There is no defence for ‘Conscientious objection’ in reproductive health care

Abstract

A widespread assumption has taken hold in the field of medicine that we must allow health care professionals the right to refuse treatment under the guise of ‘conscientious objection’ (CO), in particular for women seeking abortions. At the same time, it is widely recognized that the refusal to treat creates harm and barriers for patients receiving reproductive health care. In response, many recommendations have been put forward as solutions to limit those harms. Further, some researchers make a distinction between true CO and ‘obstructionist CO’, based on the motivations or actions of various objectors. This paper argues that ‘CO’ in reproductive health care should not be considered a right, but an unethical refusal to treat. Supporters of CO have no real defence of their stance, other than the mistaken assumption that CO in reproductive health care is the same as CO in the military, when the two have nothing in common (for example, objecting doctors are rarely disciplined, while the patient pays the price). Refusals to treat are based on non-verifiable personal beliefs, usually religious beliefs, but introducing religion into medicine undermines best practices that depend on scientific evidence and medical ethics. CO therefore represents an abandonment of professional obligations to patients. Countries should strive to reduce the number of objectors in reproductive health care as much as possible until CO can feasibly be prohibited. Several Scandinavian countries already have a successful ban on CO.

Fiala C, Arthur JH. Eur J Obstet Gynecol Reprod Biol. 2017 Jul 23. pii: S0301-2115(17)30357-3. doi: 10.1016/j.ejogrb.2017.07.023. [Epub ahead of print]

 

Ontario Today: Should doctors be forced to refer?

CBC Radio

Outline of the programme

00:00 Introduction

03:00  Dr. Sephora Tang, psychiatrist (objecting physician).  Discussion points include potential problem of access to euthanasia/assisted suicide faced by frail and isolated patients, those in rural areas or  “negative elements” in families, central referral service alternative, issue of complicity, physician-patient relationship.

12:16  Caller Dr. Terry, primary care (objecting physician). Discussion points include erosion of medical ethics, erosion of trust in physician-patient relationship, relationship between law and ethics, distinction in skill sets needed for euthanasia/assisted suicide vs. abortion.

19:25  Interviewer outlines points in position of the Canadian Medical Association

20:19  Caller Vivi. Favours compulsory referral because access to euthanasia/assisted suicide should be considered from patient perspective, not doctor’s.

22:32  Dr. Sephora Tang responds to points made by caller.

24:14  Interviewer outlines policy on effective referral of College of Physicians & Surgeons of Ontario [There are two relevant documents: POHR and MAID; Administrator]

24:34  Caller Dr. Ramona Coelho (objecting physician). Explains why she will not make effective referral.

25:42  Caller Dr. David Roussell, President, College of Physicians & Surgeons of Ontario (CPSO).  Interviewer puts to him opposition to effective referral by the Canadian Medical Association, more liberal policies in other provinces.  Dr. Roussell discusses College policy requiring effective referral.  Asserts that the College is primarily concerned with access to euthanasia/assisted suicide etc. by patients who might have difficulty doing do if their physician does not assist.  Notes that both Nova Scotia and Quebec have similar requirements, so Ontario is not alone.  Notes that referral does not always result in procedure being obtained.  Characterizes objections to effective referral as oversensitive.  Acknowledges that loss of licence to practice is one possible outcome of complaint against a physician for refusing to refer.

35:12  Caller Dr. Christine (objecting physician).  Emphasizes central care coordinating system and self-referral by patients would be more efficient and avoid conflicts of conscience.

37:20  Caller Dr. Roussell agrees that central coordination system and self-referral is promising, but asserts that this can “fall apart” in some cases.

38:25 Caller David.  Opposed to compulsory referral.  Believes it is safer to ensure diversity of views in society, especially in life and death matters, by protecting freedom of conscience.

41:30  Interviewer asks Dr. Roussell to respond to concerns about freedom of conscience.

42:00  Caller Dr. Roussell notes “private beliefs, religious or otherwise, are not the purview, shouldn’t be the purview of the College or the government . . . What we’re talking about here is from the public’s point of view. There’s a legally available service to, in most people’s minds, alleviate suffering, which is what medicine is supposed to be about.  And the battle’s been fought, the war’s been won, the law has been passed.  Why are we throwing up obstacles to a legally accessible service?  Especially throwing up obstacles at the last moment to people who are in some sense suffering.”

43:04 Caller Joel (medical student).  Supports compulsory referral.  “Doctors in Canada should not be practising medicine in Canada if they feel that their moral code supersedes what is law.”  He adds, “It is great for doctors to unite and object on some things” and refers to the Alberta system (which has proved acceptable to objecting physicians).  He believes that effective referral for euthanasia or assisted suicide does not make a physician a “conduit of death,” but means that the patient can access a specialist with appropriate training.  He characterizes acceptance of conscientious objection as a “slippery slope.”

44:45  Caller Erica.  Supports compulsory referral.  Her mother (whom she identified as a Christian) was suffering from multiple sclerosis.  She was joyful when euthanasia was legalized [Criminal Code amendments given Royal Assent in June, 2016; Administrator].  She was not euthanized/assisted with suicide until the end of December, 2016 because her physician (whom Erica also identified as a Christian) refused, and refused to refer her. Erica stated that this “absolutely shattered her.  It took her days to pick herself up and decide she was going to keep trying to find somebody.” Asserts that denying such people access to a medical procedure is unfair.

46:31  Interviewer notes that less than 75 physicians in Ontario are actually providing euthanasia/assisted suicide. Erica explains that a doctor was found after a CBC interview made her situation public.

47:28  Dr. Sephora Tang responds.  Notes that patients want access, and she does not wish to impede.  The system set up by the government made it impossible for patients to access euthanasia/assisted suicide on their own. If society wants people to have access, there are alternative ways to ensure access that should be considered.

48:07  Interviewer asks about patients being fearful of the “judgement” of their physicians.

48:27  Dr. Sephora Tang emphasizes importance of trust in physician-patient relationship.   It is better for the patient to know where she stands on some issues, so there “no guessing around that.”  It is possible to agree to disagree.

49:16  Dr. Chantal (euthanasia/assisted suicide provider).  Supports compulsory referral, because “patients need access.”  Abortion clinics are not an appropriate comparison.  Referral must include all relevant medical information.  “No medical information is necessary for a physician to do an abortion,” but is needed prior to performing euthanasia/assisted suicide.  To expect patients to go to hospitals and doctors to gather all of the relevant medical information is “completely unreasonable.”  Patients would be “significantly compromised” if objecting physicians refused to provide the relevant information.

Postscript from Dr. Christine (Reproduced with permission)

Just because a physician may conscientiously object to formal participation by the administrative/legal/ethical agreement implied by a documentation-based referral (re: linking billing numbers between 2 practitioners for review +/- enactment of a desired procedure),this does NOT mean that an objecting physician would ever dare to obstruct the subsequently requested movement of health file information (which is first and foremost a property that emanates from the patient!) to the clinician to whom the patient wishes to receive lethal injections from. 

Furthermore:  If a patient seeks a care pathway that may end in MAiD, through a care coordination service in the ideal case, then there are administrative health professionals in all the offices who can and do link with each other to physically get the records moving. 

(Again, a physician is not the one pulling the files in a Norman Rockwell/1950’s-style office; we now have digital spigots to move information, and physicians are not required to unlock the content in our current collaborative environment of ConnectingOntario/PRO/OLIS).

 My original point in the call is that forcing a physician to fill out referrals (and limiting the power/responsibility to do this, to physicians) is ironically creating (rather than removing) a barrier to care. 

 (Incidentally – and not all people know this – it is also quite typical and not an exception for most referrals to come with inadequate background case information, even in non-controversial indications; doctors know how to probe for what’s missing [and often have to ask for information in several iterations and from multiple parties], and gaps from healthcare fragmentation are not so much a product of malfeasance as simply laziness…)

 

In Argentina’s religious freedom row, politics makes strange bedfellows

Crux

Ines San Martin

ROME – Argentina didn’t exist as a nation when Shakespeare inspired the line “politics make strange bedfellows,” but if the Bard were around today, he might well look to the pope’s native country for proof, where the once leading conservative rival of the future pontiff and Amnesty International find themselves in an unlikely alliance over a proposed religious freedom law.

In the case of Archbishop Héctor Rubén Aguer of La Plata, seen as the country’s most fiercely traditional prelate on matters such as the legalization of abortion and contraception, he insists the law could threaten the Church’s protected status under the country’s constitution, while Amnesty International fears the law could deprive Argentine youth of their sexual rights. . . [Full text]

 

UCSF sued for refusing to help woman die

Daughters: Mother died “excruciating” death she didn’t want

The Mercury News

Tracy Seipel

In what may be the first-of-its-kind lawsuit related to California’s End of Life Option Act, the family of a San Francisco terminally ill cancer patient is suing the UC San Francisco Medical Center alleging that her physician and the system misrepresented that they would help the dying woman use California’s right-to-die law when her time came.

Instead, according to the July 7 civil lawsuit filed in San Francisco Superior Court, Judy Dale’s wish for a peaceful death was denied to her by the defendants’ “conscious choice to suppress and conceal” their decision that they would not participate in the law, despite Dale’s repeated indications to doctors and social workers that she intended to use its provisions. The suit also names the university’s Helen Diller Family Comprehensive Cancer Center, UCSF Health, a UCSF oncologist and the UC Board of Regents. . . [Full text]

 

La conscience et les médecins canadiens

English

Collectif des médecins contre l’euthanasie

Depuis la légalisation de l’euthanasie, il y a un an, nous voyons qu’il y a une forte pression politique pour normaliser sa pratique au Canada. Pourtant, beaucoup de médecins s’opposent toujours à cette pratique. Nombre d’entre eux désireraient qu’elle soit rigoureusement restreinte. Et plusieurs, pour des raisons de conscience, personnelle ou professionnelle, refusent catégoriquement d’y collaborer.

Malheureusement, nos politicien(ne)s ne nous permettent aucun doute quant à leur intention d’ignorer le jugement des médecins dissidents, et d’étouffer leur opposition. Or, les pires de ces politiciens semblent se trouver parmi les rangs de notre propre profession.

Considérons, à titre d’exemple, la nouvelle politique (2015), du College of Physicians and Surgeons of Ontario, au sujet du « Droit de Conscience » de ses membres.

Cette politique est identifiée comme étant une simple mis à jour révisée, mais en réalité elle s’apparent peu à la version précédente (2008).

Et la raison en est évidente : sans jamais parler franchement de l’euthanasie, du suicide assisté, ou même de l’aide médicale à mourir, cette nouvelle politique fut, dès le départ, façonnée pour faciliter une redéfinition radicale, à la manière Orwellienne, de « l’euthanasie », de l’homicide en soin médical. Cela oblige, effectivement, tous les médecins ontariens à participer au programme d’euthanasie.

De manière pratique :

« Dans le cas où des médecins ne voudraient pas fournir certains soins pour des raisons de conscience ou de religion, ces derniers sont tenus de référer le patient à un autre fournisseur de soins. »

Bien-sûr, on voit, ici, l’obstacle principal à la collaboration de nombreux docteurs qui considèrent le fait d’orienter leurs patients vers d’autres agences de mort  comme étant aussi horrible que de pratiquer eux-mêmes l’acte d’euthanasier.

Cependant, le problème éthique ne s’arrête pas à  l’obligation de référer le patient à d’autres ressources. Il y a également le « devoir d’informer » :

« Les médecins doivent fournir de l’information à propos de toutes les options cliniques qui peuvent être disponibles ou appropriés pour répondre aux besoins cliniques du patient ou à ses préoccupations ».

« Les médecins ne doivent pas retenir de l’information au sujet d’une procédure ou d’un traitement pour des raisons de conflit avec leur conscience ou leur croyance religieuse ».

Prenez bien note des italiques ajoutés : apparemment, le médecin se trouverait dans l’obligation d’informer ses patients de toutes les options légalement disponibles, même si elles s’avèrent inappropriées ! Et cette obligation aurait préséance sur toute conviction morale ou professionnelle du médecin.

L’aspect impératif de ce “devoir d’informer” dépasse même celui du « devoir de référer”. Dans chaque cas où les critères associés à l’euthanasie seraient satisfaits, il y aurait obligation de soumettre le patient aux terribles stress et doutes soulevés par le constat, ainsi imposé, qu’il fait partie du groupe select de personnes pour lesquelles l’euthanasie est devenue praticable. Aucune objection de jugement, aucune objection de conscience, ne pourrait excuser le médecin du devoir de livrer ce message effroyable, avec la suggestion implicite qu’il véhicule.

En Ontario, donc, par proclamation du CPSO, le rôle du médecin serait réduit à celui d’une machine distributrice automatique qui afficherait les options d’euthanasie mandatés par l’état, et qui offrirait passivement de boutons correspondants que le patient puisse actionner.

Évidemment, la force et l’étendu d’un telle politique sont extraordinaires. Le jugement professionnel est la fondation de la pratique médicale. Le « Droit de Conscience » est à la base de tout notre système de démocratie séculaire. Tous les deux sont écartés. Nous devons réellement nous trouver devant une situation de crise colossale pour justifier de telles mesures draconiennes !

Mais voilà. Il n’existe aucune urgence semblable.

Rappelons-nous que le programme original d’euthanasie nous fut vendu comme la réponse impérative au sort de ce patient hypothétique, au seuil de la mort et affligé de souffrances, à la fois, insoutenables et intraitables. Rappelons aussi, comment ce cas extrême, que dis-je, ce cas virtuellement mythique, fut exploité pour nous acheminer doucement vers tous ces morts, sans rapport, que nous devons craindre actuellement. Encore, de nouveau, une stratégie similaire se poursuit. Cette fois, le besoin absolu, pour tous les médecins, de faire la promotion de l’euthanasie (en tout temps et auprès de leurs patients les plus vulnérables), nous est présenté comme le prix nécessaire pour pallier à la possibilité hypothétique qu’un seul patient puisse être frustré dans son désir de mourir.

On nous demande de croire que n’importe quel fardeau réel, qu’il soit financier, professionnel ou moral, serait justifié quand il est question de faciliter une seule mort volontaire et idéalisée. Ce serait un genre d’inversion grotesque de la proposition voulant que « aucun prix n’est trop élevé, pourvu qu’un seul enfant puisse vivre… », qui devient dans la discussion actuelle : « pourvu qu’une seule personne puisse mourir… »

D’autres juridictions, pas moins respectables que l’Ontario, ont épousé des principes tout à fait opposés. Et il n’existe aucune évidence que quiconque aurait souffert, ou souffrira ultérieurement.

Le Manitoba élabore actuellement une loi qui reconnaitrait explicitement le droit de non-participation et de non-orientation des patients vers l’euthanasie pour les médecins, ainsi que pour les autres professionnels de la santé. Deux des principaux hôpitaux de Winnipeg ont signalé leur refus de permettre l’euthanasie dans leur établissement.

Dans l’État de Vermont, une bataille judiciaire autour des mêmes principes s’est soldée, dernièrement, par une victoire complète des droits des médecins.

Et en Ontario, un groupe de médecins, dévoués et courageux, a récemment engagé une action à ce sujet contre le CPSO; les arguments furent écoutés Juin 13-15, 2017.

Ce jugement sera rendu plus tard dans l’année. Nous espérons que la cour tranchera, cette fois, du bon côté !

Mais nonobstant la nature de ce jugement, le temps qu’il faudra, la dépense; nonobstant les efforts législatifs qui peuvent être éventuellement exigés : Cette politique autoritaire du College of Physicians and Surgeons of Ontario n’est ni nécessaire, ni justifiée. Elle n’est pas désirable. Elle n’est même pas raisonnablement défendable. Elle est extrême. Elle est irrationnelle. Surtout, elle serait profondément préjudiciable pour les médecins,  leurs patients, et tout le système médical. Elle représente une injustice et une honte qui ne peuvent être acceptées.

 

Conscience and Canadian doctors

Francais

Physicians’ Alliance Against Euthanasia

In the year since euthanasia became legal, we have witnessed a powerful political push to normalize it as part of medicine in Canada. Yet many doctors remain opposed to the practice. Most would like to see it rigorously limited. And some, for reasons of personal and/or professional conscience, refuse categorically to be part of it.

Unfortunately, our politicians have made it perfectly clear that they intend to ignore the judgement of opposing doctors and to stifle their dissent. In fact, the worst of these politicians are to be found within our own profession.

Consider, as a case in point, the new (2015) College of Physicians and Surgeons of Ontario policy on doctors’ conscience rights.

This CPSO policy is identified as a mere “revised update”, but it actually bears little resemblance to the earlier version (2008).

And it is obvious why this is so: Without ever honestly mentioning euthanasia, assisted suicide, or even MAID, the new policy was designed from the start to facilitate a radical new Orwellian redefinition of “euthanasia”, from homicide to medical treatment. It effectively obliges all Ontario physicians and surgeons to participate in the euthanasia program.

In practical terms:

“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.”

This, of course, is the main sticking point for many doctors, who consider referring their patient to any agency of death to be an act just as abhorrent as performing the euthanasia themselves.

But “effective referral” is by no means all. There is also the “duty to inform”:

“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.”

Please note the italics: The physician apparently has a duty to inform his patients of all options legally available even if they are inappropriate! And this obligation shall override any moral or professional convictions that physician might hold.

The violence of the obligation to “inform” goes even beyond that of “effective referral” itself. Every patient who fits the criteria for euthanasia must be subjected to the terrible stress and doubt of learning that he or she belongs to that select group of people for whom medically-inflicted death has become an option. And no objection of judgement or of conscience can free the doctor from delivering that terrible message and its implicit suggestion.

In Ontario, then, by proclamation of the CPSO, the doctor’s role is reduced to that of an automatic vending machine which simply displays state-mandated euthanasia options and passively offers corresponding buttons for the patient to push.

Obviously, the scope and impact of such a policy is astounding. Professional judgement is the bedrock of medical practice. Freedom of conscience is the underpinning for our entire system of secular democracy. Both are set aside.  The scale of the emergency must be colossal to require such draconian measures!

But, of course, there is no such urgency.

Let us remember that the original euthanasia program was sold to us as an imperative response to a hypothetical terminally ill patient in unbearable and untreatable pain.  Let us recall how that extreme, no, that virtually mythical case, was leveraged into all of the totally unrelated deaths that we now apprehend. Once again, a similar strategy is at work. This time, the absolute need for all doctors to promote euthanasia (all the time and to all of their most vulnerable patients), is presented as a required response to the hypothetical possibility of even one patient, desirous to die, but who is frustrated in her wish.

We are asked to believe that any real burden whatsoever, financial, professional, or moral, can be justified in the interest of allowing that one sacred voluntary death. It is a sort of grotesque inversion of the proposition that “no price is too high” provided that “only one child be saved…”.  Which becomes in this case: “if only one person might die…”.

Other jurisdictions, no less respectable than Ontario have taken an opposite stance, and there is no evidence that anybody has suffered or will suffer.

Manitoba is in the process of explicitly recognizing the right of non-participation and non-referral of all health professionals and others working in health care. Major hospitals in Winnipeg have announced their refusal to euthanize patients.

In the State of Vermont a judicial battle over similar issues has resulted in an unambiguous victory for doctors’ rights.

And in Ontario, a group of dedicated and courageous doctors launched a court challenge in defense of doctors’ conscience, which was heard June 13-15, 2017.

That judgement will be rendered later this year.  Let’s hope our courts get it right this time!

But regardless of that outcome, regardless of the timeframe, and regardless of expense; regardless of the legislative efforts that may ultimately be required: This authoritarian policy of the College of Physicians and Surgeons of Ontario is neither necessary nor justified. It is not desirable. It is not even reasonably defensible. It is extreme. And it is irrational. Above all, it is profoundly harmful to individual doctors and patients and to the whole medical profession. It constitutes both an injustice and an embarrassment which cannot be allowed to stand.

 

Why I don’t support conscientious objection to MAID

Medscape

Lesley Barron

Bill 84 has been passed into law in Ontario and outlines the legal issues surrounding medical aid in dying (MAID), which has been legal in Canada since last year. The patient’s death must be “reasonably foreseeable” and their suffering “grievous and irremediable” to qualify for the service. Groups such as those with advance directives, mental illness, and minors are left out, and whether they should be allowed access to this service in the future is an issue for another time.

One of the most contentious aspects of Bill 84 is the requirement for the treating physician in Ontario to provide a referral for a patient who has requested MAID to a physician who provides it. . . [Full text]

Should doctors be paid a premium for assisting deaths?

Physicians can make more doing paperwork than performing this legal, but emotionally demanding, service. For many, it’s just not worth it.

MacLeans

Catherine McIntyre

Back in March, Dr. Tanja Daws took time off from her family practice to travel from B.C.’s Comox Valley to a remote community on Vancouver Island and provide an elderly patient who was dying and suffering with medical assistance in dying (MAID). After the five-and-a-half hour endeavour, which involved some of the most emotionally and technically difficult work Daws has ever done, the physician calculated that, after factoring in her staffing costs and other office expenses, she had lost about $28 for every hour she worked.

“It struck me that I can’t keep doing this,” says Daws. “I can work for nothing, but I can’t work for a loss.” . . . [Full text]

Victory For Christian Pharmacists’ Conscience Rights In Great Britain

Cross Rhythms

Heather Bellamy

Heather Bellamy spoke with Ciaran Kelly, the Head of Communications at the Christian Institute, about the importance of reasonable accommodation in balancing people’s rights, and how after consultation, the General Pharmaceutical Council have chosen to continue to value their pharmacists faith and conscience, as well as patient care.

For the past few months, Christian pharmacists in Great Britain anticipated having to choose between their faith and their job, but after a huge campaign and the threat of legal action from the Christian Institute, their regulatory body has backed away from ending conscience rights. Heather Bellamy spoke with Ciaran Kelly, the Head of Communications, at the Christian Institute, to find out more. . . [Full text]

 

Arkansas panel votes to study health-care conscience bill

Arkansas News

John Lyon

LITTLE ROCK — A legislative panel voted Monday to conduct a study in the interim between sessions on a bill that would allow a health-care provider to refuse to provide a service that violates his or her conscience.

The House and Senate committees on public health, welfare and labor voted, without discussion, to study legislation by Rep. Brandt Smith, R-Jonesboro, that failed to advance out of the House public health panel during this year’s session.

House Bill 1628, titled The Healthcare Freedom of Conscience Act, would have allowed a person or institution that provides health care to refuse to participate in a non-emergency service that contradicts his or her religious, moral or ethical principles. It would have prohibited the person or institution from being punished for the refusal through criminal, civil or administrative action. . . [Full text]