Redefining the Practice of Medicine

Euthanasia in Quebec

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

Sean Murphy*

Part 4: The Problem of Killing

Killing patients

The original text of Bill 52 did not define "medical aid dying" (MAD).  Nothing in the original Act Respecting End-of-Life Care specified that MAD included killing a patient. Thus, on the face of it, there was no conflict with Canadian criminal law and no basis for a constitutional challenge by the federal government.  Despite this, everyone knew that, whatever the law actually said, it meant euthanasia; it was meant to authorize physicians to kill patients who met MAD guidelines. 

MAD  =  euthanasia = killing

This was obvious from the names of some of the organizations opposed to Bill 52 (Quebec Rally Against Euthanasia; Physicians Alliance for Total Refusal of Euthanasia) and from  submissions to the legislative committee in the fall of 2013.  Living with Dignity cited the Report of the Select Committee on Dying with Dignity1 to demonstrate that "medical aid in dying" is equivalent to euthanasia.2  Dr. Catherine Ferrier, a palliative care physician, told the legislators that  "almost all my patients meet on the criteria to be eligible to be killed by this bill."3  Professor Margaret Somerville warned against the corruption of medical practice by "this awful killing aspect."4

MAD = "homicide"

Now, since these points were made by groups or individuals opposed to the bill, it might be thought that their terminology was deliberately tendentious.  Health Minister Véronique Hivon seemed annoyed that people continued to say that "medical aid in dying" meant euthanasia, which, she said, is "a very loaded word,"

 . . .because we're talking about euthanasia of animals, because we're talking about euthanasia in the Nazi regime. So, yes, it is a word very, very loaded.5

However, even though she insisted that "medical aid in dying" should not be considered euthanasia,6 she admitted that it qualified as homicide.7 

MAD = "intentionally causing death"

Further, even groups and individuals supporting the bill implicitly or explicitly acknowledged that they understood "medical aid in dying" to mean physicians killing patients.  The Collège des médecins du Québec, for example, agreed that "medical aid in dying" involved "an act of intentionally causing the death of a person."8  Professor Jocelyn Downie, who applauded the bill, noted that it clearly included "the provision of a lethal injection."9  She recommended that patients be given a choice between assisted suicide  by a self-ingested toxic drug and death by lethal injection,10 and suggested that the bill could include euthanasia by starvation and dehydration in addition to "the lethal injection category,"11 thus providing patients with another lethal "option."12

Lawyer Stéphanie Vallée, now Quebec Minister of Justice but then a Liberal member of the committee, noted that "in the context of medically assisted dying . . . the purpose is death," adding that "there is a distinction between a treatment for alleviate suffering, which is not intended to . . . administer a lethal dose, and medical assistance to die . . .which is really aimed at the death."13

MAD = "lethal injection"

Gloria Jeliu, representing the Observatory for Aging and Society, which did not take a position for or against euthanasia, cautioned that those who want "medical help to die" must understand "it is a lethal injection and is extremely fast. . ."

But I guess most people, I suspect, know with certainty that the medical assistance to die is the sting, the final sting, the sting ... Doctor, give me the shot. I do not want to live. That is the definition of physician-assisted dying. It is a lethal injection of barbiturate and curare, if I remember correctly, and it causes death within minutes.14

Indeed, the repeated reference to killing disturbed Liberal committee member Yves Bolduc, a physician and former Quebec Minister of Health.

"[M]ost people," he said, "always talk to us about killing," adding, "Athough I do not agree. We are not in medicine to kill."15

However, Bolduc himself, reflecting on the results of surveys purporting to indicate physician support for euthanasia, also understood that Bill 52 was intended to authorize physicians to kill their patients:

I think that what people said they wanted to do at the end of life, they were ready to give morphine to relieve the people, but I'm not sure they are willing to a give big dose of morphine or barbiturate, or curare to kill the person in the space of five minutes.16

MAD = "hastening death" = killing

Despite the absence of a formal definition of "medical aid in dying," these admissions and assertions show that the Minister of Health, legislators and those making submissions to the committee all understood MAD to mean that physicians should kill patients under the conditions specified in Bill 52.  ARELC's definition of MAD simply confirms the obvious, even though it tries to conceal the obvious by using "hastening death" as a rhetorical figleaf.17 

Disputes about killing

It is generally agreed that killing someone is a matter of considerable moral or ethical gravity, even when it is agreed that the killing is justified.  But justifications offered for euthanasia are sharply disputed, so it is not surprising to find serious disagreement about MAD among health care workers.  As committee member Stephanie Vallee observed, "the polarization in the debate is really about the issue of physician-assisted dying, because it resonates with all of us in our most fundamental values."18

Conflicting claims, dubious statistics

Conflicting claims are made about the extent of opposition to or support for euthanasia within health care professions.  These are difficult to evaluate because of the variables affecting responses to surveys or polls, as well as the natural inclination of partisan groups to emphasize or interpret results in ways favourable to their causes.  In addition, health care workers seem more inclined to contact groups that share their concerns rather than groups opposed to them.  For example, Living with Dignity reported contacts from people opposed to euthanasia in general and family medicine,19 while the Quebec Association for the Right to Die with Dignity claimed that "many caregivers" in the palliative care community support euthanasia,20 but are unable to express their views.21 

A review of the transcripts of the legislative committee hearings into Bill 52 might be criticized as merely anecdotal, but it is instructive nonetheless.

". . . a big difference . . ."

Quebec's Interprofessional Health Federation told legislators that conscientious objection to euthanasia was not an issue raised among their members.22  On the other hand, the Order of Nurses said that it did not consider MAD to be a form of "care," but "a procedure that terminates life,"23 while the Association of Health Facilities and Social Services anticipated that physicians, at least at the outset, would be reluctant to be the first  to start the practice.24

Liberal committee member Dr. Yves Bolduc supported euthanasia, but was sensitive to the moral significance of killing a patient by lethal injection.  Thus, he was shocked by the claim by the province's human rights commissioner that there is "no significant moral, ethical, or legal difference between unplugging a person or the fact of accelerating [death] to allow him to relieve his suffering."25

Dr. Bolduc (Jean-Talon): . . . I am a doctor and I'm not a lawyer, but I must admit I was a little confused by what you are telling me.  There is a big difference between injecting someone and letting him die. . . Did you have doctors who advised you, in your opinion?26

When assured that the commission included a physician, he mused that the opinion probably included "a value judgment."27  In fact, the opinion included much more than that, but, for present purposes, it is enough to recognize in this exchange the existence of serious disagreement among physicians about Quebec's euthanasia project.

Hospices, palliative care, family medicine

Hospices, though not required to allow physicians to kill their patients, spoke strongly against euthanasia and expressed fears that legalizing the procedure would ultimately compromise their operations.28 Most palliative care physicians - up to 90% - are adamantly opposed to the MAD provisions in ARELC.29  Some have stated that they will resign if euthanasia is introduced into their units.30  Speaking for the Quebec Palliative Care Network, Dr. Christiane Martel emphasized how legalizing euthanasia would cause profound conflicts for palliative care physicians:

 And I was at a conference a few weeks ago, 140 or 150 stakeholders in palliation asked the question: What will I do with the request for  medically assisted dying? And there I saw more doctors cry than I've ever seen in my 18 years in medicine because it concerns us deeply. It is we who are there at the end of life, it is we who receive these requests , and it is a conflict with our values.31

The anti-euthanasia organization Living with Dignity told legislators that health care workers in general and family medicine had contacted them, and plan to agitate for exemption from legal requirements to participate in euthanasia.  "There are many who are preparing to do this, warned Marc Beauchamp. "If you pass this law," he said, "you will being firing a slingshot into the medical system such as you cannot even imagine."32

Dr. Claude Morin, who might be taken as representative of those most strongly opposed to euthanasia, was adamant that he would not provide it, help anyone else to do it, or even offer suggestions about how the service might be provided.33 

"It's like the death penalty."

The testimony of others appearing before the committee also suggested that health care workers and others were often profoundly disturbed by the idea of killing a patient.  One of the more striking examples was an experience related by Marie-Claude Mainville of NOVA Montreal, who told the committee about a woman who asked her to lethally inject her dying mother.  Mainville gave the woman a morphine syringe (actually a palliative rather than lethal dose) and said, "You do the injection."

"And she was just outraged," Mainville said, "saying: But you're not actually going to ask me to kill my mother? You are paid for it, you!"34

So there is a difference between wanting it "generally" and doing it. It's like the death penalty, there are people who may be in favour, but that would certainly not be the executioner who would do the lethal injection. So we, that is our position also ... We agree with the idea not to prolong the suffering, the idea of ​​pushing the syringe that causes death, that is another debate.35

Mainville, canvassing NOVA nurses, found some nurses willing to provide lethal injections and other who said they would never do so.36

Who will kill?

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."37

Similarly, Dr. Bolduc warned his committee colleagues not to assume that physicians who  express support for euthanasia will also be willing to kill a patient.

 The real question, it will be: Yes, you agree to the medical assistance to die, if you agree that if that, are you ready to do it? It's going to be the challenge. Because there are many people who all agree that someone else should, but how many are willing to do it [themselves]?38

So marked was the evidence of opposition to euthanasia that Dr. Bolduc - almost alone among his committee colleagues - repeatedly raised the question of how access to euthanasia could be provided if physicians were unwilling to provide it for reasons of conscience.39

 "If people agree to respect the conscientious objection," he observed, "it is possible that there will be nobody who is willing to do it,"40 at least in some locations.41

 . . . I'm not sure that there are many physicians in Quebec who will want to do this. And when you're in a region as large as Montreal, the Laurentians where there are hundreds of thousands of people, in practice, you can always eventually find someone who will agree to do it . . . But when you are in Sainte-Anne-des-Monts, you know, a population of 12,000 or 13,000 people, Îles-de-la-Madeleine, about 12,000 people, also the area of ​​Bonaventure thirty thousand people, I'm not sure we'll be able to find a professional who will do it. . . .But when the time comes for the injection, it cannot be done remotely and a nurse can't be asked to do it. . . the doctor will have to do it himself.42

At various points, Dr. Bolduc expressed grave doubts about whether or not the law could be successfully implemented.  "I'm not sure we'll be able to give effect to the law," he said, adding that he hoped "that there are professionals who will have enough conviction to say, "I'll be ready to help people in situations that require it."43 

Applying political pressure

He also expressed some annoyance at five professional organizations - the Collège des médecins,  the Quebec Federation of General Practitioners, the Quebec Federation of Medical Specialists, the Quebec Association of Boards of Physicians, Dentists and Pharmacists and the Quebec Medical Association -  which told the committee that "the vast majority of their members were in agreement," an assertion that he had come to question.44

If, after passing the law, it were found that few physicians are willing to provide the service, he warned, "then we will have to have  those groups come and explain how it is that they  unanimously agreed with the commission that accessibility would not be a problem," since the law was based on that assurance.45

. . .this  is not just a government responsibility, then, there are groups who came here and told us that it would work, then they will have responsibility . . . we will remind people: the application of the law will not just be the responsibility of the government, it will be the responsibility of all the major ... groups who came here and told us that it was a good thing to do, and who were willing to cooperate.46

Dr. Bolduc, now a minister in Quebec's Liberal government, is in a position to call Quebec's medical establishment to account should his predictions about the implementation of ALERC prove accurate.  The prospect of being called to account is likely to provide an additional incentive for the five organizations to secure the compliance of Quebec physicians.

Implementing euthanasia

The implementation of An Act respecting end-of-life care (ARELC) and introduction of euthanasia into Quebec's health care system is to be accomplished using the structures and powers established by other Quebec statutes that govern the delivery of health care in the province, notably the Act Respecting Health Services and Social Services. This is the law that provides the administrative framework for the delivery of health care and the enforcement of health care policy. Other relevant statutes include the Professional Code and the laws specific to each of the health care professions. These laws have established a multi-layered and overlapping bureaucracy of committees, councils, commissions, boards, directors, examiners, coordinators, syndics and commissioners.

Appendix "A" identifies the key statutes and the health care structures established by them relevant to the purposes of ARELC. Appendix "B" describes statutory complaint and disciplinary procedures that could be turned against health care workers who decline to provide or facilitate euthanasia.

Physicians and other health care providers who want no part of euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system, a prominent feature of which is an emphasis on rights47 and the vindication of "user rights,"48 including a purported "right" to "medical aid in dying" promised by ARELC.49

The MAD matrix

The Minister for Social Services and Youth Protection is empowered to issue "policy directions" that are to guide health and social service agencies and institutions in providing end-of-life care, including euthanasia.50 As noted in Part 1, the official representatives of major professional organizations have made clear their support for euthanasia.  For example, the Collège des médecins du Québec, the regulator of medical practice, believes that euthanasia can be an acceptable "medical act," consistent with a Code of Ethics requirement (i.e., that physicians ensure that "death occurs with dignity" and that "appropriate support and relief" is provided to the patient).51

Health care in every region in Quebec is delivered under the direction of a regional health and social service agency (Appendix A2).  ARELC requires every agency to establish general rules concerning access to end-of-life care, including euthanasia, for all institutions and palliative care hospices in its jurisdiction.52 The agencies must inform people living in their regions of how to access end-of-life services, including euthanasia, and provide information about "the rights and options of end-of-life patients."53 In addition to regional health and social service agencies, "local health and social services networks" have been established (Appendix A5). These are intended to focus particularly on access to services, which, in this case, means euthanasia.

Almost all institutions that operate local community service centres, hospital centres or residential and long-term care centres54 are required to offer end-of-life care (which includes euthanasia),55 to establish clinical programmes56 and policies concerning it,57 and to include reference to it in their codes of ethics.58 This includes rehabilitation centres, described in the Act Respecting Health and Social Services, which serve developmentally disabled patients.59

Exceptions

It was noted above that almost all institutions will be required to offer end-of-life care that includes euthanasia. One exception to the general rule is palliative care hospices, which may offer euthanasia, but are not required to do so. Before admitting patients, they must explain what kind of end-of-life care they offer.60 (Part 8)

Section 72 of the Act concerns any institution operating a "general and specialized hospital centre" that offers only palliative care.  Such institutions "may continue to offer that care exclusively" (i.e., need not provide euthanasia), as long as they notify patients of this before admitting them.61  According to the government, this section is intended to apply only La Maison Michel Sarrazin.62  (Part 8)

Standards and enforcement

Obviously, every individual or group that is authorized to enact or supervise adherence to policies or standards can become a MAD functionary, using codes of ethics, protocols, guidelines, directives, etc. to normalize euthanasia. Similarly, every disciplinary or complaints procedure can be used to force participation in MAD services. However, two elements of the MAD matrix warrant special notice.

First, regional and local complaints commissioners and the Health and Social Services Ombudsman are all empowered to take action on their own initiative to enforce "the rights of a user or group of users" (Appendices B3.3, B9.2), while syndics (investigators) for professional orders may lodge complaints of professional misconduct without waiting for a complaint (Appendix B10.2). Any or all of these individuals who are MAD advocates could create considerable difficulty for physicians who are unwilling to participate in or facilitate euthanasia.

Second, the Professional Code provides that anyone who "knowingly helps or, by encouragement, advice or consent" leads a member to violate the order's code of ethics can be fined not less than $1,500.00 and not more than $20,000.00 for each day the violation continues. In the case of an incorporated entity, the minimum and maximum fines are $3,000.00 to $40,000.00 per day. (Appendix B10.3) The Collège des médecins du Québec believes that its Code of Ethics supports euthanasia, and will likely become an active MAD advocate. Thus, the Physicians' Alliance for Total Refusal of Euthanasia, the Euthanasia Prevention Coalition and other groups that oppose euthanasia might face prosecution and substantial fines if they continue to help, encourage or advise physicians not to participate in the procedure.

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Notes

1.  "Euthanasia: An act that involves deliberately causing the death of another person to put an end to that person’s suffering."  Report of the Select Committee on Dying with Dignity, (March, 2012), p. 18

2.  Consultations & hearings on Quebec Bill 52 (Hereinafter "Consultations), Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#023 

3.  Consultations,Tuesday 24 September 2013 - Vol. 43 no. 37: Physicians' Alliance for Total Refusal of Euthanasia (Dr. Catherine Ferrier, Dr Serge Daneault, Dr François Primeau), T# 040 

4.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Professor Margaret Somerville, T#092

5.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#039 

6.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#040 

7.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#039 

8.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34:  Collège des médecins (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#013

9.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Professor Joceyln Downie, T#019  

10.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Professor Joceyln Downie, T#020

11.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Professor Joceyln Downie, T#072

12.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Professor Joceyln Downie, T#085

13.  Consultations, Thursday, 19 September 2013 - Vol. 43 no. 36: Quebec Bar (Johanne Brodeur, Marc Sauvé, Michel Doyon), T#060

14.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Observatory for Aging and Society (André Ledoux, Gloria Jeliu, Denise Destrempes, Claude Tessier), T#117

15.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Professor Margaret Somerville, T#059

16.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#113

17.  ARELC, Section 3(6).

18.  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#059

19.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#103

20.  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#018

21.  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#037

22.  Consultations, Thursday, 26 September 2013 - Vol. 43 no. 39: Interprofessional Health Federation of Quebec  (Régine Laurent, Julie Martin, Michàle Boisclair, Brigitte Doyon), T#110, T#112

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

24.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#109

25.  Consultations, Friday, 4 October 2013 - Vol. 43 no. 43: Commission on Human Rights and Youth Rights (Jacques Fremont,  Renée Dupuis, Daniel Carpentier, Marie Carpentier), T#096

26.  Consultations, Friday, 4 October 2013 - Vol. 43 no. 43: Commission on Human Rights and Youth Rights (Jacques Fremont,  Renée Dupuis, Daniel Carpentier, Marie Carpentier), T#098

27.  Consultations, Friday, 4 October 2013 - Vol. 43 no. 43: Commission on Human Rights and Youth Rights (Jacques Fremont,  Renée Dupuis, Daniel Carpentier, Marie Carpentier), T#102

28.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#014;  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#014, T#059

29.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 41: Quebec Society of Palliative Care Physicians (Dr. Patrick Vinay, Dr. Michelle Dallaire), T#043

30.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#102

31.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Quebec Palliative Care Network (Alberte Déry, Dr.Christiane Martel, Danielle Blondeau, Pierre Deschamps, Jessy Savaria, Yvan Lessard), T#064

32.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity (Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#103,  T#104

33.  Consultations, Tuesday 24 September 2013 - Vol. 43 no. 37: Quebec Rally Against Euthanasia (Dr. Claude Morin, Dr. Marc Bergeron, Daniel Arsenault, Clément Vermette), T#101

34.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#121

35.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#122

36.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#038, T#106

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

38.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#117

39.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#101; Consultations, 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, Thursday, 26 September 2013 - Vol. 43 no. 39: Interprofessional Health Federation of Quebec  (Régine Laurent, Julie Martin, Michàle Boisclair, Brigitte Doyon), T#054,  T#055, T#057; Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#110, T#116; Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#049

40.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec (Dr. Louis Godin, Dr. Marc-André Asselin),T#103

41.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#095

42.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#054

43.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#119

44.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#110

45.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#115

46.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#116

47.   An Act Respecting Health Services and Social Services (R.S.Q. Chapter S-4.2) (Hereinafter "ARHS&SS") Sections 2(8), 3(2), 4-28. (Accessed 2014-07-26)

48.  ARHS&SS, Sections 33, 40,49, 52, 64(4), 66, 72, 74, 76.7, 76.10, 76.11(4), etc.  (Accessed 2014-07-26)

49.  ARELC, Section 4.

50.  ARELC, Section 19.

51.  Collège des médecins du Québec, Physicians, Appropriate Care and the Debate on Euthanasia: A Reflection. (16 October, 2009) p. 2. For the Collège's view on the acceptability of euthanasia, see p. 3 to 7. (Accessed 2014-07-26)

52.  ARELC, Section 17.

53.  ARELC, Section 18.

54.  ARELC, Section 3(1).

55.  ARELC, Section 7.

56.  ARELC, Section 9.

57.  ARELC, Section 8.

58.  ARELC, Section 10.

59.  ARHS&SS, Sections 86-87. (Accessed 2014-07-26)

60.  ARELC, Section 13

61.  ARELC, Section 72

62.  Note: in Bill 52, the original section number was 65. Consultations & hearings on Quebec Bill 52, 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#030, T#032