IV.    MEETINGS AND NEW PROPOSALS

IV.1    MEC and Council meetings (April, 2017)

IV.1.1    The Committee was advised of plans for the conferences Tokyo in September and in Vatican City in November.  It was also advised that a three day WMA Ethics Conference would be held in conjunction with the WMA General Assembly in Reykjavik, Iceland.  The conference is to be open to the public.  At this stage, plans called for the second day of the Ethics Conference to replace the usual scientific session of the General Assembly.  Denmark, Canada, Netherlands, Turkey, Kuwait, Brazil, CPME, Japan, Spain, South Africa, Belgium, and the Chair of Medical Ethics Committee volunteered to assist in developing topics for the conference.1

IV.1.2    Dr. Miguel Roberto Jorge of Brazil reported of that the conclusions of the Latin American conference held the previous month had been endorsed by 14 national associations.  The Royal Dutch Medical Association (RDMA) claimed that some of the conclusions in the report did not accurately reflect the situation in the Netherlands.  This presumably refers to mention of "the phenomenon of the 'slippery slope' that has led in the Netherlands to its application in people who had not requested it or did not meet the legal requirements."  The Belgian Medical Association stated that its regulations were similar to the Dutch laws, but Belgium was not mentioned in the report.2

IV.2    MEC and Council meetings (October, 2017)

IV.2.1    In an oral report to the Medical Ethics Committee, the Secretary General described the end-of-life conference held the previous month in Tokyo.  He said that, with the exception of Australia and New Zealand, "the appetite for discussing euthanasia and physician assisted suicide in the Asia region is very low," and that no medical association in the area supports the procedures.3 (The written report of the conference that would be received later states that "all participants opposed euthanasia and physician assisted suicide", apart from Zealand and Australia, there is "no appetite" for discussion of the procedures in the region (III.3.4) emphasis added).

IV.2.2    At the Council meeting in October, only a brief and oblique reference was made to the organization of the regional end-of-life conferences.4

IV.3    Canada and Netherlands on "assisted dying" in WM Journal (October, 2017)

IV.3.1    The October issue of the World Medical Journal included two lengthy articles on euthanasia and assisted suicide, one by Dr. Jeff Blackmer about the CMA's approach to legalization of the procedures,5 and the other by two RDMA bioethicists, explaining and defending Dutch law and practice.6  Notwithstanding disclaimers in both articles, they were written to support the campaign by Canada and the Netherlands to change WMA policy, so it is important to attend not only to what they emphasize, but what they leave out.

Euthanasia in the Netherlands

IV.3.2    The Dutch bioethicists wrote in response to two previous articles which, arguing for maintaining WMA opposition to euthanasia and assisted suicide, had criticized the Dutch system.7,8  The authors did not aim "to convince others or settle the debate" but to correct "misconceptions" and to present alternative views worth considering.  Only points relevant to physician freedom of conscience are considered here.  Note that the term "euthanasia," as used by the authors, includes assisted suicide. 

IV.3.3    De Jong and van Dijt emphasize that euthanasia remains a criminal offence if the criteria set out in the law are not satisfied, that patients seeking it have no right to require physicians to assist, and that physicians are "never obliged" to do so.  For these reasons they claim that euthanasia is neither a "therapeutic intervention" nor "regular medical care,"9 and contrary assertions do not reflect "the reality of the situation in the Netherlands."

IV.3.4    If all of this were really the case, it would be most gratifying from the perspective of the protection of physician freedom of conscience, for there would then seem to be no reason to insist that physicians should be involved in euthanasia and assisted suicide, no justification for attempting to ensure their participation or collaboration, and no reason for the WMA to change its policy.  In point of fact, however, the RDMA does consider euthanasia and assisted suicide to be therapeutic medical acts, though not, as the authors correctly state, part of  "regular"  or "standard" care.

A request for euthanasia is one of the most intrusive and onerous demands that a patient can make of a physician. Most physicians find it difficult to perform euthanasia or assisted suicide. This is all the more true if that wish is not prompted by a terminal illness.10

IV.3.5    Nonetheless, the RDMA acknowledges (as the authors do not) that the Dutch widely (though incorrectly) believe that they have a right to euthanasia and assisted suicide from physicians, describing this as "a common misconception."10 It also acknowledges (as the authors do not) "burdensome" and "increasingly vocal" public pressure to provide euthanasia to those with dementia and psychiatric conditions and to "seniors who feel they have 'completed life,'" in response to which the RDMA insists that "euthanasia is an exceptional medical procedure that inherently entails a dilemma for the physician," and that "plenty of physicians" are "unwilling or morally indisposed" to participate.11

Patients have the right to request euthanasia, but physicians are not obligated to grant their request: fundamental objections to euthanasia and assisted suicide must be respected. After all, euthanasia and assisted suicide are anything but ordinary medical procedures.12

IV.3.6    Despite this, the RDMA demands that physicians unwilling to kill patients or help them commit suicide or assisted suicide must help them find a colleague willing to do so.  "Though there is no legal obligation to refer patients," it states, "there is a moral and professional duty to provide patients with timely assistance in finding a physician (for example, within the clinic) who does not have fundamental objections to euthanasia and assisted suicide."12

IV.3.7    While the authors agree that physicians may be morally obliged to provide euthanasia,13 many objecting physicians emphatically reject the claim that physicians have a "moral duty" to facilitate homicide and suicide under any circumstances, especially in the absence of a legal requirement to that effect.  That the RDMA demands such collaboration, a critical point left out by the authors, is surely relevant to any reconsideration of WMA policy on euthanasia and assisted suicide.  It is also relevant to evaluating the protection of conscience provision in the CMA/RDMA proposal, which is contradicted by RDMA policy on this point (VI.4.4.3, VII.4.3.4).

IV.3.8    While it is true that euthanasia remains a criminal offence if the criteria set out in the law are not satisfied, this simply reflects the fact that it is not feasible to entirely abolish the law against deliberate homicide; legalization of euthanasia entails making an exception.  On this point, Canadian legislation is identical; non-consensual homicide and assisted suicide remain criminal offences unless performed by a physician in accordance with legal criteria,14  in which case they are considered therapeutic medical interventions.15,16  That is the basis for demands by some euthanasia advocates and regulators that Canadian physicians must provide or facilitate the procedures by referral.

IV.3.9    On the other hand, the authors identify an important substantive requirement of Dutch euthanasia law, but fail to appreciate its relevance to physician freedom of conscience.  Dutch law requires that the attending physician - not just the patient - must be satisfied that the patient's suffering is unbearable, with no prospect of improvement, and that there is "no alternative" to euthanasia or assisted suicide;17 the RDMA insists that euthanasia must be literally a "last resort."9 These essential requirements for legality not being met, it would be a criminal offence to facilitate euthanasia or assisted suicide by referral.  In most cases, objecting physicians would probably not agree that a patient's suffering cannot be ameliorated, or that there is no alternative to euthanasia.  Thus, it would likely be impossible to successfully prosecute an objecting physician for refusing to refer patients.

The Work of the Canadian Medical Association

IV.3.10    It is instructive to compare Dr. Blackmer's journal article with details of the events as they unfolded (Appendix "B"), filling in some details he omits and drawing attention to points he does not develop.

IV.3.11    Dr. Blackmer describes the CMA Board of Directors decision to actively shape the debate and law on euthanasia and assisted suicide.  His article discusses the CMA's internal and external consultation process, the passage of a key policy resolution, its intervention in the Carter case, and its activities following the decision and subsequent legislation.  He suggests that the WMA and other national associations should learn from the CMA's example.  In his view, there is no point in arguing about the morality of  euthanasia and assisted suicide because "no one is likely to change their views on this."  Rather, he says, it is better to unite the medical profession in its approach to the procedures if they are legalized.

IV.3.12    According to the Journal article, the CMA's public consultation disclosed general agreement that access to palliative and hospice care was important and that a national strategy was needed to advance that goal, but that the public was divided on whether or not euthanasia or assisted suicide should be legalized.  The article highlights agreement on the need for "strict protocols and safeguards" if the law were changed, but does not make clear that this could only have been supported by those uncertain about or in favour of legalization.  It also omits the finding that the potential impact of legalization on the medical profession "should be carefully considered and studied further." (B3.3)

IV.3.13    The meetings with physicians confirmed the need for advance care planning and palliative care.  They also demonstrated that euthanasia and assisted suicide were "no longer taboo subjects," that physicians were ready to discuss the subject and even "lead the conversation", and what Dr. Blackmer describes as the essential intractability of opinions about euthanasia and assisted suicide: "No amount of argument or evidence was likely to change anyone's mind." 

IV.3.14    That is Dr. Blackmer's view: the report itself referred only to the intractability of certain medical conditions, not physician opinions.18 Dr. Blackmer correctly states that it found  "the profession. . .divided on the issue of assisted death," but omits the fact that the great majority of physicians - over 70% - were opposed to the procedures and a change in CMA policy (B3.4). 

IV.3.15    Dr. Blackmer highlights the policy resolution adopted by the CMA's Annual General Council, which is especially significant because it is very similar to the first of three WMA policy changes recommended by Canada and the Netherlands.

The Canadian Medical Association supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.

IV.3.16    This is discussed in more detail in Part VI and VII and Appendix "B." For the present, it is important to note that this did not lead the CMA to adopt a neutral position on assisted suicide and euthanasia.  The Board of Directors, having convinced the delegates at the Annual General Council to approve an ostensibly neutral resolution (B5.8, B6.), later reversed CMA policy against the procedures, formally approving both (subject to legal constraints) as forms of "end of life care." Moreover, the policy committed the Association to support euthanasia and assisted suicide as end-of-life care not only for competent adults, but for any patient group and for any reason approved by the courts or legislatures, including minors, the incompetent or the mentally ill (B9).19

IV.3.17     Legalization of euthanasia and assisted suicide has had serious adverse consequences for objecting physicians (B10.5-9) that are not mentioned in his Journal article.  He does not, for example, acknowledge that, as a direct consequence of the reversal of CMA policy and legalization of the procedures, objecting physicians have had to lobby the CMA for support and make "tearful pleas at several CMA General Council meetings, asking their non-objecting colleagues to support them and to defend their rights."20

IV.3.18    Dr. Blackmer states that, after the Supreme Court of Canada ruling in Carter, "the CMA was tasked with formulating a suggested legislative and regulatory approach to these complex issues."  What actually happened is that the federal government did nothing for almost five months, then called (and lost) an election, leaving the CMA and other stakeholders scrambling to develop policies without any direction as to what changes would be made to the criminal law. The result was a policy and regulatory maelstrom that lasted several months. The Board of Directors, having concentrated on shaping the debate and changing CMA policy, was quite unprepared to mount a cogent, articulate and persuasive defence of physician freedom of conscience. (B10.19) 

IV.4    MEC and Council meetings (April, 2018)

IV.4.1    The Medical Ethics Committee received four written reports concerning the regional end-of-life conferences, supplemented by oral reports from the Nigerian and German Medical Associations.  The Secretary General stated that the regional conferences were to lead to "an international discussion" at the WMA Ethics Conference in Iceland in October.  This was the first indication in the minutes of the Medical Ethics Committee that euthanasia and assisted suicide would be on the agenda of the Ethics Conference.21

IV.4.2    It must have been clear to the Committee that virtually all national associations that had participated in the regional conferences were opposed to euthanasia and physician assisted suicide, and were presumably satisfied with existing WMA policies.  Moreover, while there was public interest in New Zealand and Australia in legalizing the procedures, the national medical associations in both countries remained opposed to physician participation. 

IV.4.3    The minutes disclose only that there was "further debate" about the subject.  According to the World Medical Journal, there was a brief discussion about the fact that current WMA policy states that euthanasia is unethical, but it has been legalized in some countries.  The discussion must have highlighted the difference between the ethical position of the WMA and that of constituent medical associations like the CMA and RDMA. The committee was told "there would be ample time to discuss this matter further at the medical ethics conference in Reykjavik."22

IV.4.4    The Journal added another detail not recorded in the minutes.  The CMA and RDMA stated that they would be returning in October with a revised proposal on euthanasia and assisted suicide "to see if they could accommodate all the divergent views among members."22

IV.5    New proposal re:  "Policy Consistency" (3 July, 2018)

IV.5.1    In the first week of July, five associate members submitted a policy proposal to be considered at the meeting of associate members at the WMA General Assembly in October in Iceland.  The proposal is relevant to discussion at the April Medical Ethics Committee meeting about inconsistency between WMA policy on euthanasia and that of some of its constituent members (VI.4.3).  One of the five sponsors of the new proposal is a Canadian medical resident who appears to have closely followed and frequently signalled approval of Dr. Blackmer’s tweets from the conference in the Vatican (III.4.6 to III.4.21; III.4.28 to III.4.30).

IV.5.2    In the preamble, the proposal states that it is important that WMA and constituent member policies should, as far as possible, be consistent with one another.  It notes that, while WMA policy development includes a review of national policies, a review of WMA policy is less likely to happen during policy development by national associations. The document proposes that policy development by national associations should always include formal systematic consultation of WMA policies.

IV.5.3    However, the proposal identifies "ethical policy" as  "a special case where consistency is most important and in some circumstances may not be possible."  Hence, while national medical association policy "should be specific and consistent with World Medical Association Ethical Policy," the sponsors argue that WMA ethical policies should accommodate "national and culture differences."

When an NMA has an ethical opinion that is not consistent with WMA policy, but is consistent with the law in its country and is clearly generated by benevolence toward patients, WMA may allow for national and cultural differences in formulating its own ethical policies.

IV.5.4     Euthanasia and assisted suicide are always described by EAS advocates as expressions of benevolence or beneficence (within the present context it is assumed the terms are interchangeable).  Thus, if accepted, the policy would force the WMA to "allow for" physician participation in euthanasia and assisted suicide and even to allow for the coercion of objecting physicians (VII.5.9).

IV.6    CMA & RDMA introduce revised EAS proposal

IV.6.1    At the end of July the CMA and RDMA reintroduced the proposal they had withdrawn previously, with revisions (Appendix "C").  While they had stated that the revisions were intended to "accommodate divergent views" among WMA constituent members (IV.4.4), the only divergent views accommodated were those of the CMA, RDMA and other EAS supporters, which diverge from the overwhelming majority of medical associations around the world.  The revisions are outlined below.  The revised proposal will be considered in detail in Part VI.

Minor revisions

IV.6.2    Many of the revisions are minor.  For example, "assisted suicide" in the original is now "assisted death;" those seeking the services were "patients" in the original but are "persons" in the revised version.  Some, like the definitions of euthanasia and "assisted death," are clarifications.23  A new section about the need to support for patients at the end of life is unremarkable.24  The remaining changes are rhetorical, rhetorical and substantive or substantive.

Rhetorical revisions

IV.6.3    There is special emphasis in the revised proposal on democracy - "democratic processes" and "extensive democratic legislative processes" - and redoubled emphasis on legislation, court decisions and public debate.25

IV.6.4    The most obvious rhetorical change reflects an attempt to minimize the overwhelming opposition to euthanasia and assisted suicide in the medical profession worldwide, amply demonstrated by the results of the regional conferences.  The admission that "the majority of physicians" find the procedures to be irreconcilable with medical ethics has been struck out entirely, replaced with the statement that "many physicians" merely recognize a conflict.26

IV.6.5    A new paragraph emphasizes a 'diversity' of responses to this conflict.  While it may reflect the associate members' proposal introduced earlier in the same month (IV.5), it is identical to a statement about abortion introduced into the revised Declaration of Oslo that will be considered by the General Assembly in October:27

Diverse responses to resolve this dilemma reflect the diverse cultural, legal, traditional, and regional standards of medical care throughout the world.28

Rhetorical and substantive revisions

IV.6.6    With respect to physician freedom of conscience, the wording of the original proposal was very similar to the resolution used by the CMA Board of Directors as the basis for reversing CMA policy against euthanasia and assisted suicide (B5, B6, B7, B9).  A new paragraph has been added, a slightly modified passage also taken from the revised Declaration of Oslo.

Attitudes toward euthanasia and physician assisted death are evolving and are a matter of individual conviction and conscience that should be respected.29

At first glance, this seems only to lend more weight to the emphasis on freedom of conscience.

IV.6.7    However, this is also a substantive change.  If attitudes toward euthanasia and assisted suicide continue to evolve, so will the criteria for the procedures.  All evidence to date demonstrates that the evolution is exclusively in the direction of expanded access, which generally speaking, entails increasingly controversial criteria.  If, as this statement requires, the WMA must respect all attitudes toward euthanasia and assisted suicide no matter how they evolve, the statement commits the WMA to accept euthanasia and assisted suicide for any reason acceptable in law.

Substantive revisions

IV.6.8    With respect to EAS providers, the original proposal stated that they were motivated by "compassion for their patients."  They are now said to be responding to "the immediate needs of their patients."30  The change implies an objectively verifiable need to be killed or helped to commit suicide, so that by approving the policy the WMA would acknowlede such a need.

IV.6.9    Palliative care was first said to be part of "part of good and appropriate medical care," but in the revised proposal this is only the case when it is "available."  The implication may be that actual access to palliative care need not be a precondition for the provision of euthanasia and assisted suicide.31  Consistent with this, the original statement that euthanasia and assisted suicide "should never" be substitutes for palliative care has been revised to read that they "should not" be.32

IV.6.10    Originally, the CMA and RDMA proposed only that the WMA affirm that it does not condemn EAS providers, but now wants the Association to state, in addition, that they are not acting unethically.33 

IV.6.11    A new provision in the proposal states that euthanasia and assisted suicide should be provided by competent physicians or health care providers.34  If the WMA approves this proposal, it will not only reverse its policy against the procedures, but affirm that, where the procedures are legal, physicians have an ethical obligation to kill their patients or help them commit suicide.

IV.6.12    The revised proposal narrows the protection offered to objecting physicians.  The CMA and RDMA first stated that objecting physicians should not be forced to refer patients to other physicians.  They now state that physicians should not be forced to refer "to another physician in order to provide assistance in dying" (emphasis added).  This does not preclude compulsory referral to physicians who will provide required consultations preliminary to lethal injection by someone else, nor does it preclude compulsory referral to euthanasia delivery coordinators.35

IV.6.13    Finally, in 2016, the CMA and RDMA insisted that euthanasia and assisted suicide "should be seen as a last resort for those whose intractable and hopeless suffering cannot be alleviated through any other ordinary means."  This restriction has been struck out completely,36 indicating that the ultimate goal of the CMA and RDMA is the WMA's unconditional approval of euthanasia and assisted suicide as legitimate forms of medical treatment.

---

Notes

1.    World Medical Association.  MEC 206/Report/Apr2017: Report of the Medical Ethics Committee (20-21 April, 2017).

2.    World Medical Association.  Council 206/Minutes/Apr2017: Minutes of the 206th Council Session (20, 22 April, 2017) p.4.

3.    World Medical Association.  MEC 207/Report/Oct2017: Report of the Medical Ethics Committee (11 October, 2017) 3.10 Regional meetings on End-of-Life Question (EoL workshop), p. 4-5.

4.    World Medical Association.  Council 207/Minutes/Oct2017: Minutes of the 207th Council Session (11 and 13 October, 2011) p.2.

5.    Blackmer J.  Assisted Dying and the Work of the Canadian Medical Association.  World Medical J [Internet]. 2017 Oct [Cited 2018 Sep 29]; 63(3):6-9 [Blackmer-WMJ]

6.    de Jong A, van Dijt G. Euthanasia in the Netherlands: balancing autonomy and compassion. World Medical J [Internet]. 2017 Oct [Cited 2018 Sep 29]; 63(3)10-15 [de Jong-van Digt].

7.    Requena P.  Why Should the World Medical Association not Change its Policy towards Euthanasia? World Medical J [Internet]. 2016 Oct [Cited 2018 Sep 29]; 62(3) 99-102 (Accessed 2018-05-31).

8.    Keown J.  Voluntary Euthanasia and Physician-assisted Suicide: Should the WMA Drop its Opposition?  World Medical J [Internet]. 2016 Oct [Cited 2018 Sep 29]; 62(3) 103-107(Accessed 2018-05-31).

9.    Similarly, Herman Nys, writing in 2001: "In the Netherlands the majority of health-care lawyers believe that euthanasia is not a 'normal medical act', although it must be administered by a physician. There is no medical indication for euthanasia and there exists no professional medical standard for its permissibility. Whether euthanasia is to be allowed or not is a matter for society, not for the medical profession. The same is true of, say, non-therapeutic abortion. Moreover, if euthanasia were a normal medical act, the physician should in principle administer it. Nobody is of that opinion in the Netherlands."  Nys H. Euthanasia in the low countries: a comparative analysis of the law regarding euthanasia in Belgium and the Netherlands. Ethical Perspect [Internet] 2002 [Cited 2018 Sep 29]; 9(2):73-85.

10.    Royal Dutch Medical Association [Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG)].  The Role of the Physician in the Voluntary Termination of Life [Internet].  Utrecht, Netherlands:KNMG; 2011 Jun 23 [Cited 2018 Sep 29] [RDMA-Role of the Physician] p. 6.

11.    RDMA-Role of the Physician, p. 6-7.

12.    RDMA-Role of the Physician, p. 33.

13.    ". . . the principle of compassion may require physicians to grant such a request for euthanasia." de Jong-van Digt, p. 15.

14.    Criminal Code. RSC 1985, c. C-46, s 227, 241(2) to (5.1) [Internet] [Cited 2018 Sep 29]

15.    Doctor-assisted suicide a therapeutic service, says Canadian Medical Association.  CBC News, 6 February, 2016 (Accessed 2018-06-09).

16.    The Canadian Medical Association describes euthanasia and physician assisted suicide as "legally permissible medical service[s]."  Canadian Medical Association. Medical Assistance in Dying [Internet] 2017 May [Cited 2018 Sep 29] [CMA-MAID 2017].

17.    Dutch law on Termination of life on request and assisted suicide (complete text) [Internet]. The World Federation of Right to Die Societies. Termination of Life on Request and Assisted Suicide (Review Procedures) Act [Cited 2018 Sep 29], 1(b) and (d)

18.    Canadian Medical Association. End-of-Life Care: A National Dialogue. CMA Member Consultation Report [Internet] 2014 Jul [Cited 2018 Sep 29][CMA Member Consultation] p. 8.

19.    When the CMA revised the policy in 2017, it reintroduced the distinction between euthanasia and physician assisted suicide and other forms of end-of-life care. CMA-MAID 2017.

20.    Blackmer J.  Letter from Dr. Jeff Blackmer, Vice President, Medical Professionalism, Canadian Medical Association, to Physicians' Alliance Against Euthanasia [Internet]. Collectif des Médecins Contre L'Euthanasie; 2018 Apr 30 [Cited 2018 Sep28].

21.    World Medical Association.  MEC 209/Report/Apr2018: Report of the Medical Ethics Committee (27 April, 2018)

22.    Medical Ethics Committee, End of Life Questions.  World Medical J [Internet]. 2018 Aug [Cited 2018 Sep 29]; 64(2):8-9.

23.   World Medical Association.  MEC 210/Euthanasia and PAD/Oct2018: Proposed WMA Reconsideration of the Statement, Resolution and Declaration on Euthanasia and Physician Assisted Dying [2018C/RDMA] §2.  See also Appendix "C": Comparison of 2016 and 2018 CMA/RDMA proposals [Appendix "C"] Ref. E, F.

24.    2018C/RDMA §13 (Appendix "C,"Ref. U)

25.    2018C/RDMA §1, 9 (Appendix "C," Ref. C, N)

26.    Compare MEC 203/Euthanasia-Physician Assisted Dying/Apr2016: MEC 203/Euthanasia-Physician Assisted Dying/Apr2016: Proposed WMA Reconsideration of the Statement on Euthanasia and Physician Assisted Dying [2016 CDMA] §7 with 2018C/RDMA §8 (Appendix "C," Ref. K).

27.    World Medical Association. MEC 209/ Therapeutic Abortion REV4/Apr2018: Proposed WMA Statement on Medically-Indicated Termination of Pregnancy [Abortion Rev4], paragraph 3.

28.    2018C/RDMA §8 (Appendix "C," Ref. L)

29.    2018 C/RDMA, §8 (Appendix "C," Ref. P); compare Abortion Rev4, paragraph 2.

30.    Compare 2016C/RDMA §1, with 2018C/RDMA §2 (Appendix "C," Ref. C)

31.    Compare 2016C/RDMA §5, with 2018C/RDMA §6 (Appendix "C," Ref. H)

32.    Compare 2016C/RDMA §10, with 2018C/RDMA §12 (Appendix "C," Ref. T)

33.    Compare 2016C/RDMA§8, with 2018C/RDMA §9 (Appendix "C," Ref. O)

34.    2018C/RDMA §11 (Appendix "C," Ref. S)

35.    Compare 2016C/RDMA §9, with 2018C/RDMA §10 (Appendix "C," Ref. Q)

36.    2016C/RDMA §10 (Appendix "C," Ref. T)