Doctors with moral objections to assisted dying should be able to opt out, committee hears

Assisted dying law could be coupled with improved palliative care, committee hears

CBC News

Peter Zimonjic

Doctors who morally object to physician-assisted dying should not be obligated to refer patients to a doctor who will provide the service, a joint Commons-Senate committee studying the issue heard Wednesday.

Dr. Cindy Forbes, president of the Canadian Medical Association told the panel that doctors shouldn’t have to refer a patient, but they must “advise the patient on all of their options … including physician assisted dying, and make sure the patient has the information they need to access that service” . . . [Full text]

A “uniquely Canadian approach” to freedom of conscience

Provincial-Territorial Experts recommend coercion to ensure delivery of euthanasia and assisted suicide

Recommendations designed to broaden and maximize impact of Supreme Court ruling

Sean Murphy*


The Experts’ recommendations are intended to extend and maximize the impact of the Carter ruling. They will effectively require all institutions, facilities, associations, organizations and individuals providing either health care or residential living for elderly, handicapped or disabled persons to become enablers of euthanasia and assisted suicide. This will entail suppression or significant restriction of fundamental freedoms.

The broader the criteria for the provision of morally contested procedures, and the more people and groups captured in the Experts’ enablers’ net, the greater the likelihood of conflicts of conscience.  Relevant here are recommendations to make euthanasia/assisted suicide available to mentally ill and incompetent persons, and to children and adolescents, even without the knowledge of their parents.

The Experts’ distinction between “faith-based” and “non-faith-based” facilities is meaningless. They impose identical obligations on both. All will be forced to allow homicide and suicide on their premises, or compelled to arrange for euthanasia or assisted suicide elsewhere.
Likewise, they recommend that objecting physicians be forced to actively enable homicide or suicide by providing referrals, arranging direct transfers or enlisting or arranging the enlistment of patients in a euthanasia/assisted suicide delivery system.

The Supreme Court did not rule that people ought to be compelled to become parties to homicide and suicide, but that is what the Experts recommend. This is not a reasonable limitation of fundamental freedoms, but a reprehensible attack on them and a serious violation of human dignity.

Other countries make euthanasia and assisted suicide available without attacking fundamental freedoms. In this respect, the Experts’ claim to have produced “a uniquely Canadian approach to this important issue” is regrettably accurate. They fail to provide any evidence that the suppression of freedom of fundamental freedoms they propose can be demonstrably justified in a free and democratic society.

Table of Contents

I.    Background

I.1    Formation and work of the Advisory Group

II.    Overview of the Final Report

II.1    Moral/ethical unanimity
II.2    “Statement of Principles and Values”
II.3    Recommendations broadening the Carter criteria
II.4    Recommendations impacting freedom of conscience and religion

III.    The Experts’ “uniquely Canadian approach”

III.1     Expanded criteria and increasing likelihood of conflict

III.1.1    “Irremediable medical condition”.
III.1.3     Euthanasia approved for future suffering.
III.1.7     No waiting/reflection period.
III.1.10     Adolescents and children.
III.1.13     Euthanasia/assisted suicide by non-physicians.
III.1.15     Doctor shopping.
III.1.18     Physicians need not be present at suicides.
III.1.20     Euthanasia/assisted suicide wherever people live.
III.1.22     Families, caregivers may not be advised.

III.2    Institutions, associations, organizations

III.2.1     The meaning of institution.
III.2.3    All “institutions” must allow/arrange euthanasia/assisted suicide
III.2.6     All “institutions” must disclose policies.
III.2.8     “Institutions” may not manifest or enforce commitments

III.3    Objecting physicians: information, disclosure, non-discrimination

III.3.3    Objecting physicians must provide information.
III.3.8    Objecting physicians must disclose views and their implications.
III.3.11    Objecting physicians must not illicitly discriminate.

III.4    Objecting physicians must become critical enablers

III.4.4    Referral or direct transfer of care.
III.4.5    Referral to “system/third party.”
III.4.8    The Experts’ proposal and the CMA’s proposal.

IV.    Project response

IV.1    Expert recommendations broadening Carter criteria
IV.2    Expert recommendations and fundamental freedoms in general
IV.3    Expert recommendations and freedom of conscience

V.    Conclusion

Appendix “A”  Supreme Court of Canada, Carter v. Canada (Attorney General), 2015 SCC 5

A1.    Carter criteria for euthanasia and physician assisted suicide
A2.    Carter and the criminal law
A3.    Carter and freedom of conscience and religion

Appendix “B”  Expert recommendations re: broadening Carter criteria

B1.     Expanding the Carter criteria

B1.1    “Grievous and irremediable medical condition” includes mental illness
B1.2    Suffering not a prerequisite
B1.3    Competence not a prerequisite: euthanasia for dementia
B1.4    Euthanasia and assisted suicide for children and adolescents
B1.5    Assessment, euthanasia and assisted suicide by non-physicians

B2.    Increasing the impact of Carter

B2.3    Doctor shopping
B2.4    No “waiting/reflection” period
B2.5    Physicians need not be present at suicides
B2.6    Euthanasia & assisted suicide in hospitals, hospices, etc.
B2.7    Families and caregivers may not be advised

Appendix “C”    Expert recommendations re: freedom of conscience and religion

C1.    Institutions

C1.1    Meaning of “institution”
C1.2    “Institutions” must allow or arrange for euthanasia or assisted suicide
C1.3    All “institutions” must disclose position on euthanasia and assisted suicide
C1.4    “Institutions” must not require patients/residents to give up “the right to access,” interfere with employees providing eutanasia or assisted suicide elsewhere

C2.    Objecting physicians/health care providers

C2.1    Must provide information on “all options”
C2.2    Must disclose views on euthanasia and assisted suicide
C2.3    Must not discriminate
C2.4    Must act as critical enablers

C2.4.1  Three alternatives
C2.4.2  Referral
C2.4.3  Direct transfer of care
C2.4.4  Transfer to “a publicly-funded system” or “third party”
C2.4.5  The Experts’ “system/third party” and the CMA’s “central service”

Appendix “D”    Canadian Medical Association on euthanasia and assisted suicide

D1.    CMA policy: Euthanasia and Assisted Death (2014)
D2.    CMA Annual General Council, 2015

D2.1    Surveys on support for euthanasia/assisted suicide
D2.2    Physician freedom of conscience

D3.    CMA rejects “effective referral”

Appendix “E”    International comparisons

E1.    Netherlands
E2.    Luxembourg
E3.    Belgium
E4.    Oregon
E5.    Washington
E6.    Vermont
E7.    California

Appendix “F”    An Act to Safeguard Against Homicide and Suicide


College of Physicians and Surgeons of Ontario decided results of consultation before it started

College decided that physicians must refer for euthanasia/assisted suicide at least a month before consultation began

News Release

Protection of Conscience Project

The College of Physicians and Surgeons of Ontario (CPSO) decided by the first week of November, 2015, that it will force Ontario physicians who refuse to kill patients or help them commit suicide to find someone willing to do so.  The decision was made a month before the College began a public consultation purporting to solicit input on that and other questions related to euthanasia and assisted suicide.

The decision was revealed in the Report of the Federal External Panel consultations on euthanasia and assisted suicide, released today.

When College representatives appeared before the Panel in Toronto between 2 and 6 November, they told the Panel  “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.” (p. 100)

“The Protection of Conscience Project submission was made on 10 January, said Sean Murphy, Project Administrator.

“Two days later, the Canadian Medical Association made an excellent submission rejecting the proposal of  ‘effective referral’,” he added.

“Many people responded in good faith to the College’s invitation to participate in the consultation,” said Murphy.  “But it seems that public consultations about College policy are an expensive and time-consuming charade.”

Last year, College officials wrote the final version of the CPSO policy demanding “effective referral” for morally contested procedures a month before the consultation closed. About 90% of 9,000 submissions on the subject were received after the final version had been written.





Canadian Medical Association Submission to the College of Physicians and Surgeons of Ontario

Consultation on CPSO Interim Guidance on Physician-Assisted Death

Project Introduction

The following submission sets out the position of the Canadian Medical Association (CMA) on referral, within the context of the provision of euthanasia and assisted suicide.  The submission concerns a proposed policy by the state regulator of medicine in the province of Ontario, the College of Physicians and Surgeons (CPSO).  The College proposed that its policy of “effective referral” for morally contested services be applied to euthanasia and assisted suicide.

Among the excellent points made by the Association:

It is in fact in a patient’s best interests and in the public interest for physicians to act as moral agents, and not as technicians or service providers devoid of moral judgement. . . . medical regulators ought to be articulating obligations that encourage moral agency, instead of imposing a duty that is essentially punitive to those for whom it is intended and renders an impoverished understanding of conscience.

Full text of the CMA submission


Submission to the College of Physicians and Surgeons of Ontario


Re: Interim Guidance on Physician Assisted Death


Virtually all of what is proposed in Interim Guidance on Physician-Assisted Death (IGPAD) is satisfactory, requiring only clarifications to avoid misunderstanding and appropriate warnings concerning the continuing effects of criminal law.

The College has no basis to proceed against physicians who refuse to do anything that would entail complicity in homicide or suicide, including “effective referral,” because they believe that a patient does not fit the criteria specified by Carter. College policies and expectations are of no force and effect to the extent that they are inconsistent with criminal prohibitions.

Proposals about respect for patients, access to services, and providing information are acceptable, subject to some clarifications and limitations with respect to offering the option of suicide. Simple and uncontroversial recommendations are offered to avoid problems associated with failed assisted suicide and euthanasia attempts, and in urgent situations.

However, the requirement for “effective referral “is completely unacceptable. It is ludicrous to assert that the reasoning that underpins the law on criminal complicity and culpability, civil liability and the College policy that prohibits referral for Female Genital Cutting can be dismissed as legally irrelevant to the exercise and protection of fundamental freedoms of conscience and religion.

The College cannot justify a demand for “effective referral” on the grounds that it cannot be understood to involve morally significant complicity in killing patients or helping them to commit suicide, nor can it be justified as a reasonable limitation on fundamental freedom.
The only apparent basis for the College’s demand for effective referral is that it has decided what the Supreme Court of Canada did not decide: that euthanasia and assisted suicide in circumstances defined by Carter are morally/ethically acceptable. College officials seem to consider the College justified in using force – the force of law – to compel dissenting physicians to conform to their moral/ethical views.

This is not a reasonable limitation of freedom but a reprehensible attack on them. It is a paradigmatic example of the authoritarian suppression of freedom of conscience and religion and a serious violation of human dignity. Examples of alternative acceptable policies demonstrate that access to assisted suicide and euthanasia can be ensured without suppressing freedom of conscience and religion.


I.    Outline of the submission

II.    Avoiding foreseeable conflicts

II.1    Failed assisted suicide and euthanasia II.2    Urgent situations
II.3    Project recommendations

III.    IGPAD and criminal law

IV.    IGPAD on respect, access, notification and providing information

IV.1    Treat patients respectfully; do not impede access
IV.2    Notification of objections
IV.3    Providing information

V.    Freedom of conscience

V.1    IGPAD and “effective referral”
V.2    “Effective referral” and criminal law
V.3    Legal vs. ethical/moral evaluation of euthanasia, assisted suicide
V.4    The College position: “error has no rights”

VI.    Project response

VI.1    Previous submissions
VI.2    Making freedom easy – or impossible
VII.    Alternative acceptable policies

VIII.    Conclusion

Appendix “A”    Supreme Court of Canada, Carter v. Canada (Attorney General), 2015 SCC 5

A1.    Carter criteria for euthanasia and physician assisted suicide
A2.    Carter and the criminal law
A3.    Carter and freedom of conscience and religion

Appendix “B”    Carter in theTrial Court, Part VII: A Judicial Soliloquy on Ethics

B1.    A note of caution
B2.    The questions addressed in Part VII
B3.    Plaintiffs’ claim shapes and limits the analysis
B4.    Ethics: which one?
B5.    Medical ethics
B5.1    Ethics and the willingness of physicians
B5.2    Ethics and the positions of medical associations
B5.3    Ethics and the opinions of ethicists
B5.4    Ethics and current end-of-life practices
B6.    Ethics of society
B6.2    Ethics and public opinion
B6.3    Ethics and public committees
B6.4    Ethics and prosecution policies
B7.    Summary of the ethical debate
B8.    Conclusions about the ethical debate
B8.2    Would Canadian physicians provide the services?
B8.3    Current medical practice with respect to end-of-life care?
B8.4   Does the law attempt to uphold a conception of morality?
B9.    Carter Part VII: in brief
B9.1    Unanswered questions
B9.2    Meaningless findings
B9.3    Inconclusiveness
B9.4    Neglected evidence
B9.5    Deficient review of end-of-life decision-making
B10.    On appeal to the Supreme Court of Canada

Appendix “C”    Physician Exercise of Freedom of Conscience and Religion

C1.    Introduction
C2.    Providing information to patients
C3.    Exercising freedom of conscience or religion
C4.    Reminder: treatments in emergencies