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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude

Policy Positions

College of Physicians and Surgeons of New Brunswick (Canada)

Freedom of conscience and religion

Annotated Extracts and Links


Comment by College of Physicians and Surgeons of New Brunswick
Re: Declining to provide service on moral/religious grounds
November, 2002
Reproduced with permission
[Original text- Accessed 2014-12-30]

One of the most difficult dilemmas in the patient/physician relationship occurs when the physician has a personal moral objection to a procedure or treatment that the patient may request or inquire about. Such issues create a conflict between the recognized autonomy of a competent patient to make their own decisions regarding health care and the autonomy of physicians to practice according to their own knowledge, experience and conscience.

It is the Council's view that the autonomy of both patients and physicians can be respected, on the basis of physicians following the principles of good medical practice, the Code of Ethics, and College Regulations.

To that end, it is a basic obligation under the Code of Ethics and College Regulations for physicians to advise patients when their personal morality would influence any recommendation or practice they may make regarding a patient. In other words, it would be improper to refuse a patient's request without stating such. The basic requirement is that patients should be informed as to why a physician is declining to provide the service or treatment requested.

Council also feels that, while it is not an obligation to do so, it is preferred practice for physicians who have such objections to refer the patient to another where such objections may not arise. Nevertheless, if the physician feels even that is unacceptable, Council does view it as an acceptable alternative for the physician to provide information, upon the patient's request, regarding resources which may be directly accessible to the patient.

In any case, any discussions, should these issues arise, should be dealt with in a manner which is neither judgemental, nor intimidating.

Physicians are also reminded that other factors may have some influence here. In addition to the Code of Ethics and College Regulations, the Human Rights Act prevents physicians discriminating in access to care based on a number of factors, including specifically "race, colour, religion, national origin, ancestry, place of origin, age, physical disability, mental disability, marital status, sexual orientation or sex."

Finally, physicians are reminded that, should a complaint arise, any care offered will be judged by accepted medical and scientific standards.

Project Annotations

In a 2001 bulletin, when the Council sought feedback about appropriate guidelines for situations in which physicians have moral or ethical objections to a service or procedure wanted by a patient, it noted  "that no physician is obligated to participate in a treatment or process to which they morally object."  The statement above was issued the next year.

The identification of referral as a "preferred" but not a "required" practice is not necessarily problematic.  It prompts objecting physicians to consider, in each case, whether or not referral is a morally acceptable option, thus providing them with the opportunity to refine and better articulate their ethical reasoning.


Guideline [Original]
 
Directive
Moral Factors and Medical Care
 
Les Facteurs Ethiques et les Soins Medicaux

From time to time, physicians may be confronted with situations where they may be requested to provide a treatment or procedure to which they have an objection on moral or religious grounds. In that regard, physicians should be guided by the Code of Ethics, which advises as follows:

 

Les médecins peuvent parfois recevoir des demandes d'un traitement ou d'une intervention auxquels ils s'opposent en raison de leurs convictions morales ou religieuses. Dans ce cas, les médecins doivent s'appuyer sur le Code de déontologie qui recommande ce qui suit :

12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.

 

12. Avertir le patient lorsque ses valeurs personnelles influeraient sur la recommandation ou la pratique d'une intervention médicale que le patient souhaite ou dont il a besoin.

21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.

 

21. Fournir au patient les renseignements dont il a besoin pour prendre des décisions éclairées concernant les soins médicaux et répondre de son mieux à ses questions.

Based on these principles, Council believes physicians should respond to such situations as follows:

 

En se fondant sur ces principes, le conseil estime que dans la situation évoquée, les médecins doivent agir comme suit :

(1) A physician must communicate clearly and promptly about any treatments or procedures the physician chooses not to provide because of his or her moral or religious beliefs.

 

(1) Un médecin doit faire connaître clairement et promptement les traitements et les interventions qu'il choisit de ne pas prodiguer en raison de ses convictions morales ou religieuses.

(2) A physician must not withhold information about the existence of a procedure or treatment because providing that procedure or giving advice about it conflicts with their moral or religious beliefs.

(2) Un médecin ne peut pas refuser de donner des renseignements sur l'existence d'une intervention ou d'un traitement parce que le fait d'exécuter cette intervention ou de donner des conseils s'y rapportant entre en conflit avec ses convictions morales ou religieuses.

(3) A physician must not promote their own moral or religious beliefs when interacting with patients.

 

(3) Un médecin ne doit pas promouvoir ses propres convictions morales ou religieuses dans son interaction avec les patients.

(4) When moral or religious beliefs prevent a physician from providing or offering access to information about a legally available medical or surgical treatment or service, that physician must ensure that the patient who seeks such advice or medical care is offered timely access to another physician or resource that will provide accurate information about all available medical options.

 

(4) Lorsque les convictions morales ou religieuses d'un médecin l'empêchent de fournir des renseignements ou les moyens d'en obtenir concernant un traitement ou un service médical ou chirurgical permis par la loi, ce médecin doit s'assurer que le patient qui demande ces conseils ou ces soins médicaux a accès en temps opportun à un autre médecin ou à d'autres ressources qui lui fourniront des renseignements exacts sur toutes les options médicales disponibles.

Project Annotations

This guideline was adopted in 2012, "based on an inititiative" by the College of Physicians and Surgeons of Alberta.

The policy recognizes a key distinction between providing information and providing or facilitating a morally contested service or procedure. 

With respect to providing information, it 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.

Physicians are expected to provide information necessary to satisfy the requirements of informed medical decision making, such as prognosis, the treatments or procedures available, benefits and burdens of treatment, risks, etc.  Only if a physician is unwilling to provide this information is an offer of "timely access" to another physician or resource required.  The purpose of arranging timely access in this situation is to ensure that the patient has information needed for decision-making.  Offering timely access may be achieved in various ways.

Assistance in Dying (December, 2015)
[Full Text]

3.  In accordance with prevailing guidelines, a physician may decline to assist a patient in dying if the physician has a moral objection. 

It is known there are physicians who object to the concept of assisting a patient in dying and who would resist offering any such assistance.  As in other situations, physicians are not obligated to participate in a process to which they have a strong personal objection.  Furthermore, some physicians would object to any related activity including actively referring the patient to another physician for purposes of accessing the patient for assistance in dying.  The current College policy does allow physicians to decline to participate, even in a limited way such, as a direct referral.

That said, it should be remembered that a referral by a physician does not mean the physician necessarily agrees with the patient's chosen intervention.  In many other situations, the physician may not, but wishes to avail the patient of an opinion from a suitable consultant regarding the issue at hand.  Similarly, in the case of assistance in dying, the physician may refer the patient to an appropriate practitioner, but still make it clear that the referring physician is personally opposed.  This will also offer that physician the opportunity to provide information which will be useful in any determination of whether the patient is eligible for assistance in dying, including the specific diagnosis, prognosis, competence, and treatments provided or not provided up to that point.

Even if the physician is reluctant to provide an active referral, they remain obligated to provide information to the patient regarding resources which may be directly accessible.  In other words, they cannot, by inaction, obstruct the patient who wishes to be evaluated for this option.

Project Annotations

The policy recognizes a key distinction between providing information and providing or facilitating a morally contested service or procedure.  It also acknowledges that physicians unwilling to provide a morally contested procedure for reasons of conscience may also be unwilling to refer patients to colleagues willing to provide it.

The discussion of the possibility of referral is a reasonable invitation to reflection.  It prompts objecting physicians to consider, in each case, whether or not referral is a morally acceptable option, thus providing them with the opportunity to refine and better articulate their ethical reasoning.

 

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