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D1.    CMA policy: Euthanasia and Assisted Death (2014)

D1.1    The policy of the Canadian Medical Association (CMA) on euthanasia and physician assisted suicide (which the CMA calls "assisted death") does not exclude minors, the incompetent or the mentally ill, and the policy is not meant to apply only to the terminally ill or those with uncontrollable pain. It refers directly only to "patients" and "the suffering of persons with incurable diseases." The policy, which predates the Carter ruling, classifies euthanasia and assisted suicide as "end of life care." Under this rubric, the CMA supports patient access to euthanasia and assisted suicide for any patient group for any reason and under any circumstances approved by the courts or legislatures.1

D1.2    By formally approving physician assisted suicide and euthanasia under circumstances defined by law, the Association has taken the position that, in those circumstances, physicians have a professional obligation to kill patients or to help them kill themselves.2 By describing this as "end of life care," the CMA has made homicide and suicide normative for the medical profession. It is the refusal to kill patients or assist in suicide in the circumstances set out in Carter that must be justified or excused as an exception to professional obligations.

D1.3    Thus, the CMA is prepared to support the exercise of freedom of conscience and religion by objecting physicians only to the extent that this does not compromise patient access to euthanasia and assisted suicide. However, it sets no limits on what non-objecting physicians might agree to do beyond what might be set by law. Notwithstanding claims that the Association supports both physicians willing to provide euthanasia and assisted suicide and those who do not, the weight and influence of the entire Association has been set against physicians who believe that it is wrong to kill patients or help them to kill themselves, or, at least, that physicians should not do so.

D1.4    The formal support of the CMA for a euthanasia/assisted suicide regime even broader than that proposed in Carter appears to be in tension with the opinions of many CMA members, not just objecting physicians.  Unlike the Experts, Canadian physicians are anything but unanimous in their opinions about euthanasia and physician assisted suicide, and support for the Carter decision among them is hardly unqualified.  This has been obscured by a habit of  presenting the most optimistic view of physician support for the procedures.

D1.5    Both the habitually optimistic approach and the volatile nature of the opinions of physicians were evident in the analysis of CMA surveys offered to delegates at the Annual  General Council (AGC) in August, 2015.  

D2.    CMA Annual General Council, 2015

D2.1    Surveys on support for euthanasia/assisted suicide

D2.1.1    A report prepared by CMA officials stated that "recent polls show that CMA members are evenly divided on the issue of legalizing assisted dying, and a significant minority of respondents to these polls said they will participate in offering this service to their patients."3 The report referred to an on-line dialogue in which 595 CMA members (less than 1% of the CMA's 80,000 members) "registered to participate."4 It did not acknowledge that only about 150 physicians contributed comments to the dialogue. 

D2.1.2    The details were provided in a presentation by Dr. Jeff Blackmer at the AGC. Most of his presentation drew from two on-line surveys of about 1.75% and .465% of the CMA membership. 

D2.1.3    Using slides, he produced what he called "the key on-line survey results" of a poll taken after the Carter ruling. The 2015 survey to which he referred appears to be the on-line survey consultation survey completed by 1,407 physicians.5 The question asked was, "Following the Supreme Court of Canada decision regarding medical aid in dying, would you consider providing medical aid in dying if it was requested by a patient?"6

D2.1.4    The survey question did not distinguish between assisted suicide or euthanasia, so we do not know if the respondents believed that they were answering a question about euthanasia, assisted suicide or both.

D2.1.5    From the very first, reports about the Carter decision in the major media constantly and almost uniformly described the decision as legalizing physician assisted suicide, with no reference to euthanasia. Dr. Blackmer himself, two weeks after the ruling, claimed that he was uncertain whether the Court legalized only physician assisted suicide, or euthanasia as well.7

D2.1.6    Since significantly fewer physicians are willing to provide euthanasia than assisted suicide,8 the failure to distinguish between them introduces some uncertainty into the interpretation of the results.

D2.1.7    Note that the survey asked only if physicians would "consider" providing the procedures, not if they would actually do so.

D2.1.8    29% of those surveyed stated that they would "consider" it. "That might seem to be a very small percentage," Dr. Blackmer said, "but when you think of it in terms of absolute numbers, we're talking tens of thousands of Canadian physicians that are now saying, 'I will participate.'"9

D2.1.9    Here we see the habitual optimism noted above (D1.4). In fact, the respondents stated that they would "consider" participating, not that they would participate. Further, while "tens of thousands" was arithmetically accurate (29% of 80,000 = 23,200 physicians = 2 x 10,000), the rhetorical slant was toward an optimistic evaluation of the returns.

D2.1.10    Continuing to 'unpack' the survey results, Dr. Blackmer told delegates that, of the physicians willing to consider providing either euthanasia or assisted suicide, "only 20% said yes" with respect to "someone whose suffering was purely psychological." The actual number noted in the chart on the slide was 19%, not 20%. He acknowledged that the response from this statistical subset represented about 6% of the total number of respondents.10

D2.1.11    "And when we asked, 'Would you provide medical aid in dying to someone who is not suffering from a terminal illness,' he said, '43% said yes.'"11

D2.1.12    Dr. Blackmer did not draw attention to the fact that this appears to represent only about 14% of the total number of respondents. His slides illustrated the responses proportionate to the subset, not to the total number of respondents, so the graphic images reflected proportionately greater support for euthanasia and assisted suicide among respondents (19% vs. 6%; 43% vs. 14%).

D2.1.13    The slides in the video below draw on the same data used by Dr. Blackmer in the preceding slides, but graphically represent the increasingly adverse responses to the conditions specified by the survey questions.

D2.1.14    An alternative and arguably more useful rendering of the 2015 survey results is possible.12

● The number of physicians willing to provide euthanasia or assisted suicide appears to range from 6% to 29%, depending upon the condition of the patient, and excluding consideration of safeguards.

● The number of physicians unwilling to provide euthanasia or assisted suicide ranges from 63% to 78%, again depending upon the condition of the patient, and excluding consideration of safeguards.

● Of physicians willing to consider providing euthanasia or assisted suicide, the number willing to provide the procedures for non-terminal illness drops by almost 50% , and drops by almost 80% in the case of purely psychological suffering (i.e., in the absence of pain), excluding consideration of safeguards.

D2.1.15    Dr. Blackmer presented a much more optimistic view.  He showed delegates a slide with pie charts side by side for the purpose of comparing surveys done in 2014, before the Carter ruling, and in 2015, after it.  Delegates had 24 seconds to take in the following charts and his commentary before he moved to the next slide.

Blackmer: So this is before the court decision and after the court decision. And you can see that the number of participants who said that they were very likely or likely to participate in assisted dying has actually gone up, from 24% to 29% since the Supreme Court decision.13

D2.1.16    He did not point out that the number of physicians unwilling to consider providing the service also went up by 5% after the Carter ruling, from 58% to 63%.

D2.1.17    Again, the survey question asked physicians if they would consider providing the services, but Dr. Blackmer presented the responses as indicative of the number of physicians actually willing to do so.  

D2.1.18    Apparently to reinforce the message he wanted to get across, Dr. Blackmer introduced slides to present data from a survey of family physicians concerning the Carter decision.14 He cautioned delegates that "the numbers are a little smaller."15 A "little smaller" seems to minimize the difference: 372 members compared to 1,407.

D2.1.19   In any case, Dr. Blackmer told delegates that "59% of members actually said, 'Yes, I agree with that,' so over half of physicians agreed with the Supreme Court decision."16

Blackmer:  And when they asked, "Would you help a competent, consenting patient end his or her life," a total of 66% actually said "yes," although most of those - 54% - said, "Yes, but only if appropriate and rigorous checks and balances are in place.17

D2.1.20    Assuming both slides drew from 372 responses, more physicians agreed with the Carter decision than were willing to provide assisted suicide and euthanasia. 27% disagreed with the decision, but 33% said they would "never" help patients end their lives.

D2.1.21    On the other hand, willingness to provide euthanasia or assisted suicide was conditional. As Dr. Blackmer noted, 66% were willing to do so, but the number dropped to 12% in the absence of "appropriate rigorous checks and balances."

D2.1.22    Most important, Dr. Blackmer left out one critical word. The actual question (as stated on the slide) was, "Would you help a competent, consenting DYING patient end his or her life." (Emphasis added)

D2.1.23    The CMA's larger survey demonstrated that support for euthanasia and assisted suicide among physicians willing to provide it can drop by almost 50% if the patient is not terminally ill (D2.1.12-D2.13).  The slide was displayed for only about 15 seconds, so it is doubtful that many delegates had a chance to reflect on the fact that the survey asked only about dying patients.

D2.1.24    An alternative and more cautious account of the College of Family Physicians survey results is possible.

D2.1.25    Taking time to look at the numbers just as they were presented, they did not support the claim that physicians were "evenly divided" in their opinions about euthanasia and assisted suicide. The returns indicated that the great majority of physicians were opposed to both. Moreover, support for the procedures among favourably disposed physicians was highly volatile, depending heavily upon the diagnosis, the condition of the patient and the rigour of the regulatory regime.

D2.1.26    This was reflected in the Globe and Mail headline: "Less than a third of doctors willing to aid in assisted dying."18 The National Post response was similar: "Majority of doctors opposed to participating in assisted death of patients."19 The Canadian Medical Association Journal acknowledged that "Many doctors won't provide assisted dying."20

D2.2    Physician freedom of conscience

D2.2.1    Dr. Blackmer introduced what he described as "the very complex and difficult issue of conscientious objection" with the results of the on-line survey.21 With respect to the question of what a physician who refuses to provide euthanasia or assisted suicide should be required do, "the most popular response" (29%) was, "They should not be required to do anything."

D2.2.2    25% of the responses were categorized as "other"; this was unexplained at the General Council.22  The CMA kindly provided the Project with the summary of the returns under the category "Other," broken down as follows:

D2.2.3    When joined to the information that was disclosed at the Annual General Council (approximated in the Project chart below), it appears that the great majority of respondents (about 68%) clearly believed that objecting physicians should not be required to refer patients for anything other than information.

D2.2.4    "Effective referral" was favoured by 19% of respondents, 10% less than the number of physicians who identified themselves as willing to consider providing euthanasia or assisted suicide (D2.1.3).

D2.2.5    Returning to the subject later in his presentation, Dr. Blackmer noted that "the vast majority expressed the view that physician conscience rights must be integrally protected." He reminded delegates of the resolution passed at the 2013 Annual ' Council "saying that no physician should be forced to participate in an assisted dying against their moral conscience," adding that "the Supreme Court noted that in their ruling." However, he cautioned that "there was disagreement about was this means."23 Finally, he stated that there was "broad agreement" that physician freedom of conscience "must be protected in a way that balances patients' ability to access assisted dying."24

D2.2.6    Here he referred to four options for physicians who refuse to provide euthanasia or assisted suicide, somewhat different from those presented in the on-line consultation:25

1. Duty to refer directly to a non-objecting physician

2. Duty to refer to an independent third party.

3. Duty to provide complete information on all options and advise on how to access directly a separate central information, counselling and referral service.

4. Patient self-referral to a separate central information, counselling and referral service.

D2.2.7    In listing the "pros" and "cons" of each, he acknowledged that the third "may be the most widely morally acceptable option," but warned that it presupposed the existence of a separate counselling service - "a fairly large presupposition at this point in time."26

D2.2.8    The third option was a summary of what had been proposed to the CMA by the Christian Medical Dental Society, the Federation of Catholic Physicians Societies and Canadian Physicians for Life. The groups urged delegates to accept it for the following reasons:

Options '1' and '2' require the objecting physician to refer. Many physicians will have moral convictions that assisted death is never in the best interests of the patient, while others may object to assisted death because of the particular circumstances of the patient.  A referral is essentially a recommendation for the procedure, and facilitates its delivery. A requirement to refer means that physicians will be forced to act against their consciences.

Option '4' allows the patient to directly access assisted death, but does not necessarily provide an opportunity for counselling by a physician who has a longer term relationship with the patient.

Option '3' allows the discussion of all options to occur with the patient and the physician who knows them. If, after considering all of the options, the patient still wants assisted death, the patient may access that directly. This option ensures that all reasonable alternatives are considered. It respects the autonomy of the patient to access all legal services while at the same time protecting physicians' conscience rights.27

D2.2.9    After a lengthy discussion, the third option was approved in a straw poll, supported by about 75% of the delegates, who agreed that "physicians should provide information to patients on all end-of-life options available to them but should not be obliged to refer."18

D2.2.10    This account of the outcome is consistent with the fact that only the first two options included a "duty to refer," while the third did not.  A further point, which would not have been apparent to the delegates at the time, was that the outcome reflected the (undisclosed) fact that 69% of survey respondents had indicated that they were opposed to a requirement to refer to someone who would provide euthanasia or assisted suicide (D2.2.3).

D2.2.11    The day after the delegates approved the third option (a duty to provide information), Dr. Ken Burns and Dr. Shawn Whatley proposed another resolution specific to referral:

The Canadian Medical Association policy on physician-assisted death will reflect that physicians with consciencious [sic] objections should not be obligated to refer for medical aid in dying. [Motion DM 5-60]28

D2.2.12    The rationale offered in support of the motion repeated the kind of arguments made the day before:

CMA has indicated (survey and draft document) that referral is an acceptable method to deal with a physician's conscience conflict. This not true for many physicians. A forced referral (even through another party) for a procedure they believe is wrong is not protecting conscience. CMA has opposed the College of Physicians and Surgeons of Ontario's new policy but appears to be backing down in its position. ' Council needs to decide if it is going to protect even a minority of members' legal rights.

A very large number of CMA membership see any form of forced referral against their conscience.They expect their organization to support their fundamental rights.29

D2.2.13   However, after significant opposition from a number of delegates, the motion was defeated, 79% of them voting against it.30

D2.2.14   The most likely explanation for this is the terminological problem that plagues discussion about "referral." It has a technical meaning: a letter written by a physician to another physician requesting treatment examination. It also has a popular meaning: some kind of informal direction to a patient about where to obtain or how to find a service or treatment. It is likely that many of the delegates who had, the day before, approved the third option, considered it to be a form of referral in the second sense. In that case, they likely rejected the resolution because it appeared to them to contradict what they had approved the previous day.

D2.2.15    Unfortunately, the rejection of the second motion created the impression in some quarters that the CMA was opposed to physician freedom of conscience. For example, Alex Schadenburg of the Euthanasia Prevention Coalition reported that the CMA "voted to reject a motion to protect the conscience rights of physicians who refuse to refer patients to die by euthanasia."31 The Western Catholic Reporter published a story quoting Mr. Schadenburg under the headline, "Doctors to lose conscience rights under CMA decision."32

D2.2.16   At their October, 2015 meeting, the CMA Board of Directors approved Principles-based Recommendations for a Canadian Approach to Assisted Dying as amended in consequence of the discussion at the Annual ' Council.33 The section on conscientious objection stated:

Physicians are not obligated to fulfill requests for assisted dying. There should be no discrimination against a physician who chooses not to participate in assisted dying. In order to reconcile physicians' conscientious objection with a patient's request for access to assisted dying, physicians are expected to provide the patient with complete information on all options available to them, including assisted dying, and advise the patient on how they can access any separate central information, counseling, and referral service.34

D2.2.17    This was included the the CMA presentation on 20 October, 2015 to the panel appointed by the federal government to report on the implementation of the Carter ruling. The CMA offered the following comments:

As the Federal External Panel is aware, the Carter decision emphasizes that any regulatory or legislative response must seek to reconcile the Charter rights of patients (wanting to access assisted dying) and physicians (who choose not to participate in assisted dying on grounds of conscientious objection). The notion of conscientious objection is not monolithic. While some conceptions of conscience encompass referral, others view referral as being connected to, or as akin to participating in, a morally objectionable act.

It is the CMA's position that an effective reconciliation is one that respects, and takes account of, differences in conscience, while facilitating access on the principle of equity. To this end, the CMA's membership strongly endorses the recommendation on conscientious objection as set out in section 5.2 of the CMA's enclosed Principles-based Recommendations for a Canadian Approach to Assisted Dying.35

D2.2.18    The section in the document concerning conscientious objection was later modified by the Board of Directors.  The revision did not change the original section (in blue font below), but added further details.

Physicians are not obligated to fulfill requests for assisted dying. This means that physicians who choose not to provide or participate in assisted dying are not required to provide it or participate in it or to refer the patient to a physician or a medical administrator who will provide assisted dying to the patient. There should be no discrimination against a physician who chooses not to provide or participate in assisted dying.

Physicians are obligated to respond to a patient’s request for assistance in dying. There are two equally legitimate considerations: the protection of physicians’ freedom of conscience (or moral integrity) in a way that respects differences of conscience and the assurance of effective patient access to a medical service. In order to reconcile physicians’ conscientious objection with a patient’s request for access to assisted dying, physicians are expected to provide the patient with complete information on all options available, including assisted dying, and advise the patient on how they can access any separate central information, counseling, and referral service.

Physicians are expected to make available relevant medical records (i.e., diagnosis, pathology, treatment and consults) to the attending physician when authorized by the patient to do so; or, if the patient requests a transfer of care to another physician, physicians are expected to transfer the patient’s chart to the new physician when authorized by the patient to do so.

Physicians are expected to act in good faith, not discriminate against a patient requesting assistance in dying, and not impede or block access to a request for assistance in dying.36

D3.    CMA rejects "effective referral"

D3.1    The Canadian Medical Association has continually grappled with the issue of referral for morally contested procedures since at least 1970, when the CMA Board of Directors decided that it would be ethical for a physician to refer a patient to another physician for consideration of an abortion, but not to an "abortion counselling agency."37  The difficult compromise eventually arrived at required objecting physicians to disclose personal moral convictions that might prevent them from recommending a procedure to patients, but did not require the physician to refer the patient or otherwise facilitate the morally contested procedure.38

D3.2    It appears that the compromise was primarily a pragmatic response to controversy.  At any rate, the CMA did not offer a principled ethical or philosophical rationale to support it, beyond general references to the need to "strike a balance" between patient and physician autonomy or rights.  In 2014/2015, when the  College of Physicians and Surgeons of Ontario (CPSO) developed a policy requiring objecting physicians to make an "effective referral," the CMA was notably absent from the public controversy surrounding it.

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.39

D3.3    However, a crisis of sorts seems to have been generated by the Carter ruling, as physicians awakened to its implications for freedom of conscience and religion and even for the legitimate diversity of clinical judgement.  Within this context, the perennially controversial issue of referral became more urgent, with literally life or death consequences attached to it.  Perhaps as a result, the CMA has now issued a statement that articulates the basis for its rejection of "effective referral," this time in response to CPSO plans to impose "effective referral" for euthanasia and assisted suicide.40

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Notes:

1. Canadian Medical Association Policy: Euthanasia and Assisted Death (Update 2014) (Accessed 2015-06-26).

2.  Blackmer J, Francescutti LH, "Canadian Medical Association Perspectives on End-of-Life in Canada." HealthcarePapers, 14(1) April 2014: 17-20.doi:10.12927/hcpap.2014.23966

3. Canadian Medical Association, A Canadian Approach to Assisted Dying: A CMA Member Dialogue Summary Report. (August, 2015) p. 2 (Accessed 2015-10-23). (Hereinafter, "Summary Report").

4.  Summary Report, p.2.

5.  Canadian Medical Association Annual General Council 2015, Education session 2: Setting the context for a principles-based approach to assisted dying in Canada. Webcast- 13:40-13:45.  (Hereinafter "Ed2-webcast")(Accessed 2015-12-29)

6.  Ed2-webcast - 15:00-15:22

7.  Kirkey S. "How far should a doctor go? MDs say they ‘need clarity' on Supreme Court's assisted suicide ruling."  National Post, 23 February, 2015 (2015-07-04)

8.  In a 2014 poll of 5,000 CMA members, 27% of physicians surveyed said they were willing to participate in assisted suicide, while 20% were willing to participate in euthanasia. Assuming that the results can be applied to the whole Association, that indicated about 21,600 physicians available for assisted suicide and 16,000 for euthanasia. Moore E. "Doctor is hoping feds will guide on assisted suicide legislation." Edson Leader, 12 February, 2015. (Accessed 2015-07-16).

9.  Ed2-webcast - 15:00-15:22

10.  Ed2-webast - 15:23 - 15:39

11.  Ed2-webast - 15:42 - 15:51

12.  Assuming, (a) that those who would provide euthanasia or assisted suicide for terminal illness make up the 10% difference between 19% and 29% of the subset of willing physicians, and (b) that those willing to provide euthanasia and assisted suicide for psychological suffering would also be willing to provide the services for the non-terminally ill and the terminally ill, though the reverse would not necessarily hold.

13.  Ed2-webcast - 16:50-17:13

14.  https://www.cfpc.ca/uploadedFiles/Health_Policy/_PDFs/ePanel_psa_results_EN.pdf

15.  Ed2-webcast - 17:20-17:25.

16.  Ed2-webcast - 17:14-17:38.

17.  Ed2-webcast - 17:38-17:55.

18.  Picard A. "Less than a third of doctors willing to aid in assisted dying: CMA poll." Globe and Mail, 25 August, 2015 (Accessed 2015-10-22).

19.  Kirkey S. "Majority of doctors opposed to participating in assisted death of patients: CMA survey." National Post, 25 August, 2015. (Accessed 2015-10-22).

20.  Vogel L. "Many doctors won't provide assisted dying." CMAJ, 31 August, 2015 (Accessed 2015-10-22).

21.  Ed2-webcast - 20:09.

22.  Ed2-webcast - 15:53-16:22.

23.  Ed2-webcast - 20:09-20:41.

24.  Ed2-webcast - 20:41-20:50.

25.  Ed2-webcast - 16:22-16:31.

26.  Ed2-webcast - 22:29-22:50.

27.  Christian Medical and Dental Society, Doctors' Group urges Canadian Medical Association to defend conscience rights on assisted death. News release, 24 August, 2015 (Accessed 2015-10-23)

28.  Canadian Medical Association, 148th Council Delegates' Motions - End-of-life Care
(Accessed 2015-10-23).

29.  148th ' Council Delegates' Motions - End-of-life Care. Accessed 2015-10-23

30.  Rutka J. "Conscientious objections, referral for assisted dying prove controversial topics at CMA meeting ." Canadian Health Care Network, 26 August, 2015

31.  Schadenburg A., "Canadian Medical Association delegates rejects conscience rights for physicians with regard to euthanasia." (Accessed 2015-10-23).

32.  Gyapong D. "Doctors to lose conscience rights under CMA decision." Western Catholic Reporter, 14 September, 2015 (Accessed 2015-10-23).

33.  Canadian Medical Association, Board of Directors October 2015 Meeting Highlights (Accessed 2015-10-23)

34.  Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying, Foundational Principle 2  (Accessed 2015-11-24).

35.  Canadian Medical Association, Submission to the Federal External Panel on Options for a Legislative Response to Carter vs. Canada (Federal External Panel) 19 October, 2015 (Accessed 2015-10-24)

36.  Canadian Medical Association,  Principles-based Recommendations for a Canadian Approach to Assisted Dying (2016) (Accessed 2016-01-09).

37.  Board of Directors Meeting: "Therapeutic Abortion Study Major Association Project: Finance Committee Reports Mild Optimism for Year." CMAJ Volume 103(11) 1218, November 21, 1970. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1930622/pdf/canmedaj01607-0085.pdf) Accessed 2015-06-17

38.  Murphy S.  "NO MORE CHRISTIAN DOCTORS,  Appendix 'F' - The Difficult Compromise. Canadian Medical Association, Abortion and Freedom of Conscience." Protection of Conscience Project

39.  College of Physicians and Surgeons of Ontario, Professional Obligations and Human Rights (March, 2015) (Accessed 2015-12-28).

40.  Canadian Medical Association, "Submission to the College of Physicians and Surgeons of Ontario: Consultation on CPSO Interim Guidance on Physician-Assisted Death"(13 January, 2016) (Hereinafter "CMA Submission")