Despite the Supreme Court's unanimous decision in Carter v. Canada, assisted dying continues to run into obstacles across the country. The highest-profile setback came last spring, when the federal government restricted the service to those for whom death is "reasonably foreseeable."

However, opponents of the right to medically assisted death have also been active at the provincial level. In Ontario, their efforts have been particularly fruitful, taking the form of a new variation on an old theme known as conscientious objection. For patients nearing the ends of their lives, as well as anybody concerned about our governments' capacity to shape health-care provision, the implications are startling.

Conscientious objection means that physicians and other providers who have a moral problem with a particular procedure will not be obliged to perform it. While they may have to refer the patient to somebody else, individual providers retain the right to personally opt out. Pro-choice advocates (and their opponents) are already quite familiar with this concept, which has led to spotty abortion access across the country. Despite the consequences for patients, conscientious objection is often viewed as a necessary compromise for "controversial" health-care procedures.

Now we can see just how vague the limits of this principle really are. In the case of assisted dying, those overseeing Ontario's Catholic hospitals have been advocating for extending conscientious objection to institutions. They argue that, since their institutional beliefs preclude them from allowing medically assisted death, they should be allowed to override the individual beliefs of providers under their jurisdiction and altogether ban the practice within their walls. Instead of protecting physicians and other health-care providers, conscientious objection could be used to curtail their professional freedom, allowing their workplaces to dictate what they should find objectionable.

While for some time it looked like the province might stand firm, Ontario has now caved to these demands, prompting outrage from advocacy groups such as Dying With Dignity. During the summer prorogation, the Wynne government quietly altered Bill 41, also known as the Patients First Act, to stipulate that religious institutions receiving public money could indeed exercise freedom of conscience and opt out of providing the services mandated in the Supreme Court decision. To paraphrase former presidential candidate Mitt Romney, hospitals are now people, my friends.

For patients, the consequences are severe. Many requesting access to medical assistance in dying will have already resided in a particular facility for a very long time. If that facility refuses the patient's request, they will have to uproot themselves from their beds, travel potentially long distances and place themselves in the care of total strangers, all the while facing the stigma that inherently accompanies being refused health care on moral grounds. This is not a dignified way to treat people at the end of their lives.

Moreover, the Ontario government's decision has subtle but important implications for what's public and what's private in health care provision. Canada has never actually had fully state-directed health care. Medicare in Saskatchewan initially substituted private insurance for a publically funded alternative, a model that was subsequently diffused across the country through a federal cost-sharing program.

From there, provinces gradually asserted a larger role for government in shaping and regulating the system and its boundaries. Today, Canadians like to boast about their "socialized" medicine, particularly in contrast to the American state of affairs. However, the line between the public and the private in Canada remains blurrier than we'd like to admit, as the assisted dying case demonstrates. After all, if even hospitals are not required to reflect the law of the land, how "public" can our system really be?

When we think about health-care privatization, what immediately comes to mind might be P3 schemes, extra billing or two-tiered access. But there are also softer ways in which policymakers might erode the public nature of our system, such as when faith-based institutions are systematically allowed to deny patients their rights.

Canadian progressives already instinctively resist the encroachment of private money into our system of universal health insurance, which despite its many flaws remains among the most popular symbols of Canadian identity. They should be equally suspicious of private morals. If we accept proposals to limit access to medical assistance in dying, we place an unfair burden on those seeking access to their rights and weaken the extent to which Canadian health care is truly public.

Following a decision as monumental and conclusive as Carter v. Canada, we must expect better from those who govern how our health care is delivered.

Benjamin Diepeveen is a PhD candidate in political science at the University of Ottawa. He studies physicians' political mobilization, interprofessional relations and contentious health-care debates across the country.

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Image: Flickr/Premier of Ontario Photography