I.    Introduction

I.1    The Protection of Conscience Project is a non-denominational, non-profit initiative that advocates for freedom of conscience among health care workers who want to provide the best care for their patients without violating their own personal and professional integrity. It is supported by an Advisory Board and team.

I.2    The Project does not take a position on the moral/ethical acceptability of contested services like euthanasia and assisted suicide. This submission is thus limited to consideration of sections 8–10 and 14 of Alberta Government Bill 18 (2026)1 in relation to the exercise of freedom of conscience.

II.    Relevant considerations

II.1    The Project’s review of the relevant provisions of Bill 18 reflects seven considerations, three drawn drawn directly from the Supreme Court judgement in Carter v. Canada (Attorney General) 2015 SCC 52 in which the Project was an intervener.

1. Only two rights were established by Carter. Both are negative rights subject to Section 1 of the Canadian Charter of Rights and Freedoms:

a) state actors must not impede or obstruct patients seeking euthanasia and assisted suicide (EAS/MAiD) from willing practitioners, and

b) state actors must not impede or obstruct willing practitioners who wish to provide EAS/MAiD (See Appendix “A”).

2. The Supreme Court of Canada expressly limited the Carter ruling to a declaration that the absolute criminal prohibition of EAS/MAiD was constitutionally invalid. Carter imposed no duty to enact legislation to facilitate EAS/MAiD. Health care practitioners have no individual or collective obligation to provide EAS/MAiD (See Appendix “B”).

3. The Supreme Court also stated that a decision to participate in EAS/MAiD (which includes but is not limited to providing the services) is a matter of conscience or religious belief. On this point it cited comments by Justice Beetz in R v Morgentaler, which imply that neither objecting health care facilities nor objecting practitioners can be compelled to participate directly or indirectly in EAS/MAiD (See Appendix “B”).

4. All hospitals and other health care facilities are entitled to exercise freedom of conscience to protect their moral/ethical integrity (See Appendix “C”).

5. All denominational/religious hospitals and health care facilities are entitled to exercise freedom of religion and association to protect their religious/denominational integrity in secular public health care systems (See Appendix “D”).

6. Non-governmental health care facilities and practitioners who refuse to provide or collaborate in EAS/MAiD for reasons of conscience are not government actors in relation to those services and do not violate the Charter by refusing to do so (See Appendix “E”).

7.  Distinctions between perfective and preservative freedom of conscience must be recognized. The primacy and priority of preservative freedom of conscience must be affirmed, and preservative freedom of conscience must be provided especially robust protection in law and policy (See Appendix “F”).

III.    Section 8

III.1    Provisions

III.1.1    Section 8 applies to nurse and medical practitioners and health care facilities defined in Section 1(h) or prescribed by regulation, including hospitals, practitioner clinics, continuing care homes and supportive living accommodations.

III.1.2    In the case of nurse and medical practitioners, Section 8 applies to - refusal to provide EAS/MAiD as defined by the Criminal Code: that is, refusal to administer, prescribe or provide a lethal substance intended to kill a person or to be used by a person to kill himself [s 8(1)a]; and - refusal to provide an opinion about either the foreseeability of natural death or whether an individual meets “federal eligibility criteria” [s 8(1)b].

III.1.3    In the case of health care facilities, Section 8 applies to refusal to permit practitioners from providing EAS/MAiD or related opinion as to forseeability of natural death or the “eligibility” of an individual.

III.1.4    When practitioners or heath care facilities refuse to provide EAS/MAiD or offer a related opinion, Section 8 requires them to direct the individual refused or his representative “to a resource” that they “reasonably [believe] would provide accurate information about all available medical options.”

III.1.5    Section 8 does not apply to refusals to facilitate, aid or assist in providing EAS/MAiD by means other than immediate participation, nor does it apply to refusals to perform or permit evaluations or assessments to establish “eligibility” for EAS/MAiD.

III.1.6    Section 8 does not protect regulated healthcare professionals other than nurse and medical practitioners.

III.1.7    Section 8 does not specify or limit motivations for refusal. Motivations could include practical considerations (e.g. pyscho-social constraints or limitations, lack of resources or suitable private operational space). They may also involve religious or non-religious matters of thought, opinion or belief or the exercise of freedom of religious or non-religious association. Finally, refusals may be motivated by moral/ethical convictions applied in the exercise of freedom of conscience — the focus of this submission.

III.2    Project comment

Refusal of practitioners to provide EAS/MAiD & related opinions

III.2.1    Section 8(1)a: Affirmation of the freedom of nurse and medical practitioners to refuse to provide EAS/MAiD is satisfactory.

III.2.2    Section 8(1)b: Affirmation that they can refuse to provide an opinion related to EAS/MAiD is, for practical purposes, sufficient to prevent them from being compelled to provide assessments/evaluations related to the procedures. There would be no point in compelling them to provide assessments if they could refuse to provide the results of the assessments.

III.2.3    However, in two respects Section 8 is too narrow.

i) Need to prevent other forms of coerced collaboration

III.2.4    Since the legalization of EAS/MAiD, only a few of the most strident EAS/MAiD and human rights activists have demanded that objecting health care professionals must personally kill their patients or help them to commit suicide.3 Rather, EAS/MAiD activists typically demand that practitioners unwilling to kill their patients or help them commit suicide must refer patients to someone willing to do so and/or positively assist them to connect with an EAS/MAiD practitioner.4 Health Canada supports such policies (generally called “effective referral”).5

III.2.5    Policies demanding effective referral and other forms of collaboration with EAS/MAiD are unacceptable to many who object to the procedures for reasons of conscience. They also encourage aggressive harassment and intimidation of objecting practitioners. Seven Canadian physicians warned their international colleagues in 2019 that these pressures were creating toxic practice environments. “For refusing to collaborate in killing our patients,” they wrote, “many of us now risk discipline and expulsion from the medical profession,” are accused of human rights violations and “even called bigots.”6

III.2.6    Almost 60 Canadian physicians from across the country endorsed the article. Signatories included a Canadian Medical Hall of Fame member known as the father of palliative care in North America,7 a member of an expert advisory group on euthanasia and assisted suicide convened by Canadian provinces and territories,8 and a regional director of palliative care who resigned when a health authority demanded that objecting hospices permit euthanasia and assisted suicide on their premises.9 The Project is aware of practitioners who have left geriatric and palliative practice or left provinces because of such pressures.

ii. Need to protect other regulated health professionals

III.2.7    While medical and nurse practitioners are the only regulated health professionals authorized to provide EAS/MAiD and related assessments, they are not the only regulated health professionals likely to be called upon to collaborate in the services. Pharmacists supply the lethal drugs required for the services and are mentioned several times in the Criminal Code in that regard. Registered nurses, licensed practical nurses, health care aides, psychologists and others — including ambulance paramedics10 – may be called upon to assist with or facilitate EAS/MAiD and related assessments. These and other forms of collaboration with EAS/MAiD are unacceptable to many who object to the procedures for reasons of conscience.

III.2.8    There is no principled reason to deny the protection afforded by Section 8 to medical and nurse practitioners to all regulated health professionals. On the contrary: there would seem to be greater need for it, since other regulated health care professionals may lack the status, independence and employment security usually associated with medical and nurse practitioners.

iii) Recommendations

III.2.9 Section 8 should be amended to include an affirmation of the freedom of all regulated health professionals to refuse to provide or actively assist in or facilitate the provision of EAS/MAiD, and to prohibit bullying or harassment of and discrimination against regulated health professionals who refuse to collaborate in the services.

Refusal of health care facilities to permit EAS/MAiD

III.2.10    Section 8(2): Affirmation of the freedom of health facility operators to refuse to permit EAS/MAiD on their premises is laudable and necessary from the perspective of freedom of conscience, though some health facility refusals may be based on concerns that do not arise for individual practitioners.

Refusal of health care facilities to permit opinions

III.2.11    Section 8(2): The provision that affirms the freedom of health facility operators to refuse to permit the provision of opinions related to EAS/MAiD on their premises invites confusion and conflict because its practical application to facilities is different from its application to individual practitioners (see III.2.2).

III.2.12    Refusing to permit the provision of opinions about the foreseeability of natural death or “eligibility” for EAS/MAiD is not the same as refusal to permit evaluations or assessments that would form the basis for such opinions. To illustrate: an Alberta entity analogous to the Delta Hospice Society may interpret Bill 18 to affirm its freedom to disallow EAS/MAiD assessments in its health care facilities and enact a policy to that effect. However, patients and EAS/MAiD practitioners, pointing to the present text of Section 8, may ignore and challenge enforcement of the policy. The validity of a regulation establishing an exclusion zone based on such a policy would be equally open to challenge.

Recommendation

III.2.13    Assuming that Bill 18 is intended to affirm the freedom of the operators of health care facilities to refuse to allow EAS/MAiD assessments in their premises, that is what Section 8 should say.

Duty of refusing practitioners/facilities

III.2.14    Section 8(3):  The duty to direct an individual or his representative “to a resource” that refusing practitioners or facility operators “reasonably [believe] would provide accurate information about all available medical options” does not require that refusing practitioners or facilities direct an individual to an EAS/MAiD practitioner nor to a dedicated EAS/MAiD delivery service.

III.2.15   This is a critical distinction because many practitioners or facilities refusing EAS/MAiD for reasons of conscience would consider such a requirement an unacceptable form of collaboration. On the other hand, these practitioners and facilities would likely be willing to direct an individual to a resource like MyHealthAlberta.ca11 or Health Link 81112 precisely because these resources provide information about all options (including EAS/MAiD).

III.2.14    The balance struck by S 8 allows those refusing for reasons of conscience to preserve their moral/professional integrity by stepping aside to avoid complicity in EAS/MAiD while allowing individuals to seek the services from willing practitioners and facilities.

IV.    Section 9

IV.1    Provisions

IV.1.1    Section 9 applies only to health care facilities that refuse to permit “health services” as defined in Section 8 (i.e., EAS/MAiD and/or provision of related opinions). They are required to notify the responsible government minister of their refusal. See II.2.11-12 for an explanation of the problems likely to arise from the present text of Section 8.

IV.1.2    Upon receiving such notice, Section 9 requires the responsible government minister to “establish an exclusion zone” within 150 metres of the legal boundary of the facility, apparently by means of a regulation made by order–in-council. Neither the refusing health care facility nor the responsible minister have any discretion as to requesting or establishing exclusion zones.

IV.1.3    Once an exclusion zone has been established, practitioners must not provide services within the exclusion zone that have been prohibited by the health care facility it encompasses except as specified in the exclusion zone regulation.

IV.2    Project comment

IV.2.1    It does not appear that Section 9 is essential to ensure the protection of freedom of conscience in the operation of a health care facility, though in some circumstances it may be desirable for the protection of patients,13 or from the perspective of the Alberta government or of a particular facility.

V.    Section 10

V.1    Provisions

V.1.1    Unlike Section 8, Section 10 applies to all regulated health professionals. Regulated health professionals in Alberta include registered nurses, licensed practical nurses, health care aides, psychologists, therapists and counsellors, midwives, social workers, dental professionals, and others.14

V.1.2    Section 10(1) prohibits all regulated health professionals from publicly displaying or permitting the public display of information about EAS/MAiD a defined health care facility, which would include a practitioner’s clinic.

V.1.3    Section 10(2) prohibits all regulated health professionals from providing information about EAS/MAiD “in the course of providing a health service” unless the individual they are serving requests such information “on their own initiative.”

V.2     Project comment

V.2.1    This kind provision exists in some legislation outside Canada.15 While it is intended to protect vulnerable people during interactions with health professionals, it also ensures that practitioners unwilling to initiate discussion of euthanasia or assisted suicide cannot be compelled to do so.

V.2.2    Practitioners may be unwilling to gratuitously raise EAS/MAiD

a) in particular cases due to susceptibilities of an individual being served; or

b) in all cases, because they believe doing so always entails an unacceptable risk of harm; or

c) in all cases, because they want to avoid complicity in EAS/MAiD.

V.2.3    Note that practitioners who do not object to euthanasia/assisted suicide in principle may take positions (a) or (b).

V.2.4    Note that all of these positions entail the exercise of freedom of conscience, since in all these situations the practitioner is motivated by a belief that to raise EAS/MAiD gratuitously is or is likely to be harmful, and that it would be immoral/unethical to do so. Refusing to do something thought to be harmful is not infrequently cited as an ethical requirement of medical practice and therefore a (not only permissible but required) exercise of “professional” conscience. A distinction between “professional” and “personal” conscience in these situations is erroneous.16

VI.    Section 14    

VI.1    Provisions

VI.1 Section 14 authorizes the Lieutenant Governor in Council to make regulations concerning the delivery of EAS/MAiD. Regulations relevant to this submission are those that would govern the operation of Section 8 and 9, particularly those “respecting the direction of an individual or their representative for the purpose of section 8(3).”

VI.2    Project comment

VI.2.1    It is important to ensure that regulations drafted under Section 14 do not weaken or introduce any ambiguity regarding the obligations of a refusing practitioner or health care facility set out in Section 8(3). This will be especially important after the legislation has been in force for some time and regulations are amended or prepared by individuals not involved with the development of Bill 18.

VII.    Summary of Project recommendations

Section 8

VII.1    The protection offered under Section 8(1)a and 8(1)b to medical and nurse practitioners should be extended to include

 a) all regulated health professionals; and

b) refusal to aid or assist in providing EAS/MAiD by means other than immediate participation, including refusal to perform evaluations or assessments to establish “eligibility” for the procedures.

VII.2    The protection offered under Section 8(2) to health care facilities should be clarified by affirming their freedom to refuse to permit EAS/MAiD and EAS/MAiD evaluations, assessments and opinions on their premises.

Section 9

VII.3    Section 9 should be amended to reflect changes made in Section 8.

Section 14

VII.4    Care should be taken in drafting regulations under Section 14 that regulatory terminology and provisions do not introduce ambiguity into the obligations of a refusing practitioner or health care facility set out in Section 8(3).

Recommendations applied (example):

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Notes

1.    Bill 18, Safeguards for Last Resort Termination of Life Act, 2nd Sess, 31st Leg, Alberta, 2026.

2.    Carter v Canada (Attorney General), 2015 SCC 5, [2015] 1 SCR 331 [Carter SCC 2015].

3.    Julian Savulescu & Udo Schuklenk, “Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception” (2016) 31:3 Bioethics 162–170; Amir Attaran, “The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada” (2016) 36:1 Health Law Can. 2016 Feb;36(3):86.

4.    See e.g. comments of Dr. James Downar in Laura Eggertson, “Rights may conflict with assisted dying ruling” (2015) CMAJ 187:5 E149-E150 at E150.

5.    Health Canada, "Model Practice Standard for Medical Assistance in Dying (MAID)" (27 March, 2023), Health Canada (website) at 5.2, 5.2.1.

6.    R Leiva et al, “Euthanasia in Canada: A Cautionary Tale” (2018) 64:3 World Med J 17-23 at 18.

7.    Dr. Balfour Mount. See Devon Phillips, “Balfour Mount (1939-2025)” (2026), McGill University - Palliative Care McGill (website) online: < https://www.mcgill.ca/palliativecare/portraits-0/balfour-mount>.

8.    Dr. Nuala Kenny. See Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying, Final Report (Toronto, Ont: Government of Ontario, Ministry of Health and Long Term Care, 2015 Nov 30, online: <: https://novascotia.ca/dhw/publications/Provincial-Territorial-Expert-Advisory-Group-on-Physician-Assisted-Dying.pdf> at 13.

9.    Dr. Neil Hilliard. See Pamela Fayerman, “Delta hospice rebels against Fraser Health's mandate to provide medical assistance in dying”, Vancouver Sun; (6 February, 2018) online: https://vancouversun.com/news/local-news/delta-hospice-rebels-against-fraser-healths-mandate-to-provide-medical-assistance-in-dying>.

10.    Alberta Health Services, “EMS requests related to medical assistance in dying events” (12 June, 2019), Alberta Health Services (website), online: https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-ems-req-med-assist-dying-events-ps-ems-09.pdf.

11.    Government of Alberta, “My.Health.Alberta.ca” (2026) Government of Alberta (website).

12.    Alberta Health Services, “HealthLink 811" (2026) Find Healthcare: Programs and Services (Website).

13.    See e.g. Chris Purdy, “Woman had assisted-death assessment on sidewalk outside Catholic hospital”, Toronto Star (23 October, 2018).

14.    Government of Alberta, “Regulated health professions and regulatory colleges” (website) Primary and Preventive Health Services.

15.    See e.g. End of Life Choice Act (NZ), 2019/67 at s 10.

16.    Ewan C Goligher, “Understanding Conscience in Healthcare” (21 April, 2021), CMDA.