How far should a doctor go? MDs say they ‘need clarity’ on Supreme Court’s assisted suicide ruling

National Post

Sharon Kirkey

Canada’s doctors are seeking clarity from the federal government on what the Supreme Court of Canada intended in its landmark ruling on assisted dying, including the question of how far a doctor is permitted to go in contributing to a patient’s death.

“We’ve got a few key questions that we think need clarity and this is one of them: Is it euthanasia or is it assisted dying?” said the Canadian Medical Association’s director of ethics and professional affairs, Dr. Jeff Blackmer.

The powerful doctors’ lobby said it is not clear whether the high court has opened the door not just to assisted suicide  –  where a doctor writes a prescription for a lethal overdose of drugs the patient takes herself  –  but also to something many physicians find profoundly more uneasy: pushing the syringe themselves. . . [Full text]


Doctors with conscience speak out

Times of India

Rema Nagarajan

NEW DELHI: In order to benefit the hospital and meet its commercial needs, one has to do things like keeping patients in the hospital longer than necessary, and doing unnecessary investigations and procedures (including angioplasty) since there was pressure from the management of the hospital.

My conscience began pricking and I left the hospital- Dr Gautam Mistry, Kolkata, cardiologist who left a corporate hospital after seven years. . . [Full text]


Protect doctors’ right to choose


It’s all about choice. The Supreme Court of Canada has ruled that suffering Canadians have the right to choose to end their life through assisted suicide.

But doctors must also have the right to choose  –  to choose whether they are a part of this process or not.

A recent article in the Canadian Medical Association Journal showcases several points worth repeating. They report that a majority of palliative care physicians actually don’t envision assisted suicide as part of their work. . . [Full text]


American Medical Association provides details of new freedom of conscience policy

AMA submission to Ontario College of Physicians an improvement on quality of briefing by College working group

Sean Murphy*

The American Medical Association has made a submission to the public consultation on physician freedom of conscience being conducted by the College of Physicians and Surgeons of Ontario (CPSO).  The AMA letter provides important details about a policy on physician freedom of conscience adopted by the AMA House of Delegates in November, 2014, but not due to be formally published until June of this year.

The current consultation on a controversial draft policy, Professional Obligations and Human Rights (POHR), was approved by College Council in December, 2014.  Briefing materials provided to Council members by the College working group at that time included the American Medical Association as one of the organizations selected for international comparison of policies.

However, the single sentence offered by the working group as representative of AMA policy was taken from an on-line source of short essays about medical ethics, not an authoritative source of information about AMA policy. In fact, the article was about conscientious objection among pharmacists, not about the policies of the American Medical Association concerning freedom of conscience in health care.

The letter from the AMA is a substantial improvement upon what the Protection of Conscience Project submission characterizes as the “deficient and superficial” briefing materials concerning the United States supplied to College Council in December.

. . .In the Council’s view, an account of the nature and scope of a physician’s duty to inform or to refer when a patient seeks treatment that is in tension with the physician’s deeply held personal beliefs must address in a nuanced way the question of moral complicity. The Council concurs that physicians must provide information a patient needs to make a well-considered decision about care, including informing the patient about options the physician sincerely believes are morally objectionable. However, the Council sought to clarify that requirement, holding that before initiating a patient-physician relationship the physician should “make clear any specific interventions or services the physician cannot in good conscience provide because they are contrary to the physician’s deeply held personal beliefs, focusing on interventions or services that a patient might otherwise reasonably expect the practice to offer.”

The Council also reached a somewhat different conclusion than the College with respect to a duty to refer.

The College’s draft policy provides that, when a physician is “unwilling to provide certain elements of care on moral or religious grounds,” the physician must provide “an effective referral” to “a nonobjecting, available, and accessible physician or other health care provider.”

This seems to us to overstate a duty to refer, risk making the physician morally complicit in violation of deeply held personal beliefs, and falls short of according appropriate respect to the physician as a moral agent. On our view, a somewhat less stringent formulation of a duty to refer better serves the goals of non-abandonment, continuity of care, and respect for physicians’ moral agency. The council concluded that:

In general, physicians should refer a patient to another physician or institution to provide treatment the physician declines to offer. When a deeply held, well-considered personal belief leads a physician also to decline to refer, the physician should offer impartial guidance to patients about how to inform themselves regarding access to desired services.

On the Council’s analysis, the degree or depth of moral complicity is defined in part by ones “‘moral distance’ from the wrongdoer or the act, including the degree to which one shares the wrongful intent.”

Other factors also influence complicity, including “the severity of the immoral act, whether one was  under duress in participating in the immoral act, the likelihood that one’s conduct will induce others to act immorally, and the extent to which one’s participation is needed to facilitate the wrongdoing.” . . .

Project Submission to the College of Physicians and Surgeons of Ontario

 Re: Professional Obligations and Human Rights


The focus of this submission about Professional Obligations and Human Rights (POHR) is its demand for “effective referral” – the demand that physicians do what they believe to be wrong – even gravely wrong – even arranging homicide or suicide – and the implied threat that they will be punished if they refuse.

This is a dangerous and extraordinarily authoritarian policy, completely at odds with liberal democratic aspirations and our national traditions. The burden of proof is on the working group to prove beyond doubt that it is justified and that no reasonable alternatives are available. The working group has not done so.

The working group provided no evidence that such a policy is necessary, and there is evidence that it is not. The briefing materials supplied to Council in support of POHR were not only seriously deficient, but erroneous and seriously misleading. “Public sentiment” captured by a random poll does not justify the suppression of fundamental freedoms, and the results of consultation, when carefully considered, suggest that a policy of “effective referral” is highly controversial.

An example of a reasonable alternative is available from the Australian Medical Association – an example not offered to Council members by the working group, which, instead, completely misrepresented AMA policy.

This submission, supported by detailed analysis in the appendices, provides good reason for Council members to doubt that the requirement for effective referral in POHR is necessary or justifiable, or prudent policy. It also provides reason for them to believe that reasonable alternatives can be developed.

Council members unpersuaded by the working group or left in doubt about POHR should give the benefit of doubt to freedom of conscience and refuse to approve the draft policy in its present form. They should direct the working group to collaborate with those opposed to the present draft to produce a broadly acceptable text. If the real goal is to ensure access – not ideologically driven ethical cleansing – there is no reason to demand that physicians do what they believe to be wrong. If the College’s real goal is to ensure access to services – not to punish objecting physicians, or drive them out of family practice, or out of the profession – that goal is best served by connecting patients with physicians willing to help them.


  1. Introduction
  1. Reasons for doubt

III.    POHR in practice

  1. Giving freedom of conscience the benefit of the doubt
  2. Conclusion

Appendix “A”:  The Review Process

Appendix “B”:  Unreliability of Jurisdictional Review by College Working Group

Appendix “C”:  Consultation on Physicians and the Human Rights Code

Appendix “D”: A Case for Evidence-based Policy Making

Appendix “E”: Legal Criticism

Full text available on line at

Submission to the College of Physicians and Surgeons of Ontario

Re: Professional Obligations and Human Rights

Justice Centre for Constitutional Freedoms


The draft Policy “Professional Obligations and Human Rights” (the “Draft Policy”) proposed to the College of Physicians and Surgeons of Ontario (the “College”) contains a number of critical legal errors, which render the affected portions of the Draft Policy constitutionally indefensible.

The Draft Policy incorrectly assumes that patients enjoy a legal right to access even controversial medical services from any and every physician. In fact, patients have virtually no legal rights to medical care. The Courts have expressly stated that there is no Charter right to health care, or to any particular health services. Conversely, the Charter expressly protects physicians’ religious and conscience rights. The civil government, and government bodies such as the College, cannot violate physicians’ Charter rights to freedom of conscience and religion unless such violation is demonstrably justified. In light of the context of health services in Ontario, the purposes of eliminating discrimination and promoting access to health care, while praiseworthy, do not justify the Draft Policy’s violation of physicians’ Charter rights.

The Draft Policy purports to address discrimination in the provision of health services, and repeatedly references Ontario’s Human Rights Code. However, a physician who is unable to provide or refer a patient for a particular health service on account of the physician’s sincere religious or conscientious belief is not engaging in discrimination; this inability or refusal does not violate the Code. The inability to provide or refer for that health service is not based on or related to the patient’s personal characteristics (e.g. age, gender, religion, disability, etc.). Rather, this inability to provide a particular service or referral stems from the physician’s religious or conscientious belief that the service in question causes harm.

Promoting access to health services is a commendable objective. No one could deny that in many areas health services are subject to undesirable even unacceptable delays. And despite the Supreme Court’s ruling in Chaoulli c. Quebec, 1 the effective prohibition of private health insurance impedes many Canadians in accessing timely health services. However, there is no basis on which to conclude that physicians, by exercising their freedom of conscience, actually impede access to health care. Some patients may occasionally experience minor inconvenience when informed by a physician that reasons of conscience prevent the physician from providing or referring with respect to a desired service. However, with an abundance of physicians and facilities available to perform such controversial services,2 patients will still receive these services in timely manner. The Draft Policy neither provides nor points to any evidence showing that controversial services such as abortion suffer greater delays in access to care than noncontroversial services, such as knee surgery.

The clinical aspect of the practice of medicine cannot be separated from the moral, religious and ethical beliefs of physicians that form an essential part of providing health services to other human beings. The Draft Policy’s attempt to separate the “clinical” from the “moral” in the practice of medicine is a dangerous and destructive step that contradicts the ethical foundations of medicine that have existed for millennia.

Government bodies such as the College have an obligation under the Charter and Ontario’s Human Rights Code to accommodate the religious and conscientious beliefs of physicians to the point of undue hardship. The Draft Policy ignores this obligation entirely, while incorrectly asserting a need to “balance” Charter rights with the wishes and desires of patients. These wishes and desires are not legal rights.

The Draft Policy’s requirement that physicians provide referrals for, and in some cases perform, services which they sincerely believe are morally wrong is grossly deficient from a Charter perspective, and if adopted would be found unconstitutional by a court. A referral is not a morally neutral action, as the College itself recognizes. Further, the drastic measure of forcing physicians to violate their consciences by performing services they believe are wrong is vague and subjective, making it impossible to qualify as a reasonable limit on physicians’ conscience rights. The College cannot point to evidence of a pressing need that would justify these requirements.

The College should seek to support physicians’ adherence to their own individual consciences.  Alternative measures which reasonably accommodate physicians with religious or conscientious objections should be developed and implemented. [Full text]


An attack on the conscience rights of physicians

National Post
Reproduced with permission

John Carpay

Ontario’s College of Physicians and Surgeons is determined to force every family doctor to participate in abortion and euthanasia, either by providing these services, or by referring patients to other doctors who will.

The College dismisses Charter-protected conscience rights as “personal values and beliefs” that are not nearly as important as “clinical” beliefs. This distinction is wholly artificial, as shown by the very existence of modern medical ethics. There is nothing clinical or scientific about the moral prescriptions in the Hippocratic Oath: To “take care that patients suffer no hurt or damage” and to “use knowledge in a godly manner.” This “sacred oath” cuts across religious, philosophical, and political boundaries, and has been the bedrock of the physician’s pledge to his patients and society for over two millennia.

Medical ethics, both ancient and modern, are based entirely on religious and moral beliefs. A doctor guided by science to the exclusion of morality is inherently untrustworthy. A good doctor acts on both moral and scientific beliefs.

The college’s draft policy on doctors’ professional obligations assumes that patients have a “right” to receive whatever medical services they may desire from any doctor. The college provides no basis for this assumption, because, in fact, patients do not enjoy a legal right to obtain whatever medical services or treatments they want.

The college’s justification for coercing pro-life doctors into referring patients for abortion or euthanasia services relies heavily on Ontario’s Human Rights Code. But the code says nothing about which medical procedures should be available to patients, or whether all doctors must be willing to provide them. The code merely requires doctors to serve all patients equally, regardless of the patient’s age, race, gender, religion, etc. The code would, for example, prohibit a pro-choice doctor from providing abortions only to patients of some ethnic groups, but not others.

The college then jumps to the argument that a doctor’s Charter-protected freedom of conscience and religion needs to be “balanced” against a patient’s “right” to receive desired services from every doctor. But there is no need to balance a Charter right against another right that doesn’t exist.

The college claims that refusing to participate in abortion and euthanasia amounts to “impeding” access. This argument is quite a stretch. If a doctor refuses to prescribe an abortion-inducing drug to a patient, that doctor is certainly causing the patient inconvenience. But in no way is that doctor “impeding” the patient from obtaining the drug from other doctors, the vast majority of whom routinely prescribe such drugs.

While claiming to be concerned about patients’ access to health care, the college ignores the Supreme Court’s ruling in Chaoulli v. Quebec, which declared that “access to a waiting list is not access to health care.” The court in Chaoulli was unanimous in holding that a government monopoly over health care, when it condemns patients to suffer and die on waiting lists, violates the constitutional rights of Canadians.

When it comes to essential health services like cancer diagnosis, cancer treatment and orthopaedic surgery, politicians in Ontario and other provinces have passed laws that make it effectively illegal for patients to use their own after-tax dollars to buy private medical services and private health insurance. The college is not troubled by the fact that patients are entirely at the mercy of the bureaucrats and politicians who run the Ontario government’s health-care monopoly, and who alone decide what medical services patients will and will not have access to.

In short, the college’s attack on physicians’ conscience rights has nothing to do with patients’ access to health care. In light of the willingness of most doctors to provide or refer for abortion and euthanasia, the minority of pro-life doctors are making a statement, not impeding access. But rather than advocate for expanded access to all kinds of health care for all patients, the college acts ideologically to remove all visible opposition to its own popularly accepted moral beliefs. This ideological attack strikes at the root of Canada’s free society, which should welcome the full participation of all persons, even those with unpopular convictions.


American Civil Liberties Union: referral for abortion not good enough

Sean Murphy*

The American Civil Liberties Union (ACLU) is suing a Washington state public hospital district, claiming that it is failing to provide medical and surgical abortions.  In fact, the hospital district provides both, but refers patients to other facilities for abortion when they cannot be provided in one of the district hospitals because of conscientious objection to the procedure by staff.  It thus appears that the ACLU is not content with forcing facilities to refer for abortion, but intends to force them to provide the procedure despite conscientious objection by physicians and health care workers.  [Reuters]


The Carter v. Canada Conundrum: Next Steps for Implementing Physician Aid-in-Dying in Canada

Sally Bean and Maxwell Smith (Bioethics Program Alum, 2010)

We applaud the February 6, 2015 Supreme Court of Canada’s (SCC) unanimous ruling in Carter v. Canada (Attorney General), 2015 SCC 5. The Court found the criminal prohibition of assisted death to be in violation of section 7 of the Canadian Charter of Rights and Freedoms, which guarantees the right to life, liberty and security of the person. The ruling has been suspended for 12 months to enable time for a Parliamentary response. In the wake of this landmark ruling, we identify and briefly discuss three issues that require serious attention prior to the implementation of Physician Aid-in-Dying (PAD) in Canada. . . [Full text]


Colombia to Finalize Euthanasia Law in March

Court Gives Health Ministry 30 Days to Regulate Assisted Suicide

Pan Am Post

Sabrina Martín

On Tuesday, February 17, the Colombian Constitutional Court gave the Ministry of Health 30 days to implement a number of protocols pertaining to euthanasia, setting guidelines for all health care providers in the Andean country.

During this time, health agencies are tasked with forming interdisciplinary committees to advise patients and their families on their decision to resort to euthanasia, in order to prevent such a decision being made as a result of mood or depression. . . [Full text]