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Submission to the Canadian Medical Association

Re: 2018 Revision of the CMA Code of Ethics

2 April, 2018


VIII.    Postscript: torture

VIII.1    The 2018 revision incorporates and revises 2004 paragraph 9:

2004 Code
9. Refuse to participate in or support practices that violate basic human rights.

2018 Revision
B2. . . . Respect and promote the inherent dignity and equal worth of all persons and refuse to participate in or support practices that violate basic human rights; never participate in or facilitate torture. [Emphasis added]

VIII.2    The addition of the reference to torture is instructive because it implies that moral responsibility attaches not only to direct participation in an act, but also to indirect forms of facilitation. This is precisely the reason why physicians who object to a procedure for reasons of conscience may be unwilling to provide an effective referral for it.

VIII.3    Nonetheless, the reference is out of keeping with the general approach that has been characteristic of CMA Codes of Ethics since 1970, and superfluous because torture is a criminal offence in Canada and prohibited by international law. The CMA has been on record as opposing torture since 1979,1 and there is no evidence that Canadian physicians are participating or likely to participate in torture.

VIII.4    Moreover, it is odd to insist that physicians must not participate in or facilitate torture, while remaining silent about capital punishment. The current state of criminal law precludes physician participation in both, so if the Code of Ethics is to speak to one, one would expect it to speak to the other.

VIII.5    Thus, proscribing physician involvement in torture while remaining silent about capital punishment could be construed as an indication of neutrality concerning physician participation in executions. This, in turn, could be linked to euthanasia, given the similarity of the procedures and drugs used for euthanasia and execution by lethal injection.2 On the other hand, for this very reason, adding a reference to capital punishment to the Code of Ethics could be as problematic as remaining silent about it.

VIII.6    Finally, the legal ban on euthanasia and assisted suicide was described by counsel for the claimants in the Carter case as "tantamount to torture."3 The same argument was made in the Supreme Court of Appeal South Africa in 2016.4 It requires little imagination to see that an otherwise inexplicable reference to torture in the Code of Ethics could be turned against physicians who refuse to participate in euthanasia or assisted suicide, just as a reference to capital punishment could be turned against physicians who provide the services.

VIII.7    In sum, the added reference to torture in the Code of Ethics is unnecessary. It is not responsive to present or reasonably foreseeable circumstances in Canada, and is likely to generate troublesome distractions. It seems prudent to delete it.

Notes

1.  Canadian Medical Association. Policy resolution BD80-03-99: Treatment of prisoners [Internet]. 1979 Dec 8; Reviewed 2017 Mar 4 [cited 2018 Mar 30].

2.   Standard euthanasia guidelines direct the use of a drug (thiopental, propofol, phenobarbital) to induce an artificial coma, followed by the administration of a neuromuscular blocker (rocuronium, altracurium, cisatracurium) to cause respiratory arrest and death by anoxia. In Quebec, this is preceded by the administration of a drug (midazolam) to induce anxiolysis ( minimal sedation that reduces anxiety). [See Royal Dutch Medical Association, Royal Dutch Pharmacists Association. Guidelines for the Practice of Euthanasia and Physician-Assisted Suicide. 2012; at 13–13; Collège des médecins du Québec. Medical Aid in Dying: 11/2015 Practice Guidelines. 2015; at 42–48.] Executions by lethal injection (in practice, infusion) parallel euthanasia procedures in using a drug (thiopental, pentobarbital, midazolam, propofol) to induce an artificial coma, followed by a neuromuscular blocker (rocuronium, pancuronium, vercuronium) to cause respiratory arrest, but a third drug (potassium chloride) is then used to cause cardiac arrest. [See Glossip et al v Gross et al, 576 US __ (2015), 135 S Ct 2736 (2015) at p 3–8. See also Krol D.  The Drugs Used in Execution by Lethal Injection. Forbes [Internet] 2014 May 1 [cited 2018 Mar 13].

3.  Keller J. Euthanasia Ban Like Torture, BC Appeal Court Hears. Huffington Post [Internet]. 2013 Mar 20 [cited 2018-03-10].

4.  Pilane P. Denying the right to day may be state-sanctioned torture, legal body says. Bhekisisa [Internet]. 2016 Nov 3 [cited 2018 Mar 10].

 

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