ISSN 2256-0580 World Medical Journal Official Journal of The World Medical Association, Inc. Nr. 3, September 2018 vol. 64

Contents “So, do you like being a treasurer? Yes. What, really??” ...... 1

Regulating the Regulators? ...... 3

Patient-reported Indicator Survey (PaRIS) ...... 8

Physician Complicity in Capital Punishment ...... 14

Euthanasia in : a Cautionary Tale ...... 17

Telemedicine and its Ethical Aspects ...... 24

Global Migration and the Health Workforce: the Experiences of Internationally Educated Health Professionals ...... 27

Some Ethical Aspects of Aesthetic Medicine in Adolescents ...... 31

Pseudosciences/Pseudotherapies ...... 36

New IFPMA Code of Practice 2019 ...... 37

Interview with Dr. Otmar Kloiber ...... 39

World Federation for Medical Education ...... iii World Medical Association Officers, Chairpersons and Officials

Dr. Yoshitake YOKOKURA Dr. Ketan DESAI Dr. Leonid EIDELMAN Dr. Ardis D. HOVEN WMA President WMA Immediate Past-President WMA President-Elect WMA Chairperson of Council Japan Medical Association Indian Medical Association Israeli Medical Association American Medical Association 2-28-16 Honkomagome Indraprastha Marg 2 Twin Towers, 35 Jabotinsky St., AMA Plaza, 330 N. Wabash, 113-8621 Bunkyo-ku, 110 002 New Delhi P.O. Box 3566 Suite 39300 Tokyo, Japan India 52136 Ramat-Gan 60611-5885 Chicago, Illinois Israel United States

Dr. René HÉMAN Dr. Joseph HEYMAN Dr. Heidi STENSMYREN Dr. Otmar KLOIBER WMA Chairperson of the Finance WMA Chairperson WMA Chairperson of the Medical Secretary General and Planning Committee of the Associate Members Ethics Committee World Medical Association P.O. Box 20051 163 Middle Street Swedish Medical Association 13 chemin du Levant 3502 LB, Utrecht West Newbury, Massachusetts 01985 (Villagatan 5) P.O. Box 5610 01212 Ferney-Voltaire Netherlands United States SE – 114 86 Stockholm France Sweden

Prof. Dr. Frank Ulrich Dr. Andrew DEARDEN Dr. Miguel Roberto JORGE MONTGOMERY WMA Treasurer WMA Chairperson of the Socio- WMA Vice-Chairperson of Council British Medical Association Medical Affairs Committee Bundesärztekammer BMA House, Tavistock Square Brazilian Medical Association Herbert-Lewin-Platz 1 (Wegelystrasse) London WC1H 9JP Rua-Sao Carlos do Pinhal 324, 10623 Berlin United Kingdom CEP-01333-903 Sao Paulo-SP Germany Brazil

www.wma.net

Official Journal of The World Medical Association

Editor in Chief Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia Phone +371 67 220 661 [email protected], [email protected]

Co-Editor Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany

Assistant Editor Maira Sudraba, Velta Pozņaka; [email protected]

Journal design by Pēteris Gricenko

Layout and Artwork The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia

Publisher The Latvian Medical Association, “Latvijas Ārstu biedrība”, Skolas street 3, Riga, Latvia.

ISSN: 2256-0580

Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions CANADA Ethical Aspects of Health Care

Euthanasia in Canada: a Cautionary Tale

Rene Leiva Margaret Catherine Ferrier Sheila Rutledge Timothy Lau Terence John F Scott M Cottle Harding McQuiston

We are Canadian physicians who are dis- commit suicide, who refuse to facilitate eu- the country [3]. law allows only eu- mayed and concerned by the impact – on thanasia or by others, and thanasia, and only for someone “at the end patients, on doctors, on medical practice – who practise in a country where such refus- of life” who is in an “advanced state of irre- of the universal implementation, in our als are widely thought to reflect unaccept- versible decline in capability” [1]. Similarly, country, of euthanasia defined as medical ably extreme and unprofessional views. Our the Criminal Code states that the natural “care” to which all citizens are entitled (sub- perspective has been missing in WMA dis- death of the candidate must be “reasonably ject to the satisfaction of ambiguous and cussions until now. foreseeable” (an undefined term) and repli- arbitrary qualifying criteria). Many of us cates Quebec’s requirement of an advanced feel so strongly about the difficulty of prac- state of decline. It also specifies that the ticing under newly prescribed constraints The Law candidate’s illness, disease or disability be that we may be forced, for reasons of per- incurable [3]. sonal integrity and professional conscience, In Canada, the federal government is re- to emigrate or to withdraw from practice sponsible for criminal law and the prov- Determined patients who do not meet altogether. All of us are deeply worried inces have jurisdiction over health care and these requirements because of natural dis- about the future of medicine in Canada. enforcement of criminal law. In 2014, the ease processes can opt to starve themselves We believe this transformation will not Province of Quebec exploited this consti- to the point of qualifying for the procedures only be detrimental to patient safety, but tutional arrangement by legally redefining [4]. This has been denounced as “cruel” and also damaging to that all-important per- end-of-life medical care to include eutha- suggested as a reason to abolish the require- ception by the public – and by physicians nasia [1]. The law came into force in De- ments [5]. Lawsuits underway in British themselves – that we are truly a profession cember 2015. Columbia [6] and Quebec [7] assert the dedicated to healing alone. Thus, we are requirements are unconstitutional. alarmed by attempts to convince the World In February 2015, the Supreme Court of Medical Association (WMA) to change its Canada ruled in Carter v. Canada that phy- policies against physician participation in sicians may provide euthanasia or assisted Expanding Access euthanasia and assisted suicide. suicide for competent adults who clearly to Euthanasia and consent, who have a grievous and irreme- Notwithstanding the disavowals of those diable medical condition (including illness, Assisted Suicide promoting change of the WMA policies, disease, or disability) that causes enduring such a change would encourage legalization and intolerable physical or psychological If current lawsuits are successful, euthana- of the procedures in other countries, and it suffering, and that cannot be relieved by sia and assisted suicide will be available as is certain that this would have a major ad- means acceptable to the individual [2]. The a supposed “treatment” for mental illness, verse impact on our patients and colleagues criteria are broader than those specified in since not all mental illnesses permanently around the world. Hence, we believe it is the Quebec statute. impair decisional capacity. Moreover, the important for them to reflect upon our per- Supreme Court did not rule out allowing spective: that of Canadian physicians who The Criminal Code was amended in June euthanasia and assisted suicide for reasons refuse to kill our patients or to help them 2016 to give effect to the ruling throughout beyond those identified inCarter [2].

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Within a year of the ruling, the pressure plete forms and fax reports to the coroner and expulsion from the medical profession. for “Carter Plus” had become so great that [13;15]. What others see as safeguards, they How has this come about? the federal government legally commit- characterized as “disincentives” to physician ted itself to consider allowing euthanasia participation that were creating “barriers” to and assisted suicide for adolescents and access. Access to Euthanasia and children, for indications caused by mental Assisted Suicide as Entitlements illness alone, and by advance directive (for those who lack capacity, like patients with Demand for Collaboration Part of the explanation is that Canada’s dementia) [8]. state-run health insurance system pays for EAS practitioners also claimed that there “medically necessary hospital and physician In sum, while the WMA regional meetings was “a crisis” because so few physicians were services” from public funds. Most Canadian demonstrate there is no appetite for eutha- willing to provide euthanasia or assisted physicians are independent contractors paid nasia outside some parts of Europe and the suicide [16]. Their alarm seems to have only for services we provide, but many Ca- European diaspora, in Canada we have ob- been triggered by a 46.8% increase in EAS nadians now believe we are state employees, served that even the prospect of legalization deaths in the second half of the first year of and we face an entrenched attitude of en- whets the appetite for it, and the appetite is legalization. Canada’s EAS death rate in the titlement. Since taxpayers pay for “medical- not satisfied by legalization alone. first year – about 0.9% of all deaths [17] – ly necessary” health services, many people was not reached by Belgium for seven to think it is unacceptable for physicians to eight years [18]. refuse to provide those [21]. The unreliability of Legal “Safeguards” However, inter-jurisdictional comparisons And what counts as a “medically necessary” indicate that, even in the first year of legal- service? In brief, anything declared to be The believed that ization, more than enough Canadian EAS so by the state. As we have seen, in 2014 “a carefully designed and monitored system practitioners were available to meet the the Quebec government redefined medi- of safeguards” would limit risks associated demand [19]. This ought to make coercion cal practice to include euthanasia. Indeed, with allowing physicians to kill patients or of unwilling physicians unnecessary, but Quebec deliberately restricted the practice help them commit suicide [2]. However, the prominent, influential and powerful people of euthanasia to physicians [1]. Vulnerable Persons Standard, developed to in Canada disagree. assist in establishing such safeguards, finds current Canadian law seriously deficient It is true that nothing in the Criminal Access to Euthanasia [9]. Even supplemented by provincial and Code requires physicians to personally kill and Assisted Suicide professional guidelines, current criteria are patients or help them commit suicide [3]. so broad as to have permitted lethal injec- However, nothing in the Criminal Code as Human Rights tion of an elderly couple who preferred to prevents compulsion by other laws or poli- die together by euthanasia rather than at cies. Thus, for example, Canada’s largest The sponsor of Quebec’s law claimed that different times by natural causes [10]. medical regulator demands that physicians euthanasia would remain “very exceptional” who are unwilling to personally provide eu- [24]. However, the law also said qualified Despite this, only a year after legalization, thanasia or assisted suicide must collaborate patients had a right to euthanasia, and the Canadian Euthanasia and Assisted Suicide in homicide and suicide by referring pa- exercise of a right cannot be exceptional. (EAS) practitioners were already complain- tients to colleagues who are willing to do Thus, all public health care institutions ing about having to meet with patients so [20]. (residences, long term care facilities, com- (perhaps more than once), review their munity health centres and hospitals – in- often “lengthy and complicated” medical We categorically refuse. Such collabora- cluding palliative care units) are required to histories, counsel and overcome resistance tion would make us morally responsible provide or arrange for euthanasia [1]. Even from family members [11], refer patients for killing our patients; if not for the Carter this, however, has not been enough. to psychiatrists or social workers [12], find decision, it would make us criminally re- two independent witnesses to verify the sponsible and liable to conviction for mur- McGill University Health Centre complied voluntariness of a patient’s request [13], der, just as it still does in most parts of the with Quebec law by arranging to transfer and manage the “paperwork and bureau- world. For refusing to collaborate in killing patients from the palliative care unit to be cracy involved,”[14] such as having to com- our patients, many of us now risk discipline lethally injected elsewhere in the facility.

18 CANADA Ethical Aspects of Health Care

The Quebec Minister of Health forced eu- mant that only physicians should provide physicians opposed to euthanasia and as- thanasia into the palliative care unit, citing euthanasia [29]. sisted suicide have lobbied the CMA to “patients’ lawful right to receive end-of-life support their right to refuse to participate care” [23; 24]. The Canadian Medical Association (CMA) in the procedures. “They have made tear- secured approval of an apparently neutral ful pleas at several CMA General Council Quebec law allows hospices to opt out of resolution on euthanasia and assisted sui- meetings, asking their non-objecting col- providing euthanasia [1], but when Quebec cide, supporting both physicians willing to leagues to support them and to defend their hospices opted out, the Minister of Health provide the services and those unwilling rights”[35]. We have had to do this precise- denounced them for “administrative funda- to do so [30]. The CMA later told the Su- ly because of the reversal of CMA policy mentalism,” declaring their refusal “incom- preme Court of Canada those positions for against physician participation in euthaniz- prehensible.” Notwithstanding the law, a and against physician participation in eu- ing patients, the reclassification of euthana- prominent Quebec lawyer urged that their thanasia/assisted suicide were both ethically sia and assisted suicide as medical services, public subsidies be withdrawn, accused defensible, and that its long-standing policy and the insistence that there should be no them of compromising the right of access against physician participation would be re- “undue delay” in providing them [36]. to care, and warned that allowing refusal vised to reflect support for both views [31]. was a slippery slope [25]. A similar situa- To be fair, our pleading has not been in vain. tion is also being faced by the hospices in However, in 2014, prior to the 2015 Su- The CMA does support physicians who re- other provinces such as British Columbia preme Court ruling its legalization, the fuse to provide or refer for euthanasia and [26]. CMA formally approved physician assist- assisted suicide, asserts that the state should ed suicide and euthanasia (subject to legal develop mechanisms to allow patients di- Quebec physicians and health care practi- constraints) as responses to “the suffering rect access to the services without violating tioners now work in environments charac- of persons with incurable diseases.” It clas- physicians’ moral commitments, and rejects terized by an emphasis on a purported ‘right’ sified both practices as “end of life care,” discrimination against objecting practitio- to euthanasia. The notion that access to eu- and promised to ensure access to “the full ners [36]. But this advice can be ignored thanasia and assisted suicide is a fundamen- spectrum” of end of life care (i.e., including and, when it is, Hippocratic practitioners tal human right has spread across Canada euthanasia and assisted suicide) [32]. The face the state in court and foot the bill for since the Supreme Court of Canada ruling Supreme Court cited the CMA’s new policy expensive constitutional challenges [37]. in Carter. We are accused of violating hu- when it struck down the law two months Further, public calls from influential voices man rights – even called bigots – because later [2]. have been heard for those medical students we refuse to kill or collaborate in killing our who are personally opposed to the euthana- patients [27]. By redefining euthanasia and assisted sui- sia imperative, to either abandon, or refrain cide as therapeutic medical services [33], from applying for, medical training [38]. the CMA made physician participation Providing Euthanasia as an normative for the medical profession; refus- Ethical/Professional Obligation ing to provide them in the circumstances set Canada’s Euthanasia/ out by law became an exception requiring Assisted Suicide Regime Leaders of the medical profession contrib- justification or excuse. That is why public uted substantially to the legal redefinition of discourse in Canada has since centred large- The CMA is sincerely convinced that it “did euthanasia as a medical act and to the le- ly on whether or under what circumstances the right thing” in shaping the debate and galization of physician assisted suicide and physicians and institutions should be al- law in Canada and that it is on the right euthanasia. lowed to refuse to provide or collaborate in side of history. It is urging the WMA to fol- homicide and suicide: hence the “long de- low its lead [34]. Our colleagues in other The Collège des médecins du Québec bate” about conscientious objection at the countries thus need to be aware that the (CMQ) told Quebec legislators that ac- CMA’s 2015 annual meeting to which the EAS regime in Canada is one of the most tively causing the death of a patient is “a CMA Vice-President, Medical Profession- radical in the world. medical procedure” for which physicians alism referred in his World Medical Journal must be completely responsible, insisting article [34]. Patients do not have a ‘right to euthanasia’ that physician assume “the moral burden” in the Netherlands [39] or in Belgium [40], of killing patients [28]. The Federation of The CMA Vice-President, Medical Profes- though long practice inclines the public to General Practitioners of Quebec was ada- sionalism elsewhere noted that, for years, the contrary view [41]. Euthanasia is not

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permitted in either country unless a phy- peutic obstinacy and responding to their cide and euthanasia caused “changes in the sician is personally convinced there is no suffering with compassion, competence, and medical culture” leading to “general, overall reasonable alternative [42; 43]. Similarly, palliative care. We are disturbed that the comfort” with the law [52]. Dutch and Belgian physicians must be per- number of Quebec practitioners entering sonally convinced that a patient’s suffering palliative care dropped after legalization of However, when emergency physicians re- is intolerable and enduring [42, 43], and euthanasia, and the CMQ and the Quebec fuse to resuscitate patients who attempt Belgian physicians may insist upon criteria Society for Palliative Care are concerned suicide and urge disabled patients in crisis beyond those set by law [42]. that patients are choosing euthanasia be- to request euthanasia, such “changes in the cause adequate palliative care is unavailable medical culture” are not, in our view, consis- In Canada, however, access to euthanasia [48]. tent with ensuring patient safety, nor with and assisted suicide is seen as a tax-paid en- maintaining the trust essential to preserving titlement, is described as a “constitutionally We are disturbed and grieved by the story the Hippocratic physician-patient relation- protected civil and human right” [44], and of a 25-year-old disabled woman in acute ship. homicide and suicide are legally and profes- crisis in an Emergency ward, pressured to sionally defined to be therapeutic medical consider assisted suicide by an attending And when physicians are told to write ‘natu- services. Moreover, a physician’s conviction physician, who called her mother “selfish” ral death’ instead of ‘euthanasia’ on the death that there are other reasonable and effica- for protecting her [49]. certificates [53,54] – and, by extension, to cious alternatives is irrelevant; patients can misrepresent facts – “changes in the medical insist upon lethal injection. Finally, the We are disturbed and angered to hear that culture” may make physicians comfortable, criterion of intolerable suffering is entirely hospital authorities denied a chronically ill, but we do not believe that they will sustain subjective, established unilaterally by the severely disabled patient the care he needed, trust in the medical profession. Even newly patient. suggesting euthanasia or assisted suicide in- released federal guidelines for monitoring stead [50]. euthanasia lack any emphasis on prevention Small wonder, then, that the onus seems of EAS, in favour of merely regulating these increasingly to lie on physicians to show And we were astonished to hear that some practices [55; 56; 57]. why euthanasia should be refused, and that emergency physicians in Quebec were, for a health care administrators may be more time, letting suicide victims die even though Finally, when a Jewish nursing home for- anxious about being accused of “obstructing they could have saved their lives. The inci- bids euthanasia and assisted suicide on its access” [45] than about “killing people who dents came to light at about the time the premises out of respect for Jewish beliefs really ought not to be killed” [46]. Quebec euthanasia law came into force, and and concern for its residents (who include the president of the Association of Quebec Holocaust survivors), “changes in the medi- Only a year after legalization, Dr. Yves Rob- Emergency Physicians speculated that the cal culture” may encourage applause for the ert, Secretary of the CMQ was alarmed by law and accompanying publicity may have EAS practitioner who crept in at night to “the rapidity with which public opinion ‘confused’ the physicians about their role lethally inject someone [58], but we do not seems to have judged [the new law] insuf- [51]. applaud; we are aghast. ficient.” These incidents are entirely consistent with Our observations and personal experiences “If anything has become apparent over the the acceptance of euthanasia and physician over the last two years confirm our belief past year, it is this paradoxical discourse assisted suicide and they illustrate grave vio- that the practice of Hippocratic medicine is that calls for safeguards to avoid abuse,” he lations of traditional medical ethics. This is fundamentally incompatible with euthana- wrote, “while asking the doctor to act as if not coincidental. sia and assisted suicide. Mandating system- there were none. … [W]e sees the emer- wide provision and physician involvement gence of pressure demanding a form of in the practices can be expected to trans- death à la carte,” he warned [47]. Euthanasia and the form medical culture, ultimately making Transformation of Hippocratic medical practice impossible. Patients and Palliative Care Medical Culture The WMA regional conferences demon- strate that the great majority of physicians As Hippocratic practitioners, our focus is Canadian medical leaders learned that, in worldwide agree with us. Nonetheless, it is on the good of our patients, avoiding thera- other jurisdictions, legalizing assisted sui- true that some physicians and patients seek

20 CANADA Ethical Aspects of Health Care

euthanasia or assisted suicide where the References [Internet]. CBC News; 2017 Jul 10 [cited 2018 1. Act Respecting End of Life Care [Internet]. Sep 01]. Available from: http://www.cbc.ca/ procedures are legal. Supposing that killing news/canada/toronto/assisted-dying-ontar- people or helping them to commit suicide 2014 [cited 2018 Sep 01]. Available from: http:// www.assnat.qc.ca/en/travaux-parlementaires/ io-1.4195368 might sometimes be an acceptable response projets-loi/projet-loi-52-40-1.html 13. Lupton A. Meet 1 of only 2 London doctors to human suffering (something we do not 2. Carter v. Canada (Attorney General), 2015 SCC willing to help their patients die [Internet]. concede), how might these demands be ac- 5 [Internet]. 2015 [cited 2018 Sep 01]. Avail- CBC News; 2017 Jul 4 [cited 2018 Sep 01]. commodated? able from: https://scc-csc.lexum.com/scc-csc/ Available from: http://www.cbc.ca/news/cana- scc-csc/en/item/14637/index.do da/london/doctor-anderson-medically-assisted- dying-1.4186223 The answer is intuitively obvious: with the 3. Criminal Code, Section 241.1 [Internet]. 2016 [cited 2018 Sep 01]. Available from: http:// 14. Kirkey S. “Take my name off the list, I can’t do least possible disruption of existing long- laws-lois.justice.gc.ca/eng/acts/C-46/page-54. any more”: Some doctors backing out of as- standing medical practice. And from this html#h-79 sisted death [Internet]. National Post; 2017 Feb perspective a completely non-medical 4. College of Physicians and Surgeons of Brit- 26 [cited 2018 Sep 01]. Available from: http:// news.nationalpost.com/news/0227-na-eutha- solution would be best. Where this is no ish Columbia, Final Disposition of the Inquiry nasia longer practicable, law and policy should Committee [Internet]. 2018 Feb 13 [cited 2018 Sep 01]. Available from: http://eol.law.dal.ca/ 15. Letter from Jesse A. Pewarchuk, MD, FRCPC. allow medical practice to remain largely wp-content/uploads/2017/11/College-letter-. “Dear referring physician” [Internet]. Undated unchanged. Patients have no entitlement; pdf [cited 2018 Sep 01]. Available from: https://as- practitioners and institutions have no duty; 5. Downie J. Has stopping eating and drinking be- sets.documentcloud.org/documents/3884668/ medical associations respectfully continue come a path to assisted dying? Policy Options Drletter.pdf [Internet]. 2018 Mar 23 [cited 2018 Sep 01]. 16. Grant K. Canadian doctors turn away from as- unresolved ethical debates; the amplitude sisted dying over fees [Internet]. The Globe and of the phenomena remains proportional to Available from: http://policyoptions.irpp.org/ magazines/march-2018/has-stopping-eating- Mail; 2017 Jul 3 [cited 2018 Sep 01]. Avail- minority demands. The introduction of eu- and-drinking-become-a-path-to-assisted-dy- able from: https://www.theglobeandmail.com/ thanasia in Canada has caused doubt, con- ing/ news/national/payment-complications-turning- flict and crisis. In our view, new disciplines, 6. BC Civil Liberties Association. Lamb v. Canada canadian-doctors-away-from-assisted-dying/ new professions and new methods may Case Documents [Internet]. 2016 Aug 22 [cited article35538666/ 17. Health Canada. 2nd Interim Report on Medical arise to satisfy new social goals; but not 2018 Sep 01]. Available from: https://bccla.org/ our_work/lamb-v-canada-case-documents/ Assistance in Dying in Canada [Internet]. Ot- in the name of Medicine. We believe that 7. Stevenson V. 2 Montrealers with degenerative tawa: Health Canada, 2017 Oct [cited 2018 Sep doctors, and medical associations, should diseases challenge medically assisted dying law 01]. Available from: https://www.canada.ca/en/ vigorously defend the successful model [Internet]. CBC News; 2017 Jun 14 [cited 2018 health-canada/services/publications/health-sys- inherited from our past. Euthanasia is not Sep 01]. Available from: https://www.cbc.ca/ tem-services/medical-assistance-dying-interim- medicine. news/canada/montreal/assisted-dying-quebec- report-sep-2017.html canada-legal-challenged-1.4160016 18. Murphy S. Euthanasia reported in Belgium: sta- 8. Bill C-14, An Act to amend the Criminal Code tistics compiled from the Commission Fédérale As , we are saddened by this situ- and to make related amendments to other Acts de Contrôle et d’ Évaluation de l’Euthanasie Bi- ation, but we hope that our experience and (medical assistance in dying) Section 9.1 [Inter- annual Reports [Internet]. Protection of Con- observations will serve as a warning for our net]. 2016 [cited 2018 Sep 01]. Available from: science Project. 2017 August [cited 2018 Sep colleagues in other countries, and their pa- http://www.parl.ca/DocumentViewer/en/42-1/ 01]. Available from: http://www.consciencelaws. org/background/procedures/assist018.aspx tients. Most important: The World Medical bill/C-14/royal-assent 9. Vulnerable Persons Standard [Internet]. 2017 19. Murphy S. Canada’s Summer of Discontent: Association must recognize that accommo- Mar [cited 2018 Sep 01]. Available from: http:// Euthanasia practitioners warn of nationwide dating the kind of radical change in medical www.vps-npv.ca/ “crisis”: Shortage of euthanasia practitioners culture underway in Canada is ill-advised. 10. Grant K. Medically assisted death allows couple “a real problem” [Internet]. Protection of Con- Mindful of the legacy of past WMA lead- married almost 73 years to die together [Inter- science Project. 2017 Oct [cited 2018 Sep 01]. ers, such as former Secretary General, Dr. net]. The Globe and Mail; 2018 Apr 1 [cited Available from: http://www.consciencelaws.org/ background/procedures/assist026.aspx Andre Wynen, who, based on his personal 2018 Sep 01]. Available from: https://www. theglobeandmail.com/canada/article-medically- 20. College of Physicians and Surgeons of Ontario. experience, stood courageously against any assisted-death-allows-couple-married-almost- Medical Assistance in Dying [Internet]. 2017 minimization of the dangers of euthanasia 73-years-to-die/ Jul [cited 2018 Sep 01]. Available from: https:// to patients and physicians [59], we advise 11. McIntyre C. Should doctors be paid a premium www.cpso.on.ca/Policies-Publications/Policy/ against any compromising additions or for assisting deaths? [Internet]. Maclean’s; 2017 Medical-Assistance-in-Dying modifications to existing WMA declara- Jul 12 [cited 2018 Sep 01]. Available from: htt- 21. Laidlaw S. Does faith have a place in medicine? ps://www.macleans.ca/society/should-doctors- [Internet]. Toronto Star; 2008 Sep 18 [cited tions, and strongly support a full defence be-paid-a-premium-for-assisted-deaths/ 2018 Sep 01]. Available from: https://www. of established policy against euthanasia and 12. Dunn T. Why don’t more Ontario doctors pro- thestar.com/life/health_wellness/2008/09/18/ assisted suicide. vide medically assisted dying? It’s not the money does_faith_have_a_place_in_medicine.html

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22. Consultations & hearings on Quebec Bill 52: preme Court of Canada, 15 October 2014. Harry 40. De Hert M, Van Bos L, Sweers K, Wampers Quebec Association of Gerontology (Catherine Underwood (Counsel for the Canadian Medical M, De Lepeleire J, Correll CU. Attitudes of Geoffroy, Nathalie Adams) [Internet]. Thursday, Association) [Internet]. Protection of Conscience Psychiatric Nurses about the Request for Eu- 2013 Oct 3 [cited 2018 Sep 01] – Vol. 43 no. 42, Project; Undated [cited 2018 Sep 01]. Available thanasia on the Basis of Unbearable Mental T#075. Available from: http://www.consciencel- from: http://consciencelaws.org/law/commen- Suffering (UMS) [Internet]. PLoS One. 2015 aws.org/background/procedures/assist009-030. tary/legal073-009.aspx#Harry_Underwood [cited 2018 Sep 01]; 10(12): e0144749. Avail- aspx#075 32. Canadian Medical Association. Policy: Eutha- able from: http://journals.plos.org/plosone/ 23. Plante C. MUHC’s assisted death policy re- nasia and Assisted Death (Update 2014) [Inter- article?id=10.1371/journal.pone.0144749 pealed: Barrette [Internet]. Montreal Gazette; net]. 2014 [cited 2018 Sep 01]. Available from: 41. Described by the Royal Dutch Medical As- 2016 Jul 07 [cited 2018 Sep 01]. Available from: https://www.cma.ca/Assets/assets-library/docu- sociation as a “common misconception.” https://montrealgazette.com/news/quebec/ ment/en/advocacy/EOL/CMA_Policy_Eutha- Royal Dutch Medical Association [Konin- muhcs-assisted-death-policy-repealed-barrette nasia_Assisted%20Death_PD15-02-e.pdf klijke Nederlandsche Maatschappij tot be- 24. Plante C. Barrette chastises MUHC over policy 33. Doctor-assisted suicide a therapeutic service, vordering der Geneeskunst (KNMG)]. not to provide medically assisted death [In- says Canadian Medical Association [Internet]. The Role of the Physician in the Voluntary ternet]. Montreal Gazette; 2016 Jul 05 [cited CBC News; 2016 Feb 06 [cited 2018 Sep 01]. Termination of Life [Internet]. Utrecht, 2018 Sep 01]. Available from: https://montre- Available from: http://www.cbc.ca/news/health/ Netherlands:KNMG; 2011 Jun 23 [cited 2018 algazette.com/news/quebec/barrette-chastises- doctor-assisted-suicide-a-therapeutic-service- Sep 01]. Available from: https://www.knmg. muhc-administration-over-policy-not-to-pro- says-canadian-medical-association-1.2947779 nl/web/file?uuid=b55c1fae-0ab6-47cb-a979- vide-medically-assisted-de 34. Blackmer J. Assisted Dying and the Work of the 1970e6f60ae6&owner=5c945405-d6ca-4deb- 25. Lacoursière A, Gagnon K. Maisons de Soins Canadian Medical Association. World Medical aa16-7af2088aa173&contentid=262 Palliatifs: Le financement pourrait être remis en Association Journal. 2017 Oct [cited 2018-Sep 42. Termination of Life on Request and Assisted question, croit un expert [Internet]. La Presse; 01]; 63(3):6-9. Available from: https://lab.ar- Suicide (Review Procedures) Act [Internet]. 2018 Sep 03 [cited 2018 Sep 01]. Available from: stubiedriba.lv/WMJ/vol63/october-2017/ 2002 Apr 01 [cited 2018 Sep 01]. Available http://plus.lapresse.ca/screens/62045f35-5443- 35. Dr. Blackmer Blog Response [Internet]. Physi- from: https://www.eutanasia.ws/leyes/leyholan- 4333-b9ba-6e5d3427c90b|yNd_68fPrlvF.html cians’ Alliance against Euthanasia; 2018 Apr 30 desa2002.pdf 26. A hospice must provide a medically-assisted [cited 2018 Sep 01]. Available from: https:// 43. The Belgian Act on Euthanasia of May 28th, death if a patient asks: Fraser Health [Inter- collectifmedecins.org/en/dr-blackmer-blog- 2002 [Internet]. Ethical Perspectives 9 (2002) net]. Global News; 2018 Feb 07 [cited 2018 response/ [cited 2018 Sep 01] 2-3, 182-188. Avail- Sep 01]. Available from: https://globalnews. 36. The Canadian Medical Association describes able from: http://www.ethical-perspectives.be/ ca/news/4012677/hospices-medically-assisted- euthanasia and physician assisted suicide as viewpic.php?TABLE=EP&ID=59 death-fraser-health/ “legally permissible medical service[s]” [Inter- 44. A.B. v Canada (Attorney General) [Internet]. 27. Attaran A. Doctors can’t refuse to help a patient net]. Canadian Medical Association. Medical 2017 ONSC 3759 (CanLII). 2017 Jun 19 [cited die – no matter what they say [Internet]. iPoli- Assistance in Dying; 2017 May [cited 2018 2018 Sep 01]. Available from: https://www. tics; 2015 Nov 13 [cited 2018 Sep 01]. Available Sep 01]. Available from: https://www.cma.ca/ canlii.org/en/on/onsc/doc/2017/2017onsc375 from: http://ipolitics.ca/2015/11/13/doctors- Assets/assets-library/document/en/advocacy/ 9/2017onsc3759.html?autocompleteStr=A.B. cant-refuse-to-help-a-patient-die-no-matter- EOL/cma_policy_medical_assistance_in_dy- v. Canada (Attorney Gene what-they-say/ ing_pd17-03-e.pdf 45. Stockland P. MAiD and Modern Medicine [In- 28. Consultations & hearings on Quebec Bill 52: 37. McKeen A. Doctors challenge Ontario policy on ternet]. Convivium; 2018 Jun 18 [cited 2018 Sep College of Physicians of Quebec (Dr. Charles assisted-death referrals: Physicians go to court 01]. Available from: https://www.convivium.ca/ Bernard, Dr. Yves Robert, Dr. Michelle March- over requirement to send patients to other doc- articles/maid-and-modern-medicine and) [Internet]. 2013 Sep 17 [cited 2018 Sep tors if they don’t want to provide medical assis- 46. Justice Moldaver, referring to the consequences 01] – Vol. 43 no. 34. Available from: http://www. tance in dying [Internet]. Toronto Star; 2017 Jun of failing to provide adequate safeguards. Su- consciencelaws.org/background/procedures/as- 13 [cited 2018 Sep 01]. Available from: https:// preme Court of Canada, 35591, Lee Carter, et sist009-001.aspx#121 www.thestar.com/news/gta/2017/06/13/group- al. v. Attorney General of Canada, et al (British 29. Consultations & hearings on Quebec Bill 52: of-doctors-challenge-policy-requiring-referral- Columbia) (Civil) (By Leave) [Webcast}. 2016 Federation of General Practitioners of Quebec to-services-that-clash-with-morals.html Jan 11 [cited 2018 Sep 01], 171:28 | 205:09 to (Dr. Louis Godin, Dr. Marc-André Asselin) 38. Blackwell T. Ban conscientious objection by 171:56 | 205:09 Available from: http://www. [Internet]. 2013 Sep 17 [cited 2018 Sep 01] – Canadian doctors, urge ethicists in volatile com- scc-csc.ca/case-dossier/info/webcastview-web- Vol. 43 no. 34. Available from: http://www. mentary [Internet]. National Post; 2016 Sep 22 diffusionvue-eng.aspx?cas=35591&urlen=http% consciencelaws.org/background/procedures/as- [cited 2018 Sep 01]. Available from: https:// 3a%2f%2fwww4.insinc.com%2fibc sist009-002.aspx - 084 nationalpost.com/health/ban-conscientious- 47. Dr. Robert’s regrets: Towards death à la carte? 30. Canadian Medical Association, 147th General objection-by-canadian-doctors-urge-ethicists- (Vers la mort à la carte?) [Internet]. Collège des Council Delegates’ Motions: End-of-Life Care: in-volatile-commentary Médecins du Québec; 2017 May 10 [cited 2018 Motion DM 5-6 [Internet]. 2014 Aug 15 [cited 39. de Jong A, van Dijk G. Euthanasia in the Neth- Sep 01]. English translation published by the 2018 Sep 01]. Available from: https://www. erlands: balancing autonomy and compassion. Physicians’ Alliance against Euthanasia. Avail- cma.ca/Assets/assets-library/document/en/GC/ World Medical Association Journal [Internet]. able from: https://collectifmedecins.org/en/dr- Delegate-Motions-end-of-life.pdf 2017 Oct [cited 2018 Sep 01]; 63(3):6-9. Avail- roberts-regrets/ 31. Murphy S. Re: Joint intervention in Carter v. able from: https://lab.arstubiedriba.lv/WMJ/ 48. http://www.cmq.org/nouvelle/fr/vers-la-mort- Canada – Selections from oral submissions. Su- vol63/october-2017/ a-la-carte.aspx

22 CANADA Ethical Aspects of Health Care

49. CBC News. Lack of palliative care pushing gc.ca/rp-pr/p2/2018/2018-08-08/html/sor- Timothy Lau, MD, MSc, FRCPC Quebecers toward medically assisted death, dors166-eng.html Geriatric Psychiatry College of Physicians says. 31 May 2018 [cited 58. Frazee C. Medically assisted dying needs 2018 Sep 01]. Available from: https://www. more monitoring [Internet]. The Star; 2018 Royal Ottawa Hospital cbc.ca/news/canada/montreal/lack-of-palli- Aug 29 [cited 2018 Sep 01]. Available from: Associate Professor, University of Ottawa ative-care-pushing-quebecers-toward-med- https://www.thestar.com/opinion/contribu- Ottawa, Ontario, Canada ically-assisted-death-college-of-physicians- tors/2018/08/29/medically-assisted-dying- says-1.4685470 needs-more-monitoring.html Terence McQuiston, MD 59. Lazaruk S. Jewish care home accuses doctor of 50. Fatal Flaws Film Clip : “They wanted me to do Family Medicine (special an assisted suicide death on her” [Video]. You- ‘sneaking in and killing someone’ [Internet]. Tube; 2017 Oct 10 [cited 2018 Sep 01]. Avail- Vancouver Sun; 2018 Jan 05 [cited 2018 Sep interest in Geriatrics) able from: https://youtu.be/hB6zt43iCs8 01]. Available from: https://vancouversun.com/ Donway Place Retirement Residence 51. Chronically ill man releases audio of hospital news/local-news/jewish-care-home-accuses- Toronto, Ontario, Canada staff offering assisted death [Internet]. CTV doctor-of-sneaking-in-and-killing-someone News; 2018 Aug 02 [cited 2018 Sep 01]. Avail- 60. World Medical Association issues Madrid Dec- John F Scott, MD, MDiv able from: https://www.ctvnews.ca/health/ laration against euthanasia [Internet]. 1987 chronically-ill-man-releases-audio-of-hospital- Nov 20 [cited 2018 Sep 01]. Available from: Palliative Care staff-offering-assisted-death-1.4038841 https://larouchepub.com/eiw/public/1987/eir- Associate Professor, University of Ottawa 52. Hamilton G. Some Quebec doctors let suicide v14n46-19871120/eirv14n46-19871120_014- The Ottawa Hospital victims die though treatment was available: dr_andre_wynen.pdf Ottawa, Ontario, Canada college [Internet]. National Post; 2016 Mar 17 [cited 2018 Sep 01]. Available from: https:// (Institutional affiliations are provided for Acknowledgements and Endorsements nationalpost.com/news/canada/some-quebec- doctors-let-suicide-victims-die-though-treat- identification purposes only and do not imply The authors want to express our deepest thanks ment-was-available-college endorsement by the institutions. See below for insights, edits and support received from 53. Geddes J. Interview: The CMA’s president on for list of professional designation abbrevia- many of our colleagues. The final article has assisted dying [Internet]. Macleans; 2015 Feb tions.) been explicitly endorsed by the following Ca- 06 [cited 2018 Sep 01]. Available from: http:// nadian physicians: www.macleans.ca/politics/ottawa/interview- the-cmas-president-on-assisted-dying/). This Rene Leiva, MDCM, CCFP part of the interview is not included in the edit- (COE/PC), FCFC Balfour M Mount, Anita Au, ed published transcript, but can be heard on the Family Medicine, Palliative Sasha Bernatsky, Thomas Bouchard, linked audio file (02:43-03:25) [cited 2018 Sep Care, Care of the Elderly Julia Bright, Myra Butler, Luigi Castagna, 01] Available from: https://soundcloud.com/ Bruyere Continuing Care Julia Cataudella, Cyril Chan, Luke Chen, macleans-magazine/john-geddes-in-conversa- Ottawa, Ontario, Canada Joyce Choi, Andre Constantin, Alana Cormier, tion-with-cma-president-chris-simpson 54. Murphy S. A bureaucracy of medical decep- MD, David D’Souza, Ed Dubland, tion: Quebec physicians told to falsify eutha- Margaret M Cottle, MD, CCFP (PC) Abraham Fuks, Dominique Garrel, nasia death certificates [Internet]. Protection of Palliative Care Richard Haber, Ronald E Hiller, Conscience Project; 2015 [cited 2018 Sep 01]. Assistant Professor, University Neil Hilliard, Todd C Howlett, Available from: http://www.consciencelaws.org/ of British Columbia Evelyne Huglo, K. Issigonis, background/procedures/assist012.aspx 55. Michael Swan. Can a doctor-assisted death be Vancouver, British Columbia, Canada Andre Jakubow, Will Johnston, Lynn Kealey, ‘natural’ and ‘suicide’? [Internet]. The Catho- Nuala P Kenny, Anthony T Kerigan, lic Register; 2018 Aug 08 [cited 2018 Sep 01]. Catherine Ferrier, MD, Edmond Kyrillos, Joseph M Lam, Available from: https://www.catholicregister. CCFP (COE), FCFP Renata Leong, Constant H. Leung, org/item/27790-can-a-doctor-assisted-death- Family Medicine, Care of the Elderly Henry Lew, Andrea H. S. Loewen, be-natural-and-suicide McGill University Health Centre Jean-Noel Mahy, François Mai, 56. Globe editorial: Ottawa should do more to ex- amine how medically-assisted death is working Assistant Professor of Family Karen MacDonald, Karen Mason, [Internet]. The Globe and Mail; 2018 Aug 16 Medicine, McGill University John R McLeod, J Stephen Mitchinson, [cited 2018 Sep 01]. Available from: https:// Montreal, Quebec, Canada Ibrahim Mohamed, José A. Morais, www.theglobeandmail.com/opinion/editorials/ Louis Morissette, Laurence Normand‑Rivest, article-globe-editorial-ottawa-should-do-more- Sheila Rutledge Harding, MD, MA, FRCPC Liette Pilon, Roger Roberge, to-examine-how-medically/ 57. Regulations for the Monitoring of Medical As- Hematology Cameron Ross, Paul Saba, Kevin Sclater, sistance in Dying: SOR/2018-166 [Internet]. Saskatchewan Health Authority William F. Sullivan, Vanessa Sweet, ; 2018 Jul 27 [cited 2018 Professor, University of Saskatchewan Sephora Tang, Mark Tsai, Stephen Tsai, Sep 01]. Available from: http://www.gazette. Saskatoon, Saskatchewan, Canada James Warkentin, Maria Wolfs, Paul Yong

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