Extracts of Briefs, Edited Video Transcripts

McPhee, Margaret [Full text]

. . . Physicians who object to carrying out PAD should be obliged to refer the patient to someone who is willing to carry it out, or at least provide the patient with the name of such a physician, if the patient is capable of referring him/herself. . .

Morison, Rhonda [Full text]

5.  I understand not all physicians may want this responsibility so agree that they should have the right ofconscientious objection. They then however, must provide timely information and effective referrals (or transfers of care) to an institution, independent agency or other provider.

6.  It is imperative that publicly funded healthcare institutions, including hospitals, hospices and long-termcare facilities are allowed and even required to provide physician-assisted dying on their premises. All publicly funded healthcare institutions must allow PAD on their premises, no matter their belief systems. If no doctors on staff are willing to provide, an external doctor must be permitted into the hospital to provide the service. This policy is especially relevant for small communities where healthcare options may be limited.

Munroe, Pamela [Full text]

. . . It is also acceptable that a doctor or practitioner who does not wish to provide PAD must refer the patient to someone who will.

All publicly funded healthcare institutions must allow PAD on their premises. If no doctors on staff are willing to provide it, an external doctor must be permitted into the facility to provide the service. This is especially important in small communities where facilities may be limited or restricted by religious affiliations. . .

Peterson, Heather [Full text]

. . . Some physicians may be opposed to assisted dying which is their right. But they must not be allowed to stop the patient from gaining access to their own right to die. Please ensure that dissenting doctors be required to refer the patient to doctors who are accepting of the law. . .

Physicians' Alliance Against Euthanasia [Full text]

4. No doctor or other health professional should ever be required to participate in "physician-assisted dying", even by referring a patient to another professional or an administrative body who will facilitate it. There should be no discrimination against health professionals or trainees in the health professions who are unwilling to collaborate in this act. No jurisdiction in the world requires such collaboration.

5. Similarly, all health care institutions should be free to prohibit the practice of euthanasia within their walls, in order to create a safe space for patients who are afraid of being euthanized without having requested it.

Protection of Conscience Project [Full text]

IV.    Coerced complicity in homicide and suicide

IV.1     The position of the Provincial-Territorial Expert Advisory Group and some influential or powerful individuals or groups is that a learned or privileged class, a profession or state institutions can legitimately compel people to be parties to homicide or suicide - and punish them if they refuse.

IV.2     Nothing of the kind is stated or implied in Carter. This is not a reasonable limitation of fundamental freedoms, but a reprehensible attack on them and a serious violation of human dignity.  From an ethical perspective, it is incoherent, because it posits the existence of a moral or ethical duty to do what one believes to be wrong.  From a legal and civil liberties perspective, it is profoundly dangerous. If the state can demand that citizens must be parties to killing other people, and threaten to punish them or discriminate against them if they refuse, what can it not demand?  Yet the Group appears to experience resistance to coerced participation in homicide and suicide as a "uniquely Canadian" mountain to be climbed.

IV.3     Other countries have demonstrated that it is possible to provide euthanasia and physician assisted suicide without suppressing fundamental freedoms.  None of them require "effective referral," physician-initiated "direct transfer" or otherwise conscript objecting physicians into euthanasia/assisted suicide service (Appendix "A"). It appears that they recognize a point made by Dr. Monica Branigan when she appeared before the Committee: that one "cannot build a sustainable system on moral distress."

V.    Federal and provincial jurisdiction

V.1     Provincial governments have primary jurisdiction over human rights law, subject to the Canadian Charter of Rights and Freedoms. By virtue of the subject matter in this particular case (homicide and suicide), the federal government has jurisdiction in criminal law.

V.2     Criminal law is not used to enforce or defend fundamental rights and freedoms per se. For that, Canada relies upon human rights statutes. But Canada does use the criminal law to prevent and to punish particularly egregious violations of fundamental freedoms that also present a serious threat to society: unlawful electronic surveillance, unlawful confinement and torture, for example.

V.3     Coercion, intimidation or other forms of pressure intended to force citizens to become parties to homicide or suicide is both an egregious violation of fundamental freedoms and a serious threat to society that justifies the use of criminal law.

V.4     For this reason, whatever might be decided about laws regulating euthanasia and assisted suicide, the Project proposes that the federal government make it a matter of law and national public policy that no one can be compelled to become a party to homicide or suicide, or punished or disadvantaged for refusing to do so, even if the homicide or suicide is not a criminal offence. Appendix "B" offers an amendment to the Criminal Code designed to achieve that end.

Provincial Territorial Expert Advisory Group [Edited video]

Hon. James S. Cowan:  The business of conscientious objection. Nobody is trying to force anybody to participate in this process. But, the corollary of that, that protects the practitioner, whether its a physician or another medical professional. But looking at it from the point of view of the patient, how do we ensure that there is what I would call an effective referral. Something more than simply saying, “I'm not, I can't be involved in this. You're on your own. Go and look it up on the Internet. Go call the medical society, and they may be able to help you”. Don't you agree that we need to have, design a regime that ensures there is a more effective referral than that?

Dr. Jennifer Gibson: Yes

Hon. James S. Cowan: What would that look like?

Dr. Jennifer Gibson:  This became clear to us through the consultation. We heard from many physicians who initially felt like this was weighing down a burden and it was falling only on physicians' shoulders.

But, on the issue of access, very clearly, there are multiple actors that need to be operating together in order to be able to make this, to ensure access. What we've recommended, is that, in here, we've defined roles for different levels and institutions, institutional roles, including regional health authorities, to facilitate access.

Quite apart from the issue of conscientious objection, access - period -  is going be a challenge for many in Canada. And so, there is going to need to be system coordination, and that will be at the provincial and at the regional level within provinces indeed.

Hon. James S. Cowan: That's the role of the regulatory authorities, the colleges of physicians . . .

Dr. Jennifer Gibson:  The regulatory authorities, indeed. And I think this is where the Supreme Court of Canada invited us to balance rights.

And so, we do acknowledge in clinical practice - and not just physicians but other health professionals as well - that they have a right of conscience. And, in fact, one of our members, Sister Nuala Kenny, Dr. Sister Nuala Kenny, who was a member of our expert advisory group, reminded us that conscience also applies to those who are proponents and are willing to practise physician-assisted death. Their conscience tells them that this is the right thing to do.

And unless we want, we need to be able to ensure that we have a regime that calls on physicians and clinicians to stay closely anchored to what they're called to do in terms of public service. So, this is, you know, Colleges do have a key role in making very clear what the expectations are of their members in terms of facilitating access.

 It's been very clear in our recommendations, and also we're hearing this from some of the, especially from the physicians in palliative care, that an effective transfer of care would be important, but that all physicians, all clinicians ought to be able to provide all information about all options. That doesn't mean that the physician needs to participate in the act of physician-assisted death, but they must be able to provide information on the options and, if necessary, on the basis of conscience, facilitate an effective transfer. And to do that well, they're going to need others in the system facilitating it.

Hon. James S. Cowan: Exactly. Can I just make sure that your comments would also apply to institutions?

Dr. Jennifer Gibson: Yes. . .

Mr. John Aldag:  . . . In your report, you talk about physicians refraining from - this is in recommendation 36 - and I'm just really curious, in your discussions about how big of an issue it was on physicians refraining from participating in physician assisted dying, and if you see that it's a large issue that we need to pay a lot of attention to on the conscientious objection?

Or, just any quick thoughts on that?

Ms. Maureen Taylor:  Yeah.  I'm not a legal expert, but I have a feeling that this is going to be seen as something that the provinces will say they have jurisdiction over. That's what we were told by the Attorney General.

But I will say that I love that you're thinking along those lines, because, again, we want, we don't want a patchwork approach to this. As we know, right now in Prince Edward Island, women cannot get an abortion. We do not want that to happen with physician-assisted dying. Anything your group can do to ensure in the absence of provinces -  This is one worry - I'll be blunt - is that some provinces will do nothing after next June.  They won't bring in legislation. And I think you were talking about that yesterday.

So if you can have something in place where those Canadians who live in a province that wants to bury its head in the sand won't be left without this option.  I don't know what those things are, I'm not the expert, but I love that you're thinking about it.

This is an issue that seems fairly uniquely Canadian. Of course, there are physicians who conscientiously object in the other jurisdictions, but as far as we knew from our research, it has never been such a mountain to climb as it seems to be in Canada, and I have no insight as to why that is.

REAL Women of Canada [Full text]

Conscience Rights of Physicians Ignored

The Supreme Court of Canada in its decision also made the statement, without supporting evidence, that “Nothing in this declaration would compel physicians to provide assistance in dying.” The court has quickly been proven wrong on this point. The Colleges of Physicians and Surgeons of the provinces of Saskatchewan and Ontario have declared that any physician who, for conscience or religious reasons, may not wish to participate in assisted suicide, must refer a patient to another physician to carry out this procedure.

To coerce physicians to provide services that go against their religion or consciences is not acceptable. It is contrary to the Charter's right of freedom of conscience and religion. It is also a serious incursion into the professional standing of the physician. A proper balancing of the rights of physicians with the concept of patient autonomy, must not result in the trumping of the rights of a physician in his/her medical practice. Such rights extend not only to refusing to perform assisted suicide and euthanasia, but the right not to be obliged to refer to other practitioners or third parties, who may be willing to provide such services. The reality is that the requirement to refer for assisted suicide or euthanasia procedures, to which the physician objects on the grounds of conscience or religion, compels that physician to violate his or her conscience by being a participant in the very act, the very procedure to which he or she objects in the first place.

Saba, Paul MD [Full text]

. . . In Quebec at this time, where the provisions of euthanasia of the Quebec law were being challenged (32), there is the clear infringement on the constitutional rights and freedoms of physicians. It obliges physicians, who refuse to administer euthanasia by reason of their medical code of conduct and medical conscience of best medical practice and best interest of their patients, to nevertheless participate by way of referral. Physicians are compelled to report to the medical director of the establishment that they have received a request of medical aid in dying even if they consider this not the best medical scientifically proven way to provide medical care and least harmful way to provide care. (32) . . .

Salvation Army [Full text]

The Salvation Army calls on the Government of Canada to:

2. protect the conscience of individuals as well as facilities and the organizations that operate them with respect to the provision of physician-assisted death

Protection of Conscience of Individuals and Health-Care Facilities

The development of a system that permits access to physician-assisted death while simultaneously protecting the right of conscience and the right to life of vulnerable people will require careful balancing. The Salvation Army submits that the right of conscience exists not only for physicians but for health-care facilities and the organizations that operate them. Recognizing a right of conscience for institutions would not result in the denial of a patient's Charter right; rather it would be the same as for a health practitioner exercising their right of conscience. The institution would do everything necessary to ensure the patient receives the desired care and would ensure the transfer of care in an expedient and compassionate manner should physician assisted death be desired.

One of the objectives of Carter was to balance the right of access to physician-assisted death with the right of conscience for those who do not wish to participate. Permitting some facilities to be exempt from providing physician-assisted death will not limit access in a meaningful way. Rather, allowing for institutions to be exempt will offer protection to the conscience, morality and beliefs of patients, health-care providers and organizations who do not wish to engage with physician-assisted death. We note that several other jurisdictions such as Washington and Oregon offer health facilities or health care providers the option to decline from participating in physician-assisted death.

Conclusion

We recognize there are many other practical considerations, as physician-assisted death becomes a reality in Canada. The Salvation Army in Canada therefore calls on Government to:

2. Ensure the protection of the conscience of individuals as well as facilities with respect to the provision of physician-assisted death so that individuals who choose not to participate may do so in a trustworthy and safe environment where physician-assisted death is not present

Santoro, Burrell [Full text]

. . . Carter requires Parliament to specifically legislate protections for individuals and groups in the healthcare field who object on matters of conscience.

Recommendation 1: It is proposed that Parliament provide explicitly that health care workers and/or institutions cannot be subject to obligation or sanction, including professional sanction, as a result of their failure to participate in physician assisted suicide or euthanasia.

I. PARLIAMENT MUST ENACT CONSCIENCE PROTECTIONS:

The Carter decision in no way compels doctors or other healthcare workers to unwillingly cooperate in a suicide. Carter was based on two important factual conditions: a willing patient and a willing doctor. The applicants in Carter all had willing doctors. Had there been no willing doctor, the Supreme Court may have still held the applicants had a right to assisted suicide, but not necessarily by a physician. The finding of the Court in the specific case of Carter does not positively obligate physicians to add assisted suicide or euthanasia to their medical practices.

Many doctors and other healthcare workers object to assisted suicide and euthanasia on the grounds of moral conscience; others object as a matter of professional ethics, which is no less an objection of conscience. In paras. 130-132 of the Carter decision, the Supreme Court held "a physician's decision to participate in assisted dying is a matter of conscience and, in some cases, of religious belief." The Court then invited Parliament, along with provincial legislatures and physician's colleges, to implement a scheme which protects these rights.

Parliament should explicitly affirm that physicians and all other health care workers are not obligated in any way to participate in physician assisted suicide or voluntary euthanasia, either in the act of killing itself, or in the process which might lead to such a killing. Parliament should affirm that the failure to so participate does not infringe the rights of patients, and is not a reason for discipline or other sanction, either criminal or professional.

It is established law in Canada that doctors are not government actors, and therefore cannot violate the Charter rights of other individuals (see: Stoffman v. Vancouver General Hospital, [1990] 3 S.C.R. 483). Only government can violate the constitution, and under the constitution, doctors are private actors. The facts that doctors are regulated by a public body, that they are largely paid by public dollars, and that Canada has a system of socialized medicine, do not render doctors public actors whose conduct is measured against the Charter. Like lawyers, engineers, and other professionals, doctors are private actors. Carter does not and cannot place any obligation on individual physicians to assist in a suicide or euthanasia, especially where to do so would violate their fundamental freedoms of conscience and religion. This reasoning applies equally to protect other healthcare workers such as nurses and pharmacists, who are similarly private actors.

Some assume that the government has a positive obligation to facilitate assisted suicide or voluntary euthanasia for those who qualify per Carter. Firstly, it must be noted that this argument is made in the absence of any evidence establishing that access to assisted suicide and euthanasia will be a problem. However, even assuming this to be the case, a government obligation to facilitate a Charter right does not require individual non-government actors (i.e. healthcare workers) to be compelled to cooperate in an action to which they object as a matter of fundamental moral conscience. To the extent that government sets forward a scheme to facilitate access to assisted suicide and euthanasia, such a scheme cannot place obligations on or sanction individuals who object to assisted suicide or euthanasia as a matter of conscience. Individual physicians who object as a matter of conscience to assisted suicide or euthanasia cannot be compelled to refer patients to another physician who will provide these, if this referral would also violate their consciences.

Parliament should also recognize the rights of patients who may wish to seek care in institutions where physician assisted suicide and euthanasia are not offered. This is an important matter of patient choice, especially for those patients who are not comfortable with physician assisted death, and for whom its existence undermines their trust in their physicians and damages the therapeutic relationship. Some patients have concerns that they will be coerced into physician assisted death, and that there will conflicts of interest (including possibly financial conflicts) regarding their care. The existence of institutions which do not provide physician assisted death will greatly assist such patients in maintaining confidence in the medical system. . .

***

ii. The PTG's failure to properly balance conscience rights against patient interests Respecting conscience rights, the PTG rightly recognizes that physicians with moral reservations must be exempt from being forced to participate in assisted suicide. However, this does not adequately protect the conscientious objector from being complicit in what they regard to be a most serious offence against life. As such, the exemption should extend to all health care workers (e.g. nurses and pharmacists and others) who might be requested to assist in a suicide. It must also exempt physicians from being required to refer a patient for assisted suicide, as referring a patient for suicide is considered by many conscientious objectors as an unacceptable form of cooperation in the killing of a human being. Rather than requiring mandatory discussions and referrals, there could be made publically available a registry of participating physicians and institutions for self-referral by patients.

Secular Connexion Séculière [Full text]

Public Funding & Doctor Participation: Both medically assisted suicide and voluntary euthanasia should be a part of public medical funding so that there is no issue of differing availability because of financial reasons. Doctors and other medical care providers must have the right to exercise their own personal philosophy in these matters, but must not have the right to inhibit the right of individuals to choose their own path to completing life with dignity.

Society of Rural Physicians of Canada [Edited video]

Dr. John Soles (President, Society of Rural Physicians of Canada): . . . As you know, Canada is 90% rural by geography, and has slightly less than 20% of the population being rural. And roughly 10% of Canadian doctors work in rural areas. Canada's rural population is poorer; it's less healthy, and it has a significantly higher proportion of indigenous peoples, particularly in the north. Rural Canadians have less access to health care and may have to travel very significant distances, particularly in the north, to get such care. Canada's rural physicians are older, they are much more likely to be international medical graduates - I'm an exception in that instance. The health care in very small rural communities may be provided by nurses and other health care workers rather than physicians. Access to specialists is limited, and most rural physicians work as generalists and include palliative care within their skill set. . .

. . .the question of who does what. I believe that whatever the personal beliefs of a physician may be, they must be willing to discuss all legal options with their patients and make appropriate referrals if they themselves are unable to take part in that service. I think here the way abortion works in Canada, is a reasonable, has some similarities. Physicians should not be obligated to be involved with a service that they have moral difficulties with, however they should be able to have such a discussion with their patients and to refer when necessary.

One of the questions that has arisen in the past, or in discussions about this is death certificates and how they're filled out. I think death certificates should have physician-assisted dying as the immediate cause of death with the diagnosis that led to this as an underlying cause.

And now the concerns in rural areas. The challenge in rural areas is often, as in the community  I live, that there is a group of physicians who work together, and how is it possible to arrange a second opinion about someone's suitability for this, or their competence? I think it's inappropriate to do that within a group of physicians who work together. How is it possible to arrange and expedite a psychiatric consultation, if that's required?  If all physicians in a group are conscientious objectors to this process, how do patients obtain a service, which is considered legal in a small community, where the physicians are not able morally to provide that service? This is a little different than the abortion discussion in that these patients are much less likely to be able to travel safely.

Where and how in a rural community where everyone knows everyone is it possible to carry out this process? What would the effect be on other members of the community? What would the effect be on the staff of a rural hospital? What would the effect be if there was radically different viewpoints within a small group of physicians?

Those are the important points . . .

I think the role of telemedicine was mentioned. If we're looking at a patient that has requested physician-assisted death and is in one of these communities in which there is only one physician group, it would be most appropriate that this patient be assessed by a second physician. And if that can't be done in person, then it needs to be done in some other fashion; and that would presumably be via video or telephone link, preferably video.

If you had a small community where there was no physician who was willing to participate in this process, other than informing a patient about, if the patient requests it, informing them about what the process was, it creates a great challenge, because I really don't think that it's appropriate for these decisions to be solely made without actually sitting in the room with the patient. . .

Hon. Nancy Ruth:  . . . how can nurse practitioners or other people in rural areas deal with this, if there is a legitimate request, maybe assessed through telehealth, for physician-assisted death for someone who wants to stay in their home, be they living in Grise Fiord in the high Arctic or anywhere else in Canada. And a cocktail of drugs could be flown in by mail, like other drugs are sent by mail. Do you ever, can you imagine that happening? And what kinds of problems would there be?

Dr. John Soles:  Certainly I can imagine, as any physician who's provided palliative care, I prescribe lethal doses of drugs to patients all the time without the expectation that they take them.

Just to clarify that for the committee, if I have a patient who has terminal cancer, for instance, they will go home perhaps with a dose of medication that, if you or I had it, it would be terminal. And the striking thing to me is that I cannot recall, in my personal experience, any patient that has chosen to take their medication in that fashion.

I think the real challenge, if you're prescribing medications at a distance and you're sending them, you know, through the mail and they're being administered by the patient's family or a nurse, what happens when things go wrong? I don't really want to make this comparison, but there's been cases where death by lethal injection in the States has gone badly wrong, and those are cocktails delivered by physicians. I would hate to think of some nurse in Grise Fiord who has that kind of experience.

Somerville, Margaret [Full text]

3. Roles and regulation of healthcare pracitioners

For nearly 2,500 years, physicians and the profession of medicine have recognized that assisted suicide and euthanasia are not medical treatment and this position should be maintained and these interventions- should be kept out of medicine. (See J. Donald Boudreau and Margaret A. Somerville, "Euthanasia is not medical treatment", British Medical Bulletin 2013; 106: 45--66, 001:10.1093/bmb/ldtOlO explaining this stance.)

Consequently, a new profession should be established to carry out euthanasia. The practitioners should not be healthcare professionals or, if so, only ones who have permanently retired from practice. Practitioners should be specially trained, licensed and have travel money provided to give people across Canada equal access to euthanasia.

If this approach is not adopted, two publicly available lists of physicians and institutions should be established, those who will provide euthanasia and those who will not. This is a reasonable compromise between Canadians who agree with euthanasia and those who oppose or fear it. The Supreme Court emphasized that the Charter right to "security of the person" includes freedom from fear about what could happen to us when we are dying, which often seems to be forgotten or ignored with respec to this right of those fearul of euthanasia.

This approach will also solve most freedom of conscience issues. Healthcare professionals must not be forced to provide or refer for euthanasia when they have ethical or conscience objections to doing so. It must be kept in mind that respect for physicians' patients and can be the last such protection against doing them serious harm or other serious wrongdoing. . .

Oral Submission  [Edited video]

[As above]

Squires, Collette [Full text]

Freedom of Conscience

Physician-assisted death runs contrary to the ethical practice of doctors who want to promote health and life where they can, and who prefer to provide excellent end-of-life care within a palliative framework. Our Charter of Rights guarantees freedom of conscience; this needs to be protected for our doctors.

Other doctors may feel comfortable with ending a patient's life. This creates an inherent conflict. Who will train these doctors? What will be the ethical principles guiding their work? How will you keep the process free from the potential for monetary gain? Should this become a money-maker for certain health professionals, as private abortion clinics have become?

How will you guarantee "safe places" for patients and medical staff where no one will feel compelled or coerced?

Sumner, Wayne [Full text]

PAD is a controversial matter. Some physicians will have no religious or ethical objection to providing this service for their patients, while for others it will violate the dictates of their conscience. A policy must include a 'conscience clause' which enables providers to decline to offer the service on grounds of personal conviction. However, it must also require that they not abandon patients who request PAD; they must then be obliged to provide patients with an effective and timely referral to a provider willing to help them. On the other hand, publicly funded health care institutions should be required to permit PAD on their premises if a physician is willing to provide it. Otherwise, patients in many communities with religiously affiliated hospitals will be denied timely access to the service.

Svec, Katherine Meaney [Full text]

3. Non-compliant health care providers, hospitals, and care facilities must not impede an eligible patient's right to obtain Physician-Assisted Dying.

3. Non-compliance: Many physicians have responded to surveys stating they will not agree to hasten a patient's death, nor will they refer. Other than simply abandoning their patient to self-help, I have as yet seen no alternative offered by these non-compliant physicians. This crucial gap in the process must be addressed and a solution found which balances the rights of such physicians and the rights of suffering patients. Hospitals and care facilities with a religious component must not be allowed to dictate terms. Patients who meet the criteria and who request Physician-Assisted Dying must have timely access to a cooperating physician.

4. Physicians need clarity and firm guidelines e.g. How are Ontario physicians to comply with the CMA Policy of no duty to refer which is at odds with the CPSO policy on this issue?

4. Clear Guidelines: If the CMA insists there is no duty to refer, one is left to wonder how Ontario physicians are to comply, in light of the CPSO's policy on Professional Obligations and Human Rights which clearly states: "Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another health-care provider must be provided to the patient. An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency. The referral must be made in a timely manner to allow patients to access care. Patients must not be exposed to adverse clinical outcomes due to a delayed referral. Physicians must not impede access to care for existing patients, or those seeking to become patients." (Limiting Health Services for Legitimate Reasons: Policy Number:#2-15 Reviewed and Updated March 2015) Of particular note is the fact that this policy was confirmed after the SCC ruling on the Carter case, yet there is no mention of any exclusions (such as physician- assisted dying) to be applied to the duty to refer.

United Church of Canada [Full text]

. . . The emphasis on physician-assisted dying being a decision between an individual and their doctor implies that the doctor must also be allowed the right not to participate if they believe it inappropriate to do so. Support for physician-assisted dying must take into account the difficulties faced by medical staff both in contributing to the ending of an individual's life, and in the emotional implications that might result. . .

Where an individual who qualifies for physician-assisted death under the new legislation requests their doctor's assistance to end their life, but the doctor has objections to participating, the doctor ought to be obliged to refer the individual to another doctor. This is consistent with other legislation, such as the abortion laws, which allow freedom of conscience for medical professionals without jeopardizing equal access to medical care for individuals. . .

von Fuchs, Ruth (Right to Die Society of Canada) [Full text]

. . . Ultimately there will be a situation of patient's orders and doctor compliance (or doctor refusal and patient referral, if assisted dying is chosen and the doctor is unwilling to provide it). . .

Warren, John [Full text]

3. Referral - Physicians who oppose PAD must be required to refer patients to another doctor or a third-party referral agency.

3. Conscientious Objection The whole idea of the Right To Die movement is to provide choice at the end of life. Proponents, like me, want control over our own bodies and we respect that right for others. I totally support the right of physicians and other healthcare providers to refuse to provide Physician Assisted Death to a patient who requests it but the patient's right to it must also be protected. Physicians who oppose assisted dying must be required to refer patients who request it to another doctor or a third-party referral agency. Sick and dying patients should not be responsible for finding an alternate doctor on their own.

4. Institutions - All publicly funded healthcare institutions must allow PAD on their premises.

4.Publicly Funded Healthcare Institutions The protection of every patient must be a paramount consideration of the Bill and no patient can be denied access to PAD because of the beliefs or policies of religious institutions. All publicly funded healthcare institutions must allow PAD on their premises. If no doctors on staff are willing to provide it, an external doctor must be permitted into the hospital to provide the service. This policy is especially relevant for small communities where healthcare options may be limited. For example, some communities may only have Catholic-affiliated hospitals or hospices nearby. If those institutions refuse to provide PAD on their premises, then access to PAD will be heavily restricted in the communities they serve. Even in larger centres, a patient may be rushed to an emergency department at a Catholic hospital. Moving the patient to a non-denominational institution would cause unnecessary stress and may not be possible depending on the patient's condition.

Wilson, Linda [Full text]

b)  Any tax payer supported facility, must provide the facility for the patient to have their pain end in a kind and compassionate manner.

e)  All medical parties must adhere to the document, not using their own personal bias to ignore the documented / witnessed wishes of the patient, this includes the “family doctor”.