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Protection of Conscience Project

Service, not Servitude
Legal Commentary

Redefining the practice of medicine

Euthanasia in Quebec

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

Sean Murphy*

Appendix "A": Health Care Delivery in Quebec
A1. Statutes

A1.1 An Act Respecting Health Services and Social Services provides the administrative framework for the delivery of health care in Quebec, outlines principles that inform the system and sets out the rights and obligations of various parties. It supported by An Act respecting the Health and Social Services Ombudsman.

A1.2 The Professional Code establishes the structure of professions in the province (called "orders") including the health care professions. It also establishes the Office des professions du Québec, consisting of five government appointees. Among other things, the Office has the power to supervise the professions to ensure that they conform to the requirements of the Professional Code.1

A1.3 Subject to the Professional Code, separate statutes govern pharmacists,2 nurses,3 physicians4 and midwives.5

A2. Regional health and social service agencies

A2.1 A health and social services agency established by the government in each region of the province is designated as the state agency responsible for responsible for the delivery and coordination of health care in the region.6 Every agency must establish a public health department, and may request the Minister for Social Services and Youth Protection to appoint a public health director.7

A3. Regional service quality and complaints commissioner

A3.1 Regional complaints commissioners are answerable to the regional health agency that appoint them but are expected to act independently to enforce "user rights" and respond diligently by investigating "user complaints."8 They are to promote and explain the complaint process to people in the region9 and encourage and support people in formulating complaints.10

A4. Regional nursing and multidisciplinary commissions

A4.1 In each region, the government has established a nursing commission.11 A nursing commission is responsible to the board of directors of the regional health and social services agency and provides advice about nursing care, staffing and other issues.12 The government has also established a multidisciplinary commission in each region, with analogous functions.13

A5. Local health and social services networks

A5.1 In addition to regional health and social service agencies, "local health and social services networks"14 have been established "to foster a greater sense of responsibility among all the health and social service providers in the network to ensure that the people in the network's territory have continuous access to a broad range of general, specialized and superspecialized health services and social services."15 These networks are coordinated by local authorities operating local community service centres, residential and long-term care centres or general and specialized hospital centres.16 Local authorities have numerous responsibilities,17 among which is working with other elements of the health care bureaucracy to "create conditions that foster accessibility, continuity and networking of general medical services, focusing in particular on accessibility."18

A6. Community organizations

A6.1 Incorporated non-profit community organizations governed by boards of directors may engage " in activities related to the field of health and social services,"19 including (if authorized by the Minister) the provision of abortion.20 Community organizations may receive subsidies from regional health and social services agencies,21 or from the Quebec government,22 but remain free to define their "orientations, policies and approaches."23 Subsidized community organizations must send annual activity and financial reports to the subsidizing authorities.24 They may also agree to be subject to the regional complaint process (see Appendix "B").25

A7. Accredited private resources

A7.1 Private nursing homes, private institutions that operate residential and long term care centres and community organizations may apply to the regional health and social services agency for accreditation.26 Accreditation may be granted by the Minister only if they conform to the Minister's accreditation requirements.27 Accreditation may be granted temporarily or for specified periods; continued accreditation depends upon continued compliance with the Act and the conditions set by the Minister.28  Regional health and social service agencies may grant a financial allowance only to accredited persons.29

A8. Private homes for seniors and vulnerable clients

A8.1 A private seniors' residence is a facility for persons at least 65 years of age that provides residential accommodation and at least two services identified by regulation. Every regional health and social services agency must maintain a register of private seniors' residences in its jurisdiction.30 All such residences are subject to regulation and inspection and require certificates of compliance in order to operate.31

A9. Specialized medical centres

A9.1 A specialized medical centre may be opened only by physicians. It must be governed by a board, the majority of whom must be physicians practising in the centre32 and supervised by a medical director appointed from among them.33 Specialized medical centres may provide "services necessary for a hip or knee replacement, a cataract extraction and intraocular lens implantation" and other specialized medical treatment authorized by the government through regulation.34

A10. Health care facilities

A10.1 Health care is provided in five kinds of facilities: a local community service centres, hospital centres, child and youth protection centres, residential and long-term care centres and rehabilitation centres.35

A11. Health care institutions

A11.1 As a general rule, any person or partnership who carries on "activities inherent in the mission" of one of these five kinds of centres is considered to be an "institution."36 However, there are some exceptions, including persons or partnerships operating private health facilities37 and some religious or teaching institutions that operate infirmaries for their personnel, members or followers.38

A11.2 Institutions are public or private.39 Institutions are public if they are non-profit corporations, or if they are incorporated or are formed as a result of amalgamation or conversion under the Act Respecting Health Services and Social Services.40

A11.3 Private institutions are unincorporated, or profit-making corporations, or non-profit corporations providing some kinds of health care for fewer than 20 patients.41

A12. Institutional Boards of Directors

A12.1 Public institutions are governed by boards of directors42 constituted43 and functioning44 in accordance with the Act. Each board must form governance, ethics, audit and watchdog committees45 and appoint a local service quality and complaints commissioner.46 Boards of directors of private institutions have the same functions and responsibilities.47

A12.2 Presumably under the auspices of the board of directors, every institution "must adopt a code of ethics which shall set out the rights of the users and the practices and conduct expected, with respect to the users, from the employees, the trainees, including medical residents, and the professionals practising in a centre operated by the institution" and provide a copy of it to every institutional "user" upon request.48

A13. Local Service Quality and Complaints Commissioners

A13.1 Local complaints commissioners are answerable to the institutional boards that appoint them but are expected to act independently to enforce "user rights" and respond diligently by investigating "user complaints."49 They are to promote and explain the complaint process to people served by an institution50 and encourage and support them in formulating complaints.51

A14. Executive Directors

A14.1 Executive directors, appointed by and responsible to boards of directors, are responsible for day-to-day operations of institutions.52

A15. Directors of Professional Services

A15.1 Every local authority in charge of a health and social services network and every institution operating a hospital must appoint a physician as director of professional services. Other institutions may appoint directors of professional services, but are not required to do so.53

A15.2 Acting under the authority of the executive director, the director of professional services coordinates the professional and scientific activities of an institution.54 In particular, they direct and supervise clinical department heads55 and councils of physicians, dentists and pharmacists.56

A16. Directors of Nursing Care

A16.1 Every local authority in charge of a health and social services network and every institution operating a hospital must appoint a nurse as director of nursing care. Alternatively, the executive director may designate a nurse to take charge of nursing. Other institutions may appoint directors of nursing care, but are not required to do so.57 Acting under the authority of the executive director, directors of nursing care supervise and monitor nursing care.58

A17. Midwifery Services Coordinators

A17.1 Every institution operating a local community service centre in which midwifery is practised must appoint midwife as midwifery services coordinator. Coordinators must define standards of care, and supervise midwives and coordinate the provision of midwifery services.59

A18. Medical Examiners

A18.1 An institutional board of directors must appoint a Medical Examiner, either for each of the facilities it operates, or as Medical Examiner for all of them. A Director of Professional Services may be so designated. Medical Examiners are responsible to the board of directors for the investigation of complaints involving physicians, dentists or pharmacists, or a medical resident.60

A19. Institutional Councils
Physicians, dentists and pharmacists

A19.1 Every public institution with a centre employing at least five physicians, dentists or pharmacists must form a council of that includes all of them. Boards of directors that operate more than one institution may form a single council composed of the practitioners in all of the institutions.61 Councils of physicians, dentists and pharmacists are, among other things, responsible for assessing and maintaining professional standards62 and making recommendations about medical care and dental care and the use of medicines.63

A19.2 Councils of physicians, dentists and pharmacists can give opinions about disciplinary measures against physicians, pharmacists or dentists,64 and make recommendations about obligations associated with privileges granted to physicians or dentists, especially with respect to participation in clinical activities.65


A19.3 Every public institution with a centre employing at least five nurses must form a council of nurses that includes all of them. Boards of directors that operate more than one institution may form a single council composed of the practitioners in all of the institutions.66 An executive committee of at least four nurses exercises the responsibilities of the council.67 Councils of nurses are responsible for assessing and maintaining the quality of nursing care68 and making recommendations about it.69 A council of nurses is also responsible for forming a committee to perform the council's functions with respect to nursing assistants.70


A19.4 Every public institution that has contracted with at least five midwives must form a council of midwives consisting of all of them,71 unless the midwives and the council of physicians, dentists and pharmacists agree that the latter should exercise the function of a council of midwives.72 When a council of midwives is formed, an executive committee comprised of at three midwives and the executive director of the institution exercises the powers of the council.73 These include monitoring and assessing the work of the midwives,74 recommending standards of care75 and "obligations to be attached to the practice of midwifery,"76 and confirming the qualifications of midwife applicants.77

Other disciplines

A19.5 Multidisciplinary councils must be formed in every public institution, consisting of employees (except physicians, dentists, pharmacists and nurses) who hold college diplomas or university degrees who perform functions in their field of expertise directly related to nursing assistance, health services, social services, and research or teaching.78 Multidisciplinary councils assessing and improving the quality of the professional activities of their members, and making recommendations concerning them.79

A20. Clinical Department Heads

A20.1 Every clinical department in a hospital must be headed by a physician, pharmacist, dentist or clinical biochemist.80 Clinical department heads are primarily responsible for coordinating and supervising professional activities81 and the allocation and use of resources in each department.82 They may also offer opinions about the granting or maintenance of professional status and privileges and the obligations attached to them.83

A21. Users' Committees

A21.1 Every public and private institution must establish and provide funds for a Users' Committee, consisting of at least five members elected by users of institutional facilities84 for terms not exceeding three years.85 Among their responsibilities, Users' Committees are to "inform users of their rights and obligations,"86 defend the rights and interests of users,87 and accompany and assist users in making complaints.88

A22. Health and Social Services Ombudsman

A22.1 The office of Health Services Ombudsman is exercised by a Deputy Public Protector appointed under the Public Protector Act. The Ombudsman is to ensure that people seeking heath care are respected and that their rights are enforced.89


1.  Professional Code (R.S.Q. c C-26) Sections 3-16.8 (Accessed 2014-07-27)

2.  Pharmacy Act (R.S.Q. c-P10) (Accessed 2014-07-27)

3.  Nurses Act (R.S.Q. c I-8) (Accessed 2014-07-27)

4.  Medical Act (R.S.Q. c M-9) (Accessed 2014-07-27)

5.   Midwives Act (R.S.Q.. c S-0.1) (Accessed 2014-07-27)

6.  An Act Respecting Health Services and Social Services, (R.S.Q. Chapter S-4.2) (Hereinafter "ARHS&SS) Sections 339-342.1. (Accessed 2014-07-27)

7.  ARHS&SS, Sections 371-372. (Accessed 2014-07-27)

8.  ARHS&SS, Section 66. (Accessed 2014-07-27)

9.  ARHS&SS, Section 66(2). (Accessed 2014-07-27)

10.  ARHS&SS, Section 66(3). (Accessed 2014-07-27)

11.  ARHS&SS, Sections 370.1. (Accessed 2014-07-27)

12.  ARHS&SS, Section 370.3. (Accessed 2014-07-27)

13 ARHS&SS, Sections 370.5-370.7. (Accessed 2014-07-27)

14 ARHS&SS, Section 99.2. (Accessed 2014-07-27)

15 ARHS&SS, Section 99.3. (Accessed 2014-07-27)

16 ARHS&SS, Section 99.4. (Accessed 2014-07-27)

17 ARHS&SS, Sections 99.5-99.8. (Accessed 2014-07-27)

18 ARHS&SS, Section 99.9.7. (Accessed 2014-07-27)

19 ARHS&SS, Section 334. (Accessed 2014-07-27)

20 ARHS&SS, Section 338.1. (Accessed 2014-07-27)

21 ARHS&SS, Section 336. (Accessed 2014-07-27)

22 ARHS&SS, Section 337. (Accessed 2014-07-27)

23 ARHS&SS, Section 335. (Accessed 2014-07-27)

24 ARHS&SS, Section 338. (Accessed 2014-07-27)

25 ARHS&SS, Sections 76.6, 76.7. (Accessed 2014-07-27)

26 ARHS&SS, Section 457. (Accessed 2014-07-27)

27 ARHS&SS, Section 456. (Accessed 2014-07-27)

28 ARHS&SS, Section 458. (Accessed 2014-07-27)

29 ARHS&SS, Section 454, 455. (Accessed 2014-07-27)

30 ARHS&SS, Section 346.0.1. (Accessed 2014-07-27)

31 ARHS&SS, Sections 346.0.2, 346.0.4, 346.0.8. (Accessed 2014-07-27)

32 ARHS&SS, Section 333.2. (Accessed 2014-07-27)

33 ARHS&SS, Section 333.5. (Accessed 2014-07-27)

34 ARHS&SS, Section 333.1. (Accessed 2014-07-27)

35 ARHS&SS, Sections 79. (Accessed 2014-07-27)

36 ARHS&SS, Sections 94. (Accessed 2014-07-27)

37 ARHS&SS, Sections 95. (Accessed 2014-07-27)

38 ARHS&SS, Sections 96. (Accessed 2014-07-27)

39 ARHS&SS, Sections 97. (Accessed 2014-07-27)

40 ARHS&SS, Sections 98. (Accessed 2014-07-27)

41 ARHS&SS, Sections 99. (Accessed 2014-07-27)

42 ARHS&SS, Sections 119-128.1. (Accessed 2014-07-27)

43 ARHS&SS, Sections 129-156. (Accessed 2014-07-27)

44 ARHS&SS, Sections 157-180. (Accessed 2014-07-27)

45 ARHS&SS, Sections 181-181.0.1. (Accessed 2014-07-27)

46 ARHS&SS, Section 30. (Accessed 2014-07-27)

47 ARHS&SS, Section 182. (Accessed 2014-07-27)

48 ARHS&SS, Section 233. (Accessed 2014-07-27)

49 ARHS&SS, Sections 31, 33. (Accessed 2014-07-27)

50 ARHS&SS, Section 33(2). (Accessed 2014-07-27)

51.   ARHS&SS, Section 33(3). (Accessed 2014-07-27)

52 ARHS&SS, Sections 192.1-201. (Accessed 2014-07-27)

53 ARHS&SS, Section 202. (Accessed 2014-07-27)

54 ARHS&SS, Section 203. (Accessed 2014-07-27)

55 ARHS&SS, Section 204(1). (Accessed 2014-07-27)

56 ARHS&SS, Section 204(4). (Accessed 2014-07-27)

57 ARHS&SS, Section 206. (Accessed 2014-07-27)

58 ARHS&SS, Section 207-208. (Accessed 2014-07-27)

59 ARHS&SS, Section 208.1-208.3. (Accessed 2014-07-27)

60 ARHS&SS, Section 42. (Accessed 2014-07-12)

61 ARHS&SS, Section 213. (Accessed 2014-07-27)

62 ARHS&SS, Section 214(2). (Accessed 2014-07-27)

63 ARHS&SS, Section 214(6). (Accessed 2014-07-27)

64 ARHS&SS, Section 214(5). (Accessed 2014-07-27)

65 ARHS&SS, Section 2414(7)a. (Accessed 2014-07-27)

66 ARHS&SS, Section 219. (Accessed 2014-07-27)

67 ARHS&SS, Section 224. (Accessed 2014-07-27)

68 ARHS&SS, Section 220(1). (Accessed 2014-07-27)

69 ARHS&SS, Section 220(2)-(4). (Accessed 2014-07-27)

70 ARHS&SS, Section 223. (Accessed 2014-07-27)

71 ARHS&SS, Section 225.1. (Accessed 2014-07-27)

72.  In that case, three midwives will participate in the council of physicians, dentists and pharmacists, though they can vote only on matters concerning midwifery. ARHS&SS, Section 225.2. (Accessed 2014-07-27)

73 ARHS&SS, Section 225.6. (Accessed 2014-07-27)

74 ARHS&SS, Section 225.3(1)225.4(2). (Accessed 2014-07-27)

75 ARHS&SS, Section 225.3(2). (Accessed 2014-07-27)

76 ARHS&SS, Section 225.3(5). (Accessed 2014-07-27)

77 ARHS&SS, Section 225.3(4). (Accessed 2014-07-27)

78 ARHS&SS, Section 226. (Accessed 2014-07-27)

79 ARHS&SS, Section 227. (Accessed 2014-07-27)

80 ARHS&SS, Section 188. (Accessed 2014-07-27)

81 ARHS&SS, Sections 189(1), (5), 190(1)-(2). (Accessed 2014-07-27)

82 ARHS&SS, Sections 189(2)-(4), (7), 191, 192. (Accessed 2014-07-27)

83 ARHS&SS, Section 190(3). (Accessed 2014-07-27)

84 ARHS&SS, Section 209. (Accessed 2014-07-27)

85 ARHS&SS, Section 209.1. (Accessed 2014-07-27)

86 ARHS&SS, Section 212(1). (Accessed 2014-07-27)

87 ARHS&SS, Section 212(3). (Accessed 2014-07-27)

88 ARHS&SS, Section 212(4). (Accessed 2014-07-27)

89.  An Act Respecting the Health and Social Services Ombudsman (R.S.Q. c P-31.1) Section 1. (Accessed 2014-07-27)


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