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Early childhood development

https://policybase.cma.ca/en/permalink/policy11476
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
Text
Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.1,2 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.3,4 Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. Even for those children who don't encounter these types of barriers, there can be problems in the early years. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.5 Just as children are susceptible to negative influences in early life, the period of rapid development means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.6 At the government and national level there are four main areas of action: Early childhood learning and care; Support for parents; Poverty reduction; and Data collection for early childhood development. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. While most of what is necessary for early childhood development will be done by governments and stakeholders outside of the health care system, there are opportunities for physicians to influence this important social determinant both through medical education, and clinical practice. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Background Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. The early childhood period is the most important development period in life.7 Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.8,9 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.10,11 According to research done by the Centers for Disease Control and Prevention in the adverse childhood event (ACE)a study, child maltreatment, neglect, and exposure to violence can significantly impact childhood development. The study involved a retrospective look at the early childhood experiences of 17,000 US adults and the impact of these events on later life and behaviour issues. An increased number of ACEs was linked to increases in risky behaviour in childhood and adolescence12 and to a number of adult health conditions including alcoholism, drug abuse, depression, diabetes, hypertension, stroke, obesity, heart disease, and some forms of cancer.13,14 The greater the number of adverse experiences in childhood the greater the likelihood of health problems in adulthood.15 A high level of ACEs was linked to language, cognitive and emotional impairment; factors which impact on school success and adult functioning.16 Finally, the study found a correlation between experiencing ACEs, suicide, and being the victim of or perpetrating intimate partner violence.17 Poverty is a significant barrier to healthy child development. Children who grow up in poor families or disadvantaged communities are especially susceptible to the physiological and biological changes associated with disease risk.18 Poverty is associated with a number of risk factors for healthy development including: unsupportive parenting, inadequate nutrition and education, high levels of traumatic and stressful events19, including higher rates of traumatic injuries20, poorer housing, lack of services, and limited access to physical activity.21 Children from low-income families score lower than children from high-income families on various measures of school readiness, cognitive development and school achievement22,23, and this gap increases over time with children of low-income families being less likely to attend post-secondary education and gain meaningful employment.24 Children who grow up in poverty are more likely to be poor as adults25,26 and to pass this disadvantage on to their own children.27,28 Children living in poverty have more problem behaviours such as drug abuse, early pregnancy, and increased criminal behaviour.29 Finally, economic hardship in childhood has been linked to premature mortality and chronic disease in adulthood.30 Early adverse events and poverty are serious impediments to healthy development, however, it is not just disadvantaged children that need attention. The early years are critical for all children regardless of socio-economic status. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.31 By 2030, 90% of morbidity in high income countries will be related to chronic diseases.32 These diseases are due in large part to risk factors such as smoking, poor nutrition, alcohol and drug abuse, and inadequate physical activity.33 These risk factors can be heavily influenced by the environment in which people live and can be increased by poor early childhood experiences.34,35 Health promotion and disease/injury prevention programs targeted at adults would be more effective if investments were made early in life on the origins of those diseases and conditions.36,37 Areas for Action While there is reason for concern regarding early childhood development, there is positive news as well. Just as children are susceptible to negative influences in early life, the period of rapid development also means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.38 Government and National: Early Childhood Learning and Care Research suggests that 90% of a child's brain capacity is developed by age five, before many children have any access to formal education.39 More than one quarter of Canadian children start kindergarten vulnerable in at least one area of development.40 Approximately two thirds of these deficiencies can be considered preventable. Evidence suggests that each 1% of excess vulnerability in school readiness leads to a reduction in GDP of 1% over the course of that child's life.41 Children who aren't ready for kindergarten are half as likely to read by the third grade, a factor that increases the risk of high school drop-out significantly. 42 While it is possible to intervene later to address these learning deficiencies, these interventions are less effective and much more costly.43 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.44,45 A recent analysis of 84 preschool programs in the United States concluded that children participating in effective pre-school programs can acquire about a third of a year of additional learning in math, language and reading skills.46 Since the implementation of the universal childcare program in Quebec, students in that province have moved from below the national average on standardized tests to above the average.47 In addition, effective early childhood learning programs offer a significant return on investment. Research done on US preschool programs found a return on investment of between four and seventeen dollars for every dollar spent on the program. Evidence from the Quebec universal child care program indicates that the program costs are more than covered by the increased tax revenues generated as a result of increased employment among Quebec mothers. For every dollar spent on the Quebec program, $1.05 is received by the provincial government with the federal government receiving $0.44.48 In terms of early childhood learning and care, Canada is lagging far behind - tied for last place among 25 countries in Organization for Economic Cooperation and Development (OECD) early childhood development indicators.b,49 Canada spends the least amount of money on early childhood learning and care of all countries in the OECD (0.25% of GDP)50, or one quarter of the recommended benchmark. Of this money, fully 65% is attributable to Quebec's universal daycare program.51 Canadian families face great pressures in finding affordable and accessible quality early childhood learning and care spots across the country. In Quebec 69% of children 2-4 regularly attend early childhood learning programs; outside of Quebec the number falls to 38.6%. The challenges for low-income families are even more pronounced with almost 65% of poor children 0-5 receiving no out-of home care.52 The federal government and the provinces and territories must work to bring Canada in line with other OECD countries on early childhood learning and care. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. Support for Parents A supportive nurturing caregiver is associated with better physical and mental health, fewer behavioural problems, higher educational achievement, more productive employment, and less involvement with the justice system and social services.53 Studies have demonstrated that improved parental-child relationships can minimize the effects of strong, prolonged and frequent stress, referred to as toxic stress54,55, and that the effects of poverty can be minimized with appropriate nurturing and supportive parenting.56 Parental support programs can act as a buffer for children at the same time as strengthening the ability of parents to meet their children's developmental needs.57 Caregivers who struggle with problems such as depression or poverty may be unable to provide adequate attention to their children undermining the attachment relationships that develop in early life. The relatively limited attention that is focused on addressing the deficiencies in time and resources of parents across all socio-economic groups can undermine healthy childhood development.58 One approach that has been shown to improve parental functioning and decrease neglect and child abuse is early childhood home visiting programs, sometimes referred to as Nurse Family partnerships. These programs provide nursing visits to vulnerable young mothers from conception until the children are between two and six depending on the program. The home visits provide prenatal support, educate parents about early childhood development, promote positive parenting, connect parents with resources, and monitor for signs of child-abuse and neglect.59 Results from several randomized controlled trials of these programs in the United States have shown that the program reduces abuse and injury, and improves cognitive and social and emotional outcomes in children. A 15 year follow-up study found lower levels of crime and antisocial behaviour in both the mothers and the children that participated in these programs.60 In Canada Nurse Family Partnerships were first piloted in Hamilton, Ontario. They are now undergoing a broader implementation and review in the Province of British Columbia. These programs should continue to be supported and expanded to all families who would benefit from this proven early childhood intervention. Many Canadian provinces have established community resources for parents. Alberta has recently announced plans to establish parent link centres across the province. These will deliver parenting programs, and be home to community resources and programs.61 Similar programs exist in other provinces such as the early years centres in Ontario62, and family resource centres in Manitoba.63 Early Childhood Development Centres in Atlantic Canada are combining child care, kindergarten and family supports into early childhood centres that are aligned with schools.64 While these programs can go a long way in reducing abuse and neglect, there is still a need for an overarching strategy to reduce neglect and child abuse across the country. As the ACE study in the United States clearly demonstrated, exposure to early adverse events such as family violence or neglect have troubling implications for adult health and behaviours.65 Action must be taken to ensure that avoidable adverse events are eliminated. The CMA Recommends that: 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. Poverty reduction In 1989 the Canadian government made a commitment to end child poverty by 2000. As of 2011, more Canadian children and their families lived in poverty than when the original declaration was made.66 Canada ranks 15th out of 17 peer countries with more than one in seven children living in poverty (15.1%).67 Canada is one of the only wealthy nations with a child poverty rate that is actually higher than the overall poverty rate.68 Child poverty is a provincial and territorial responsibility as well. As of 2012, only four provinces had child poverty strategies that met the guidelines put forward by the Canadian Paediatric Society.c,69 Poor children grow up in the context of poor families which means that solutions for child poverty must necessarily minimize the poverty of their parents.70 Efforts to increase the income as well as employment opportunities for parents, in particular single parents, must be part of any poverty reduction strategy.71 Programs, such as affordable child care, that allows parents to be active participants in the work force represent one approach72,73 Quebec's program of early childhood care has increased female workforce participation by 70,000 and reduced the child poverty rate by 50%.74 Addressing poverty could minimize problem areas in child development. According to a 2009 report by the Chief Public Health Officer of Canada, of 27 factors seen as having an impact on child development, 80% of these showed improvement as family income increased.75 Increasing income has the greatest impact on cognitive outcomes for children the earlier in life the reduction in poverty takes place.76 The federal government and the provinces and territories must work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children. The CMA Recommends that: 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. Data Collection for Early Childhood Development The evidence shows the importance of early childhood development for later success and health. In order to properly design effective interventions to mitigate developmental concerns, there is a need for appropriate data on early childhood health indicators and interventions. Given the variation in outcomes of children among different communities and demographic groups, there is a need for individual level data which is linked to the community level. This will allow providers and governments to develop appropriate interventions. Such an approach is being used by the Manitoba Centre for Health Policy, the Human Early Learning Partnership in British Columbia, and Health Data Nova Scotia. Researchers at these centres are creating a longitudinal data set by linking administrative data from a range of sources.77 Such data sets should be supported in all provinces and territories. Another tool being used to measure the progress of Canadian children is the Early Development Instrument (EDI). This tool is a 104 item checklist completed by teachers for every child around the middle of the first year of schooling. The checklist measures five core areas of early child development that are known to be good predictors of adult health, education and social outcomes. These include: physical health and well-being; language and cognitive development; social competence; emotional maturity; and communication skills and general knowledge.78,79 This tool has been used at least once in most of the provinces and territories with a commitment from most jurisdictions to continue this monitoring.80 While this is a good start, it gives only a snapshot of development. Ideally a monitoring system plots several points of time in development to identify trajectories of children. Ontario has introduced an enhanced well baby visit at 18 months. This clinical intervention could allow for the capture of development data at an earlier time. There is a need for more comprehensive information at the 18-month and middle childhood phases.81 The CMA Recommends that: 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. Medical Education: Given the importance of early childhood experiences on adult health there is a need for a greater understanding of the biological basis of adult diseases. The medical community needs to focus more attention on the roots of adult diseases and disabilities and focus prevention efforts on disrupting or minimizing these early links to later poor health outcomes.82 The science of early brain development and biology is rapidly evolving. There is a need to ensure that future and current physicians are up to date on this information and its implications for clinical practice.83 The Association of Faculties of Medicine and the Norlien foundation have partnered to provide funding and support for a series of e-learning tools on early brain and biological development.84 Continuing medical education does exist for some components of early childhood development and more work is underway. The Ontario College of Family Physicians has developed a CME that explores early childhood development for practitioners.85 These initiatives must be supported and expanded to all physicians who provide primary care to children and their families. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. Clinical Practice: While many of the threats to early childhood development lie outside of the hospital or medical clinic, there are a number of ways that physicians can help to address this important determinant of health within their practices. Primary care practitioners are uniquely qualified to address this fundamental population health issue,86 and can provide one important component in a multi-sectoral approach to healthy early childhood development.87 Screening and support for parents The health care system is the primary contact for many child-bearing mothers, and for many families, health-care providers are the only professionals with whom they have regular contact during the early years.88,89 According to data from the Institute for Clinical Evaluative Sciences, 97% of Ontario children aged zero to two are seen by a family physician.90 Within a patient-centred medical home, health-care providers can give support and information to parents about issues such as parenting, safety, and nutrition, and can link them to early childhood resourcesd, and other supports such as housing and food security programs. 91,92 Primary-care providers can help patients connect with public health departments who have many healthy baby and healthy child programs.93 Primary-care providers can ensure that screening takes place to identify risk factors to appropriate development.94 This screening should take place as early as the prenatal stage and continue throughout childhood. Screening should include regular assessments of physical milestones such as height, weight and vision and hearing etc. In addition, providers can identify risk factors such as maternal depression, substance abuse, and potential neglect or abuse.95 Given the negative consequences of early violence and neglect on childhood development96, this is a key role for primary-care providers. Screening for social issues such as poverty, poor housing and food insecurity should also be completed.97 A significant time for screening occurs at 18 months. This is the time for the last set of immunizations and in many cases the last time a child will have a regularly scheduled physician visit before the start of school.98 The 18 month well baby visit provides an opportunity to screen for not only medical concerns but child development as well. The enhanced 18 month well baby visite developed in Ontario combines parental observations and clinical judgment to screen for any risks a child might have.99 In Ontario, parental observation is captured through the Nipissing District Developmental Screen (NDDS). The parents complete this standardized tool and report the results to their physicians or other primary-care providers. The NDDS checklist is not meant to be a diagnostic tool but instead helps to highlight any potential areas of concern while also providing information to parents about childhood development. The 'activities for your child' section which accompanies the tool can also help reinforce the importance of development.100 As part of the visit primary-care providers fill out a standardized tool known as the Rourke Baby Record. This tool is an evidence based guide which helps professionals deliver the enhanced visit. This combined with the parental report through the NDDS, allows for a complete picture of the physical as well as the development health of the child at 18 months. Primary-care providers can use the results to discuss parenting and development and link children to specialized services, as necessary, and other community supports and resources. In Ontario early child development and parenting resource system pathways have been developed in many communities to help ensure that primary care providers can be aware of the resources and supports available for their patients.101 As was already noted, almost two thirds of vulnerabilities in readiness for school can be prevented.102 Appropriate identification through screening is a first step in correcting these issues. While the expansion of this approach is currently being reviewed in Nova Scotia, it should be implemented in all provinces and territories with appropriate compensation mechanisms and community based supports. Additionally, consideration should be made to developing screening tools for physicians outside of primary care, ie. emergency departments, who see children who might not have regular primary care physicians. The CMA Recommends that: 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. Literacy By 18 months disparities in language acquisition begin to develop.103 According to US research, by age four, children of families on welfare will hear 30 million less words than children from families with professional parents.104 This can lead to ongoing disparities in childhood learning as evidence suggests that exposure to reading and language from parents is fundamental for success in reading by children.105 Physicians and other primary-care providers can play a role in helping to reduce these disparities. They can encourage reading, speaking, singing and telling stories as part of a daily routine.f Studies have demonstrated that when physicians discuss literacy with parents and provide them with appropriate resources, such as developmentally appropriate children's books, increases in reading frequency and preschool language scores have been found.106 One program which has integrated reading and literacy into clinical practice is the 'Reach out and Read' program in the United States. This program partners with physicians, paediatricians, and nurse practitioners to provide new developmentally appropriate books to children ages 6 months through 5 years, as well as guidance for parents about the importance of reading.107,108 The success of this program has been significant with parents in the program being four to ten times more likely to read frequently with their children, and children scoring much higher on receptive and expressive language scores on standardized tests.109 Given the success of this program for American children, a similar program should be explored in the Canadian context. The CMA Recommends that: 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Conclusion The early years represent the most important time of development. The first five years can 'get under the skin' and influence outcomes throughout the life course. Negative experiences such as poverty, violence, poor nutrition, and inadequate parenting can determine behaviours as well as adult health outcomes. Effective early interventions can help to minimize or capitalize on these experiences. Government actions and supports to reduce poverty, child abuse, violence and to enable parents to care for their children are necessary. In addition, appropriate high quality early childhood learning and care programs are required for all Canadians regardless of socio-economic status. Finally, health care providers can play a role in identifying children at risk, supporting their parents to encourage healthy childhood development, and advocating for communities that ensure all Canadian children have the opportunity to grow up happy and healthy. References a The adverse childhood events are: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, incarcerated household member. http://www.cdc.gov/ace/prevalence.htm#ACED b The indicators used for the comparison include: Parental leave of one year with 50% of salary; a national plan with priority for disadvantaged children; subsidized and regulated child care services for 25% of children under 3; subsidized and accredited early education services for 80% of 4 year-olds; 80% of all child care staff trained; 50% of staff in accredited early education services tertiary educated with relevant qualification (this is the only indicator that Canada met); minimum staff-to-children ratio of 1:15 in pre-school education; 1.0% of GDP spent on early childhood services; child poverty rate less than 10%; near-universal outreach of essential child health services. UNICEF (2008) The child care transition: A league table of early childhood education and care in economically advanced countries. Available at: http://www.unicef-irc.org/publications/pdf/rc8_eng.pdf c To meet the CPS guidelines a province/territory requires anti-poverty legislation promoting long-term action and government accountability for at least three years, and has a poverty reduction strategy with specific targets. d For a list of some of the resources available for early childhood development across the country please see the Canadian Paediatric Society Resource Page: http://www.cps.ca/en/first-debut/map/community-resources e For more detailed information on the enhanced 18 month well baby visit please see the Canadian Paediatric Society Position statement- Williams R & J Clinton. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa, ON; 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (Accessed 2014 Jan 24). For resources available to Ontario primary-care providers please visit: http://machealth.ca/programs/18-month/default.aspx f For information and resources on early literacy please see the Canadian Paediatric Society at: http://www.cps.ca/issues-questions/literacy 1 Williams R et.al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 2 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 3 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 4 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 5 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 6 Hutchison P Chair. Inquiry into improving child health outcomes and preventing child abuse, with a focus on pre-conception until three years of age. New Zealand House of Representatives. Wellington (NZ); 2013. Available: http://media.nzherald.co.nz/webcontent/document/pdf/201347/Full-report-text1.pdf (accessed 2014 Mar 3). 7 World Health Organization. Closing the Health Equity Gap: Policy options and opportunities for action. Geneva, Switzerland; 2013. Available: http://www.paho.org/equity/index2.php?option=com_docman&task=doc_view&gid=103&Itemid (accessed 2013 Dec 20) 8 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 9 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 10 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 11 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 12 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 13 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 14 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 15 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 16 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 17 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 18 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 19 Luby J et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. Published online October 28, 2013. 20 Oliver LN, Kohen DE. Neighbourhood variation in hospitalization for un intentional injury among children and teenagers. Health Rep 2010;21(4):9-17 21 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 22 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 23 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 24 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 25 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 26 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 27 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 28 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 29 Dreyer BP. To Create a Better World for Children and Families: The Case for Ending Childhood Poverty. Acad. Pediat. Vol 13 No 2. Mar-Apr 2013. Available: http://download.journals.elsevierhealth.com/pdfs/journals/1876-2859/PIIS1876285913000065.pdf (accessed 2013 Dec 10). 30 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 31 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 32 Bygbjerg IC. Double Burden of Noncommunicable and Infectious Diseases in Developing Countries. Science Vol.337 21 September 2012 pp.1499-1501. Available: http://health-equity.pitt.edu/3994/1/Double_Burden_of_Noncommunicable_and_Infectious_Diseases.pdf (accessed 2014 Mar 11). 33 World Health Organization. Global Status Report on Non-Communicable diseases 2010. Chapter 1: Burden: mortality, morbidity and risk factors. Geneva, Switzerland; 2010. Available: http://www.who.int/nmh/publications/ncd_report_chapter1.pdf (accessed 2014 Mar 11). 34 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 35 Dreyer BP. To Create a Better World for Children and Families: The Case for Ending Childhood Poverty. Acad. Pediat. Vol 13 No 2. Mar-Apr 2013. Available: http://download.journals.elsevierhealth.com/pdfs/journals/1876-2859/PIIS1876285913000065.pdf (accessed 2013 Dec 10). 36 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 37 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 38 Hutchison P Chair. Inquiry into improving child health outcomes and preventing child abuse, with a focus on pre-conception until three years of age. New Zealand House of Representatives. Wellington (NZ); 2013. Available: http://media.nzherald.co.nz/webcontent/document/pdf/201347/Full-report-text1.pdf (accessed 2014 Mar 3). 39 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 40 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 41 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 42 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 43 Heckman JJ. The Case for Investing in Disadvantaged Young Children. Available: http://heckmanequation.org/content/resource/case-investing-disadvantaged-young-children (accessed 2014 Feb 6). 44 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011. 45 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013. Available: http://ec.europa.eu/justice/fundamental-rights/files/c_2013_778_en.pdf (accessed 2013 Jan 24). 46 Yoshikawa H et al. Investing in Our Future: The Evidence Base on Preschool Education. Society for Research in Child Development & Foundation for Child Development. New York (NY); 2013. Available: http://fcd-us.org/sites/default/files/Evidence%20Base%20on%20Preschool%20Education%20FINAL.pdf (accessed 2014 Feb 6). 47 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 48 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 49 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2012 Jan 24). 50 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 51 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 52 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 53 Shonkoff JP et.al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 54 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 55 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 56 Luby J et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. Published online October 28, 2013. 57 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 58 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 59 Knoke D. Early childhood home visiting programs. Centres of Excellence for Children's Well-Being. Toronto(ON); 2009. Available: http://cwrp.ca/sites/default/files/publications/en/HomeVisiting73E.pdf (accessed 2014 Mar 7). 60 Mercy JA, Saul J. Creating a Healthier Future Through Early Interventions for Children. JAMA June 3, 2009 Vol 301, No.21. 61 Government of Alberta. Alberta improves supports for families. Edmonton(AB); 2014. Available: http://alberta.ca/release.cfm?xID=356434F454042-9B0A-23FD-4AD0402F87D70805 (accessed 2014 Jan 7). 62 Ontario Ministry of Education. Ontario Early Years Centres: Frequently asked questions. Toronto (ON):N.D. Available: http://www.oeyc.edu.gov.on.ca/questions/index.aspx (accessed 2015 Jan 30). 63 Healthy Child Committee of Cabinet. Starting Early, Starting Strong: Manitoba's Early Childhood Development Framework. Government of Manitoba, Winnipeg (MB); 2013. Available: http://www.gov.mb.ca/cyo/pdfs/sess_ECD_framework.pdf (accessed 2014 Jan 10). 64 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 65 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 66 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 67 Conference Board of Canada. Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Jun 20). 68 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 69 Ibid. 70 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 71 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 72 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 73 Fauth B, Renton Z & Solomon E. Tackling child poverty and promoting children's well-being: lessons from abroad. National Children's Bureau. London (UK); 2013. Available: http://www.ncb.org.uk/media/892335/tackling_child_poverty_1302013_final.pdf (accessed 2014 Jan 10). 74 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 75 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 76 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 77 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 78 Human Early Learning Partnership. Early Development Instrument. N.D. Available: http://earlylearning.ubc.ca/edi/ (accessed 2014 Oct 8). 79 Adamson P. Child well-being in rich countries: A comparative overview: Innocenti Report Card 11. UNICEF, Florrence, Italy; 2013. Available: http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf (accessed 2014 Jan 10). 80 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://firstwords.ca/wp-content/uploads/2014/05/Early-Years-Study-3.pdf (accessed 2014 Feb 11). 81 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 82 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 83 Garner AS et al. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics 2012;129;e224. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2662.full.pdf+html (accessed 2014 Feb 11). 84 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 85 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 86 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 87 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 88 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 89 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 90 The Minister of Children and Youth announces that every child will receive and enhanced 18-month visit: Family Physicians Play Key Roles in Healthy Child Development. Toronto(ON). Available: http://ocfp.on.ca/docs/cme/enhanced-18-month-well-baby-visit-key-messages-for-family-physicians.pdf?sfvrsn=1 (accessed 2012 Feb 20). 91 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 92 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 93 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 94 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 95 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21). 96 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 97 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 98 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 99 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 100 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 101 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 102 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 103 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 104 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 105 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10). 106 Ibid. 107 Reach out and Read. Reach Out And Read: The Evidence. Boston (MA); 2013. Available: https://www.reachoutandread.org/FileRepository/Research_Summary.pdf (accessed 2014 Mar 5). 108 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 109 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10).
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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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