Redefining the Practice of Medicine
Euthanasia in Quebec
An Act Respecting End-of-Life Care (June, 2014)
Sean Murphy*
Part 5:
An
Obligation to Kill
Statistics from jurisdictions where euthanasia and/or assisted
suicide are legal suggest that the majority of physicians do not
participate directly in the procedures. Statistics in Oregon and Washington
state indicate that the proportion of licensed
physicians directly involved in assisted suicide is extremely small. At most, 2.31% of all Belgian physicians were directly involved in
reported euthanasia cases, and the actual number could be much lower.
A maximum of 9% to 12% of all Dutch physicians have been directly
involved, most of them general practitioners. The current situation in
Belgium and the Netherlands suggests that, for some time to come, a
substantial majority of Quebec physicians will probably not lethally
inject patients or provide second opinions supporting the practice.
It is anticipated that between 150 and 600 patients will be killed
annually in Quebec by lethal injection or otherwise under the MAD
protocol authorized by ARELC. While these estimates amount to only
a small percentage of the deaths in the province each year, and while
Quebec has about 8,000 physicians in general practice, there is concern
that only a minority of physicians will be willing to provide
euthanasia, and it may be difficult to implement ARELC.
The reason for the concern appears to be that ARELC purports to
establish MAD as a legal "right" that can be exercised and enforced
anywhere in the province, but physicians willing to provide the service
are unlikely to be found everywhere. As a result, in some areas, if no
physicians are willing to provide MAD services, patients wanting
euthanasia may be unable to exercise the "right" guaranteed by the
statute.
Rather than deny either patients' access to euthanasia or
physicians' freedom of conscience, several mechanisms have been proposed
to accommodate both. Delegation is not permitted by law, and
transfer of patients will not normally be feasible. However,
workable alternatives include the advance identification of willing
physicians in each region, the use of electronic communication services
to permit remote consultation and the establishment of mobile "flying
squads" of euthanatists to provide services not otherwise available in
some parts of the province.
Euthanasia proponents deny that they intend to force physicians to
personally kill patients, but the exercise of freedom of conscience by
objecting physicians who refuse to kill patients can lead to unjust
discrimination against them. Discriminatory screening of physicians
unwilling to kill patients can be effected by denying them employment in
their specialties and denying them hospital privileges.
By such strategies one can truthfully affirm that physicians are not
actually being forced to kill, although those unwilling to do so may be
forced to change specialties, leave the profession or emigrate.
The accuracy of official euthanasia and assisted suicide returns is disputed,
though it is usually agreed that the actual number of cases is probably higher
than the reported number. However, with respect to the reported cases, the
returns indicate that the majority of physicians do not participate directly in the
procedures. In fact, depending on the jurisdiction, the number of
physicians who actually kill patients or write prescriptions for lethal drugs or
provide second opinions in support of euthanasia or assisted suicide can be very
small.
For reasons connected with reporting requirements, this is easier to establish
in the United States than in Europe.
Though euthanasia has been legal in Belgium since 2002, the number of Belgian
physicians who actually provide lethal injections and second opinions is
apparently unknown. The reason for this appears to be that the Federal Control and
Evaluation Commission for Euthanasia cannot identify the physicians who report
they have performed euthanasia unless it decides that the law may have been
broken.1
Nonetheless, the statistics produced by the Commission establish the
maximum number of physicians who have been involved in reported euthanasia
cases each year. By comparing this to the estimated number of licensed
physicians in the country it is possible to estimate the proportion
of Belgian physicians directly involved in euthanasia reported to the
Commission. The percentage has been increasing steadily, but it is
still quite low: euthanasia is provided by 0.62% to 2.31% of all Belgian physicians (Appendix
C1). Moreover, these are maximums; the actual number of physicians
directly involved could be much lower. For example, in 2013, Dr. Sarah Van
Laer said publicly that she had killed 28 patients since 2002,2 which, in
Commission statistics, would be reflected as the work of 28 physicians, not
one.
This may explain the anecdotal reports that most Belgian physicians will not provide
euthanasia. Only
about 400 of 20,000 physicians in Flanders (2%) were involved in providing
second opinions in 2013; they considered themselves overburdened and underpaid.3 Dr. Sarah Van Laer told a Belgian newspaper that there were too few
physicians willing to perform euthanasia, and that this problem had been "badly
underestimated." As a result, she said, she and others willing to provide
the service were becoming burned out.4
Finally, Dr. Wim Distelmans, a Belgian physician who is a leading
practitioner and advocate of euthanasia and co-chairman of the Federal Control
and Evaluation Commission has complained that many physicians, hospitals and
nursing homes are reluctant to provide the service. He described them
as "still very prudent," adding, "There are still a lot of people suffering
unbearably because they ask for euthanasia and they don’t get it."5
Physicians may provide both euthanasia and assisted
suicide in the Netherlands, but, here, too, the number of physicians directly
involved is uncertain. As in the case of Belgium, it is impossible to
determine from published statistics whether or not a subset of euthanasia
practitioners is responsible for killing most of the patients.
What is clear, however, is that general
practitioners in the Netherlands are overwhelming responsible for performing
euthanasia, and the numbers are rising. In 2004 almost 21% of Dutch
general practitioners were directly involved; by 2010 it was over 28%.
In comparison, the next most active category, hospital specialists,
represented less than 2% of Dutch medical specialists directly involved with
euthanasia or assisted suicide. Overall, the statistics indicate that
a maximum of 9% to 12% of all Dutch physicians have been directly involved
in reported euthanasia cases each year (Appendix
C2).
This is consistent with a report that euthanasia
is usually provided by general practitioners, but many refuse to do so.
It was for this reason that, in 2012, Right to Die NL formed mobile teams to provide
euthanasia for patients at home.6
Published statistics in Oregon and Washington state provide a more accurate
picture of the actual involvement of physicians in assisted suicide than can be
had from Belgian and Dutch authorities. The proportion of licensed
physicians directly involved is extremely small.
In Oregon, where assisted suicide has been legal since 1997, between 33 and
64 physicians wrote prescriptions for lethal medication each year from 2002 to
2013, a range of 0.38% to 0.62% of the state's active registered physicians (Appendix
C3).
The state of Washington legalized assisted suicide in March, 2009. The
number of physicians prescribing lethal medications has increased steadily from
53 to 89, from 0.21% to 0.34% of licensed physicians. The number of
pharmacists dispensing lethal drugs has been more variable, rising from 2009 to
2011 and dropping thereafter. From 2009 to 2013, 23 to 46 pharmacists
dispensed drugs for assisted suicide annually, representing 0.25% to 0.52% of
licensed pharmacists (Appendix C4).
While interesting, the extremely low physician participation rates in
Oregon and the state of Washington pertain solely to assisted suicide, not
euthanasia, and there are many other cultural, legal and political
differences between Quebec and these western American states.
It is more promising to consider
what would happen if developments in Quebec were to approximate those in
Belgium or the Netherlands. Quebec and Belgium have some linguistic similarities, share some
civil law traditions,7 and the state in
both jurisdictions is responsible for the delivery of health care.
Moreover, the situation in Belgium is of particular interest in Quebec
because ARELC was modelled on the Belgian euthanasia law.
If we apply the
highest physician participation rate reflected in the Belgian figures
(2.31%) to the number of active members registered with Quebec's College of
Physicians (19,818),8 one might predict that about 458 Quebec physicians
would actually provide lethal injections and/or second opinions. Since two
physicians are required for each case, the predicted number of available
physicians would suffice to process 229 euthanasia requests each year:
slightly more than one third the highest estimate of anticipated demand (600
cases annually).
Applying the highest Dutch physician participation rates (12% overall,
28% of general practitioners), one might predict direct
involvement of 2,378 Quebec physicians overall, or 1,440 general practitioners.
Taking a different perspective, the highest Belgian and Dutch physician
participation rates suggest that, more than ten years after legalization of
assisted suicide and euthanasia, between 88% and 98% of physicians in
Belgium and the Netherlands are not directly involved in the
procedures. This estimate seems so high as to be improbable.
On the other hand, abortion - another highly controversial procedure that
involves killing - has been available in Canada since 1969 and completely
unrestricted since 1988. Yet, as of 2011, over 99.5% of registered
physicians in British Columbia were not performing abortions;
almost 25 years after the legalization of abortion, proportionately
fewer physicians were performing abortions in British Columbia than
were writing prescriptions for assisted suicide in neighbouring Oregon.9
Thus, while it would be unwise to assert that 88 to 98% of Dutch and Belgian
physicians are not providing euthanasia or assisted suicide, such high rates
of non-provision are not without precedent.
In any case, the current situation in Belgium and the Netherlands
suggests that, for some time to come, a substantial
majority of Quebec physicians will probably not lethally inject patients or
provide second opinions supporting the practice.
During the committee hearings, then Minister of Health Véronique Hivon took note of the possibility that
few physicians would be willing to kill patients, but emphasized that this
had to be set against the expectation that only "a very small number" of
patients would actually seek the service, "between 0.2% to 1.8% of deaths."10
Overnight,
then there
will not be a flood
of applications from everyone
wanting to get
to have medical help
to die,
it will be in the special
case where it
is really
not possible to relieve
a person.
So, in
those jurisdictions that we have seen,
this is often less than
1% of all deaths. So it means
that it is still very
exceptional, and
it is good that it is
like that.11
Similarly, committee member Hélène Daeault, comparing the
populations of Quebec and Belgium, estimated that there might be
150 to 200 cases of euthanasia each year "a tiny fraction" of
the 60,000 deaths annually.12 Dr. Yves Bolduc
offered a higher estimate: 300 to 600 cases annually.13
Citing the Quebec Medical Association Survey that found 41% of
physicians willing to provide euthanasia, Minister Hivon argued
that, although many physicians might not be prepared to provide
MAD, "there is
still a significant
number of doctors who
say they are willing."14
Setting aside physician surveys,
Dr. Yves Bolduc approached the question from a different angle.
He considered his estimate of 300 to 600 anticipated MAD cases each year a relatively
small number of deaths. That being the case, he concluded
that only
a minority of physicians would actually be involved in meeting
the demand, since, "we cannot think that every doctor will have
the expertise, even if he wants to."
"We can believe in the project," he explained, "but if you do it
once every two years, you are perhaps better not to touch it."15
Why, then, was Dr. Bolduc so concerned that there might not be
enough willing physicians available to implement the law?
Part of the explanation might concern the administrative impact of the
need to arrange for the killing of up to 600 patients each
year. Michel Racicot of Living with Dignity pointed out
that this is the equivalent of emptying the
Drapeau-Deschambault Centre, a 223 bed long term care facility,16
two or three times a year.17
Adopting Dr. Bolduc's figures, about 30 hospitals would be
required to provide MAD service;18 600 MAD
cases annually would average about one every two weeks in each
institution. Since the MAD protocol requires prior consultations
with at least the patient and a second physician, any
significant resistance by physicians or other health care
workers would make this a year-round, almost daily
administrative headache.
Still, there are over 8,000 physicians in general practice in
Quebec.19 If only ten per cent of that
number were willing to provide MAD, it would seem that there are
more than enough physicians available to lethally inject 600
patients each year. Nonetheless, Dr. Bolduc repeatedly
expressed concern that it would be very difficult to implement
the law. Why?
The answer was provided, in part, by Véronique Hivon, who insisted
that, in the interests of fairness, both palliative care and MAD must be
made available in the state health care system, so that people who live in
cities like Montreal or rural areas like Gaspé "have the same access."20
Beyond a general concern about equality of access, however, Dr.
Bolduc repeatedly drew attention to the fact that Bill 52/ARELC
purports to establish a "practically inalienable" legal right to MAD, which, in
turn, imposes an obligation on all health care institutions in
the province to fulfil demands for euthanasia.21 Thus, even though only a minority of patients are
expected to seek the service, the law requires that the whole
health care delivery system be arranged to accommodate them.22
Committee member Stéphanie Vallée explained:
[The law] gives a right
to every person, regardless of his place of residence in Quebec,
so that if it is in the Northern Quebec, whether
in Montreal, whether in Montérégie , it gives the right to
anyone to have palliative care, to have [continuous] palliative
sedation, to have physician-assisted dying, we must ensure that at the time of implementation,
those services will be available and we will not have to run
around Quebec to be able meet the demand, to be able to respond to the request of
the patient.23
While
Dr. Bolduc agreed with this in principle,24 he
feared that it would lead to serious confrontations:
Take, for example,
there were people
this morning who practised at
Notre Dame in palliative
care, they will
simply refuse
out of conviction, and
probably even resign
from the hospital
rather than be
required to do that,
though in the law,
there is an obligation
to do it.25
Moreover, he reminded his colleagues that genuine respect for
physician freedom of conscience added another level of
difficulty, "[b]ecause there are
three elements: you have the right of the patient, you have
the obligation of the
institution and then
you can also
have your conscientious objection."26
[I]f
we find ourselves in places
where
death is relatively
imminent and
there is nobody in
the medical team who can
perform these tasks,
will this not undermine the
right of the patient or prevent the person who has a
conscientious objection, from acting on his conscientious
objection?27
"What will be the priority or have primacy?" he asked. "Will it
be the patient's right?"
"Or," he asked, "will there be a way
to force professionals to provide the service?"28
Rather than deny the patient's access to euthanasia or
physicians' freedom of conscience, Dr. Bolduc insisted that some
kind of timely mechanism must be developed to accommodate both,
although he understood that this would probably take some time to accomplish.29
The Quebec Association of Gerontology wondered if lethal
injection might be delegated to nurses.30
Leaving aside the question of the ethics of delegation, this
would simply move the question one step further back, since a
nurse might take the same position as an objecting physician.
Moreover as Yves Bolduc observed,31ARELC
states that it is the physician's task to administer the lethal
substance. There is no provision for delegation.32
If no local physicians or facilities can supply a specialized service,
such as heart surgery, it is common practice to transfer patients elsewhere.
However, the Alliance of Quebec Hospices noted that it is not a simple
matter to transfer a terminally ill patient from one facility to another,
especially after he has been in the first institution for some time,33
and Dr. Bolduc confirmed that one would not expect a patient to be
transferred to access MAD services.34 Thus, while
transferring a patient in a particular case might be practical, it would
likely occur only in exceptional circumstances.
In addition to recommending that regional health administrators
should be personally aware of the scope of practice of
professionals in their territories,35 the Quebec College of
Pharmacists suggested that access to lethal drugs for MAD and
accommodation of freedom of conscience for pharmacists who
object to euthanasia could be accomplished by adopting an
existing practice:
[The regional health authority] sends a request to
community pharmacists to clarify the various services they
offer: anticoagulation, the ACO program methadone, syringe
recovery ... There are several services. So, medical assisted
dying could also be a service . . . for which we require
pharmacists to indicate whether they are available . . .36
Similarly, the Quebec Association of Health Facilities and Social
Services suggested that regional health authorities could ask physicians
willing to assist with or provide MAD services to identify themselves in
advance.37 Such advance planning
was also supported by the Association of Councils of Physicians, Dentists
and Pharmacists of Quebec.38 The maintenance of a registry of
physicians willing to cooperate in the provision of defined services has
been recommended by Holly Fernandez Lynch in Conflicts of Conscience in
Health Care: An Institutional Compromise. She describes a
register of health care providers in Texas who are willing to accept
patients who want treatment or care either continued or discontinued near
the end of life.39
While the act of killing a patient would have to be performed by
a physician on the spot, Dr. Bolduc suggested that other aspects
of the MAD process might be managed by using telecommunications
systems and digital technology that would permit remote
monitoring.40
For example, if a physician in Gaspé wanted to provide a
lethal injection but could not find another local physician
willing to provide the required second consultation, he could consult physicians in Quebec or
Montreal who might be willing to support him. Michel Gervais of
the Quebec Association of Health Facilities and Social Services,
noting the effective use of telepsychiatry and teleradiology,
thought the suggestion "very valuable and very possible."41
Committee members Yves Bolduc and Hélène Daneault
suggested that "flying squads" could be
established to provide MAD services around the province or in the regions as an alternative to
transferring patients, which is not normally feasible.42
The idea of such "visiting physicians" found favour with the Quebec Association
for the Right to Die with Dignity,43 but the Quebec
Rally Against Euthanasia warned that, if such teams had to "crisscross
Quebec by plane," money would be spent providing euthanasia rather than palliative
care.44
Dr. Pierre Gagon thought "the idea of
people coming in from outside" seemed "very artificial" and "goes a little
against the principles of medicine." He cautioned the committee that
the concept required "systematic evaluation."
Well, I think there was a phenomenon much like that in
Switzerland. It went very, very badly. Some mobile teams who
came did very little evaluation ... They were a bit like at odds
with palliative care teams. I do not know, it is very delicate.
. .45
When Dr. Bolduc asked if there was a way to force physicians to kill, he
asked the question only to emphasize that, "in reality," in
his view, no physician could be forced to do so.46
"We cannot force professionals," he said. "Despite what it looks like:
The patient has rights - you cannot go and tell a professional: You'll have
to do that."47
This seems to imply that people who are not professionals
can be forced to do what they are told: that physicians are
exempt from such coercion precisely because they are professional.
If that is Dr. Bolduc's view, he will eventually have a very rude
awakening. A number of prominent academics have been making an
argument for some time that one of the essential features of medical
"professionalism" means doing what one believes to be immoral,
unethical or unjust.48
In any case, Dr. Bolduc did not offer principled reasons for his
assertion that physicians cannot be forced to provide euthanasia. His
argument was purely pragmatic:
If we start with that principle, then you will destroy the bill.
Society is in agreement to date, according to the polls, but if
you start to force people to do things like this, if you want my
opinion, you can talk because you defend a position, but I will
not follow you that far, that's for sure. Most professionals do
not follow you that far.49
His warning was addressed to the Quebec Association for the Right to Die
with Dignity, which responded, that it had always said
that it respected "the freedom of the professional." Speaking for
the Association, Hélène Bolduc (no relation to the legislator) said that
the organization had never had any intention of forcing physicians to
provide euthanasia, as "there is not a doctor who would do it well if,
in addition, it was not his inclination to do so, and
it is not to
anyone's advantage to give
this impression."50
The answer satisfied Dr. Bolduc,
but he failed to take into account that the exercise of freedom of
conscience by objecting physicians who refuse to kill patients can lead
to unjust discrimination against them.
This was demonstrated during the committee hearings into Bill 52, when
the Interprofessional Health Federation of Quebec told legislators that no
one is forced to work in palliative care units,
"so the person who applies for this position will go knowing what is
required." The Federation did not anticipate much problem being caused
by conscientious objection "because when people apply to a specialized
department they know what they have to do."51
The assumption, of
course, is that providing euthanasia will become one of the duties of
palliative care units, so that those wanting to practise palliative care but
who are unwilling to kill patients will not apply. And if they do
apply, of course, management may deny them employment, as now happens in at
least one major Canadian maternity hospital that denies employment to
qualified maternity nurses who have moral or religious objections to
assisting with abortion, including third trimester abortions.
Discriminatory screening of physicians unwilling to kill patients can
also be effected by denying them hospital privileges (Appendix B1), as explained by the
Association of Councils of Physicians, Dentists and Pharmacists of Quebec:
Let me explain, skills, when a doctor applies to a
health facility, the [Council of Physicians, Dentists and Pharmacists] will
ensure he has the necessary skills and will grant him a status and
privileges. Privileges usually come with obligations. These obligations also
allow the guidance of practice and ensure that we will practise within the
framework provided by organization, yet based on the reality of practice and
skill level. . . So, to grant privileges in a CSSS, it might be meaningful
to this necessary and required training for the physician to practise this
activity. . . 52
By such strategies one can truthfully affirm that physicians are not
actually being forced to kill, although those unwilling to do so may be
forced to change specialties, leave the profession or emigrate.
Notes
1.
The Belgian Act on Euthanasia of May 28, 2002, Section 7, 8.
(Accessed 2014-07-18)
2. Cook Michael,
"First-world problems 2: I’m really not into the whole
'turbo-euthanasia'
thing." Bioedge, 27 June, 2013. (Accessed 2014-07-15)
3. HLN.be,
"Artsen die dokters bijstaan bij euthanasie overbevraagd." 24 June,
2013. (Accessed 2014-07-15)
4. Cook Michael,
"First-world problems 2: I’m really not into the whole
'turbo-euthanasia'
thing." Bioedge, 27 June, 2013. (Accessed 2014-07-15)
5. Hamilton G.
"Death by doctor: Controversial physician has made his name delivering
euthanasia when no one else will." National Post, 22
November, 2013 (Accessed 2014-07-15)
6. Jolly, D.,
"Push for the Right to Die Grows in the Netherlands." New York
Times, 2 April, 2012. (Accessed 2014-07-15)
7. Société de législation comparée,
European Contract Law :
Materials for the CFR (April, 2008) (Accessed 2014-07-17)
8. Collège des Médecins du Québec,
Rapport Annuel, 2013-2014. (Accessed 2014-07-17)
9. In 2011, only 50 (0.46%) of 10,842 professionally
active registered physicians provided abortions in British Columbia. Norman
WV, Soon JA, Maughn N, Dressler J. (2013)
"Barriers to Rural Induced Abortion Services in Canada: Findings of the
British Columbia Abortion Providers Survey (BCAPS)" (2013) PLoS ONE
8(6): e67023. doi:10.1371/journal.pone.0067023 (Accessed 2013-07-25);
College of Physicians and Surgeons of British Columbia,
2011 Annual
Report, p. 12 (Accessed 2014-07-12) In contrast, 0.60% of
active registered Oregon physicians wrote lethal prescriptions for assisted
suicide in 2011 (Appendix
C3.).
10.
Consultations & hearings on Quebec Bill
52 (Hereinafter "Consultations"), Thursday, 19 September 2013 - Vol. 43 no. 36: Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#041
11.
Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42:
Quebec Association of Gerontology (Catherine Geoffroy, Nathalie
Adams), T#075
12.
Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services
(Michel
Gervais, Diane Lavallée), T#108
13.
Consultations,
Thursday, 19 September 2013 - Vol. 43 no. 36: Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#099
14.
Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42:
Quebec Association of Gerontology (Catherine Geoffroy, Nathalie
Adams), T#076
15.
Consultations,
Thursday, 19 September 2013 - Vol. 43 no. 36: Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#099
16.
Quebec Ministry of Health and Social Services,
Rapport de Viste d'Évaluation de la Qualité du
Milieu de Vie (2013) (Accessed 2014-07-09)
17.
Consultations,
Wednesday, 25 September 2013 - Vol. 43 no. 38:
Living with Dignity(Nicolas
Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#079
18.
Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45:
Dr. Annie Tremblay, Dr. Pierre Gagnon, T#112
19. Fédération des médecins
omnipraticiens du Québec:
Mission. (Accessed 2014-07-10)
20. Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42:
Quebec Association of Gerontology (Catherine Geoffroy, Nathalie
Adams), T#074
21. Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42:
Quebec Association of Gerontology (Catherine Geoffroy, Nathalie
Adams), T#062
22. Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4:
NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#116
23. Consultations,
Thursday, 19 September 2013 - Vol. 43 no. 36:
Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#054
24.
Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45:
Dr. Annie Tremblay, Dr. Pierre Gagnon, T#112
25.
Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4:
NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#116
26. Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4:
NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#118
27.
Consultations,
Tuesday, 17 September 2013 - Vol. 43 no. 34:
Collège des médecins
(Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#158
28.
Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec
(Dr. Louis Godin, Dr. Marc-André Asselin),T#103
29. Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services
(Michel
Gervais, Diane Lavallée), T#095;
T#101; Wednesday, 2 October 2013 - Vol. 43 no. 4:
NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#118; Wednesday, 9 October 2013 - Vol. 43 N° 45:
Dr. Annie Tremblay, Dr. Pierre Gagnon, T#112;
Thursday, 19 September 2013 - Vol. 43 no. 36: Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#099
30. Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42:
Quebec Association of Gerontology (Catherine Geoffroy, Nathalie
Adams), T#055
31. Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42:
Quebec Association of Gerontology (Catherine Geoffroy, Nathalie
Adams), T#062
32.
ARELC, Sections 3(6),
30
33.
Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40:
Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#146
34. Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec
(Dr. Louis Godin, Dr. Marc-André Asselin),T#103; Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services
(Michel
Gervais, Diane Lavallée), T#095
35. Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34:
College of Pharmacists of Quebec (Dianne Lamarre, Manon
Lambert),T#050
36. Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34:
College of Pharmacists of Quebec (Dianne Lamarre, Manon
Lambert),T#063
37.
Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35:
Quebec Association of Health Facilities and Social Services
(Michel
Gervais, Diane Lavallée), T#109
38. Consultations,
Thursday, 19 September 2013 - Vol. 43 no. 36:
Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#014
39.
Fernandez-Lynch, Holly, Conflicts of
Conscience in Health Care: An Institutional Compromise. Cambridge, Mass.: The MIT Press, 2008, p. 146.
40.
Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services
(Michel
Gervais, Diane Lavallée), T#095
41. Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services
(Michel
Quebec Association of Health Facilities and Social Services
(Michel
Gervais, Diane Lavallée), T#103
42.
Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec
(Dr. Louis Godin, Dr. Marc-André Asselin),T#103;
Tuesday 24 September 2013 - Vol. 43 no. 37:
Quebec Rally Against Euthanasia
(Dr. Claude Morin, Dr. Marc Bergeron, Daniel Arsenault, Clément
Vermette), T#099; Consultations,
Wednesday, 9 October 2013 - Vol. 43 N° 45: Dr. Annie Tremblay, Dr. Pierre Gagnon, T#148
43. Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:
Quebec Association for the Right to Die with Dignity
(Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#072
44.
Consultations,
Tuesday 24 September 2013 - Vol. 43 no. 37:
Quebec Rally Against Euthanasia
(Dr. Claude Morin, Dr. Marc Bergeron, Daniel Arsenault, Clément
Vermette), T#102, T#103
45. Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45:
Dr. Annie Tremblay, Dr. Pierre Gagnon, T#150
46. Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec
(Dr. Louis Godin, Dr. Marc-André Asselin),T#103
47. Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:
Quebec Association for the Right to Die with Dignity
(Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#102
48. See, for example, Cantor, Julie D.,
"Conscientious Objection Gone Awry - Restoring Selfless
Professionalism in Medicine." N Eng J Med 360;15, 9 April, 2009;
Charo, R. Alta, "The
Celestial Fire of Conscience- Refusing to Deliver Medical Care."
N Eng J Med 352:24, June 16, 2005. (Accessed 2008-09-13);
Kolers, A. "Am I My Profession's Keeper?" Bioethics,
Vol. 28, No. 1, 2014.
49.
Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:
Quebec Association for the Right to Die with Dignity
(Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#102
50.
Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:
Quebec
Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel
Boisvert, Dr. Georges L'Espérance), T#107
51.
Consultations, Thursday, 26 September 2013 -
Vol. 43 no. 39:
Interprofessional Health Federation
of Quebec (Régine Laurent, Julie Martin, Michàle
Boisclair, Brigitte Doyon), T#058
52.
Consultations,
Thursday, 19 September 2013 - Vol. 43 no. 36: Association of Councils of Physicians,
Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger),
T#017