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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude
Policy Positions

College of Physicians and Surgeons of Ontario (Canada)

Freedom of conscience and religion

Annotated Extracts and Links


Agreement with Dr. Stephen Thomas Dawson (2002)
Reproduced with permission

As from August 22, 2002, Dr. Stephen Thomas Dawson undertakes to the College of Physicians and Surgeons of Ontario,

  1. To have copies of "Schedule 1" to his undertaking openly available in his waiting room. [See Schedule 1 below.]
  2. To provide to his patients only the explanation in Schedule 1 explaining why he does not, in his practice,

    a) prescribe birth control pills to unmarried patients for the purpose of birth control;

    b) prescribe Viagra to unmarried men;

    c) participate in securing abortions for his patients

    unless a patient should specifically request further information about the religious beliefs on which his position is based.

Schedule 1:

On February 8, 2000, I [Dr. Stephen Thomas Dawson] established a policy in this Medical Centre to stop prescribing birth control pills to unmarried patients for the purpose of birth control. I also established a policy of not prescribing Viagra to unmarried men.

I have never involved myself in abortions. As a Christian physician, the prescription of birth control pills to unmarried women for birth control purposes is contrary to the dictates of my conscience and religion. Similarly, arranging for abortions and the prescription of Viagra to unmarried men is contrary to the dictates of my conscience and religion.

According to the Canadian Medical Association Code of Ethics, one of the responsibilities of a physician is to inform the patient:

when his morality or religious conscience alone prevents him from recommending some form of therapy . . .

In accordance with my Christian beliefs and the Canadian Medical Association's Code of Ethics, I am setting out my policy so that you are informed in advance of my beliefs and practice. If you wish further information about the religious basis for my policy, please feel to ask me about it.

Project Annotations

The agreement was a consequence of a complaint to the College of Physicians and Surgeons of Ontario described in the following articles:


Professional Obligations and Human Rights (March, 2015)
[Full Text]

. . . While the Charter entitles physicians to limit the health services they provide for reasons of conscience or religion, this cannot impede, either directly or indirectly, access to these services for existing patients, or those seeking to become patients.

. . . The College requires physicians, who choose to limit the health services they provide for reasons of conscience or religion, to do so in a manner that:

i. Respects patient dignity;

ii. Ensures access to care; and

iii. Protects patient safety.

i. Respecting Patient Dignity

Where physicians object to providing certain elements of care for reasons of conscience or religion, physicians must communicate their objection directly and with sensitivity to existing patients, or those seeking to become patients, and inform them that the objection is due to personal and not clinical reasons.i

In the course of communicating their objection, physicians must not express personal moral judgments about the beliefs, lifestyle, identity or characteristics of existing patients, or those seeking to become patients. This includes not refusing or delaying treatment because the physician believes the patient's own actions have contributed to their condition. Furthermore, physicians must not promote their own religious beliefs when interacting with patients, or those seeking to become patients, nor attempt to convert them.ii

ii. Ensuring Access to Care

Physicians must provide information about all clinical options that may be available or appropriate to meet patients' clinical needs or concerns. Physicians must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.iii

Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another health-care provider must be provided to the patient.

An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.18 The referral must be made in a timely manner to allow patients to access care.

Patients must not be exposed to adverse clinical outcomes due to a delayed referral. Physicians must not impede access to care for existing patients, or those seeking to become patients.

The College expects physicians to proactively maintain an effective referral plan for the frequently requested services they are unwilling to provide.iv

iii. Protecting Patient Safety

Physicians must provide care in an emergency, where it is necessary to prevent imminent harm, even where that care conflicts with their conscience or religious beliefs.19

18.  In the hospital setting, referral practices may vary in accordance with hospital policies and procedures.

19.  this expectation is consistent with the College's Providing Physician Services During Job Actions policy. For further information specific to providing care in health emergencies, please see the College's Physicians and Health Emergencies policy.

Project Annotations

i.  That objections are in all cases "due to personal and not clinical reasons" is a mistaken assumption. Objecting physicians may have both clinical and ethical/moral objections to providing euthanasia and assisted suicide. Where both reasons exist, it is appropriate to inform the patient of both. Indeed: to withhold clinical reasons would seem to violate the requirements of informed medical decision-making.

ii.  Physicians who comply with the requirement to disclose treatments or procedures they will not provide because of moral or religious beliefs may be accused of being "judgemental."  An effort to make themselves understood and to avoid giving offence to a patient by providing information about their reasoning may be misconstrued as a form of preaching or evangelization.

iii.  The expectation presumes either that the mere giving of information or advice has no moral significance, or, if it does, that it is inconsequential. This is not necessarily the case.  The difficulty here is to balance the desire of a physician to avoid complicity in a wrongful act with the importance of informed decision-making by the patient, which requires that the patient have all of the information relevant for the purpose of choosing a course of treatment. It is necessary to respect both the freedom of conscience of the physician and the freedom and right of the patient to make a fully informed choice.

iv.  Requiring "effective referral" is unacceptable to many conscientious objectors because they believe that it makes them unacceptably complicit in immoral acts.  The College enacted this element in the policy despite overwhelming opposition during public consultations.  There was no evidence that such a policy was necessary.  Briefing materials supplied to the College Council relevant to this point were not only seriously deficient, but erroneous and seriously misleading.

This element in the policy triggered a lawsuit against the College by physicians' groups on the grounds that it violates constitutional guarantees of freedom of conscience and religion.

For a critique of the policy, see the Project Submission to the CPSO (20 February, 2015).

Other comment:


Fact Sheet: Ensuring Access to Care - Effective Referrali
[Full Text]

When physicians limit the health services they provide for reasons of conscience or religion, the CPSO requires that they provide patients with an 'effective referral'. 1

What is an effective referral?
A physician makes an effective referral when he or she takes positive action to ensure the patient is connected in a timely manner to another physician, health-care provider, or agency who is non-objecting, accessible and available to the patient.

Objective: Ensuring Access to Care, Respecting Patient Autonomy
An effective referral does not guarantee a patient will receive a treatment, or signal that the objecting physician endorses or supports the treatment. It ensures access to care and demonstrates respect for patient autonomy.

All effective referrals involve the following steps:

1.  The physician takes positive action to connect a patient with another physician, health-care provider or agency.  The physician can make the referral him/herself OR assign the task to another. The physician must ensure the designate complies with the CPSO expectations for an effective referral.

2.  Referrals must be made to non-objecting physicians, health-care providers or agencies that are accessible and available to the patient.  The physician, health-care provider or agency must be accepting patients/open, must not share the same religious or conscience objections as the referring physician and must be in a location that is reasonably accessible to the patient or via telemedicine where appropriate.

3.  Referrals must be made in a timely manner, so that the patient will not experience an adverse clinical outcome due to a delayed referral.
A patient would be considered to suffer an adverse outcome due to a delay if their untreated pain or suffering is prolonged, their clinical condition deteriorates, or the delay results in the patient no longer being able to access care (e.g., for time sensitive matters such as emergency contraception, an abortion or when a patient wishes to explore medical assistance in dying.)

Examples:

  • The physician or designate contacts a non-objecting physician or non-objecting health-care professional and arranges for the patient to see that physician/professional.ii
  • The physician or designate transfers the patient2 to a non-objecting physician or non-objecting health-care provider.ii
  • The physician or designate connects the patient with an agency charged with facilitating referrals for the health-care service, and arranges for the patient to be seen at that agency.ii
  • A practice group in a hospital, clinic or family practice model identifies patient queries or needs through a triage system. The patient is directly matched with a non-objecting physician in the practice group with whom the patient can explore all options in which they have expressed an interest.iii
  • A practice group in a hospital, clinic or family practice model identifies a point person who will facilitate referrals or who will provide the health care to the patient. The objecting physician or their designate connects the patient with that point person.ii

1.  The requirement for an effective referral is included in the Professional Obligations and Human Rights policy, and the Physician-Assisted Death policy.

2.  A transfer of care in this situation would be specific to the care to which the physician objects. A transfer is not equivalent to ending the physician-patient relationship. Physicians must not terminate the physician-patient relationship simply because the patient wishes to explore a care option to which the physician has a conscientious objection.

Project Annotations

i.  The Fact Sheet was issued in conjunction with the following policy on euthanasia and assisted suicide.

Requiring "effective referral" is unacceptable to many conscientious objectors because they believe that it makes them unacceptably complicit in immoral acts.  The College enacted this element in the policy despite overwhelming opposition during public consultations.  There was no evidence that such a policy was necessary.  Briefing materials supplied to the College Council relevant to this point were not only seriously deficient, but erroneous and seriously misleading.

This element in the policy triggered a lawsuit against the College by physicians' groups on the grounds that it violates constitutional guarantees of freedom of conscience and religion. For a critique of the policy, see the Project Submission to the CPSO (20 February, 2015).

ii.  Many objecting physicians would consider it unacceptable to actively facilitate a morally contested procedure in the manner described.

 iii.  This kind of arrangement can be acceptable.  The Project is aware of locations where such a practice has been employed successfully for years. 


Medical Assistance in Dying (June, 2016)
[Full Text]

C. Conscientious Objection

The federal legislation does not address how conscientious objections of physicians, nurse practitioners, or other healthcare providers are to be managed.  In the Carter case, the Supreme Court of Canada noted that the Charter rights of patients and physicians would have to be reconciled.

Physicians who have a conscientious objection to providing medical assistance in dying are directed to comply with the College's expectations for conscientious objections in general, set out in the Professional Obligations and Human Rights policy.i

 These expectations are as follows:

  • Where a physician declines to provide physician-assisted death for reasons of conscience or religion, the physician must do so in a manner that respects patient dignity.ii Physicians must not impede access to physician-assisted death, even if it conflicts with their conscience or religious beliefs.iii

  • The physician must communicate his/her objection to physician-assisted death to the patient directly and with sensitivity. The physician must inform the patient that the objection is due to personal and not clinical reasons.iv In the course of communicating an objection, physicians must not express personal moral judgments about the beliefs, lifestyle, identity or characteristics of the patient.

  • In order to uphold patient autonomy and facilitate the decision-making process, physicians must provide the patient with information about all options for care that may be available or appropriate to meet the patient's clinical needs, concerns and/or wishes. Physicians must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.

  • Where a physician declines to provide physician-assisted death for reasons of conscience or religion, the physician must not abandon the patient. An effective referral must be provided. An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, nurse practitioner or agency. The referral must be made in a timely manner to allow the patient to access physician-assisted death. Patients must not be exposed to adverse clinical outcomes due to delayed referrals.10,11 |v

The federal legislation does not compel physicians to provide or assist in providing medical assistance in dying. For clarity, the College does not consider providing the patient with an 'effective referral' as 'assisting' in providing medical assistance in dying.vi

10.  For more information on and examples of what constitutes an 'effective referral', please see document titled, 'Fact Sheet: Ensuring Access to Care: Effective Referral', available on the College's website: http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/PAD-Effective-Referral-FactSheet.pdf

11.  The College acknowledges that the number of physicians, healthcare providers, and/or agencies to which an effective referral would be directed may be limited, particularly at the outset of the provision of medical assistance in dying in Ontario, and that this is relevant to any consideration of whether a physician has complied with the requirement to provide an effective referral. The Ministry of Health and Long-Term Care has established a toll-free referral support line to help Ontario physicians to arrange referrals for patients requesting medical assistance in dying.  Clinicians seeking assistance in making a referral can call toll-free: 1-844-243-5880. If physicians have general questions about the referral support line, or wish to register as a potentially willing provider, please contact the Ministry of Health and Long-Term Care at MAIDregistration@ontario.ca. The College expects physicians to make reasonable efforts to remain apprised of resources that become available in this new landscape.

Project Annotations

i.  Professional Obligations and Human Rights is the subject of a lawsuit on the grounds that its requirement for "effective referral" entails the unjustified suppression of freedom of conscience and religion. 

ii.  The experience of the Project is that patients are normally treated respectfully by objecting physicians, though refusal itself is sometimes misunderstood or deliberately misconstrued as a disrespectful act.

iii.  Physicians who simply refuse to help patients find someone willing to kill them or help them commit suicide are no more impeding or abandoning patients than colleagues who refuse to help patients find someone willing to provide virginity certificates or sell organs.

iv.  That objections are in all cases "due to personal and not clinical reasons" is a mistaken assumption. Objecting physicians may have both clinical and ethical/moral objections to providing euthanasia and assisted suicide. Where both reasons exist, it is appropriate to inform the patient of both. Indeed: to withhold clinical reasons would seem to violate the requirements of informed medical decision-making.

v.  Requiring "effective referral" is unacceptable to many conscientious objectors because they believe that it makes them unacceptably complicit in homicide and suicide.

vi.   The Carter decision referred to not only to providing euthanasia or assisted suicide, but to "participation." Further: physcians are not obliged to accept the College's definitions of key terms used in moral, ethical or philosophical reasoning. 

The Carter decision changed the law on murder and assisted suicide by making exemptions in defined circumstances, but it did not change the reasoning that underpins the law on parties to offences. The reasoning that supports the law against aiding or abetting murder is exactly the same reasoning used by physicians and health care providers who would refuse to provide "effective referral" for euthanasia. Finally the College accepts and applies this reasoning in its policy on Female Genital Mutilation.

For a detailed critique of the policy, see the Project Submission to the CPSO (10 January, 2016).

 

 

 

 

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