Canadian Medical Association and euthanasia and assisted suicide in Canada
Critical review of CMA approach to changes in policy and law

September, 2018

PART II    CMA ON FREEDOM OF CONSCIENCE AFTER CARTER

On Carter's eve

On the eve of the Carter ruling, Dr. Simpson said that CMA members would not likely support any measure that would compel an unwilling physician to kill a patient or even to refer a patient to a colleague willing to do so. He was optimistic that "the right of physicians not to be involved" could be preserved by ensuring that "enough people and enough places" would provide euthanasia and assisted suicide for patients.1

However, the long-standing controversy about physician freedom of conscience was still bubbling, and other comments made just before the ruling indicated that it would quickly come to a full boil if the Court struck down the law.

Dr. Catherine Ferrier of McGill University Health Centre in Montreal said that she would neither provide euthanasia nor refer a patient to someone who would because she would be "sending somebody to their death." In response, Dr. James Downar, a palliative and critical care physician and euthanasia activist, said:

I think we need to recognize that conscientious objection in this context can serve as a barrier and we need a very robust system to make sure that the physician's right to conscientious objection does not impinge on the patients' right to receive what would be a legal treatment.2

Carter, the CMA, and the obligation to kill

Dr. Downar's reference to a patient's "right" implied an obligation to kill.  Recall that CMA officials had explicitly recognized that legalization of physician-administered euthanasia and assisted suicide would impose such an obligation on physicians.3  Over a year after the Supreme Court delivered its ruling in Carter, Dr. Blackmer once more acknowledged this.

If you ask the public, what you're really asking them is, 'Do you want to have a right to access these interventions if you come to the end of your life and you're suffering?' That's a very different question than if you ask a medical professional, 'Do you want to kill your patients? Or do you want to assist in the death of your patients?' One is a right, the other is an obligation. Those are intricately related. If someone in society has a right to something, it means someone else has an obligation to provide that.4

He went on to assert that the Supreme Court of Canada imposed an obligation to kill upon Canadian physicians, implying that the Supreme Court was to blame for the problems and conflicts this created for the medical profession.

So basically the Supreme Court that has told Canadian physicians, after centuries of this being illegal and completely in opposition to all teachings in medical ethics, 'We are now going to make this legally available, and you as a profession have an obligation to step forward and provide it.'4

Aside from contradicting what the CMA told the Supreme Court in its intervention,5 this is manifestly unfair and inaccurate. 

The fundamental conflict presented by imposing an obligation to kill upon unwilling physicians was foreseeable and had been foreseen by CMA officials,3 and the consequent attacks upon physician freedom of conscience, particularly with respect to referral, were predictable. They knew that the overwhelming majority of Canadian physicians would refuse to make killing patients part of their medical practice.4 Nonetheless, on behalf of the medical profession, the CMA Board accepted an obligation to kill when it reversed CMA policy against euthanasia and assisted suicide two months before the Carter ruling (See Part I: CMA Board approves euthanasia and assisted suicide).

The Supreme Court gave legal effect to a policy the CMA had already approved, but it was a legal effect more restricted than what the revised CMA policy would have allowed.  The Supreme Court cannot be faulted because CMA leaders were ill-prepared to deal with the consequences of a ruling entirely consistent with their own policy, and realized, too late, that events set in chain by the Carter decision were beyond their control. 

After the ruling, CMA officials found themselves caught between anxious physicians who wanted nothing to do with killing their patients and activists accusing objectors of patient abandonment.  And it seems they discovered, to their dismay, that state authorities were not nearly as receptive to CMA lobbying as they had anticipated.  Dr. Blackmer later disclosed that his attempt to explain the burden imposed on physicians who provide euthanasia was dismissed by "some very senior federal politicians" in "not very nice language."

I even had one tell me, 'I think doctors love to play God, and you're all gonna be just fine with this because it's just an extension of your desire to play God.'

. . . I told this federal politician I was very offended by that, and that to suggest that - even behind closed doors - was incredibly insulting to a profession that's now being asked to do this. This was a politician who in public was saying how much we trust the medical profession.4 

Months before this disclosure, a source reporting first hand observations advised the Project Administrator that the CMA and its officials were being "beat up" institutionally and personally when they attempted to defend physician freedom of conscience, especially in relation to referral, and were encountering marked hostility to objecting physicians among government representatives and the public.6

This demonstrates that CMA officials were actually struggling, against the odds, to support objecting physicians, and this was admirable. However, it was also predictable; that was why the Protection of Conscience Project, Catholic Civil Rights League and Faith and Freedom Alliance intervened in Carter at the Supreme Court of Canada in defence of physician freedom of conscience, emphasizing the issue of referral. 

Long before the Carter decision there had been increasingly strident demands for mandatory referral for morally contested services, including referral for euthanasia and assisted suicide. CMA officials were fully aware of the controversy about referral. For forty-five years the CMA had consistently maintained the position that objecting physicians were not obliged to collaborate in what they believed to be wrongdoing by finding someone else to do it. Arguments for compulsory referral made during years of skirmishing about abortion were simply retooled and applied to euthanasia.7

However, while CMA officials had repeatedly affirmed the Association's commitment to protect physician freedom of conscience, they had never developed a principled foundation for that commitment, and the Board did not do so before reversing CMA policy on euthanasia and assisted suicide.  Its focus was on the role the CMA and physicians would play in implementing new euthanasia and assisted suicide laws, not on freedom of conscience, except to the extent that it could be used to further its goal of changing the CMA's policy.

As a result, when the Carter decision was released, the CMA was ready to spring into the saddle to help plan the provision of the services,8,9  but was quite unprepared to mount a cogent, articulate and persuasive defence of physician freedom of conscience, especially in relation to referral.  This became evident in the weeks and months following the Carter decision.

Carter - Day 1

CMA officials on conscience

Once the ruling was announced,10 CMA President Dr. Chris Simpson immediately pointed out that "there was nothing in the language in the ruling today that suggested that individual physicians would be compelled" to provide euthanasia or assisted suicide. He was pleased that the Supreme Court quoted the new CMA policy that "supports physicians being able to follow their conscience in choosing whether to participate in medical aid in dying."9

We can't just simply say we're going to compel physicians to do things that they personally, morally and ethically can't do.11

I think it's fair to say no patient would want a physician to be individually coerced into doing something that they felt was against their personal moral, morals or ethics or religious beliefs. That's not going to serve anybody well.12

Doctors are far more deeply divided on assisted suicide than the general public, Simpson said, "and we'll be looking really carefully for language that protects individual doctors' right to conscientiously object, and not participate. My early feeling is that there is a lot of reassuring language on that."11

Dr. Simpson referred to the Supreme Court comment that the rights of patients and physicians would have to be reconciled.

The core of that reconciliation will be that we respect individual doctors' rights to conscientiously object.

That's in patients' best interests. Ultimately, no patient is going to want their physician pulled in against their will to help them with such a profound issue.13

He emphasized the need to find the correct balance between "the need now to provide this service in an equitable way to the small number of patients who need it and are eligible for it" while protecting individual physicians who wanted no part of it.11

What we want to do is really make sure patients who are eligible under the new rules have access to this therapeutic service, but at the same time we need to be very careful that physicians have the right to conscientious objection for moral or ethical reasons or religious reasons.14

An important element in Dr. Simpson's approach to the problem was his conviction that only a very small number of patients would actually ask for euthanasia or assisted suicide, and that there were more than enough doctors in Canada willing to do as they wished.

Simpson said the number of patients who would likely be eligible for, or even request assisted death, would be so small, based on experience in other jurisdictions, that there would be sufficient numbers of doctors to provide equitable access for all, "without compelling a large number of doctors to personally participate."11

While acknowledging that some physicians would refuse to be involved, Dr. Simpson cautioned that "society now has a different view" and the Supreme Court had ruled that "patients have a right to equitable access" to physician-assisted suicide and euthanasia "and it's up to us to figure out how to achieve that."11

We need to have a system that balances the right of physicians not to participate, and perhaps not even to refer, but that has to be done in a way that doesn't impair access for patients who would qualify for this. [Emphasis added].11

Two things warrant attention here. First: the Court actually said nothing about "equitable access." Dr. Simpson may, at this point, have actually been articulating the position of the CMA Board.

The second was, arguably, more important: his qualifier, ". . . and perhaps not even to refer" - as if this might be an excessive concession, or was at least negotiable - that Dr. Ferrier might, perhaps, not have to "send somebody to their death," as she put it.2

On the other hand, in other interviews immediately after the ruling, Dr. Simpson admitted that there was "no consensus" in the medical profession that physicians should provide euthanasia and assisted suicide,13 correctly identified and indicated that he understood the issue of referral:

"The ruling appears to be quite clear that physicians should not be compelled to participate and for many the act of participation is the act of referral somewhere else," Simpson said.

"So we really need to develop capacity in the country to provide the service without compelling every single physician, and even most physicians, to participate."15

Euthanasia/assisted suicide activists push back on conscience

Dr. Simpson's comments were promptly challenged by Professor Jocelyn Downie of Dalhousie University, who was a member of the winning legal team in Carter. Professor Downie had long argued that objecting physicians should be forced to facilitate procedures they believe to be wrong - even if the procedure in question is killing people. "I would say that they have a duty to refer," she said, "But that will get spelled out in the legislation."16

Dr. James Downar and Dr. Brett Belchetz, both members of a group that intervened in Carter in support of euthanasia and assisted suicide, were pleased with the Supreme Court ruling. The day after the judgement Dr. Downar acknowledged "the right to conscientious objection is a really critical one" and "clearly an important moral question."

"We have to recognize that, similar to abortion and other things in medical practice, there are physicians who will object to this," Downar said. "We want to make sure that nobody feels they're forced to participate."17

However, Dr. Downar soon made clear that physicians unwilling to kill patients or help them commit suicide should be forced to direct them to someone who would.

Downar said it is critical that legislators involve stakeholders in crafting a process to ensure all Canadians have access to physicians who will assist them in dying if they meet prescribed conditions. Any process must also require doctors who have a conscientious objection to refer patients to a colleague who will medically assist them with dying.13

Dr. Belchetz referred to a draft policy of the College of Physicians and Surgeons of Ontario (CPSO), Professional Obligations and Human Rights, suggesting it as a model that could be used to accommodate physicians who did not want to be involved with killing patients or helping them to commit suicide. The draft policy permitted physicians to refuse to provide abortion, contraception or other services for reasons of conscience on the condition that they provide an "effective referral" - that is, promptly help the patient obtain the procedure elsewhere.17  This was unacceptable to many objecting physicians, and a constitutional challenge to the policy was launched after it was enacted.18

CMA officials on referral

Vice-President hedges

Dr. Jeff Blackmer identified referral as the central problem facing the CMA following the Carter ruling.

For those who do not want to participate, the basic principle is this: If you do not want to, you do not have to do it and no one is going to force you to do it. I have not heard anyone say anything to the contrary. The real crux of the issue is what I call the referral question. If I refuse to participate, do I then have a moral, legal, or regulatory obligation to refer to someone who will provide that service?19

He referred to controversial draft policies proposed by the Colleges of Physicians and Surgeons of Ontario and Saskatchewan that had not been finalized.  They had generated overwhelming opposition in public consultations precisely because of their demand that objecting physicians should be forced to refer for morally contested procedures.20 He noted that they did not mention specific procedures. "Understandably," he said, "a number of our members are very concerned."

"Now the flip side of that is the issue of access. To what extent can physicians exercise their moral views if this has a detrimental impact on patient care?

CMA policy is essentially silent on mandatory referral. As a result of [the CMA] being silent, the policy has been interpreted as saying [referral] should not be mandated, which is probably accurate. We need to have a more open discussion on this as part of discussions on the legislated framework.19

The assertion that CMA policy was "essentially silent on mandatory referral" and that it was only "probably accurate" to say the CMA opposed it was noteworthy. For forty five years, the CMA had held that physicians should not be obliged to make referrals for procedures to which they object for reasons of conscience. 

A 1977 revision of the Code of Ethics that was taken to imply the contrary generated major controversy and was reversed the following year.  CMA Director of Ethics Dr. John R. Williams, Dr. Blackmer's predecessor, at least twice explicitly repudiated the idea that objecting physicians could be forced to do what they believed to be wrong - including referral.  In 2007, Dr. Blackmer himself rejected claims that CMA policy obliged objecting physicians to refer for abortions.  The following year, the Chair of the CMA Ethics Committee reaffirmed the Association's support for physicians who refused to refer for abortion for reasons of conscience.7 Since Dr. Blackmer was well aware of this history, his statement that "a more open discussion on this" was needed was remarkable, as if the previous discussions had never occurred, or decisions made at Annual General Councils had not been sufficiently "open." 

It is true that, in 2007, Dr. Blackmer wrote an article in the World Medical Journal in which, citing four sources, he asserted that "the majority of the current literature, if not current policy and legislation, appears to support the obligation to refer."  He also wrote that objecting physicians must not "actively or passively" obstruct patients from obtaining services from another clinician (emphasis added), without defining "passive obstruction."21 However, Dr. Blackmer's comments about referral in the article cannot be understood to have displaced the well-established contrary position of the CMA, which, at the time of the Carter ruling, had not changed.

CMA President faces question, avoids answer

Dr. Blackmer initially took comfort in the results of the CMA's 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.22

"That's thousands and thousands of physicians across the country," he said elsewhere. "For most Canadians, access might not be a problem."17

However, Carter also established broad eligibility criteria - quite possibly broader than what the willing physicians surveyed in 2014 had in mind. Thus, the actual number of physicians willing to participate may have fallen once the ruling was issued and they realized what would be expected of them.

There are indications that a shift of this kind began to occur after the ruling. Dr. Simpson was asked about physicians being expected to provide euthanasia for a patient physically incapable of self-administering a lethal drug. He avoided giving a direct answer to the question.

Simpson calls this one of the "important nitty-gritty details" yet to be worked out. It's a question that needs to be explored by doctors groups, legislators and legal experts as a framework for how medical aid in dying will actually be delivered.23

In fact, this was not simply a "nitty-gritty detail." This was exactly the proposition put to the trial court by the plaintiffs and pursued in their appeals: that physicians should be able to lethally inject patients who were incapable of committing suicide even with assistance.24 The Supreme Court of Canada agreed, and that is what Carter approved.

The only "nitty-gritty detail" that remained to be worked out in this respect was whether or not the attending physician would have to personally kill the patient in such circumstances, or if the actual killing could be done by someone else. Since at least a very large number of physicians were opposed to killing patients, this was probably not the kind of discussion that Dr. Simpson cared to have in the media.

"A lot of doctors regard the prescribing of a lethal substance as the moral equivalent to actually administering a lethal substance," he said. And while hooking up an IV and giving a fatal dose could be done by any trained physician, "many doctors are saying there should be another class of clinicians who does only this."

"I'm not sure that really absolves anybody because the hard work is in the decision-making. The hard work is not in hooking up the IV."23

CMA officials "really grappling" with physician resistance to referral

By the last week of February, feedback from concerned physicians was beginning to trouble Dr. Blackmer. In the first place, it seems that legalization of euthanasia in addition to assisted suicide was proving to be of greater concern to more physicians than the CMA had anticipated. Saying that the CMA was uncertain if the Carter ruling permitted both assisted suicide and euthanasia, he noted that "pushing the syringe themselves" made physicians much more uneasy than assisted suicide.  "Many thousands of physicians" considered euthanasia and assisted suicide quite different.

A strong, philosophical argument could be made "that you're probably splitting hairs from a moral standpoint - that the act of writing the prescription is probably morally equivalent" to actively administering a lethal injection with the intention of ending a patient's life, Dr. Blackmer said.

"But regardless of that, there's clearly a certain percentage of doctors who feel that that's not the case - that they would be comfortable with writing that prescription where they would not be comfortable with injecting the medication directly," he said.22

It is puzzling that, two weeks after the ruling, CMA officials were still not sure if Carter approved both euthanasia and assisted suicide.  From the very beginning, almost four years earlier, it was abundantly clear that the case was about the legalization of both physician assisted suicide and physician administered euthanasia.24 Both were authorized by the trial court judge25 and both were unambiguously approved by the Supreme Court of Canada (para. 40, 127).10

Quite apart from concerns about assisted suicide vs. euthanasia, Dr. Blackmer was getting emails daily from physicians, most - "five or six in the last hour alone," he told a reporter - who were not only unwilling to kill patients or help patients kill themselves, but who were also unwilling to refer patients for euthanasia or assisted suicide.

The CMA does not have a policy on the issue. Its policy on abortion, however, is silent on mandatory referral. "That has been interpreted as meaning that the CMA does not support mandatory referral, and I think that is probably a reasonably accurate interpretation," Dr. Blackmer said.

But, "We are currently really grappling with this," he said.22

As noted previously, the CMA had consistently and publicly opposed mandatory referral for abortion for decades, so the claim that its actual position was unclear is unsupportable.  The fact that, in 2015, were CMA officials "really grappling" with the issue in such critical circumstances was a consequence of their failure to grapple with it before they decided to shape the debate and the law on euthanasia and assisted suicide (See Part I: CMA Board decides to shape the debate and the law).

CMA officials take stand against mandatory referral

When, in March, the CMA Board endorsed seven foundational principles concerning assisted suicide and euthanasia, two were particularly relevant to physician freedom of conscience.  "Equity" addressed the issue of access to the procedures, equating them with "any other medically approved intervention."  The second seemed to reflect feedback from increasingly concerned physicians.

Equity - all Canadians who meet the criteria should have access to assisted dying, as for any other medically approved intervention.

Respect for conscientious objection by physicians and other care providers; no physician or other health care provider should be forced to take part in any aspect of the assisted dying process against their wishes.26

CMA President Dr. Chris Simpson took a particularly strong position when interviewed by the media about the development.

No physician in the country should be forced to play a role in any aspect of assisted dying against their moral or religious beliefs - including referring patients to another doctor willing to help them die, the Canadian Medical Association says.

Legalized physician-assisted death will usher in such a fundamental change in practice "we simply cannot accept a system that compels physicians to go against their conscience as individuals on something so profound as this," CMA president Chris Simpson said in an exclusive interview.

Dr. Simpson said that many doctors who conscientiously object to assisted dying feel the very act of referral "is contrary to their personal ethics or moral or religious beliefs."

He said resources could be provided to allow patients to "self-refer" for assisted death - for example, a website listing the names of doctors willing to provide it.

"Then the patient themselves can take that initiative rather than have the physician who they are normally attached to, who conscientiously objects, make the call," Dr. Simpson said.

Hospital administrators, an ombudsman or local health authorities could also be legislated to act on the behalf of patients, he said.

"I can't emphasize enough that in us taking this position about conscientious objection we feel equally strong that we need to have other mechanisms to make sure that patients who need the service get it," Dr. Simpson said.27

Again citing the 2014 survey indicasting that about 25% of physicians were willing to participate in physician-assisted suicide (not euthanasia) Dr. Simpson said, "I don't think there's going to be a shortage of physicians who are going to be willing to help patients," although he conceded that access to euthanasia and assisted suicide in rural or remote regions might be difficult and would have to be worked out.27

EAS activists push back on mandatory referral

The strong statement prompted immediate responses from euthanasia activists. One, Professor Udo Schuklenk, was one of the authors of the Royal Society of Canada report cited as a reliable authority by Dr. Smith in the CMA's application to intervene in Carter.28 Professor Schuklenk wondered why physicians should be allowed to "opt out" at all.27

Wanda Morris, CEO of Dying with Dignity Canada, did not go that far. She said that objecting physicians should not be forced to directly provide euthanasia or assist with suicide.

"But imagine a scenario where you have a patient who is on their death bed, they're very weak, and the attending doctor says, 'I want nothing to do with this, I won't even refer.' Are they effectively denying that patient his or her rights?"27

Morris argued that physicians should only be allowed to refuse to refer patients for assisted suicide and euthanasia if physician referral is made unnecessary by a "legislative or regulatory framework" that can assure access to the services.29

Euthanasia activists Dr. James Downar and Dr. Derryk Smith complained that the CMA President was unfairly prioritizing the rights of physicians over the rights of patients.

"Terminally or grievously ill patients are rarely able to advocate for themselves," said Dr. James Downar, a palliative care physician in Toronto. "If a physician refuses to provide a treatment and refuses to involve anyone else, then it is hard to imagine how that patient's request will be respected."

"It is understandable that, for religious or ethical reasons, some doctors won't want to provide assistance in dying," Smith said. "However, it is the beliefs and healthcare needs of the patient that are critical in these situations. Patients seeking assisted dying should not be denied access to medical care just because of the beliefs of their doctor."29

Their reaction had an immediate effect.  Another CMA statement appeared a week later under the headline, "We need clear guidelines on referral in physician assisted dying: Simpson." It included statements by Dr. Simpson supportive of physician freedom of conscience, but added:

Mandatory referral in physician-assisted dying is one of the major issues that need to be resolved in the wake of the unanimous court ruling. While the CMA does not have specific policy in this controversial area, it will be consulting with its members in the coming months and hopes to have guidance following its General Council meeting in August.30

While it was technically correct to say that the CMA did not have a stand-alone policy on referral,  the statement creates the false impression that the referral controversy was something new to the Association and that it had not previously taken a position on the issue.

CMA Board pulls back on support for objecting physicians

In May, the Board approved the draft framework, Principles-Based Approach to Assisted Dying in Canada,31 adding two foundational principles to the seven published in March.  It also backed away from the strong commitment to physician freedom of conscience26,27 that had provoked sharp criticism by EAS activists.27,29

The March statement affirmed support not only for physicians, but other health care workers, and referred to "conscientious objection," which is a particular expression of freedom of conscience. Only physicians were mentioned in the revised statement, and respect for constitutionally guaranteed freedom of conscience was downgraded to respect for physician "values."

The March statement referred to "tak[ing] part in any aspect of the assisted dying process." This statement was broad enough to encompass referral. The revised text offered support only for those who refuse to provide euthanasia and assisted suicide, thus implicitly withdrawing support for physicians who refuse to facilitate the procedures by referral or other means.

The phrase "without discrimination" was ambiguous. It was not clear if it meant that physicians who follow their consciences should not be discriminated against, or if it meant that, in deciding whether or not to provide euthanasia or assisted suicide, physicians must not engage in illicit discrimination.

Finally, the condition that there must be no "undue delay" in accessing EAS services provided grounds for suppressing physician freedom of conscience if facilities, institutions or the government failed to provide resources needed to ensure access without involving objecting physicians.

"Help eligible patients end lives or refer them to someone who will, CMA to urge Mds"
National Post, August, 2015

By the opening of the General Council in August, the CMA Board seemed poised to reverse the Association's longstanding opposition to mandatory referral, just as it had reversed the policy against physician participation in euthanasia and assisted suicide. Contradicting the position he had taken only four months earlier, CMA President Dr. Chris Simpson was reported as saying that physicians unwilling to provide assisted suicide or euthanasia "should refer patients to someone willing and able to make it happen."

We don't support anything that's going to impede patients from access a legal service. . . Maybe the third party is a hospital CEO. . . So, if the attending physician says, 'the patient has requested assisted dying, I'm not comfortable having anything to do with this' … somebody would then sort of take charge of finding a physician, or finding the service to be done, so that the care is handed over formally to someone else who can facilitate it.32

Principles-Based Approach to Assisted Dying in Canada was the draft framework used to organize consultation and deliberation among CMA members and was the focus of critical decision-making at the CMA's Annual General Council in August, 2015.  Prior to the Council the CMA distributed the document widely, including not just the medical community but "patient groups, public groups, and groups such as the . . . Christian Medical and Dental Society, the anti-euthanasia coalition and Dying with Dignity."33

Consistent with CMA policy and Dr. Simpson's statements as the Council opened, the draft framework presumed an obligation to kill patients or help them commit suicide in the circumstances defined by the Supreme Court.  Moreover, it asserted that physicians were obliged to "ensure equitable access" to euthanasia and assisted suicide,34 a claim unacceptable to many objecting physicians.

The key provision in the framework offered protection of conscience for physicians who refused to personally kill patients or help them commit suicide, but not for physicians who refused to refer them to colleagues who would do so.

5.2 Conscientious objection by a physician
Physicians are not obligated to fulfill requests for medical aid in dying. There should be no discrimination against a physician for their refusal to participate in medical aid in dying. In order to reconcile physicians' conscientious objection with patient access to care, a system should be developed whereby referral occurs by the physician to a third party that will provide assistance and information to the patient.31 (Emphasis added)

"Refusal to participate" in 5.2 actually meant only refusing to personally provide a lethal injection or write a lethal prescription. Most readers were probably not aware of this because it was not explained in the document, and it may not have been known even to all of the small number of participants in the on-line dialogue where it was disclosed.35  This restricted definition of "participation" was not only contrary to common usage; it was inconsistent with distinction between providing and participating found in the CMA's submission to the Supreme Court of Canada36 and in the Carter ruling.37

All 80,000 CMA members were invited to discuss the draft framework and related topics in an on-line member dialogue (forum, chat room) about EAS policy, but only 595 registered.38 In fact, by 19 July, 2015, only 144 CMA members had participated, less than 0.0025% of the membership.  Of these, 94 contributed to only one of seven topic strands.39

A report of the on-line dialogue stated that physician freedom of conscience was "by far the most hotly debated issue."40 Many objecting physicians found referral for euthanasia and assisted suicide unacceptable because they believed that it made them complicit in the acts, even if the referral was made "to a neutral individual or organization." Most rejected the proposal in 5.2 to refer patients "to a third party that will provide assistance and information."41

The report noted that other dialogue participants disagreed, summarizing their concerns in a quote from one of them:

"I have also heard from many patients and families who have indicated that this might be an unacceptable burden under what will likely be extremely difficult circumstances," said one physician.42

This "one physician" was actually the moderator, Dr. Jeff Blackmer,43 whose other on-line statements were explicitly identified in the report.

The dialogue is of doubtful value as an indicator of general opinion among CMA members because there were so few participants and all were self-selected. However, Dr. Blackmer's contributions can be taken to reflect the perspective of the CMA leadership. This can be summed up as:

• The discussion is over.
• Physicians are obliged to support euthanasia and assisted suicide.
• Self referral/direct patient access is unacceptable.

The discussion is over

CMA policy had long stated that "a fundamental reconsideration of traditional medical ethics would be required" before physician participation in euthanasia and assisted suicide could be approved, and it told the Supreme Court that ethical positions for and against physician participation in the procedures were both defensible.44  Despite this, the CMA Board took sides, as it were: it committed the Canadian medical profession to providing euthanasia and assisted suicide if the procedures were legalized.  It did not have to do this; as Dr. Blackmer explained, the CMA could have said, "ethics trumps the law."45 

But he took the opposite position in moderating the on-line dialogue.  He told participants, "the debate on whether physicians as a profession will be participating is now basically a moot one."46

"It is a done deal," he said. "But we still have an opportunity to help shape what it will look like in practice."47

This approach shut down continuing debate about what the CMA had previously described as an unresolved ethical dispute, and it precluded reconsideration of the Board's commitment to physician participation.  All that remained to be settled were practical points associated with implementing the Carter regime, like identifying patients eligible for euthanasia or assisted suicide and delivering the services.  Dr. Blackmer acknowledged that not everyone would "feel comfortable" about doing this, but, "[w]e need to work out, as a profession, a system whereby those who do qualify will have access in a timely manner as for any other type of intervention."48

Physicians are obliged to support euthanasia and assisted suicide

From the perspective of objecting physicians, the problem with this expectation was the implied collective professional obligation to facilitate access to euthanasia and assisted suicide.  Those opposed to killing patients were not simply "uncomfortable" about working out how that could be done efficiently, but rejected such collaboration as morally repugnant.  One of the participants argued that the fact that the Supreme Court struck down the law did not imply that physicians had a collective or individual obligation to ensure access to EAS services.

Dr. Blackmer admitted that "this might be factually correct."

But given the current situation, where these acts will soon be legal, and where we know that approximately 20% of our colleagues will elect to participate, it is very difficult for the medical profession to ignore reality.

Having the opinion that this is unethical or ought not to be part of medical practice is, of course, quite reasonable, and many will agree with this position.

However, if the profession were to refuse to participate in working out a system that meets the needs of physicians, we would most certainly be doing so to our own detriment, and to that of our many colleagues who will participate and need our assistance and support, regardless of what our own personal views might be.49

His concern was that if "the profession as a collective" declined to participate in implementing the law, then "others" (i.e. non-physicians) would be making the rules for the "25% or so" of physicians providing EAS services.47  However, "25% or so" amounted to about 20,000 physicians, surely a number sufficient to provide the medical perspective thought necessary to inform the regulatory process. 

While it was obvious that the profession could not "ignore reality," the reality indicated by his statistics included the fact that 75% to 80% of physicians would refuse to provide euthanasia or assisted suicide.

Which reality should have been the focus of CMA policy making?

In fact, CMA officials were attempting to accommodate both groups.

"Whether you agree with euthanasia or not, whether you decide to participate or not," wrote Dr. Blackmer, "we will be at the table protect your rights and interests."47

Granted this was the intention, having formally endorsed the position of EAS providers, the CMA was compromised in its support of EAS objectors. Objecting physicians quite reasonably held that their rights and interests were ignored, not protected, by an expectation that they would assist and support the provision of euthanasia and assisted suicide.  This seems to have been lost on CMA officials.

Dr. Blackmer attempted to overcome their resistance with an appeal to the authority of the overwhelming vote in favour of the resolution at the 2014 Annual General Council:50

I would like to note that it is our members, who voted on this issue, who chose to support all Canadian physicians, yourself included, whether they decide to participate in assisted dying or not. We know that 25% of physicians are likely to participate in assisted dying. 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.51

This misrepresented the resolution. Dr. Blackmer said at the time that it did not imply support for euthanasia or assisted suicide.52  It affirmed only the right of physicians to choose whether or not to provide euthanasia or assisted suicide if the law changed: nothing more.  It did not impose a collective obligation to support or facilitate the provision of the services should the law change.53

The actual source of a purported collective obligation was not the 2014 resolution, nor even the Carter decision, but the Board's commitment on behalf of the entire profession to "support access to the full spectrum of end of life care" - including euthanasia and assisted suicide. The Board came to the 2015 Annual General Council intent upon keeping that commitment, convinced that, in Section 5.2 of the draft framework, it was offering those who disagreed the best deal they were going to get.

Self referral/direct patient access is unacceptable

Dr. Blackmer introduced Section 5.2 to the on-line dialogue in his first comment in the thread "Conscientious objection and equitable access." He argued that it was necessary "to find a balance between the right to conscientious objection and the right of patients to access an intervention that has now been deemed to be legal."43

In fact, the CMA had already faced and resolved this problem. In revising its Code of Ethics in 1970 after abortion law reform, it decided that physicians unwilling to provide a service for reasons of conscience were expected to give timely notice to patients, so that patients can find another physician willing to provide it. The policy was explicitly affirmed by the CMA General Council in 1971.54 Except for a short period in 1977/78, the CMA had maintained this position for 45 years.7 Within the context of accommodating conscientious objection by physicians, this approach came to be known as "self-referral" or "direct access," with the understanding that the state or other agencies could help connect patients with willing physicians.  The CMA Board and president had strongly advocated self referral in March27 but had promptly retreated when challenged by EAS activists.

Dr. Blackmer, well aware of all of this, merely said that self-referral "may be one possibility," adding, "I have also heard from many patients and families who have indicated that this might be an unacceptable burden under what will likely be extremely difficult circumstances." He then proposed "referral to an independent third party" as something to be considered, soliciting feedback.43

The description of the proposal was vague and could obviously entail unacceptable complicity and was opposed by a number of participants, so Dr. Blackmer provided more information.

Let me clarify that this is not referral to a physician who will be providing the intervention. It is intended to serve as a "middle ground." Most patients who receive this referral will not access assisted dying, but rather will learn about the variety of options available to them, including palliative and spiritual care. It does not facilitate access to assisted dying. It facilitates access to information.55

He emphasized that the proposal did not entail "effective referral,"56 a term defined by the College of Physicians and Surgeons of Ontario:

An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.57

Rather than "effective referral", he said, "We are examining the option of referral to an independent third party, which would not necessarily result in assisted dying - and would not be likely to do so in the majority of cases."56

The distinction between providing information to enable informed enable medical decision-making and facilitating a morally contested procedure by effective referral was valid and important. However, most objecting physicians are willing to personally advise patients "about the variety of options available to them, including palliative and spiritual care." There would actually be no need for most to refer patients for that purpose, so dialogue participants may have considered the Board's "preferred solution" to be irrelevant in most cases.

More important, the acceptability of the "third party" solution depended upon what the third party would actually do. Providing assistance and information was not problematic, but active third party facilitation would be.  As Dr. Simpson's comments at the opening of the Council indicated, that possibility was not ruled out, and a third party system had yet to be designed.  It is not surprising that objecting physicians were reluctant or unwilling to accept an arrangement before such important details had been worked out.

In any case, when they persisted in expressing preference for self-referral or direct access, Dr. Blackmer became more emphatic in rejecting the idea. He explained that the CMA had tried "to work with the regulators to find language that might meet the needs of both objectors and their patients," and did not understand Section 5.2 to mandate referral. If physicians refused to accept the third party proposal, he warned, "there is a very real possibility that mandatory direct referral to a non-objecting physician will be imposed."

"This is the outcome we are trying to avoid," he said, "a 'win-lose scenario' where we have no control over the final outcome."58

In fact, having declared euthanasia and assisted suicide to be legitimate forms of end-of-life care, having affirmed that it would ensure patient access to the procedures, and having qualified its support for physician freedom of conscience by insisting that there should be no "undue delay" in providing them, the CMA lost "control of the final outcome" once the Supreme Court ruled in Carter. Regulators could quite plausibly claim that demanding "effective referral" was simply a logical application of commitment made by the CMA when it reversed its policy against euthanasia and assisted suicide.

CMA officials, negotiating at a significant disadvantage of their own making, were desperate to find a policy "acceptable to the regulators" and to objecting physicians whose fundamental freedoms they had rashly jeopardized. Thus, Dr. Blackmer repeatedly hammered home the message that if physicians continued to support only self-referral, mandatory effective referral would be imposed.46,56,58

"The key," he said, "is in finding a solution that will ensure both and protect the physicians' right to conscientious objection while not impeding access."46

The problem, however, was that the largest medical regulator in the country had already imposed a policy of effective referral for every other morally contested service so that physicians would not "impede access to care" by conscientious objection,57 and would later extend the policy to include euthanasia and assisted suicide59 because, consistent with CMA policy, it saw "no qualitative difference" between therapeutic homicide and suicide and "other health care services"60 (in the framework's reference to "equity," "any other approved medical intervention").

CMA delegates reject effective referral

Writing three years later in response to criticism of CMA lobbying to change World Medical Association policy against euthanasia and assisted suicide, Dr. Blackmer remarked that objecting physicians had "made tearful pleas at several CMA General Council meetings, asking their non-objecting colleagues to support them and to defend their rights."61

He did not acknowledge that this was necessary because the Board had reversed CMA policy against euthanasia and assisted suicide, affirmed both as medical care, and insisted that all physicians are obliged to ensure equitable and timely access to them "as for any other type of intervention."48 This effectively shifted the onus to physicians to show why they should not be parties to killing eligible patients.  This was why objecting physicians, in particular, needed the support of their colleagues, and why they were forced to resort to begging, tearful pleading and expensive constitutional court challenges in support of their fundamental freedoms.

Fortunately, physicians surveyed about the issue in 2015 seem to have been supportive. Statistics presented at the Council disclosed that only 17% supported the Board's "preferred solution" and over 50% held that objecting physicians either had no obligation to do anything further (31%) or provide only support and information — not referral (20%).

Overall, only 19% believed objecting physicians should be forced to refer (a proportion remarkably close to the proportion of physicians said to be willing to provide EAS services), while almost 68% clearly believed that objecting physicians should not be required to refer patients for anything other than information.

At the General Council, delegates were presented with a refinement of the wording in Section 5.2 developed by physician groups representing those opposed to euthanasia and assisted suicide.62 It specified that objecting physicians should "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," making it clearer that referral to an EAS delivery service was not expected.63  Delegates approved this option by a margin of about 75%64 — by Irish abortion referendum standards, a landslide.

This was a development of the basic framework provided by the Code of Ethics and the CMA's longstanding position of physician freedom of conscience in relation to morally contested procedures.  It was, however, a largely pragmatic response guided by a general notion of "striking a balance" between patient and physician autonomy or rights. It was specific to euthanasia and assisted suicide, and it was unsupported by principled ethical or philosophical rationale. It is unlikely that more than this could have been achieved in the circumstances, and objecting physicians were fortunate to have achieved this much.

The CMA Board later approved Principles-based Recommendations for a Canadian Approach to Assisted Dying as amended at the Annual General Council.65  The framework was not a policy document in the ordinary sense, but was meant to provide interim guidance in discussions with federal and provincial authorities, which had yet to respond to the Carter ruling.

Postscript

The CMA later produced a strong defence of physician freedom of conscience in relation to referral for euthanasia and assisted suicide.66  Current CMA policy on euthanasia and assisted suicide has been improved in this respect, more carefully articulating the issues of access to services and protection of freedom of conscience (or moral integrity).  In particular, it states that objecting physicians "are not required to provide it, or to otherwise participate in it, or to refer the patient to a physician or a medical administrator who will provide assistance in dying to the patient."  It also appears to put the onus on the state "to implement an easily accessible mechanism to which patients can have direct access" to obtain the services so that physicians can adhere to their moral commitments.67 

These changes deserve recognition and thanks, but they were late in coming.  The submission on referral came only in January, 2016, almost a year after the Carter ruling.  The articulation of physician freedom of conscience found in current policy on the procedures dates from May, 2017 - more than three years after Carter.

Moreover, mandatory referral for euthanasia and assisted suicide was recommended by a Royal Society panel of experts in 2011.68  The CMA cited this report in its 2014 application to intervene in Carter - but only because the experts dismissed the risk of a "slippery slope" should euthanasia and assisted suicide be legalized.69  It took the CMA over four years to respond to the experts' tendentious claim that referral is an acceptable form of accommodation, and almost seven years to reject their demand that physicians should be forced to refer for euthanasia and assisted suicide.  There was arguably no need for the CMA to respond to the experts in 2011; it was then opposed to physician participation altogether, so the issue of referral was moot.  That was certainly not the case in 2014, when the Board was planning its intervention in Carter.

Finally, by the time the CMA did respond, objecting physicians were on the defensive in a treacherous and even hostile environment.  A policy demanding effective referral for all morally contested services is the subject of a constitutional challenge in Ontario.18  The trial court ruled against the physician plaintiffs, who have appealed the decision.70 The case will likely go to the Supreme Court of Canada, and the outcome will determine whether or not physicians unwilling to be parties to killing their patients will be able to continue to practise medicine in Canada.

CONCLUSION

The Canadian Medical Association and Royal Dutch Medical Association are attempting to convince World Medical Association to drop its opposition to euthanasia and assisted suicide.  This review was prompted by the CMA's further suggestion that the WMA and other national associations should follow the CMA's example in revising euthanasia and assisted suicide policy.

While changes to euthanasia and assisted suicide policies can be considered from a number of perspectives and entail serious engagement with grave moral/ethical issues, the focus of the Protection of Conscience Project is limited to ensuring that the freedom of conscience of physicians and other health care workers is not violated by compelling them to do what they believe to be wrong.

Hence, this review does not address the acceptability of euthanasia or assisted suicide, nor the arguments for or against legalization or changes in medical association policy.  It considers the CMA's efforts to shape the debate and the law on euthanasia and assisted suicide only in relation to its impact on physician freedom of conscience. 

This review demonstrates that, if the World Medical Association (WMA) or some of its constituent national medical associations wish to change their policies on physician participation in euthanasia or assisted suicide, they should not follow the example of the Canadian Medical Association if they wish to prevent physicians and other health care workers from being compelled to do what they believe to be wrong.

Before advocating changes of policy or law that could involve such a risk, a medical association must establish a robust, comprehensive and rationally defensible protection of conscience policy that takes fully into account the issue of complicity arising from various forms of cooperation.  It should also ensure that its policy cannot be ignored or overridden by the state or by powerful or influential private interests, if, need be, by insisting that it be supported by appropriate legislation. 

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Notes

1.    Ubelacker S.  Doctors ready for Supreme Court decision on assisted suicide.  CTV News, 5 February, 2015 (Accessed 2018 Sep 10).

 2.    Grant K.  Canadian doctors drafting new rules in case doors open to assisted suicide. Globe and Mail, 5 February, 2015 (Accessed 2018 Sep 10).

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

4.    Proudfoot S.  A CMA doctor on the burdens and ethics of assisted death.  MacLeans, 8 June, 2016 (Accessed 2018 Sep 10).

5.    Compare "completely in opposition to all teachings in medical ethics" with text accompanying notes 52 and 53 in Part I.

6.    Personal communication with Protection of Conscience Project Administrator, 7 January, 2016.

7.    The history of the CMA's long-standing position on referral is summarized and documented in the Project's Submission to the Canadian Medical Association Re: 2018 Revision of the CMA Code of Ethics - Part II: CMA against mandatory referral.  Protection of Conscience Project (2 April, 2018).

8.    Rich P.  CMA positioned to take lead role in crafting new regulations.  Canadian Medical Association, 6 February, 2015 (Accessed 2018 Sep 10).

9.    CMA examining Supreme Court ruling striking down ban on doctor-assisted death.  Canadian Medical Association, 6 February, 2015 (Accessed 2018 Sep 10).

10.    Carter v. Canada (Attorney General), 2015 SCC 5 [Carter-SCC] (Accessed 2018 Sep 10).

11.    Kirkey S. Top court's ruling on assisted suicide leaves many questions for doctors. o.Canada.com, 6 February, 2015 (Accessed 2018 Sep 10). 

12.    Geddes J.  Interview: The CMA's president on assisted dying: Dr. Chris Simpson calls for a process to set new rules.  Macleans, 6 February, 2015  (Accessed 2018 Sep 10). Full transcript by Protection of Conscience Project [Geddes Full Transcript], lines 33-36.

13.    Eggertson L. Rights may conflict with assisted dying ruling. CMAJ 2015 DOI:10.1503/cmaj.109-4994 (Accessed 2018 Sep 10).

14.     Doctor-assisted suicide a therapeutic service, says Canadian Medical Association: Many technical questions remain following Supreme Court decision to allow medical aid in dying.  CBC News, 6 February, 2015 (Accessed 2018 Sep 10).

15.    Hume J.  Supreme Court strikes down ban on assisted suicide.  Toronto Sun, 6 February, 2015 (Accessed 2018 Sep 10).

16.    Branswell H. Canadian MDs, many hesitant about assisted death, assessing Supreme Court ruling. Times Colonist, 6 February, 2018 (Accessed 2018 Sep 10).

17.   Ballingall A.  Assisted death: How to weigh doctors' rights with right to die?  Canada's medical circles abuzz with debate over how to balance newly recognized right to assisted death with doctors' right not to provide it.  The Star, 7 February, 2015 (Accessed 2018 Sep 10).

18.   Pelly L. Christian doctors' group says new college policy infringes on freedom of conscience. Toronto Star, 24 March, 2015 (Accessed 2018 Sep 10).

19.   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 2018 Sep 10).

20.   CPSS undermines, Supreme Court of Canada affirms conscience rights for Saskatchewan doctors. News release, Christian Medical Dental Society of Canada, 6 March, 2015.

21.    Blackmer J. Professionalism and the medical association. World Medical Journal 2007; 53 (3):58-74 (Accessed 2018 Sep 10).

22.    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 (Accessed 2018 Sep 10).

23.    Ubelacker S. Medical professionals try to answer burning questions on doctor-assisted death. Associated Press, 13 February, 2015 (Accessed 2018 Sep 10).

24.   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) (26 April, 2011) Part 1, para. 6, 7.

25.    Carter v. Canada (Attorney General) 2012 BCSC 886 (Accessed 2015-07-05).
In the summary of the ruling, the judge states that Taylor "will be permitted to seek, and her physician will be permitted to proceed with, physician assisted death." (para. 19). However, the judge later specifies she is striking down the "impugned provisions" to the extent that they prohibit physician-assisted suicide or consensual physician-assisted death." (para. 1393(b), emphasis added.) "Consensual physician-assisted death" is distinguished from physician-assisted suicide in the plaintiffs' Amended Notice of Claim (para. 7, 8) and defined as the act of a medical practitioner that causes the death of a patient. This is acknowledged by the judge in the ruling (para. 23). The judge herself does not define the term, but "consensual physician-assisted death" is encompassed by her definition of euthanasia (para. 38). Consistent with this, the constitutional exemption granted to plaintiff Gloria Taylor states that "the mechanism for the physician-assisted death shall be one that involves her own unassisted act and not that of any other person," unless she is "physically incapable." (para. 1414(f)) This would authorize a lethal injection by a physician, which, but for the ruling, would be homicide, not assisted suicide.

26.    Rich P. 'Our work is far from finished:' CMA to continue leadership role on end-of-life care. Canadian Medical Association, 3 March 2015 (Accessed 2018 Sep 10).

27.   Kirkey S.  Unacceptable to force doctors to participate in assisted dying against their conscience: CMA head.  National Post, 5 March, 2015 (Accessed 2018 Sep 10).

28.    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) [Simpson Affidavit] para. 29 (Accessed 2018 Sep 10).

29.  DWD responds to CMA statement on assisted dying.  Dying with Dignity, 6 March, 2015 (Accessed 2018 Sep 10).

30.    Rich P. We need clear guidelines on referral in physician assisted dying: Simpson. Canadian Medical Association, 13 March, 2015 (Accessed 2018 Sep 10).

31.    Canadian Medical Association. Principles-Based Approach to Assisted Dying in Canada (Backgrounder) (Accessed 2018 Sep 10).

32.    Kirkey S. Help eligible patients end lives or refer them to someone who will, CMA to urge Mds. National Post, 18 August, 2015 (Accessed 2018 Sep 10).

33.    Canadian Medical Association Annual General Council 2015, Education session 2: Setting the context for a principles-based approach to assisted dying in Canada. Ed2-webast - 14:00-14:30.

34.    Murphy S.  Canadian Medical Association plans for physician assisted suicide, euthanasia: Commentary on revised draft framework (August, 2015).  Protection of Conscience Project.

35.    Project Administrator's Redacted Record of 2015 CMA On-line Consultation [CMA On-line Consultation]: Principles based approach to assisted dying, Blackmer Comment No. 14 (ca. 2015-07-05).  Note: The date of comments in the on-line dialogue was given only as "X days ago" or "one month ago," and the time was not indicated. The dates given here are based on the information provided in the dialogue. For reference purposes, numbers have been assigned to Dr. Blackmer's comments, beginning with "1" in each topic thread.

36.    "[N]o physician should be compelled to participate in or provide" (Emphasis added). In the SCC on appeal from the BCCA, Factum of the Intervener, The Canadian Medical Association (27 August, 2014) para. 27.

37.    "[N]othing in the declaration of invalidity which we propose to issue would compel physicians to provide assistance in dying. . . a physician's decision to participate in assisted dying is a matter of conscience and, in some cases, of religious belief." (Emphasis added) Carter-SCC, para. 132.

38.    Canadian Medical Association, A Canadian Approach to Assisted Dying: A CMA Member Dialogue Summary Report. (August, 2015) p. 2 (Accessed 2018 Sep 10) ["Summary Report"].

39.    Project Administrator's Overview of 2015 CMA On-line Consultation.

40.    Summary Report, p. 8.

41.    Summary Report, p. 3, 9.

42.    Summary Report, p. 10.

43.   CMA On-line Consultation: Conscientious objection and equitable access.  Blackmer Comment No. 1 (ca. 2015-06-19). 

44.    Murphy S. Re: Joint intervention in Carter v. Canada: Selections from oral submissions (Supreme Court of Canada, 15 October, 2014). Harry Underwood (Counsel for the Canadian Medical Association) [CMA Oral Submission] Protection of Conscience Project.  See the webcast of the submission from 225:53/491:20 to 236:13/491:20 at the Supreme Court of Canada.

45.    Kirkey S. Canadian doctors want freedom to choose whether to help terminal patients die: CMA to revisit issue of doctor-assisted death after delegates pass motion supporting physician's right to 'follow their conscience'. canada.com, 19 August, 2014 (Accessed 2018 May 26).

46.     CMA On-line Consultation: Principles based approach to assisted dying,  Blackmer Comment No. 9 (ca. 2015-07-01). 

47.    CMA On-line Consultation: Principles based approach to assisted dying, Blackmer Comment No. 13 (ca. 2015-07-01).

48.    CMA On-line Consultation: Conscientious objection and equitable access,  Blackmer Comment No. 1(ca. 2015-06-19).

49.    CMA On-line Consultation: Conscientious objection and equitable access, Blackmer Comment No. 2 (ca. 2015-06-19).

50.    See Part I: CMA General Council (August, 2014), Adoption of resolution on freedom of conscience

51.    CMA On-line Consultation: Principles based approach to assisted dying, Blackmer Comment No. 10 (ca. 2015-07-01).

52.    Swan M. Medical association vows to protect conscience rights. The Catholic Register,
27 August, 2014 (Accessed 2018 Sep 10).

53.    Canadian Medical Association. 147th General Council Delegates' Motions: End-of-Life Care: Motion DM 5-6 (Accessed 2018 Sep 10).

54.    Canadian Medical Association 104th Annual Meeting, Halifax, Nova Scotia. CMAJ Volume 104(12) 1132-1134, June 19, 1971 (Accessed 2018 Sep 10).

55.   CMA On-line Consultation: Conscientious objection and equitable access, Blackmer Comment No. 6 (ca. 2015-07-07).

56.   CMA On-line Consultation: Review and comment on the draft framework,  Blackmer Comment No. 4 (ca. 2015-07-07).

57.   College of Physicians and Surgeons of Ontario, Professional Obligations and Human Rights. Policy #2-15 (March, 2015) (Accessed 2018 Sep 10).

58.    CMA On-line Consultation: Principles based approach to assisted dying, Blackmer Comment No. 14 (ca. 2015-07-05).

59.    College of Physicians and Surgeons of Ontario. Medical Assistance in Dying.
Policy No. 4-16 (July 2017) C. Conscientious Objection (Accessed 2018 Sep 10).

60.    The Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2018 ONSC 579, para. 169 (Accessed 2018 Sep 10).

61.     Dr. Blackmer Blog Response. Physicians' Alliance against Euthanasia (30 April, 2018)  (Accessed 2018 Sep 10).

62.    Christian Medical Dental Society, the Federation of Catholic Physicians Societies and Canadian Physicians for Life.

63.    Principles-based Recommendations for a Canadian Approach to Assisted Dying.  Canadian Medical Association (Accessed 2018 Sep 10).

64.    Picard A. Less than a third of doctors willing to aid in assisted dying: CMA poll. Globe and Mail, 25 August, 2015 (Accessed 2018 Sep 10)

65.    CMA Board of Directors October 2015 Meeting Highlights.  Canadian Medical Association. (Accessed 2018 Sep 10).

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

67.    CMA Policy: Medical Assistance in Dying (May, 2017) (Accessed 2018 Sep 10)

68.    Schuklenk U, van Delden JJM, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making. [Internet] Royal Society of Canada. 2011 Nov, p. 69, 101.

69.    Simpson Affidavit, para. 29.

70.     Sonier F. Physicians seek leave to appeal Ontario court ruling against physician freedom of conscience. Canadian Physicians for Life, 2 March, 2018.