Redefining the Practice of Medicine- Euthanasia in Quebec, Part 2: ARELC in Detail


An Act Respecting End-of-Life Care (“ARELC”) is intended to legalize euthanasia by physicians in the province of Quebec.  It replaces the original Bill 52, the subject of a previous commentary by the Project. ARELC purports to establish a right to euthanasia for a certain class of patients by including it under the umbrella of “end-of-life care.”  ALERC calls euthanasia for competent patients “medical aid in dying” (MAD).  ALERC provides for but does not  identify euthanasia for incompetent patients, called here Euthanasia Below the Radar (EBTR).
ARELC’s definition of palliative care clearly distinguishes palliative care from MAD.  In defining MAD, the statute does not say “kill,”  but employs a euphemism: “hastening death.”  Nonetheless, it is obvious that ARELC authorizes a physician to kill patients.

The MAD guidelines for euthanasia restrict it to legally competent persons at least 18 years old who are insured under the provincial Health Insurance Act.  Beyond age, legal competence and residency/insurance, someone seeking euthanasia must be at “the end of life,” suffering from an incurable serious illness, in an advanced state of irreversible decline and suffering from constant and unbearable physical or psychological pain.  The patient need not be terminally ill and is free to refuse effective palliative treatments.

A qualifying patient must personally make a written request for MAD “in a free and informed manner.” It must be signed in the presence of professional, who must also sign the request. The attending physician must confirm the eligibility of the patient and the free and informed nature of the request. He must verify the persistence of suffering and a continuing desire for euthanasia, speak to other members of the health care team and see that the patient is able to discuss the decision with others. However, the physician cannot advise family members unless the patient so wishes. Thus, a physician may kill a patient without the knowledge of the family. Finally, the attending physician must obtain a written opinion of an independent physician confirming eligibility for euthanasia.

Only physicians may administer the lethal drugs or substances, and, having done so, must remain with a patient until he dies. Physicians who provide MAD must report the fact to institutional authorities or the College of Physicians, as well as the Commission on End-of-Life Care.

A central role in the provision of euthanasia is assigned to institutional councils of physicians, dentists and pharmacists (or, in their absence, institutional directors of care).  They are to adopt MAD guidelines, and then review reports from physicians who have provided the procedures to “assess the quality of the care provided.” The Collège des médecins is also to receive such reports from physicians and, apparently, to establish or at least recognize “clinical standards” relative to the procedures.

In addition to the MAD protocol, ARELC permits a substitute decision-maker to order that an incompetent patient be starved and dehydrated to death.  This provides an alternative form of euthanasia subject to none of the restrictions or conditions imposed by MAD guidelines: hence the term used here – “Euthanasia Below the Radar” (EBTR).  Since death by starvation and dehydration would be a painful process, it is likely that, in such circumstances, continous palliative sedation (CPS) would be used to anesthetize the patient. This may lead to the under-reporting of the actual number of euthanasia cases and further confusion about continuous palliative sedation.

Canadian criminal law is not affected by ARELCA physician who does what ARELC requires in the MAD protocol will have provided excellent evidence that the killing was intentional, planned and deliberate. Conforming to the Act Respecting End-of-Life Care would seem to increase the likelihood that a physician – and anyone counselling, aiding, abetting his act – could be charged and convicted for first degree murder, for which the punishment is life imprisonment without parole for 25 years. [Full Text]

Entrenching a ‘duty to do wrong’ in medicine

Canadian government funds project to suppress freedom of conscience and religion

 Sean Murphy*

A 25 year old woman who went to an Ottawa walk-in clinic for a birth control prescription was told that the physician offered only Natural Family Planning and did not prescribe or refer for contraceptives or related services. She was given a letter explaining that his practice reflected his “medical judgment” and “professional ethical concerns and religious values.” She obtained her prescription at another clinic about two minutes away and posted the physician’s letter on Facebook. The resulting crusade against the physician and two like-minded colleagues spilled into mainstream media and earned a blog posting by Professor Carolyn McLeod on Impact Ethics.

Professor McLeod objects to the physicians’ practice for three reasons. First: it implies – falsely, in her view – that there are medical reasons to prefer natural family planning to manufactured contraceptives. Second, she claims that refusing to refer for contraceptives and abortions violates a purported “right” of access to legal services. Third, she insists that the physician should have met the patient to explain himself, and then helped her to obtain contraception elsewhere by referral. Along the way, she criticizes Dr. Jeff Blackmer of the Canadian Medical Association (CMA) for failing to denounce the idea that valid medical judgement could provide reasons to refuse to prescribe contraceptives. . .
Full Text


Hearings on Quebec Bill 52:Professor Joceyln Downie

Wednesday, 9 October 2013 – Vol. 43 N° 45

Note: The following translation is the product of a first run through Google Translate.  In most cases it is sufficient to identify statements of interest, but more careful translation is required to properly understand the text.  Translation block numbers (T#) have been assigned by the Project as references to facilitate analysis and discussion.

Caution: raw machine translation


Original Text

(version non révisée)
 (Reprise à 12 h 16)
Le Président (M. Bergman): Alors, Mme Downie, bienvenue à notre commission, et nous sommes heureux de vous avoir avec la Commission des services de santé et sociaux. Et, comme vous le dites dans votre mémoire pour nous, c’est la démocratie à son meilleur. 001 Le Président (M. Bergman) : So, Ms. Downie, welcome to our commission, and we are happy to have you with the commission of health and social services. And, as you said in your memoire to us, this is the democracy at its best.
Vous avez 15 minutes pour faire votre présentation, suivie d’un échange avec les membres de la commission. Je voudrais donc vous demander de commencer dès maintenant, nous donner votre nom avec vos titres, et vous commencer votre présentation. 002 You have 15 minutes to make your presentation, followed by the exchange with the members of the commission. So I would ask you to begin now, give us your name with your titles, and you commence your presentation.
Mme Downie (Jocelyn): Merci beaucoup. Mon nom est Jocelyn Downie et je suis un professeur dans les facultés de droit et de médecine à l’Université Dalhousie. 003 Mme Downie (Jocelyn) :Thank you very much. My name is Jocelyn Downie and I am a professor in the faculties of law and medicine at Dalhousie University.
Tout d’abord, je tiens à vous remercier de m’avoir invité à m’adresser à vous aujourd’hui. C’est, en effet, un processus mémorable, et je suis reconnaissant d’avoir l’occasion d’être une partie de celui-ci. 004 First, I would like to thank you for the invitation to speak with you today. This is, indeed, a momentous process, and I am greatful to have the opportunity to be a part of it.
Deuxièmement, je voudrais commenter [féliciter] Mme Hivon pour introduire ce projet de loi et les autres membres du comité restreint de mourir dans la dignité pour le leadership dont ils ont pris sur la question. 005 Second, I’d like to comment [commend] Mme Hivon for introducing this Bill and the other members of the select committee on dying with dignity for the leadership they took on the issue.

Full translation

Welcome to the wild, wild north

Conscientious Objection Policies Governing Canada’s Medical, Nursing, Pharmacy, and Dental Professions

Bioethics. doi: 10.1111/bioe.12057

J. Shaw, J. Downie


In Canada, as in many developed countries, healthcare conscientious objection is growing in visibility, if not in incidence. Yet the country’s health professional policies on conscientious objection are in disarray. The article reports the results of a comprehensive review of policies relevant to conscientious objection for four Canadian health professions: medicine, nursing, pharmacy and dentistry. Where relevant policies exist in many Canadian provinces, there is much controversy and potential for confusion, due to policy inconsistencies and terminological vagueness. Meanwhile, in Canada’s three most northerly territories with significant Aboriginal populations, whose already precarious health is influenced by funding and practitioner shortages, there are major policy gaps applicable to conscientious objection. In many parts of the country, as a result of health professionals’ conscientious refusals, access to some legal health services – including but not limited to reproductive health services such as abortion – has been seriously impeded. Although policy reform on conscientious conflicts may be difficult, and may generate strenuous opposition from some professional groups, for the sake of both patients and providers, such policy change must become an urgent priority. [Full Text]