III. CANADA

Two aspects of Canadian society are particularly determinative of the Canadian approach to bioethics: (1) the country's universally accessible, publicly funded healthcare system, and (2) the role of law. While a multitude of bioethical issues have occupied Canadians since the 1960s, there have been three major areas of bioethical activity: clinical ethics, research ethics, and ethics in public policy. The history of bioethics in Canada can be divided into two time periods: from 1800 to the 1960s, and from the 1960s to the present. During the first period, medical ethics predominated, although theological ethics and the ethics of nursing were also important. Since 1960, the field of medical ethics has been incorporated into the broader field of bioethics.

Medical Ethics: 1800–1960

In 1867, the year of Canada's formation as a nation, the Canadian Medical Association (CMA), came into being. At its first annual meeting in 1868, the CMA adopted the Code of Ethics of the Canadian Medical Association, which was closely modeled on the American Medical Association's code of ethics. Since then there have been a number of revisions to the CMA Code of Ethics, most recently in 1996. This code outlines general responsibilities, responsibilities to the patient, responsibilities to society, responsibilities to the profession, and responsibilities to oneself.

The Canadian Nurses Association (CNA) was established in 1908. However, the association did not have a code of ethics until 1954, when it adopted the one that had been prepared the previous year by the International Council of Nurses. In 1980 the CNA moved to establish its own code, which was published as CNA Code of Ethics: An Ethical Basis for Nursing in Canada. This code has since been revised on a regular basis (1985, 1991, 1997, and 2002) and is now entitled Code of Ethics for Registered Nurses. The content is structured around three themes: (1) the nature of ethics in nursing, (2) nursing values defined, and (3) nursing values and responsibility statements.

The Roman Catholic Church has played an important role in healthcare in Canada since colonial times. The Catholic Hospital Association of the United States and Canada (CHAUSC), founded in 1915, adopted a code of ethics in 1921 that dealt primarily with surgical issues in obstetrics and gynecology. This document was updated in 1935, and in 1949 it was revised and published as Ethical and Religious Directives for Catholic Hospitals. In 1954 the Catholic Hospital Council of Canada (established in 1942) declared its independence from CHAUSC and renamed itself the Catholic Hospital Association of Canada. It adopted its own moral code in 1955. Now known as the Catholic Health Association of Canada, this organization updated and renamed its moral code, the Health Ethics Guide, in 1971, 1991, and again in 2000. This document addresses issues related to social services and organizational ethics. The core focus areas for the Catholic Health Association of Canada are ethics, spirituality, values development, and social justice.

Canadian contributions to the medical ethics literature were few and far between until the 1940s. The most renowned Canadian physician of this period, Sir William Osler (1849–1919), made few references to medical ethics in his many publications. He did, however, have a great deal to say about the practice of medicine and about physician behavior. The chief virtues of the individual physician are variously referred to in his writings as equanimity (aequanimitas), imperturbability, and detachment. His stated ideal for the medical profession was that of "noblesse oblige" (Osler).

Not until the 1940s did a significant number of Canadian publications in medical ethics begin to appear, most of them written by Catholic theologians (e.g., LaRochelle and Fink). Some Catholic schools of medicine (e.g., the University of Ottawa) and nursing (e.g., the University of Montreal) made faculty appointments in medical ethics; and the professors who took these posts contributed to the growing body of Catholic literature in this field (e.g., Paquin,). However, comparable work by philosophers and health professionals was noticeable by its absence.

Bioethics: 1960s–2000s

Beginning in the mid-1960s, the field of medical ethics underwent a radical transformation, and by the end of the 1970s it displayed all the features of what has become known as bioethics. In Canada the major actors in the development of bioethics have been professional associations, public commissions, and academic institutions.

The major professional health associations expanded their ethics activities during this period. In the early 1980s the CMA remandated its Committee on Ethics to deal with the whole range of bioethical issues, rather than those affecting only physicians. In 1989 the CMA established a Department of Ethics and Legal Affairs. The Royal College of Physicians and Surgeons of Canada created a Biomedical Ethics Committee in 1977, and the College of Family Physicians of Canada followed suit in 1991. The Canadian Nurses Association established an ad hoc ethics committee that met regularly from 1985 to 1997 to revise its code of ethics. In the Spring of 1997 this committee was given permanent standing.

A favored way of dealing with contentious social issues in Canada is through public commissions, such as federal and provincial law reform commissions. The federal Law Reform Commission was established in 1971 to review the federal laws of Canada on a continuing basis, and to make recommendations for their improvement, modernization, and reform. Bioethical issues were dealt with in the Protection of Life Project, one of four commission projects. Between 1979 and 1992, a dozen or so study papers, working papers, and reports to Parliament were published on topics such as euthanasia and assisted suicide, experimentation on human subjects, and medically assisted procreation. In 1992 the commission was terminated by the government for budgetary reasons. Five years later, in 1997, the federal government created the Law Commission of Canada. This commission has not undertaken specific projects concerning bioethics, but it has supported work on the governance of research involving humans.

Academic institutions have experienced tremendous growth in the area of bioethics since the 1960s. Courses in this field have proliferated in philosophy and religious-studies departments, where they are often the most heavily subscribed offerings. Bioethics instruction is now offered in every Canadian medical school at the basic degree level and is rapidly expanding into residency training programs. Nursing, health administration, and dentistry programs have also formalized ethics teaching, and in many universities instruction in the ethical aspects of animal experimentation is required for biology, zoology and psychology students.

Research in bioethics has been fostered by the creation of centers, institutes, and professional associations for practitioners in this field. The Center for Bioethics of the Clinical Research Institute of Montreal, established in 1976, was the first such organization in Canada. It was followed three years later by the Westminster Institute for Ethics and Human Values, based in London, Ontario (now defunct). By 2002 there were at least nineteen research centers and groups in Canada, most of them university based. A national association, the Canadian Bioethics Society, was formed in 1988 through a fusion of two previously established associations.

The Institutional Matrix of Bioethics

The Canadian healthcare system and Canadian law have been two of the most important forces shaping the context within which bioethics has developed in Canada. The healthcare system has also been the source of some of the most difficult bioethical issues Canadians have faced since 1971, when the country's national health insurance program was fully set in place (Taylor). Although Canadian legislation and jurisprudence have largely guided and supported work in bioethics, there have also been points on which they have clashed.

THE CANADIAN HEALTHCARE SYSTEM. The Canadian healthcare system is in reality not a single system, but rather a network of ten provincial and three territorial healthcare systems. The coherence of this network derives from the Canada Health Act (1984) and a series of accords between the federal, provincial, and territorial governments. The federal government provides funds to the provinces and territories for healthcare; the latter governments, in return, agree to incorporate the essential features of the national health insurance program into their healthcare systems. This sharing of responsibility is currently being challenged, however.

The Canadian national health insurance system, as defined in the Hospital Insurance Act (1957) and reaffirmed in the Canada Health Act (1984), is founded on a values system to which the Canadian people fiercely adhere. The principal features of this program (comprehensiveness; universality; accessibility; portability; and public administration) derive from Canadians' commitment to the principle of equality. Equality before the healthcare system, as Robert Evans has phrased it, is as strong a principle in Canada as equality before the law (Evans). The basis of this principle is that all Canadians should have access to a similar level of care, regardless of their ability to pay for it.

There have been challenges, however, to the Canadian healthcare system's principle of universal access to hospital and medical services. The practice of user fees and extra billing by doctors, which is prohibited by the Canada Health Act, represented one such challenge. Extra billing would allow doctors to bill patients for charges exceeding what the national health insurance plan paid doctors for a medical service. For a short time in the mid-to late 1980s extra billing occurred in seven provinces. In response to this violation of the Canada Health Act, the federal government stopped transfer payments to these provinces, thereby providing the provincial governments with the necessary incentive to enforce the principles of the Canada Health Act. Extra billing has not occurred since.

The way a country organizes its healthcare system as a whole is not just an issue of economics and administration. It is also an issue of public ethics and is deeply rooted in the conflict between powerful interest groups and the requirements of justice (as interpreted by a society's governing ethos. The Canadian ethos of universal access with equal terms and conditions for all is being challenged by new questions of fairness. For example, the current Canadian Medicare program pays for physician and hospital services, but not drugs (unless these are administered in a hospital). For many patients, good health depends upon access to expensive medications, and since these are not covered by the national health insurance system they are at risk of incurring significant debt or, worse, doing without their medications.

Another issue concerns waiting lists. Some individuals who do not want to wait to access needed health services and who have the resources to pay for these services argue that they should not be prohibited from purchasing what they are able to pay for. Some of these concerns are examined in the final report of the National Forum on Health, which focused on values, striking a balance, the determinants of health, and evidence-based decision making The forum paid particular attention to the need to balance resources within the health sector, and between the health sector and other sectors of the economy (National Forum on Health). The emphasis in these reports was on the core Canadian value of equal access to care irrespective of ability to pay. The National Forum on Health called on the federal government to expand public health insurance to home care and drugs.

In 2002 there was renewed debate about the future of the Canadian healthcare system with particular focus on two issues: (1) public administration (whether there should be a single-or multi-payer system), and (2) delivery of goods and services (whether this should be public, private not-forprofit, or private for-profit). Two reports looked at the sustainability of the universally accessible, publicly funded healthcare system with particular attention to the question of whether Canada should move to a two-tier system by allowing the use of private hospitals and private insurance. The first of these reports was issued by the Senate Standing Committee on Social Affairs, Science and Technology, which undertook a study on the state of the healthcare system in Canada. The report is widely known as the Kirby Report—in reference to Senator Michael Kirby, who chaired the Committee. It endorses an increased role for private healthcare corporations.

The second report, Building On Values: The Future of Health Care in Canada, is by the Commission on the Future of Health Care in Canada (widely known as the Romanow Report, after the commission chair, Roy Romanow). The report examines four strategies for continuing to ensure access to high quality of care regardless of ability to pay: (1) more public investment (paid for by raising taxes or diverting resources from other programs), (2) more user pay (through charging fees as an incentive to deter abuse), (3) an increase in private choice (either for-profit or non-profit), or (4) a complete reorganization of the healthcare delivery system. A commitment to health care as a social good and service, not an economic commodity only available to those who can pay, informs the analysis.

BIOETHICS AND LAW IN CANADA. In Canada, the Constitution Act (1867) was amended in 1982 through the introduction of the Canadian Charter of Rights and Freedoms. This charter obliges government actors not to violate rights considered fundamental. Such rights include life, liberty, and security of the person; freedom of conscience, thought, belief, and expression; and freedom from discrimination. Democratic support for legislation that violates the charter does not compel the courts to uphold the legislation, since the charter protects fundamental freedoms and legal rights against even democratically composed majorities. This is illustrated in the 1988 Morgentaler decision of the Supreme Court of Canada, in which a law passed by a democratically elected government was struck down by the Supreme Court of Canada because it violated the charter.

Another significant case is the 1991 Ontario Court of Appeal decision in Malette v. Shulman. A Jehovah's Witness woman was taken to the hospital unconscious and bleeding after a car accident. The physician attending her was informed that she was carrying a signed but undated card refusing blood products, but he nonetheless gave her a transfusion in order to prevent her death from heavy loss of blood. The patient, Georgette Malette, sued him for the civil wrong of battery (unauthorized touching) and was awarded a favorable judgment, which the Ontario Court of Appeal upheld. The trial judge observed that, while the transfusion may have saved her life, the principle of respect for autonomous persons prevailed over principles of beneficence and nonmaleficence. In other words, society may not share her priority of interests, but it must respect her autonomy.

From the mid-1970s through the mid-1980s, numerous symposia, workshops, and position papers reflecting the thinking of a cross-section of Canadians supported the conclusion that contraceptive sterilization, in some circumstances, would be truly beneficial for some mentally disabled persons, as it would allow them to enjoy sexual fulfillment without the risk of bearing and rearing children. There was controversy only regarding the process that would be used to select individuals eligible for sterilization. It was not clear what conditions had to be fulfilled to protect mentally disabled persons from being sterilized for someone else's benefit. However, a 1986 decision of the Supreme Court of Canada (Eve v. Mrs. E.) clarified the law and dramatically affected practice. The Court declared categorically that sterilization should never be authorized for nontherapeutic purposes. In the absence of the affected person's consent, the Court believed that it can never be safely determined that such sterilization is for the benefit of that person. This decision has proved to be difficult for clinicians, parents, those with institutional responsibility for the care of mentally disabled persons, and, perhaps, for the latter themselves, for their social lives and privacy in relations with members of the opposite sex may be restricted for fear of pregnancy. This decision also serves as a focus for continuing discussions about what should be done when what is judged by some to be ethically justifiable has been declared to be illegal or unconstitutional.

Key Issues

Although Canadians have been preoccupied with many bioethics issues, the following discussion is limited to those issues that have most intensively mobilized the thought and action of Canadians in the fields of clinical ethics, research ethics, and ethics in public policy.

CLINICAL ETHICS. Several court cases in Canada illustrate the interplay between clinical ethics and jurisprudence when decisions have to be made regarding cessation of medical treatment. An ethical and legal consensus has grown in Canada since the late 1980s in support of the view that physicians are justified in withholding or discontinuing treatments that do little more than prolong a patient's dying and suffering. However, there continues to be debate about physician-assisted suicide and euthanasia, as illustrated in the legal cases summarized below.

In 1992 the Superior Court of Quebec affirmed that the request of a competent patient to discontinue life-supporting treatment should be honored (Nancy B. v. Hôtel-Dieu de Québec). Nancy B., a twenty-five-year-old woman, was permanently dependent on a respirator due to Guillain-Barré syndrome. After two years, while lucid and without clinical depression, she asked that the respirator be stopped, knowing that this would lead to her death. The court held that discontinuing treatment would not constitute criminal negligence or homicide. In so ruling, it cited the Canadian Law Reform Commission's recommendation that ambiguous sections of the Criminal Code of Canada should be changed so that the criminal law of Canada could not be interpreted as obliging physicians either to treat patients against their informed and free refusal or to initiate or continue treatments that are therapeutically useless and not in patients' best interests (Law Reform Commission).

A year later, in 1993, Sue Rodriguez—a competent woman suffering from amyotrophic lateral sclerosis who wanted to commit assisted suicide—brought a challenge to the prohibition against assisted suicide found in the Criminal Code. The Supreme Court of Canada upheld the prohibition by a five-to-four margin based on their application of the Charter of Rights and Freedoms to the facts of the case. Despite this decision, Sue Rodriguez ultimately died as a result of physician-assisted suicide, and no one was prosecuted in connection with her death.

Also in 1993, Robert Latimer was charged with first-degree murder in the death of his twelve-year-old daughter, Tracy Latimer. Mr. Latimer had placed his severely handicapped daughter (a quadriplegic child with the intellectual capacity of a three-month-old) in the cab of his truck and, with the intent of alleviating her suffering, asphyxiated her with carbon monoxide. In 1994 Mr. Latimer was convicted of second-degree murder and given the mandatory sentence of life imprisonment without eligibility for parole for ten years. He successfully appealed his conviction to the Supreme Court of Canada, and a new trial was ordered. In 1997 Mr. Latimer was tried again on a charge of second-degree murder, was again convicted, but was now sentenced to two years less a day (instead of the mandatory sentence of at least ten years in prison). Mr. Latimer again appealed his conviction and the Crown appealed the sentence. The Court of Appeal dismissed Latimer's appeal, allowed the Crown's appeal, and imposed the mandatory minimum sentence. Mr. Latimer then appealed to the Supreme Court, and in 2001 the Court upheld the conviction and the life sentence with no parole for ten years.

These cases show that the courts in Canada will respect the wishes of competent patients to refuse life-sustaining treatment, reject the wishes of competent patients to actively bring about their own death through physician assisted suicide, and not tolerate deliberate actions to bring about the death of another person even when the motive is to alleviate suffering.

RESEARCH ETHICS. Canadians have been intensively occupied with elaborating the conditions for ethically acceptable research involving humans. In August 1961, Walter Halushka volunteered to be a research subject in a project to test a new anesthetic drug. Halushka suffered a cardiac arrest during the experiment, and though successfully resuscitated, he was left with some brain damage and could no longer continue his university studies. The Court of Appeal found that the physician-researchers had failed to inform Halushka that the test was of a new drug, that they had little previous knowledge about this drug, that the drug was an anesthetic, and that there was risk involved in its use. The investigators also failed to tell the subject that the test would involve putting a catheter up a vein in his arm into his heart. The Court of Appeal clarified the requirements for consent in the research setting:

There can be no exceptions to the ordinary requirements of disclosure in the case of research as there may well be in ordinary medical practice.… The subject of medical experimentation is entitled to a full and frank disclosure of all the facts, probabilities and opinions which a reasonable man might be expected to consider before giving his consent. (Halushka v. the University of Sasktchewan et al.)

Though patients are rarely harmed seriously in clinical research, serious harm, and even death, can and does occur. It is particularly tragic when a research-related death occurs that might have been avoided if consent negotiations had been adequate. On October 13, 1981, Julius Weiss, a sixty-two-year-old man, died in a Montreal hospital while participating in a research project being conducted to test the efficacy of a drug (indomethacin, administered by eyedrops) designed to reduce swelling in the eye after cataract surgery. This project also required that Weiss undergo a series of radiological examinations called fluorescein angiograms to gauge the effects of the indomethacin eyedrops. Weiss had a history of heart problems and went into convulsions following a drop in blood pressure after the first injection of fluorescein dye. His heart stopped, resuscitation attempts failed, and he died. Weiss's widow and children sued the two physicians involved in the clinical study and the hospital where the study was conducted. In his judgment on this case, rendered on February 23, 1989, Judge Louis De Blois of Quebec Superior Court found that the patient would not have agreed to be in this project had he known it carried even a small risk of cardiac arrest and death (see Weiss v. Solomon).

In Canada, unlike other countries, health research involving humans is governed primarily by guidelines, not legislation. The first such guidelines were promulgated by the Medical Research Council of Canada in 1978 and later revised in 1987. Some years later, in the wake of a number of research-related controversies, a Tri-Council Working Group involving all three federal research funding agencies—the Medical Research Council of Canada (MRC), the Natural Sciences and Engineering Research Council of Canada (NSERC), and the Social Sciences and Humanities Research Council of Canada (SSHRC)—was convened to develop a common set of ethics guidelines that would govern virtually all publicly funded research involving humans in Canada (an international first). In 1998 the Tri-Council Policy Statement on Research Involving Humans was adopted. These guidelines outline the expectations regarding ethics review and set out the rules for researchers and institutions that receive public funds for research.

ETHICS IN PUBLIC POLICY. Between the 1960s and the 1990s, the issue of abortion dominated the public-policy debate in bioethics. The debate was ignited in the late 1960s, when the federal government proposed changes to the Criminal Code that would relax restrictions on divorce, homosexual acts between consenting adults, the distribution of contraceptives, and abortion. The last issue was the most contentious and engendered widespread public discussion and lobbying of members of Parliament. The law in effect at the time prohibited termination of pregnancy under any circumstances, and criminal sanctions could be brought against the pregnant woman and anyone who would perform the abortion. In 1969 a new abortion law (section 251 of the Criminal Code) was adopted that retained the criminal sanctions against both the woman seeking an abortion and anyone who would perform the act, but legalized termination of pregnancy if the following conditions were met: (1) the abortion had to be performed by a qualified medical practitioner in an accredited or approved hospital;(2) it had to be approved by a therapeutic abortion committee of the hospital; and (3) the continuation of the pregnancy would, or would be likely to, endanger the life or health of the woman seeking the abortion.

Following this liberalization of the abortion law, there were many complaints of unequal access to abortion services, as well as accusations from antiabortion groups that the law was being applied too loosely. Since the federal government refused to revise the law, both proponents and opponents of abortion decided to challenge the law in the courts.

In 1970 Dr. Henry Morgentaler established an abortion clinic in Montreal, in clear opposition to the law. After his third jury acquittal, in 1976, on charges of performing an illegal abortion, the Quebec government allowed his clinic to operate, despite vigorous protests from antiabortion forces.

In 1983 Dr. Morgentaler set up an abortion clinic in Toronto and was promptly arrested and charged, along with two colleagues. A jury once again acquitted him. This decision was appealed, and in 1985 the Ontario Court of Appeal overturned the decision of the jury and ordered a new trial. Dr. Morgentaler appealed this ruling to the Supreme Court of Canada. On January 28, 1988, the Supreme Court, in a 5-to-2 decision, overturned the Court of Appeal decision and restored the original jury acquittal. The Court also declared the 1969 abortion law unconstitutional because it violated the Canadian charter of rights and freedoms.

The Supreme Court heard another abortion-related case in 1988, this one initiated by an opponent of abortion. In 1981, Joe Borowski, a former Manitoba politician and antiabortion activist, challenged the 1969 abortion law on behalf of the fetus. A Saskatchewan court heard the case in 1983, and in its judgment rejected Mr. Borowski's claim that the fetus is a person with legal rights. Mr. Borowski appealed this decision. In 1989 the Supreme Court declined to decide the case because the appeal was moot, due to the abortion law having been struck down.

Between 1988 and 1991, the federal government made several attempts to pass a new abortion law, but none were successful. A bill introduced in 1989 would have recriminalized abortion except when performed by a doctor "of the opinion that, if the abortion were not induced, the health or life of the female person would be likely to be threatened." (Bill C-43 An Act respecting abortion, 2nd Sess., 34th Parl., 1989; defeated in the Senate January 31,1991). Health was defined as including physical, mental, and psychological well-being. The bill was approved by the House of Commons in May 1990 by a narrow margin (140–131), and it was then sent to the Senate, where it received detailed examination. In January 1991, a vote was taken, but the Senate was deadlocked. Under Canada's Senate rules, a tie is considered a defeat. As a result, Canada is in the unusual circumstance of having no criminal restrictions on abortion.

New reproductive technologies have also generated considerable public-policy activity in Canada and have been the subject of several public inquiries, including a federal Royal Commission, which received and commissioned many submissions focusing on the ethical aspects of reproductive technology. Feminist concerns (e.g., regarding commercialization in paid contractual pregnancies) have figured prominently in the Canadian discussion of these issues (Overall; Sherwin). In 1996, Bill C-47, the Human Reproductive and Genetic Technologies Act, was introduced in the House of Commons. This bill died on the Order Paper, however, when an election was called before the legislative process was complete. (Bills under consideration that have not received royal assent are on the Order Paper. When an election is called, all such bills are considered dead.) Years later, in May 2002, Bill C-56, the Assisted Human Reproduction Act, was introduced. Ironically, it too died on the Order Paper in September of the same year when Parliament was prorogued (to terminate or suspend a legislative session). Bill C-56 did not share the same fate as the earlier bill, however, in that it was reinstated as Bill C-13, which at the time of writing was continuing through the legislative process. Interestingly, much of the public debate around this bill has not been about assisted reproduction, but about whether the embryos that remain after infertility treatment can be used for human embryonic stem cell research.

The Future

Canada is a multicultural nation. For the most part, however, bioethics has been (and continues to be) monocultural, reflecting the values of the white, largely Anglo-Saxon, professional class that has dominated Canadian society, including its science and medicine. If bioethics is to be relevant to Canadian society in the future, it must develop a multicultural sensitivity and expand the range of issues it considers, the perspectives from which the issues are viewed, and even the backgrounds of individuals working in the field.

david j. roy

john r. williams (1995)

revised by franÇoise baylis

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INTERNET RESOURCES

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Medical Research Council of Canada; National Sciences and Engineering Research Council of Canada; and Social Sciences and Humanities Research Council of Canada. 1998. "Tri-Council Policy Statement on Research Involving Humans." Available from <http://www.nserc.ca/programs/ethics/english/ethics-e.pdf>.

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