Legalizing therapeutic homicide and assisted suicide

A tour of Carter v. Canada

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Notes

1.  Carter v. Canada (Attorney General) 2012 BCSC 886. (Accessed 2017-04-10). Hereinafter "Carter v. Canada." The judgement refers to the "impugned provisions" of the Criminal Code, including the law against counselling or assisting suicide (Criminal Code, Section 241) and the law that consent is not a defence to a charge of murder (Criminal Code, Section 14). Carter v. Canada, para. 101.

2.  In the summary of the ruling, the judge states that Taylor "will be permitted to seek, and her physician will be permitted to proceed with, physician assisted death." ( Carter v. Canada, para. 19). However, the judge later specifies she is striking down the "impugned provisions" to the extent that they prohibit physician-assisted suicide or consensual physician-assisted death." ( Carter v. Canada, para. 1393(b), emphasis added.) "Consensual physician-assisted death" is distinguished from physician-assisted suicide in the plaintiffs' Amended Notice of Claim (para. 7, 8) and defined as the act of a medical practitioner that causes the death of a patient. This is acknowledged by the judge in the ruling (Carter v. Canada, para. 23). The judge herself does not define the term, but "consensual physician-assisted death" is encompassed by her definition of euthanasia ( Carter v. Canada, para. 38). Consistent with this, the constitutional exemption granted to plaintiff Gloria Taylor states that "the mechanism for the physician-assisted death shall be one that involves her own unassisted act and not that of any other person," unless she is "physically incapable." ( Carter v. Canada, para. 1414(f)) This would authorize a lethal injection by a physician, which, but for the ruling, would be homicide, not assisted suicide.

3.  "Therapeutic homicide" refers to this kind of act, otherwise called euthanasia. The term was not used in the judgement, but in the title of an editorial in the Canadian Medical Association Journal responding to the ruling.  While novel, it is actually a legally precise formulation, since, in Canadian law, 'homicide' refers simply to the killing of a human being, without an implication of illegality. Flegel K. and Fletcher J. "Choosing when and how to die: Are we ready to perform therapeutic homicide?" Early release, 25 July, 2012. CMAJ 2012. DOI:10.1503/cmaj.120961 (Accessed 2012-06-26).

4.  Carter v. Canada (Attorney General) 2015 SCC 5 (Accessed 2017-04-10).

5.  "Assisted-suicide crusader Gloria Taylor dies in B.C. Taylor's death due to a severe infection was sudden and unexpected." CBC News, 5 October, 2012 (Accessed 2017-04-10).

6.   Rodriguez v. British Columbia (Attorney General), 3 S.C.R. 519 (1993), 107 D.L.R. (4th) 342, 85 C.C.C. (3d) 15 (Accessed 2012-06-27).

7.  Protection of Conscience Project, Chief Justice favours assisted suicide, willing to order assistance.

8.  Jocelyn Downie, curriculum vitae (Accessed 2017-04-10).

9.  Dalhousie University, Schulich School of Law, Jocelyn Downie (Accessed 2012-07-16).

10.  The two day conference at Carelton University was called "Ethical, Legal, and Social Perspectives on Physician Assisted Suicide." Professor Downie presented "Rodriguez Revisited: Canadian Assisted Suicide Law and Policy in 2007." Dalhousie University, ListServ Home Page, FABLIST Archives, Message from Rebecca Kukla, 6 February, 2007. "Symposium on physician assisted suicide" (Accessed 2017-04-10).

11.  It does not appear that Prof. Downie's presentation was published. A detailed account of it was written by Alex Schadenberg of the Euthanasia Prevention Coalition, who was present when it was delivered. Schadenberg, Alex, Dalhousie law professor seeks to re-visit Rodriguez court decision. Euthanasia Prevention Coalition.

12.  Downie, Jocelyn and Bern, Simone, "Rodriguez Redux." Health Law Journal 2008 16:27-64 (Accessed 2012-06-27).

13.  Carter v. Canada, para. 124.

14.  In the Supreme Court of British Columbia, Notice of Civil Claim between Lee Carter, Hollis Johnson, Dr. William Shoichet and the British Columbia Civil Liberties Association (Plaintiffs) and the Attorney General of Canada (Defendant) dated 26 April, 2011 (Accessed 2017-04-10) Hereinafter "Original Notice of Claim."

15.  Original Notice of Claim, Part 3, para. 23.

16.  Original Notice of Claim, Part 3, para. 5-11.

17.  Original Notice of Claim, Part 3, para. 12-14.

18.  Original Notice of Claim, Part 3, para. 15-17.

19.  Original Notice of Claim, Part 3, para. 2.

20.  Original Notice of Claim, Part 2, para. 35.

21.  Original Notice of Claim, Part 2, para. 1-3.

22.   Original Notice of Claim, Part 1, para. 6, 7.

23.  BC Civil Liberties Association, "BCCLA launches lawsuit to challenge criminal laws against medically-assisted dying." (26 April, 2011)(Accessed 2017-04-10) (Hereinafter BCCLA release 2011-04-26).

24.  Original Notice of Claim, Part 1, para. 6-9.

25.  In the Supreme Court of British Columbia, between Lee Carter, Hollis Johnson, Dr. William Shoichet, the British Columbia Civil Liberties Association and Gloria Taylor (Plaintiffs) and the Attorney General of Canada (Defendant), Notice of Application and Amended Notice of Civil Claim dated 15 August, 2011 (Accessed 2011-05-01) Hereinafter "Amended Notice of Claim."

26.  Carter v. Canada, para. 137-142.

27.  Carter v. Canada, para. 29.

28.   Canadian Charter of Rights and Freedoms, Section 15. (1) Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age or mental or physical disability.

29.  Carter v. Canada, para. 1026.

30.  Canadian Charter of Rights and Freedoms, Section 1. The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society.

31.  Carter v. Canada, para. 1169.

32.  Canadian Charter of Rights and Freedoms, Section 7. Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.

33.  Carter v. Canada, para. 1331-1332.

34.  Carter v. Canada, para. 1339.

35.  Carter v. Canada, para. 1373-1375.

36.  Canadian Charter of Rights and Freedoms, Section 1. The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society.

37.  Carter v. Canada, para. 1379-1382.

38.  Carter v. Canada, para. 1383.

39.  Carter v. Canada, para. 1288.

40.  Carter v. Canada, para. 1339, 1348, 1361.

41.  Carter v. Canada, para. 1376.

42.  Carter v. Canada, para. 952, 954, 1172, 1217.

43.  Carter v. Canada, para. 1172, 1288, 1348.

44.  F.H. v. McDougall, 2008 SCC 53, 2008 (Accessed 2012-07-02).

45.  Quoted in Carter v. Canada, para. 1178.

46.  Carter v. Canada, para. 114.

47.  Carter v. Canada, para. 115.

48.  Carter v. Canada, para. 157.

49.  Carter v. Canada, para. 144.

50.  Carter v. Canada, para. 115.

51.  Carter v. Canada, para. 653.

52.  Carter v. Canada, para. 656.

53.  Carter v. Canada, para. 657.

54.  Carter v. Canada, para. 667.

55.  Carter v. Canada, para. 671.

56.  Carter v. Canada, para. 672.

57.  Carter v. Canada, para. 684.

58.  Carter v. Canada, para. 685.

59.  Carter v. Canada, para. 709-730.

60.  Carter v. Canada, para. 731.

61.  Carter v. Canada, para. 732-735.

62.  Carter v. Canada, para. 736.

63.  Carter v. Canada, para. 746.

64.  Carter v. Canada, para. 9.

65.  Carter v. Canada, para. 798.

66.  Carter v. Canada, para. 815.

67.  Carter v. Canada, para. 831.

68.  Carter v. Canada, para. 775.

69.  Carter v. Canada, para. 843.

70.  Carter v. Canada, para. 853, 847.

71.  Carter v. Canada, para. 853.

72.  Carter v. Canada, para. 883.

73.  "The party must be of years of discretion, and in his senses, else it is no crime. But this excuse ought not to be strained to that length, to which our coroner's juries are apt to carry it, viz. that the very act of suicide is an evidence of insanity; as if every man, who acts contrary to reason, had no reason at all: for the same argument would prove every other criminal non compos, as well as the self-murderer. The law very rationally judges that every melancholy or hypochondriac fit does not deprive a man of the capacity of discerning right from wrong; which is necessary, as was observed in a former chapter, to form a legal excuse." Blackstone, William, Commentaries on the Laws of England (12th ed), Vol. IV. London: A. Strahan and W. Woodfall, 1795, p. 188-189.

74.  Rodriguez

75.  Carter v. Canada, para. 102-107. The parties and most commentators often fail to distinguish between suicide and attempted suicide. As the judge explicitly states (para. 103-105), it was the offence of attempted suicide - not suicide - that was abolished in 1972. Suicide was an offence at common law in England at Confederation and was thus part of criminal law at that time, but was arguably abolished as an offence in Canada with the enactment of the first Criminal Code in 1892. It was certainly abolished when Parliament formally abolished all common law offences in 1955 (Criminal Code, Section 9).

76.  Carter v. Canada, Part VII (para. 161-884).

77.  Carter v. Canada, para. 175. See Original Notice of Claim, Part 2, para. 1-3. This refers to the liberty interests of others who wish to help someone obtain "physician-assisted dying services," not suicide per se (Original Notice of Claim, Part 3, para. 12-14).

78.  Carter v. Canada, para. 175, 180-181.

79.  Carter v. Canada, para. 180-181.

80.  Carter v. Canada, para. 339. The judge uses the term "ethical," not "moral," and more frequently employs the former, but she treats them as synonyms when addressing the question, "Does the law attempt to uphold a conception of morality inconsistent with the consensus in Canadian society?" (para. 340-358) Moreover, witnesses on both sides do not typically distinguish between ethical and moral issues. See, for example, Dr. Shoichet (plaintiffs) at para. 75, Prof. Sumner (plaintiffs) at para. 237, Dr. Bereza (defendants) at para. 248, Dr. Preston (plaintiffs) at para. 262. The judge defines ethics as "a discipline consisting of rational inquiry into questions of right and wrong" and frames the question accordingly: " whether it is right, or wrong, to assist persons who request assistance in ending their lives and, if it is right to do so, in what circumstances." (para. 164). Most would see in this passage no way to distinguish between ethics and moral philosophy.

 81.  Disagreement may have been implicit in at least some of the more generic statements, such as those offering support for "the sanctity of life," (British Columbia) the "inviolability principle" (Christian Legal Fellowship) and the assertion that "human life is intrinsically valuable and inviolable" (Euthanasia Prevention Coalition). The nearest approach to a challenge appears to have come in a later part of the case from Canada, which asserted that "suicide is not a fundamental institution" (para. 1146) and emphasized that "suicide is not condoned, let alone recognized as a legal right." (para. 1147) However it also argued that disabled people were not disadvantaged by the prohibition of assisted suicide because they could still commit suicide "by refusing treatment, hydration or nutrition,"which implied that suicide could be considered advantageous (para. 1049).

82.  "One justification for the different legal treatment of suicide and assisted suicide is that suicide is essentially a private act and should be judged according to one’s own morality." Somerville, M. Death Talk: The Case Against Euthanasia and Physician-Assisted Suicide. Montreal & Kingston: Queen’s University Press, 2001, p. 103.

83.  Carter v. Canada, para. 813-814.

84.  Carter v. Canada, para. 812, 827. The judge applied this distinction later (para. 833) in referring to evidence from the plaintiffs’ witness: "[W]hile it is possible for a person who is grievously and irremediably ill to be ‘suicidal’ in the traditional sense, this is not necessarily the case for those seeking physician-assisted death and it cannot be assumed to be so. Instead, the decisions often reflect long-held, deep-seated values and are rational, consultative, informed and considered." Note that the "traditional" view applied by the judge was narrower than the older common law approach, which encompassed both culpable and non-culpable suicide.

85.  Carter v. Canada, para. 1262.

86.  Carter v. Canada, para. 842.

87.  Carter v. Canada, para. 339. See statement by Professor Wayne Sumner (para. 237).

88.  Carter v. Canada, para. 234 (Sumner).

89.  This may explain, in part, why Professor Margaret Somerville, upon reading the judgement, was left with "a strong impression that [the judge] is far from neutral about physician-assisted suicide and euthanasia" and that she favoured the interventions in some cases. "Legalizing Euthanasia: Evolution or Revolution in Societal Values?" In Somerville M. Bird on an Ethics Wire: Battles about Values in the Culture Wars. Montreal & Kingston: McGill-Queen’s University Press, 2015, p. 120.

90.  Carter v. Canada, para. 234-236 (Sumner); 242 (Upshur).

91.  This ethical equivalence was arguably implicit in the plaintiff’s use of "assisted dying" to mean both assisted suicide and voluntary euthanasia (Carter v. Canada, para. 23), which was adopted by Madame Justice Smith (para. 39).

92.   Carter v. Canada, para. 237. Professor Margaret Somerville made particular note of this point in her critique of the ruling. "Legalizing Euthanasia: Evolution or Revolution in Societal Values?" In Somerville M. Bird on an Ethics Wire: Battles about Values in the Culture Wars. Montreal & Kingston: McGill-Queen’s University Press, 2015, p. 129-130.

93.  They may be culpably or non-culpably mistaken in identifying the good, or culpably or non-culpably fail to pursue it, but this does not affect the natural orientation of moral reasoning toward something thought to be good in some sense.

94.  Fleming v. Ireland & Ors (2013) IEHC 2 (Accessed 2016-08-28) (Hereinafter "Fleming").

95.  Fleming, para. 87, 90.

96.  The Irish government asserted that the Irish Constitution did not either "expressly or implicitly" provide a right to die, while the Human Rights Commission claimed that people have a right to take their own lives in "defined and extreme" circumstances. (Fleming, para. 6, 9) These sharply contrasting statements may have enabled the Irish judges to see and approach key issues differently.

97.  The evidence of defendant witnesses Dr. Tony O’Brien (Fleming, para. 34-41) and Professor Robert George (para. 42-47) appears to have been clearer and stronger on palliative care, the use of opioids, sedation, palliative sedation and the likely efficacy of safeguards than that offered by defendant witnesses in Carter, although this could also reflect differences in the receptivity to and reporting of the evidence by the judges.

98.  Cross examination of Professor Margaret Pabst Battin, who was also a plaintiff witness in the Carter trial, may have been more effective (Fleming, para. 30-33).

99.  Fleming, para. 69.

100.  Fleming, para. 53, 55, 93.

101.  Fleming, para. 104.

102.  Fleming, para. 67.

103.   Supreme Court of Canada, Webcast of the Hearing on 2014-10-15, 35591, Lee Carter, et al. v. Attorney General of Canada, et al (British Columbia) (Civil) (By Leave). Joseph Arvay, Oral Submission, 84:20/491:20 - 86:45/491:20.

104.  The qualification "ethically"is implicit in the reasoning but not stated.

105.  Carter v. Canada, para. 1039-1050, 1064.

106.  Carter v. Canada, para. 258, 1277-1278.

107.  Carter v. Canada, para, para. 1032.

108nbsp; CarterCarter v. Canada, para. 1158.

109nbsp; Carter v. Canada, para. 1159.

110.  Carter v. Canada, para. 1161.

111.  Carter v. Canada, para, Part XII (paras 1163-1285).

112nbsp; Carter v. Canada, para. 1171.

113.  Carter v. Canada, para. 1169.

114.  Carter v. Canada, para. 168, 1147, 1187.

115.  Carter v. Canada, para. 169.

116.  Carter v. Canada, para. 171.

117.  Carter v. Canada, para. 172.

118. .  ". . . the law of England widely and religiously considers, that no man hath a power to destroy life, but by commission from God, the author of it:and, as the suicide is guilty fo a double offence; one spiritual, in invading the prerogative of the Almighty, and rushing into his immediate presence uncalled for; the other temporal, against the king, who hath an interest in the preservation of all his subjects; the law has therefore ranked this among the highest crimes, making is a peculiar species of felony, a felony committed on one's self. And this admits of accessories before the fact, as well as other felonies; for if one persuades another to kill himself, and he does so, the adviser is guilty of murder." Blackstone, William, Commentaries on the Laws of England (12th ed), Vol. IV. London: A. Strahan and W. Woodfall, 1795, p. 188.

119nbsp; Carter v. Canada, para. 105, 1146.

120.  Carter v. Canada, para. 352.

121.  Carter v. Canada, para. 1185, 1187.

122.  Rodriguez, 595.  Note that "purpose" in relation to the law against assisted suicide is singular.

123.  Rodriguez, 601.  Again, note that "purpose" is singular.

124.  Rodriguez, 608. 

125.  Carter v. Canada, para. 1191.

126.  Carter v. Canada, para. 1187: "In submissions that I take to be alternative to its main submission that Rodriguez is binding. . . "

127.  Carter v. Canada, para. 1189.

128.  Carter v. Canada, para. 1184; see also para. 926.

129.  Carter v. Canada, para. 16, 926, 1116, 1126, 1166, 1184-1185, 1187-1188, 1190, 1199, 1348, 1362.

130.  Carter v. Canada, para. 1202-1206.

131.  Carter v. Canada, para. 1207-1210.

132.  Carter v. Canada, para. 237, 339, 1124, 1136, 1185, 1190, 1362.

133.  Carter v. Canada, para. 1172.

134. Carter v. Canada, para. 1232.

135.  Carter v. Canada, para. 359.

136.  Carter v. Canada, para. 1192-1196, 1230, 1236, 1349, 1351. The term "wrongful death" was rejected by the judge, but for the sake of convenience, she uses it in the ruling nonetheless. Carter v. Canada, para. 755 to 758.

137.  Carter v. Canada, para. 1193.

138.  The possibility of error does not seem to have been a significant factor when abolition actually occurred. The government had a de facto policy of commuting all death sentences to life imprisonment. However, in the summer of 1976 it was faced with the prospect of having to review the death sentences of four men who had unquestionably murdered policemen in circumstances that provided no publicly acceptable rationale for commutation. Two (Vincent Cockriell and John Harvey Miller) had gone looking for a policeman to kill, and two (James Hutchison and Richard Ambrose) had murdered two policemen in New Brunswick (See Malette, Chris, "Cop killers don't deserve mercy (comment)." The Intelligencer, 12 June, 2009. (Accessed 2012-07-02). The trial judge in the latter case said that there were no extenuating circumstances to justify a recommendation for the royal prerogative of mercy. "Moncton hangings delayed." Montreal Gazette, 10 June, 1975 (Accessed 2012-07-03) Seven other men were also awaiting execution at the time. Gadoury, Lorraine and Lechasseur, Antonio, Persons Sentenced to Death in Canada, 1867-1976: An Inventory of Case Files in the Fonds of the Department of Justice. Government Records Division, Government of Canada (Accessed 2012-07-02).

139.  Carter v. Canada, para. 169, 284.

140.  Carter v. Canada, para. 1190.

141.  Carter v. Canada, para. 1200, 1356.

142.  Carter v. Canada, para. 1353.

143.  Carter v. Canada, para. 435, 1198-1199, 1230-1231, 1237.

144.  Carter v. Canada, para. 1240.

145.  For example, Carter v. Canada, para. 653, 815.

146.  Carter v. Canada, para. 1240.

147.  Carter v. Canada, para. 1243.

148.  Carter v. Canada, para. 1246.

149.  Carter v. Canada, para. 1247-1249; 1252.

150.  Carter v. Canada, para. 1268.

151.  Carter v. Canada, para. 1269-1274.

152.  Carter v. Canada, para. 1282.

153.  Carter v. Canada, para. 1264, 1277-1279, 1281.

154.  Carter v. Canada, para. 1275-1276.

155.  Carter v. Canada, para. 1267.

156.  Carter v. Canada, para. 1265.

157.  Carter v. Canada, para. 1283.

158.  Carter v. Canada, para. 940.

159.  Carter v. Canada, para. 1294,1304.

160.  Carter v. Canada, para. 1296-1297.

161.  Carter v. Canada, para. 1303, 1304.

162.  Carter v. Canada, para. 1314.

163.  Carter v. Canada, para. 1315.

164.  Carter v. Canada, para. 1320.

 165.  Carter v. Canada, para. 1322.

166.  Carter v. Canada, para. 1325.

167.  Carter v. Canada, para. 1326.

168.  Carter v. Canada, para. 1327.

169.  Carter v. Canada, para. 1328.

170.  Carter v. Canada, para. 1329.

171.  Carter v. Canada, para. 17.

172.  Carter v. Canada, para. 1337.

173.  Carter v. Canada, para. 1348.

174.  Carter v. Canada, para. 1365, 1367.

175.  Carter v. Canada, para. 1366-1367.

176.  Carter v. Canada, para. 1369.

177.  Carter v. Canada, para. 1370.

178.  Carter v. Canada, para. 1378.

179.  Carter v. Canada, para. 1393.

180.  Supreme Court of Canada, Lee Carter, et al. v. Attorney General of Canada, et al, Webcast of Hearing on 2014-10-15, 100:20/491:20 - 100:44/491:20. (Accessed 2016-08-31).

181. Mr. Arvay used the terms "active and passive euthanasia." Supreme Court of Canada, Lee Carter, et al. v. Attorney General of Canada, et al, Webcast of Hearing on 2016-01-11, 101:27/491:20 - 102:01/491:20 (Accessed 2016-09-13). However, the terms "active" and "passive" euthanasia were not used by the trial court judge. Unlike Mr. Arvay, she did not characterize the withdrawal or withholding of treatment as "passive euthanasia."

182. Carter v. Canada, para. 4 to 10.

183. Carter v. Canada, para. 12 to 18.

184. Carter v. Canada, para. 1393.

185.  Carter v. Canada, para. 1399.

186.  Carter v. Canada, para. 1414.

187.  Carter v. Canada, para. 1415.

188.  Carter v. Canada, para. 1415(b).

189.  Carter v. Canada, para. 883; also para. 16, 342, 1233, 1243, 1267, 1283.

190.  Oregon Death With Dignity Act

191.  Carter v. Canada, para. 414.

192.  In British Columbia, it is acknowledged that suicides may result from stress and depression arising from terminal or debilitating illness or a mental disorder. The cause of death is plainly stated, and the death is classified as a suicide, but if the underlying illness or disorder is known it is reported as a contributing factor. This better serves the end of  transparency.  "Suicides sometime occur as a result of stress and depression because the decedent may have been suffering from a terminal or debilitating illness or mental disorder."  Vital Statistics British Columbia, Physicians' and Coroners' Handbook on Medical Certification of Death and Stillbirth, 2004 Revision, p. 13 (Accessed 2012-07-04).

193.  The underlying cause of death is defined by the World Health Organization as
 "(a) the disease or injury which initiated the train of morbid events leading directly to the death, or (b) the circumstances of the accident or violence which produced the fatal injury." The reason for the definition "is to ensure that all the relevant information is recorded and the certifier does not select some conditions for entry and reject others." World Health Organization, International Statistical Classification of Diseases and Health Related Problems (Tenth Revision) Vol. 2, Second Edition, 2004, p. 23 (Accessed 2012-07-04).

194.  CBC Radio, Cross Country Checkup, 24 June, 2012 (Accessed 2012-06-28).

195. Dr. Charles Bentz and Dr. N. Gregory Hamilton (Oregon); Prof. John Keown (U.S.A.); Baroness Illora Finlay of Llandaff (United Kingdom). Carter v. Canada, para. 160.

196.  Dr. Jean Bernheim and Prof. Luc Deliens (Belgium); Dr. Georg Bosshard (Switzerland); Dr. Linda Ganzini, Ms. Ann Jackson and Dr. Peter Rasmussen (Oregon); Dr. Gerrit Kimsma, Prof. Johan Legemaate and Dr. Johannes J.M. van Delden (Netherlands); Prof. Helene Starks and Dr. Thomas Preston (Washington). Carter v. Canada, para. 160.

197.  Carter v. Canada, para.743-745.

198.  Carter v. Canada, para. 254: Dr. William Shoichet, Dr. Bell, Dr. Marcel Boisvert, Dr. Boyes, Dr. Eric Cassell, Dr. Cohen, Dr. Klein, Dr. Librach, Dr. Meckling, Dr. Smith, Dr. Upshur, Dr. Welch. Canada challenged the weight to be given to the opinions of Dr. Boyes and Dr. Boisvert (para. 255).

199.  Carter v. Canada, para. 261: Dr. Ashby (Australia), Dr. Nancy Crumpacker (Oregon, U.S.A.), Dr. Kimsma (Netherlands), Dr. jThomas Preston (Washington, U.S.A.), Dr. Peter Rasmussen (Oregon, U.S.A.) and Dr. Syme (Australia).

200.  Carter v. Canada, para. 256. Cites Klein, para. 257, Cohen, para. 258, Librach para. 259-260; quotes Preston, para. 262.

201.  Carter v. Canada, para. 263: Dr. Chochinov, Dr. Downing, Dr. Hendin, Dr. Romayne Gallagher, Dr. McGregor, Dr. Jose Pereira, Dr. Sheldon.

202.  Carter v. Canada, para. 265 (McGregor); para. 267 (Downing); para. 268-270.

203.  Carter v. Canada, para. 272 ( Hendin).

204.  Carter v. Canada, para. 271.

205.  University of Manitoba, Dr. Harvey Max Chochinov (Accessed 2012-07-16).

206.  Carter v. Canada, para. 270.

207.  Carter v. Canada, para. 353.

208.  McGill University, Biomedical Ethics: Eugene Bereza (Accessed 2012-07-16).

209.  Carter v. Canada, para. 251.

210.  Carter v. Canada, para. 253.

211.  In response to the interviewer's question, "Why can't we have both?" (i.e. accessible palliative care and assisted suicide/euthanasia for the 3-6% who can't be palliated) he said, ". . . What I think I'm saying to you is 'exactly,' right? Um, in my experience - and it's just my experience - I would honestly say that in the thousands and thousands of cases I've been party to. . . there probably has been, have been a very few where I would argue that it was ethically permissible to consider something like physician assisted suicide or euthanasia. But I'm talking about, possibly I could count on one hand. Because all the others . . . the 98% of the others would have been very well and better handled through good palliative care. For those other rare ones, what can we do? Well, maybe then we should consider some kind of exception, but that's not what we're doing now. We're jumping to that other one before we've taken care of that huge percentage. So my concern - I mean, at the end of the day, I think we might possibly need both, but we're already thinking about changing the second one way before we've addressed the issue of, you know, 65-70% of Canadians can't access the very thing that, if they had, wouldn't make us have to consider this option." CBC Radio, Cross Country Checkup, 24 June, 2012 (Accessed 2012-06-28).

212.  Carter v. Canada, Written Submissions of the Plaintiffs, 1 December, 2011, para. 225 (Accessed 2012-06-16).

213.  Carter v. Canada, para. 265.

214.  Carter v. Canada, para. 354.

215.  Note that the comments about safeguards in the submission of the Christian Legal Fellowship referred only to Professor Keown (para. 23, note 17; para. 70, note 48; para. 72, note 49; para. 73, note 50; para. 75, note 51; para. 78, note 56) and Dr. Hendin (para. 28, note 18) Carter v. Canada, Christian Legal Fellowship's Written Submissions.

216.  United Kingdom House of Lords, Baroness Finlay of Llandaff. (Accessed 2012-06-30)  General Medical Council (U.K.) Developing medical guidance on End of Life Care: Consultative Conference, 3 June, 2009: Professor Baroness Finlay of Llandaff (Accessed 2012-06-30).

217.  Physicians for Compassionate Care Board Members: Charles J. Bentz, M.D.  (Accessed 2012-06-30).

218.  Georgetown University. John Keown (Accessed 2012-06-30).

219.  Centre for Research and Intervention on Suicide and Euthanasia: Brian L. Mishara (Accessed 2012-06-30).

220.  Suicide Prevention Initiatives, Dr. Herbert Hendin (Accessed 2012-06-30).

221  University of Ottawa Department of Medicine, José Pereira MBChB DA CCFP MSc(MEd) (Accessed 2012-06-30).

222. Carter v. Canada, para. 382-386. Baroness Finlay appears to have been responsible for only two articles about assisted suicide and euthanasia in professional journals, both of them responses rather than research papers. Finlay IG, Wheatley VJ, Izdebski C. The House of Lords Select Committee on the Assisted Dying for the Terminally III Bill: implications for specialist palliative care. Palliat Med. 2005 Sep;19(6):444-53; Finlay IG, George R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups--another perspective on Oregon's data. J Med Ethics. 2011 Mar;37(3):171-4. Epub 2010 Nov 11.

223. Carter v. Canada, para. 387.

224.  Carter v. Canada, , para. 411.

225.  Carter v. Canada,, para. 244-245, 374-375, 452, 501.

226. Carter v. Canada,, para. 603.

227. Carter v. Canada, para. 377. Pereira, J. "Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls."    Curr Oncol 2011:18:c38-45.(Accessed 2012-07-16)

228.  Carter v. Canada, para. 373.

229.   Carter v. Canada, para. 504.

230.  Carter v. Canada, para. 664.

231.  Pereira, J. "Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls." Curr Oncol 2011:18:c38-45 (Accessed 2012-07-16).

232.  Downie J. Chambaere K. "Pereira's attack on legalizing euthanasia or assisted suicide: smoke and mirrors." Curr Oncol 2012:19:3:133-138 at 133  (Accessed 2012-07-16).

233.  Farewell Foundation for the Right to Die, Carter Trial, Day 8: Wednesday, November 23, 2011 (Accessed 2012-06-28).

234.  "Pereira makes a number of factual statements without providing any sources. Pereira also makes a number of factual statements with sources, where the sources do not, in fact, provide support for the statements me made. Peirera also makes a number of false statements about the law and practice in jurisdictions that have legalized assisted suicide and euthanasia." Downie J. Chambaere K.  "Pereira's attack on legalizing euthanasia or assisted suicide: smoke and mirrors." Curr Oncol 2012:19:3:133-138 (Accessed 2012-07-16).

Dr. Pereira responded to the criticism, acknowledging "some errors in the references and subtleties that are regrettable," insisting that most of the paper is correct. (Pereira J. "Casting stones and casting aspersions: let's not lose sight of the main issues in the euthanasia debate." Curr Oncol 2012:19:3:139-142 (Accessed 2012-07-16).

235.  Farewell Foundation for the Right to Die, Carter Trial, Day 9-10: November 24-25, 2011 (Accessed 2012-07-16).

236.  Professor Penney Lewis (professor of law, researcher)(commentator); Professor Mary Shariff (researcher); Professor Sabine Machalowski (law); Professor Johan Legematte (professor of health law); Mark Connelly (lawyer, civil liberties advocate); Dr. Georg Bosshard (family physician, ethicist, researcher).

237.  George Eighmey, Jason Renaud and Robb Miller of Compassionate & Choices. Carter v. Canada, para. 407-408.

238.  Dr. Gerritt Kimsma and Dr. Nancy Crumpacker. Carter v. Canada, para. 744-745.

239.  Ann Jackson (retired director and CEO of Oregon Hospice Association). Carter v. Canada, para. 409.

240.  Dr. Michael Ashby (palliative care specialist), Dr. Jean Berheim (oncology, researcher).

241.  Ghent University & Vrije Universteit Brussel End of Life Care Research Group: Luc Deliens (Accessed 2012-06-30).

242.  University of Washington, Department of Health Services: Helene E. Starks (Accessed 2012-06-30).

243.  "A Dutch family practitioner, and an Extern Associate Professor of medical ethics and philosophy at the Radbout University Medical Center in Nijmegen, the Netherlands. He has been a program developer and instructor for the program in the Netherlands that provides support and consultation to physicians in connection with patient requests for euthanasia ("SCEN"). Carter v. Canada, para. 160 .

244.  Oregon University, Health and Science: Linda Ganzini (Accessed 2012-06-30).

245.  University of Utah Dept. of Philosophy, Margaret Battin (Accessed 2012-06-30).

246.  Johannes J.M. van Delden, MD, PhD, curriculum vitae (Accessed 2012-06-30).

247.  Carter v. Canada, para. 521.

248.  Bilsen J. et al, Changes in medical end-of-life practices during the legalization process of euthanasia in Belgium. Soc Sci Med 2007 Aug; 65(4) 803-8.

Chambaere K. et al., Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. Can Med Assoc J 2010 June 15; 182(9) 895-901.

Chambaere K. et al., Trends in Medical End-of-Life Decision Making in Flanders, Belgium 1998-2001-2007. Med Decis Making 2011 May-June 31(3) 500-10.

DDeliens, L. End of Life Decisions in Medical Practice in Flanders, Belgium: A Nationwide Survey. Lancet 2000 Nov. 25 356 (9244) 1806-11.

Smets et al. Legal euthanasia in Belgium: characteristics of all reported euthanasia cases. Med Care. 2010 Feb;48(2):187-92.

Smets T. et al, Euthanasia in patients dying at home in Belgium: interview study on adherence to legal safeguards. Brit J Gen Pract 2010 April: 60 (573).

Smets et al., Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. Brit Med J 2010 Oct 5:341: c5174.

Van Wesemael Y. et al, Process and outcomes of euthanasia requests under the Belgian Act on euthanasia: a nationwide survey.. J Pain Symptom Manage. 2011 Nov;42(5):721-33.

249.  Carter v. Canada, para. 439. One study she co-authored was cited in the ruling: A.J. Bharucha et al., The Pursuit of Physician-Assisted Suicide: Role of Psychiatric Factors. J Palliat Med 2003 Dec; 6(6) 873-83.

250.  Carter v. Canada, para. 160, 489. The study is Norwood F. et al, Vulnerability and the 'slippery slope' at the end-of-life: a qualitative study of euthanasia, general practice and home death in The Netherlands. Fam Prac 2009 26(6): 472-80.

251.  Battin MP et al, Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on 'vulnerable' groups. J Med Ethics 2007 Oct; 33(1); 591-7.

Battin, MP Physician-Assisted Dying and the Slippery Slope: the Challenge of Empirical Evidence (2008) 45 Willamette L Rev 91.

Battin MP et al, a href="http://jme.bmj.com/content/37/3/171/reply"> Legal physician-assisted dying in Oregon and the Netherlands: The question of 'vulnerable' groups. AA reply to I.G. Finlay and R. George. 2011;37:3 171-174.

252.  Carter v. Canada, para. 160.

253.  Carter v. Canada, para. 447, 451. The paper is Ganzini L. et al, Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. Brit Med J 2008 Oct 7; 337 a1682.

254. Carter v. Canada, para. 160.

255.  Carter v. Canada, para. 651-652.

256.  Carter v. Canada, para 664.

257.  Carter v. Canada, para. 653.

258.  Carter v. Canada, para. 576-577.

259.  Dr. Eugene Bereza: para. 807, 821; Dr. Harvey Chochinov: para. 801, 815, 827-828, 830; Dr. G. Michael Downing: para. 839; Euthanasia Prevention Coalition: para. 853; Baroness Finlay: para. 774, 797, 808, 841 ; Professor Catherine Frazee: para. 811, 815, 848-851, 853; Dr. Romayne Gallagher: para. 765, 771-772, 797, 801, 808, 815, 821, 822-823, 840; Professor Marnin Heisel: para. 768-769, 792, 796, 812, 815, 827, 845; Dr. Herbert Hendin: para. 794, 796; David Martin: para. 848; Professor Brian Mishara: para. 766-767, 791, 796, 799-800, 809, 832-834, 838 ; Dr. Jose Pereira: para. 821; Dr. Gary Rodin:para. 827-828; Dr. Leslie J. Sheldon: para. 776, 796 ; Rhonda Wiebe: para. 848.

260.  Professor Margaret Battin: para. 833, 835, 842-843, 847, 852; Professor Jean Bernheim: para. 807, 821, 846; Professor Luc Deliens: para. 846-847, 852; Dr. Martha Donnelly: para. 762-764, 781-784, 790, 794, 803-804, 815; Mr. Eighmey: para. 836;
Dr. Linda Ganzini: para. 775, 777, 788-789, 793-794, 802-803, 805, 809, 815, 824, 828-829, 835, 847; Dr. Scott K. Meckling: para. 773, 825; Dr. Peter Rasmussen: para. 810; Mr. Renaud: para. 836; Dr. Derryck Smith: para. 778-780, 786-787, 794; Professor Helene Starks: para. 828, 835; Dr. Johannes J. M. van Delden: para. 847; Professor James Werth: para. 813-814, 833.

261.  Carter v. Canada, para. 795-797.

262.  Carter v. Canada, para. 815.

263.  Carter v. Canada, Christian Legal Fellowship's Written Submissions, para. 85.

264.  Carter v. Canada, para. 161-162, 183, 316.

265.  Carter v. Canada, para. 173.

266.  Carter v. Canada, para. 173.

267.  Carter v. Canada, para. 173.

268.  Carter v. Canada, para. 165.

269.  Carter v. Canada, para. 317.

270.  Carter v. Canada, para. 163.

271.  Carter v. Canada, para. 174.

272.   Carter v. Canada, para. 175.

273.  Carter v. Canada, para. 176.

274.  Carter v. Canada, para. 177.

275.  Carter v. Canada, para. 1184-1190.

276.  Carter v. Canada, para. 178.

277.  Carter v. Canada, para. 364.

278.  Carter v. Canada, para. 370.

279.  Carter v. Canada, para. 173.  Emphasis added.

280.  Carter v. Canada, para. 175. See Original Notice of Claim, Part 2, para. 1-3. This refers to the liberty interests of others who wish to help someone obtain "physician-assisted dying services," not suicide per se. (Original Notice of Claim, Part 3, para. 12-14)

281.  Carter v. Canada, para. 175, 180-181.

282.  Carter v. Canada, para. 164.

283.  Carter v. Canada, para. 173.

284.  St. Augustine, On the Free Choice of the Will (De Libero Arbitrio Voluntatis), Book I,V. Indianapolis-New York: Bobbs-Merrill, 1964, p. 11; St. Thomas Aquinas, Summa Theologica, II.I.96.4 (Accessed 2012-07-10); King, Martin Luther, Letter from Birmingham Jail, 16 April, 1963. (Accessed 2017-04-05)

285.  Carter v. Canada, para. 163, 200, 234, 236, 300, 303-306, 308-309, 311, 322, 349. Such reference also occur outside Part VII: para.5, 8, 492, 1198, 1336, 1369.

286.  Carter v. Canada, para. 254,259.

287.  Carter v. Canada, para. 261.

288.  Carter v. Canada, para. 263.

289.  Carter v. Canada, para. 265-267, 270.

290.  Carter v. Canada, para. 319, 344.  They are identified in para. 254.

291.  "Germany's medical association has adopted a declaration apologizing for sadistic experiments and other actions of doctors under the Nazis. . . The medical association says "these crimes were not the actions of individual doctors but involved leading members of the medical community" and should be taken as a warning for the future." "German medical association apologizes for Nazi-era crimes committed by doctors." Associated Press, 25 May, 2012. (Accessed 2012-07-23). See alslo Lifton, Robert Jay, The Nazi Doctors: Medical Killing and the Psychology of Genocide. United States: Basic Books, 1986, p.33-35.

292.  For example, "The nature of a fiduciary relationship makes a consensual sexual relationship between physician and patient impossible." College of Physicians and Surgeons of British Columbia, Professional Standards and Guidelines: Sexual Boundaries in the Physician-Patient Relationship (October, 2009) (Accessed 2012-07-10).

293.  Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG), Seksueel contact tussen arts en patiënt: Het mag niet, het mag nooit. [Royal Dutch Medical Association, Sexual contact between doctor and patient: It should not be, it should never be.](2000) (Accessed 2012-07-10).

294.  Royal Dutch Medical Association, The Role of the Physician in the Voluntary Termination of Life (30 August, 2011) (Accessed 2012-07-12).

295.  General Medical Council, Maintaining Boundaries: Guidance for Doctors. (November, 2006) (Accessed 2012-07-19); Hunt, Liz, "Sex with patients remains taboo. BMA conference: Doctors take steps to repair their tarnished image." The Independent, 28 June, 1996 (Accessed 20-12-07-19).

296.  Barilan, Y Michael, Of Doctor-Patient Sex and Assisted Suicide. IMAJ 5:460-463. June, 2003. (Accessed 2012-07-10).

297.  Carter v. Canada, para. 274-277.

298.  Carter v. Canada, para. 233. Plaintiff witnesses: Prof. Wayne Sumner; Dr. Marcia Angell; Prof. Margaret Battin; Dr. Upshur; Dr. Gerritt Kimsma. Defendant witnesses: Prof. John Keown; Prof. Thomas Koch; Dr. Bereza.

299.  Carter v. Canada, para. 234.

300.  Carter v. Canada, para. 238.

301.  Carter v. Canada, para. 242.

302.  Carter v. Canada, para. 240.

303.  Carter v. Canada, para. 246-247.

304.   Carter v. Canada, para. 244.

305.  Carter v. Canada, para. 253.

306.  Carter v. Canada, para. 235-236.

307.  Carter v. Canada, para. 251.

308.  Carter v. Canada, para. 243.

309.  Carter v. Canada, para. 203-204, 680.

310.   Carter v. Canada, para. 1370.

311.   Carter v. Canada, para. 185.

312.  Carter v. Canada, para. 207-223.

313.  Carter v. Canada, para. 227-230.

314.  Carter v. Canada, para. 231.

315.  Carter v. Canada, para. 318, 320.

316.  Carter v. Canada, para. 163, 176; 186, 234-237, 321-322.

317.  Carter v. Canada, para. 177.

318.  Carter v. Canada, para. 278-284, 286-287.

319.   Carter v. Canada, para. 285.

320.  Carter v. Canada, para. 347.

321.  Carter v. Canada, para. 280.

322.  Carter v. Canada, para. 347.

323.  Carter v. Canada, para. 288-292.

324.  Carter v. Canada, para. 295-296, 298.

325.  Prof. Sheila McLean, Prof. Jocelyn Downie, Prof. Ross Upshur, Prof. Johannes J.M. van Delden, Prof. Udo Schuklenk.

326.  Carter v. Canada, para. 123. The witnesses were Prof. Ross Upshur, Prof. Johannes J.M. van Delden and Prof. Udo Schuklenk. Prof. Jocelyn Downie instructed plaintiff witnesses.

327.  Carter v. Canada, para. 124.

328.  Couture, Linda, Results of public hearings held by The Select Committee on dying with dignity in Quebec: Briefs submitted. (15 November, 2011) (Accessed 2012-07-22).

329.  Carter v. Canada, para. 290-292, 346.

330.  Carter v. Canada, para. 346.

331.  Carter v. Canada, para. 300-307.

332.  Carter v. Canada, para. 355.

333.  Carter v. Canada, para. 299.

334.  Director of Public Prosecutions, Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide. February, 2010, para. 43.14
(Accessed 2012-07-13).

335.  Carter v. Canada, para. 314-315.

336.  Carter v. Canada, para. 309; 190-193.

337.  Carter v. Canada, para. 309.

338.  Carter v. Canada, para. 310.

339.  Carter v. Canada, para. 311. Her comment also demonstrates she shaping and limiting power of the pleadings, which exclude consideration of others whose interests might be affected by the judgement.

340.  Carter v. Canada, para. 312-313.

341.   Carter v. Canada, para. 316.

342.   Carter v. Canada, para. 364.

343.   Carter v. Canada, para. 370.

344.  Carter v. Canada, para. 326-333.

345.  Carter v. Canada, para. 321-323.

346.  Carter v. Canada, para. 324-325.

347.  Carter v. Canada, para. 330.

348.  Rodriguez, 607.

349.  Carter v. Canada, para. 929.

350.  Carter v. Canada, para. 334.

351.  Carter v. Canada, para. 5.

352.  Carter v. Canada, para. 335.  Emphasis added. She elsewhere referred to this as "the preponderant ethical opinion" (para. 1336).

353.  Carter v. Canada, para. 336-337.

354.  Carter v. Canada, para. 338.

355.  Carter v. Canada, para. 1369.

356.  "If a legal rule requires a fact to be proved (a "fact in issue"), a judge or jury must decide whether or not it happened. There is no room for a finding that it might have happened. The law operates a binary system in which the only values are 0 and 1. The fact either happened or it did not. If the tribunal is left in doubt, the doubt is resolved by a rule that one party or the other carries the burden of proof. If the party who bears the burden of proof fails to discharge it, a value of 0 is returned and the fact is treated as not having happened. If he does discharge it, a value of 1 is returned and the fact is treated as having happened." Re B (Children) [2008] UKHL 35; [2008] 2 FLR 141, para. 2. (Accessed 2016-08-27).

357.  "In any civil case the plaintiff must prove their case on a balance of probabilities if they are to succeed. This means that the plaintiff must prove that his facts tip the scale in his favor even if it is only a 51% probability that he is correct." McIver v. Power, [1998] P.E.I.J. No. 4, Prince Edward Island Supreme Court, para. 5.
(Accessed 2016-08-27).

358.   Sopinka, J. (For the majority): "Medical experts ordinarily determine causation in terms of certainties whereas a lesser standard is demanded by the law." Quoting Louisell, David W. Medical Malpractice, vol. 3. By Charles Kramer. New York: Matthew Bender, 1977-1990, in Snell vs. Farrell [1990] 2 SCR 311 (Accessed 2016-08-27).

359.  Carter v. Canada, para. 339.

360.  Carter v. Canada, para. 335, 339.

361.  Sopinka, J. (For the majority): "The administration of drugs designed for pain control in dosages which the physician knows will hasten death constitutes active contribution to death by any standard. However, the distinction drawn here is one based upon intention -- in the case of palliative care the intention is to ease pain, which has the effect of hastening death, while in the case of assisted suicide, the intention is undeniably to cause death. The Law Reform Commission, although it recommended the continued criminal prohibition of both euthanasia and assisted suicide, stated, at p. 70 of the Working Paper, that a doctor should never refuse palliative care to a terminally ill person only because it may hasten death. In my view, distinctions based upon intent are important, and in fact form the basis of our criminal law. While factually the distinction may, at times, be difficult to draw, legally it is clear. The fact that in some cases, the third party will, under the guise of palliative care, commit euthanasia or assist in suicide and go unsanctioned due to the difficulty of proof cannot be said to render the existence of the prohibition fundamentally unjust"( Rodriguez, 607). Only Mr. Justice Cory asserted that there was no difference between withdrawal or withholding treatment and euthanasia, though he did not dispute the majority’s statement about the significance of intention (Rodriguez, 630-631).

362.  Carter v. Canada, para. 328-330.

363.  Carter v. Canada, para. 340, 357.

364.  Carter v. Canada, para. 5

365.  Carter v. Canada, para. 8-10, 15-18

366.  Sachedina, Abdulaziz, Islamic Biomedical Ethics: Principles and Application. Oxford: University Press, 2009, p. 166

367.  Carter v. Canada, para. 350

368.  Carter v. Canada, para. 171.

369.  Carter v. Canada, para. 351.

370.  Carter v. Canada, para. 343.

371.  Carter v. Canada, para. 345-346.

372.  Carter v. Canada, para. 348.

373.  Carter v. Canada, para. 358. See also para. 6, 7.

374.  Carter v. Canada, para. 342, 358.

375.  Carter v. Canada, para. 4-7.

376.  Carter v. Canada, para. 8-10.

377.   Halsbury’s Laws of England, Vol. 12 (2009) 5th Ed., Paras. 1109-1836 /3. Organization and Administration of Civil Courts/(11) Judicial Decisions as Authorities. (Accessed 2016-09-02).

378.  "Obiter dicta" and "judicial dicta." The former are often described as the "passing remarks" of a judge. Part VII of Carter, expressing more considered opinions, falls within the latter category.

379.  Carter v. Canada, para. 231.

380.  Carter v. Canada, para. 309.

381.  Carter v. Canada, para. 231.

382.  General Medical Council, End of life care: Clinically assisted nutrition and hydration. (Accessed 2012-07-27)

383.  For an exchange of views on this and an introduction to some of the complexities of providing assisted nutrition and hydration, see Craig G, On withholding nutrition and hydration in the terminally ill: has palliative medicine gone to far? JMed Ethics, 1994 20: 139-143 ( Accessed 2012-07-27); Dunlop RJ, Ellershaw JE, Baines MJ, Sykes N, Saunders CM, On withholding nutrition and hydration in the terminally ill: has palliative medicine gone to far? A reply. JMed Ethics 1995; 21:141-143 (Accessed 2012-07-27); Ashby M, Stoffell B, Artificial hydration and alimentation at the end of life: a reply to Craig. J Med Ethics 1995; 21:135-140 (Accessed 2012-07-27)

384.  "To withdraw fluids and food from a person who is not otherwise dying, even if that person has a significant cognitive disability, is euthanasia because death is directly and intentionally caused by the withdrawal of basic care, that being fluids and food. Whether fluids and food are provided by a fork, a spoon or a tube, they represent a basic necessary of life that should be provided unless the person cannot assimilate or is actually nearing death." Schadenberg, Alex, "UK Judge decides not to dehydrate woman to death." Euthanasia Prevention Coalition, 29 September, 2011. (Accessed 2012-07-26)

385.  Patricia Brophy (1986) [Patricia E. Brophy v. New England Sinai Hospital, 398 Mass. 417; 497 N.E.2d 626; 1986 Mass. LEXIS 1499 (Accessed 2012-07-26)]; Nancy Cruzan (1990) [Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990) (Accessed 2012-07-25)]; Tony Bland (1993) [Airedale NHS Trust (Respondents) v.Bland (acting by his Guardian ad Litem) (Appellant) (4 February 1993) (Accessed 2012-07-26)]; Terri Schiavo (1998-2005 ) [Findlaw Special Coverage, Terri Schiavo Case: Legal Issues Involving Health Care Directives, Death and Dying. (Accessed 2012-07-26)]; Eulana Englaro (2009) [Procedimento Escritto Nel Reg. della Vol. Giur. al n.:88/2008, La Corte d'Appello di Milano, Prima Sezione Civile (25 June, 2008) (Accessed 2012-07-26)

386.  Donadio, Rachel, "Death ends coma case that set of furor in Italy." New York Times, 9 February, 2009 (Accessed 2012-07-25). Three Canadian cases cited in Carter concerned withdrawal of interventions, but none raised the specific issue of assisted nutrition and hydration. In Golubchuk and Rasouli the patients were on ventilators as well as having assisted nutrition and hydration, while in Sawatzky the issue was a "Do Not Resuscitate" order that had been improperly issued. Golubchuk v. Salvation Army Grace General Hospital 2008 MBQB 49 (Accessed 2012-07-26);
Rasouli v. Sunnybrook Health Sciences Centre 2011 ONCA 482 (Leave to appeal to SCC granted [2011] SCCA No. 329) (Accessed 2012-07-26); Sawatzky v. Riverview Health Centre Inc. (1998) 167 DLR (4th) 359 (Man QB)
Benson, Iain T., Miller Brad, "Court Gives Course in Medical Ethics to Public Trustee." Lexview 23.0, 8 December, 1998 (Accessed 2012-07-26)

387.  Carter v. Canada, para. 207-220; CLF para. 42-44..

388.  Carter v. Canada, para. 1065-1076.

389.  Carter v. Canada, para. 221-224.

390.  Rosin J, Sonnenblick M, Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation. J Med Ethics 1998; 24:44-48 (Accessed 2012-07-27).

391.  Congregation for the Doctrine of the Faith, Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration (1 August, 2007) (Accessed 2012-07-27).

392.  This was the view of Lord Keith in Airedale NHS Trust (Respondents) v.Bland (acting by his Guardian ad Litem) (Appellant) (4 February 1993) (Accessed 2012-07-26 )

393.  Somerville, Margaret, Death Talk: The Case Against Euthanasia and Physician-Assisted Suicide. Montreal & Kingston: McGill-Queens University Press, 2001, p. 362, note 161.

394.  Carter v. Canada, para. 224.

395.  Carter v. Canada, para. 245.

396.  Carter v. Canada, Christian Legal Fellowship's Written Submissions, para. 46, citing cross examination of Prof; Keown at p. 29-30 and 80. (Accessed 2012-07-27).

397.  Carter v. Canada, para. 257.

398.  Carter v. Canada, para. 1071.

399.  Carter v. Canada, para. 312.

400.  Carter v. Canada, para. 313.

401.  Carter v. Canada, para. 321.

402.  Carter v. Canada, para. 323.

403.  Carter v. Canada, para. 1049, 1067, 1068.

404.  Ng v. Ng 2013 BCSC 97 (Accessed 2016-09-01). While the case was decided after the trial court ruling in Carter, the relevant statutory framework predated the Carter decision.

405.  Carter v. Canada, para. 200.

406.  Carter v. Canada, para. 201, 202, 226.

407.  Carter v. Canada, para. 201, 202, 226, 312.

408.  The judge also mentions controversy about the use of palliative sedation for "relief of existential suffering," (Carter v. Canada, para. 312), which refers to a sense of loss of dignity or other non-physical symptoms (Carter v. Canada, para. 190, 312). There is controversy among palliative care practitioners about this, but the judge gives no account of it in the ruling. Moreover, the context of the remark is again indicative of the context of the withdrawal of assisted nutrition and hydration.   This lack of clarity is unhelpful.

409.  The Royal Society of Canada, Report of the Expert Panel: End of Life Decision Making, p. 34 (Accessed 2012-07-27).

410.  Sachedina, Abdulaziz, Islamic Biomedical Ethics: Principles and Application. Oxford: University Press, 2009, p. 170.

411.  Hilberman M, Kutner J, Parsons D, Murphy DH, Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR). J Med Ethics, 1997; 23: 361-367 (Accessed 2012-07-29 ) Note that the decision to complete an advance directive or order is properly determined by the medical history, needs and condition of an individual, not by membership in a sub-group of patients.

412.  Somerville, Margaret, Death Talk: The Case Against Euthanasia and Physician-Assisted Suicide. Montreal & Kingston: McGill-Queens University Press, 2001, p. 73.

413.  Eisenberg, Daniel, The Sanctity of the Human Body. Catechism of the Catholic Church, 2288; Sachedina, Abdulaziz, Islamic Biomedical Ethics: Principles and Application. Oxford: University Press, 2009, p. 168, 183-184.

414.  See, for example, Carter v. Canada, Christian Legal Fellowship's Written Submissions, para. 45 (Accessed 2012-07-27).

415.  Carter v. Canada, para. 324-325

416.  Carter v. Canada, para. 330

417.  Carter v. Canada, para. 321. She later states that she found this argument "persuasive." Carter v. Canada, para. 335.

418.  Karen Ann Quinlan Memorial Foundation, History of Karen Ann Quinlan and the Memorial Foundation. (Accessed 2012-07-30)

419.  Carter v. Canada, para. 5