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Committee Appearance – Senate Legal and Constitutional Affairs Committee: Bill C-7 – An Act to Amend the Criminal Code (medical assistance in dying)

https://policybase.cma.ca/en/permalink/policy14380

Date
2020-11-23
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Date
2020-11-23
Topics
Ethics and medical professionalism
Text
Committee Appearance – Senate Legal and Constitutional Affairs Committee: Bill C-7 – An Act to Amend the Criminal Code (medical assistance in dying) November 23, 2020 Dr. Sandy Buchman Past President of the Canadian Medical Association Monday, November 23, 2020 Speaking Remarks ____________________________________________________________ Thank you, Madam Chair. I appear before the committee today as the past president of the Canadian Medical Association with the honour and responsibility of speaking for all our members - the frontline physicians. My name is Dr. Sandy Buchman. I am a palliative care physician in Toronto. I am also a MAiD Assessor and Provider. It is incumbent upon us now to consider the effects that the passing of Bill C-7 will have on patients, but also the effects on the medical professionals who provide medical assistance in dying - MAiD. When the original MAiD legislation was developed as Bill C-14, the CMA was a leading stakeholder. We have continued that commitment with Bill C-7. Having examined Bill C-7, we know that, in a myriad of ways, the results of our extensive consultations with our members align with the findings of the government’s roundtables. Nicole Gladu, whose name is now inextricably tied to the government’s decision on MAiD, spoke as unequivocally as perhaps anyone could when she affirmed that it is up to people like her, and I quote, “To decide if we prefer the quality of life to the quantity of life." Perhaps not everyone agrees with this sentiment. Few can argue, though, that it is a powerful reminder of the real stakeholders when it comes to considerations of this bill. This applies no less critically to those who are currently MAiD providers or those who will become providers. These practitioners are our members. But we can’t overlook the fact that there must be complete support of both patients and providers. Fundamentally, the CMA supports the government’s prudent and measured approach to responding to the Truchon-Gladu decision. This thoughtful and staged process undertaken by the government is consistent with the CMA’s position for a balanced approach to MAiD. Through our consultations however, we learned that many physicians felt there is a lack of overall clarity. Recent federal efforts to provide precision for physicians are exceedingly welcome. The CMA is pleased to see new non-legislative measures lending more consistency to the delivery of MAiD across the country. The quality and availability of palliative care, mental health care, and care and resources for those suffering from chronic illness, and for persons with disabilities, to ensure that all patients have access to other, appropriate health care services is crucial. The CMA remains firm on our convictions on MAiD from Bill C-14 to C-7. We believe that the choice of those Canadians who are eligible should be respected. We also believe that the rights of vulnerable Canadians must be protected. This demands strict attention to safeguards. And we believe that an environment must exist that fosters the insistence that practitioners abide by their moral commitments. Each of these three tenants is equally unassailable. Our members are in strong support of allowing advance requests by eligible patients who may lose capacity before MAiD can be provided. The CMA believes in the importance of safeguards to protect the rights of vulnerable Canadians and those who are eligible to seek MAiD. Expanding data collection to provide a more thorough account of MAiD in Canada is important. However, this effort must not create an undue administrative burden on physicians. The CMA views some of the language in the bill as precarious. The CMA recommends amending the language in section 2.1 which states “mental illness is not considered to be an illness, disease or disability” to avoid the unintended consequence of having a stigmatizing effect. The legislation should also clearly indicate that the exclusion is for mental illness as a sole underlying medical condition, not mental illness as a comorbidity. To be clear, the CMA is not recommending a revision to the legislative intent. We trust that Parliament will carefully consider the specific language used in the bill. Finally, the CMA endorses the government’s staged approach to carefully examine more complex issues. We must move forward, though, by ensuring that practitioners are given the tools that will be required to safely administer MAiD on a wider spectrum. Support for developing clinical practice guidelines that aid physicians in exercising sound clinical judgment are a prime example. Such guidance would also serve to reinforce consistency in the application of the legal criteria. In conclusion, Madam Chair, allow me to thank the committee for the invitation to participate in today’s proceedings. Sharing the perspective of Canada’s physicians is a privilege. That together we pursue a painless and dignified end-of-life is noble. The assurance that the providers of this practice are supported is an ethical imperative.

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Standing Committee on Health’s study on violence faced by healthcare workers

https://policybase.cma.ca/en/permalink/policy14052

Date
2019-05-14
Topics
Health care and patient safety
Ethics and medical professionalism
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2019-05-14
Topics
Health care and patient safety
Ethics and medical professionalism
Health human resources
Physician practice/ compensation/ forms
Text
Re: Standing Committee on Health’s study on violence faced by healthcare workers Dear Mr. Casey: I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for consideration by the Standing Committee on Health (the Committee) as part of the study on violence faced by healthcare workers. The CMA is deeply concerned with the state of workplace safety in all health care settings, including hospitals, long-term care, and home care settings. As in all experiences of violence, it is unacceptable for healthcare workers to be victims of violence in the provision of care to patients. While there is limited data nationally to understand the incidence of violence against healthcare workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity. A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in the previous month, nearly one-third of respondents had been exposed to some form of aggressive behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family physicians in active practice are subjected to regular abuse from their patients or family members of their patients.”1 These concerns were brought to the CMA’s General Council in 2015, where our members passed a resolution calling for: “the federal government to amend the Criminal Code by making it a specific criminal offence to assault health care providers performing their duties.” The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a recognition of the role of the workplace, primarily health care settings, and safe working conditions as having an important influence of physician health and wellness. …/2 1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9). Mr. Bill Casey Addressing violence against providers in healthcare settings will require action from both federal and provincial/territorial governments. In light of the above, the CMA respectfully submits the following recommendations for consideration by the Committee in its study on violence against healthcare workers: 1) The CMA recommends that the Committee on Health support the call to amend the Criminal Code of Canada to introduce a new criminal offence for assault against a healthcare provider performing their duty. 2) The CMA recommends that the Committee on Health support establishing monitoring of violence against healthcare workers, that is consistent across jurisdictions, and have an active role in responding appropriately to trends. 3) The CMA recommends that the Committee on Health support federal leadership in a pan- Canadian approach to support workplace safety in healthcare settings, including collaborating with the provinces and territories to improve violence prevention. Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy to address growing incidents of violence against health care workers.” In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the Committee’s report on this topic and the opportunity to collaborate on federal and provincial/territorial action in this matter. Sincerely, F. Gigi Osler, BScMed, MD, FRCSC President c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health Don Davies, M.P., Vice Chair Standing Committee on Health

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Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government

https://policybase.cma.ca/en/permalink/policy13940

Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
  1 document  
Policy Type
Policy endorsement
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
Text
Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON This open letter is signed by the following organizations and individuals: Bathurst United Church TOPS 1. Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON 2. Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON 3. Michaela Beder, MD FRCPC, Psychiatrist, Toronto ON 4. Ritika Goel, MD, Family Physician, Toronto ON 5. Gordon Guyatt, MD FRCPC, Internal Medicine Specialist, McMaster University, Hamilton ON 6. Melanie Spence, RN, Nursing, South Riverdale Community Health Centre, Toronto ON 7. Yipeng Ge, BHSc, Medical Student, University of Ottawa, Ottawa ON 8. Stephen Hwang, MD, Professor of Medicine, University of Toronto, Toronto ON 9. Gigi Osler, BScMed, MD, FRCSC, Otolaryngology-Head and Neck Surgery, Canadian Medical Association, Ottawa ON 10. Anjum Sultana, MPH, Public Policy Professional, Toronto ON 11. Danyaal Raza, MD, MPH, CCFP, Family Medicine, Toronto ON 12. P.J. Devereaux, MD, PhD, Cardiologist, McMaster University, Brantford ON 13. Mathura Karunanithy, MA, Public Policy Researcher, Toronto ON 14. Philip Berger, MD, Family Physician, Toronto ON 15. Nanky Rai, MD MPH, Primary Care Physician, Toronto ON 16. Michaela Hynie, Prof, Researcher, York University, Toronto ON 17. Meb Rashid, MD CCFP FCFP, Family Physician, Toronto ON 18. Sally Lin, MPH, Public Health, Victoria BC 19. Jonathon Herriot, BSc, MD, CCFP, Family Physician, Toronto ON 20. Carolina Jimenez, RN, MPH, Nurse, Toronto ON 21. Rushil Chaudhary, BHSc, Medical Student, Toronto ON 22. Nisha Toomey, MA (Ed), PhD Student, University of Toronto, Toronto ON 23. Matei Stoian, BSc, BA, Medical Student, McMaster University, Hamilton ON 24. Ruth Chiu, MD, Family Medicine Resident, Kingston ON 25. Priya Gupta, Medical Student, Hamilton ON 26. The Neighbourhood Organization (TNO), Toronto, ON 27. Mohammad Asadi-Lari, MD/PhD Candidate, University of Toronto, Toronto ON 28. Kathleen Hughes, MD Candidate, McMaster University, Hamilton ON 29. Nancy Vu, MPA, Medical Student, McMaster University, Hamilton ON 30. Ananthavalli Kumarappah, MD, Family Medicine Resident, University of Calgary, Calgary AB 31. Renee Sharma, MSc, Medical Student, University of Toronto, Toronto ON 32. Daniel Voloshin, Medical Student , McMaster Medical School , Hamilton ON 33. Sureka Pavalagantharajah, Medical Student, McMaster University, Hamilton ON 34. Alice Cavanagh , MD/PhD Student, McMaster University, Hamilton ON 35. Krish Bilimoria, MD(c), Medical Student, University of Toronto, North York ON 36. Bilal Bagha, HBSc, Medical Student, St. Catharines ON 37. Rana Kamhawy, Medical Student, Hamilton ON 38. Annie Yu, Medical Student, Toronto ON 39. Samantha Rossi, MA, Medical Student, University of Toronto, Toronto ON 40. Carlos Chan, MD Candidate, Medical Student, McMaster University, St Catharines ON 41. Jacqueline Vincent, MA, Medical Student, McMaster, Kitchener ON 42. Eliza Pope, BHSc, Medical Student, University of Toronto, Toronto ON 43. Cara Elliott, MD, Medical Student, Toronto ON 44. Antu Hossain, MPH, Public Health Professional, East York ON 45. Lyubov Lytvyn, MSc, PhD Student in Health Research, McMaster University, Burlington ON 46. Michelle Cohen, MD, CCFP, Family Physician, Brighton ON 47. Serena Arora, Medical Student, Hamilton ON 48. Saadia Sediqzadah, MD, Psychiatrist, Toronto ON 49. Maxwell Tran, Medical Student, University of Toronto, Toronto ON 50. Asia van Buuren, BSc, Medical Student, Toronto ON 51. Darby Little, Medical Student, University of Toronto, Toronto ON 52. Ximena Avila Monroy, MD MSc, Psychiatry Resident, Sherbrooke QC 53. Abeer Majeed, MD, CCFP, Family Physician, Toronto ON 54. Oluwatobi Olaiya, RN, Medical Student, Hamilton ON 55. Ashley Warnock, MSc, HBSc, HBA, Medical Student, McMaster University, Hamilton ON 56. Nikhita Singhal, Medical Student, Hamilton ON 57. Nikki Shah, MD Candidate, Medical Student, Hamilton ON 58. Karishma Ramjee, MD Family Medicine Resident , Scarborough ON 59. Yan Zhang, MSc, Global Health Professional, Toronto ON 60. Megan Saunders, MD, Family Physician, Toronto ON 61. Pooja Gandhi, MSc, Speech Pathologist, Mississauga ON 62. Julianna Deutscher, MD, Resident, Toronto ON 63. Diana Da Silva, MSW, Social Worker, Toronto ON Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government Sign here - https://goo.gl/forms/wAXTJE6YiqUFSo8x1 The Right Honourable Justin Trudeau, Prime Minister of Canada The Honourable Ginette P. Taylor, Minister of Health The Honourable Ahmed D. Hussen, Minister of Immigration, Refugees and Citizenship CC: Mr. Dainius Puras, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON

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Supporting the enactment of Bill C-14, Medical Assistance in Dying

https://policybase.cma.ca/en/permalink/policy13693

Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
Text
In this submission to the House of Commons Standing Committee on Justice and Human Rights, the CMA’s feedback is focused on three of the legislative objectives of Bill C-14, given their relevance to the CMA’s Principles-based Recommendations for a Canadian Approach to Assisted Dying. On behalf of its more than 83,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. i) Robust Safeguards First, the CMA supports the legislative objective of ensuring a system of robust safeguards to the provision of medical assistance in dying. The safeguards proposed by Bill C-14 include: patient eligibility criteria, process requirements to request medical assistance in dying, as well as monitoring and reporting requirements. The CMA is a voluntary professional organization representing the majority of Canada’s physicians and comprising 12 provincial and territorial divisions and over 60 national medical organizations. ii) Consistent, Pan-Canadian Framework Second, the CMA supports the legislative objective that a consistent framework for medical assistance in dying in Canada is desirable. In addition to robust safeguards, key measures proposed by Bill C-14 support the promulgation of a consistent framework across jurisdictions include legislating definitions for “medical assistance in dying” and “grievous and irremediable condition.” The CMA’s Principles-based Recommendations reflect on the subjective nature of what constitutes “enduring and intolerable suffering” and a “grievous and irremediable condition” as well as the physician’s role in making an eligibility determination. iii) End-of-Life Care Coordination System Thirdly, the CMA supports the objective to develop additional measures to support the provision of a full range of options for end-of-life care and to respect the personal convictions of health care providers. The fulfilment of these commitments with federal non-legislative measures will be integral to supporting the achievement of access to care, respecting the personal convictions of health care providers, and developing a consistent, pan-Canadian framework. The CMA encourages the federal government to rapidly advance its commitment to engage the provinces and territories in developing a pan-Canadian end-of-life care coordinating system. It will be essential for this system to be in place for June 6, 2016. At least one jurisdiction has made a system available to support connecting patients with willing providers. Until a pan-Canadian system is available, there will be a disparity of support for patients and practitioners across jurisdictions. iv) Respect Personal Convictions Finally, it is the CMA’s position that Bill C-14, to the extent constitutionally possible, must respect the personal convictions of health care providers. In the Carter decision, the Supreme Court of Canada emphasized that any regulatory or legislative response must seek to reconcile the Charter rights of patients wanting to access assisted dying and physicians who choose not to participate in medical assistance in dying on grounds of conscientious objection. The CMA’s Principles-based Recommendations achieves an appropriate balance between physicians’ freedom of conscience and the assurance of effective and timely patient access to a medical service. From the CMA’s significant consultation with our membership, it is clear that physicians who are comfortable providing referrals strongly believe it is necessary to ensure the system protects the conscience rights of physicians who are not. While the federal government has achieved this balance with Bill C-14, there is the potential for other regulatory bodies to implement approaches that may result in a patchwork system. The CMA’s position is that the federal government effectively mitigate this outcome by rapidly advancing the establishment of the pan-Canadian end-of-life care coordinating system. CMA Supports Cautious Approach for “Carter Plus” The CMA must emphasize the need for caution and careful study in consideration of “Carter Plus”, which includes: eligibility of mature minors, eligibility with respect to sole mental health conditions, and advance care directives. The CMA supports the federal government’s approach not to legislate these issues, rather to study them in greater detail. Word count: 750

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CMA’s formal submission to the Federal External Panel on assisted dying

https://policybase.cma.ca/en/permalink/policy11750

Last Reviewed
2019-03-03
Date
2015-10-19
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2015-10-19
Topics
Ethics and medical professionalism
Text
Dear Members of the Federal External Panel: On behalf of the Canadian Medical Association (CMA), I appreciate the opportunity to provide input toward the Federal External Panel's national consultation to support the federal government's legislative response following the Supreme Court of Canada's ruling in Carter v. Canada. As the national professional association representing Canada's physicians, the CMA has played an important role in leading the public dialogue on end-of-life care, including assisted dying. In 2014, the CMA led a national consultation on end-of-life care which included a series of public and member town hall consultations across the country. This national dialogue focused on three main issues: advance care planning, palliative care, and physician-assisted dying. As highlighted in the summary report (enclosed as Appendix 1), the Canadian public emphasized the need for strict protocols and safeguards if the law on physician-assisted dying were to change. This initial consultation provided valuable insights to inform the concurrent CMA's in-depth and comprehensive consultation with its membership as well as medical and health stakeholders as an intervener before the Supreme Court and following the Carter decision. This consultation included engagement of the CMA's Ethics Committee, policy debates as part of the CMA's Annual Meetings in 2014 and 2015, in-person member forums across the country, and an online dialogue. The consultation was critical to the development of the CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying (enclosed as Appendix 2). These recommendations, guided by a set of ten foundational principles, address patient eligibility for access to and assessment for assisted dying, procedural safeguards for eligibility criteria, the roles and responsibilities of the attending and consulting physicians, and the issue of conscientious objection. Taken together, these recommendations form the CMA's position on the forthcoming legislative and regulatory framework to govern assisted dying in Canada. In addition to our recommendations, we would like to highlight key points that are of particular relevance to physicians: NATIONAL, PAN-CANADIAN LEGISLATIVE AND REGULATORY FRAMEWORK The CMA strongly recommends the establishment of national and coordinated legislative and regulatory processes and systems in response to the Carter decision. The CMA is deeply concerned that in the absence of federal action to support the establishment of national guidelines for assisted dying, a patchwork of differing and potentially conflicting approaches could emerge across jurisdictions. Legislative action at the federal level is needed to provide further clarity for physicians and their patients and support the promulgation of a coordinated and consistent approach across all jurisdictions in Canada. The CMA has been working with the medical regulatory colleges at the national level to mitigate this risk through the development of the CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying which has encouraged similar efforts by the regulatory colleges. In addition to these initiatives, federal action is required. CONSCIENTIOUS OBJECTION As the Federal External Panel is aware, the Carter decision emphasizes that any regulatory or legislative response must seek to reconcile the Charter rights of patients (wanting to access assisted dying) and physicians (who choose not to participate in assisted dying on grounds of conscientious objection). The notion of conscientious objection is not monolithic. While some conceptions of conscience encompass referral, others view referral as being connected to, or as akin to participating in, a morally objectionable act. It is the CMA's position that an effective reconciliation is one that respects, and takes account of, differences in conscience, while facilitating access on the principle of equity. To this end, the CMA's membership strongly endorses the recommendation on conscientious objection as set out in section 5.2 of the CMA's enclosed Principles-based Recommendations for a Canadian Approach to Assisted Dying. ADDITIONAL SUPPORTS The CMA recognizes, and supports addressing, the need to develop education materials for physicians. To this end, the CMA is actively developing education modules for physicians following an environmental scan of existing courses and discussions with other jurisdictions (e.g., the Royal Dutch Medical Association). The CMA has the support of the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Canadian Medical Protective Association to lead this initiative. Finally, as previously stated, the CMA strongly encourages the federal government to make the report of the Federal External Panel publicly available once final. The CMA urges the members of the Federal External Panel to support this recommendation to the federal government. Thank you once again for the opportunity to provide input. The CMA looks forward to our meeting with the Federal External Panel on October 20, 2015. Sincerely, Cindy Forbes, MD, CCFP, FCFP President Jeff Blackmer MD, MHSc, FRCPC Vice-President, Medical Professionalism Enclosed: Appendix 1 - Summary Report: End-of-Life Care A National Dialogue (please see pdf for link to document) Appendix 2 - CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying Principles-based Recommendations for a Canadian Approach to Assisted Dying On Feb. 6, 2015, the Supreme Court of Canada unanimously struck down the law prohibiting assisted dying. The court suspended that decision for 12 months. This has provided an opportunity for the Canadian Medical Association (CMA) to build on its past work and pursue further consultation with provincial and territorial medical associations, medical and non-medical stakeholders, members, legislatures and patients for processes, whether legal, regulatory or guidelines, that respect patients' needs and reflects physicians' perspectives. The goal of this process is twofold: (a) discussion and recommendations on a suite of ethical-legal principles and (b) input on specific issues that are particularly physician-sensitive and are worded ambiguously or not addressed in the Court's decision. The touch points are reasonable accommodation for all perspectives and patient-centeredness. For purposes of clarity, CMA recommends national and coordinated legislative and regulatory processes and systems. There should be no undue delay in the development of these laws and regulations. The principles are not designed to serve as a tool for legislative compliance in a particular jurisdiction or provide a standard of care. Rather, the CMA wishes to provide physicians with guidance and a vision of what physicians might strive for to further their professional and legal obligations in a complex area. The CMA recommends adopting the following principles-based approach to assisted dying in Canada: Foundational principles The following foundational principles underpin CMA's recommended approach to assisted dying. Proposing foundational principles is a starting point for ethical reflection, and their application requires further reflection and interpretation when conflicts arise. 1. Respect for patient autonomy: Competent adults are free to make decisions about their bodily integrity. Specific criteria are warranted given the finality of assisted dying. 2. Equity: To the extent possible, all those who meet the criteria for assisted dying should have access to this intervention. Physicians will work with relevant parties to support increased resources and access to high quality palliative care, and assisted dying. There should be no undue delay to accessing assisted dying, either from a clinical, system or facility perspective. To that end, the CMA calls for the creation of a separate central information, counseling, and referral service. 3. Respect for physician values: Physicians can follow their conscience when deciding whether or not to provide assisted dying without discrimination. This must not result in undue delay for the patient to access these services. No one should be compelled to provide assistance in dying. 4. Consent and capacity: All the requirements for informed consent must clearly be met, including the requirement that the patient be capable of making that decision, with particular attention to the context of potential vulnerabilities and sensitivities in end of life circumstances. Consent is seen as an evolving process requiring physicians to continuously communicate with the patient. 5. Clarity: All Canadians must be clear on the requirements for qualification for assisted dying. There should be no "grey areas" in any legislation or regulations. 6. Dignity: All patients, their family members or significant others should be treated with dignity and respect at all times, including throughout the entire process of care at the end of life. 7. Protection of patients: Laws and regulations, through a carefully designed and monitored system of safeguards, should aim to minimize harm to all patients and should also address issues of vulnerability and potential coercion. 8. Accountability: An oversight body and reporting mechanism should be identified and established in order to ensure that all processes are followed. Physicians participating in assisted dying must ensure that they have appropriate technical competencies as well as the ability to assess decisional capacity, or the ability to consult with a colleague to assess capacity in more complex situations. 9. Solidarity: Patients should be supported and not abandoned by physicians and health care providers, sensitive to issues of culture and background, throughout the dying process regardless of the decisions they make with respect to assisted dying. 10. Mutual respect: There should be mutual respect between the patient making the request and the physician who must decide whether or not to perform assisted dying. A request for assisted dying is only possible in a meaningful physician-patient relationship where both participants recognize the gravity of such a request. Recommendations Based on these principles, the Supreme Court decision in Carter v. Canada (2015)1 and a review of other jurisdictions' experiences, CMA makes the following recommendations for potential statutory and regulatory frameworks with respect to assisted dying. We note that this document is not intended to address all potential issues with respect to assisted dying, and some of these will need to be captured in subsequent regulations. 1. Patient eligibility for access to assisted dying 1.1 The patient must be a competent adult who meets the criteria set out by the Supreme Court of Canada decision in Carter v. Canada (2015. 1.2 Informed decision * The attending physician must disclose to the patient information regarding their health status, diagnosis, prognosis, the certainty of death upon taking the lethal medication, and alternatives, including comfort care, palliative and hospice care, and pain and symptom control. 1.3 Capacity * The attending physician must be satisfied that: - the patient is mentally capable of making an informed decision at the time of the request(s) - the patient is capable of giving consent to assisted dying, paying particular attention to the potential vulnerability of the patient in these circumstances - communications include exploring the priorities, values and fears of the patient, providing information related to the patient's diagnosis and prognosis, treatment options including palliative care and other possible interventions and answering the patient's questions * If either or both the attending physician or the consulting physician determines that the patient is incapable, the patient must be referred for further capacity assessment. * Only patients on their own behalf can make the request while competent. 1.4 Voluntariness * The attending physician must be satisfied, on reasonable grounds, that all of the following conditions are fulfilled: - The patient's decision to undergo assisted dying has been made freely, without coercion or undue influence from family members, health care providers or others. - The patient has a clear and settled intention to end his/her own life after due consideration. - The patient has requested assisted dying him/herself, thoughtfully and repeatedly, in a free and informed manner. 2. Patient eligibility for assessment for decision-making in assisted dying Stage 1: Requesting assisted dying 1. The patient submits at least two oral requests for assisted dying to the attending physician over a period of time that is proportionate to the patient's expected prognosis (i.e., terminal vs non-terminal illness). CMA supports the view that a standard waiting period is not appropriate for all requests. 2. CMA recommends generally waiting a minimum of 14 days between the first and the second oral requests for assisted dying. 3. The patient then submits a written request for assisted dying to the attending physician. The written request must be completed via a special declaration form that is developed by the government/department of health/regional health authority/health care facility. 4. Ongoing analysis of the patient's condition and ongoing assessment of requests should be conducted for longer waiting periods. Stage 2: Before undertaking assisted dying 5. The attending physician must wait no longer than 48 hours, or as soon as is practicable, after the written request is received. 6. The attending physician must then assess the patient for capacity and voluntariness or refer the patient for a specialized capacity assessment in more complex situations. 7. The attending physician must inform the patient of his/her right to rescind the request at any time. 8. A second, independent, consulting physician must then also assess the patient for capacity and voluntariness. 9. Both physicians must agree that the patient meets eligibility criteria for assisted dying to proceed. 10. The attending physician must fulfill the documentation and reporting requirements. Stage 3: After undertaking assisted dying 11. The attending physician, or a physician delegated by the attending physician, must take care of the patient until the patient's death. 3. Role of the physician 3.1 The attending physician must be trained to provide assisted dying. 3.2 Patient assessment * The attending physician must determine if the patient qualifies for assisted dying under the parameters stated above in Section 1. * The attending physician must ensure that all reasonable treatment options have been considered to treat physical and psychological suffering according to the patient's need, which may include, independently or in combination, palliative care, psychiatric assessment, pain specialists, gerontologists, spiritual care, and/or addiction counseling. 3.3 Consultation requirements * The attending physician must consult a second physician, independent of both the patient and the attending physician, before the patient is considered eligible to undergo assisted dying. * The consulting physician must - Be qualified by specialty or experience to render a diagnosis and prognosis of the patient's illness and to assess their capacity as noted in Stage 2 above. 3.4 Opportunity to rescind request * The attending physician must offer the patient an opportunity to rescind the request at any time; the offer and the patient's response must be documented. 3.5 Documentation requirements * The attending physician must document the following in the patient's medical record: - All oral and written requests by a patient for assisted dying - The attending physician's diagnosis and prognosis, and their determination that the patient is capable, acting voluntarily and has made an informed decision - The consulting physician's diagnosis and prognosis, and verification that the patient is capable, acting voluntarily and has made an informed decision - A report of the outcome and determinations made during counseling - The attending physician's offer to the patient to rescind the request for assisted dying - A note by the attending physician indicating that all requirements have been met and indicating the steps taken to carry out the request 3.6 Oversight body and reporting requirements * There should be a formal oversight body and reporting mechanism that collects data from the attending physician. * Following the provision of assisted dying, the attending physician must submit all of the following items to the oversight body: - Attending physician report - Consulting physician report - Medical record documentation - Patient's written request for assisted dying * The oversight body would review the documentation for compliance * Provincial and territorial jurisdictions should ensure that legislation and/or regulations are in place to support investigations related to assisted dying by existing provincial and territorial systems * Pan-Canadian guidelines should be developed in order to provide clarity on how to classify the cause on the death certificate 4. Responsibilities of the consulting physician * The consulting physician must verify the patient's qualifications including capacity and voluntariness. * The consulting physician must document the patient's diagnosis, prognosis, capacity, volition and the provision of information sufficient for an informed decision. The consulting physician must review the patient's medical records, and should document this review. 5. Moral opposition to assisted dying 5.1 Moral opposition by a health care facility or health authority * Hospitals and health authorities that oppose assisted dying may not prohibit physicians from providing these services in other locations. There should be no discrimination against physicians who decide to provide assisted dying. 5.2 Conscientious objection by a physician * Physicians are not obligated to fulfill requests for assisted dying. There should be no discrimination against a physician who chooses not to participate in assisted dying. In order to reconcile physicians' conscientious objection with a patient's request for access to assisted dying, physicians are expected to provide the patient with complete information on all options available to them, including assisted dying, and advise the patient on how they can access any separate central information, counseling, and referral service. 1 Carter v. Canada (Attorney General), [2015] 1 SCR 331, 2015 SCC 5 (CanLII)

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Amendments to PIPEDA, Bill S-4

https://policybase.cma.ca/en/permalink/policy11194

Date
2014-06-09
Topics
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Date
2014-06-09
Topics
Health information and e-health
Ethics and medical professionalism
Text
The Canadian Medical Association (CMA) is pleased to make submissions on Bill S-4. CMA has followed the history of PIPEDA and participated in the studies of various Standing Committees, most notably and recently in 2007 to the House of Commons Standing Committee on Access to Information, Privacy and Ethics. CMA is pleased that amendments to PIPEDA are once again being considered. The Canadian Medical Association represents over 80,000 physicians in Canada. Privacy is an important value to physicians and the patients to whom they serve. This is reflected in our Code of Ethics and policies, in particular, Principles for the Protection of Patients' Personal Health Information and Statement of Principles: The Sale and Use of Data on Individual Physicians' Prescribing. Physicians are also required to abide by privacy and confidentiality standards of practice. Thus, the CMA has a strong interest and valuable insights into the topic of personal information and privacy with respect to health information. We thank the Standing Committee for the opportunity to comment on the proposed amendments to PIPEDA. Our key comments are outlined below: Issue 1: CMA supports the existing legislative framework on the collection, use and disclosure of personal information produced by an individual in the course of their employment, business or profession ("work product") and suggests further amendments focus on strengthening it further. CMA supports the current standing of work products, that work products are considered to be personal information. That is, we support the framework defining personal information as information about an identifiable individual and that there is no carved out definition or exemption for "work product". CMA supports the position of the Office of Privacy Commissioner's following its 2007 investigation on work products, that they should not be exempted for two main reasons: * The exemption is not needed, and it would be inconsistent with the balanced approach in the current definition of personal information. The current definition of personal information and the approach to deciding issues based on that definition have worked well. They have promoted a level of privacy protection that balances the right of privacy in personal information with the needs of organizations for the reasonable and appropriate collection, use and disclosure of personal information. ...Because the concept of "work product" is ambiguous, excluding it from the definition of personal information could have unpredictable consequences that would diminish privacy unnecessarily. * (http://www.priv.gc.ca/parl/2007/sub_070222_03_e.asp) It is the CMA's position that work products should be considered personal information and given the section 7 amendments, work products should only be collected, used or disclosed without consent only if it is consistent with the purposes for which the information was produced. In the case of physicians, a prime example of a physician's work product is prescribing information. Prescribing information is a synthesis of assessing patients - by probing into their health, familial, social and sometimes financial background - infused with medical knowledge, skill and competencies resulting in a diagnosis and treatment plan, which often includes prescribing a medication or test. Not only is the physician's prescribing information a product of physicians' work but would not exist but for a trusting physician-patient relationship wherein the patient's private and personal information are shared under circumstances of vulnerability and trust. The outcome is that this is personal information. Prescribing information is about an individual: it includes the name of the patient, the name of the prescribing physician, and the drug name, dosage, amount and frequency; giving major clues as to what the patient's health issue(s) are. For further clarity, however, CMA recommends that physician information, and physician work products, should be specifically recognized within the legislation as personal information. To this end, we would propose that the following addition be made to the definition section under personal health information: Section 2.(1) "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual; CMA supports the amendments to subsections 7(1)-(3) of the Act that any subsequent collection, use and disclosure of work products without consent must be related to the original purpose (of collection, use and disclosure). This relationship reflects the government's understanding and faithfulness to privacy principles. This is particularly critical when dealing with health information, and is even more critical in today's world given the ease of linking information through advancements in technology. In the absence of a causal relationship, personal information should not be used for system performance, commercial enterprise, data brokering, research, assessment or other purposes. CMA recommends that the legislation should go further and allow persons who believe that protection cannot be afforded under the legislation that they have the authority to refuse to communicate the information. This is the conceptual approach taken in Quebec's Act Respecting the Protection of Personal Information in the Private Sector wherein persons have an opportunity to refuse that professional information (as defined therein) be used for commercial purposes. Physicians are constantly writing prescriptions and such information should only be used for other purposes in the interests of patients and the health care system, and not to serve commercial interests or marketing strategies. If physicians do not feel that such protection is afforded patients, then they should be permitted to refuse that such information be collected, used or disclosed. Patient privacy should be primary. And finally, addressing work products in legislation clears up past differences of interpretation by Privacy Commissioners thus, providing certainty and clarity to the public. Recommendation 1: That Section 2. (1) "personal health information", be amended to read as follows: "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual; Issue 2: CMA is pleased to see a section on breaches of security safeguards and recommends greater specificity. As noted above, physicians have responsibilities as data stewards and custodians of health information. As such, CMA supports breach notification measures that would enhance and protect patient privacy. In principle, we support the proposed amendments of breach disclosures to the Privacy Commissioner, to individuals and to organizations. However, CMA is concerned that meeting the requirements may be confusing. For example, in the health care context, it is easy to surmise that all health information is "sensitive". A far more difficult matter is determining whether the risk reaches the threshold of "significant harm" and the "probability" that the information "will be misused". The result being that incidental disclosures will be reported causing unnecessary concern and confusion in the patient population. Further specificity is recommended and we suggest something akin to Ontario's Personal Health Information Protection Act, 2004 (PHIPA). The PHIPA is an act specifically dealing with personal health information. One of its purposes is "to establish rules for the collection, use and disclosure of personal health information about individuals that protect the confidentiality of that information and the privacy of individuals with respect to that information, while facilitating the effective provision of health care" (section 1a ). The PHIPA notification provision states that the individual shall be notified "...at the first reasonable opportunity if the information is stolen, lost or accessed by unauthorized persons", [section 12(2)]. CMA is unaware of any concerns with this approach. The language of PIPIEDA is one of reasonable belief of real risk of significant harm to an individual. The issue is the test for required notification of patients for incidental inadvertent breaches and decreasing "notification fatigue". To illustrate the issue, if physicians were told today that patient data could be retrieved from the drums of discarded photocopiers and printers, it would be inappropriate for legislation to suggest that the entire patient population during the life of the photocopier or printer be notified. To this end, we recommend that there be acknowledgement that in some circumstances notification may not be required. The probability of misuse under PIPEDA is more ambiguous than the PHIPA test. Under PHIPA, the approach is more objective in that the data must be stolen, lost or accessed by unauthorized persons. To our knowledge, the Ontario model has been in place for almost a decade with no significant issues and thus we submit is one that works. In other jurisdictions (eg., Newfoundland and Labrador, Nova Scotia, New Brunswick) with health privacy legislation, there is acknowledgement of trying to balance notification and those breaches unlikely to result in harm by directly indicating when notification is not required. Recommendation 2: CMA recommends that the statute move towards a more objective test and acknowledge that there are situations when notice is not required. Issue 3: CMA supports disclosure without consent under limited circumstances, but finds the current list of disclosures overly inclusive. Health information is considered highly sensitive information and is initially collected for the purpose of individual patient health care. It should only be disclosed with consent and in only some exceptions without consent. The PIPEDA amendments for disclosure without consent have been broadened. Privacy, confidentiality and trust are the foundations of the patient-physician relationship. Without these fundamental values in play, open and honest communications cannot occur and patients would not receive the care they require. Both the patient and the physician have significant investment in the relationship. CMA respects the requirements to disclose information without consent under certain premises, such as required by court order or statute. However, any kind of activity requiring physicians to disclose patient's information without consent for the purposes of advancing a government or institution's goal could jeopardize the relationship. Both the patient's consent and the physician's consent should be required if there is potential to disturb this relationship. The physician is fiduciary of the relationship and is appropriately situated to assess and determine whether disclosure will disturb the relationship. While CMA acknowledges that certain situations may require that disclosure occur without consent (eg. purposes of investigating fraud, national security, abuse or as legally required), disclosure for less malicious activities (e.g., breaches of an agreement, insurance claims) ought to require a court order or warrant. For example, under the proposed section 7(3)(d.1) if a physician were in default of a contract with a technology company supplying electronic medical record software or app to his/her clinic, the company could disclose health information without consent for the "purposes of investigating a breach of an agreement". While we appreciate that there is a caveat that disclosure without advising the patient can only occur if there is a reasonable expectation that the disclosure would compromise the investigation, we submit that leaving the determination of what is "reasonable" to an interested party to the breach is unfair to all. Another example, if a physician is a witness to a dispute between an employer and union representing an employee for denial of long term disability by an insurance company, and has filed a witness statement which includes a medical report he/she wrote to the employer's insurance company, under the proposed section 7(3)(e.1) disclosure of health information without consent is permitted in order to assess, process or settle an insurance claim. CMA is concerned that the disclosure amendments are overly broad and do not differentiate sufficiently between highly time sensitive or grossly malicious situations, and those where it is merely expedient or an administrative encumbrance to seek consent. In addition, the disclosure requirements are framed in permissive (ie., may) and not mandatory language (ie., shall). This is very problematic when the "organization" is a physicians' clinic unless the physician's own consent is made as a pre-condition. CMA believes this suggestion is a progressive one in keeping with the broadened disclosure amendments. Physicians are in a relationship of trust and take seriously the protection of patient privacy and confidentiality, for which they are trained and are ethically and legally required to protect. To place physicians in a position which might entail breaching this trust may impact the confidence of the physician and the patient in the patient-physician relationship which is required to properly formulate appropriate treatment plans; thus, negatively impacting the health of Canadians. Recommendation 3: That disclosures of health information without consent require a warrant or subpoena or court order. Furthermore, disclosures of health information require the physician's consent that in his/her opinion the disclosure does not harm the patient-physician relationship. And, finally any broadened disclosure situations be restricted to criminal activity or that impacting national security. Conclusion Once again, CMA appreciates the opportunity to provide comment as part of the committee's study of Bill S-4. CMA is prepared to work with Parliament, governments, health professionals and the public in ensuring legislative frameworks for the collection, usage and disclosure of personal information for legitimate and reasonable purposes.

Documents

Less detail

Carter: CMA submission regarding euthanasia and assisted death

https://policybase.cma.ca/en/permalink/policy13935

Last Reviewed
2011-03-05
Date
2014-08-27
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
  1 document  
Policy Type
Court submission
Last Reviewed
2011-03-05
Date
2014-08-27
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Text
S.C.C. No. 35591 IN THE SUPREME COURT OF CANADA (ON APPEAL FROM THE COURT OF APPEAL FOR BRITISH COLUMBIA) BETWEEN: LEE CARTER, HOLLIS JOHNSON, DR. WILLIAM SHOICHET, THE BRITISH COLUMBIA CIVIL LIBERTIES ASSOCIATION and GLORIA TAYLOR Appellants - and - ATTORNEY GENERAL OF CANADA and ATTORNEY GENERAL OF BRITISH COLUMBIA Respondents -and- ATTORNEY GENERAL OF ONTARIO, ATTORNEY GENERAL OF QUEBEC, ALLIANCE OF PEOPLE WITH DISABILITIES WHO ARE SUPPORTIVE OF LEGAL ASSISTED DYING SOCIETY, ASSOCIATION FOR REFORMED POLITICAL ACTION CANADA, THE CANADIAN CIVIL LIBERTIES ASSOCIATION, THE CANADIAN HIV/AIDS LEGAL NETWORK AND THE HIV & AIDS LEGAL CLINIC ONTARIO, THE CANADIAN MEDICAL ASSOCIATION, THE CANADIAN UNITARIAN COUNCIL, THE CATHOLIC CIVIL RIGHTS LEAGUE, THE FAITH AND FREEDOM ALLIANCE AND THE PROTECTION OF CONSCIENCE PROJECT, THE CATHOLIC HEALTH ALLIANCE OF CANADA, THE CHRISTIAN LEGAL FELLOWSHIP, THE CHRISTIAN MEDICAL AND DENTAL SOCIETY OF CANADA, THE CANADIAN FEDERATION OF CATHOLIC PHYSICIANS' SOCIETIES, THE COLLECTIF DES MEDECINS CONTRE L'EUTHANASIE, THE COUNCIL OF CANADIANS WITH DISABILITIES AND THE CANADIAN SOCIETY FOR COMMUNITY LIVING, THE CRIMINAL LA WYERS' ASSOCIATION (ONTARIO), DYING WITH DIGNITY, THE EV ANGELICAL FELLOWSHIP OF CANADA, THE FAREWELL FOUNDATION FOR THE RIGHT TO DIE and THE ASSOCIATION QUEBECOISE POUR LE DROIT DE MOURIR DANS LA DIGNITE, and THE EUTHANASIA PREVENTION COALITION AND THE EUTHANASIA PREVENTION COALITION - BRITISH COLUMBIA FACTUM OF THE INTERVENER THE CANADIAN MEDICAL ASSOCIATION Rules 37 and 42 of the Rules of the Supreme Court of Canada Interveners POLLEY FAITH LLP The Victory Building 80 Richmond Street West Suite 1300 Toronto, Ontario M5H 2A4 Harry Underwood and Jessica Prince Tel: ( 416) 365-1600 Fax: (416) 365-1601 hunderwood@polleyfaith.com jprince@polleyfaith.com Jean Nelson Tel: (613) 731-8610 Fax: (613) 526-7571 j ean.nelson@cma.ca Counsel for the Intervener, the Canadian Medical Association GOWLING LAFLEUR HENDERSON LLP 160 Elgin Street, Suite 2600 Ottawa, Ontario KIP 1 C3 D. Lynne Watt Tel: (613) 786-8695 Fax: (613) 788-3509 email lynne. watt@gowlings.com Ottawa Agent for the Intervener, the Canadian Medical Association ORIGINAL TO: The Registrar Supreme Court of Canada 301 Wellington Street Ottawa, Ontario KIA OJI COPIES TO: Counsel for the Appellants, Lee Carter, Hollis Johnson, Dr. William Shoichet, The British Columbia Civil Liberties Association and Gloria Taylor Joseph J. Arvay, Q.C. and Alison M. Latimer Farris, Vaughan, Wills & Murphy LLP 25 th Floor, 700 West Georgia Street Vancouver, BC V7Y 1B3 Tel: (604) 684-9151 Fax: (604) 661-9349 Email: jarvay@farris.com -and- Sheila M. Tucker Davis LLP 2800- 666 Burrard Street Vancouver, BC V6C 2Z7 Tel: (604) 643-2980 Fax: (604) 605-3781 Email: stucker@davis.ca Agent for the Appellants Jeffrey W. Beedell Gowling Lafleur Henderson LLP 160 Elgin Street, Suite 2600 Ottawa, Ontario KIP 1C3 Tel: (613) 233-1781 Fax: (613) 788-3587 Email: jeff. beedell@gowlings.com Counsel for the Respondent, Attorney General of Canada Donnaree Nygard and Robert Frater Department of Justice Canada 900 - 840 Howe Street Vancouver, BC V6Z 2S9 Tel: (604) 666-3049 Fax: (604) 775-5942 Email: donnaree.nygard@justice.gc.ca Counsel for the Respondent, Attorney General of British Columbia Jean M. Walters Ministry of Justice Legal Services Branch 6th Floor - 1001 Douglas Street PO Box 9230 Stn Prov Govt Victoria, BC V8W 9J7 Tel: (250) 356-8894 Fax: (250) 356-9154 Email: jean.walters@gov.bc.ca Counsel for the Intervener, Attorney General of Ontario Zachary Green Attorney General of Ontario 720 Bay Street, 4th Floor Toronto, ON MSG 2Kl Tel: ( 416) 326-4460 Fax: (416) 326-4015 Email: zachary.green@ontario.ca Agent for the Respondent, Attorney General of Canada Robert Frater Department of Justice Canada Civil Litigation Section 50 O'Connor Street, Suite 50 Ottawa, Ontario KIA 0H8 Tel: (613) 670-6289 Fax: (613) 954-1920 Email: ro bert. frater@ j ustice. gc.ca Agent for the Respondent, Attorney General of British Columbia Robert E. Houston, Q.C. Burke-Robertson 441 MacLaren Street, Suite 200 Ottawa, Ontario K2P 2H3 Tel: (613) 236-9665 Fax: (613) 235-4430 Email: rhouston@burkerobertson.com Agent for the Intervener, Attorney General of Ontario Robert E. Houston, Q.C. Burke-Robertson 441 MacLaren Street, Suite 200 Ottawa, Ontario K2P 2H3 Tel: (613) 236-9665 Fax: (613) 235-4430 Email: rhouston@burkerobertson.com Counsel for the Intervener, Attorney General of Quebec Sylvain Leboef and Syltiane Goulet Procureur general du Quebec 1200, Route de L'Eglise, 2eme etage Quebec, QC GlV 4Ml Tel: (418) 643-1477 Fax: ( 418) 644-7030 Email: sylvain.leboeuf@justice.gouv.gc.ca Counsel for the Intervener, Council of Canadians with Disabilities and the Canadian Association for Community Living David Baker Sarah Mohamed Bakerlaw 4 711 Yonge Street, Suite 509 Toronto, Ontario M2N 6K8 Tel: (416) 533-0040 Fax: ( 416) 533-0050 Email: dbaker@bakerlaw.ca Counsel for the Intervener, Christian Legal Fellowship Gerald D. Chipeur, Q.C. Miller Thomirson LLP 3000, 700-9t A venue SW Calgary, Alberta T2P 3V4 Tel: (403) 298-2425 Fax: (403) 262-0007 Agent for the Intervener, Attorney General of Quebec Pierre Landry Noel & Associes 111 Champlain Street Gatineau, QC J8X 3Rl Tel: (819)771-7393 Fax: (819) 771-5397 Email: p.landry@noelassocies.com Agent for the Intervener, Council of Canadians with Disabilities and the Canadian Association for Community Living Marie-France Major Supreme Advocacy LLP 397 Gladstone A venue, Suite 100 Ottawa, Ontario K2P 0Y9 Tel: (613) 695-8855 Ext: 102 Fax: (613) 695-8580 Email: mfmajor@supremeadvocacy.ca Agent for the Intervener, Christian Legal Fellowship Eugene Meehan, Q.C. Supreme Advocacy LLP 397 Gladstone A venue, Suite 100 Ottawa, Ontario K2P 0Y9 Tel: (613) 695-8855 Ext: 101 Fax: (613) 695-8580 Email: emeehan@supremeadvocacy.ca Counsel for the Intervener, Agent for the Intervener, Canadian HIV/AIDS Legal Network and the Canadian HIV/AIDS Legal Network and the HIV & AIDS Legal Clinic Ontario HIV & AIDS Legal Clinic Ontario Gordon Capern Michael Fenrick Paliare, Roland, Rosenberg, Rothstein, LLP 155 Wellington Street West, 35 th Floor Toronto, Ontario M5V 3Hl Tel: ( 416) 646-4311 Fax: (416) 646-4301 Email: gordon.capem@paliareroland.com Counsel for the Intervener, Reformed Political Action Canada Andre Schutten ARPA Canada I Rideau Street, Suite 700 Ottawa, Ontario KIN 8S7 Tel: (613) 297-5172 Fax: (613) 670-5701 Email: andre@ARP A Canada.ca Counsel for the Intervener, Collectif des medecins contre l'euthanasie Pierre Bienvenu Andres C. Garin Vincent Rochette Norton Rose Fulbright Canada LLP 1, Place Ville Marie, Bureau 2500 Montreal, Quebec H3B IRI Tel: (514) 847-4452 Fax: (514) 286-5474 Email: pierre. bienvenue@nortonrose.com Marie-France Major Supreme Advocacy LLP 397 Gladstone Avenue, Suite 100 Ottawa, Ontario K2P 0Y9 Tel: (613) 695-8855 Ext: 102 Fax: (613) 695-8580 Email: mfmajor@supremeadvocacy.ca Agent for the Intervener, Collectif des medecins contre l'euthanasie Sally Gomery Norton Rose Fulbright Canada LLP 1500-45 O'Connor Street Ottawa, Ontario KIP 1A4 Tel: (613) 780-8604 Fax: (613) 230-5459 Email: sally. gomery@nortonrose.com Counsel for the Intervener, Evangelical Fellowship of Canada Geoffrey Trotter Geoffrey Trotter Law Corporation 1185 West Georgia Street, suite 1700 Vancouver, British Columbia V6E 4E6 Tel: (604) 678-9190 Fax: (604) 259-2459 Email: gt @ gtlawcorp .com Counsel for the Intervener, Christian Medical and Dental Society of Canada Albertos Polizogopoulos Vincent Dagenais Gibson LLP 260 Dalhousie Street, Suite 400 Ottawa, Ontario KlN 7E4 Tel: (613) 241-2701 Fax: (613) 241-2599 Email: albertos @ vdg.ca Counsel for the Intervener, Canadian Federation of Catholic Physicians' Societies Geoffrey Trotter Geoffrey Trotter Law Corporation 1185 West Georgia Street, suite 1700 Vancouver, British Columbia V6E 4E6 Tel: (604) 678-9190 Fax: (604) 259-2459 Email: gt@gtlawcorp.com Agent for the Intervener, Evangelical Fellowship of Canada Albertos Polizogopoulos Vincent Dagenais Gibson LLP 260 Dalhousie Street, Suite 400 Ottawa, Ontario K 1 N 7E4 Tel : (613) 241-2701 Fax: (613) 241-2599 Rmail: albertos@vdg.ca Agent for the Intervener, Canadian Federation of Catholic Physicians' Societies Marie-France Major Supreme Advocacy LLP 397 Gladstone Avenue, Suite 100 Ottawa, Ontario K2P 0Y9 Tel: (613) 695-8855 Ext : 102 Fax: (613) 695-8580 Email: mfmajor@.supremeadvocacy.ca Counsel for the Intervener, Dying with Dignity Cynthia Petersen Kelly Doctor Sack Goldblatt Mitchell LLP 1100-20 Dundas Street West, Box 180 Toronto, Ontario MSG 2G8 Tel: (416) 977-6070 Fax: (416) 591-7333 Email: cpetersen@sgmlaw.com Counsel for the Intervener, Catholic Health Alliance of Canada Russell G. Gibson Albertos Polizogopoulos Vincent Dagenais Gibson LLP 260 Dalhousie Street, Suite 400 Ottawa, Ontario K 1 N 7E4 Tel: (613) 241-2701 Ext. 229 Fax: (613) 241-2599 Email: russell.gibson@vdg.ca Counsel for the Intervener, Criminal Lawyers' Association (Ontario) Marlys A. Edwarth Daniel Sheppard Sack Goldblatt Mitchell LLP 1100-20 Dundas Street West Toronto, Ontario MSG 2G8 Tel: (416) 979-4380 Fax: (416) 979-4430 Email: medwarth@ sgmlaw.com Agent for the Intervener, Dying with Dignity Raija Pulkkinen Sack Goldblatt Mitchell LLP 500-30 Metcalfe Street Ottawa, Ontario KIP 5L4 Tel: (613) 235-5327 Fax: (613) 235-3041 Email: rpulkkinen@sgmlaw.com Agent for the Intervener, Criminal Lawyers' Association (Ontario) D. Lynne Watt Gowling Lafleur Henderson LLP 160 Elgin Street, Suite 2600 Ottawa, Ontario K 1 P 1 C3 Tel: (613) 786-8695 Fax: (613) 788-3509 Email: lynne. watt@gowlings.com Counsel for the Intervener, Farewell Foundation For The Right To Die Joseph J. Arvay, Q.C. Alison Latimer Farris, Vaughan, Wills & Murphy LLP 700 West Georgia Street, 25th Floor Vancouver, British Columbia V7Y 1B3 Tel: (604) 684-9151 Fax: (604) 661-9349 Email: jarvay@farris.com Counsel for the Intervener, Association Quebecoise pour le droit de mourir dans la dignite Joseph J. Arvay, Q.C. Alison Latimer Farris, Vaughan, Wills & Murphy LLP 700 West Georgia Street, 25th Floor Vancouver, British Columbia V7Y 1B3 Tel: (604) 684-9151 Fax: (604) 661-9349 Email: jarvay@farris.com Counsel for the Intervener, Canadian Civil Liberties Association Christopher D. Bredt Ewa Krajewska Margot Finley Borden Ladner Gervais LLP Scotia Plaza, 40 King Street West Toronto, Ontario M5H 3Y4 Tel: (416) 367-6165 Fax: (416) 361-7063 Email: cbredt@blg.com Agent for the Intervener, Farewell Foundation For The Right To Die Jeffrey W. Beedell Gowling Lafleur Henderson LLP 160 Elgin Street, Suite 2600 Ottawa, Ontario KIP 1C3 Tel: (613) 786-0171 Fax: (613) 788-3587 Email: jeff.beedell@gowlings.com Agent for the Intervener, Association Quebecoise pour le droit de mourir dans la dignite Jeffrey W. Beedell Gowling Lafleur Henderson LLP 160 Elgin Street, Suite 2600 Ottawa, Ontario K 1 P 1 C3 Tel: (613) 786-0171 Fax: (613) 788-3587 Email: jeff.beedell@gowling .com Agent for the Intervener, Canadian Civil Liberties Association Nadia Effendi Borden Ladner Gervais LLP World Exchange Plaza 100 Queen Street, Suite 100 Ottawa, Ontario KlP 119 Tel: (613) 237-5160 Fax: (613) 230-8842 Counsel for the Intervener, Catholic Civil Rights League Ranjan K. Agarwal Jack R. Maslen Bennett Jones LLP 3400 One First Canadian Place P.O. Box 130, Station 1st Canadian Place Toronto, Ontario M5X 1A4 Tel: (416) 863-1200 Fax: (416) 863-1716 Email: agarwalr@bennettjones.com Counsel for the Intervener, Faith and Freedom Alliance and Protection of Conscience Project Geoffrey Trotter Ranjan K. Agarwal Jack R. Maslen Geoffrey Trotter Law Corporation 1185 West Georgia Street, suite 1700 Vancouver, British Columbia V6E 4E6 Tel: (604) 678-9190 Fax: (604) 259-2459 Email: gt@gtlawcorp.com Agent for the Intervener, Catholic Civil Rights League Sheridan Scott Bennett Jones LLP 1900-45 O'Connor Street World Exchange Plaza Ottawa, Ontario KlP 1A4 Tel: (613) 683-2302 Fax: (613) 683-2323 Email: scotts@bennettjones.com Agent for the Intervener, Faith and Freedom Alliance and Protection of Conscience Project Marie-France Major Supreme Advocacy LLP 397 Gladstone Avenue, Suite 100 Ottawa, Ontario K2P 0Y9 Tel: (613) 695-8855 Ext: 102 Fax: (613) 695-8580 Email: mfmajor@supremeadvocacy.ca Counsel for the Intervener, Alliance of People with Disabilities who are Supportive of Legal Assisted Dying Society Angus M. Gunn, Q.C. Borden Ladner Gervais LLP 1200-200 Burrard Street Vancouver, British Columbia V7X 1 T2 Tel: (604) 687-5744 Fax: (604) 687-1415 Counsel for the Intervener, Canadian Unitarian Council Tim A. Dickson R.J.M. Androsoff Farris, Vaughan, Wills & Murphy LLP 700 West Georgia Street, 25 th Floor Vancouver, British Columbia V7Y 1 B3 Tel: (604) 661-9341 Fax: (604) 661-9349 Email: tdickson@farris.com Counsel for the Intervener, Euthanasia Prevention Coalition and Euthanasia Prevention Coalition -British Columbia Hugh R. Scher Scher Law Professional Corporation 69· Bloor Street East, Suite 210 Toronto, Ontario M4W 1A9 Tel: (416) 515-9686 Fax: ( 416) 969-1815 Email: hugh@sdlaw.ca Agent for the Intervener, Alliance of People with Disabilities who are Supportive of Legal Assisted Dying Society Nadia Effendi Borden Ladner Gervais LLP World Exchange Plaza 100 Queen Street, Suite 100 Ottawa, Ontario KIP 1J9 Tel: (613) 237-5160 Fax: (613) 230-8842 Agent for the Intervener, Canadian Unitarian Council Nadia Effendi Borden Ladner Gervais LLP World Exchange Plaza 100 Queen Street, Suite 100 Ottawa, Ontario KIP 1J9 Tel: (613) 237-5160 Fax: (613) 230-8842 Agent for the Intervener, Euthanasia Prevention Coalition and Euthanasia Prevention Coalition -British Columbia Yael Wexler Fasken Martineau DuMoulin LLP 55 Metcalfe Street, Suite 1300 Ottawa, Ontario MlP 6L5 Tel: (613) 236-3882 Fax: (613) 230-6423 Email: ywexler@fasken.com Index Part I: Overview of Argument .... ... .. . ... . ... . ...... . ............. ... ... ... ......... .. .. .. . .. ... ... ... .. ... .. ..... .... .. ... ..... 1 Part II: Statement of Argument. ... ... .. ...... ... .. ........ ... ... ..... .... ... .. ..... ... ... ... .. .. ... .... ... ......... ...... ... ..... 2 A. The CMA's policy on euthanasia and assisted suicide .. ....... ......... .... .. ..... ...... ..... ... ... .. 2 B. The implications of a change in the law ...................... .... ... ................. ..... ... ...... .. ... ...... 5 1. Palliative care .............................................................. ...... ... .. ... ... ....... ... ............ . 5 2. Concerns over safeguards .................................. ..... . ........ . .......... .. ......... ........... .. 7 3. Protections for physicians ...... ..... .. .... ......... ... .... ... .. ... .. .. ... ... . .......... . .. ... ... .. ... .. .. ... 8 Part III: Submissions regarding remedy ............. ... ...... ... ... ... .... ... ... ... ........ ............................. ... . 9 Part IV: Submissions regarding costs ..... . ...... ........ ..... .. ........ . ... .. .. ....... ....... ... .... .. ..... ..... .. ... . ..... .. 9 Part V: Request for oral argument.. .... ... .. .. .......... .. .. ... .. ..... .. ..... .. ... . ........ ... .. .... .......... ....... ...... .. 10 -1- Part I: Overview of Argument 1. The policy of the Canadian Medical Association ( the "CMA") on euthanasia and assisted suicide1 forms part of the trial record.2 The policy was debated at successive annual meetings of the CMA's members in 2013 and 2014, resulting in its amendment. In 2013, new definitions were added to clarify key terminology used. In August 2014, a motion was passed by delegates to CMA's General Council, and affirmed by the CMA Board of Directors, supporting the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether or not to provide medical aid in dying. 3 The policy will be amended as a consequence. 2. It is anticipated that the policy, once amended, will continue to reflect the ethical principles for physicians to consider in choosing whether or not to participate in medical aid in dying. 3. The statement of support for matters of conscience now exists alongside the statement in the CMA policy that "Canadian physicians should not participate in euthanasia or assisted suicide." As long as such practices remain illegal, the CMA believes that physicians should not participate in medical aid in dying. If the law were to change, the CMA would support its members who elect to follow their conscience. 4. A portion of the CMA's membership believes that patients should be free to choose medical aid in dying as a matter of autonomy. Other voices highlight that participation would undermine long-established ethical principles applicable to the practice of medicine. Amidst this 1 CMA Policy: Euthanasia and Assisted Suicide (Update 2014), https://www.cma.ca/Assets/assetslibrary/ document/en/about-us/PD14-06.pdf#search=assisted%20death. 2 Carter v. Canada (Attorney General}, 2012 BCSC 886, paragraphs 6 and 274. 3 Resolutions adopted at the 14ih Annual Meeting of the Canadian Medical Association, Aug. 18-20, 2014: ~www.cma.ca/Assets/assets-lib rary/document/en/advocacy/ Flnal -Resolutions-GC-2014-end-of-lifecare. pdf. -2- diversity of views, however, there is a unifying theme: one of respect for the alternative perspective. This element was highlighted in the policy motion coming out of the CMA's August 2014 General Council meeting. 5. The CMA accepts that the decision of whether or not medical aid in dying should be allowed as a matter of law is for lawmakers, not medical doctors, to determine. The policy itself acknowledges, uniquely among CMA policies in this respect, that "[i]t is the prerogative of society to decide whether the laws dealing with euthanasia and assisted suicide should be changed." 6. As the national voice of physicians across the country, the CMA intervenes in this appeal desiring to assist the Court by providing its perspective on the rationale for the diverse views expressed by its membership, and to highlight practical considerations that must be assessed if the law were to change. Part II: Statement of Argument A. The CMA's policy on euthanasia and assisted suicide 7. The CMA's policy on euthanasia and assisted suicide4 was adopted in 2007, replacing and consolidating two previous CMA policies5 , and has been amended twice since then as noted above. 8. In an effort to promote broad public and member discussion, in the first half of 2014 the CMA hosted a series of town hall meetings across Canada on end of life care issues. Members of the public and the profession were able to attend the town halls in person, or post comments 4 CMA Policy: Euthanasia and Assisted Suicide (Update 2014): https://www.cma.ca/Assets/assetslibrary/ document/en/about-us/PD14-06.pdf#search=assisted%20death. 5 Physician Assisted Death 1995 and Euthanasia and Assisted Suicide (1998). -3 - online, to provide their perspectives and opm1ons on, inter alia, euthanasia and physicianassisted suicide. 6 9. The CMA adopts policies in order to inform the organization's advocacy efforts, and to provide physician members with an understanding of the views and opinions of their national representative organization and to reflect the views of its membership. The CMA' s policies are not meant to mandate a standard of care for members or to override an individual physician's conscience. 10. The CMA recognizes that many of its policies are referenced by other health care groups and the courts, as well as the provincial and territorial medical regulatory authorities. 11. In general, those CMA members who oppose medical aid in dying do so because of the derogation from established medical ethical principles and clinical practices that would result. Those who support medical aid in dying do so because of the equally established principles of considering patient well-being and patient autonomy. The policy in its current form reflects these various considerations . 12. Physicians have a tremendous amount of compassion and concern for patients who are suffering near the end of their lives, and strive to improve their patients' quality of life for the remainder of their lives. Physicians are trained to be healers. For most Canadian physicians , the question is not a simple matter of balancing between patient autonomy and professional standards, but goes much deeper, to the very core of what it means to be a medical professional. 6 The CMA published two reports coming out of the end of life care town halls - a public report in June 2014 and a CMA members' report in July 2014 - both of which can be found on the CMA's website. -4- 13. One rationale for the position in opposition to physician participation is that euthanasia and assisted suicide would have, as the policy states, "unpredictable effects on the practice of medicine" as well as the physician-patient relationship. 7 14. At the same time, the policy recognizes the principle of patient autonomy, and the fact that it is a competing consideration. It cites several articles from the CMA Code of Ethics 8 that emphasize the importance of patient well-being and autonomy. 9 Physicians are advised to "consider first the well-being of your patient." 15. Opposition to paiiicipation is found in statements from the World Medical Association and various national medical associations akin to the CMA. 10 In jurisdictions where medical aid in dying has been legali zed , the practice is considered "ethically sound .. . and part of end of life care" by the national medical association in the Netherlands and the Belgian association has not published any policy . 11 7 CMA Policy: Euthanasia and Assisted Suicide (Update 2014): https://www.cma.ca/Assets/assetslibrary/ document/en/about-us/PD14-06.pdf#search=assisted%20death. 8 For example, "Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability"; "Respect the right of a competent patient to accept or reject any medical care recommended"; and "Ascertain wherever possible and recognize your patient's wishes about the initiation, continuation or cessation of life-sustaining treatment." 9 The concept of patient autonomy is usually associated with allowing or at least enabling patients to make their own decisions about which health care treatments they will or will not receive, or incorporating their point of view into assessments of the appropriateness and effectiveness of treatment options. See: Entwistle, VA. , Carter, SM ., Cribb, A. & Mccaffery, K. (2010) . 'Supporting patient autonomy : The importance of clinician-patient relationships'. Journal of General Internal Medicine, vol 25, no. 7, pp. 741-745; and Sullivan MD. "The new subjective medicine: taking the patient's point of view on health care and health" . Soc Sci Med 56:1595 - 1604, 2003 . 10 World Medical Association Statement on Physician-Assisted Dying. Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992 and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005: http ://www.wma.net/en/30publications/10policies/p13/. British Medical Association. What is the current BMA policy on assisted dying? http://bma.org.uk/practical-support-at-work/ethics/bma-policyassisted- dying. Australian Medical Association. Position Statement on the Role of the Medical Practitioner in End of Life Care 2007, section 10 : https://ama .com.au/position -statement/role-medical- pr actit ioner-end -life-ca re-2007 . American Medical Association' s Opinion 2. 211- Physician-Assisted Suicide: http://www .amaass n.org/ama/pub/p hys i cian-r esources/ medi ca1 -ethic s/ co de-med ica l-ethi cs/o pin ion2211 .page ?. 11 KNMG. Euthanasia in the Netherlands. Available at: http://knmg.artsennet.nl/Dossiers-9/Dossiersthematrefwoord / Levenseinde/ Eu t hanasia-in-the-Netherlands -1.htm. -5- 16. It is acknowledged that just moral and ethical arguments form the basis of arguments that both support and deny assisted death. The CMA accepts that, in the face of such diverse opinion, based on individuals' consciences, it would not be appropriate for it to seek to impose or advocate for a single standard for the medical profession. 1 7. In any event, the CMA accepts that the decision as to the lawfulness of the current prohibition on medical aid in dying is for patients and their elected representatives as lawmakers to determine, not physicians. B. The implications of a change in the law 18. The CMA and its members have practical and procedural concerns to bring to the Court for reflection with respect to the legalization of medical aid in dying and the implications for medical practice. Three such implications are addressed below. 1. Palliative care 19. One question and element highlighted in CMA policy formulation is the role of palliative care and whether adequate public access is a precondition to changing the law. The CMA acknowledges that the desire to access medical aid in dying is predicated, at least in part, on the inadequacy or inability of palliative care to address a patient's needs in particular circumstances. The policy currently recognizes that adequate palliative care is a prerequisite to the legalization of medical aid in dying. That is because patients should never have to choose death because of unbearable pain which can, in fact, be treated, but the treatment cannot, in reality, be accessed. 20. However, even if palliative care were readily available and effective, there would likely be some patients who would still opt for medical aid in dying over palliative care. Moreover, it -6- seems wrong to deny grievously ill patients the option of medical aid in dying simply because of systemic inadequacies in the delivery of palliative care. 21. The public and the medical profession lack current, specific and non-anecdotal information as to the availability of adequate palliative care across Canada. Notwithstanding this lack of rigorous data, concerns are often expressed. 12 As Justice Smith held at trial, "High quality palliative care is far from universally available in Canada."13 The policy itself provides that "[ e ]fforts to broaden the availability of palliative care in Canada should be intensified." 22. Canada has no national strategy to ensure the delivery of a uniformly high standard of palliative care across the country. Similarly, there are no national uniform standards which direct when and how palliative care is to be provided and by which physicians. At the CMA's annual meeting in August 2014, motions were passed as policy affirming that (i) all health care providers should have access to referral for palliative care services and expertise, (ii) a strategy should be developed for advance care planning, palliative and end of life care in all provinces and territories, and (iii) the CMA will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative care throughout Canada. 14 23. Regardless of the outcome of this appeal, the Canadian public and the medical profession must unite in insisting upon the dedication of appropriate resources to overcome the deficiencies identified above. Palliative care will continue to be a focus of the CMA's future policy development. 12 The Senate of Canada: the Honourable Sharon Carstairs, Raising the Bar: A Roadmap for the Future of Palliative Care in Canada, June 2010, http://www.chpca.net/media/7859/Raising the Bar June 2010.pdf, pages 12 and 16. 13 Carter v. Canada (Attorney General). 2012 BCSC 886, paragraph 192. 14 Resolutions adopted at the 14ih Annual Meeting of the Canadian Medical Association, Aug. 18-20, 2014: https://www.cma.ca/Assets/assets~libra ry/document/en/advocacy/Final-Resolutions-GC-2014-end-of-!ife-care.pdf -7- 2. Concerns over safeguards 24. The trial judge placed great reliance on the ability of physicians to assess the competency of patients requesting medical aid in dying and the voluntariness of their wishes. 15 The CMA submits that the challenges physicians will face in making these assessments have been understated, especially in the end of life care context where the consequences of decisions are particularly grave and in a public medical system in which resource constraints are a pressing issue. 16 25. The CMA submits that these assessments will involve significant new responsibilities that warrant comprehensive study by and with physicians for the following reasons: 15 a) Patients must be afforded a full right of informed consent, but the ordinary context in which a physician obtains the patient's informed consent would not apply since the intervention would be initiated not by the physician's recommendation but by the patient's request and since the patient's decision may tum more than usually is the case upon considerations apart from the expected efficacy of the treatment. b) A patient may be subject to influences which the patient is motivated not to disclose to his or her physician and which may be very difficult to detect. c) Such important decisions are best made following careful discussions between physician and patient, well in advance, concerning the patient's end of life wishes generally. The CMA and its provincial and territorial medical association colleagues note that these types of discussions do not now routinely occur, and that when they do, patients' assessments of their goals can and do evolve over the course of their illness. 17 Carter v. Canada (Attorney General}, 2012 BCSC 886, paragraphs 883, 1240 and 1367. 16 Chaoulli v. Quebec (Attorney General}, (2005] 1 SCR 791, paragraphs 173 and 221-222. 17 The Policy urges that "a Canadian study of medical decision making during dying" be undertaken. It explains that "relatively little" is known about "the frequency of various medical decisions made near the end of life, how these -8- d) It may be very difficult to assess competency and voluntariness in some patients (for example, the very old, the very ill and the depressed) and in some settings (for example, the emergency room and the intensive care unit) where there may not be an established physician-patient relationship. e) Institutional supports are lacking, including recognition in provincial fee schedules of the time that is required for meetings with patients and their families. 3. Protections for physicians 26. The CMA submits that, if the law were to change, any regime of medical aid in dying must legally protect those physicians who choose to participate from criminal, civil or disciplinary proceedings or sanctions. 27. In addition, if the law were to change, no physician should be compelled to participate in or provide medical aid in dying to a patient, either at all, because the physician conscientiously objects to medical aid in dying, or in individual cases, in which the physician makes a clinical assessment that the patient's decision is contrary to the patient's best interests. Notably, no jurisdiction that has legalized medical aid in dying compels physician participation. 18 If the decisions are made and the satisfaction of patients, families, physicians and other caregivers with the decisionmaking process and outcomes." See also the Ontario Medical Association, 'Ontario Doctors Launch End of Life Care Plan'. Available at: https:Uwww.oma.org/resources/documents/eolcstrategyframework.pdf. 18 Quebec: Bill 52, An Act respecting end-of-life care, 1st Sess, 41st Leg, Quebec, 2014 cl 50 (assented to 10 June 2014), SQ 2014, c2; Netherlands: Termination of Life on Request and Assisted Suicide (Review Procedures) Act (2002) .b.1ti;! ://www .eu th anasi ecom missie .n 1/1 mages/Wet%20toetsi ng%201evensbeei nd iging%20op%20verzoek%20en%20 hulp%20bij%20zelfdoding%20Engels tcm52-36287.pdf; Switzerland: Suiss Criminal Code, Book Two : Specific Provisions, Title One: Offences against Life and Limb, Article 115 (1942). http://www.admin.ch/ opc/ en/ classifiedcompilation/ 19370083/index.html; Belgium: Loi relative a l'euthanasie, Chapitre 6, article 14 (2002) http://www.ejustice.just.fgov.be/cgi lei/change lg.pl?language=fr&la=F&ta ble name=loi&cn=2002052837; Luxembourg: Loi du 16 mars 2009 sur l'euthanasie et /'assistance au suicide, Chapitre 7, article 15 (2009). http://www.legil ux. pu bl ic.Ju/1 eg/a/arch ives/2009/0046/a046. pdf#page= 7; Washington: The Washington Death with Dignity Act, RCW, 70 §70.245.190 (2009). http://apps.leg.wa.gov/RCW/default.aspx?cite=70.245.190; Oregon: The Oregon Death with Dignity Act, ORS, 127 §127.885 4.01 (1997). http ://public. hea Ith. oregon .gov /P roviderP a rtnerReso u rces/Eva I u ati on Res ea rch/Deathwith Dign i tyAct/Docu men ts/ statute.pdf; Vermont: An act relating to patient choice and control at the end of life, VSA, 113 § 5285 (a) {2013). -9- attending physician declines to participate, every jurisdiction that has legalized medical aid in dying has adopted a process for eligible patients to be transferred to a participating physician. 19 28. While the Court cannot and should not set out a comprehensive regime, the CMA submits that it can indicate that a practicable legislative regime for medical aid in dying must legally protect those physicians who choose to provide this new intervention to their patients, as well as those who do not. Part III: Submissions regarding remedy 29. If the law is changed, the CMA would ask this Court to adopt a remedy that would preserve the autonomy and constitutional rights of patients and their health care providers. To that end, the CMA asks the Court to adopt a remedy akin to what Justice Smith ordered at the trial level: suspending the effect of a declaration for one year from the date of any decision and instituting a process for individual exemptions such as that afforded to the late Ms. Taylor. Part IV: Submissions regarding costs 30. The CMA seeks no costs and asks that none be awarded against it. http://www.leg.state.vt.us/docs/2014/Acts/ACT039.pdf; New-Mexico: Morris v New-Mexico (2014); and Montana: Baxter v Montana, 482 LEXIS at 59 (2008). 19 Canadian Medical Association, Schedule A: Legal Status of Physician-Assisted Dying (PAD) in Jurisdictions with Legislation, https://www.cma.ca/ Assets/ assets-II bra ry/ document/ en/advocacy/ EO L/Leg a 1-status-p hysicia nassi sted-d eat h-j u risd i cti on slegislation. odf#search=schedule%20A%3A%201egal%20stacus%20of%20physician%2Dassisted%20death, page 3. -10- Part V: Request for oral argument 31. The CMA requests permission to make fifteen minutes of oral argument at the hearing of this appeal. ALL OF WHICH IS RESPECTFULLY SUBMITTED, this 27th day of August, 2014. /_/ - Harry Underwood Jean Nels

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Review of the Personal Information Protection and Electronic Documents Act (PIPEDA) : CMA's Presentation to the House of Commons Standing Committee on Access to Information, Privacy and Ethics - December 13, 2006

https://policybase.cma.ca/en/permalink/policy8668

Last Reviewed
2019-03-03
Date
2006-12-13
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2006-12-13
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
Text
The Canadian Medical Association (CMA) is pleased to be here today to participate in your review of the Personal Information Protection and Electronic Documents Act, or PIPEDA. The CMA has had a long-standing interest in privacy-related matters, including enhancing measures to protect and promote the privacy of health information. We welcome the opportunity to share our policies and thoughts on these vital matters. As a pediatric oncologist from Winnipeg and Chair of the CMA's Committee on Ethics, I come here today with one bottom line: Physicians have always- and continue to - take their patients' privacy very seriously. This is the cornerstone of the special bond between patients and their doctor and has been thus since the time of Hippocrates. In recognition of the importance of privacy, the CMA has produced such documents as the CMA Code of Ethics and the CMA Health Information Privacy Code to guide our more than 64,000 members across the country. These documents existed before the federal government introduced PIPEDA. It is out of our concern for protecting and ensuring the privacy of medical information that we speak to you today. There are three specific areas which we would like to raise: 1) Recognition in law of the unique nature of health care; 2) Physician information as "work product"; and 3) Emerging Privacy and Health information issues. 1. Recognition in law of the unique nature of health care I would like to highlight the importance of recognizing in law the special circumstances of protecting health information. In fact, when PIPEDA was first being debated, CMA posed questions about the scope of the Act and was told that the legislation, originally designed for commerce and the private sector, would not capture health information. We were also told that even if it did, PIPEDA wouldn't change how we practiced medicine. The passing of PIPEDA generated enough concern and uncertainty that government agreed to delay its application to health for 3 years. For example, PIPEDA failed to clarify the issue of implied consent for the sharing of patient information between health professionals providing care. For example, when the family physicians says to a patient "I'm going to send you to see an oncologist to run some tests" and the patient agrees and follows that course of action, then clearly there is "consent" to the sharing of their health information with others. As an oncologist I assume there is consent to send the test results to other specialists that I may need to consult in order to advance the patient's care in a timely fashion. This, however, needed to be addressed before PIPEDA was applied to health care. The delayed application allowed the federal government and health care community to work together and develop a set of guidelines for how PIPEDA would be applied. The resulting PIPEDA Awareness Raising Tools, known as PARTs, contain a series of questions and answers that make up guidelines for health care providers. They answered many of our concerns, provided necessary definitions and allowed for the implied consent model to continue to be used within the circle of care. The CMA applauds the government for this collaborative effort and the resulting guidelines have been used by health care providers ever since. However, we remain concerned that the PARTs guidelines have no legal status. This limitation creates a degree of uncertainty that the CMA would like this legislative review to see addressed by ensuring the PARTs series of questions and answers are referenced in PIPEDA. In addition to participating in the PARTS initiative, since PIPEDA's implementation, the CMA has designed practical tools for physicians and patients: * adopted the CMA policy Principles Concerning Physician Information to address the importance of protecting the privacy of physician information; * produced Privacy in Practice: a handbook for Canadian physicians to help physicians maintain best practices in the protection of patient health information; and * created the PRIVACYWIZARD(tm) designed to help physicians record their current privacy practices, communicate these to patients and identify possible areas for enhancement. 2. Physician Practice Information as "Work Product" I referred earlier to CMA's Policy document on physician information. The CMA strongly believes that physicians have legitimate privacy concerns about the use by third parties of information - such as prescribing and other practice data for commercial purposes. Currently deemed "work product" this information can be collected, used and disclosed without consent. We feel PIPEDA inadequately protects this information. We recognize that it is information generated out of the patient-physician relationship. We disagreed with findings of the previous Privacy Commissioner that physician prescribing information is not subject to PIPEDA's privacy protection provisions for "personal information". The CMA has consistently advocated that physician prescribing data and other practice information is personal information and appeared as an intervener in a Federal Court review of this issue that was ultimately settled by the main parties. Also, insufficient regard for the privacy of prescribing and other physician data could have a negative impact on the sanctity of the physician-patient relationship. Patients confide highly sensitive information to physicians with the expectation this information will be kept in the strictest confidence. This expectation exists because they know that physicians are under ethical and regulatory dictates to safeguard their information and that physicians take this responsibilities very seriously. The perceived and indeed actual loss of control by physicians over information created in the patient encounter, such as prescribing data, could undermine the confidence and faith of our patients that we are able to safeguard their health information. This concern is not hypothetical. For physicians, so called "work product" information also encompasses practice patterns such as discharge rates, referral rates, billing patterns, hospital length of stays, complaints, peer review results, mortality and re-admittance rates. With the advent of electronic medical records and growth in pay-for-performance and outcome-based incentive programs for physicians, there is an enormous potential for the resulting physician "performance" data or "work product" to be "mined" by other parties and used to influence performance review (traditionally the purview of the medical licensing authorities) as well as decisions around treatment funding and system planning. The lack of transparency in the sale and compilation of physicians' prescribing and other performance data means that physicians might find themselves to be the unwitting subject and targets of marketing research. We believe practice decisions must be made in the best interest of patients and not the bottom-line interests of businesses and marketers. CMA therefore recommends a legislative change to include physician information as personal information under PIPEDA. Legislation in Quebec provides an example that is consistent with CMA's approach since it requires regulatory oversight and gives individuals the right to opt out of the collection, use and disclosure of "professional" information. 3. Emerging Privacy and Health information issues With budgetary and demographic pressures, our health care system is under strain and physicians are striving to deliver timely, quality care to patients, often with competing and multiple demands. Physicians are therefore seeking assurances from law makers that any amendments to PIPEDA will take into account the potential impact on them and their patients. Therefore, we seek assurances that: * health care is recognized as unique when it comes to the disclosure of personal information before the transfer of a business (one physician transferring his/her practice to another) because it is regulated at the provincial level through the appropriate licensing body. As a general rule, physicians must give notice to the public, whether via a newspaper ad or a notice in the office about the change in practice. * the federal government will consider the impact of the trans-border flow of personal information on telehealth and Electronic Health Record activities. Communications between patients and physicians via electronic means are likely to increase and to move across geographic boundaries with increasing frequency; and * the federal government will study the issue of international cross border data flows, particularly among Canadian researchers who receive funding from US drug companies. These arrangements should be governed by Canadian law (PIPEDA) not American (HIPAA or the US Patriot Act). In closing, the privacy protection of personal health information is a responsibility that my colleagues and I do not take lightly. It is a key pillar of our relationship with Canadians, they not only expect it-they deserve it. I look forward to taking questions from Committee members. Canadian Medical Association Ottawa, December 13, 2006

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Notes for an address by Dr. Eugene Bereza, Chair, Committee on Ethics, Canadian Medical Association : Bill C-6 (An act respecting assisted human reproduction) : Presentation to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2007

Last Reviewed
2011-03-05
Date
2004-02-18
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2004-02-18
Topics
Ethics and medical professionalism
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My name is Dr. Eugene Bereza. I am a physician and clinical ethicist at McGill University Health Centre in Montreal and Chair of the Canadian Medical Association’s Committee on Ethics. I am accompanied today by Dr. Jeff Blackmer, our Director of Ethics. I am here today representing the CMA, but I would also like to advocate on behalf of those patients affected by infertility and those patients suffering, or who will suffer, from the myriad diseases for which medical science is searching out a cure. While there has been considerable debate over the past decade on the moral and ethical issues associated with assisted human reproduction, discussion of this as a health issue has been overlooked all to often. We must remember this is about the practice of medicine and above all, the health of Canadians. My remarks today will focus on the inappropriateness of using criminal sanctions to deal with medical and scientific activities. The Issue It is important to make it clear at the outset that the CMA does not oppose the prohibition of certain medical and scientific activities. Others here today are in a better position to address concerns regarding the specific prohibitions proposed under Bill C-6. Our issue is the means chosen to give effect to these prohibitions and their potential impact on the ability of a physician to ensure the welfare of his or her patients. Criminal law is a blunt instrument. As parliamentarians, you know how difficult it can be to change the law. For some activities prohibited under the criminal law, such as murder and theft, change is not an issue. However, the science of medicine evolves constantly, doubling every 18-24 months. Advances in science and medical practice, coupled with the difficulty of anticipating new developments, make it difficult to adjust the law to remove criminal prohibitions as science and society changes. In the context of prohibiting medical and scientific activities, it is the CMA’s position that the use of criminal law is inappropriate, as it would ultimately not serve our patient’s best interests. Prohibitions, specifically those listed as prohibited activities under Bill C-6, (formerly Bill C-13) could be secured through much less drastic means than criminalization. The CMA proposes that the determination of permissible activities, temporarily or for the longer-term, should be made by the proposed Regulatory Agency working with up-to-date scientific information while providing for public input and ethical review. The Regulatory Agency, as proposed in the Bill, would determine if and when changes in health and safety considerations, public attitudes and values might justify allowing certain formerly prohibited activities to take place under specific conditions. Questions to Consider Bill C-6 begins with the statement: “This enactment prohibits assisted reproduction procedures that are considered to be ethically unacceptable.” However, many Canadians, especially those who are infertile, do not consider some or all of these procedures to be ethically unacceptable nor do the many physicians charged with their care. The CMA questions whether criminal prohibitions are appropriate for dealing with activities about which there is considerable ethical disagreement among Canadians. Legislators in Canada have been justifiably reluctant to use criminal law to deal with medical and scientific issues such as abortion, withdrawal of life-sustaining treatment and the conduct of medical research. Why is an exception being made for assisted reproduction? What sort of precedent will this set for other controversial bioethical issues? What about the chilling effect criminalization will have on research in this important area? For the CMA, the most important question is: what about the patients? What about patients suffering from conditions for which research is banned but may lead to a cure? Should they be denied the opportunity to benefit from this research? Just as Bill C-6 unfairly targets patients, so too does the Bill’s penalties for infractions. Jail terms of up to 10 years and fines up to $500,000 will create a climate of fear and excessive caution for physicians and scientists working in this area. The chill created by these penalties will be such that scientists may well avoid any activity potentially covered by the bill even to the detriment of patient care. The CMA recognizes the good faith among parliamentarians in proposing statutory bans to prohibit certain activities. However, we are convinced in this case the potential for harm outweighs the potential benefits. There is a better way to prohibit these activities while still facilitating important research and necessary treatments. An Alternative Solution Instead of instituting criminal prohibitions within the legislation, the CMA suggest the Assisted Human Reproduction Agency of Canada manage procedures deemed permissible by moving the procedures listed under “Prohibited Activities” to “Controlled Activities.” We recommend that criminal sanctions apply to breaches of agency directives such as performing activities prohibited by the agency and performing controlled activities without a license. Such an approach would have the dual advantage of being able to both prohibit activities deemed unethical while still providing the flexibility to ensure legitimate medical and scientific progress in the treatment of infertility. The regulatory agency should be established as soon as possible and should build on the experience and expertise of existing assisted reproduction organizations and structures that deal with practice standards, education, certification and accreditation. Conclusion The CMA’s overriding concern in addressing this legislation is the well-being of patients, in this case patients who are infertile and patients afflicted by conditions for which medical research offers significant promise of treatment. We support government efforts to regulate assisted human reproduction and related activities, including the prohibition of certain practices temporarily or permanently where necessary. However, we do not believe that criminalization of medical and scientific activities named in the bill is an appropriate way to achieve those objectives. We believe we have advanced a workable alternative within the spirit of the Bill. Thank you.

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Notes for an address by Dr. Eugene Bereza, Chair, Committee on Ethics, Canadian Medical Association : Bill C-13 - An act respecting assisted human reproduction : Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy1963

Last Reviewed
2010-02-27
Date
2002-11-20
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2002-11-20
Topics
Ethics and medical professionalism
Text
BILL C-13 - AN ACT RESPECTING ASSISTED HUMAN REPRODUCTION Presentation to the House of Commons Standing Committee on Health Ottawa, Ontario November 20, 2002 BILL C-13 - AN ACT RESPECTING ASSISTED HUMAN REPRODUCTION Madame Chair and Members of the Committee: My name is Dr. Eugene Bereza. I am a physician and clinical ethicist at the Royal Victoria Hospital in Montreal and Chair of the Canadian Medical Association Committee on Ethics. I am here today representing our members, more than 54,000 physicians from across Canada. I also wish to speak as a advocate for our patients, especially those affected by infertility and those who are or will suffer from diseases for which medical science is searching for cures. I am accompanied today by Dr. John Williams, our Director of Ethics. You will recall that we appeared before this Committee on October 23, 2001 in company with representatives from eight other national health provider and scientific organizations to present our views on draft legislation on assisted human reproduction. Although we were pleased that your December 2001 report recommended the establishment of an assisted reproduction regulatory body outside the Department of Health, we were disappointed that you did not find favour with other recommendations we put forward. The government responded to your report with Bill C-56, now Bill C-13. It is this bill that we are here to address today. Although there are many details in the bill on which we would like either clarification or changes, we intend to focus our remarks on the issue that we consider of greatest importance for our patient’s wellfare and the practice of medicine. That issue is the use of the criminal power to deal with medical and scientific activities. The Standing Committee Report and Bill C-13 In your December 2001 report, you acknowledged our position on this issue: “Some witnesses recommended the elimination of the prohibited activities category altogether. Citing the benefits of regulatory flexibility, they felt that all activities should come under the controlled activity category, including the more reprehensible activities like reproductive cloning for which licences, arguably, would never be allowed under the regulations” (page 9). However, you rejected this view on the grounds that “a licence-related prohibition of this sort would not carry the same weight or degree of social censure as the statutory prohibition…. An outright statutory ban signals more clearly that certain activities are either unsafe or socially unacceptable. The use of the statutory ban also signals that these activities are of such concern to Canadians that their status as a prohibited activity may not be altered except with the approval of Parliament” (page 9). Bill C-13 reflects your views on this matter. We recognize your good faith in proposing and defending this position but we are convinced that its potential for harm outweighs its potential benefits. And so we are pleased to have this opportunity to reiterate the reason why the CMA believes that Bill C-13 will adversely affect the patient-physician relationship and the advance of medical science. Need to Change Bill C-13 As you know, our position on this matter is supported by legal scholars such as Patrick Healy, McGill University Faculty of Law, Tim Caulfield, Director of the University of Alberta Health Law Institute, and Bartha Knoppers, Université de Montréal Centre de Recherche en Droit Publique. In essence, our position is that the criminal law is a blunt instrument and very difficult to change and is therefore appropriate for activities whose status is unlikely to change over time, such as murder and theft, rather than medical and scientific activities that are constantly developing. The latter are better left to a representative regulatory body to determine if and when changes in health and safety considerations and public attitudes and values might justify allowing certain formerly prohibited activities to take place under specific conditions. Bill C-13 begins with the statement: “This enactment prohibits assisted reproduction procedures that are considered to be ethically unacceptable.” This echoes the conclusions in your report. However, as the transcripts of your hearings demonstrate, many Canadians, especially those who are infertile, do not consider some or all of these procedures to be ethically unacceptable. As a matter of public policy, should Canadians who hold this view be denied access to medical treatment for infertility because others consider such treatments to be ethically unacceptable? Should patients who suffer from conditions for which research that is forbidden in Bill C-13 might lead to a cure be denied that opportunity? We question whether criminal prohibitions are appropriate for dealing with activities on which there is considerable ethical disagreement among Canadians. In Canada legislators have been justifiably reluctant to use the criminal law to deal with medical and scientific issues such as abortion, withdrawal of life-sustaining treatment and the conduct of medical research. Why is an exception being made for assisted reproduction? What sort of precedent will this set for other controversial bioethical issues? We are also concerned about the bill’s penalties for infractions: jail terms up to 10 years and fines up to $500,000. These are disproportionate to the penalties for crimes that injure persons or property and, as such, will create a climate of undue fear and excessive caution for physicians and scientists working in this area, such that they will avoid any activity that is potentially covered by the bill, even to the detriment of patient care. Given the rapid advance of science and medical practice and the difficulty of anticipating new developments, it will be difficult to adjust the law to deal with new applications of prohibited activities that may be ethically acceptable. An Alternate Solution The CMA has stated repeatedly that we are not opposed to the prohibition of certain assisted human reproduction activities. Instead of instituting criminal prohibitions within the legislation, we remain convinced that an independent body on an ongoing basis should determine the activities that are permissible or prohibited on the basis of up-to-date scientific research, public input and ethical review. This can be accomplished very easily in Bill C-13 by moving the procedures listed under “Prohibited Activities” (sections 5-9) to “Controlled Activities” and adding the words “except in accordance with the regulations and a licence” to each of the provisions in sections 5-9. Consistent with this recommendation we consider that the regulatory agency should be established as soon as possible and be given as much authority as possible over the matters that Bill C-13, section 65, reserves to regulations of Governor in Council. We hope that the agency will build upon the experience and expertise of existing organizations and structures in the field of assisted reproduction that deal with practice standards, education, certification and accreditation. Conclusion To summarize, we strongly support government efforts to regulate assisted human reproduction and related activities, including the prohibition of certain practices either temporarily or permanently. However, like others who have appeared before this Committee, we do not believe that criminalizing the medical and scientific activities named in the bill is an appropriate way to achieve those objectives. We consider that the objectives could be as well achieved by far less drastic means than criminalization and, moreover, that criminalization would create major obstacles to legitimate medical and scientific progress in the treatment of infertility. We recommend that the proposed agency be empowered to regulate these practices and that the criminal power be invoked when controlled activities are performed without authority of a licence from the agency or in defiance of the licensing conditions established by the agency. Thank you, Madame Chair and members of the Committee. We will be pleased to respond to your questions.

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