Redefining the Practice of Medicine

Euthanasia in Quebec

An Act Respecting End-of-Life Care (June, 2014)

Sean Murphy*

Full Text

Part 9: Codes of Ethics and Killing

Introduction

During the legislative committee hearings into Bill 52, Dr. Yves Bolduc noted that "conscientious objection. . . goes a long way."

We heard groups there, that do not at all agree with [physician assisted dying] . . . to such an extent that even the fact of collaborating indirectly with others goes against their consciences.

"I'm not saying that this is what we meet in the system, most of the time," he added, but he was clearly concerned about the potential for conflict.1

What is much less clear is whether or not he or others understood that such refusals are morally and ethically legitimate responses to indirect participation in perceived wrongdoing.  As noted in Part 6, refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is not aberrant behaviour.  On the contrary: it is the response expected of physicians by professional bodies and regulators.

A review of the transcripts of the hearings into Bill 52 discloses that this point was not grasped by any of the legislators or supporters of the bill.  A principal contributor to this lack of awareness - if not actually the source of it - is the Code of Ethics of the Collège des médecins du Québec.

Collège des médecins Code of Ethics

"It is as if you did it anyway."

Dr. Charles Bernard, President and Director General of Quebec's Collège des médecins , acknowledged that, like society, members of the medical profession were not unanimous in supporting euthanasia, "[s]o it is certain that there will be a number of people who will not do this."  Physicians, he said could withdraw because of religious beliefs.2.  Further, Dr. Bernard concisely stated and appeared to agree with the reasoning of physicians who refuse to refer for or facilitate morally contested procedures:

[I]f you have a conscientious objection and it is you who must undertake to find someone who will do it, at this time, your conscientious objection is [nullified]. It is as if you did it anyway. / [Original French] Parce que, si on a une objection de conscience puis c'est nous qui doive faire la démarche pour trouver la personne qui va le faire, à ce moment-là, notre objection de conscience ne s'applique plus.  C'est comme si on le faisait quand même.3

Nullification of freedom of conscience

This is a striking admission.  Dr. Bernardin's explanation is entirely consistent with the generally accepted view of culpable indirect participation discussed in Part 6.  However, it is not consistent with the Collège des médecins Code of Ethics.  Quebec is the only province in which the physician regulator demands that objecting physicians assist patients to obtain morally contested procedures.

The Collège's Code of Ethics requires that physicians who are unwilling to provide a service for reasons of conscience "offer to help the patient find another physician."4 The gloss provided by the Collège mentions abortion and contraception and emphasizes an expectation of active assistance by the objecting physician to locate, not just another physician, but the services themselves.5  The result is precisely what Dr. Bernard's found problematic; freedom of conscience is nullified.

Strictly speaking, the Code itself requires an offer of help, but does not specify what constitutes "help," nor does the gloss specify what is considered satisfactory assistance.  In the Project's experience, physicians who wish to avoid becoming morally complicit in a procedure are usually willing to provide a patient with general information, such as the address of a registry of physicians maintained on the website of a regulatory authority. It could be argued that this suffices for compliance with the Code, and it may be that, until now, neither patients nor the Collège have consistently tried to push for more.

Intuitive recognition of the problem

Be that as it may, the presentation of the officers of the Collège des médecins du Québec on this point exposed both the problem with the Collège Code of Ethics and their intuitive recognition of the problem.  As noted above, Dr. Bernard acknowledged that referral results in moral culpability. Thus, he was pleased with the provision in the bill (retained in ARELC)6 that requires a physician who refuses to provide euthanasia for reasons of conscience to notify the executive director of an institution or local authority.  Since the  executive director becomes responsible for finding a willing physician, Dr. Bernard felt that solved the problem of complicity, at least for the objecting physician.  Concerning this arrangement, he said, "We like it a lot."7

Sidestepping the problem

Dr. Bernard and his Collège colleague, Dr. Michelle Marchand, were pleased with the provision in the law because it sidestepped the problem they would otherwise face as a result of the requirement for referral in the Code of Ethics. 

Dr. Marchand noted the requirement in the Code of Ethics, but described the provision as "an obligation to transfer" (l'obligation de transférer).  An obligation to "transfer" does not necessarily involve the physician in finding a physician willing to take the patient; it can mean simply providing medical records to a physician who has been found by someone else.  This is not what the Code means, and she seems to have meant referral rather than transfer, so her terminology confuses the issue.  However, she, too, was pleased with the idea of collective or institutional rather than individual responsibility.

But it is conceivable that, when implementing a practice like this early on, the transfer will be difficult. So I think it's a good idea to make it the collective responsibility of physicians and facilities to make this possible, so that the patient ultimately is not deprived of a service that should be accessible.8

Her explanation actually underscores the signifcance of the earlier discussion of culpable indirect participation, and the problem with the Collège des médecins Code of Ethics.  Dr. Marchand said she expected difficulty "early on" in requiring transfer (i.e., referral, helping a patient to find a physician to provide a lethal injection), and thought this could be overcome by relieving physicians of individual responsibilty.

Why expect difficulty? 

Because she knew that some physicians believe that euthanasia is gravely wrong, and, for that reason, they would refuse to facilitate it even indirectly by referral. 

Why difficulty "early on"? 

Because she believed that, as time goes on, more and more physicians will accept euthanasia as a legitimate practice, and will have no objection to referral if they are unwilling to do it themselves.

Relieving physicians of what individual responsibility?

The responsibility imposed by the Collège's Code of Ethics on an objector to help the patient find a willing colleague.

A problematic responsibility

Dr. Marchand's concern about encountering difficulty was shared by Dr. Gaétan Barrette, then representing the Federation of Medical Specialists.  He emphasized that, in the case of conscientious objection, "someone in the system" should be responsible for finding a replacement, because if it were made the responsibility of the objecting physician "there will be too much opposition."9

Dr. Yves Bolduc was of the same opinion:

When a doctor decides he does not practice medical assistance to die and that at this time the patient should consult another doctor or another team , I must confess that I am of the school that says we should not ask doctors to find or even participate in it because it will be too complex. And what will happen is that while people are arguing , the patient will not receive treatment.10

The difficulties anticipated by Collège representatives, Dr. Barrette and Dr. Bolduc arise from the conflict between the Collège des médecins Code of Ethics and a fundamental ethical norm that all of them intuitively recognized.

No escape from the Code

The Minister of Health understood why the Collège des médecins liked Section 31 "a lot", but, unlike Dr. Bernard and Dr. Marchand, she recognized that the concomitant obligation in the Code of Ethics is not affected by ARELC:

 . . .you can imagine that doctors, who had some reservations about being forced at all costs to find another doctor, are very relieved to see that they are not alone, though, in the code of ethics, they have the obligation, so they are supported by the institution. So the idea there, is to find balance. (emphasis added)11

Recall that, in Part 7, we noted that the protection of conscience provision in ARELC appeared to provide objecting physicians with a much narrower exemption than other health care workers.  Physicians may only refuse  "to administer" euthanasia - a very specific action -  which seems to suggest that they are expected to participate in other ways.  And ARELC states that objectors must "ensure that continuity of care is provided. . . in accordance with their code of ethics." (emphasis added) 

Thus, whether or not an objecting physician conforms to Section 31 of ARELC by notifying an executive director of refusal to provide euthanasia, the Collège des médecins Code of Ethics can be cited to try to force them to facilitate MAD services by referral or other means, and this may actually be supported by the restricted exemption for physicians in Section 50, together with its reference to physicians' Code of Ethics.

It is interesting to note that this is consistent with what the Provincial Association of User Committees demanded during legislative hearings into Bill 52:

 We want to make sure that professionals who have responsibilities under the law must refer a user who wants to access terminal palliative sedation or medical assistance to die to another professional.  It should ensure that, even in private practice, and I know that you have discussed, a home care professional is required to redirect user who wants these forms of care to another professional.12

The Quebec Association of Health Facilities and Social Services was even more direct, quoting the Collège des médecins Code of Ethics in support of its demand:

So, the code of ethics of physicians, we know, that states that it is still the doctor, who must provide the patient with assistance in finding another doctor. So we must, of course, not disempower this premise and AQUESSS believes that it would be inappropriate  for the legislature to impose on the  [executive director] full responsibility to find a replacement when a doctor refuses his patient medical help to die. (emphasis added)13

The Association complained that on objecting physician who notified the executive director that he was refusing to provide euthanasia could thereby discharge his responsibility, which, they understood, "benefits the physician who refuses to refer the matter to someone else."  However, they were insistent:  "Do not relieve the doctor of responsibility in this process with the client and family."14

This seems to be what has happened.  Section 31 provides objecting physicians with an alternative to the demand in the Code of Ethics, and it may prove acceptable in many situations.  However, if push comes to shove, Section 31 of ARELC does not displace the demand for referral in the Code, and ARELC Section 50 can be understood to support it.

Other professions

Since the  Collège des médecins Code of Ethics conflicts significantly with the generally accepted view of culpable indirect participation discussed in Part 6, it is unfortunate that its mandatory referral provision was and continues to be used as a paradigm by other  professions.  Predictably, the intuitive recognition of the problem evident in the Collège presentation surfaced when the subject of freedom of conscience was raised with pharmacists.

Pharmacists

Representatives of the College of Pharmacists of Quebec told legislators that (like physicians) objecting pharmacists are required to help the patient find another pharmacist.  Their Code of Ethics states: 

Pharmacists must, where their personal convictions may prevent them from recommending or providing pharmaceutical services that may be appropriate, so inform their patients and explain the possible consequences of not receiving the services. Pharmacists must then offer to help the patients find another pharmacist.15

This appears to have developed as a result of conscientious objection to "emergency oral contraception."16 Véronique Hivon commented that this was "just like" the Collège des médecins Code of Ethics, but added that this did not impose an obligation "for results."17  That is, the Code imposes an obligation to help the patient find another pharmacist, not to ensure product delivery by another pharmacist. 

It does not appear that the full significance of this distinction was recognized by either representatives of College of Pharmacists of Quebec or the legislators.  The difference is important because a literal reading of the Code indicates that the obligation to help find another pharmacist can be discharged by referring the patient to a telephone book or a list of pharmacies in the area.  The experience of the Project is that most objectors are willing to direct the patient to this kind of publicly available information that is not specific to the provision of the morally contested service.  Since the majority of pharmacists do not object to dispensing oral contraceptives, telephone listings or a local list of pharmacies probably coincides more or less exactly with a list of oral contraceptive dispensers, so that this kind of general approach would likely result in the patient getting the drug.

That is not the case, however, with euthanasia drugs. Linda Vaillant, speaking for the Pharmacists Association of Health Facilities of Quebec, told the committee that Bill 52 caused discomfort for many members of the association because "[p]eople have really made ​​it clear they do not want them to be seen as people who help others to die."18

While she was representing pharmacists working in health facilities, it is not unreasonable to believe that unwillingness to being associated with euthanasia exists among pharmacists outside institutional walls.  In this context, committee member Stéphanie Vallée once more recognized the problem created by establishing a purported "right" to euthanasia:

 A pharmacist, for example, by conscientious objection does not stock the required drugs . . . the only pharmacist in a community that, for some reason very, very personal, says I, I do not intend to offer that service, so I will not order the medication, what do we do? . . . I understand that you want to respect this freedom, but at the same time, we have a bill that makes ... which gives a right, access to the entire territory of certain services, including medical assistance to die. So how can we reconcile the freedom of conscience in that context and the right as provided in the bill?19

Unfortunately, the position of the College of Pharmacists seems likely to exacerbate this tension.  It seems that, whatever the Code actually says, the College interprets it to mean that an objecting pharmacist must help to find a pharmacist willing to dispense lethal medication for the purpose of killing a patient (see the italicized section in the passage below).  Leaving aside the validity of the interpretation, the College anticipates more serious problems with requests for drugs for lethal injections or toxic milkshakes than it has encountered with requests for oral contraceptives.20 

On the human level now, indeed, we may end up with more problematic situations. And the idea of ​​having a system to facilitate, I would say, the inventory of pharmacists who are able to offer medical assistance to die, without placing the pharmacist in a situation he has to run after other pharmacists, we think it may be welcome in a case like this. But it is clear that we do not want to remove this obligation, the obligation to refer to another pharmacist, but if it occurred it would be difficult for him to do, well, a helping hand, just like what is done for doctors, could be welcome, especially considering that  you want a better quality of care for these patients. (emphasis added)21

The "helping hand" referred to here is Section 31 of ARELC, which allows an objecting physician to turn over to health system administrator the responsibility for finding someone willing to kill a patient.  The Pharmacists Association of Health Facilities of Quebec also supported the idea.  "We should not force [objecting pharmacists] to look for a colleague," said François Paradis. "I think it further complicates the process."22

As noted in Part 5, it was to avoid such problems that the Quebec College of Pharmacists suggested that regional health authorities canvas pharmacists in advance to identify those willing to provide euthanasia drugs.23 

Nurses

The Code of Ethics for Quebec nurses has no provison that recognizes freedom of conscience.24  Since, under ARELC, only physicians may actually kill a patient, the absence of such recognition may not seem important with respect to MAD services.  However, as the Quebec Order of Nurses pointed out, nurses are continuously and intimately involved with the care and treatment of patients.25  While they cannot be delegated the task of killing a patient, it is not unreasonable to believe that nurses may be asked to participate in euthanasia in other ways: by, for example, preparing the lethal injection, or monitoring vital signs to ensure that death occurs following the administration of lethal drugs.  Thus, as discussed in Part 6, there remain concerns about indirect but morally significant participation in killing.

Two provisions of the Code seem relevant to the case of a nurse who refuses to participate in certain activities for reasons of conscience.  The first states, "A nurse who is providing care and treatment to a client may not abandon him or her without a serious reason."26

Whether or not refusing to participate in euthanasia amounts to "patient abandonment" is disputed; euthanasia and assisted suicide advocates sometimes use such rhetoric in order to compel participation in the procedures.27

The second provision states that nurses must "take reasonable measures to ensure the continuity of care and treatment."28

Nurse representatives offered the following explanation:

. . . if a nurse is caring for a client, but has a conscientious objection in relation to a specific situation, as provided in the bill at this time she could [exercise] conscientious objection, but she should ensure that . . . there is a continuity of care so that you don't end up with a customer who does not receive care. . .29

In fact, this provision in their Code of Ethics imposes a duty to ensure not just continuity of care, but also continuity of "treatment," which, under ARELC's terms, would include killing a patient by administering lethal drugs.  Here, the distinction the nurses' Code makes between care and treatment is important, because, under Section 50 of ARELC, an objecting nurse is required to ensure only continuity of care.  Elsewhere, nurse representatives explained that nurses did not consider euthanasia to be "care," but "a procedure that terminates life."30 It thus seems that ensuring continuity of care should not be interpreted to require nurses to participate in euthanasia.  That does not mean that they will not be pressured to do so under the rubric of "continuity of care."

Examined emotions

Both the Collège des médecins and College of Pharmacists of Quebec anticipate problems arising from the requirements in their respective Codes of Ethics, apparently developed in response to conscientious objection to contraception and abortion, that physicians and pharmacists who refuse to provide services or procedures they believe to be wrong are obliged to help patients find someone who will provide them.  Of course, if it is legitimate to force objecting physicians to help patients obtain morally contested services or procedures like abortion, then it is legitimate to force them to help patients obtain euthanasia and assisted suicide.

Nonetheless, one detects discomfort about the problem created by their codes, and relief (in the case of the Collège des médecins) that ARELC may allow them to avoid it.  The intuitive awareness of the Colleges of the problems likely to arise in compelling objecting professionals to facilitate what they believe to be wrong warrants attention.  So, too, is their discomfort in contemplating the application of such a policy, and relief at the prospect of avoiding it.  Here we can apply a suggestion by Professor Margaret Somerville that "moral intuition" and "examined emotions" may provide valuable ethical insights by asking some questions.31

Whence the awareness of the problem?  Why the discomfort?  Why the relief?  

The most probable explanation is that, as a general rule,32 it is fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence.  It is thus a serious error to include such a requirement in a code of ethics.  College representatives were aware of this because, in the words of Project advisor Jay Budziszewski, this is one of those things we can't not know, though we may not know them "with unfailing perfect clarity" or have worked out "their remotest applications."33 

An absence of clarity or sufficient reflection may explain why this error was not apparent to College representatives with respect to contraception and abortion, but it became intuitively obvious to them when the subject shifted from facilitating access to birth control to facilitating the killing of patients.  This explains why they were uncomfortable and even doubtful about the wisdom of forcing objecting physicians and pharmacists to find colleagues willing to kill patients, and why they were relieved by the prospect that they might be able to sidestep the problem. 

A dangerous idea

When one works out the remote applications of the policy of mandatory referral for contraception and abortion adopted by Quebec regulatory authorities, it becomes clear that it is not only erroneous, but dangerous.  It establishes the principle that a learned or privileged class, a profession or state institutions can legitimately compel people to do what they believe to be wrong - even gravely wrong - and punish them if they refuse.  It purports to entrench  a 'duty to do what is wrong' in medical practice, which, through ARELC, is to include a duty to kill or facilitate the killing of patients.  One of the leading proponents of this view is Professor Jocelyn Downie of Dalhousie University.

Mandatory referral for abortion

In 2006 Professor Downie was one of two law professors who wrote a guest editorial in the Canadian Medical Association Journal claiming that physicians who refuse to provide abortions for reasons of conscience had an ethical and legal obligation to refer patients to someone who would. This elicited a flood of protest, and the CMA reaffirmed its position that objecting physicians were not obliged to refer for the procedure, repeating the affirmation in 2008. The negative response to the editorial from the medical profession convinced Professor Downie that policy reform by the CMA was unlikely, so she turned her attention to provincial regulatory authorities to persuade them to force the medical profession to conform to her views.34

Mandatory referral for assisted suicide/euthanasia

Professor Downie was also a member of the "expert panel" of the Royal Society of Canada that, five years later, recommended legalization of assisted suicide and euthanasia. The panel conceded that health care workers may object to providing euthanasia or assisted suicide, and that compelling them to do so might constitute a limitation of their "liberty or freedom of conscience and religion." For these reasons, Professor Downie and her expert colleagues recommended that health care professionals who object to euthanasia and assisted suicide should be compelled to refer patients to someone who would provide the procedures.35

Their explanation:

Today's procedural solution to this problem is, in Canada as well as many other jurisdictions, that health care professionals may provide certain reproductive health services that some religious health care professionals object to on conscientious grounds, however, they do not have to provide those services, in case the provision of those services would violate their conscience. Such objecting health care professionals are required to transfer an assistance seeking person on to other health care professionals who will provide the required services in a timely manner. The underlying rationale for this procedural solution lies in this kind of reasoning: If only health care professionals are permitted to provide assistance but they are not obligated to do so, then their autonomy is not limited but the autonomy of those seeking assistance could potentially be unfairly limited. Hence the requirement on conscientious objectors to refer assistance seekers to colleagues who are prepared to oblige them.36

Two points warrant attention here.

The first is that the panel argued that, because it is agreed that we can compel objecting health care professionals to refer for abortion, we are justified in forcing them to refer for euthanasia.

The second and more remarkable point is that, outside of Quebec, there is, in fact, no agreement that objecting health care professionals should be compelled to refer for abortions. Given the repudiation of her views by the CMA, Professor Downie must have been aware of that. This inconvenient fact was left out, apparently to make it appear that compulsory referral for euthanasia and assisted suicide is an entirely reasonable and uncontested "procedural solution" to the "problem" caused by people who refuse to do what they believe to be wrong. Presumably this accounts for the absence of any cited reference to back up their assertion.

Two perspectives on killing patients

We have seen that, as a matter of Canadian constitutional law, ARELC does not affect Canadian criminal law. Hence, no matter what ARELC purports to do, killing patients under the conditions specified by the act would constitute first degree murder (murder that is "planned and deliberate"37) and anyone counselling, aiding, abetting the killing (by referral, for example) would be considered a party to the offence.38

Now, it is not inconceivable (and this is the hope of the Quebec government) that a court might rule that killing a patient in accordance with ARELC is not murder under the criminal law. An undetermined number of physicians and health care workers would then begin or continue with killing patients under the terms of the law, in the belief that what they were doing was not only legal, but morally acceptable. In a sense, this would not be remarkable, because that sort of thing has happened in the past, and it is happening now, in Belgium and the Netherlands, for example.

Nonetheless, there is no doubt that most of those opposed to the bill in principle would, despite the ruling of the court, continue to consider euthanasia to be (morally) planned and deliberate murder. Having this view, it would come as no surprise if they were to refuse to kill patients or refuse to encourage or facilitate the killing of patients by counselling, referral or other means. And this would not be remarkable, because this has also happened in the past.

Normalizing mandatory participation in killing

It is at this point that one realizes the unique character of the 'duty to do what is wrong' movement, exemplified by Professor Downie and enshrined in the Collège des médecins du Québec Code of Ethics. Recall that, for Professor Downie and the other Royal Society panel of experts (and those who share their views) it is not sufficient to simply encourage and allow willing health care professionals to kill patients. They demand that health care professionals be compelled to participate in and facilitate the killing of patients - even if they believe it to be wrong, even if they believe it to be murder - and that they should be punished if they refuse to do so. This is quite extraordinary, even if there are precedents for it.

Killing is not surprising; even murder is not surprising. It has even been said that there is something uniquely human about murder. But to hold that the state or a profession can, in justice, compel an unwilling soul to commit or even to facilitate what he sees as murder, and justly punish or penalize him for refusing to do so - to make that claim ought to be beyond the pale.  If the state or civil society or professional organizations can legitimately require people to commit or aid in the commission of murder, what can they not require?

At the crossroads

This is the ultimate problem that comes of establishing a 'duty to do what is wrong' in medical practice.  It typically begins, as it began in Quebec, by forcing objecting physicians or pharmacists to help patients obtain contraceptives or abortion.  These services are so popular that many people are willing to nullify freedom of conscience among health care workers so that they can have access to them on demand.

But, as illustrated by the response of the Collège des médecins and Quebec College of Pharmacists to ARELC, forcing physicians and pharmacists to facilitate the provision of contraception and abortion is a dress rehearsal for forcing them to facilitate euthanasia and assisted suicide, because both policies are supported by the same erroneous principle: that some authority can impose a duty to do what one believes to be wrong, or that the acceptance of such a duty can be made a condition membership in a profession.

Quebec's medical establishment can correct the error by removing the mandatory referral provisions of their codes of ethics that nullify freedom of conscience.  This would prevent objecting physicians and pharmacists from being cited for professional misconduct for refusing to facilitate euthanasia.  However, it would also prevent them from being disciplined for refusing to facilitate other procedures to which they object for reasons of conscience, including contraception and abortion.  Unfortunately, correcting the error would almost certainly antagonize consumers who have been conditioned to expect health care workers to set aside moral convictions and provide or at least facilitate provision of contraception and abortion.

It remains to be seen whether or not the Quebec medical establishment will maintain the erroneous provisions, preferring to force objecting health care workers to become parties to homicide rather than risk occasionally inconveniencing people, such as the young Ontario woman and her supporters who were outraged because she had to drive around the block to obtain The Pill.39 

Notes

1.  Committee on Health and Social Services of the Quebec National Assembly, Consultations & hearings on Quebec Bill 52 (Hereinafter "Consultations"), Thursday, 26 September 2013 - Vol. 43 no. 39: Interprofessional Health Federation of Quebec  (Régine Laurent, Julie Martin, Michàle Boisclair, Brigitte Doyon), T#055

2..  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34:  Collège des médecins du Québec (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#141(a)

3.  Consultations: Tuesday 17 September 2013 - Vol. 43 no. 34: Collège des médecins du Québec, (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#154

4..  Collège des médecins du Québec, Code of Ethics of Physicians, para. 24 (Accessed 2013-06-23)

5.   "For example, a physician who is opposed to abortion or contraception is free to limit these interventions in a manner that takes into account his or her religious or moral convictions. However, the physician must inform patients of such when they consult for these kinds of professional services and assist them in finding the services requested." Collège des médecins du Québec, Legal, Ethical and Organizational Aspects of Medical Practice in Québec. ALDO-Québec, 2010 Edition, p. 156. (Accessed 2013-06-23)

6.  ARELC, Section 31.

7.   Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34:  Collège des médecins du Québec (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#154

8.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34:  Collège des médecins du Québec (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#156

9.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of Quebec Medical Specialists (Dr. Gaétan Barrette, Dr. Diane Francoeur, Nicole Pelletier), T#076

10.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#087

11.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#032

12.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Provincial Association of User Committees (Claude Ménard, Pierre Blain), T#012

13.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#017

14.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#038

15.  Code of Ethics of Pharmacists (Quebec), Section 26 (Accessed 2014-08-12)

16.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#047

17.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#074

18.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Pharmacists Association of Health Facilities of Quebec  (François Paradis, Linda Vaillant)T#031

19.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#053

20.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#080

21.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#081

22.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Pharmacists Association of Health Facilities of Quebec  (François Paradis, Linda Vaillant)T#020

23.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#063

24.  Code of Ethics of Nurses (Quebec)  Accessed 2014-07-23

25.  Consultations, Tuesday, 8 October 2013 - Vol. 43 no. 44: Quebec Order of Nurses (Lucie Tremblay, Claudia Gallant, Suzanne Durand, Sylvie Truchon), T#021

26.  Code of Ethics of Nurses (Quebec), Section 43  (Accessed 2014-07-23)

27.  For example, the testimony of Prof. Margaret Battin referred to at Paragraph 239 in Carter v. Canada (Attorney General) 2012 BCSC 886. Supreme Court of British Columbia, 15 June, 2012. Vancouver, British Columbia.

28.  Code of Ethics of Nurses (Quebec), Section 44(3)  (Accessed 2014-07-23)

29.  Consultations, Tuesday, 8 October 2013 - Vol. 43 no. 44: Quebec Order of Nurses (Lucie Tremblay, Claudia Gallant, Suzanne Durand, Sylvie Truchon), T#064

30.  Consultations, Tuesday, 8 October 2013 - Vol. 43 no. 44: Quebec Order of Nurses (Lucie Tremblay, Claudia Gallant, Suzanne Durand, Sylvie Truchon), T#099

31.  "Although feelings can sometimes be misleading in terms of ascertaining what is and is not acceptable conduct (as indeed can rationality, which we have sometimes found to our sorrow), we ignore feelings at our peril.  We need to take into account 'examined emotions'. . ." Somerville, Margaret, Death Talk: The Case against Euthanasia and Physician-Assisted Suicide.  McGill-Queens University Press, 2001, p. 75-76.

32.  "As a general rule," since exceptions might be imagined, as in the case of a delusional driver who refuses to stop for red lights.  However, the general rule states the default position, and a serious burden of proof lies on those who want to set it aside in particular cases.  Murphy S, Genuis SJ, "Freedom of Conscience in Health Care: Distinctions and Limits." Journal of Bioethical Inquiry, October 2013,  Vol. 10 No. 3, p. 347-354  

33.  "However rude it may be these days to say so, there are some moral truths that we all really know - truths which a normal human being is unable not to know.  They are a universal possession, the emblem of a rational mind, an heirloom of the family of man.  That doesn't mean that we know them with unfailing perfect clarity, or that we have reasoned out their remotest implications; we don't and we haven't.  Nor does it mean that we never pretend not to know them even though we do, or that we never lose our nerve when told they aren't true; we do, and we do.  It doesn't even mean that we are born knowing them, that we never get mixed up about them, or that se assent to them just a readily whether they are taught to us or not.  That can't even be said of 'two plus two is four.'"  Budziszewski J., What We Can't Not Know: A Guide.  Dallas: Spence Publishing, 2003, p. 19.

34.  "(We decided to proceed by way of these provincial regulatory bodies rather than the CMA, in part, because of the negative reaction of the CMA to the Rodgers/Downie editorial, which made policy reform by the CMA seem unlikely.)" McLeod C, Downie J. "Let Conscience Be Their Guide? Conscientious Refusals in Health Care." Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12075 Volume 28 Number 1 2014 pp ii–iv

35.  Schuklenk U, van Delden J.J.M, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011) p. 101 (Accessed 2014-02-23)

36.  Schuklenk U, van Delden J.J.M, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011) p. 62 (Accessed 2014-02-23)

37.  Criminal Code (R.S.C., 1985, c. C-46) (Hereinafter "CC") Section 231(2). (Accessed 2014-02-24)

38.  CC, Section 745(a); CC, Section 21(b); CC, Section 21(c); CC, Section 22 (Accessed 2014-02-24)

39.  Murphy, S. "NO MORE CHRISTIAN DOCTORS": Crusade against NFP only physicians.  Protection of Conscience Project