Redefining the Practice of Medicine

Euthanasia in Quebec

An Act Respecting End-of-Life Care (June, 2014)

Sean Murphy*

Full Text

Part 5:  An Obligation to Kill

Most physicians will not kill

The accuracy of official euthanasia and assisted suicide returns is disputed, though it is usually agreed that the actual number of cases is probably higher than the reported number.  However, with respect to the reported cases, the returns indicate that the majority of physicians do not participate directly in the procedures.  In fact, depending on the jurisdiction, the number of physicians who actually kill patients or write prescriptions for lethal drugs or provide second opinions in support of euthanasia or assisted suicide can be very small.   For reasons connected with reporting requirements, this is easier to establish in the United States than in Europe. 

Demand vs. supply

Belgium

Though euthanasia has been legal in Belgium since 2002, the number of Belgian physicians who actually provide lethal injections and second opinions is apparently unknown.  The reason for this appears to be that the Federal Control and Evaluation Commission for Euthanasia cannot identify the physicians who report they have performed euthanasia unless it decides that the law may have been broken.1

Nonetheless, the statistics produced by the Commission establish the maximum number of physicians who have been involved in reported euthanasia cases each year.  By comparing this to the estimated number of licensed physicians in the country it is possible to estimate the proportion of Belgian physicians directly involved in euthanasia reported to the Commission.  The percentage has been increasing steadily, but it is still quite low: euthanasia is provided by 0.62% to 2.31% of all Belgian physicians (Appendix C1).  Moreover, these are maximums; the actual number of physicians directly involved could be much lower.  For example, in 2013, Dr. Sarah Van Laer said publicly that she had killed 28 patients since 2002,2 which, in Commission statistics, would be reflected as the work of 28 physicians, not one. 

This may explain the anecdotal reports that most Belgian physicians will not provide euthanasia.  Only about 400 of 20,000 physicians in Flanders (2%) were involved in providing second opinions in 2013; they considered themselves overburdened and underpaid.3  Dr. Sarah Van Laer told a Belgian newspaper that there were too few physicians willing to perform euthanasia, and that this problem had been "badly underestimated."  As a result, she said, she and others willing to provide the service were becoming burned out.4

Finally, Dr. Wim Distelmans, a Belgian physician who is a leading practitioner and advocate of euthanasia and co-chairman of the Federal Control and Evaluation Commission has complained that many physicians, hospitals and nursing homes  are reluctant to provide the service.  He described them as "still very prudent," adding, "There are still a lot of people suffering unbearably because they ask for euthanasia and they don’t get it."5

Netherlands

Physicians may provide both euthanasia and assisted suicide in the Netherlands, but, here, too, the number of physicians directly involved is uncertain.  As in the case of Belgium, it is impossible to determine from published statistics whether or not a subset of euthanasia practitioners is responsible for killing most of the patients.

What is clear, however, is that general practitioners in the Netherlands are overwhelming responsible for performing euthanasia, and the numbers are rising.  In 2004 almost 21% of Dutch general practitioners were directly involved; by 2010 it was over 28%.  In comparison, the next most active category, hospital specialists, represented less than 2% of Dutch medical specialists directly involved with euthanasia or assisted suicide.  Overall, the statistics indicate that a maximum of 9% to 12% of all Dutch physicians have been directly involved in reported euthanasia cases each year (Appendix C2). 

This is consistent with a report that euthanasia is usually provided by general practitioners, but many refuse to do so.  It was for this reason that, in 2012, Right to Die NL formed mobile teams to provide euthanasia for patients at home.6

Oregon and Washington State

Published statistics in Oregon and Washington state provide a more accurate picture of the actual involvement of physicians in assisted suicide than can be had from Belgian and Dutch authorities.  The proportion of licensed physicians directly involved is extremely small.

In Oregon, where assisted suicide has been legal since 1997, between 33 and 64 physicians wrote prescriptions for lethal medication each year from 2002 to 2013, a range of 0.38% to 0.62% of the state's active registered physicians (Appendix C3). 

The state of Washington legalized assisted suicide in March, 2009.  The number of physicians prescribing lethal medications has increased steadily from 53 to 89, from 0.21% to 0.34% of licensed physicians.  The number of pharmacists dispensing lethal drugs has been more variable, rising from 2009 to 2011 and dropping thereafter.  From 2009 to 2013, 23 to 46 pharmacists dispensed drugs for assisted suicide annually, representing 0.25% to 0.52% of licensed pharmacists (Appendix C4).

Implications for Quebec

While interesting, the extremely low physician participation rates in Oregon and the state of Washington pertain solely to assisted suicide, not euthanasia, and there are many other cultural, legal and political differences between Quebec and these western American states. 

It is more promising to consider what would happen if developments in Quebec were to approximate those in Belgium or the Netherlands.  Quebec and Belgium have some linguistic similarities, share some civil law traditions,7 and the state in both jurisdictions is responsible for the delivery of health care.  Moreover, the situation in Belgium is of particular interest in Quebec because ARELC was modelled on the Belgian euthanasia law. 

 If we apply the highest physician participation rate reflected in the Belgian figures (2.31%) to the number of active members registered with Quebec's College of Physicians (19,818),8 one might predict that about 458 Quebec physicians would actually provide lethal injections and/or second opinions.  Since two physicians are required for each case, the predicted number of available physicians would suffice to process 229 euthanasia requests each year: slightly more than one third the highest estimate of anticipated demand (600 cases annually). 

Applying the highest Dutch physician participation rates (12% overall, 28% of general practitioners),  one might predict direct involvement of 2,378 Quebec physicians overall, or 1,440 general practitioners.

Taking a different perspective, the highest Belgian and Dutch physician participation rates suggest that, more than ten years after legalization of assisted suicide and euthanasia,  between 88% and 98% of physicians in Belgium and the Netherlands are not directly involved in the procedures.  This estimate seems so high as to be improbable.

On the other hand, abortion - another highly controversial procedure that involves killing - has been available in Canada since 1969 and completely unrestricted since 1988. Yet, as of 2011, over 99.5% of registered physicians in British Columbia were not performing abortions; almost 25 years after the legalization of abortion, proportionately fewer physicians were performing abortions in British Columbia than were writing prescriptions for assisted suicide in neighbouring Oregon.9  Thus, while it would be unwise to assert that 88 to 98% of Dutch and Belgian physicians are not providing euthanasia or assisted suicide, such high rates of non-provision are not without precedent.

In any case, the current situation in Belgium and the Netherlands suggests that, for some time to come, a substantial majority of Quebec physicians will probably not lethally inject patients or provide second opinions supporting the practice. 

Number of MAD cases anticipated

During the committee hearings, then Minister of Health Véronique Hivon took note of the possibility that few physicians would be willing to kill patients, but emphasized that this had to be set against the expectation that only "a very small number" of patients would actually seek the service, "between 0.2% to 1.8% of deaths."10

Overnight, then there will not be a flood of applications from everyone wanting to get to have medical help to die, it will be in the special case where it is really not possible to relieve a person. So, in those jurisdictions that we have seen, this is often less than 1% of all deaths. So it means that it is still very exceptional, and it is good that it is like that.11

Similarly, committee member Hélène Daeault, comparing the populations of Quebec and Belgium, estimated that there might be 150 to 200 cases of euthanasia each year "a tiny fraction" of the 60,000 deaths annually.12 Dr. Yves Bolduc offered a higher estimate: 300 to 600 cases annually.13

Number of willing physicians

Citing the Quebec Medical Association Survey that found 41% of physicians willing to provide euthanasia, Minister Hivon argued that, although many physicians might not be prepared to provide MAD,  "there is still a significant number of doctors who say they are willing."14

Setting aside physician surveys, Dr. Yves Bolduc approached the question from a different angle.  He considered his estimate of 300 to 600 anticipated MAD cases each year a relatively small number of deaths.  That being the case, he concluded that only a minority of physicians would actually be involved in meeting the demand, since, "we cannot think that every doctor will have the expertise, even if he wants to." 

"We can believe in the project," he explained, "but if you do it once every two years, you are perhaps better not to touch it."15

Why, then, was Dr. Bolduc so concerned that there might not be enough willing physicians available to implement the law?

Administrative issues

Part of the explanation might concern the administrative impact of the need to arrange for the killing of up to 600  patients each year.  Michel Racicot of Living with Dignity pointed out that this is the equivalent of emptying  the Drapeau-Deschambault Centre, a 223 bed long term care facility,16 two or three times a year.17  Adopting Dr. Bolduc's figures, about 30 hospitals would be required to provide MAD service;18 600 MAD cases annually would average about one every two weeks in each institution.  Since the MAD protocol requires prior consultations with at least the patient and a second physician, any significant resistance by physicians or other health care workers would make this a year-round, almost daily administrative headache.

Still, there are over 8,000 physicians in general practice in Quebec.19 If only ten per cent of that number were willing to provide MAD, it would seem that there are more than enough physicians available to lethally inject 600 patients each year.  Nonetheless, Dr. Bolduc repeatedly expressed concern that it would be very difficult to implement the law.  Why?

A right implies an obligation

The answer was provided, in part, by Véronique Hivon, who insisted that, in the interests of fairness, both palliative care and MAD must be made available in the state health care system, so that people who live in cities like Montreal or rural areas like Gaspé "have the same access."20

Beyond a general concern about equality of access, however, Dr. Bolduc repeatedly drew attention to the fact that Bill 52/ARELC purports to establish a "practically inalienable" legal right to MAD, which, in turn, imposes an obligation on all health care institutions in the province to fulfil demands for euthanasia.21  Thus, even though only a minority of patients are expected to seek the service, the law requires that the whole health care delivery system be arranged to accommodate them.22  Committee member Stéphanie Vallée explained:

[The law] gives a right to every person, regardless of his place of residence in Quebec, so that if it is in the Northern Quebec, whether in Montreal, whether in Montérégie , it gives the right to anyone to have palliative care, to have [continuous] palliative sedation, to have physician-assisted dying, we must ensure that at the time of implementation, those services will be available and we will not have to run around Quebec to be able meet the demand, to be able to respond to the request of the patient.23

While Dr. Bolduc agreed with this in principle,24 he feared that it would lead to serious confrontations:

Take, for example, there were people this morning who practised at Notre Dame  in palliative care, they will simply refuse out of conviction, and probably even resign from the hospital rather than be required to do that, though in the law, there is an obligation to do it.25

Moreover, he reminded his colleagues that genuine respect for physician freedom of conscience added another level of difficulty, "[b]ecause there are three elements: you have the right of the patient, you have the obligation of the institution and then you can also have your conscientious objection."26

[I]f we find ourselves in places where death is relatively imminent and there is nobody in the medical team who can perform these tasks, will this not undermine the right of the patient or prevent the person who has a conscientious objection, from acting on his conscientious objection?27

"What will be the priority or have primacy?" he asked. "Will it be the patient's right?"

"Or," he asked, "will there be a way to force professionals to provide the service?"28

Accommodating conscience and killing

Rather than deny the patient's access to euthanasia or physicians' freedom of conscience, Dr. Bolduc insisted that some kind of timely mechanism must be developed to accommodate both, although he understood that this would probably take some time to accomplish.29

Delegation

The Quebec Association of Gerontology wondered if lethal injection might be delegated to nurses.30  Leaving aside the question of the ethics of delegation, this would simply move the question one step further back, since a nurse might take the same position as an objecting physician.  Moreover as Yves Bolduc observed,31ARELC states that it is the physician's task to administer the lethal substance.  There is no provision for delegation.32

Transferring patients

If no local physicians or facilities can supply a specialized service, such as heart surgery, it is common practice to transfer patients elsewhere.  However, the Alliance of Quebec Hospices noted that it is not a simple matter to transfer a terminally ill patient from one facility to another, especially after he has been in the first institution for some time,33 and Dr. Bolduc confirmed that one would not expect a patient to be transferred to access MAD services.34  Thus, while transferring a patient in a particular case might be practical, it would likely occur only in exceptional circumstances.

Identifying physicians in advance

In addition to recommending that regional health administrators should be personally aware of the scope of practice of professionals in their territories,35 the Quebec College of Pharmacists suggested that access to lethal drugs for MAD and accommodation of freedom of conscience for pharmacists who object to euthanasia could be accomplished by adopting an existing practice:

 [The regional health authority] sends a request to community pharmacists to clarify the various services they offer: anticoagulation, the ACO program methadone, syringe recovery ... There are several services. So, medical assisted dying could also be a service . . . for which we require pharmacists to indicate whether they are available . . .36

Similarly, the Quebec Association of Health Facilities and Social Services suggested that regional health authorities could ask physicians willing to assist with or provide MAD services to identify themselves in advance.37  Such advance planning was also supported by the Association of Councils of Physicians, Dentists and Pharmacists of Quebec.38  The maintenance of a registry of physicians willing to cooperate in the provision of defined services has been recommended by Holly Fernandez Lynch in Conflicts of Conscience in Health Care: An Institutional Compromise.  She describes a register of health care providers in Texas who are willing to accept patients who want treatment or care either continued or discontinued near the end of life.39

Remote monitoring

While the act of killing a patient would have to be performed by a physician on the spot, Dr. Bolduc suggested that other aspects of the MAD process might be managed by using telecommunications systems and digital technology that would permit remote monitoring.40

For example, if a physician in Gaspé wanted to provide a lethal injection but could not find another local physician willing to provide the required second consultation, he could consult physicians in Quebec or Montreal who might be willing to support him. Michel Gervais of the Quebec Association of Health Facilities and Social Services, noting the effective use of telepsychiatry and teleradiology, thought the suggestion "very valuable and very possible."41 

Flying squads

Committee members Yves Bolduc and Hélène Daneault suggested that "flying squads" could be established to provide MAD services around the province or in the regions as an alternative to transferring patients, which is not normally feasible.42  The idea of  such "visiting physicians" found favour with the Quebec Association for the Right to Die with Dignity,43 but the Quebec Rally Against Euthanasia warned that, if such teams had to "crisscross Quebec by plane," money would be spent providing euthanasia rather than palliative care.44 

Dr. Pierre Gagon thought "the idea of people coming in from outside" seemed "very artificial" and "goes a little against the principles of medicine."  He cautioned the committee that the concept required "systematic evaluation."

Well, I think there was a  phenomenon much like that in Switzerland. It went very, very badly. Some mobile teams who came did very little evaluation ... They were a bit like at odds with palliative care teams. I do not know, it is very delicate. . .45

Forcing physicians to kill

When Dr. Bolduc asked if there was a way to force physicians to kill, he asked the question only to emphasize that, "in reality," in his view, no physician could be forced to do so.46

"We cannot force professionals," he said. "Despite what it looks like: The patient has rights - you cannot go and tell a professional: You'll have to do that."47

This seems to imply that people who are not professionals can be forced to do what they are told: that physicians are exempt from such coercion precisely because they are professional.  If that is Dr. Bolduc's view, he will eventually have a very rude awakening.  A number of prominent academics have been making an argument for some time that one of the essential features of medical "professionalism" means doing what one believes to be immoral, unethical or unjust.48 

In any case, Dr. Bolduc did not offer principled reasons for his assertion that physicians cannot be forced to provide euthanasia.  His argument was purely pragmatic: 

 If we start with that principle, then you will destroy the bill. Society is in agreement to date, according to the polls, but if you start to force people to do things like this, if you want my opinion, you can talk because you defend a position, but I will not follow you that far, that's for sure. Most professionals do not follow you that far.49

His warning was addressed to the Quebec Association for the Right to Die with Dignity, which responded, that it had always said that it respected "the freedom of the professional."  Speaking for the Association, Hélène Bolduc (no relation to the legislator) said that the organization had never had any intention of forcing physicians to provide euthanasia, as "there is not a doctor who would do it well if, in addition, it was not his inclination to do so, and it is not to anyone's advantage to give this impression."50

Discrimination for refusing to kill

The answer satisfied Dr. Bolduc, but he failed to take into account that the exercise of freedom of conscience by objecting physicians who refuse to kill patients can lead to unjust discrimination against them. 

This was demonstrated during the committee hearings into Bill 52, when the Interprofessional Health Federation of Quebec told legislators that no one is forced to work in palliative care units, "so the person who applies for this position will go knowing what is required."  The Federation did not anticipate much problem being caused by conscientious objection "because when people apply to a specialized department they know what they have to do."51 

The assumption, of course, is that providing euthanasia will become one of the duties of palliative care units, so that those wanting to practise palliative care but who are unwilling to kill patients will not apply.  And if they do apply, of course, management may deny them employment, as now happens in at least one major Canadian maternity hospital that denies employment to qualified maternity nurses who have moral or religious objections to assisting with abortion, including third trimester abortions.

Discriminatory screening of physicians unwilling to kill patients can also be effected by denying them hospital privileges (Appendix B1), as explained by the Association of Councils of Physicians, Dentists and Pharmacists of Quebec:

Let me explain, skills, when a doctor applies to a health facility, the [Council of Physicians, Dentists and Pharmacists] will ensure he has the necessary skills and will grant him a status and privileges. Privileges usually come with obligations. These obligations also allow the guidance of practice and  ensure that we will practise within the framework provided by organization, yet based on the reality of practice and skill level. . . So, to grant privileges in a CSSS, it might be meaningful to this necessary and required training for the physician to practise this activity. . . 52

By such strategies one can truthfully affirm that physicians are not actually being forced to kill, although those unwilling to do so may be forced to change specialties, leave the profession or emigrate.

Notes

1.  The Belgian Act on Euthanasia of May 28, 2002, Section 7, 8. (Accessed 2014-07-18)

2.  Cook Michael, "First-world problems 2: I’m really not into the whole 'turbo-euthanasia' thing."  Bioedge, 27 June, 2013. (Accessed 2014-07-15)

3.  HLN.be, "Artsen die dokters bijstaan bij euthanasie overbevraagd."  24 June, 2013.  (Accessed 2014-07-15)

4.  Cook Michael, "First-world problems 2: I’m really not into the whole 'turbo-euthanasia' thing."  Bioedge, 27 June, 2013.  (Accessed 2014-07-15)

5.  Hamilton G.  "Death by doctor: Controversial physician has made his name delivering euthanasia when no one else will."  National Post, 22 November, 2013 (Accessed 2014-07-15)

6.  Jolly, D., "Push for the Right to Die Grows in the Netherlands."  New York Times, 2 April, 2012.  (Accessed 2014-07-15)

7.  Société de législation comparée, European Contract Law : Materials for the CFR (April, 2008) (Accessed 2014-07-17)

8.  Collège des Médecins du Québec, Rapport Annuel, 2013-2014.  (Accessed 2014-07-17)

9.  In 2011, only 50 (0.46%) of 10,842 professionally active registered physicians provided abortions in British Columbia. Norman WV, Soon JA, Maughn N, Dressler J. (2013) "Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS)" (2013) PLoS ONE 8(6): e67023. doi:10.1371/journal.pone.0067023 (Accessed 2013-07-25); College of Physicians and Surgeons of British Columbia, 2011 Annual Report,  p. 12 (Accessed 2014-07-12) In contrast, 0.60% of active registered Oregon physicians wrote lethal prescriptions for assisted suicide in 2011 (Appendix C3.).

10.  Consultations & hearings on Quebec Bill 52 (Hereinafter "Consultations"), Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#041

11.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#075

12.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#108

13.  Consultations, Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#099

14.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#076

15.  Consultations, Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#099

16.   Quebec Ministry of Health and Social Services, Rapport de Viste d'Évaluation de la Qualité du Milieu de Vie (2013) (Accessed 2014-07-09)

17.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Living with Dignity(Nicolas Steenhout, Dr. Marc Beauchamp, Michel Racicot), T#079

18.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Dr. Annie Tremblay, Dr. Pierre Gagnon, T#112

19.  Fédération des médecins omnipraticiens du Québec: Mission.  (Accessed 2014-07-10)

20.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#074

21.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#062

22.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#116

23.  Consultations, Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#054

24.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Dr. Annie Tremblay, Dr. Pierre Gagnon, T#112

25.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#116

26.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#118

27.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34:  Collège des médecins (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand), T#158

28.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec (Dr. Louis Godin, Dr. Marc-André Asselin),T#103

29.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#095; T#101; Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#118;  Wednesday, 9 October 2013 - Vol. 43 N° 45: Dr. Annie Tremblay, Dr. Pierre Gagnon, T#112; Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#099

30.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#055

31.  Consultations, Thursday, 3 October 2013 - Vol. 43 no. 42: Quebec Association of Gerontology (Catherine Geoffroy, Nathalie Adams), T#062

32.  ARELC, Sections 3(6), 30

33.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#146

34.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec (Dr. Louis Godin, Dr. Marc-André Asselin),T#103; Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#095

35.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#050

36.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: College of Pharmacists of Quebec (Dianne Lamarre, Manon Lambert),T#063

37.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#109

38.  Consultations, Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#014

39.  Fernandez-Lynch, Holly, Conflicts of Conscience in Health Care: An Institutional Compromise. Cambridge, Mass.: The MIT Press, 2008, p. 146.

40.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#095

41.  Consultations, Wednesday 18 September 2013 - Vol. 43 no. 35: Quebec Association of Health Facilities and Social Services (Michel Quebec Association of Health Facilities and Social Services (Michel Gervais, Diane Lavallée), T#103

42.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec (Dr. Louis Godin, Dr. Marc-André Asselin),T#103;  Tuesday 24 September 2013 - Vol. 43 no. 37: Quebec Rally Against Euthanasia (Dr. Claude Morin, Dr. Marc Bergeron, Daniel Arsenault, Clément Vermette), T#099; Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Dr. Annie Tremblay, Dr. Pierre Gagnon, T#148

43.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#072

44.  Consultations, Tuesday 24 September 2013 - Vol. 43 no. 37: Quebec Rally Against Euthanasia (Dr. Claude Morin, Dr. Marc Bergeron, Daniel Arsenault, Clément Vermette), T#102, T#103

45.  Consultations, Wednesday, 9 October 2013 - Vol. 43 N° 45: Dr. Annie Tremblay, Dr. Pierre Gagnon, T#150

46.  Consultations, Tuesday, 17 September 2013 - Vol. 43 no. 34: Federation of General Practitioners of Quebec (Dr. Louis Godin, Dr. Marc-André Asselin),T#103

47.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#102

48.  See, for example, Cantor, Julie D., "Conscientious Objection Gone Awry - Restoring Selfless Professionalism in Medicine." N Eng J Med 360;15, 9 April, 2009; Charo, R. Alta, "The Celestial Fire of Conscience- Refusing to Deliver Medical Care." N Eng J Med 352:24, June 16, 2005. (Accessed 2008-09-13); Kolers, A. "Am I My Profession's Keeper?"  Bioethics, Vol. 28, No. 1, 2014.

49.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#102

50.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#107

51.  Consultations, Thursday, 26 September 2013 - Vol. 43 no. 39: Interprofessional Health Federation of Quebec  (Régine Laurent, Julie Martin, Michàle Boisclair, Brigitte Doyon), T#058

52.  Consultations, Thursday, 19 September 2013 - Vol. 43 no. 36:  Association of Councils of Physicians, Dentists and Pharmacists of Quebec (Dr. Martin Arata, Annick Lavoie, Annie Léger), T#017