APPENDIX "B"

CMA APPROVAL OF EUTHANASIA AND ASSISTED SUICIDE

B1.    Canadian Medical Association (CMA) General Council (August, 2013)

B1.1    In June, 2012, in the case of Carter v. Canada (Attorney General), a judge of the Supreme Court of British Columbia struck down the absolute criminal prohibition of physician assisted suicide and physician administered euthanasia, suspending the ruling for one year to give governments the opportunity to implement the decision.1 

B1.2    When the CMA Annual General Council convened in August, 2013, an appeal of the Carter decision was in progress, and a euthanasia bill had been introduced in the Quebec legislature. Delegates were presented with a motion from the Quebec Medical Association that the CMA should ask "all relevant levels of government to conduct a large-scale public consultation to consider the recognition of medical aid in dying as appropriate end-of-life care."2

B1.3    A contentious debate followed, centred on the wording of the motion and the definition of terms, and the motion was defeated. Instead, delegates voted "to refer the issue to the CMA Board for future deliberation." The outgoing chair of the medical ethics committee said that the vote reflected "deep divisions within the medical community."2 

B1.4    Another motion called for the CMA to replace the term "physician-assisted suicide" with "physician-assisted death" in all its official documents. According to a Globe and Mail report, this motion also generated a "passionate debate."

"Suicide is an unhappy word," said John O'Brien-Bell of Surrey, B.C., a past CMA president. "Assisting suicide is also illegal." Lawrence Erlick of Scarborough, Ont., tried to find a compromise, suggesting the unwieldy term "patient-requested medically assisted death." Robin Saunders, chair of the CMA ethics committee, would have none of it. "Let's call a spade a spade: It's euthanasia," he said.

Delegates voted to have the CMA Board review the issue and make a decision.3

B1.5    However, delegates did pass the following motion:

36. The Canadian Medical Association supports the right of any physician to exercise conscientious objection when faced with a request for medical aid in dying. (DM 5-22).4

B2.    CMA Board decides to shape the debate and the law

The decision

B2.1    In October, 2013, the BC Court of Appeal reversed the Carter trial court ruling.5  The Court of Appeal quoted the CMA policy against physician participation in euthanasia and assisted suicide, setting it beside the policies of other associations, as the trial judge did, to make the point that the evidence at trial "did not demonstrate a clear consensus of public or learned opinion on the wisdom of permitting physician-assisted suicide."6  It was generally understood that the case would be appealed to the Supreme Court of Canada.

B2.2    The CMA Board of Directors held a retreat the same month, apparently for the purpose of deciding upon a course of action concerning euthanasia and physician assisted suicide. In describing the "dilemma" faced by the Board, Dr. Blackmer noted that polls had demonstrated that the large majority of physicians were opposed to euthanasia and assisted suicide, but the public was increasingly in favour of the procedures.  Consistent with the position of the majority of physicians, CMA policy was against both.  According to CMA Vice-President Dr. Jeff Blackmer, the choice faced by the Board was to leave the policies unchanged, or "play a more active role in representing its membership." The Board opted to become involved in what Dr. Blackmer called the "national conversation." It meant to shape the debate and law concerning euthanasia and assisted suicide, and authorized "a substantial budget and significant internal resources" for that purpose.7  CMA President Chris Simpson later explained, " "We realized that this was something that society needs us to lead on."8

Shaping the debate and the law: in brief

B2.3    The great majority of CMA members opposed legalization of euthanasia and assisted suicide, but, in representing CMA members in the "conversation," the Board appears to have decided to include both majority and minority perspectives.  This was challenging but worthwhile, and need not have had any adverse effects on physician freedom of conscience. 

B.2.4    However, by the summer of 2014, it appears that the Board's plan to shape the debate and the law had evolved into a plan to overturn CMA policy against the procedures, notwithstanding the opposition of the majority of physicians, apparently because it had concluded that euthanasia and/or assisted suicide should be legalized in at least some cases.  According to Dr. Chris Simpson, then CMA President, the Board decided that there was no consensus on the procedures, and "There can't be a one-size-fits-all. We have to have the ability to fit everybody's legitimate concerns and aspirations here."9

B2.5    Belief that the Carter case would result in legalization of the procedures also seems to have contributed to the Board's plan to change CMA policy.10,11 The Directors wanted to ensure not only that the CMA would be involved in writing and implementing a new law,12,13,14,15 but would be in the vanguard of what would be a momentous change.16,17,18,19 That meant being on the right side of history if, as widely expected, the Supreme Court ruled that the law should be changed.20,21 However, that also meant achieving a major policy change at the General Council in August, as the next opportunity to do so would not come for another year.

B2.6    Beginning in June, 2014, with a General Council two months away and a Supreme Court hearing expected in the fall, the Board put into action what was probably a still evolving plan, without reflecting adequately upon the effects of their actions on medical practice and the fundamental freedoms of physicians.  As a result, they were surprised by elements of the Supreme Court ruling and ill-prepared to respond, especially to challenges to physician freedom of conscience.

B3.    CMA Board revises euthanasia and assisted suicide policy (December, 2013)

B3.1    In December, 2013, the CMA Board approved changes to Association policy on euthanasia and assisted suicide.22  The update, published in 2014, introduced new terminology and reiterated the Association's opposition to the procedures. Three statements in the policy are of particular interest:

A change in the legal status of these practices in Canada would represent a major shift in social policy and behaviour. For the medical profession to support such a change and subsequently participate in these practices, a fundamental reconsideration of traditional medical ethics would be required. (p. 2, emphasis added)

Physicians, other health professionals, academics, interest groups, the media, legislators and the judiciary are all deeply divided about the advisability of changing the current legal prohibition of euthanasia and assisted suicide. Because of the controversial nature of these practices, their undeniable importance to physicians and their unpredictable effects on the practice of medicine, these issues must be approached cautiously and deliberately by the profession and society. (p. 2)

The CMA recognizes that it is the prerogative of society to decide whether the laws dealing with euthanasia and assisted suicide should be changed. The CMA wishes to contribute the perspective of the medical profession to the examination of the legal, social and ethical issues. (p. 3)

B3.2    There was no reference to the resolution passed by the Annual General Council in 2013 asserting "the right of any physician to exercise conscientious objection when faced with a request for medical aid in dying" (B1.4), but this would have been premature.  Assisted suicide or euthanasia were still illegal, and the Association still stated that physicians should not participate in either.

CMA studies euthanasia & assisted suicide (January-June, 2014)

B3.3    During 2014, pursuing the direction given by the Board the previous October, CMA officials quietly studied the provision of physician assisted suicide and euthanasia in Oregon, Washington, Montana, Vermont and New Mexico, Netherlands, Belgium and Switzerland.11 It also held five town hall meetings across Canada in the first half of the year, ending on 27 May in Mississauga.  With respect to euthanasia and assisted suicide, the report about the meetings noted that "the public often had diametrically opposed views,"23  was divided on whether or not the procedures should be legalized,24 and stated that the potential impact of legalization on the medical profession "should be carefully considered and studied further."25

B3.4    Six meetings were also held with physicians across the country, and a website was maintained for physician-only comment from February to the end of May. The report of the consultation stated that the meetings and on-line responses were characterized by "diametrically opposed views" on euthanasia and assisted suicide.26  The majority of CMA members participating opposed physician involvement in the procedures,27 (71.5% of an on-line poll28), while "[a] significant minority" (25.8% of poll respondents28) believed that the policy "should at least be reviewed if not revised to support some form of physician-assisted dying."27.

B3.5   A majority of about 66% in the recent Irish abortion referendum has been described as "overwhelming,"29 a "landslide"30 and "decisive."31 By this standard, a larger-than-overwhelming majority of Canadian physicians opposed a change in CMA policy.  No one has suggested that the referendum result left the Irish government doubtful about its mandate.  However, the CMA consultation report - finalized at about the time the Board seems to have launched its plan to change CMA policy (B2.6, B5.1)- stated that the Association "was not given a clear cut mandate on future activity dealing with the sensitive area of euthanasia and physician-assisted dying."27 

CMA announces plan to intervene in Carter v. Canada (April, 2014)

B3.6    The month before the town hall meetings ended, CMA President Dr. Louis Hugo Francescutti and Dr. Jeff Blackmer announced that the Association would intervene in the Supreme Court of Canada in the Carter case.

. . . the CMA will be seeking intervener status before the Court, not to offer a polarizing "pro" or "con" view on an already divisive issue - our policy is clear and speaks for itself - but to share a narrative of insights on the physician's perspective. The goal would be to provide the Court with a deeper understanding and appreciation of the findings from the CMA's dialogue on end-of-life care, the spectrum of options and the current CMA policy perspective. We would also highlight the challenges posed to physicians' understanding of their traditional roles if the Court were to change the law.32

B3.7    Dr. Blackmer and Francescutti also claimed that the 2013 Annual General Council rejected the motion calling for national consultation "to regard medical aid in dying as appropriate care" because  "medical aid in dying" had never, until that point, been properly defined."  This substantially understated the significant differences that were evident to those observing the proceedings (B1.3-4). They did, however, make the following observations:

One person's right is another person's obligation, and sometimes great burden. And in this case, a patient's right to assisted dying becomes the physician's obligation to take that patient's life.

We have heard from many of our members that this prospect makes them not only uncomfortable but downright terrified. . .

. . .only a tiny minority of patients at the end of their lives request access to medical aid in dying. Until we can provide access to palliative care to all Canadians who need it, this is where the focus of our attention should remain . . . 32

B3.8    Given the concern expressed by Dr. Blackmer and Dr. Francescutti in April, 2014 about imposing an obligation to kill upon physicians, and the ramifications of doing so, one would expect this to have been a constant concern of the CMA Board of Directors with respect to the legalization of euthanasia and assisted suicide.  However, it does not seem to have been considered again. The failure to attend to this issue left most physicians unaware of its significance, and of the significance of the policy direction taken by the CMA Board of Directors from June, 2014.

B4.    CMA applies for intervener status in Carter v. Canada (June, 2014)

B4.1    In June, 2014, the CMA applied for leave to intervene at the Supreme Court of Canada in Carter v. Canada. The application was supported by an affidavit by Dr. Chris Simpson, president-elect.12 Quoting then CMA policy, he emphasized deep divisions of opinion among physicians, other health professionals, academics, interest groups, the media, legislators and the judiciary (para. 23).

B4.2    With reference to physicians, Dr. Simpson observed that a 2011 survey indicated that only 16% of Canadian physicians would provide euthanasia or assisted suicide, while 44% would refuse (para. 33). He noted that it was clear that the public was divided on the issue (para. 38, 39d).

B4.3    While drawing attention to the strong opposition of Quebec palliative care physicians to the province's proposed euthanasia law, as well as doubts expressed by some family physicians, Dr. Simpson nonetheless noted that physicians had "worked through and continue to assess the appropriate ethical perspectives" of euthanasia, and that both the Quebec Medical Association and Collège des médecins du Québec supported the legislation (para. 44).

B4.4    In describing then current CMA policy, Dr. Simpson drew the court's attention to  worries about a "slippery slope." However, he made special note that a Royal Society panel of experts had concluded that there was "no basis to these arguments." (para. 29)

B4.5    The affidavit acknowledged but downplayed then CMA policy against physician participation in euthanasia and assisted suicide, stating that it was "not a certainty nor is it perpetually frozen in time" (para. 28):

. . .while the policy states that the CMA is opposed to physician-assisted death "Canadian physicians should not participate in euthanasia or assisted suicide"), it frames it as a societal issue and envisages the possibility of change, as informed by a dialogue between physicians, patients and the legislatures. . .(para. 25)

B4.6    Consistent with statements made two months earlier by Dr. Blackmer and Dr. Francescutti (B3.6-7), Dr. Simpson stated that a CMA intervention would not offer "a black and white perspective" (para. 57), which "would be a disservice to the issues and the Court," since, he wrote, "Such a perspective does not exist," adding, "The CMA's current policy is not static and can change (para. 58, emphasis added).

B4.7    The affidavit also envisaged a key role for physicians should the law be changed:

If the law changes, physicians will be key players in any assisted death regime. They will play two critical roles. First, they will have to determine whether an individual patient's wish to be assisted in dying meets the threshold. Second, they will have to prescribe the agents leading to death, and to provide the patient with bedside care through the process leading to death. Plainly, assisted death, if sanctioned by law, has no prospect of implementation unless physicians in sufficient numbers across the country are persuaded that the sanctioned regime is ethical, practical, and in accordance with existing medical standards. . . (para. 56)

B4.8    Nothing in the affidavit suggested that the CMA would oppose legalization of physician assisted suicide and euthanasia, and it did not state that the CMA would support it.  However, it clearly implied that, should the court legalize the procedures, the Association would likely change its policy, and that physicians would be "key players" whose cooperation would be needed to make assisted suicide and euthanasia available. 

B5.    CMA Board resolution on euthanasia and assisted suicide (June-July, 2014)

B5.1    During 2014 there was continual discussion of physician assisted suicide and euthanasia by the CMA Board of Directors. CMA Board member Dr. Ewan Affleck proposed that the Board sponsor a resolution at the August Annual General Council. What he later told the Northern News Service suggests that this probably occurred in June.

"CMA applied for intervener status with the Supreme Court," said Affleck.

"That was some of the urgency in developing our position, we knew the Supreme Court was moving forward and we wished to have a clear position."33

B5.2    At that point, the CMA's position was clear; the Association opposed physician participation in euthanasia and assisted suicide. If Dr. Affleck and others on the Board included in his "we" wanted a "clear position," they must have wanted something different.  Dr. Affleck, who described himself as "passionate about the issue of end-of-life choices" because of personal experiences, explained what happened.

"We had been discussing this issue at length at the level of the board for a good long while because it is an important issue," said Affleck.

"We had a lot of debates and then I sat down and wrote a proposal for a motion and then took it back to the board as a board member and it was quite uniformly well accepted."33

B5.3    The resolution proposed by Dr. Affleck stated:

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.34 

B5.4    The Board thus agreed that the CMA should support physicians who participate in assisted suicide and euthanasia as well as those who refuse to do so, but this could hardly be considered a "clear position" when read in conjunction with existing CMA policy.  The Board's support for the resolution conflicted with CMA policy against physician participation. 

B5.5    However, the resolution had to be accompanied by a supporting rationale, which, according to CMA rules, is the means by which the General Council gives policy guidance and direction to the Board.35 Thus, as the sponsor of the resolution, the Board wrote - or at least approved in advance - the kind of guidance it wanted to use to resolve the apparent conflict.

B5.6    The rationale for the motion noted the "polarizing nature" of the subject reflected in divisions among the public and CMA members. It argued that unanimity among Association members seemed unlikely, and that those supporting and those opposing assisted suicide and euthanasia could marshal "just moral and ethical arguments" to support their respective positions.  While the wording of the motion seemed to suggest the adoption of a laissez-faire position concerning participation by individual physicians, the rationale went much further, asserting that the current prohibition "may adversely impact patients with terminal conditions and unremitting suffering from obtaining compassionate care."

Implicit in CMA's mission statement, helping physicians care for patients is the centrality of the patient in the mandate of Canadian physicians.

CMA's current policy on euthanasia and assisted suicide suggests that Canadian physicians should not participate in assisted death. This poses a dilemma for CMA, as it could be suggested that a prohibition on physician-assisted death bars physicians from providing a service desired by some patients to alleviate pain and suffering.34

B5.7    The CMA Code of Ethics, it was argued, "implies the paramount importance of honouring the will of the patient in determining the course of therapy they receive, including end-of-life therapy."

Given that evidence supports that there are competent Canadians with terminal illness who seek the services of physicians to assist them with dying, how then can Canadian physicians justify withholding a service against the will of a patient?34

B5.8    Rhetorical questions are meant to elicit expected answers. The answer obviously expected by the Board of Directors in this case was that the CMA could not justify refusing assisted suicide and euthanasia to competent patients who are terminally ill and want to kill themselves or have a physician kill them.

B5.9    This strongly suggests that, at least by June, 2014, the Directors had come to believe that CMA should formally approve physician participation in assisted suicide and euthanasia, in order, as Dr. Simpson said, accommodate "everybody's legitimate concerns and aspirations."(B2.4)  However, they did not put this to the General Council. Instead, the resolution they sponsored was ostensibly limited to the exercise of freedom of conscience, supported by an appeal to adopt a policy of neutrality:

Rather than choosing to prohibit or approve physician-assisted death, CMA will best serve Canadians seeking quality health care by highlighting that physicians may follow their conscience when deciding whether to participate within the bounds of existing law.34 (Emphasis added)

B5.10    Consistent with the conclusion noted in B5.8, the appeal to neutrality included the decidedly non-neutral view that physician assisted suicide and euthanasia could be considered "quality health care" in at least some circumstances. 

B6.    CMA General Council (August, 2014)

Briefing materials

B6.1    Briefing materials were prepared for the CMA board of directors and delegates to the Annual General Council. The materials included relevant resolutions passed at the 2013 Annual General Council, an outline of the town hall meetings held in 2014 and a backgrounder for the strategy session on Care at the End of Life (Appendix 2).36 The 2013 resolution that physicians had a right to conscientious objection was listed with eight other resolutions passed at the same time (p. A2-1). It was not included in the summary of CMA policy that followed.

B6.2    Key elements of the then current CMA policy on euthanasia and assisted suicide were partially reproduced, the redaction of one of which is noteworthy:

For the medical profession to [*support such a change and subsequently*] . . . participate in these practices, a fundamental reconsideration of traditional medical ethics would be required." (p. A2-2) [*Replaced by elipsis*]

If even supporting legalization of euthanasia and assisted suicide would require "a fundamental reconsideration of traditional medical ethics," one would expect that a briefing note to delegates would have directed their attention to that point rather than away from it, especially since the Board planned to ask them to support a change in policy conducive to legalization.

B6.3    The backgrounder reported that the CMA had applied for leave to intervene in the Carter case. It posed five strategic questions to focus the discussion. Three referred to euthanasia and assisted suicide; the last presumed a "need for euthanasia and assisted suicide." 

3) Should the CMA revise its current policy on euthanasia and assisted suicide?

4) If the law is changed in Canada to make euthanasia or assisted suicide legal how should the medical profession respond?

5) If access to palliative care services was universal, would it eliminate the need for euthanasia and assisted suicide?(p. A2-4)[Emphasis added]

B6.4    Included in the backgrounder was "Schedule 'A'", which outlined patient eligibility, process, and physician obligations respecting euthanasia/assisted suicide in jurisdictions where the preocedures are legal.  It stated that objecting physicians in Washington, Vermont, Oregon, Belgium, and Luxembourg "have a duty to transfer patient care to another physician who can fulfil the request." (p. A2-7)This was erroneous and misleading: erroneous, because the law in Vermont said nothing of the sort;37 misleading, because it could have been taken to mean that the objecting physician has a duty to initiate the transfer to a willing colleague. This was not required in any of the jurisdictions listed. All that is required is that objecting physicians transfer the patient's medical records as requested by the patient.38,39,40,41

Adoption of resolution on freedom of conscience (19 August, 2014)

B6.5    The resolution proposed by Dr. Affleck was seconded by outgoing CMA President Dr. Francescutti:

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. (DM 5-6)34

B6.6    It was argued on the floor that "current policy on euthanasia and physician-assisted suicide does not sufficiently reflect the broad spectrum of opinions on the matter held by Canadian physicians," since it prohibited physician participation in euthanasia and assisted suicide. In contrast, the most recent survey of Canadian physicians found almost 45% of physicians supported legalizing assisted suicide, about 36% favoured legalization of euthanasia, and almost 27% were willing to be involved with providing assisted suicide if the acts were legalized.42

B6.7    Of course, the survey results also revealed that 55% of physicians surveyed were against legalizing assisted suicide, 64% against legalizing euthanasia, and 73% were unwilling to be involved with assisted suicide, but it appears that those citing the statistics preferred to accentuate the positive rather than the negative. It also appears that the numbers of those willing or unwilling to provide euthanasia, if available, were not reported.  Again, evaluating the returns using the standard applied to the Irish abortion referendum, an overwhelming majority of physicians remained opposed to euthanasia and assisted suicide.

B6.8    Nonetheless, this approach offered some strategic advantage in view of the possibility that the Supreme Court might strike down the law, especially if the Association maintained its policy against physician participation in the procedures. In that case, the resolution would have left willing physicians free to apply the law without putting them in conflict with CMA policy. It offered the Association as a whole and individual members a way to agree to disagree, at least until the policy could be revisited if the law changed.

B6.9    On the face of it, the 2014 resolution did no more than affirm the 2013 resolution supporting physicians who refuse to participate in euthanasia, while adding the promise of support for physicians wanting to do so. In the event that the procedures were legalized, the resolution appeared to commit the CMA to impartially defend both groups - nothing more. Dr. Blackmer later explained the resolution as "the other side" of conscientious objection: "almost conscientious permission."43 Even delegates opposed to euthanasia and assisted suicide would probably have been swayed by such considerations. On the other hand, voting against the resolution would have been a vote against physician freedom of conscience that would arguably have nullified the 2013 resolution in support of a right to conscientious objection. In view of all of this, it is not surprising that the outcome of the vote was 91% in favour of the resolution.

B6.10    Professor Margaret Somerville, initially satisfied with the resolution, later changed her mind:

The CMA's motion, as worded and subsequently interpreted, placed its voting members in an untenable situation. Their only options were to vote either for protection of conscience and for euthanasia or against both. The possibility of voting for freedom of conscience and against euthanasia, as I believe most would, was eliminated.44

B6.11    Unnoticed at the time was the fact that the CMA's promise to support physicians providing legal euthanasia and assisted suicide was unlimited.  It was not conditional upon patients having to meet certain criteria to qualify, such as decision-making capacity or having a terminal illness.

B6.12    A CMA report of the meeting noted that a "straw vote" showed 70% of delegates believed that the CMA should revise its policy on euthanasia and assisted suicide, and "78% felt universal access to palliative care services would not eliminate the need for euthanasia and physician-assisted death."42  These votes were obviously in response to "strategic questions" 3 and 5 posed to the delegates in their briefing material (B6.3 )

B6.13    It is difficult to verify the validity of the "straw votes" as a reflection of the views of the entire CMA membership because of the contrary views expressed during the earlier extensive physician consultations (B3.4) and the bias evident in the information supplied to delegates (B6.2-3). Especially important, one cannot determine whether the desire for policy change expressed in response to Strategic Question 3 indicated approval of euthanasia and assisted suicide or a preference for a policy of neutrality - as urged by those supporting the Board resolution.

B7.    CMA officials comment (August-September, 2014)

B7.1    Two days after the vote, the CMA Board of Directors confirmed the resolution on freedom of conscience in relation to assisted suicide and euthanasia.45 The confirmation of the resolution left the prohibition against physician participation untouched.  Some commentators - Professor Somerville among them - initially believed that the resolution was an affirmation of physician freedom of conscience rather than an expression of support for physician participation in assisted suicide and euthanasia.  In fact, that is exactly what Dr. Jeff Blackmer told The Catholic Register.

". . .It (the new policy) doesn't say we favour a change in the law," said Dr. Jeff Blackmer, the CMA's executive director of ethics.

The CMA stance opposing euthanasia remains in place.

"Our position is still that Canadian physicians should not participate in euthanasia or assisted suicide," Blackmer said.46

B7.2    Dr. Blackmer maintained the distinction in another interview:

"One of the options would have been to say our policy is unchanged. We could say ethics trumps the law."

He noted that in Belgium, where euthanasia was legalized in 2002, the Belgian Medical Association continues to discourage physician participation in the practice.43

B7.3    CMA President Dr. Chris Simpson also took this approach during an interview in the first week of September.

Simpson said he is in full agreement with Affleck - that the CMA not taking a stance one way or the other on doctor-assisted deaths by passing the motion, but only allowing Canadian physicians to follow their conscience.

"What we are doing is protecting doctors and allowing them to follow their conscience on this issue," he said.

Simpson said if a doctor does not believe in helping a patient end their life, they shouldn't have to and shouldn't be forced by law to do so.47

B7.4    With respect to euthanasia and assisted suicide, he noted that some commentator had described the resolution as "a softening of the CMA's stance on doctor-assisted death."

"I prefer to think of it as a tightening of definitions when it comes to doctors and their role around end of life care. This is a very complex, controversial issue for doctors and the public at large."

"The CMA had to be careful in its use of terminology in finalizing Affleck's motion."47

B7.5    This response is noteworthy for three reasons.  First: that Dr. Simpson preferred to describe what happened as "a tightening of definitions" did not amount to a denial that softening had occurred or was occurring. Second: the term "medical aid in dying" - the only specialized term used in the text of Dr. Affleck's motion - had been defined in CMA policy six months before he brought the motion to the Board. His motion involved no "tightening of definitions."  Third: what Dr. Simpson described as being "careful in its use of terminology in finalizing Affleck's motion" must have been a reference to the care taken in drafting the supporting rationale, since the text of the motion introduced no new terminology and changed no definitions.

B7.6    Comments by Dr. Simpson in an earlier interview provide more insight into his thinking. He expressed sympathy for physicians concerned by the prospect that euthanasia and assisted suicide might be legalized.

Most doctors aren't opposed to the notion of patients being able to choose how and when they die, "but they're uncomfortable with the role they're being asked to play," Simpson said.

"That discomfort comes a lot from this uncertainty: Am I going to be compelled to do it if I don't want to do it? Am I going to be asked to make decisions that I'm really uncomfortable with?"48

B7.7    However, referring to some kinds of cancer and diseases that cause "uncontrollable pain" and suffering that cannot be alleviated by even the best palliative care, he said, "[W]e would all agree that if we were in that situation we would be looking for potentially other solutions"48 - an obvious if euphemistic reference to death by lethal injection or assisted suicide.

B7.8    Dr. Simpson's claim that "we would all agree" to such solutions contradicted the CMA's repeated acknowledgement that there was no agreement about the acceptability of euthanasia and assisted suicide. However, it was consistent with the views he expressed in the application to intervene in Carter, as well as the arguments in favour of euthanasia and assisted suicide offered by the CMA Board in supporting Dr. Affleck's motion.

B7.9    More significant was his response to the suggestion that someone other than physicians should provide euthanasia and assisted suicide. He said, "I don't think we want to be reneging on our responsibilities to serve our patients."48 This could be understood to support the view that, in some circumstances, physicians have a legal or professional obligation to kill a patient or to help a patient kill himself.

B7.10    As outgoing CMA President, Board member and seconder of Dr. Affleck's motion, Dr. Louis Francescutti was well placed to anticipate what the CMA Board would do. The conclusion  that CMA Directors supported physician participation in euthanasia and assisted suicide (B5.8) is supported by a comment he made just after Dr. Affleck's motion was accepted by the General Council. He noted that the CMA's official policy had not changed, but "it's only a matter of time."49

B7.11    In November, 2014, looking back on the adoption of the resolution, Sandra Martin headlined it as "an overwhelming change."  Dr. Simpson, interviewed for the column, called it "a sea change"8 - not just a "tightening of definitions."47

B8.    CMA intervention in Carter v. Canada

B8.1    The CMA factum for its intervention in Carter was filed a week after the end of the Annual General Council.50 Counsel for the Association Harry Underwood made an oral submission during the Supreme Court of Canada hearing in mid-October, 2014, making clear that the Association was not arguing for or against the legalization of assisted suicide or euthanasia.51

B8.2    He explained that physicians had been historically barred from providing euthanasia and assisted suicide because of ethical considerations, notably a physician's obligation "to secure patient well-being."

But the concept of patient well-being is capable of an interpretation which encompasses the patient's right to choose death, where the alternative is certain suffering, a choice which is also supported by the concept of patient autonomy. Thus, going back to first principles, the two approaches are each possible.52

B8.3    He went on to say that the profession was divided between these approaches, "each defensible on the basis of established medical ethical considerations and compassion."  In light of this, he said, referring to the resolution passed at the General Council in August,  the Association had decided that physicians "who can square their participation with their own consciences" could provide euthanasia and assisted suicide, "without overriding the consciences" of objecting physicians.  He told the Court that CMA policy would be changed to reflect this.53

B8.4    This reinforced statements in the CMA factum:

The CMA's policies are not meant to mandate a standard of care for members or to override an individual physician's conscience. (para. 9)

It is acknowledged that just moral and ethical arguments form the basis of arguments that both support and deny assisted death. The CMA accepts that, in the face of such diverse opinion, based on individuals' consciences, it would not be appropriate for it to seek to impose or advocate for a single standard for the medical profession. (para. 16)

B8.5    "As long as such practices remain illegal," the factum stated, "the CMA believes that physicians should not participate in medical aid in dying,"  but, should the law change, "the CMA would support its members who elect to follow their conscience."(para. 3) 

B8.6    This promise was was unconditional. Consistent with the resolution sponsored by the Board in August, the factum and oral submission conveyed the message that the Association would support physicians who decided to participate in legal euthanasia or assisted suicide, no matter how broadly the Court or legislatures might cast the rules governing the procedures.  The CMA offered no suggestions concerning criteria for eligibility should the law be changed, but did tell the Court that it seemed wrong to deny assisted suicide and euthanasia to "grievously ill" (not terminally ill) patients simply because palliative care is unavailable (para. 20).

B8.7    In the last half of his presentation, Mr. Underwood addressed practical concerns raised by the legalization of physician assisted suicide and euthanasia. Notably absent from his list of concerns was the fact that, as late as August, the great majority of physicians were opposed to the procedures.  However, he had earlier insisted that the law should protect both objecting and non-objecting physicians,54 a point also made in the factum.

[N]o physician should be compelled to participate in or provide medical aid in dying to a patient, either at all, because the physician conscientiously objects . . . or in individual cases, in which the physician makes a clinical assessment that the patient's decision is contrary to the patient's best interests.  Notably, no jurisdiction that has legalized medical aid in dying compels physician participation.  (para. 27)

B8.8    The distinction made in the factum (but not in the oral submission) between participation and provision is important.  In this context, "participation" is a broader term that would seem to include referral.  The CMA was well aware of longstanding and increasingly strident demands that physicians be compelled to refer for morally contested services like abortion.55 The Association was also well aware that Jocelyn Downie, one of the leading advocates for compulsory referral for abortion, had joined other experts in recommending mandatory referral for euthanasia and assisted suicide (III.4.10);the CMA President had cited their report56 in his affidavit (B4.4).  Downie was, in fact, live-tweeting from the Supreme Court during the hearing.57

B8.9    However, rather than directing the court's attention to this problem, the CMA factum suggested vaguely that the Court could "indicate that a practicable legislative regime for medical aid in dying must legally protect those physicians who choose to provide this new intervention to their patients, as well as those who do not." (para. 28)  Worse, it advised the Court that, if a physician declines to participate, "every jurisdiction that has legalized medical aid in dying has adopted a process for eligible patients to be transferred to a participating physician."(para. 27) Here the factum cited the erroneous and misleading "Schedule A" prepared for the August AGM, which could be understood to require objecting physicians to collaborate in delivering the services(B6.4).

B8.10   Having watched the hearing, Udo Schuklenk, one of Downie's fellow experts, criticized the joint intervention by the Protection of Conscience Project, Faith and Freedom Alliance and Catholic Civil Rights League because it argued against forcing objecting physicians to refer for euthanasia and assisted suicide. He did not mention the CMA submission.57

B9.    CMA Board approves euthanasia and assisted suicide (December, 2014)

Policy against euthanasia and assisted suicide reversed

B9.1    In December, 2014, while the country awaited the decision of the Supreme Court in Carter, the CMA Board of Directors approved a change in Association policy on euthanasia and assisted suicide, renaming it "Euthanasia and Assisted Death."58  When the revised policy was published, the CMA issued a statement that it "and other changes to the CMA's approach to end-of-life care issues . . . codify resolutions adopted by delegates at the association's annual meeting in August."59

B9.2    This was misleading. The revised policy did codify the resolution that urged the Association to support for physicians who "follow their conscience." Recall, however, that the resolution was not presented as an approval of euthanasia and assisted suicide, but as a position of neutrality concerning physician participation in the practices, a distinction emphasized by both the CMA Director of Ethics and the CMA President shortly after the General Council (B7).

B9.3    Instead, the revised policy formally approved physician assisted suicide and euthanasia, subject to legal constraints, classifying both practices as "end of life care."

There are rare occasions where patients have such a degree of suffering, even with access to palliative and end of life care, that they request medical aid in dying. In such a case, and within legal constraints, medical aid in dying may be appropriate. The CMA supports patients' access to the full spectrum of end of life care that is legal in Canada.58

B9.4    Once more, this affirmation was unconditional.  The CMA Board of Directors promised to ensure patient access to "the full spectrum" of end-of-life care, including euthanasia and assisted suicide, no matter what the criteria might be. The policy did not exclude minors, the incompetent or the mentally ill, nor did it limit euthanasia and assisted suicide to the terminally ill or those with uncontrollable pain. It referred only to "patients" and "the suffering of persons with incurable diseases."  Thus, the Directors committed the Association to support euthanasia and assisted suicide not only for competent adults, but for any patient group and for any reason approved by the courts or legislatures.

 B9.5    As noted above (B3.1), the previous policy included a grave warning: For the medical profession to support such a change and subsequently participate in these practices, a fundamental reconsideration of traditional medical ethics would be required. Not having attempted such an exercise, the Board simply deleted the statement.  It also deleted a number of cautionary statements and references to concerns found in the earlier version.

B9.6    Delegates had neither been presented with nor had they approved a resolution to this effect at the Annual General Council. However, by approving the resolution supporting the right of physicians to act according to their conscience, the delegates implicitly approved the accompanying rationale that, having been carefully drafted by the Directors, could be understood to authorize the changes.  In bringing about the change of policy in this manner, the CMA Board of Directors may have been following long-established practices acceptable to the members of the Association. They might, in addition, cite the "straw votes" at the General Council and the absence of general protest as evidence of support for their reversal of CMA policy.

B10.    Effects of the policy change

A  blank cheque for the Supreme Court

B10.1    The CMA Board of Directors decided to lead society and shape the debate and law on assisted suicide and euthanasia (B2).  They convinced delegates at the General Council to approve an ostensibly neutral policy that favoured provision of the procedures, which was widely seen as an overwhelming change (B7.11).

B10.2    In its application to intervene in Carter, the Board assured the Supreme Court of Canada that CMA policy against euthanasia and assisted suicide was "not a certainty" nor "perpetually frozen in time," that it was "not static and can change," (B4.5-6) and reaffirmed this in its intervention (B8.3, B8.5).  It suggested no limits to circumstances under which euthanasia and assisted suicide might be provided, but did tell the Court  that it seemed wrong to refuse to provide the services simply because palliative care was unavailable (B8.6).  Finally, it implied that the Court could count on the cooperation of the Association, no matter what their ruling might be (B4.7, B8.5, B8.6).

B10.3    Finally, the Board reversed CMA policy against physician participation, deleting statements of concern that might have impeded legalization, and unconditionally approved euthanasia and assisted suicide as legitimate forms of medical treatment that should be provided "without undue delay"to persons suffering from incurable diseases - should the law change.  It published the new policy while the Court was considering its ruling in Carter, probably with a reasonable expectation that the Court would consider it in its decision - which it did.

B10.4    By doing all of this, the CMA Board of Directors effectively wrote a blank cheque for the judges of the Supreme Court of Canada to legalize euthanasia and physician assisted suicide on any terms acceptable to the judges, assured that the Association would accept and cooperate with legalization on whatever terms the Court set.

A professional obligation to kill

B10.5    By formally approving physician assisted suicide and euthanasia rather than adopting a neutral position, and by committing the CMA to support patients's access to physician assisted suicide and euthanasia under conditions set by law, the Board implicitly agreed that, in some circumstances, physicians have a professional obligation to kill patients or to help them kill themselves (B7.9). 

B10.6    Further, by classifying euthanasia and assisted suicide as "end of life care," the Board made participation in euthanasia and assisted suicide normative for the medical profession. This effectively mandated a standard of care for its members, something the Association had told the Supreme Court the CMA did not mean to do (B8.4). 

B10.7    The new policy also imposed a single ethical standard upon the entire profession, something the CMA had told the Supreme Court would be inappropriate (B8.4).  Once legalized, euthanasia and assisted suicided became therapeutic medical services.60,61 Refusing the services in the circumstances set out by law became an exception to professional obligations requiring justification or excuse.  This is why, since Carter, the debate in Canada has been largely about  whether or under what circumstances physicians and institutions should be allowed to refuse to provide or faciliate homicide and suicide. 

A limit on refusing to kill

B10.8    It also explains an important caveat the Directors added to the 2014 policy's reference to freedom of conscience:

A physician should not be compelled to participate in medical aid in dying should it be become legalized. However, there should be no undue delay in the provision of end of life care, including medical aid in dying.58

B10.9   Notice that, apart from mere legality, the policy placed no limits on criteria for euthanasia and assisted suicide, and no limits on what non-objecting physicians might agree to do, but implied that freedom of conscience for objecting physicians could be limited in order to ensure timely patient access to the services.

Other foreseeable unforeseen consequences

B10.10    All of the preceding effects of changing CMA policy against euthanasia and assisted suicide might have been foreseen by the CMA Board had the Directors not been so intent upon changing it within the time frame imposed by the Carter case.  Their  lack of foresight began to become evident on the eve of Supreme Court decision in Carter. 

B10.11    Just before the ruling, CMA President Dr. Chris Simpson said there was "a lot of moral angst" among physicians14 about what conditions or kinds of illness would justify the procedures13,17 what kind of suffering - physical, psychological or both - should make someone eligible,17 and how terminal illness should be defined.13 Among his other questions: should assisted suicide and euthanasia be offered only to competent adults, or also to the mentally ill, or clinically depressed17 or those with dementia?13 Should substitute decision makers be able to ask for euthanasia or assisted suicide on behalf of someone unable to do so?13,14,17 

B10.12    Just after the ruling, Dr. Simpson said that he had not anticipated that the judges would permit euthanasia and assisted suicide for any "grievous and irremediable medical condition" rather than terminal illness.60  Dr. Blackmer acknowledged that physicians who were willing to provide euthanasia in cases of terminal illness might be less willing to do so for suffering caused by other medical conditions.62 

B10.13    A few days later, Dr. Blackmer expressed concern about the eligibility criteria set by the Court.  Blindess is "irremediable," he noted, and said that the Carter decision would probably allow euthanasia and assisted suicide for chronic depression and  spinal cord injuries.

My feeling is that there would be much more support for a tighter framework in terms of requiring that the patient be terminal. This is not to minimize in any way the suffering of people who do not have a terminal illness, it is just that for a lot of doctors, this opens too many doors and generates too many questions. . . My conversations with doctors to date indicate more of a comfort level with tight parameters.63

However, he believed that the CMA "might have very little ability" to influence how the Carter criteria would be developed63 - something the CMA Board might usefully have considered when planning their intervention and before embarking upon their plan to change CMA policy.

B10.14    Dr. Blackmer also complained that the term "grievous" is entirely subjective and "is not a technical medical term."63  Expanding upon this a few months later, he referred to "some angst and discomfort" among physicians about the breadth of the Carter criteria.

"I've now given dozens or hundreds of presentations on this and every time I speak about it and I ask doctors, ‘Look, have any of you ever told a patient that you're really sorry but their condition is grievous?' Of course, no one ever has," Blackmer said. "No doctor in Canadian history, I don't think, has ever told a patient that they're suffering from a ‘grievous" condition. So none of us know what that means."64

B10.15    All of these complaints are astonishing.  Neither the CMA's factum nor its oral submission at the Supreme Court of Canada suggested that assisted suicide or euthanasia should be limited to patients with terminal illnesses, nor, in its intervention, did the CMA suggest any criteria whatever as relevant for the purpose of determining eligibility for the procedures.  The revised policy, Euthanasia and Physician Assisted Death, did not exclude minors, the incompetent or the mentally ill as candidates for assisted suicide or euthanasia, nor did it limit its application to the terminally ill or those with uncontrollable pain. It referred directly only to "patients" and "the suffering of persons with incurable diseases." 

B10.16    The question put to the courts by the plaintiffs from the very beginning in 2011 was never about terminal illness, but about "grievous and irremediable illness."64 The term was defined in the trial court ruling, where it was used extensively,66 and it appeared again in the first sentence of the appellants' factum filed in the Supreme Court of Canada.67 Finally, the CMA factum, "reviewed and approved by several senior CMA elected officials,"44 stated that it seemed wrong to deny assisted suicide and euthanasia to "grievously ill" patients just because palliative care is unavailable (emphasis added)68 - yet Dr. Blackmer later claimed that "none of us know what that means."(B10.14)

B10.17    In sum, all of the concerns voiced by Dr. Simpson and Dr. Blackmer after the Carter ruling existed when the CMA intervened in the case, but the CMA Board did not raise them. Instead, it worked steadily to remove or minimize obstacles that might have impeded legalization of physician assisted suicide and euthanasia. The legal criteria set for euthanasia and physician assisted suicide by the Supreme Court of Canada were actually more restrictive than anything the CMA had proposed in its intervention or included in its new policy. 

B10.18    Arguably, the CMA Board contributed substantially to the legalization of physician suicide and euthanasia on the broad terms set by the Court, and so were themselves, in large measure, responsible for the  "angst and discomfort" and profound unease of Canadian physicians following the ruling. 

Physician freedom of conscience

B10.19    The CMA Board, having concentrated on shaping the debate and changing CMA policy, was quite unprepared mount a cogent, articulate and persuasive defence of physician freedom of conscience, particularly the burning issue of referral (B8.8). For example, in March, 2015 the Board insisted that "no physician or other health care provider should be forced to take part in any aspect of the assisted dying process against their wishes,"69 including referral.70  Two months later, the Board pulled back, deleting reference to other health care providers and affirming only that no one should be compelled to provide euthanasia and assisted suicide.71  By August, the CMA President was saying that physicians unwilling to perform the procedures "should refer patients to someone who would be willing and able to help make it happen."72  It is remarkable that, in the midst of the confusion reflected by these shifting statements, the CMA offered to instruct the WMA about "these complex issues" (II.1.4).

B11.    Postscript

B11.1    The CMA later produced a strong defence of physician freedom of conscience in relation to referral for euthanasia and assisted suicide.73 Current CMA policy on euthanasia and assisted suicide has been improved in this respect, more carefully articulating the issues of access to services and protection of freedom of conscience (or moral integrity).  In particular, it states that objecting physicians "are not required to provide it, or to otherwise participate in it, or to refer the patient to a physician or a medical administrator who will provide assistance in dying to the patient."  It also appears to put the onus on the state "to implement an easily accessible mechanism to which patients can have direct access" to obtain the services so that physicians can adhere to their moral commitments.61 

B11.2    These changes deserve recognition and thanks, but they were late in coming.  The submission on referral came only in January, 2016, almost a year after the Carter ruling, and more than four years after mandatory referral for euthanasia and assisted suicide had been recommended by a panel of experts (B4.4, B8.8).  The articulation of physician freedom of conscience found in current policy on the procedures dates from May,2017 - more than three years after Carter. 

B11.3    Better late than never, to be sure, but, by then, objecting physicians were on the defensive in an environment made more treacherous and, at times,  more hostile by legalization of physician assisted suicide and euthanasia.

---

Notes

1.    Carter v. Canada (Attorney General) 2012 BCSC 886 [Internet]. The Courts of British Columbia [Cited 2018 Sep 30]. [Carter-BCSC].

2.    Eggertson L. CMA delegates defer call for national discussion of medically assisted death. CMAJ [Internet]. 2013 Sep 17 [Cited 2018 Sep 30]; 185 (13) E623-624.

3.    Picard A. Fears prevail during CMA policy debate on euthanasia.  [Internet]. 2014 Aug 21 [Cited 2018 Sep 30].

4.    Canadian Medical Association. Resolutions Adopted,146th Annual Meeting of the Canadian Medical Association [Internet]. [Cited 2018 Sep 30].

5.    Carter v. Canada (Attorney General) 2013 BCCA 435  The Courts of British Columbia [Cited 2018 Sep 30]. [Carter-BCCA].

6.    Carter-BCCA, para. 248.

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

8.    Martin S. The story behind the CMA's overwhelming change on assisted death. The Globe and Mail [Internet] 2014 Nov 6 [Cited 2018 Sep 30].

9.    Geddes J.  Interview: The CMA's president on assisted dying: Dr. Chris Simpson calls for a process to set new rules.  Macleans [Internet]. 2015 Feb 6 [Cited 2018 Sep 30]. For the full interview, see Geddes-Simpson Interview Transcript [Internet]. Protection of Conscience Project; 2015 Jun 15 [Cited 2018 Sep 30] [Geddes Full Transcript], lines 16-22.  [Geddes Full Transcript], lines 16-22.

10.    Dr. Chris Simpson (CMA President): "I was not surprised, we were not surprised. Perhaps the unanimous decision was a little bit of a surprise. But, at the CMA, we've been, we've been preparing for this eventuality for the last year and a half or two years."  Geddes Full Transcript, lines 4-7.

11.    Dr. Blackmer: "I think we're looking at the possibility that the court will refer this back to the lawmakers . . . They could suggest some framework from the bench that we might want to be in a position to comment on fairly quickly. . . We're preparing for all eventualities. . ." Kirkey S. Canadian doctors preparing for 'all eventualities' in case top court strikes down ban on assisted suicide. National Post [Internet]. 2014 Dec 21 [Cited 2018 Sep 30].

12.    In the Supreme Court of Canada (On Appeal from the Court of Appeal of British Columbia) Affidavit of Dr. Chris Simpson, Motion for Leave to Intervene by the Canadian Medical Association [Internet]. Canadian Medical Association; 2014 Jun 5 [Cited 2018 Sep 30]. [Simpson Affidavit] para. 56.

13.    "Should the justices rule the law on assisted death and euthanasia is unconstitutional and needs amendment, 'we feel pretty strongly that we want to be at the table' to help draft a new law and guidelines for physicians and patients, CMA president Dr. Chris Simpson said Thursday."  Ubelacker S.  Doctors ready for Supreme Court decision on assisted suicide.  CTV News [Internet]. 2015 Feb 5 [Cited 2018 Sep 30].

14.    Dr. Chris Simpson (CMA President): "We'll be very interested in having a lot of input into the operational details."  Grant K.  Canadian doctors drafting new rules in case doors open to assisted suicide.  The Globe and Mail [Internet]. 2015 Feb 5 [Cited 2018 Sep 30].

15.     "President Dr. Chris Simpson said the CMA believes it must play a key role in helping to draft the legislation that is needed to make physician-assisted dying available."  Branswell H. Many Cdn MD's unsure about assisted death, assessing SCOC ruling. Times Colonist[Internet]. 2015 Feb 6 [Cited 2018 Sep 30].

16.    Dr. Chris Simpson (CMA President): "Now that the decision has come down, we want to really take a leadership role in helping to craft the legislation and the rules and regulation around it." Hume J.  Supreme Court strikes down ban on assisted suicide. Toronto Sun[Internet]. 2015 Feb 6 [Cited 2018 Sep 30].

17.    Dr. Chris Simpson (CMA President): "[W]e're going to need to hit the ground running if we want to lead and do this well." Kirkey S.  Helping suffering patients die may be doctor's most humane option, Canadian Medical Association says.  National Post [Internet]. 2015 Feb 4 [Cited 2018 Sep 30].

18.    Dr. Chris Simpson (CMA President): "[T]hat's exactly what we'll be seeking: is some mechanism for, for us to have a prominent role in the, in the crafting of the new rules and regulations and, and legislation."  Geddes Full Transcript, lines 150-152.

19.    "The CMA is well positioned to continue to play a leadership role in the debate around end-of-life care in Canada," said Simpson. Rich P.  CMA positioned to take lead role in crafting new regulations [Internet]. Canadian Medical Association; 2018 Feb 6 [Cited 2018 Sep 30].

20.    Dr. Chris Simpson (CMA President): "This will be really historic for Canada, and we really want to make sure we get it right." Stone L. 'Historic' assisted suicide ruling could make Parliament draft new laws. Global News, 6 February, 2015 (Accessed 2018-08-28).

21.    Dr. Chris Simpson (CMA President): "It's a really historic moment and I'm very mindful of, of the role that physicians have to play and . . . I'm really, really proud of how the CMA has handled this over the last two or three years."  Geddes Full Transcript, lines 160-162.

22.    Canadian Medical Association. CMA Policy: Euthanasia and Assisted Suicide (Update 2014) [Internet]. [Cited 2018 Sep 30].

23.    Canadian Medical Association. End-of-Life Care: A National Dialogue (June, 2014) [CMA Public Consultation] p. 1 (Accessed 2018 May 26).

24.    CMA Public Consultation, p. 1, 17.

25.    CMA Public Consultation, p. 17.

26.    Canadian Medical Association. End-of-Life Care: A National Dialogue. CMA Member Consultation Report [Internet]. 2014 Jul [Cited 2018 Sep 30]. [CMA Member Consultation] p. 9.

27.    CMA Member Consultation, p. 2.

28.    CMA Member Consultation, p. 11.

29.    Henley J.  Irish abortion referendum: yes wins with 66.4% – as it happened.  The Guardian [Internet]. 2018 May 26 [Cited 2018 Sep 30].

30.    McDonald H, Graham-Harrison E, Baker S.  Ireland votes by landslide to legalise abortion. The Guardian [Internet]. 2018 May 26 [Cited 2018 Sep 30].

31.    Booth W, Stanley-Becker I.  Ireland votes to overturn its abortion ban, 'culmination of a quiet revolution,' prime minister says.  The Washington Post, 26 May, 2018 (Accessed 2018-06-05).

32.    Blackmer J, Francescutti LH. Canadian Medical Association Perspectives on End-of-Life in Canada. HealthcarePapers 2014 April; 14(1):17-20 doi:10.12927/hcpap.2014.23966.

33.    Anselmi E. Yk doc key in assisted suicide ruling: Dr. Ewan Affleck instrumental in penning resolution considered by Supreme Court.  [Internet]. 2015 Feb 13 [Cited 2018 Sep 30].

34.    Canadian Medical Association. 147th General Council Delegates' Motions: End-of-Life Care: Motion DM 5-6 [Internet]. [Cited 2018 Sep 30].

35.    Canadian Medical Association. General Council Motions - 2014 Procedures and Guidelines: Motion Development [Internet]. [Cited 2018 Sep 30] p. 2, point 6 (Accessed 2018 May 26).

36.    Canadian Medical Association. Reports to the General Council. CMA 147th Annual General Meeting, August 17-20, 2014 [Internet]. [Cited 2018 Sep 30].  Appendix 2 -Care at the End of Life (Backgrounder - Strategic Session 2) A2-1 to A2-8.

37.    Vermont Statutes Title 18: Health, Chapter 113: An act relating to patient choice and control at end of life [Internet]. Vermont General Assembly [Cited 2018 Sep 29].

38.    Belgium: "At the request of the patient or the person taken in confidence, the physician who refuses to perform euthanasia must communicate the patient's medical record to the physician designated by the patient or person taken in confidence." The Belgian Act on Euthanasia (2002) Chapter VI: Special Provisions, Section 14 [Internet] Protection of Conscience Project [Cited 2018 Sep 30].

39.    Luxembourg: "A physician who refuses to comply with a request for euthanasia or assisted suicide is required, at the request of the patient or support person, to communicate the patient's medical record to the doctor appointed by him or by the support person." Legislation Regulating Palliative Care, Euthanasia and Assisted Suicide, Art. 15  [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].

40.    Washington: "If a health care provider is unable or unwilling to carry out a patient's request under this chapter, and the patient transfers his or her care to a new health care provider, the prior health care provider shall transfer, upon request, a copy of the patient's relevant medical records to the new health care provider." Washington Death With Dignity Act, RCW 70.245.190(1)d [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].

41.    Oregon: "If a health care provider is unable or unwilling to carry out a patient's request under ORS 127.800 to 127.897, and the patient transfers his or her care to a new health care provider, the prior health care provider shall transfer, upon request, a copy of the patient's relevant medical records to the new health care provider." Death With Dignity Act, ORS
127.885 s.4.01(4) [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].

42.    Rich P.  Physician  perspective on end-of-life issues fully aired [Internet]. Canadian Medical Association; 2014 Aug 19 [Cited 2018 Sep 30].

43.    Kirkey S. Canadian doctors want freedom to choose whether to help terminal patients die: CMA to revisit issue of doctor-assisted death after delegates pass motion supporting physician's right to 'follow their conscience'. canada.com, 19 August, 2014 (Accessed 2018 May 26).

44.    Somerville S. There's no "mushy middle" on euthanasia. Mercatornet [Internet]. 2014 Oct 2 October [Cited 2018 Sep 30].

45.    Canadian Medical Association. Resolutions Adopted, 147th Annual Meeting of the Canadian Medical Association Aug. 18-20, 2014 – Ottawa, ON. (Accessed 2018 May 26).

46.    Swan M. Medical association vows to protect conscience rights. The Catholic Register,
27 August, 2014 (Accessed 2018 May 26).

47.    McFadden J. Yk docs bring motions on doctor-assisted death: Canadian law on euthanasia could be overturned by next month. Northern News Services, 8 September, 2014. (Accessed 2018 May 26).

48.    Kirkey S. Doctor-assisted death appropriate only after all other choices exhausted, CMA president says.  canada.com [Internet]. 2014 Aug 26 [Cited 2018 Sep 30].

49.    Picard A.Canadian Medical Association softens stand on assisted suicide. The Globe and Mail [Internet]. 2014 Aug 19 [2018 Sep 30].

50.    In the Supreme Court of Canada (On appeal from the Court of Appeal for British Columbia: Factum of the Intervener, The Canadian Medical Association [Internet] 2014 Aug 27 [Cited 2018 Sep 30]. [CMA Factum].

51.    Murphy S. Re: Joint intervention in Carter v. Canada: Selections from oral submissions (Supreme Court of Canada, 15 October, 2014).  Harry Underwood (Counsel for the Canadian Medical Association) [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].  [CMA Oral Submission]. See also Supreme Court of Canada: Webcast of the hearing on 2015-10-15 [Internet]. [Cited 2018 Sep 30]. From 225:53/491:20 to 236:13/491:20.

52.    CMA Oral Submission, 228:08/491:20.

53.    CMA Oral Submission, 228:32/491:20.

54.    "Consistent with the matter as being a matter of conscience, the law should offer protection to those physicians who choose to participate in physician assisted death if it is legalized, and those who do not." CMA Oral Submission, 229:29/491:20.

55.    Murphy S.  "NO MORE CHRISTIAN DOCTORS." Appendix "F": The Difficult Compromise - Canadian Medical Association, Abortion and Freedom of Conscience [Internet]. Protection of Conscience Project; 2018 Feb 21 [Cited 2018 Sep 30].

56.    Schuklenk U et al. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making [Internet]. Royal Society of Canada; 2011 [Cited 2018 Sep 28].

57.    Schuklenk U. Supreme Court of Canada heard arguments in Charter challenge to assisted dying criminalisation.  Udo Schuklenk's Ethx Blog, 16 October, 2014 (Accessed 2017-12-01).

58.    Canadian Medical Association. Policy: Euthanasia and Assisted Death (Update 2014)  [Internet]. [Cited 2018 Sep 30].

59.    Rich P. CMA updates assisted dying policy [Internet]. Canadian Medical Association; 2015 Jan 9 [Cited 2018 Sep 30].

60.    Doctor-assisted suicide a therapeutic service, says Canadian Medical Association  [Internet]. CBC News; 2016 Feb 6 [Cited 2018 Sep 30].

61.    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].

62.    Ballingall A.  Assisted death: How to weigh doctors' rights with right to die?  Canada's medical circles abuzz with debate over how to balance newly recognized right to assisted death with doctors' right not to provide it.  The Star [Internet]. 2015 Feb 7 [Cited 2018 Sep 30].

63.    Santi N.  From Courtroom to Bedside - A Discussion with Dr. Jeff Blackmer on the Implications of Carter v. Canada and Physician-Assisted Death.  UOJM [Internet]. 2015 May [Cited 2018 Sep 30]; 5(1).

64.    Kirkey S.  Doctors' group proposes assisted death protocols in absence of rules from government.  National Post [Internet]. 2015 Jun 29 June [Cited 2018 Sep 30].

65.    In the Supreme Court of British Columbia, Between Lee Carter, Hollis Johnson, Dr. William Shoichet, and the British Columbia Civil Liberties Association and Gloria Taylor, Plaintiffs, And Attorney General of Canada: Amended Notice of Civil Claim (15 August, 2011)  [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].

66.    Carter v. Canada (Attorney General) 2012 BCSC 886. Supreme Court of British Columbia, 15 June, 2012. Vancouver, British Columbia, para. 24 (Accessed 2015-06-30).

67.    In the Supreme Court of Canada (On appeal from the Court of Appeal for British Columbia): Factum of the Appellants- Lee Carter, Hollis Johnson, Dr. William Shoichet, The British Columbia Civil Liberties Association and Gloria Taylor (13 May, 2014) [Internet]. BC Civil Liberties Association [Cited 2018 Sep 30].

68.    CMA Factum, para. 20.

69.    Rich P. 'Our work is far from finished:' CMA to continue leadership role on end-of-life care [Internet]. Canadian Medical Association; 2015 Mar 3 [Cited 2018 Sep 30].

70.    Kirkey S.  Unacceptable to force doctors to participate in assisted dying against their conscience: CMA head.  National Post, 5 March, 2015 (Accessed 2015-07-04).

71.    Canadian Medical Association. Principles-Based Approach to Assisted Dying in Canada (Backgrounder) [Internet]. Canadian Medical Association [Cited 2018 Sep 30].

72.    Kirkey S.  Help eligible patients end lives or refer them to someone who will, CMA to urge MDs.  National Post [Internet]. 2015 Aug 18 [Cited 2018 Sep 30].

73.    Canadian Medical Association.  Submission to the College of Physicians and Surgeons of Ontario re: Consultation on CPSO Interim Guidance on Physician-Assisted Death (13 January, 2016) [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].