with the service because they do not want to be complicit in killing them.
Quite apart from these problems, the distinctions between an "inquiry" and "request," the different responses required of physicians and the subtle difference between providing contact information and providing reasonable access would invite confusion even if the subject matter were uncontroversial.
Effect of the policies
Alberta has been identified by freedom of conscience advocates as providing a satisfactory model of accommodation that should be imitated across the country.36 In late 2019 the head of the Alberta Medical Association and sponsor of a protection of conscience bill in the Alberta legislature agreed that existing protections were "appropriate and effective."37 On the other hand, it has been reported that Alberta physicians are obliged to refer for morally contested services,38 including assisted suicide,39 which would be unacceptable to many objecting practitioners.
This review of CPSA policies indicates that the dissonant evaluations arise from differences between actual practice and CPSA policies, mixed and arguably tendentious messages from College officials and differences between the practice standards Conscientious Objection and Medical Assistance in Dying.
How does one account for the fact that there appear to have been no complaints about non-compliance or refusals to refer, and for the high praise bestowed on the Alberta "model" by freedom of conscience advocates?
Three factors are likely relevant.
First, the number of physicians who refuse to refer patients for morally contested services or provide AMCCS contact information is probably small.
Second, physicians who decline to refer for services or provide AMCCS contact information probably respond to patients respectfully and adhere to the CMA Code of Ethics. They probably discuss patient concerns and options and provide them with contact information for Alberta Health Link,40 a general health enquiry service that can connect patients to practitioners providing all services, including morally contested services and the AMCCS.
Third, objecting physicians may be protected to the extent that tolerance is encouraged by individuals in key positions in government and the health professions, notwithstanding policy shortcomings or confusion. In short, if accommodation of physician freedom of conscience in Alberta is satisfactory, it is probably in spite of existing policies and tendentious interpretation of those policies by CPSA officials.
Summary
From 1991 to 2008 the College of Physicians and Surgeons of Alberta (CPSA) policy on abortion provided the framework for accommodating patients seeking morally contested services and physicians unwilling to provide them for reasons of conscience. The policy required physicians to provide patients with information necessary to enable informed medical decision-making, but did not require them to provide contested services or to facilitate them by referral or other means.
The CPSA Registrar promised that this would not change when Standards of Practice were adopted in 2009. However, from the outset, he offered mixed messages about referral by objecting physicians. The Alberta Medical Association elected to accept his assurance that physicians would not be obliged to facilitate procedures to which they objected for reasons of conscience. However, by 2014 media were reporting that CPSA policy required objecting physicians to make such referrals, and the CPSA published an ethics commentary to the same effect.
In 2015, without the approval of College Council, a CPSA official expressed strong support for a policy of mandatory effective referral in a formal submission to another state regulator. At least one CPSA staffer was reportedly telling Alberta physicians that CPSA policy required effective referral, and the College Registrar openly advocated effective referral for euthanasia and assisted suicide. These developments directly contradicted the assurance he have given the medical profession in 2009.
The overwhelming majority of respondents to the 2016 consultation about conscientious objection opposed requiring effective referral by objecting physicians, and the standard does not require it. However, the document is essentially the same as the 2009 version, and has been cited on various occasions as requiring physicians to refer patients for services to which they object — without contradiction by the College. Accommodation of objecting physicians is further complicated by differences between two practice standards, Conscientious Objection and Medical Assistance in Dying.
While there appear to have been no complaints about non-compliance, and the Alberta model has been praised by freedom of conscience advocates, this is probably in spite of existing policies and tendentious interpretation of those policies by CPSA officials.
If accommodation of physician freedom of conscience in Alberta is currently satisfactory, it is probably because tolerance is encouraged by individuals in key positions within government and the health professions, and because the relatively few physicians who refuse to refer patients for morally contested services treat patients respectfully, discuss their concerns and options and provide them with contact information for Alberta Health Link.
Notes:
1. The College of Physicians and Surgeons of Alberta, Standards of Practice (2019), Edmonton: 2019 [Standards] at 21.
2. The Canadian Medical Association, CMA Code of Ethics and Professionalism, Ottawa: 2018.
3. The Canadian Medical Association, Medical Assistance in Dying, Ottawa: 2017.
4. E. Kretzul, "Ethical Responsibilities in Dealing with Women Requesting Abortion Services" (1999) 73 The Messenger 6.
5. Canadian Physicians for Life, News Release, "Alberta College of Physicians and Surgeons challenged to think about conscience rights" (11 October 1999) online: Protection of Conscience Project.
6. Letter from D.E. Chadsey, Acting Registrar, to Sean Murphy, Administrator, Protection of Conscience Project (11 October 2001).
7. Canadian Physicians for Life, News Release, "Canadian Physicians for Life corrects Planned Parenthood Alberta" (5 June, 2001) online: Protection of Conscience Project.
8. Dr. Trevor Theman, "Registrar's Report: Draft standard for termination of pregnancy" (2009) 150 The Messenger at 3 [Theman 2009].
9. Ibid.
10. Trevor W. Theman, "Freedom of Conscience and the Needs of the Patient" (Presentation delivered at the Obstetrics and Gynecology Conference "New Developments- New Boundaries" Banff Alberta, (11 November 2001) [unpublished, archived at Protection of Conscience Project].
11. Letter from Trevor Theman to Sean Murphy, Administrator, Protection of Conscience Project (24 August 2009).
12. Letter from Sean Murphy to Trevor Theman (3 September, 2009).
13. Letter from Trevor Theman to Sean Murphy (9 September, 2009).
14. Letter from Sean Murphy to Dr. Christopher Doig, President, Alberta Medical Association (10 November, 2009).
15. Letter from Christopher J (Chip) Doig, President, Alberta Medical Association, to Sean Murphy, 4 December, 2009 [Doig 2009].
16. Marlene Leung, "Calgary doctor refuses to prescribe birth control due to personal belief", CTV News (28 June 2014).
17. Trevor Theman, "Trevors Take: A Patient's Right to Good Medical Care: Moral or Religious Beliefs Affecting Medical Care" (3 July, 2014), CPSA The Messenger (website).
18. Owen Heisler, "Respectful Diversity" (6 August, 2014), CPSA The Messenger (website).
19. College of Physicians and Surgeons of Ontario, "Meeting of Council, March 6, 2015" (6 March, 2015) Appendix 3 at 82, lines 156-161.
20. Letter from College of Physicians and Surgeons of Alberta to College of Physicians and Surgeons of Ontario (19 February, 2015)
21. Letter from Sean Murphy to Dr. James Stone, President, College of Physicians and Surgeons of Alberta (21 February 2015).
22. Letters from Sean Murphy to Dr. James Stone, President, College of Physicians and Surgeons of Alberta (13 March 2015 and 13 April 2015).
23. Letter from Richard G.R. Johnson, President, Alberta Medical Association to Sean Murphy (6 March 2015).
24. André Picard, "Less than a third of doctors willing to aid in assisted dying: CMA poll", The Globe and Mail (25 August 2015).
25. Sean Murphy, "‘A uniquely Canadian approach' to freedom of conscience: Experts recommend coercion to ensure delivery of euthanasia and assisted suicide" (15 June 2018), Protection of Conscience Project (website).
26. College of Physicians and Surgeons of Alberta, (26 & 27 May 2016), CPSA (website) [CPSA 2016] at 162.
27. Standards, supra note 1 at 32.
28. Doig 2009, supra note 15.
29. Nadine Yousif, "Conscience rights bill will infringe on patients' access to services, legal experts say", Star Edmonton (8 November 2019) [Yousif 2019].
30. CPSA 2016, supra note 26 at 173.
31. Order respecting Medical Assistance in Dying Standards of Practice, OIC 142/216, (10 June, 2016).
32. Standards, supra note 1 at 50.
33. Alberta Health Services, "Medical Assistance in Dying: Patients and Families" (2020) Alberta Health Services (website).
34. Directive D3-2016 from Sarah Hoffman, Minister of Health to Alberta Health Services (7 June, 2016).
35. Alberta Health Services, "Medical Assistance in Dying Care Coordination Service" (14 July, 2016), Alberta Health Services (website).
36. Ontario, Legislative Assembly, Standing Committee on Finance and Economic Affairs, "Medical Assistance in Dying Statute Law Amendment Act, 2017" in Official Report Journal of Debates des débats (Hansard), No. F-16 (23 March 2017) at F-497 (Worthen), F-513 (Halpern), F-515 (Cserti-Gazdewich), F-519 (Scott).
37. Anna Junker, "Conscience rights bill 'unnecessary,' says head of Alberta Medical Association", Edmonton Journal (13 November 2019).
38. Yousif 2019, supra note 29.
39. John Carpay, "Alberta's conscience rights bill", Western Standard (12 November 2019).
40. Alberta Health Services, "811 Health Link: Health Advice 24/7" (2020), Alberta Health Services (website).