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Protection of Conscience Project

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Service, not Servitude
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Therapeutic Homicide and Suicide in Canada: 
Collaboration, Conscription, Coercion and Conscience


Notes

1.  The Globe and Mail, for example, demanded liberalization of the law "to enable doctors to perform their duties according to their conscience and their calling.""Free the Doctor." Globe and Mail, 18 May, 1965. Quoted in de Valk, Alphonse, Morality and Law in Canadian Politics: The Abortion Controversy. Dorval, Quebec: Palm Publishers, 1974, p. 18.

2.  The Globe and Mail later said that abortion law reform should be based on the principle "that where religious moralities conflict, the State should support none, but leave the choice to individual conscience.""Now the job is to be done, let it be done right", Globe and Mail, 21 December, 1967. Quoted in de Valk, supra, p. 56.

3.  One private member's bill on abortion introduced in1967 included a conscience clause almost identical to the conscience clause in the British Abortion Act. 2nd Session, 27th Parliament, 16 Elizabeth II 1967. The House of Commons of Canada, Bill C-136: An Act Concerning the Termination of Pregnancy by Registered Medical Practitioners.

4.  2nd Session, 27th Parliament, 16 Elizabeth II 1967. The House of Commons of Canada, Bill C-122: An Act to Amend the Criminal Code (Abortion).

5.  Second Session-Twenty-seventh Parliament 1967: Standing Committee on Health and Welfare, Minutes of Proceedings and Evidence No. 1 (Thursday, June 29, 1967 and Tuesday, October 3rd, 1967), p. 3-6.

6.  Perron L. "Abortion Issue." (Letter to the Editor) Ottawa Journal, 1 February, 1969

7.  "No one is going to force a doctor to perform an abortion if he does not want to perform it. . . This legislation will show respect for people who do not believe in abortions." House of Commons Debates, Official Report: First Session, 28th Parliament, 18 Elizabeth II (Hereinafter "Hansard") 9 May, 1969, p. 8526-8527.

8.  Criminal Code, Section 287. (Accessed 2016-06-21)

9.  Opposition parties proposed seven protection of conscience amendments. It was agreed that debate on one of them would dispose of all seven. What was debated was to the following effect: "Nothing in the new law shall be construed as obliging any hospital to establish a therapeutic abortion committee, or any qualified medical practitioner to procure an abortion, or any member of a hospital staff to assist in abortion." This paraphrase reflects the effects of sub-amendment added to the original amendment. See Hansard (28 April, 1969) , p. 8056, 8063. The original conscience clause had been proposed by Robert McCleave, an M.P. who was in favour of abortion. Hansard (28 April, 1969), p. 8069.

10.  Hansard (28 April, 1969), p. 8058-8059.

11.   "The Physician and the Liberal Society: Understanding in Winnipeg." Association News, CMAJ July 18, 1970, Vol. 103, p. 195 (Accessed 2016-07-22).

12.  Canadian Medical Association Code of Ethics (1970).Transcribed from the original by
A. Keith W. Brownell MD, FRCPC and Elizabeth "Libby" Brownell RN, BA (April 2001) (Accessed 2015-06-17).

13.  "Canadian Medical Association 104th Annual Meeting, Halifax, Nova Scotia." CMAJ Volume 104(12) 1132-1134, June 19, 1971 (Accessed 2016-07-122).

14.  Waring G. "Report from Ottawa." CMAJ Nov. 11, 1967, vol. 97, 1233 (Accessed 2016-06-15).

15.   In 1970, the first year under the new rules, there were more than 11,000. In 1971 there were almost 39,000. "Therapeutic abortion: government figures show big increase in ‘71." CMAJ May 20, 1972, Vol. 106, 1131 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1940714/?page=1) Accessed 2016-06-15

16.  Geekie D.A. "Abortion: a review of CMA policy and positions." CMAJ September 7, 1974, Vol. 111, 474-477 (Accessed 2016-07-22).

17.  The number of abortions increased from 11,152 in 1970 to almost 39,000 in 1971, an increase from a rate of 3.0 to 8.3 per 100 live births.
"Therapeutic abortion: government figures show big increase in ‘71." CMAJ, May 20, 1972, Vol. 106, 1131 (Accessed 2016-07-22).

18.  By 1975 the rate was 13.8/100. J.B.S. "1975 abortion report more informative than its predecessors." CMAJ, October 22, 1977, Vol. 117, 933 (Accessed 2016-07-22).

19.  CMA President Bette Stephenson stated that the CMA was concerned about the abortion rate and "most disturbed . . . that even more abortions are being performed . . .than are indicated in the alarming figures released by Statistics Canada." Stephenson B. "Abortion: an open letter." CMAJ, 22 February, 1975, Vol. 112, 492 (Accessed 2016-07-22).

20.  In 1976 there were about 54,500 abortions (14.9/100 live births). E.M.R., "1976 advance report on abortion compares statistics with 1975." CMAJ, January 7, 1978 Vol. 118, 76 (Accessed 2016-07-22).

21.  The chairman of the BCMA hospital committee believed most of his colleagues would support forcing hospitals to comply "B.C. M.A. Annual Meeting." CMAJ November 21, 1970, Vol. 103, 1223 (http://pubmedcentralcanada.ca/pmcc/articles/PMC1930622/?page=6) Accessed 2016-07-22)

22.  The Globe and Mail (that erstwhile champion of freedom of conscience) stated, "[H]ospital boards should never have been allowed a choice in the matter. The Government should . . . require hospitals which receive public grants to establish abortion committees.""The Law Denies Equality." Globe and Mail, 18 January 1974. Quoted in de Valk, supra, p. 137.

23.   "Forty per cent of hospital employees who objected to assisting at abortions were denied the right to do so." De Valk A. "The Worst Law Ever." Edmonton: Life Ethics Centre, 1979, p. 15, citing Badgley R.F. Report of the Committee on the Operation of the Abortion Law. Ottawa, Supply and Services, 1977, p. 287.

24.  Geekie D.A. "Abortion referral and MD emigration: areas of concern and study for CMA." CMAJ, January 21, 1978, Vol. 118, 175, 206 (Accessed 2016-07-22).

25.  "Quebec City is a lively place, CMA annual meeting delegates discover." CMAJ July 9, 1977, Vol. 117, 63. (Accessed 2016-07-22).

26.  Wilson R.G. "Code of Ethics: abortion referral (letter)." CMAJ, April 22, 1978, Vol. 118, 896 (Accessed 2016-07-22).

27.  Firth S.T. "Code of Ethics: abortion referral (letter)." CMAJ, April 22, 1978, Vol. 118, 895 (Accessed 2016-07-22).

28.  Cameron P, Cohen M, Rapson L, Watters WW. "Code of Ethics: abortion referral (letter)." CMAJ, April 22, 1978, Vol. 118, 890, 895 (Accessed 2016-07-22).

29.  Forster J.M. "Code of Ethics: abortion referral." CMAJ, April 22, 1978, Vol. 118, 888 (Accessed 2016-07-22).

30.  Shea J.B. "Code of Ethics: abortion referral." CMAJ, April 22, 1978, Vol. 118, 890 (Accessed 2016-07-22).

31.  "Ethics problem reappears." CMAJ, July 8, 1978, Vol. 119, 61-62 ( Accessed 2016-07-22).

32.  Canadian Medical Association Code of Ethics (1978). Transcribed from the original by
A. Keith W. Brownell MD, FRCPC and Elizabeth "Libby" Brownell RN, BA (April 2001) (Accessed 2016-07-22).

33.  Assuming the procedure was performed in accordance with medical standards. Dunphy C. Morgentaler: A Difficult Hero - A Biography. Canada: Random House, 1996, p.175

34.  In 1978, a Liberal cabinet minister resigned when it became known that he had forged a document to help get an abortion for a married woman with whom he had had an affair. The incident occurred in Ontario prior to 1976. House of Commons Debates (Hansard),Vol. III, 1978, p. 2350 (30 January, 1978) (Accessed 2016-06-26).

35.  R. v. Morgentaler (1988) 1 S.C.R. 30 (Accessed 2016-07-22).

36.  Canadian Medical Association, Policy: Induced abortion. Approved by the CMA Board of Directors, December 15, 1988. (Accessed 2016-07-22).

37.  Otis M. "Nurses Fight for Freedom: 21 out of 30 paediatric nurses resign." The Interim, March, 1988.

38.  Kennedy FM. "Sweeney Defends Firings: Transition house workers fired, denied benefits for 'misconduct'." The Interim, March, 1989.

39.  P Johnston W. "Med-School Admission Committees: Tainted by Pro-Choice Bias?" Vital Signs, Summer, 1995.

40.  Dooley D. "Hospital Restricts Nurses' Freedom of Conscience." The Interim, June, 1993.

41.  Ko M. "Personal Qualms Don't Count: Foothills Hospital Now Forces Nurses To Participate In Genetic Terminations."Alberta Report Newsmagazine, April 12, 1999.

42.  Correspondence with Project Administrator: restricted to protect the identity of sources.

43.  Health Canada, Canada's Health Care System (Medicare). (Accessed 2016-06-23).

44.  From 1976, different provinces have had varying policies about paying for abortions provided outside hospitals. Evangelical Fellowship of Canada, Provincial Decisions: Abortion Funding in Canada - A Brief Examination of the Provincial and Territorial Government's Roles in Determining Abortion Funding in Canada. (October, 2013) (Accessed. 2016-07-22).

45.  The speaker was Dr. Preston Zuliani, the President of the College of Physicians and Surgeons of Ontario, Canada's largest medical regulator. Laidlaw, Stuart, "Does faith have a place in medicine?" Toronto Star, 18 September, 2008 (Accessed 2016-07-22).

46.  Rodgers S. Downie J. "Abortion: Ensuring Access." CMAJ July 4, 2006 vol. 175 no. 1 doi: 10.1503/cmaj.060548 (Accessed 2016-07-22).

47.  Epp Buckingham J. "Access to abortion (letter)." CMAJ, February 13, 2007 vol. 176 no. 4 doi: 10.1503/cmaj.1070004 (Accessed 2016-07-22).

48.  Read JE, Smith BJ. "Access to abortion (letter)." CMAJ, February 13, 2007 vol. 176 no. 4 doi: 10.1503/cmaj.1060175 (Accessed 2016-07-22).

49.  Humber N. "Access to abortion (letter)" CMAJ, February 13, 2007 vol. 176 no. 4 doi: 10.1503/cmaj.1060204 (Accessed 2016-07-22).

50.  Côté, A. "Access to abortion (letter)." CMAJ, February 13, 2007 vol. 176 no. 4 doi: 10.1503/cmaj.1060184 (Accessed 2016-07-22).

51.  Blackmer J. "Clarification of the CMA's position on induced abortion." CMAJ April 24, 2007 vol. 176 no. 9 doi: 10.1503/cmaj.1070035 (Accessed 2016-07-22).

52.  Rodriguez v. British Columbia (Attorney General), 3 S.C.R. 519 (1993), 107 D.L.R. (4th) 342, 85 C.C.C. (3d) 15 (Accessed 2016-07-22).

53.  Jocelyn Downie, curriculum vitae (Accessed 2016-07-22).

54.  By 2003 she was arguing for the decriminalization of assisted suicide and euthanasia. Downie J. Dying Justice: A Case for Decriminalizing Euthanasia and Assisted Suicide in Canada. Toronto: University of Toronto Press, 2004.

55.  In 2007 and 2008 she developed a legal strategy designed to reverse the Rodriguez decision, and began to look for a test case. A two day conference titled "Ethical, Legal, and Social Perspectives on Physician Assisted Suicide" was held at Carelton University in 2007. Professor Downie presented "Rodriguez Revisited: Canadian Assisted Suicide Law and Policy in 2007." Conference on Physician Assisted Suicide at Carleton. Carleton University Newsroom, 12 March, 2007. (Accessed 2016-07-22). It does not appear that Prof. Downie's presentation was published. A detailed account of it was written by Alex Schadenberg of the Euthanasia Prevention Coalition, who was present when it was delivered. Schadenberg A. Dalhousie law professor seeks to re-visit Rodriguez court decision. Euthanasia Prevention Coalition.

56.   Downie, Jocelyn and Bern, Simone, "Rodriguez Redux." Health Law Journal 2008 16:27-64. (Accessed 2016-06-24).

57.   Let their conscience be their guide? Conscientious refusals in reproductive health care. (Accessed 2016-07-22).

58.  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 (Accessed 2016-07-22).

59.  Daniel Weinstock was the other. Let their conscience be their guide? Conscientious refusals in reproductive health care: The Team. (Accessed 2016-07-22).

60.  Royal Society of Canada news release, RSC Expert Panel on End-of-Life Decision Making (27 October, 2009) (Accessed 2016-06-24).

61.  Only two of the panel members were physicians: Dr. Ross Upshur and Johannes J.M. van Delden.

62.  Downie J. Dying Justice: A Case for Decriminalizing Euthanasia and Assisted Suicide in Canada. Toronto: University of Toronto Press, 2004.

63.  Schüklenk U. "Human Self-Determination, Biomedical Progress, and God." In 50 Voices of Disbelief: Why We Are Atheists. Blackwell On Line, 11 November, 2009. (Accessed 2016-07-22).

64.  McLean S, Brittan A. The Case for Physician Assisted Suicide. London: Pandora Press, 1997.

65.   van Delden JJM, Battin MP. Euthanasia: Not Just for Rich Countries. (Draft version, December 20, 2005) (http://www.eutanasia.ws/hemeroteca/eutanasia_rich_countries.pdf) Accessed 2016-07-22.

66.   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) (Accessed 2014-02-23). (Hereinafter "Royal Society"), p. 96.

67.  Or at least provincial guarantees of immunity from prosecution for those providing the procedures, as Quebec had done with respect to abortion. Royal Society, P.97

68.  Royal Society, p. 69, 101.

69.  Royal Society, p. 62.

70.  In the Supreme Court of British Columbia, Notice of Civil Claim between Lee Carter, Hollis Johnson, Dr. William Shoichet and the British Columbia Civil Liberties Association (Plaintiffs) and the Attorney General of Canada (Defendant) dated 26 April, 2011 (Accessed 2011-05-01).

71.  Carter v. Canada (Attorney General) 2012 BCSC 886 (Hereinafter "Carter v. Canada (BCSC)"), para. 124 (Accessed 2016-06-24).

72.  Carter v. Canada (BCSC), para. 1393 (Accessed 2016-06-24).

73.  Canadian Medical Association, Euthanasia and Assisted Suicide (Updated May 29, 2007).

74.  "The Canadian Medical Association supports the right of any physician to exercise conscientious objection when faced with a request for medical aid in dying. (DM 5-22)"
Canadian Medical Association, Resolutions Adopted, 146th Annual Meeting of the Canadian Medical Association (19-21 August 2013 - Calgary, AB) (DM 5-22) (Accessed 2016-07-22).

75.  Downie J. McLeod C. Shaw J.,"Moving Forward with a Clear Conscience: A Model Conscientious Objection Policy for Canadian Colleges of Physicians and Surgeons." Health Law Review, 21:3, 2013. (Accessed 2016-07-22).

76.  Quebec, Nova Scotia, Ontario, and Saskatchewan. Letter from Bryan Salte to the Registrars of Colleges of Physicians and Surgeons in Canada.  Redacted in Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 8.

77.  Murphy S. "NO MORE CHRISTIAN DOCTORS." Protection of Conscience Project, March, 2014.

78.  Payne E. "Some Ottawa doctors refuse to prescribe birth control pills." Ottawa Citizen, 30 January, 2014 (Accessed 2016-07-22).

79.  Glauser W. "Ottawa clinic doctors' refusal to offer contraception shameful,
says embarrassed patient." Medical Post, 5 February, 2014.

80.  CBC Radio, "Should doctors have the right to say no to prescribing birth control?" Ontario Today, 25 February, 2014 (Accessed 2016-07-22).

81.  Saskatchewan's Associate Registrar had the legalization of assisted suicide and euthanasia in mind when he urged other colleges to adopt the policy. "Physician-assisted suicide, in particular, has the potential to challenge Colleges of Physicians and Surgeons to provide guidance to its members." Letter from Bryan Salte to the Registrars of Colleges of Physicians and Surgeons in Canada.  Redacted in Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 8.

82.  Saskatchewan's Associate Registrar said that the policy was intended to apply "broadly,"not only to "birth control and abortion," but "all other areas," not excluding physician assisted suicide and euthanasia. He publicly confirmed that doctors who disagree with assisted suicide could "end up being disciplined," and "could . . . lose their jobs.""Saskatchewan doctors could face discipline over assisted suicide." Global News, 13 February, 2015 (Accessed 2015-05-30). Annotated transcription at Protection of Conscience Project, Submission to the College of Physicians and Surgeons of Saskatchewan, Re: Conscientious Refusal, Appendix "C": Interview of Associate Registrar, College of Physicians and Surgeons of Saskatchewan Re: CPSS Draft Policy Conscientious Refusal, CI.2, CI.3; CIII.2 to CIII.4, CIV.1, CV.1.

83.  For a detailed discussion of the Quebec law, see Murphy S., "Redefining the Practice of Medicine: Euthanasia in Quebec." Protection of Conscience Project, 2015-10-28.

84.  Act Respecting End of Life Care (Hereinafter "ARELC") section 13.

85.  ARELC, section 31.

86.  ARELC, section 50.

87.  The Collège des médecins 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." Collège des médecins du Québec, Code of Ethics of Physicians, para. 24 (Accessed 2016-07-22).

88.  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. "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 2016-07-22).

89.  During 2014, CMA officials quietly studied the provision of physician assisted suicide and euthanasia in Oregon, Washington, Montana, Vermont and New Mexico, Netherlands, Belgium and Switzerland. Kirkey S. "Canadian doctors preparing for 'all eventualities' in case top court strikes down ban on assisted suicide." National Post, 21 December, 2014 (Accessed 2014-12-22).

90.  The CMA held town hall meetings across Canada in the first half of the year, finding diametrically opposed views among the public. Among the points noted in the report concerning the meetings: Canadian Medical Association, End-of-Life Care: A National Dialogue (June, 2014) (Accessed 2016-07-22).

91.  Six meetings and other consultations held with physicians across the country found the same division. A majority favoured maintaining the ban against physician participation. A "significant minority" believed the policy should be at least reviewed. Canadian Medical Association, End-of-Life Care: A National Dialogue. CMA Member Consultation Report (July, 2014) (Accessed 2016-07-22).

92.  The month before the town hall meetings ended, CMA President Dr. Louis Hugo Francescutti and Dr. Jeff Blackmer announced that the CMA would intervene in the Supreme Court of Canada in the Carter case but would not argue for or against legalization. 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

93.  In June, 2014, when the CMA applied for leave to intervene at the Supreme Court of Canada in Carter v. Canada, the application was supported by an affidavit implying that, should the court legalize the procedures, the Association would likely change its policy precisely because physicians would be "key players" whose cooperation would be needed to make assisted suicide and euthanasia available. In the Supreme Court of Canada (On Appeal from the Court of Appeal of British Columbia) Affidavit of Dr. Chris Simpson, Motion for Leave to Intervene by the Canadian Medical Association (5 June, 2014) p. 10 (Accessed 2016-07-22).

94.  During 2014 there was continual discussion of physician assisted suicide and euthanasia by the CMA Board of Directors. CMA Board member Dr. Ewan Affleck proposed that the Board sponsor a resolution at the August Annual General Council. Anselmi E. "Yk doc key in assisted suicide ruling: Dr. Ewan Affleck instrumental in penning resolution considered by Supreme Court." Northern News Service, 13 February, 2015 (Accessed 2016-07-22).

95.  The resolution had to be accompanied by a supporting rationale. The rules state that the rationale is the means through which the General Council gives policy guidance and direction to the Association and the Board. Thus, as the sponsor of the resolution, the Board wrote - or at least approved in advance - the kind of policy guidance it wanted to use to resolve the apparent conflict between the resolution and existing policy against participation. Canadian Medical Association, General Council Motions - 2014 Procedures and Guidelines: Motion Development, p. 2, point 6. (Accessed 2016-07-22).

96.  While the wording of the motion seemed to suggest that the Association should limit itself to taking a laissez-faire position concerning participation by individual physicians, the rationale went much further. Citing the CMA Code of Ethics, it asserted that the current prohibition "may adversely impact patients with terminal conditions and unremitting suffering from obtaining compassionate care," and asked, rhetorically, how Canadian physicians could justify "withholding a service against the will of a patient?" Rhetorical questions are meant to elicit expected answers. The answer obviously expected by the Board of Directors in this case was that the CMA could not justify refusing assisted suicide and euthanasia to competent patients who are terminally ill and want to kill themselves or have a physician kill them. It would seem to follow from this that the Board of Directors believed that CMA should formally approve physician participation in assisted suicide and euthanasia.
Canadian Medical Association, 147th General Council Delegates' Motions: End-of-Life Care: Motion DM 5-6. (Accessed 2016-07-22).

97.  The presentation of statistics at the AGC appears to reflect the pro-euthanasia bias in the resolution. It was argued on the floor that "current policy on euthanasia and physician-assisted suicide does not sufficiently reflect the broad spectrum of opinions on the matter held by Canadian physicians," since it prohibited physician participation in euthanasia and assisted suicide. In contrast, the most recent survey of Canadian physicians found almost 45% of physicians supported legalizing assisted suicide, about 36% favoured legalization of euthanasia, and almost 27% were willing to be involved with providing assisted suicide if the acts were legalized. Of course, the survey results also revealed that 55% of physicians surveyed were against legalizing assisted suicide, 64% against legalizing euthanasia, and 73% were unwilling to be involved with assisted suicide, but it appears that those citing the statistics preferred to accentuate the positive rather than the negative. It also appears that the numbers of those willing or unwilling to provide euthanasia, if available, were not reported. Rich, P.  Physician  perspective on end-of-life issues fully aired. 19 August, 2014 (Accessed 2016-07-22).

98.   In the SCC on appeal from the BCCA, Factum of the Intervener, The Canadian Medical Association (27 August, 2014) para. 27-28.

99.  Canadian Medical Association Policy: Euthanasia and Assisted Death (Update 2014) (Accessed 2016-07-22).

100.  The earlier policy required access to palliative care be ensured for all Canadians before any consideration was given to legalizing euthanasia and assisted suicide. The later policy dropped this requirement. Other concerns expressed in the earlier policy that remained valid when they were deleted included the possibility that litigation would expand the scope of euthanasia and assisted suicide, concerns about a ‘slippery slope,' with reference to neurologically impaired and infants, and the possibility of "rational suicide" by people who are not sick. After the ruling, the CMA's Dr. Jeff Blackmer voiced concerns about developments in the Netherlands and Belgium, including the Groningen Protocol, which were explicitly stated in the previous CMA policy against euthanasia and assisted suicide, but deleted from the new CMA policy approving euthanasia and assisted suicide. His concern that a constitutional challenge might expand the Carter criteria was also explicitly stated in the previous CMA policy, but that, too, was deleted in the new policy. His reference to controversial European cases and concern that many cases could qualify under the Carter criteria brings to mind the statement in the previous CMA policy, "Such extension is the ‘slippery slope' that many fear" - a concern also deleted from the new policy. Santi N.  "From Courtroom to Bedside - A Discussion with Dr. Jeff Blackmer on the Implications of Carter v. Canada and Physician-Assisted Death.UOJM Volume 5, Issue 1, May 2015 (Accessed 2016-07-22).

101.  The affidavit supporting the intervention made note of numerous cases in which courts had taken notice of CMA policy. In the Supreme Court of Canada (On Appeal from the Court of Appeal of British Columbia) Affidavit of Dr. Chris Simpson, Motion for Leave to Intervene by the Canadian Medical Association (5 June, 2014) para. 19-20 (Accessed 2016-07-22).

102.   Carter v. Canada (Attorney General), 2015 SCC 5 (Hereinafter "Carter"), para. 131-132. (Accessed 2016-07-22).

103.  Submission of the Ontario Human Rights Commission to the College of Physicians and Surgeons of Ontario Regarding the draft policy, "Physicians and the Ontario Human Rights Code" (15 August, 2008). (http://www.ohrc.on.ca/en/resources/submissions/physur) Accessed 2016-07-22.

104.  College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (Draft) (Hereinafter "POHRC") p. 4.

105.   E-mail from the College of Physicians and Surgeons of Ontario to College Members re: Draft Policy- Physicians and the Ontario Human Rights Code, 20 August 2008

106.  POHRC, p. 6-7.

107.  Murphy S. "Physicians and the Ontario Human Rights Code: Ontario Human Rights Commission attempts to suppress freedom of conscience. (August-September, 2008)"
Protection of Conscience Project.

108.  "OMA Urges CPSO to Abandon Draft Policy on Physicians and the Ontario Human Rights Code." OMA President's Update, Volume 13, No. 23 September 12, 2008.

109.  "OMA Response to CPSO Draft Policy ‘Physicians and the Ontario Human Rights Code.'" Statement of the Ontario Medical Association, 11 September, 2008.

110.  Letter from Bryan Salte to the Registrars of Colleges of Physicians and Surgeons in Canada.  Redacted in Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 8.

111.  The "draft policy statement developed by the Conscientious Objections Working Group" was discussed during a meeting of the Registrars of the Colleges of BC, Alberta, Saskatchewan, Manitoba and Ontario.  Saskatchwan's Associate Registrar Bryan Salte of seems to have taken the lead. He later reported that the other Colleges agreed to consider the policy and consider implementing it. Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 3.

112.  Murphy S. "Tunnel Vision at the College of Physicians." National Post, 13 April, 2015. (Accessed 2016-07-22).

113.  College of Physicians and Surgeons of Ontario, Professional Obligations and Human Rights (Accessed 2016-07-22).

114.  Ontario Superior Court of Justice, Between the Christian Medical and Dental Society of Canada et al and College of Physicians and Surgeons of Ontario, Notice of Application, 20 March, 2015. Court File 15-63717.

115.  College of Physicians and Surgeons of Ontario, Meeting of Council 6 March, 2015, p. 61. (Accessed 2016-07-22).

116.  The College Council was likely unaware that the policy had been co-authored by one of Canada's leading euthanasia advocates. The Associate Registrar was less than candid about its origins. Protection of Conscience Project, Submission to the College of Physicians and Surgeons of Saskatchewan Re: Conscientious Refusal (5 March, 2015) Appendix "B": Development of the CPSS Draft Policy Conscientious Refusal.

117.  "Physician-assisted suicide, in particular, has the potential to challenge Colleges of Physicians and Surgeons to provide guidance to its members. I think that it will be much better for the Colleges and the physician members if the Colleges are prepared for the issue. If no policy is in place, and either the legislation in Quebec dealing with assisted suicide comes into effect, or the Supreme Court of Canada strikes down the prohibition against assisted suicide in the Taylor [sic] case, there will be an expectation that Colleges provide guidance to their members. The situation could have to be addressed on an urgent basis if there is no policy in place at the time." Letter from Bryan Salte to the Registrars of Colleges of Physicians and Surgeons in Canada.  Redacted in Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 8. The Carter case is probably misidentified here as "Taylor" because Gloria Taylor became the most prominent plaintiff.

118.  "Saskatchewan doctors could face discipline over assisted suicide." Global News, 13 February, 2015 () Accessed 2015-05-30. Annotated transcription at Protection of Conscience Project, Submission to the College of Physicians and Surgeons of Saskatchewan, Re: Conscientious Refusal, Appendix "C": Interview of Associate Registrar, College of Physicians and Surgeons of Saskatchewan Re: CPSS Draft Policy Conscientious Refusal, CI.2, CI.3; CIII.2 to CIII.4, CIV.1, CV.1

119.  Carter, para. 132. (Accessed 2016-07-22).

120.  Department of Justice, ews release: Government of Canada Establishes External Panel on options for a legislative response to Carter v. Canada (17 July, 2016) (Accessed 2016-06-24).

121.  Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Physician Assisted Dying. (January, 2016) (Accessed 2016-06-26).

122.  Ontario Ministry of Health and Long Term Care, News Release: Provinces, Territories Establish Expert Advisory Group On Physician-Assisted Dying. Ontario Leading Provincial-Territorial Co-Ordination to Seek Advice from Experts. (14 August, 2015) (Accessed 2016-07-22).

123.  Ontario Ministry of Health and Long Term Care, Backgrounder: Provincial-Territorial Expert Advisory Group Convened On Physician-Assisted Dying (14 August, 2015) (Accessed 2016-07-22).

124.  Ruth Goba was appointed to the Ontario Human Rights Commission in 2006. In 2008 and 2014 the Commission demanded that objecting physicians be forced to refer for morally contested services. Ontario Human Rights Commission, Meet our Commissioners (Accessed 2016-06-26).

125.  Arthur Schafer, director of the Centre for Professional and Applied Ethics at the University of Manitoba, asserted in 2000 that conscientious objectors who refuse "legal services" (ie., the ‘morning after pill') to patients who have nowhere else to go should leave the profession. (Jacobs, Mindelle, "Pharmacists Want Right of Refusal," Edmonton Sun, 16 April, 2000) In 2014 he argued that objecting physicians should be forced to provide birth control and implied that they should not be allowed to publicly express opposition to it. (Weeks C. "Ontario authorities take action on doctors who deny birth control." Globe and Mail, 11 December, 2014 (Accessed 2016-07-22).

126.  The Canadian Press, "Gaétan Barrette insists dying patients must get help to ease suffering: Quebec's right-to-die law comes into effect on Dec. 10." CBC News, 2 September, 2015 (Accessed 2016-06-27).

127.  "The College of Physicians and Surgeons of Ontario took the position that physicians who object to physician-assisted dying requests have a positive obligation to make an effective referral. An effective referral, as described by the Ontario College, is a referral made in good faith to a non-objecting available and accessible physician, other health care professional, or agency. The College noted that the medical community has an obligation to ensure access and that conscientious objection should not create barriers." External Panel on Options for a Legislative Response to Carter v. Canada, Consultations on Physician Assisted Dying: Summary of Results and Key Findings - Final Report (15 December, 2015), p. 100 (Accessed 2016-06-27).

128.  College of Physicians and Surgeons of Ontario,News release: Physician Assisted Death: College Consults on Interim Guidance (7 December, 2015)(Accessed 2016-06-24).

129.  College of Physicians and Surgeons of Ontario, News release: Physician Assisted Death: College Approves Interim Guidance (26 January, 2016) (Accessed 2016-06-24).

130.  Carter v. Canada (Attorney General) 2016 SCC 4 (2016-01-15) (Accessed 2016-06-26).

131.  Hamilton, G. "First Quebec euthanasia case confirmed, two others reported." National Post (Accessed 2016-06-26).

132.  A woman with ALS was lethally injected by Dr. Ellen Wiebe. Fine S, Church E. "ALS sufferer first Canadian to receive judge's approval for assisted death." The Globe and Mail, 1 March, 2016 (Accessed 2016-07-28).

133.  Dr. Wiebe had opened Hemlock Aid in Dying next to her Willow Women's Clinic. Hemlock Aid in Dying: For people who want to take control of their own deaths. Suite 1017 - 750 West Broadway Vancouver BC (Accessed 2016-07-22). Willow Women's Clinic, Suite 1013 - 750 West Broadway Vancouver BC (Accessed 2016-07-22).

134.  Gulli C. "Assisted death is the new pro-choice. When does life - and a doctor's duty - begin and end? Assisted dying is dredging up the big questions of the abortion debate, for better or worse." Macleans, 28 May, 2016 (Accessed 2016-06-28).

135.  Special Joint Committee on Physician Assisted Dying Parliament of Canada (January-February, 2016). Meeting No. 6, 27 January, 2016: Canadian Medical Association (Dr. Jeff Blackmer, Dr. Cindy Forbes) Edited Video; Edited Video Transcript.

136.  Special Joint Committee on Physician Assisted Dying (PDAM), Meeting No. 10 (2 February, 2016). Webcast: Dr. Douglas Grant (19:30:08 to 19:31:50) (Accessed 2016-02-05). 

137.  Letter from Bryan Salte to the Registrars of Colleges of Physicians and Surgeons in Canada.  Redacted in Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 8.

138.  Report of the Special Joint Committee on Physician Assisted Dying - Medical Assistance in Dying: A Patient-Centred Approach. (February, 2016) Recommendation 10, p. 26; Recommendation 11, p. 27.

139.  Statutes of Canada 2016, Chapter 3. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) (Accessed 2016-06-26).

140.  Carter, para. 127.

141.   ARELC, Section 26(3).

142.  ARELC, Section 26(5).

143.  Statutes of Canada 2016, Chapter 3. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) (Accessed 2016-06-26).

144.   In the Supreme Court of British Columbia, Julia Lamb and British Columbia Civil Liberties Association, Plaintiffs, and Attorney General of Canada, Defendant: Notice of Civil Claim (27 June, 2016) (Accessed 2016-06-28).

145.  Statutes of Canada 2016, Chapter 3. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) Section 9.1. (Accessed 2016-06-26).

146.  Private facilities are generally prohibited from providing health care that is offered by the state.

147.  A lawsuit against the first mandatory referral policy was launched by the Christian Medical and Dental Society, the Canadian Federation of Catholic Physicians' Societies and five physicians, including one of the Ottawa physicians who had been the subject of the Facebook crusade. Ontario Superior Court of Justice, Between the Christian Medical and Dental Society of Canada et al and College of Physicians and Surgeons of Ontario, Notice of Application, 20 March, 2015. Court File 15-63717.

148.  A lawsuit against the mandatory referral policy for euthanasia and assisted suicide was filed by the Coalition for HealthCARE and Conscience, which is comprised of the Catholic Archdiocese of Toronto, the Christian Medical and Dental Society of Canada, the Catholic Organization for Life and Family, the Canadian Federation of Catholic Physicians' Societies, the Canadian Catholic Bioethics Institute, Canadian Physicians for Life, Evangelical Fellowship of Canada, Archdiocese of Vancouver, and the Catholic Health Alliance of Canada. Coalition for HealthCARE and Conscience, News release: Ontario physicians oppose referrals for assisted suicide, seek judicial review of CPSO requirement (20 June, 2016).

149.  Oral submission of the Canadian Medical Protective Association to the Special Joint Committee on Physician Assisted Dying, Meeting No. 12, 4 February, 2016.

150.  Physicians: Quebec "solution" is collaboration in killing, not an "elegant" compromise. Protection of Conscience Project, 15 February, 2016.

151.  For example, during an on-line internal CMA consultation with physicians, the moderator of the consultation suggested that the resolution at the Annual General Council in 2014 imposed an obligation on physicians opposed to euthanasia and assisted suicide to support colleagues providing the services: "It is our obligation as a collective to support them, no matter what our own individual and personal views on this difficult and complex issue." Principles based approach to assisted dying (ca. 2015-07-01) Blackmer Comment No. 10.

152.  A member of the Provincial-Territorial Expert Advisory Group described opposition from supporters of freedom of conscience as a "uniquely Canadian" mountain to be climbed. Meeting No. 5, PDAM Special Joint Committee on Physician Assisted Dying, 26 January, 2016. Maureen Taylor, speaking for the Provincial-Territorial Expert Advisory Group on Physician Assisted Dying - 19:07:53 to 19:08:11 (Accessed 2016-01-28).

153.  Standing Committee on Justice and Human Rights, House of Commons, Parliament of Canada: Meeting No. 10, 2 May, 2016. Philpott, Jane (Minister of Health), Oral Submission. Edited Video Transcript: Minister of Justice Jody Wilson-Raybould responding to Iqra Khalid and the Chair.

154.  Standing Committee on Justice and Human Rights, House of Commons, Parliament of Canada: Meeting No. 10, 2 May, 2016. Department of Health and Department of Justice, Oral Submission. Edited Video Transcript: Deputy Minister William F. Pentney, responding to Ted Falk and Mark Warawa.

155.  Unfortunately, it used the term medical aid in dying rather than homicide and suicide. "No person shall compel an individual or organization to provide or assist in providing medical assistance in dying or to provide a referral for medical in dying." Debates of the Senate (Hansard) 1st Session, 42nd Parliament. Volume 150, Issue 46, 9 June, 2016 (Accessed 2016-06-29).

156.  The Senator cited and briefly paraphrased the policies of Colleges of Physicians and Surgeons across the country, including Ontario's requirement for "effective referral," claiming that none of them had been challenged as being contrary to freedom of conscience - obviously an erroneous assertion. Debates of the Senate (Hansard), 1st Session, 42nd Parliament. Volume 150, Issue 46, 9 June, 2016 (Accessed 2016-06-19).

157.  College of Physicians and Surgeons of Ontario, Medical Assistance in Dying (June, 2016) (Accessed 2016-06-29).

158.  Medical Assisted Dying: A Patient-Centred Approach. Report of the Special Joint Committee on Physician Assisted Dying (February, 2016) (Hereinafter "PDAM Report"), Recommendation 10, p. 26.

 159.  PDAM Report, Recommendation 11, p. 27.

160.  Arendt H. The Origins of Totalitarianism. Orlando: Harcourt Inc., 1985, , p. 310, 311, 323, 326, 336, 339, 371, 392, 404-405, etc.

161.  Murphy S. "Freedom of Conscience and the Needs of the Patient." Presented at the Obstetrics and Gynaecology Conference New Developments - New Boundaries in Banff, Alberta (November 9-12, 2001).

162.  Murphy S. "Service or Servitude: Reflections on Freedom of Conscience for Health Care Workers." Protection of Conscience Project.

163.  Murphy, S. & Genuis, S.J. "Freedom of conscience in health care: distinctions and limits." Bioethical Inquiry (2013) 10: 347. doi:10.1007/s11673-013-9451-x ()

164. King, Martin Luther, Letter from Birmingham Jail, 16 April, 1963. (Accessed 2016-07-22).

165.  Kant, Immanuel, Fundamental Principles of the Metaphysic of Morals. (Accessed 2008-09-10). Quoted in The Internet Encyclopedia of Philosophy, "Immanuel Kant (1724-1804) Metaphysics" () Accessed 2008-09-10).

166.  Joad, C.E.M., Guide to the Philosophy of Morals and Politics. London: Gollancz Ltd., (1938), p. 803. Quoted in R. v. Morgentaler (1988)1 S.C.R 30 at p. 178

167.  Wojtyla, Karol, Love and Responsibility. San Francisco: Ignatius Press, 1993, p. 27

168.  Todorov, Tzvetan, Facing the Extreme: Moral Life in the Concentration Camps. London: Phoenix Books, 2000, p. 165.


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