Update: The Supreme Court has struck down a ban on doctor-assisted suicide. Read the full story.
If the Supreme Court of Canada takes the momentous step of striking down the law against assisted suicide on Friday, Canada's medical profession intends to play a significant part in crafting the new rules that would govern how the gravely ill choose to die in this country.
The Canadian Medical Association has been grappling for more than a year and a half with how best to handle euthanasia and doctor-assisted suicide if both become legal across the land. Doctors, after all, would be making the front-line decisions that go to the "very gut of one's personal ethics and morals," according to the president of the CMA. And doctors' support for assisted suicide lags behind that of the public at large.
"We'll be very interested in having a lot of input into the operational details," said Chris Simpson, a Kingston, Ont., cardiologist who represents about 80,000 physicians. "What sorts of [medical] conditions would be eligible? Should there be a waiting time between when a decision is made to allow for sober second thought? Should it be one or two physicians? Is it only going to be [available] to people who individually can consent or will people who can't consent themselves, but have substitute decision makers, be eligible?"
The CMA hosted town halls, researched right-to-die regimes in other countries and softened its old stance against hastening patients' death before its lawyers testified in front of the country's highest court last fall.
The organization was one of more than a dozen intervenors in Carter v. Canada, a potentially landmark case testing the constitutionality of the Criminal Code provision that forbids helping another person take his or her life.
The court is scheduled to rule on the case Friday. The justices could leave the law intact, but if they opt to strike it down, they are expected to suspend the ruling for a time and ask Parliament to write a new law on the issue.
That is when the CMA hopes to step in.
Last August, delegates to the CMA's annual general meeting voted 91 per cent in favour of a resolution allowing doctors "to follow their conscience when deciding whether to provide medical aid in dying," if it becomes legal.
The resolution was a sea change for an organization that had long opposed euthanasia, in which doctors actively hasten the deaths of willing patients, and physician-assisted suicide, in which doctors provide patients with the means to take their own lives, usually with medication.
A survey of nearly 5,000 CMA members conducted last summer found that 45 per cent favoured legalizing physician-assisted death and 36 per cent felt euthanasia should be legalized, a support rate that is below that of the general public.
Only 27 per cent of doctors said in the 2014 survey that they would be likely or very likely to participate if physician-assisted death was legalized, up from 20 per cent in a similar but smaller survey of CMA members conducted in 2011.
The fact that three out of four physicians would not be willing to hasten a patient's death raises questions about what would happen to patients whose doctors refuse to provide aid-in-dying that goes beyond palliative care.
The CMA's new policy on euthanasia and doctor-assisted death is silent on the question of referrals.
Several – but not all – of the province's medical regulatory colleges have policies and practice standards that require doctors to provide referrals when they refuse to offer controversial treatments, such as performing abortions or prescribing birth control.
At least two provinces, Ontario and Saskatchewan, are in the midst of updating their policies on conscientious refusals, but neither is doing so explicitly in anticipation of the Supreme Court's ruling in the Carter case.
Catherine Ferrier, a geriatric doctor at McGill University Health Centre in Montreal who opposes assisted suicide, said she would never refer a patient to another doctor for aid in dying.
"Basically, you're sending somebody to their death," Dr. Ferrier said. "I think that a [regulatory college] that obliges a doctor to violate his or her conscience is harming the profession."
James Downar, a palliative and critical care physician at Toronto General Hospital, said that although he supports his colleagues' right to refuse, that has to be weighed against the rights of patients.
"I think we need to recognize that conscientious objection in this context can serve as a barrier and we need a very robust system to make sure that the physician's right to conscientious objection does not impinge on the patients' right to receive what would be a legal treatment," he said.
The opposing views of Dr. Downar and Dr. Ferrier make it clear just how personal – and polarizing – right-to-die issues remain for physicians.
For Dr. Ferrier, caring for vulnerable elderly patients led her to become the president of the Physicians' Alliance Against Euthanasia, a Quebec-based doctors' group that has been fighting that province's medical-aid-in-dying law, which passed last year.
For Dr. Downar, tending to gravely ill patients in the intensive-care unit prompted him to become the co-chair of the physicians' advisory board for the non-profit group Dying with Dignity.
"I haven't met a doctor who hasn't thought about this," Dr. Simpson said. "There's a lot of moral angst around this, no question about it."