Feature
that self-referral may not be feasible in this
context. The national advocacy organization,
Dying with Dignity, for example, said that
the College’s position on conscientious objection should be used as the “gold standard’ for
other medical colleges across Canada.
Those opposed to this requirement were
concerned that it would make the physician
complicit in physician-assisted death, morally
culpable for the patient’s death, and would
infringe on physicians’ Charter protected
right to freedom of conscience and religion.
In its determination, Council chose to
maintain the requirement for an effective
referral. While a number of Council members
expressed sensitivity for the concerns raised
by those opposed to effective referral, it was
pointed out that the guidance on conscientious objections, including the requirement to
provide an effective referral, reconciles physician and patient rights, as was directed by the
Supreme Court.
Council also considered the argument that
an effective referral is equivalent to providing
physician-assisted death – but ultimately, it
could not accept the argument on its merits.
“That position does not accord with the
purpose or implications of referrals in clinical practice,” said Dr. Kirsh. “An effective
referral does not foreshadow or guarantee an
outcome: that a treatment will or will not
be provided. An effective referral is simply
intended to connect a patient with a physician who is willing to assess a patient, then if
the criteria for physician-assisted death as set
out by the Supreme Court of Canada is met,
provide a treatment subject to the patient’s
consent,” he said.
The feedback heard during the consultation
is reflected in a number of changes made to
the final document. This includes changes
to a Sample Process Map, which has been
provided to help physicians navigate practicerelated elements specific to the provision of
physician-assisted death.
For example, the requirement regarding
witnesses has been significantly changed in
the process map. The Interim
Guidance document now states
that only one witness is required
and specifies that this witness
The physician must
be “independent”. Council
satisfy him/herself
was satisfied that having one
that the criteria for
independent witness, and two
physicians involved in evaluatphysician-assisted
ing the patient’s request was
death have been met,
sufficient to ensure the patient
and that the patient’s
was capable, acting voluntarily,
and that he/she was not coerced
request is enduring
to make a decision to request
physician-assisted death.
Removed from the process
map is a 15-day waiting period between a first and second request for
physician-assisted death. Instead the Interim
Guidance document requires a ‘period of reflection’, in which the physician must satisfy
him/herself that the criteria for physicianassisted death have been met, and that the
patient’s request is enduring. This change is to
allow flexibility from case to case, as the period of reflection will vary, and may depend,
in part, on the rapidity of progression and the
nature of the patient’s medical condition.
Also a new stage, ‘Stage 4’ has been added –
Certification of Death. At this point, physicians are advised to contact the Ministry of
Health and Long-Term Care regarding how
to complete the medical certificate of death.
Dr. Eric Hoskins, Minister of Health and
Long-Term Care commended the College’s
guidance. “I would like to thank the College
of Physicians and Surgeons of Ontario for the
leadership they’ve shown on this important
issue and for developing Interim Guidance on
Physician-Assisted Death. We will continue to
work with the CPSO, the federal government,
our provincial and territorial colleagues and
with Ontarians as we develop a long-term plan
on this matter for Ontario,” said Dr. Hoskins.
As external resources become available, they
will be included on the College’s website. We
have FAQs about the guidance on the following pages.
Issue 1, 2016 Dialogue
11