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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude

Policy Positions

College of Physicians and Surgeons of Saskatchewan (Canada)

Freedom of conscience and religion

Annotated Extracts and Links


Conscientious Objection (September, 2015)1
[Full Text]

2. Scope

This policy does not apply to physician-assisted dying or physicians' conscientious objection related to a potential physician-assisted dying. The College recognizes that this is currently an issue which is in a state of development and may be revisited by the College at a later time.This policy applies to all other situations in which physicians are providing, or holding themselves out to be providing, health services.2

3. Definitions

Freedom of conscience: for purposes of this policy, is actions or thoughts that reflect one's deeply held and considered moral or religious beliefs.

5. Obligations

5.1 Taking on new patients

. . . Where physicians know in advance that they will not provide specific services, but will only arrange for the patient to obtain the necessary information from another source or arrange for the patient to obtain access to a medical treatment from another source (in accordance with paragraphs 5.2 or 5.3), they must communicate this fact as early as possible and preferably in advance of the first appointment with an individual who wants to become their patient.

The College expects physicians to proactively maintain an effective plan to meet the requirements of paragraphs 5.2 and 5.3 for the frequently requested services they are unwilling to provide.

5.2 Providing information to patients3

Physicians must provide their patients with full and balanced health information required to make legally valid, informed choices about medical treatment (e.g., diagnosis, prognosis, and clinically appropriate treatment options, including the option of no treatment or treatment other than that recommended by the physician), even if the provision of such information conflicts with the physician's deeply held and considered moral or religious beliefs.

The obligation to inform patients may be met by arranging for the patient to obtain the full and balanced health information required to make a legally valid, informed choice about medical treatment from another source, provided that arrangement is made in a timely fashion and the patient is able to obtain the information without undue delay. That obligation will generally be met by arranging for the patient to meet and discuss the choices of medical treatment with another physician or health care provider who is available and accessible and who can meet these requirements. The physician has the obligation to ensure that an arrangement which does not involve the patient meeting and discussing choices of medical treatment with another physician or health care provider is effective in providing the information required by this paragraph.

Physicians must not provide false, misleading, intentionally confusing, coercive, or materially incomplete information to their patients.4

All information must be communicated by the physician in a way that is likely to be understood by the patient.

While informing a patient, physicians must not communicate or otherwise behave in a manner that is demeaning to the patient or to the patient's beliefs, lifestyle, choices, or values.

Physicians must not promote their own moral or religious beliefs when interacting with a patient.

5.3 Providing or arranging access to health services

Physicians can decline to provide legally permissible and publicly-funded health services if providing those services violates their freedom of conscience. However, in such situations, they must:

a) make an arrangement for the patient to obtain the full and balanced health information required to make a legally valid, informed choice about medical treatment as outlined in paragraph 5.2; and,

b) make an arrangement that will allow the patient to obtain access to the health service if the patient chooses.5

Those obligations will generally be met by arranging for the patient to meet with another physician or other health care provider who is available and accessible and who can either provide the health service or refer that patient to another physician or health care provider who can provide the health service.

If it is not possible to meet the obligations of paragraphs a) or b), the physician must demonstrate why that is not possible and what alternative methods to attempt to meet those obligations will be provided.6

This obligation does not prevent physicians from refusing to arrange for the patient to obtain access to the health service based upon the physician's clinical judgment that the health service would not be clinically appropriate for the patient. If the physician refuses to arrange for the patient to obtain access to a health service based upon the physician's clinical judgment, the physician should provide the patient with a full explanation for the reason not to do so.

While discussing a referral with a patient, physicians must not communicate, or otherwise behave in a manner that is demeaning to the patient or to the patient's beliefs, lifestyle, choices, or values.

When physicians decline to provide a health service for reasons having to do with their moral or religious beliefs, they must continue to care for the patient until the new health care provider assumes care of that patient.

5.4 Necessary treatments to prevent harm or provide care to patients

Physicians must provide medical treatment for a patient if treatment is necessary to avoid harming the patient's health or well-being. Accordingly:

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

b) When it is not possible to arrange for another physician or health care provider to provide a necessary treatment without causing a delay that would jeopardize the patient's health or wellbeing, physicians must provide the necessary treatment even if providing that treatment conflicts with their conscience or religious beliefs. 

Physicians must provide medical treatment for a patient within the physician's competency where the  patient's chosen medical treatment must be provided within a limited time to be effective and it is not reasonably possible to arrange for another physician or health care provider to provide that treatment.

Project Annotations

1.   The first draft of this policy was virtually identical to A Model Conscientious Objection Policy for Canadian Colleges of Physicians and Surgeons, a policy proposed by Professor Jocelyn Downie of Dalhousie University, a leading euthanasia advocate, and academic colleagues.  The Associate Registrar of the Saskatchewan College, having met with them,  pushed for its adoption by Colleges across the country.  (See Project Submission to the CPSS [5 March, 2015]) This generated strong opposition in Saskatchewan and forced several revisions of the draft between January and September, 2015.

2. The first draft of the policy was proposed with the possiblity of the legalization of euthanasia and assisted suicide in mind.  Even after the Carter decision ordering the legalization of the procedures, the Associate Registrar of the College stated publicly that  physicians who refused to refer patients for assisted suicide would be liable to be disciplined by the College and forced out of the medical profession.  It appears that the strong opposition to the policy forced its proponents to retreat on this point in order to secure passage of the policy in some form. 

3.  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., or to arrange for the information to be provided by someone else.

4.  Strong underlying prejudice against objecting physicians is implied by reference to the provision of false, misleading, intentionally confusing, coercive, or materially incomplete information, which is inflammatory and unwarranted.

5.  This vague formulation reflects the intense controversy surrounding the issue of mandatory referral for morally contested procedures, which is demanded by the authors of A Model Conscientious Objection Policy for Canadian Colleges of Physicians and Surgeons and their supporters (see note 1).  This is unacceptable to many objecting physicians because they hold that it makes them parties to wrongdoing.  The final phraseology may have been proposed in the hope of producing a policy acceptable to both sides.

However, it is not clear what is meant by making "an arrangement that will allow the patient to obtain access."  Those opposed to referral will interpret it to mean that they are not obliged to refer patients for morally contested services, and any attempt by the College to coerce or discipline them is likely to be met with a lawsuit.

6.  Since the meaning of the obligation in 5.3b is doubtful, it is doubtful that this provision can be enforced.  Moreover, the legal onus of accommodation lies on the College.  If a physician demonstrates that the purported obligation the College is attempting to enforce impinges upon the exercise of freedom of conscience or religion, the College is obliged to prove that its policy is demonstrably justified in a free and democratic society. 

For more detailed commentary, see:

In contrast, following policy on the exercise of freedom of conscience in relation to euthanasia and assisted suicide (below) is simpler and acceptable.  It reflects the widespread intuitive and rational insight that it is unacceptable to force physicians to do what they believe to be gravely wrong, or to arrange for it to be done by someone else ("effective referral").  The convoluted and ambiguous text of Conscientious Objection is the result of an ideological attempt to suppress this insight.


Physician Assisted Dying (November, 2015)
[Full Text]

Foundational Principles

3) Respect for physician values: Within the bounds of existing standards of practice, and subject to the expectations in this document and the obligation to practise without discrimination as required by the CMA Code of Ethics and human rights legislation, physicians can follow their conscience when deciding whether or not to provide physician-assisted dying. . .

1. Conscientious Objection

A physician who declines to provide physician-assisted dying must not abandon a patient who makes this request; the physician has a duty to treat the patient with dignity and respect. The physician is expected to provide sufficient information and resources to enable the patient to make his/her own informed choice and access all options for care. This means arranging timely access to another physician or resources, or offering the patient information and advice about all the medical options available. Physicians must not provide false, misleading, intentionally confusing, coercive or materially incomplete information, and the physician's communication and behaviour must not be demeaning to the patient or to the patient's beliefs, lifestyle choices or values. The obligation to inform patients may be met by delegating this communication to another competent individual for whom the physician is responsible.

Project Annotations

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

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.  Offering timely access may be achieved in various ways.

As in the earlier policy, Conscientious Objection (see above) underlying prejudice against objecting physicians is implied by reference to the provision of false, misleading, intentionally confusing, coercive, or materially incomplete information.

Of greater interest, this section of the policy on euthanasia and assisted suicide would be acceptable in other contexts.  It reflects the widespread intuitive and rational insight that it is unacceptable to force someone to do what he believes to be gravely wrong, or to arrange for it to be done by someone else ("effective referral").  The convoluted and ambiguous text of Conscientious Objection (above) is the result of an ideological attempt to suppress this insight.

 

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