Dr. Robert’s regrets: Towards death à la carte?

Sean Murphy*

The state medical regulator in the province of Quebec, the Collège des Médecins du Québec, published an reflection in 2009 that effectively encouraged the legalization of euthanasia. During hearings into Quebec’s Bill 52, which eventually became the province’s euthanasia law (the Act Respecting End of Life Care), Dr. Charles Bernard , Dr. Yves Robert and Dr. Michelle Marchand appeared on behalf of the Collège.  They were effusive in their support for the proposed law, describing it as “a very important milestone,” the product of “outstanding work,” and “responsive to the vision we initially proposed.”

One of the points Dr. Bernard  emphasized was that euthanasia should be “an option of last resort for  exceptionally difficult situations at the end of life. . . in the final stages of a serious and incurable disease that is inflicting refractory suffering.”  Dr. Robert himself added that euthanasia should only be considered in what was truly the “last slice of life in the final phase of the life.”  Only then, he said, might it be considered an option “from a medical point of view.”

Consistent with these views, the original text of the Bill was amended to include a provision that a patient had to be “at the end of life,” even though the legislators could not agree on what this meant.  It is not certain that the term is being interpreted consistently throughout the province, though returns from reporting agencies sometimes report refusal to provide euthanasia because a patient is “not at the end of life.”  About 8% of refusals in the first half of 2017 were attributed to patient ineligibility, which includes this criterion, among others.

In any event, Dr. Robert has published a commentary indicating alarm at increasing pressure to provide euthanasia in circumstances and for reasons apparently not envisaged by Collège des Médecins du Québec when it published its 2009 reflection and expressed its support for the new legislation.  Of particular interest, he suggests that, if current trends to broaden criteria for euthanasia continue and are affirmed, it may be appropriate for the medical profession to be replaced by some kind of non-medical (but presumably technically competent) euthanasia service.

During the legislative hearings into Bill 52, Professor Margaret Somerville suggested that lawyers could be trained for this purpose.  Her suggestion was ignored at the time, but Dr. Robert’s comments suggest that he and other euthanasia supporters may now be more open to Dr. Somerville’s proposal.  Having a corps of voluntary euthanasia service providers would relieve the pressure now being experienced by physicians and health care workers who object to euthanasia for reasons of conscience.

  • Dr. Robert’s regrets [Full English translation of Vers la mort à la carte? provided by the Physicians’ Alliance against Euthanasia]

What’s behind the demolition of conscience rights in Canada?


Margaret Somerville*

I’ve been puzzling about why Canadian “progressive” values advocates, particularly those passionately in favour of the legalization of euthanasia and physician-assisted suicide (“physician-assisted death” (PAD)), are so adamant in trying to force healthcare professionals and institutions who have conscience or religious objections to these procedures to become complicit in them.

Complicity would occur if objecting individual physicians were forced to provide “effective referrals” or objecting institutions were forced to allow PAD in their facilities. An “effective referral” is defined by the Ontario College of Physicians and Surgeons as “a referral made in good faith, to a non-objecting, available, and accessible physician or other health-care provider.”

In general, progressive values advocates claim to give priority to rights to individual autonomy, choice, control over what happens to oneself, and tolerance for those who believe differently. Yet in relation to respect for the freedom of conscience and, where relevant, religious belief, of physicians or institutions who oppose PAD, none of these principles seem to be applied. Why? [Full text]

A modest proposal for respecting physicians’ freedom of conscience

National Post

Margaret Somerville

The Ontario College of Physicians and Surgeons is consulting on whether patients’ right of access to certain procedures, such as abortion, should trump the rights of those physicians who refuse, for reasons of conscience, to provide them. Dr. Marc Gabel, a College official, chairs the working group looking at this issue, which is drafting a new policy on “Professional Obligations and Human Rights.”

Dr. Gabel has been reported as saying that “physicians unwilling to provide or facilitate abortion for reasons of conscience should not be family physicians” and it seems wants the College to approve that stance. Sean Murphy, of the Protection of Conscience Project, argues that “if it does, ethical cleansing of Ontario’s medical profession will begin this year, ridding it of practitioners unwilling to do what they believe to be wrong.”

Freedom of conscience, like the other fundamental freedoms enshrined in the Canadian Charter of Rights and Freedoms, is a fundamental pillar of democracy. So how could breaching this right be, as Dr Gabel claims, “required by professional practice and human rights legislation”? . . . [Full text]


There’s no “mushy middle” on euthanasia


Margaret Somerville*

Many know the saying “You have to fish or cut bait”. Many fewer know the law’s equivalent, “You can’t approbate and reprobate”. But the Canadian Medical Association’s recent dealing with their 2007 Policy on Euthanasia and Assisted Suicide makes it seem they are unaware of the warning and wisdom these axioms communicate.

That CMA policy unambiguously declares: “Canadian physicians should not participate in euthanasia or assisted suicide.”  Despite that, a motion passed at the recent CMA General Council meeting, which ostensibly was meant only to ensure freedom of conscience, has allowed the CMA to make the following statement in its intervener factum in the upcoming appeal in the Supreme Court of Canada in the Carter case:

“As long as such practices [as euthanasia and assisted suicide] remain illegal, the CMA believes that physicians should not participate in medical aid in dying. If the law were to change, the CMA would support its members who elect to follow their conscience [either to refuse or to undertake euthanasia and assisted suicide].”

[Full text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 4: The Problem of Killing


Impartiality, complicity and perversityThe original text of Bill 52 did not define “medical aid dying” (MAD), but it was understood that, whatever the law actually said, it was meant to authorize physicians to kill patients who met MAD guidelines.  The Minister of Health admitted that it qualifed as homicide, while others acknowledged that MAD meant intentionally causing the death of a person, and that its purpose was death.  Various witnesses in favour of the bill referred explicitly to lethal injection and the speed of the expected death of a patient.

Given the moral or ethical gravity involved in killing, it is not surprising to find serious disagreement about MAD among health care workers.  Conflicting claims made about the extent of opposition to or support for euthanasia within health care professions are difficult to evaluate, but a review of the transcripts of the legislative committee hearings into Bill 52 is instructive.

One physician member of the committee was shocked by the assertion that there is no  moral, ethical, or legal difference betwen withdrawing life support and lethally injecting a patient.  Hospices and palliative care physicians rejected participation in euthanasia.  Sharp differences of opinion among other health care workers were reported.  Support for killing patients by lethal injection was likened to support for the death penalty; that is, many more agreed with the act in principle than were willing to do the actual killing.  So marked was the evidence of opposition to euthanasia that doubts were raised about the possiblity of implementing the law.

Since the law was passed as a result of assurances from the Quebec medical establishment that it could be implemented, a committee member who is now a minister of the Quebec government warned that they would be called to account if it is found that few physicians are willing to participate.  This political pressure is likely to provide an additional incentive for the medical establishment to secure the compliance of Quebec physicians.

The introduction of euthanasia into Quebec’s health care system is to be accomplished using the structures and powers established by other Quebec statutes that govern the delivery of health care in the province, which have established a multi-layered and overlapping bureaucracy of committees, councils, commissions, boards, directors, examiners, coordinators, syndics and commissioners.  Physicians and other health care providers who object to euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system, a prominent feature of which is an emphasis on patient rights.

Everyone authorized to enact or supervise adherence to policies or standards can become a MAD functionary, using codes of ethics, protocols, guidelines, directives, etc. to normalize euthanasia. Similarly, every disciplinary and complaints procedure can be used to force participation in MAD services.  Those who openly advocate refusal to provide or facilitate euthanasia can be fined from $1,500.00 to $40,000.00 per day under Quebec’s  Professional Code if they are deemed to have helped, encouraged, advised or consented to a member of a profession violating the profession’s code of ethics. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 1: Overview


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.  The original text of the Bill 52 did not define medical aid in dying (MAD), but ARELC now makes it clear that Quebec physicians may provide euthanasia under the MAD protocol.  In addition, substitute decision makers can order legally incompetent patients who are not dying to be starved and dehydrated to death.  This practice, identified here as Euthanasia Below the Radar (EBTR), is completely unrestricted and is not even reportable.

Neither ARELC nor MAD guidelines can abolish the criminal prohibition of euthanasia, so physicians who kill patients in the circumstances contemplated by the new law would still be liable to prosecution.  However, the Quebec government has promised that it will refuse to prosecute physicians who kill patients in accordance with MAD guidelines, thus circumventing the criminal prohibition.  Beyond that, Quebec general practitioners have asked for immunity from prosecution for failing to conform to MAD guidelines.  Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, and some physicians may be unwilling to provide euthanasia without it.

The introduction of euthanasia will require the complicity of thousands of health care workers and administrators.   Many are likely to comply because official representatives of the legal and medical establishments of Quebec have formally declared their support for the new law.  On the other hand, palliative care physicians, hospices and an undetermined number of other physicians and health care workers are opposed to euthanasia and assisted suicide.

Section 4 of ARELC states that eligible patients have a right to “end-of life-care,” which includes euthanasia and palliative care.  The statutory declaration of a “right” is the most powerful weapon in the legal arsenal likely to be used to enforce compliance with ARELC and to attack freedom of conscience among those who refuse to facilitate the procedure.

It appears that, even where euthanasia or assisted suicide is legal, the majority of physicians do not actually provide the services.  The Act may lead to discriminatory screening of physicians unwilling to kill patients, effected by denying them employment in their specialties and denying them hospital privileges.

However, objecting physicians not only refuse to kill patients, but also often refuse to do anything that they believe makes them morally responsible for the killing. Hence, it is likely that most of the attacks on freedom of conscience resulting from ARELC will be precipitated by refusal to participate indirectly in killing.

Physicians may refuse to provide euthanasia if the patient is legally ineligible, and for other reasons, including conscientious objection.  ARELC requires physicians who refuse to provide euthanasia for any reason other than non-eligibility to notify a designated administrator, who then becomes responsible for finding a MAD physician.  The idea is to have the institution or health care system completely relieve the physician of responsibility for facilitating the procedure.

The protection of conscience provision in ARELC distinguishes physicians from other health professionals, providing less protection for physicians than for others.  Physicians may refuse only  “to administer” euthanasia – a very specific action –  which seems to suggest that they are expected to participate in other ways.

Palliative care hospices and a single Quebec hospital may permit euthanasia under the MAD protocol on their premises, but they do not have to do so.  Patients must be advised of their policy before admission.  The exemptions were provided for purely pragmatic and political reasons.  The exemptions have been challenged by organizations that want hospices forced to kill or allow the killing of patients who ask for MAD. Hospice representatives rejected the first demand and gave mixed responses to the second.  A prominent hospice spokesman predicted that hospices refusing to provide euthanasia will operate in an increasingly hostile climate.

Refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is the response expected of physicians by professional bodies and regulators.  It is not clear that Quebec legislators or professional regulators understand this.  A principal contributor to this lack of awareness – if not actually the source of it – is the Code of Ethics of the Collège des médecins, because it requires that physicians who are unwilling to provide a service for reasons of conscience help the patient obtain the service elsewhere.

As a general rule, it fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence.  It was a serious error to include this a requirement in a code of ethics.  The error became intuitively obvious to the Collège des médecins and College of Pharmacists when the subject shifted from facilitating access to birth control to facilitating the killing of patients.

A policy of mandatory referral of the kind found in the Code of Ethics of the Collège des médecins  is not only erroneous, but dangerous.  It purports to entrench  a ‘duty to do what is wrong’ in medical practice, including a duty to kill or facilitate the killing of patients. To hold that the state or a profession can compel someone to commit or even to facilitate what he sees as murder is extraordinary.

Since ARELC explicitly authorizes physicians to kill patients deemed eligible for MAD by the Act, the federal government can go to court to have the statute declared unconstitutional.  However, it is possible that the federal government will take no action until after the Supreme Court of Canada ruling in Carter v. Canada and after the 2015 federal election.

It seems unlikely that Quebec physicians who provide euthanasia under MAD guidelines will be prosecuted even if the prohibition of assisted suicide and euthanasia is maintained by the Supreme Court of Canada, and even if ARELC is ultimately struck down as unconstitutional.  The continued de facto decriminalization of euthanasia in Quebec would probably generate considerable pressure in other provinces to follow suit.

Those who refuse to provide or facilitate euthanasia for reasons of conscience will likely find themselves in increasingly complicated and contentious working environments. In the end, freedom of conscience for Quebec health care workers who object to euthanasia may come to mean nothing more than the freedom to find another job, or the freedom to leave the province. [Full text]

Doctors’ conscience rights under attack in birth control debate

One physician threatens to give up his practice rather than kill patients

BC Catholic

Deborah Gyapong

Doctors who refuse to prescribe birth control pills have become the focus of a debate over physicians’ rights to freedom of conscience and religion when practising medicine.

An Alberta doctor has been in the media spotlight recently for posting a notice at the clinic where she works she will not prescribe the pill and now faces a human rights complaint. Earlier this year, three Ottawa doctors came under fire for similar reasons. The Ontario College of Physicians and Surgeons (CPSO) is doing a public consultation on its guidelines that could be revamped to restrict doctors’ rights to abstain from legal medical practices on religious or conscientious grounds.

For Dr. Howie Bright, past president of the Canadian Federation of Catholic Physicians’ Societies (CFCPS), the attack on birth control is a “fairly discrete target because it sounds weird that a modern doctor” would not prescribe contraception and is likely to “generate reaction.” [Full text]

Canadian Doctors Should Not be Forced to Do Abortions or Provide Birth Control


Reproduced with permission

Mike Schouten

The College of Physicians and Surgeons of Ontario (CPSO) is asking for public input as part of its regular review of policy guidelines. At issue in this current review is the right of doctors to refuse to provide certain treatments based on religious or moral grounds.

There will always be some tension between the moral convictions of an individual medical professional who adheres to his or her own worldview and the different procedures that are legally available in a pluralistic society. The current CPSO guidelines recognize this tension. In an effort to balance competing interests, the policy allows doctors to refrain from performing non-emergency procedures should the procedures violate their individual conscience.

It is always beneficial to review policies and guidelines, especially those pertaining to the health and wellbeing of Canadians. But the current review and discussion over CPSO guidelines is not about improving care for residents of Ontario. Instead, it seems to be about forcing medical professionals to set aside their own worldview and adopt a conflicting one.

To be clear, we are not talking about providing health-care services where a patient’s life is at risk. No, when a discussion about conscience-protection takes place it is almost always surrounding issues such as like infant male circumcision, prescribed birth control, certain types of medications, medicinal marijuana, or an abortion procedure. In the future, this list may very well include euthanasia or assisted suicide.

On occasion, the tension between the conscience of a doctor and the desire of a patient is experienced in a tangible way. Kate Desjardins is a 25-year-old Ottawa resident who, earlier this year, entered a walk-in clinic to have her prescription for birth control renewed. However, this was not a routine visit. As Ms. Desjardins quickly found out, the doctor on duty did not prescribe contraceptives. Although Ms. Desjardins’ life wasn’t in danger and she could most certainly have secured a prescription renewal at any number of surrounding clinics, her experience has been highlighted by those pushing to have the conscience objection nullified by the CPSO.

It’s not about availability of services, but about imposing morality on all physicians.

Clearly this isn’t about adequate and timely access to health-care, both of which were still available to Ms. Desjardins. Essentially, this is about a patient’s right to access all medical services from any doctor of his or her choosing. It’s not about availability of services, but about imposing morality on all physicians, to the point where doctors need to violate their own conscience in order to serve their patients.

Justin Trudeau was chastised from a wide variety of Canadians when he decided to impose his worldview on the Liberal Party of Canada by forcing Liberal MPs to violate their consciences in the event that an abortion law ever made it to a vote in Parliament. The same principle applies in the present debate surrounding conscience protection for physicians. This is a battle about conflicting worldviews, not adequate access to healthcare. The target of leftist ideologues include all those who hold to a worldview (religious or otherwise) opposed to their own. So, who actually is forcing their religion on whom?

Canadians are not perishing because doctors won’t take part in elective, non-emergency medical procedures

On the one hand, we have doctors arguing for their freedom of conscience, which is guaranteed by the Charter of Rights and Freedoms. And on the other, we have patients who believe they have the right to a medical procedure from any physician of their choosing. If the object of the CPSO guidelines is to balance rights and obligations, then taking away conscience objections would throw balance out the window altogether.

Conscience-protection guidelines are vital if we are to have a well functioning and vibrant health care system. As Dr. Margaret Somerville, the founding director of the Centre for Medicine, Ethics and Law at McGill University said recently, “Do you really want to be treated by a doctor who doesn’t care if he thinks that he’s doing something unconscionable or unethical or immoral?”

Canadians are not perishing because doctors won’t take part in elective, non-emergency medical procedures. That someone was offended because they had to walk a few extra blocks to renew their birth control prescription does not justify the CPSO forcing doctors to contravene their Charter-protected freedom of conscience.

Should doctors have the right to refuse to prescribe birth control because of their religious beliefs?

CBC Radio

Day 6

Last week Joan Chand’oiseau was outraged to learn that the physician at her Calgary walk-in clinic refused to prescribe birth control because of her religious beliefs. Chand’oiseau’s story broke just after Canada’s largest medical regulator – The College of Physicians and Surgeons of Ontario – announced it would be revisiting its policies on physicians and the Human Rights Code.  We check in with Joan Chand’oiseau, and invite  Margaret Somerville, Director of the McGill Centre for Medicine, Ethics and Law, and Arthur Schafer, director of the Centre for Professional and Applied Ethics at the University of Manitoba, to debate whether doctors should have the right to refuse to treat a patient on religious or moral grounds.



Policy allowing doctors to deny treatment on moral or religious grounds under review

Globe and Mail

Kelly Grant

Doctors who refuse to provide certain treatments on religious or moral grounds must tread delicately or risk trampling human-rights laws, according to the chief commissioner of the Ontario Human Rights Commission, which is expected to weigh in soon on a review of professional guidelines for physicians practising in Canada’s largest province.

“First and foremost their job is to provide health-care services to people who require them,” Barbara Hall said. “If [doctors] wish to put forward their own human rights as a barrier to doing that then they may come up against the fact that their rights are not absolute.”

In an interview, Ms. Hall said doctors generally do not enjoy the same legal protections as religious officials – a point her commission underlined to the College of Physicians and Surgeons of Ontario (CPSO) when the medical regulator last updated its policy on doctors and the human-rights code in 2008. . . [Full text]