Tasmania bill will allow wide-open euthanasia.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

(Tasmania is an Australian Island state).

When debating the legalization of euthanasia or assisted suicide, the specific language of the legislation is often overlooked while people debate the concept assisted death.
 
The language in the 122 page Tasmania End of Life Choices bill which is expected to have its second reading in the Upper House on September 15, allows for a wide open assisted death regime.
 
This article focuses on the definition of medical condition in the bill.
 
For the purposes of the Act, the bill defines a relevant medical condition as:

(1) a disease, illness, injury, or medical condition, of the person that is serious, incurable and irreversible. 

(2)Despite subsection(1), a mental illness, within the meaning of the Mental Health Act 2013 is not a relevant medical condition for the purposes of this Act.

What does that mean? Unless the request for assisted death is based on mental illness, the person is only required to have a serious, incurable and irreversible medical condition.

The bill states that a person must be suffering intolerably in relation to a relevant medical condition. However, this is completely subjective because the bill states that the intolerable suffering is solely determined by the opinion of the person requesting assisted death

The bill also states that a person can be approved for an assisted death not only based on the serious, incurable and irreversible condition but also based on complications that may arise from treatment being received or treatment that may possibly be received.
 
Specifically, the bill states that a person can be approved for an assisted death if that person is concerned about:

"complications that have arisen, or may arise, in relation to the treatment of the relevant medical condition or its treatment or the combination of that treatment with the treatment of other medical conditions of the person."

The bill goes on to state that assisted death is permitted if, in the opinion of the person making the request, there is no reasonable treatment that will lessen the persons suffering to an extent that is acceptable to the person.

Therefore a person can be approved for an assisted death based on a fear of suffering related to a possible effective treatment, that the person has not tried. The caveat being that the person may in fact not only forgo the effective treatment but have never considered it in the first place.
 
Some people are delusional or have nosophobia about their medical condition. As noted above stated the language of the bill allows a wide open assisted death regime.

In summary, the definition of medical condition is completely subjective because it is based on whether the person finds the condition unacceptable, which is impossible for a physician to evaluate.

In other words, this bill gives pro-euthanasia medical practitioners the ability to approve deaths without fear of wrongful deaths leading to legal concerns.

The Tasmanian assisted death bill is 122 pages long. It is a massive spider web of text that appears to have comprehensive safeguards. 

This voluminous bill is not designed to protect a vulnerable person, but rather to protect medical practitioners who choose to kill.

Seniors Advocate suggests that nursing home lockdowns may be putting lives at risk.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Isobel Mackenzie

A British Columbia (BC) Seniors Advocate is suggesting that COVID-19 nursing home lockdowns need to change as the lives of many seniors are at risk.

Rob Munro with infonews.ca reported that Seniors Advocate, Isobel Mackenzie, is concerned that the health of thousands of BC nursing home residents may be diminished by lockdown rules restricting family visits. Mackenzie has launched an online survey (Link to the survey) to assess the effect of the lockdown on seniors. 

Munro reported:

Currently only one visitor is allowed and there is a great variety in how different care homes allow those visitors. That has led to cases where close family members have only been able to visit a relative — who seemed healthy before COVID-19 — when they are on their deathbeds. 

There have been 125 long-term care residents who have died from COVID-19 in the past seven months, (in BC) Mackenzie said. But there has also been another 2,000 who have died from other causes, some of which may be related to the lockdown and subsequent isolation and loneliness.

Shirley Turton asked for assisted death

Some elderly residents have asked for assisted death rather than continue living in isolation. Munro states:

Some residents have asked families to help them with assisted suicide because their lives have become unlivable in the isolation they are suffering under since family visits were stopped in March and were only resumed on a very limited basis in July.

Munro reported that Mackenzie is also looking into the protocols

For example, she’s trying to understand why some homes allow visitors once a week in a residents’ rooms versus others that may be once a month and require the visitors to stay two metres away from their loved ones in a common area.

Mackenzie said:

“We want to keep people safe from COVID-19 but what are we keeping them safe for if it’s not to enjoy the rest of their lives?”

More articles on this topic:

• BC woman asked for assisted suicide based on COVID-19 restrictions. (Link).  
• Deaths of despair are increasing (Link).
• A different type of COVID-19 death (Link). 
• Loneliness is an epidemic among seniors that requires a caring response (Link).

Natalie Harp was urged to request assisted suicide in California.

This article was published by the American Spectator on August 26, 2020.

Natalie Harp is living proof of the importance of the “right to try.”

Natalie Harp

By Wesley Smith

The threat of assisted suicide is a portentous issue of our day that many politicians pretend isn’t there. Republicans, in particular, have tended to hide under their desks about it. That may be because the question of legalizing doctor-prescribed death and/or euthanasia doesn’t usually make pollsters’ lists of issues that drive people to the polls, and the media enjoy depicting opponents of assisted suicide legalization as people who want others to suffer.

Ignoring this issue is not the kind of leadership that our country needs. Indeed, the question of whether or not to allow killing to become an acceptable answer to human suffering could not be more important, both culturally and morally.

When we accept assisted suicide, we are not really being compassionate, but rather are tacitly validating surrender to darkness. But by opposing the “give them the pills” expedient (that’s what it really is), and instead committing unequivocally to caring for the terminally ill with loving concern, we can insure that dying people are not made to feel like burdens or allowed to believe we will allow them to wallow in misery. In doing so, we value their equality and uphold the intrinsic dignity of their lives.

That’s a difficult message to communicate in our soundbite culture — particularly when so much communication these days is mere emoting. Indeed, most depictions of assisted suicide in the media and popular culture extol people who commit suicide as empowered and “dying on their own terms.” For example, who hasn’t seen the image of the late Brittany Maynard photographed with a cute puppy when the media reports on an assisted suicide? Maynard was made an A-list celebrity by the media back in 2014 when, tragically diagnosed with terminal brain cancer, she began campaigning to legalize doctor-prescribed death. CNN even named her one of 2014’s “extraordinary persons,” simply because she killed herself — with no real reportage about how the symptoms and difficulties of dying from brain cancer can be ameliorated with proper medical care. In fact, when the palliative care expert Ira Byock was interviewed on national television about that potential, he was castigated for interfering with Maynard’s “choice.”

With that kind of propaganda machine pushing assisted suicide, perhaps we can understand why Republicans have never brought it up at their national convention. That changed Monday night. Natalie Harp — who has survived diagnosed terminal bone cancer — proved that hope can be found even in situations seemingly bereft of anything but tragedy. From her speech:

The Democrats love to talk about health care being a human right. But a right to what? Well, I’ll tell you. To them, it’s a right to marijuana, opioids, and the right to die with “dignity” — a politically correct way of saying … assisted suicide.

Harp was not saying palliation is a bad thing. Nobody would. Pain and symptom control is an essential component of contemporary medicine that everyone should support. But she was warning us that these important medical fields should not be treated as a metaphorical elephant’s graveyard where people are sent to die.

In her speech, Harp identified a real problem powerfully and succinctly:

I was told I was a burden to my family and to my country — and that by choosing to die early, I’d actually be saving the lives of others by preserving resources for them rather than wasting them on a lost cause like myself.

Can you imagine the pain of that? Can you imagine how such treatment could induce one to want to commit assisted suicide, whether for fear of symptoms or worries about being a burden?

Harp saved her life with the new “right-to-try” law that permits terminally ill people to access treatments not yet approved by the FDA. The experimental care worked, allowing her to appear on national television to tell the tale.

But one can imagine a different scenario. Depressed and dejected, told there is no hope, she could have requested poison pills — unaware that a different choice would bring continued life. And a doctor — so compassionately — acquiesces in the death.

By the way, such “the patient didn’t die as expected” scenarios happen sometimes in situations that do not involve right-to-try. I experienced such a case as a hospice volunteer.

When I first met Ernie, an elderly man expected to die of congestive heart failure, he fell into my arms, crying, “I want to die! I want to die! I want to die!” When I asked him why, he said he worried about burdening his son. I assured him that wasn’t true and notified the care team about Ernie’s deep depression so they could intervene with social and mental health services.

About three months later, I lost Ernie — not because he died, but because his health had so unexpectedly improved that he was kicked out of hospice care!

If assisted suicide had been available in California at that time — as it is today — I believe Ernie would have asked for the poison pills, he was in such despair over his situation. Look at what he would have missed — and no one would have ever known. In this regard, it is worth noting that the humorist Art Buchwald was placed in hospice care with kidney failure. He too eventually left hospice and lived long enough after that to write his last book.

That isn’t the usual course for most hospice patients, of course. But that fact doesn’t justify assisted suicide either. Hospice help patients in their last stage of life live well and with great quality. Indeed, it is something of a hospice cliché that patients tell caregivers they would not have missed their final weeks and months in hospice for anything. A few of my patients told that to me too.

By allowing Harp to walk where Republicans usually fear to tread, the Trump campaign has done a big favor to the most weak, vulnerable, and, too often, abandoned among us. Harp’s advocacy to never give up on patients, to embrace care and not killing, has opened the door to explore these issues in greater depth going forward. Thank you, Natalie Harp!

Award-winning author Wesley J. Smith is chairman of the Discovery Institute’s Center on Human Exceptionalism and a consultant to the Patients Rights Council.

Nova Scotia woman will return to court on September 24 to prevent the euthanasia death of her husband.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Nova Scotia Justice Van den Eynden heard the request for an injunction to prevent the euthanasia (MAiD) death of a Nova Scotia man today.

Van den Eynden set September 24 as the date for an appeal hearing on an injunction but the judge has not yet decided if the temporary injunction to prevent the assisted death will continue.

The Canadian Press reported that:

Justice Elizabeth Van den Eynden reserved her decision on the request to issue an injunction against a lower court ruling that allowed the 83-year-old man's medically assisted death to proceed.

The lawyers for the 82-year-old woman argued that the stay of the lower court decision is needed because they didn't get a chance to cross examine medical experts. 

The lawyers contend those experts offered conflicting opinions regarding whether the man should have been granted permission to die under the federal law. 

According to court documents, the man says he is near the end of his life due to advanced chronic obstructive pulmonary disease, but his wife maintains his wish to die is based on anxiety and delusions.

In an interview with CTV News Avis Favario, Scher suggested that this case may be appealed to the Supreme Court of Canada.

"What I think this court case speaks to fundamentally is the need to have a dispute resolution process through the courts in those rare cases where there is a fundamental disagreement or conflict between multiple experts that needs to be resolved, because they're coming to completely alternate positions about the question of whether the person meets the criteria or not,"

EPC agreed to pay for the legal bills, but in turn, we need your financial support.

Donate to the Euthanasia Prevention Coalition (Link) by:

• Paypal (Link), 
• Donate by credit card by calling the EPC office at: 1-877-439-3348, or 
• Send a cheque to the Euthanasia Prevention Coalition, Box 25033, London ON., N6C 6A8.

Katherine could not have carried out the legal proceedings or filed an appeal without the financial support of the EPC. She stated that she loved her husband and that she wanted to launch a legal action to prevent her husband's wrongful death. Thank you for helping us stop a wrongful death.

Nova Scotia woman returns to court to prevent her husband's euthanasia death.

Alex Schadenberg

Executive Director, Euthanasia Prevention Coalition

Good news: 
Justice Van den Eynden set September 24 as the date for an appeal hearing on a permanent injunction.

A Nova Scotia court heard, today, the appeal of a lower court decision in a dispute over the assisted death (euthanasia) of an 83 year-old man with chronic COPD.

On August 14 I published the article EPC needs your help to prevent a euthanasia death where I explained that EPC is financing this precedent setting court case for a woman who is trying to prevent the euthanasia death of her husband.

The request for an injunction to prevent the euthanasia was based on an assessment by a physician, an affidavit from a physician, who has known the husband for many years, and Katherine's affidavit. These affidavit's agree that her husband is not terminally ill and that he has "delusional" beliefs concerning his medical condition. There were three separate assessments for assisted death stating that her husband's natural death was not reasonably forseeable or that he has lost the capacity to decide.

Katherine

Yesterday, Taryn Grant and Elizabeth Chu reported for CBC News Nova Scotia that:

Their marriage of 48 years splintered over a dispute about his wish to die with the help of a physician. The case is set to return to court Wednesday afternoon.

At the end of July, Katherine, 83, went to Nova Scotia Supreme Court to stop her husband, 82, from going ahead with the procedure that would end his life. Her request for an injunction has yet to receive a full hearing, but by filing with the courts she forced her husband to cancel his planned death on Aug. 3.

Grant and Chu reported the issue to be decided in court:

While he says he's suffering and near the end of his life because of advanced chronic obstructive pulmonary disease (COPD), she says his wish to die is not based on physical illness, but anxiety and mental delusions.

Part of the legal argument submitted by Hugh Scher, the lawyer for Katherine, stated:

 X (husband) has made three separate requests for MAiD. X changed his mind on the first request after two of the three assessors found that he either did not have capacity to decide to die and/or that his death was not reasonably foreseeable.

Medical Assessors Bachman, du Toit and Giffin agree that X’s conditions do not meet the criteria for reasonably foreseeable death as required by law. Dr. Bachman in particular is concerned that the root cause of X’s desire to die lies in his long-standing hypochondriasis coupled with a profound and irrational fear of future suffering at the hands of relatively benign disease processes. This opinion is buttressed by the findings of Dr. du Toit about X’s disordered thought processes and depression and by NP Giffin who found that he lacks capacity due to dementia and that he is not likely to die in the foreseeable future.

Dr. Bachman stated that X’s death was not reasonably foreseeable and that his request for MAiD was based on a delusional misunderstanding of his true medical condition.

Hugh Scher

In an interview by CTV News Avis Favario, Scher suggested that this case may be appealed to the Supreme Court of Canada.

"What I think this court case speaks to fundamentally is the need to have a dispute resolution process through the courts in those rare cases where there is a fundamental disagreement or conflict between multiple experts that needs to be resolved, because they're coming to completely alternate positions about the question of whether the person meets the criteria or not,"

Katherine could not have carried out the legal proceedings and file an appeal without the financial support of the Euthanasia Prevention Coalition. She stated that she loved her husband and that she wanted to launch a legal action to prevent her husband's wrongful death.

The Euthanasia Prevention Coalition needs your help.

EPC agreed to pay for the legal bills, but in turn, we need your financial support.

Donate to the Euthanasia Prevention Coalition (Link) by: 

• Paypal (Link), 
• Donate by credit card by calling the EPC office at: 1-877-439-3348, or 
• Send a cheque to the Euthanasia Prevention Coalition, Box 25033, London ON., N6C 6A8. 

Based on privacy, we will provide more information, when it is possible.

The Popular impact of Celebrity Suicide (Who really wants to die?: Part II)

This is Part 2 in a series of articles by Gordon Friesen examining who really wants to die?

Part 1: Who really wants to die? (A Brief Quantitative Analysis of the Purported “Need” for Euthanasia) (Link)

By: Gordon Friesen
http://www.euthanasiediscussion.net/

-- The sources of popular perception examined: a great quantitative divergence between the portrayed importance, of celebrity suicide, and the observed facts.

Because most people pass much of their lives (most thankfully) far from the realities discussed here, the first source of public opinion regarding suicidal actions, generally originates with the behavior of those celebrities, dear to our hearts, who do, suddenly, face real-life crises (including sickness and disability). First knowledge, then, comes only at second hand, and (unfortunately) even then with little benefit of pondered wisdom. For at these most difficult times, we usually see a marked tendency (in public commentary) to positively lionize those individuals who take their own lives; even to the extent of lavishly praising their “courage”!

Such were, for instance, the cases of American actor Robin Williams (1951 - 2014), and the once national diva of Quebec, Pauline Julien (1928 - 1998).

Yet on the other hand, we also have heroic survival figures such as Canadian athlete Terry Fox (1958 – 1981), Quebecois politician Gerald Godin (1938 – 1994), or American actors Christopher Reeves (1952 – 1904), and Michael J. Fox (1961 - ). And these heroic characters, also, experience the exact same popular adulation... and from the exact same people!

To be fair, it would appear that the public actually vibrates with equal passion -- and equal sympathy -- regardless of the outcome: they love their celebrities and they support them, whatever they do. Moreover, to resolve the apparent contradictions raised by this inconsistency, public opinion has also adopted the notion of a sort of unjudgable personal and existential choice: equally heroic, equally noble, and equally weighted (numerically speaking) on both horns of the suicidal dilemma.

But this last part, this crucial numerical part (and hence the validity of the whole description), is, in fact, grossly distorted: because ordinary survivors have a way of passing largely unnoticed; and thus do not show their proper numerical weight.

Nor is any of this at all remarkable: for be they ever so famous in their prime, our “stars” are normally absent from the news for years at a time as they grow older. And the inevitable report of their natural deaths comes, often, as a surprising recall that they had ever existed; while the younger generation, incapable even of recognizing their names, remain essentially ignorant of those who have passed. And whereas there are occasional life-blazing heroes, like Terry fox, who shine ardently in their moment of refusal and resistance, many more numerous are those who quietly hide their disabilities, as best they may, and then simply disappear into private life and oblivion. For each Terry, then, there are innumerable (though much less visible) people, of a similar inclination.

The suicides of famous persons, however, are singular news events of the highest interest; they are immediately reported, and profusely commented upon, throughout the world. Naturally, the result of this instant and enormous emphasis is to grossly inflate their true statistical importance. For one single suicide gains such notoriety, in this manner, that it will effectively outweigh the memory of literally thousands of other, equally famous people, who have lived and died in the more usual fashion. 

• Logan Paul and the suicide contagion effect (Link).
  

Above all, the celebrities who commit these acts of suicide are deeply held in the affections of their “fans”: who have a natural desire to “understand” them; to identify with their fate; to validate their purported reasoning; to vindicate them; and to stand in solidarity with their choice. They will, in any event, be fondly remembered. And there is a corresponding tendency in the media -- on television, in the papers and in the magazines: to use a tone and a vocabulary which serve to positively glorify the meaning of such suicides (and that, regrettably, in the spirits of those most receptive and most vulnerable).

And yet, we must insist: these acts remain entirely atypical; acts which should more naturally elicit our sadness and our disappointment, I would suggest, than a congratulatory admiration.

In any case (and however that may be) -- from a purely quantitative point of view -- while we recognize that we will always be deeply affected by such tragic events (and much more frequently than we would wish): the dearly mourned celebrities who are lost, in these iconic suicidal episodes, are much fewer than those who withdraw quietly.

And such, clearly, is the enormous numerical distortion that we must recognize in the fashions of common perception. For contrary to popular prejudice and enthusiasm: the small number of celebrity suicides provides no objective justification, whatsoever, for idealizing (and still less for normalizing) the notion of suicide as a general solution (for the physical, and mental, incursions of time and fate).

But with all of that said, it might still be imagined that the demand for death among ordinary citizens, afflicted with natural suffering and decline -- that is to say: among the ordinary mass of “the halt, the sick, and the lame” – could actually be greater than among the ultra-privileged, rich and famous.

Addressing that possible misconception, then, will be our next consideration.

To be continued ... 

Previous articles by Gordon Friesen:

• Who really wants to die? (A Brief Quantitative Analysis of the Purported “Need” for Euthanasia) (Link).
• Patients can no longer assume that doctors are committed to protecting life (Link).

Practising Medicine “with conscience and dignity”

The following article was published in the Journal of the World Medical Association (WMA) on August 24, 2020.

The WMA and the Foundations of Medical Practice, Declaration of Geneva (1948), International Code of Medical Ethics (1949).

Beginning with the Declaration of Geneva (the Declaration), for over 70 years the World Medical Association (WMA) has maintained that physicians must practise medicine with conscience and dignity[1]. On the Declaration’s 70th anniversary, seven associate WMA members raised serious concerns about their ability to remain in medical practice if they fulfil this obligation by refusing to support or collaborate in the killing of their patients by euthanasia and assisted suicide (EAS)[2].
 
The physicians practise in Canada, where euthanasia and assisted suicide (EAS) are legal, [3,4] recognized as therapeutic medical services by the national medical association [5,6] and provided through a public health care system controlled by the state, which also regulates medical practice and medical ethics. The national government is now poised to make EAS available for any serious and incurable medical condition, vastly increasing the number of patients legally eligible for the service [7].

In these circumstances, it is urgent to reassert that the duty to practise medicine “with conscience and dignity” includes unyielding refusal to do what one believes to be wrong even in the face of overwhelming pressure exerted by the state, the medico-legal establishment and even by medical leaders and colleagues. That the founders of the WMA not only supported but expected such principled obstinacy is evident in the WMA’s early history and the development of the Declaration, all of which remain surprisingly relevant.
 
Early Developments: 1945–46
 
A meeting of physicians from 30 countries in London in June 1945 discussed the formation of an international medical association [8, 9]. Some continental physicians spoke of crimes by physicians in their countries during the war [10], and over the next 18 months the world medical community became increasingly aware of physician participation in crimes against humanity [8, 11, 12].
 
National medical association delegates returning London in September 1946 were uneasy and ambivalent about plans to nationalize health care systems in Britain and the Continent. On the one hand, they welcomed the growing interest in medicine by governments around the world. On the other, they worried about the consequences of (as later expressed) transforming all physicians into “Civil Servants controlled by the State” [13, 14]. They conceived an international medical association as support for national associations defending practitioners and patients from government demands. They reminded the British health minister that physicians treat human beings, not collections of tissue, and must practise with “a discipline of the heart that makes it difficult to integrate [them] into the State machine”[15].

While delegates were motivated to organize the WMA by concerns about the profession-state relationship, they were also deeply disturbed by physician participation in war crimes [8].
 
In the month following the London gathering, twenty German physicians were arraigned in Nuremberg [13]. And the organizing committee drafted the WMA constitution and prepared for the first General Assembly while the Nuremberg “Doctors Trial” was in session. Reports from the trial resonated deeply with physicians anxious about being integrated into a “State machine” [16,17,18,19].
 
First General Assembly: War Crimes and Medicine (September 1947)
 
Physician war crimes dominated the agenda of the first WMA General Assembly, displacing discussion of the profession-state relationship. Delegates heard impassioned testimony from physician victims of the Third Reich and received the BMA report, War Crimes and Medicine [20, 21, 22].
 
The report denounced physicians responsible for crimes against humanity as lacking “moral and professional conscience,” condemning them for having allowed the state to use medical knowledge and science as “instruments of wanton destruction in the pursuit of war.” It asked the WMA to endorse the prosecution of physicians for war crimes and adopt a World Charter of Medicine, explicitly reaffirming medical ethics “in the spirit of the Hippocratic Oath,” suggesting that medical graduation should include a promise to adhere to the Charter [10].
 
The Assembly accepted the recommendations and approved a public apology and undertaking to be required of the German Medical Association as a condition for admission to the WMA. It also approved an oath affirming that a physician’s first duty is to care for a patient, “to resist any ill treatment that may be inflicted on him” and “to refuse my consent to any authority that requires me to ill-treat him.” Finally, it appointed a committee to produce a report about war crimes [23, 24].

Over the following year, the war crimes committee solicited forms of medical engagement from national associations with a view to formulating an international medical oath. The WMA Council also agreed to develop an international code of medical ethics, concerned that jurists reacting to physician war crimes might do so if the WMA did not [24,25].

Second & Third General Assemblies

Declaration of Geneva (September 1948), International Code of Medical Ethics (September 1949)
 
At the second WMA General Assembly, delegates were presented with War Crimes and Medicine: The German Betrayal and a Re-statement of Medical Ethics. It urged the Assembly to prevent physician crimes against humanity by reaffirming basic Hippocratic principles, which, it argued, would be universally acceptable. Requiring medical graduates to abide by a modern version of the Hippocratic Oath would help to impress them with the fundamentals of medical ethics. The suggested modern version, containing ten promises, was approved by the Assembly and published as the Declaration of Geneva [26].

The Second General Assembly also approved the development of an international code of medical ethics. The final version, which included the Declaration of Geneva, was approved at the Third General Assembly in 1949 [27].
 
Refusing the fatal surrender of conscience

The documents make clear that what the authors of the Declaration and the ICME meant by practising medicine “with conscience and dignity” was not only doing what one believes to be right, or only doing what one believes to be best for patients, but refusing “to make the easy and fatal surrender of one’s conscience to the mass mind of the totalitarian state” (18). A British physician responding to the BMA report on war crimes commented:

During the terrible years of occupation by a brutal enemy the large majority of doctors of most of the occupied countries maintained their moral integrity, their unswerving loyalty to their patients, and their spiritual and professional freedom, even at the risk of torture and death. They thereby set a great example and vindicated the honour of their profession [19].
 
According to Leo Alexander, writing a year later, just before the ICME was adopted, Dutch physicians collectively demonstrated such heroism [28]. Steadfast refusal to do what one believes to be wrong was understood to be central to practising medicine “with conscience and dignity,” an essential safeguard for personal and professional integrity and patients.

That was then; this is now
 
It is easy to understand this duty in relation to refusing to comply with the murderous dictates of a totalitarian regime that have been universally derided for decades. It is more difficult to see why it should apply to refusing to provide legal services requested by patients in a democracy. The difficulty disappears once one admits that both totalitarian and democratic regimes can make grave moral errors in law and public policy.
 
Events in Germany from 1920 to 1945 demonstrate that physicians willingly enlisted and collaborated in the implementation of a biopolitical ideology thought to be on the cutting edge of science and progressive ideas. Exactly the same thing has happened elsewhere and is likely to happen again. When it does, the medical profession is likely to be most accommodating and even anxious to participate to ensure that the state “gets it right.”
 
At issue here is the freedom, integrity, dignity and obligations of individual physicians who are convinced that the profession and the state have got it wrong, yet face demands that they participate in activities that they reasonably believe to be immoral or contrary to good medical practice.
 
Then...

When the Nazi regime was installed, officials of the largest German medical associations “gladly” welcomed it and placed themselves at its service, celebrating the intimate links of the medical profession with “the wisdom and aims of the State”. Those intimate links were reflected in the law directing compulsory sterilisation of those with “genetic illnesses” (including alcoholism and mental deficiency) enacted in response to a petition from the associations [29]. Physicians sterilized about 300,000 persons before the war, and began killing the handicapped when the war began, a project supported directly and indirectly by colleagues and scientists [30].
 
Physicians were predisposed to cooperate because they were convinced of the value of eugenics. Eugenics was a widely accepted scientific discipline, “on the cutting edge of science”, supported by respected scholars, various scientific disciplines, major universities and scholarly journals [30, 31]. The eugenics movement propagated the belief that people inherited not only eye and hair colour, but were criminals, or rich, poor, lazy, industrious, promiscuous or faithful because they were “born that way” [32]. Leading scientists and activists campaigned to prevent the reproduction of such “defectives” by contraception and sterilization of “inferior types,” including the mentally ill, physically handicapped, criminals, and certain “degenerate” races [33,34].
 
Eugenics was popular among the socially elite, including Winston Churchill, Herbert Hoover and Alexander Graham Bell (35). Eugenic societies and scientists successfully lobbied for laws authorizing voluntary or compulsory sterilization of “defectives”, including criminals, the mentally handicapped and mentally ill; 27 US states had such laws in 1931. By 1935 sterilization laws had been adopted in Canada, Denmark, Switzerland, Germany, Norway and Sweden [36].
 
Eugenics was especially influential in Germany after the First World War [37] and was absorbed into Nazi party policy. Since physicians were among eugenics’ foremost exponents, to hear Nazi policy described as “nothing but applied biology” was especially attractive to them. Hence, many willingly joined the vanguard of what became “the most ambitious and murderous eugenics program in human history”. Their characteristic response was not just acquiescence, but “eager and active cooperation” [31,38,39].

Such eagerness was not limited to German physicians. In 1936, the Canadian Medical Association Journal featured a lengthy essay on the superiority of the Aryan/Nordic Race by an author who, the year before, had held up Germany as a model for other nations and toasted Adolph Hitler as “a great leader” [40,41]. Two years earlier it had published a glowing report about eugenic sterilizations authorized by the Alberta Eugenics Board [42].
 
Over 44 years Alberta physicians sterilized 2,822 people at the Board’s direction [43]. A court reviewing its operations found that it had routinely flouted the law, and, as late as the early 1960’s, physicians had performed illegal sterilizations and medically unnecessary castrations, hysterectomies, oophorectomies and biopsies of testicular tissue, behaviour the judge described as “unlawful, offensive and outrageous”. He excoriated one Board geneticist for, among other things, encouraging the use of persons with Down Syndrome as “medical guinea pigs” [44]. However, she had “no regrets,” defending her activities as “a very reasonable approach to a very difficult problem” [45]. Awarded the Order of Canada and other honours [46, 47, 48], she was eulogized in 2014 as one of Canada’s most respected geneticists (49).

Even as the Alberta court was ruling on the Alberta Eugenics Board, Alberto Fujimori was mobilizing physicians in Peru for the National Program for Reproductive Health and Family Planning. By the time it ended four years later, 200,000 to 300,000 people had been sterilised, most without valid consent: some forcibly, others bribed or threatenedby government officials or health care personnel. Most victims were poor and often illiterate women from indigenous ethnic groups. The technical standard of medical care was often appalling, and numbers of women died [50, 51, 52, 53].
 
The WMA’s denunciation of coercive sterilization came 12 years too late for Fujimori’s victims [54]. In the United States, Oregon abolished its eugenic sterilization law only in 1983, and another 20 years passed before the state acknowledged the injustice suffered by victims sterilized according to the ethical standards of the day [55]. The Tuskegee Syphilis Study continued until it was exposed in 1972, the same year the Alberta Eugenics Board was abolished. It took almost 25 years for victims to receive a public apology for unethical human experimentation [56, 57].
 
In 2012, a generation of German physicians unconnected with the Nazi era admitted the enthusiastic participation of German physicians at all levels of the profession in crimes against humanity, apologized, begged forgiveness, and described what their predecessors had done “as a warning for the present and the future” [58].
 
The warning points, in the first place, to the risk of sea changes with incalculable consequences. It appears that the German medical profession’s eugenic outlook and interests converged with other social and political dynamics and Hitler’s rise to power. The convergence triggered a sudden, seismic socio-political shift that supercharged Nazi biopolitical ideology. The medical profession rapidly transformed itself and was transformed to fulfil its new biopolitical responsibilities [29], and new possibilities suddenly materialized [59]. Carl Jung experienced this as an “earthquake” and an “avalanche” that was sweeping all before it [60].
 
Second, the warning reminds us that modern biopolitical ideologies are advocated worldwide by lobbyists as prominent, powerful and influential as the eugenic enthusiasts of yesteryear.
 
Finally, we are warned that state collaboration with the medical profession in support of faulty biopolitical ideologies is far more dangerous than the exercise of freedom of conscience by individual physicians. Literally millions have suffered and died as victims of what seemed like a good idea at the time, at least in the eyes of those in positions of power and influence.

Now...
 
The euthanasia/assisted suicide (EAS) movement backs a biopolitical ideology that is enormously popular in the developed world, now entrenched in Canadian law and collectively supported by the medical profession. This has serious implications for the nature of medical practice. 

Leading Canadian EAS advocates told the Supreme Court of Canada that physicians are ideal EAS practitioners because they will agree to it only “as a last resort” [61]. Indeed, they argued that “physician-assisted dying” is not only “medical treatment,” but “at the core of health care” [62]. This must place killing patients at the core of the practice of medicine and require transformation of the medical profession to fulfil its role in the new order. How far this will go remains to be seen.
 
Physicians cannot currently be compelled to personally administer or prescribe lethaldrugs, though some prominent academics argue that should change [63,64]. However, the national government allows state medical regulators to compel unwilling practitioners to facilitate EAS by effective referral [65] or effective transfer of care [66], which even some strong supporters of the procedures acknowledge to be morally equivalent to personally killing patients [64,67,68]. Courts in the province of Ontario support this coercive policy, ruling that physicians unwilling to comply can move into fields like sleep medicine, hair restoration and dermatology [69].
 
Unsurprisingly, some academics recommend that medical schools deny admittance to anyone with conscientious objections to providing whatever the state considers medical treatment or health care, including EAS [70]. Anecdotal reports indicate that some dissenting medical students face intense pressure to conform to the EAS biopolitical agenda, experiencing isolation, disregard and disdain among their peers (71).
 
No wonder Canadian physicians who refuse to support or collaborate in killing their patients feel themselves to be in the midst of a socio-political and ethical avalanche.
 
Summing up
 
The historical record suggests that support for physicians who refuse to kill or facilitate the killing of their patients is justifiable on prudential and pragmatic grounds. Tolerating refusal to participate in killing seems to be a safer course than imposing an obligation to kill and is certainly consistent with the high value EAS advocates have placed on physician reluctance to kill as a primary safeguard for patients.
 
As a matter of principle, one must distinguish what is demonstrably necessary to preserve a free and democratic society from what may be necessary to enforce a biopolitical ideology. The difference is significant but can be difficult to discern in an avalanche. EAS ideology is grounded upon metaphysical, philosophical and moral premises that can be rationally contested but cannot be empirically validated. Among these is the dogmatic claim that a human being can be better off dead. In a free and democratic society, it ought to be unacceptable to force physicians to profess this article of faith, or to demonstrate practical adherence to it by killing or facilitating the killing of a patient.
 
Finally, there is an issue that goes to the heart of what concerned the authors of the Declaration of Geneva.

Competent patients may refuse even lifesaving/sustaining interventions based entirely on their subjective views of what is beneficial, harmful, or in their best interests. Physicians ensure that patients have information relevant to such decisions and may make recommendations, but they are legally and ethically obliged to respect patients’ inviolability and abide by their decision. The foundations of medical ethics and the personal integrity of physicians who disagree are untouched by the patient’s decision.
 
While competent patients can absolutely refuse interventions, they cannot demand interventions because medical decisions to intervene are not based solely upon patients’ demands [72]. Among other things, they engage physicians as moral agents.
 
Patients request an intervention, including euthanasia, because they believe it is not harmful, is beneficial, or is in their best interests. Physicians may reasonably disagree. If, despite this, physicians are compelled to further a patient’s request, the concepts of benefit, harm and best interest become irrelevant. All that remains is the demand of the patient, backed by the power of the state to ensure compliance.

This treats physicians as mere technicians or state functionaries, as cogs in a state machine delivering services upon demand, not as responsible moral agents who, like their patients, must form and act upon judgements about benefits and harms. It imposes a form of servitude that is incompatible with human equality, dignity and personal and professional integrity.

The authors of the Declaration and ICME denounced such instrumentalization of physicians and the medical profession in the strongest terms. The precept to practise medicine with conscience and dignity imposes an obligation to resist and refuse such demands, notwithstanding overwhelming pressures exerted even in democratic societies.
 
References
1. Revised in 2017 to include, (and in accordance with good medical practice. World Medical Association. Declaration of Geneva [Internet]. [Ferney-Voltaire, France]: World Medical Association; 2018 Jul 09 [cited 2020 Mar 10]. Available from: https://www.wma.net/policiespost/wmadeclarationofgeneva/.
2. Leiva R, Cottle MM, Ferrier C, Harding SR, Lau T, Scott JF. Euthanasia in Canada: A Cautionary Tale. World Med J [Internet]. 2018 Sep [cited 2020 Mar 10]; 64:3 1723. Available from: https://www.wma.net/wpcontent/uploads/2018/10/WMJ_3_20181.pdf#page=19.
3. Carter v. Canada (Attorney General), 2015 SCC 5 [Internet]. Ottawa: Supreme Court of Canada; 2020 Jan 21 [cited 2020 Mar 10]. Available from: https://scccsc.lexum.com/scccsc/scccsc/en/item/14637/index.do.
4. Criminal Code, s 222(1) [Internet]. Ottawa: Minister of Justice; 2020 Jan 08 [cited 2020 Mar 10]. Available from: https://lawslois.justice.gc.ca/PDF/C46.pdf#page=347.
5. CMA Policy: Medical Assistance in Dying [Internet]. Canadian Medical Association; 2017 May [cited 2020 Mar 10]. Available from: https://policybase.cma.ca/documents/policypdf/PD1703.pdf.
6. Doctorassisted suicide a therapeutic service, says Canadian Medical Association [Internet]. CBC News; 2015 Feb 06 [cited 2020 Mar 10]. Available from: https://www.cbc.ca/news/health/doctor-assisted-suicide-a-therapeutic-service-says-canadian-medical-association-1.2947779.
7. Bill C-7: An Act to amend the Criminal Code (medical assistance in dying) [Internet]. Ottawa: Parliament of Canada; 2020 Feb 24 [cited 2020 Mar 10]. Available from: https://www.parl.ca/Content/Bills/431/Government/C7/C7_1/C7_1.PDF.
8. Bonah C, Schmaltz F. The reception of the Nuremberg Code and its impact on medical ethics in France: 1947-1954. In: Czech H, Druml C, Weindling P, editors. Medical Ethics in the 70 Years after the Nuremberg Code: 1947 to the Present. International Conference at the Medical University of Vienna; 2017 Mar 2-3. Central European J Med (2018) [cited 2020 Mar 10]; 130, S159-253. Available from: https://link. springer.com/content/pdf/10.1007/s00508-018-1343-y.pdf.
9. Heard at Headquarters: International Relations. BMJ [Internet]. 1945 Jun 16 [cited 2020 Feb 08]; 1(4406): S111-120. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2057579/pdf/brmedj03889-0037. pdf#page=7
10. International Relations: War Crimes. BMJ [Internet]. 1947 Jun 21 [cited 2020 Feb 07]; 1(4406): S131. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2053513/ pdf/brmedj03786-0043.pdf
11. British Medical Association. Annual Report of the Council 1945-6: International Relations. BMJ [Internet]. 1946 Apr 20 [cited 2020 Feb 10]; 1(4450): S85-86. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2058781/pdf/brmedj038290043.pdf.
12. International Medical Conference. BMJ [Internet]. 1946 Aug 24[cited 2020 Feb 10];2(4468): S67-70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2054062/pdf/brmedj037950037.pdf#page=2.
13. World Medical Association: General Assembly in London. BMJ [Internet]. 1949 Oct 22 [cited 2020 Mar 10]; 2(4633): S175-180. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051418/pdf/brmedj03647-0057.pdf.
14. World Medical Association Constituted: International Conference in London. BMJ [Internet]. 1946 Oct 05 [cited 2020 Mar 10]; 2(4474): 503-505. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2057674/pdf/brmedj038010027.pdf.
15. Government Luncheon to World Medical Association Delegates: Mr. Aneurin Bevin’s (Inauguration Speech. BMJ [Internet]. 1946 Oct 05 [cited 2020 Mar 10]; 2(4474): 506. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2057674/pdf/brmedj038010027.pdf#page=4.
16. Trials of the War Criminals before the Nuernberg Military Tribunals. Vol. I, The Medical Case [Internet]. Washington, DC: US Government Printing Office; 1950 [cited 2020 Mar 10]. 1004 p. Available from: http://www.loc.gov/rr/frd/Military_Law/pdf/NT_war-criminals_Vol-I.pdf.
17. Mellanby K. Medical Experiments on Human Beings in Concentration Camps in Nazi Germany. BMJ [Internet].1947 Jan 25 [cited 2020 Mar 10]; 1(4490): 148-150. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2052883/pdf/brmedj03765-0026.pdf.
18. Doctors on Trial. BMJ [Internet].1947 Jan 25 [cited 2020 Mar 10]; 1(4490): 143. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2052888/pdf/brmedj037650021.pdf.
19. Odlum DM. World Medical Association. BMJ [Internet]. 1947 Jul 19 [cited 2020 Mar 10]; 2(4515): 108. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2055254/pdf/brmedj037380028b.pdf.
20. World Medical Association. BMJ [Internet]. 1947 Sep 27 [cited 2020 Mar 10]; 2(4525): 498(500. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2055764/pdf/brmedj037480028.pdf.
21. British Medical Association. Proceedings of Council, Wednesday, October 29, 1947: World Medical Association. BMJ [Internet]. 1947 Nov 08 [cited 2020 Mar 10]; 2(4531): S103-104. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2056019/pdf/brmedj03754-0043.pdf.
22. Dworzeki M. “Let Us Throw the Anathema Against the Murderer Doctors” September 30 1947 [Internet]. Independence, MO: Harry S. Truman Library and Museum. [cited 2020 Mar 10]. 4 p. Available from: https://www.trumanlibrary.gov/library/researchfile/reportmarkdworzeckiletusthrowanathemaagainstmurdererdoctors.
23. World Medical Association. BMJ [Internet]. 1947 Dec 27 [cited 2020 Mar 10]; 2(4538): S165-166. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2056440/pdf/ brmedj037610051.pdf.
24. Noyer F. Du syndicalisme médical de l’entredeux guerres à la naissance de l’Association Médicale Mondiale: Vie et oeuvre du docteur Paul CIBRIE. These Presentee pour le Diplome de Docteur en Medecine [Internet]. 2016 [cited 2020 Mar 10]. 349 p. University of Strasbourg. Available from: https://dhvs.unistra.fr/fileadmin/uploads/website/dhvs/Recherche/2016_Noyer_Fabrice_Paul_Cibrie.pdf.
25. British Medical Association. Annual Representative Meeting, Cambridge 1948: The Work of the Association. BMJ [Internet]. 1948 Jul 03 [cited 2020 Mar 10]; 2(4565): S2. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2090189/pdf/brmedj036840096.pdf#page=2.
26. Crimes de Guerre et Medecine (Amendment du document C.2/48 tel qu(adopte par l’Assemblee Generale, September 1948) La Trahison Allemande et un Re-Expose de l’Ethique Medicale. In: Noyer F. Du syndicalisme médical de l’entredeux guerres à la naissance de l’Association Médicale Mondiale : Vie et oeuvre du docteur Paul CIBRIE. These Presentee pour le Diplome de Docteur en Medecine. Annex 3. [Internet]. 2016 [cited 2020 Feb 10]. 349 p. University of Strasbourg. Available from: https://dhvs.unistra.fr/fileadmin/uploads/websites/dhvs/Recherche/2016_Noyer_Fabrice_Paul_Cibrie.pdf#page=339.
27. World Medical Association. BMJ [Internet]. 1949 Oct 15 [cited 2020 Feb 08]; 2(4632): 854-855. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2051515/pdf/brmedj036460032.pdf.
28. Alexander LJ. Medical Science Under Dictatorship. N Engl J Med 1949; 241:3947. DOI:10.1056/NEJM194907142410201.
29. Hanauske-Abel HM. Not a slippery slope or sudden subversion: German medicine and National Socialism in 1933. BMJ [Internet]. 1996 (cited 2020 Feb 9); 313:145363. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2352969/pdf/bmj005710043.pdf.
30. Friedlander H. The Origins of Nazi Genocide: From Euthanasia to the Final Solution. Chapel Hill and London: University of North Carolina Press; 1995. 421 p.
31. Hayse MR. Recasting the West German Elites: Higher Civil Servants, Business Leaders and Physicians in Hesse Between Naziism and Democracy, 1945-1955. New York: Berghahn Books, 2003. 288 p.
32. Gould SJ. The Mismeasure of Man. New York: W.W. Norton & Company; 1981. 352 p.33. Goddard, H.H., Feeble-mindednes: Its Causes and Consequences. New York: MacMillan; 1914. In: Gould SJ. The Mismeasure of Man. New York: W.W. Norton & Company; 1981. 352 p.
34. Drake MJ, Mills IW, Cranston D. On the Chequered History of Vasectomy. BJU International [Internet]. 2001 Dec 25 [cited 2020 Mar 10]. Available from: https://onlinelibrary.wiley.com/doi/full/10.1046/j.1464410x.1999.00206.x.
35. Benedict S. Fertile Ground for Murder. In Benedict S, Shields L, editors. Nurses and Midwives in Nazi Germany: The “Euthanasia Programs”. New York, London: Routledge Taylor & Francis Group; 2014. Chapter 2; p. 23-26.
36. Osborn F. Eugenics. In: Encyclopaedia Britannica. Vol. 8. Chicago: Encyclopaedia Britannica Inc.; 1973. p. 815-817.
37. O’Donnell A, Drummond J, Simpson M, Benedict S, Shields L. The Eugenic Movement in Germany. In: Benedict S, Shields L, editors. Nurses and Midwives in Nazi Germany: The “Euthanasia Programs”. New York, London: Routledge Taylor & Francis Group 2014. Chapter 2.2; 15-24.
38. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books; 1986. 561 p.
39. Proctor RN. Racial Hygiene: Medicine Under the Nazis. Cambridge, MA: Harvard University Press; 1988. 414 p.
40. Campbell CG. The Lessons of Racial History. Can Med Assoc J (Special Article) [Internet] 1936 Jul [cited 2020 Mar 10]; 35(1): 80-84. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1561696/pdf/canmedaj00514-0134.pdf.
41. Lombardo PA. The American Breed: Nazi Eugenics and the Origins of the Pioneer Fund. Albany Law Review [Internet]. 2002 [cited 2020 Mar 10] 65(3):743-830. Available from: https://www.academia.edu/836113/The_American_ Breed_Nazi_Eugenics_and_the_Origins_of_the_Pioneer_Fund_2002_.
42. Association notes – The Sixty-fifth Annual Meeting of the Canadian Medical Association
(June, 1934). Can Med Assoc J [Internet] 1934 Oct [cited 2020 Mar 10]; 31(4): 433-436. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC403584/pdf/canmedaj00148-0087.pdf#page=3.
43. Caufield T, Robertson G. Eugenic Policies in Alberta: From the Systematic to the Systemic. Alberta Law Review [Internet]. 1996 [cited 2020 Mar 10]; 35(1): 59-79. Available from: https://www.albertalawreview.com/index.php/ALR/article/view/1063/1053.
44. Muir v. Alberta, 1996 CanLII 7287 (AB QB) [Internet]. Ottawa: Canadian Legal Information Institute; 2020 Feb 22 [cited 2020 Mar 10]. Available from: http://canlii.ca/t/1p6lq.
45. Cairney R. “Democracy was never intended for degenerates”: Alberta’s flirtation with eugenics comes back to haunt it. CMAJ [Internet] 1996 Sept 15 [cited 2020 Mar 10]; 155(6): 789-792 at 792. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1335257/.
46. Mrs. Margaret W. Thompson, Order of Canada, Member of the Order of Canada [Internet]. Ottawa: Governor General of Canada [cited 2020 Mar 10]. Available from: https://www.gg.ca/en/honours/recipients/1462897.
47. Past Founders Award for Career Achievement [Internet]. Kingston, ON: Canadian College of Medical Geneticists; 2017 [cited 2020 Mar 10]. Available from: https://www.ccmgccgm.org/80members/122founderspast.html.
48. Dr. Margaret Thompson Trainee Award [Internet]. Kingston, ON: Canadian College of Medical Geneticists; 2017 [cited 2020 Mar 10]. Available from: https://www.ccmgccgm.org/91members/awards/148traineeawardees.html.
49. Csillag R. Gifted scientist Margaret Thompson had a lasting impact on health care. Globe and Mail [Internet] 2014 Dec 14 [updated 2018 May 12] [cited 2020 Mar 10]. Available from: https://www.theglobeandmail.com/news/national/giftedscientistmargaretthompsonhadalastingimpactonhealthcare/article22078694/.
50. Inter-American Commission on Human Rights. Report No. 71/03, Petition 12.191, Friendly Settlement: Maria Mamérita Mestanza Chávez – Peru [Internet]. 2013 Jan [cited 2020 Mar 10]. Washington, DC: Global Health and Human Rights Database; Available from: https://www.globalhealthrights.org/wpcontent/uploads/2013/01/IAComHR2003MariaMameritaMestanzaChavezv.Peru.pdf.
51. Inter-American Commission on Human Rights. Report No. 24/19, Petition 947-10, Report on Admissibility: Celia Edith Ramos Durand and Family – Peru [Internet] 2019 Mar 07 [cited 2020 Mar 10]. Available from: http://www.oas. org/en/iachr/decisions/2019/PEAD94710EN.docx
52. Sastre Á. Mujeres esterilizadas en Perú: “Me ataron y vendaron, pero veía los serruchos y la sangre” [Internet]. La Razon; 2018 Apr 28 [cited 2020 Mar 10]. Available from: https://www.larazon.es/internacional/mujeresesterilizadasenperumeataronyvendaronperoveialosserruchosylasangreMJ18220914/.
53. Peru apologizes for forced sterilizations [Internet]. UPI; 2002 Jul 24 July [cited 2020 Mar 10]. Available from: https://www.upi.com/Defense-News/2002/07/2/Peruapologizesforforcedsterilizations/80301027529085/?ur3=1.
54. World Medical Association. WMA Statement on Forced and Coerced Sterilization [Internet]. [Ferney-Voltaire, France]: World Medical Association; 2017 Feb 20 [cited 2020 Mar 20]. Available from: https://www.wma.net/policiespost/ wmastatementonforcedandcoercedsterilisation/.
55. Associated Press. Apology for Oregon Forced Sterilizations [Internet]. Los Angeles Times; 2002 Dec 03 [cited 2020 Mar 10]. Available from: https://www.latimes.com/archives/laxpm-2002dec03nasterile3story.html.
56. U.S. Public Health Service Syphilis Study at Tuskegee – Presidential Apology: Remarks of the President in Apology for Study Done in Tuskegee (The White House, Office of the Press Secretary, For Immediate Release May 16, 1997) [Internet]. Washington, DC: Centers for Disease Control and Prevention; 2015 Dec 14 [cited 2020 Feb 22]. Available from: https://www.cdc.gov/tuskegee/clintonp.htm.
57. Final Report of the Tuskegee Syphilis Study Legacy Committee – May 1996 [Internet].
Charlottesville VA: University of Virginia; 2007 [cited 2020 Feb 22]. Available from: http://exhibits.hsl.virginia.edu/badblood/report/.
58. Gale A. German Medical Association Finally Apologizes For Atrocities Committed by German Physicians Under the Nazis. Mo Med [Internet] 2013 Nov-Dec (cited 2020 Feb 15);
110(6): 486–488. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6179814/.
59. Bruns F. Turning Away from the Individual: Medicine and Morality Under the Nazis. In: Bialas W, Fritze L, editors. Nazi Ideology and Ethics. Newcastle upon Tyne: Cambridge Scholars Publishing; 2014. p. 211-236.
60. Purrington. Carl Jung: A Rejoinder to Dr. Bally [A response to charges of Anti-Semitism]. [Internet]. Carl Jung Depth Psychology 2019 Nov 12 [cited 2020 Feb 19]. In: Adler G, editor, translator, Hull RFC, editor. Collected Works of CG Jung. 2nd ed. Vol. 10, Civilization in Transition. Bollingen Series XX. Princeton: Princeton University Press. 612 p. Available from: https://carljungdepthpsychologysite.blog/2019/11/12/carl-jung-rejoinder-dr-bally-response-chargesanti-semitism/.
61. Supreme Court of Canada, 35591, Lee Carter, et al. v. Attorney General of Canada, et al (British Columbia) (Civil) (By Leave) Webcast of the Hearing on 2014-10-15 [Internet]. Ottawa: Supreme Court of Canada; 2018 Jan 22 [cited 2020 Mar 10]. 00:20:02 – 00:20:40.
Available from: https://www.scc-csc.ca/casedossier/info/webcastview-webdiffusionvueeng.
aspx?cas=35591&id=2014/2014-10-15--35591&date=2014-10-15&fp=n&audio=n.
62. Supreme Court of Canada, 35591, Lee Carter, et al. v. Attorney General of Canada, et al (British Columbia) (Civil) (By Leave) Webcast of the Hearing on 2014-10-15 [Internet]. Ottawa: Supreme Court of Canada; 2018 Jan 22 [cited 2020 Mar 10]. 00:06:53 to 00:07:03,
Available from: https://www.scc-csc.ca/casedossier/info/webcastview-webdiffusionvueeng.
aspx?cas=35591&id=2014/2014-10-15--35591&date=2014-10-15&fp=n&audio=n.
63. Attaran A. The Limits of Conscientious and Religious Objection to Physician Assisted Dying after the Supreme Court’s Decision in Carter v Canada. Health L Can. 2016; 36(3):86-98.
64. Savulescu J, Schuklenk U. Doctors Have no Right to Refuse Medical Assistance in Dying,
Abortion or Contraception. Bioethics. [Internet] 2016 Sep 22 [cited 2020 Mar 10]; 31(3): 162-170. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/bioe.12288.
65. College of Physicians and Surgeons of Ontario. Medical Assistance in Dying [Internet]. Toronto: College of Physicians and Surgeons of Ontario; 2018 Dec [cited 2020 Feb 20]. Available from: https://www.cpso.on.ca/Physicians/PoliciesGuidance/Policies/MedicalAssistanceinDying.
66. College of Physicians and Surgeons of Nova Scotia. Professional Standard Regarding Medical Assistance in Dying [Internet]. Bedford, NS: College of Physicians and Surgeons of
Canada; 2017 Oct 13 [cited 2020 Feb 20]. Available from: https://cpsns.ns.ca/wpcontent/
uploads/2016/06/MedicalAssistanceinDying-Standard.pdf.
67. Journal des débats (Hansard) of the Committee on Health and Social Services. 40th Legislature, 1st Session (October 30, 2012 au March 5, 2014) Tuesday, September 17, 2013 – Vol. 43 No. 34. Special consultations and public hearings on Bill 52, An Act respecting end-of-life care [Internet]. Quebec City: Assemblée Nationale du Québec; 2013 Sep 17 [cited 2020 Mar 10]. Available from: http://www.assnat.qc.ca/en/travaux-parlementaires/commissions/csss-40-1/journal-debats/CSSS-130917.html#_Toc386455854.
68. Consultations & hearings on Quebec Bill 52: College of Physicians of Quebec – Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand. Tuesday 17 September 2013 – Vol. 43 no. 34: Collège des médecins du Québec [Internet]. Powell River, BC: Protection of Conscience Project [cited 2020 Mar 10]. Available from: http://www.consciencelaws.org/background/procedures/assist009-001.aspx#154.
69. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of
Ontario, 2019 ONCA 393 (CanLII) [Internet] Ottawa: CanLII; 2020 Jan 27 [cited 2020 Mar
10]. Available from: https://www.canlii.org/en/on/onca/doc/2019/2019onca393/2019onca393.html.
70. Browne R. Medical schools should deny applicants who object to provide abortion, assisted death: bioethicist [Internet]. Global News; 2019 Nov 23 [cited 2020 Mar 10]. Available from: https://globalnews.ca/news/6183548/medicalschool-applicants-abortion-assisted-death-conscientious-objectors/.
71. Concerned Ontario Medical Student. Comments on: “Conscience Rights Matter.” 2020 Feb 27 [cited 2020 Mar 10]. In: Gandhi S. justanoldcountrydoctor [Internet]. 2020 Feb 26. Wordpress.com. Available from: https://justanoldcountrydoctor.com/2020/02/26/conscience-rights-matter/comment-page-1/?unapproved=664&moderation-hash=0eac7b968ac93439f9316a8bc063dc6a#comment-664.
72. Coggon J. Mental Capacity Law, Autonomy, and best Interests: An Argument for Conceptual and Practical Clarity in the Court of Protection. Med Law Rev [Internet]. 2016 Summer [cited 2020 Mar 10];24(3):396-414. Available from: https://academic.oup.com/medlaw/article/24/3/396/2733270.

Sean Murphy, 
Administrator Protection of Conscience Project
British Columbia Canada
 
Dr. Ramona Coelho,
MDCM, CCFP
 
Dr. Philippe D. Violette, MSc.
MDCM, FRCSC
Assistant Professor Depts. of Surgery and Health Research Methods, Evidence and Impact,
McMaster University, Hamilton, Ontario, Canada.
 
Ewan C Goligher MD PhD
Assistant Professor
Interdepartmental Division of Critical Care Medicine
University of Toronto
 
Timothy Lau, MD, FRCPC
Distinguished Teacher, Associate Professor, Faculty of Medicine,
Department of Psychiatry, Geriatrics, Royal Ottawa Hospital.
 
Sheila Rutledge Harding,
MD, MA, FRCPC
Hematology
Saskatchewan Health Authority
Professor, University of Saskatchewan Saskatoon, Saskatchewan, Canada