Referrals for Services Prohibited In Catholic Health Care Facilities


  • Context | Catholic hospitals control a growing share of health care in the United States and prohibit many common reproductive services, including ones related to sterilization, contraception, abortion and fertility. Professional ethics guidelines recommend that clinicians who deny patients reproductive services for moral or religious reasons provide a timely referral to prevent patient harm. Referral practices in Catholic hospitals, however, have not been explored.
  • Methods | Twenty-seven obstetrician-gynecologists who were currently working or had worked in Catholic facilities participated in semistructured interviews in 2011–2012. Interviews explored their experiences with and perspectives on referral practices at Catholic hospitals. The sample was religiously and geographically diverse. Referral-related themes were identified in interview transcripts using qualitative analysis.
  •  Results | Obstetrician-gynecologists reported a range of practices and attitudes in regard to referrals for prohibited services. In some Catholic hospitals, physicians reported that administrators and ethicists encouraged or tolerated the provision of referrals. In others, hospital authorities actively discouraged referrals, or physicians kept referrals hidden. Patients in need of referrals for abortion were given less support than those seeking referrals for other prohibited services. Physicians received mixed messages when hospital leaders wished to retain services for financial reasons, rather than have staff refer patients elsewhere. Respondents felt referrals were not always sufficient to meet the needs of low-income patients or those with urgent medical conditions.
  •  Conclusions | Some Catholic hospitals make it difficult for obstetrician-gynecologists to provide referrals for comprehensive reproductive services.

Stulberg DB, Jackson  RA, Freedman LR.  Referrals for Services Prohibited In Catholic Health Care Facilities. Perspect Sex Repro H, 48:111–117. doi:10.1363/48e10216

Submission to the College of Physicians and Surgeons of Nova Scotia

Re: Standard of Practice: Physician Assisted Death


The Project considers the proposed standard of practice satisfactory with respect to the accommodation of physician freedom of conscience and respect for the moral integrity of physicians. Neither direct nor indirect participation in euthanasia and assisted suicide is required.

The Project offers simple and uncontroversial recommendations to avoid conflicts of conscience associated with failed assisted suicide and euthanasia attempts and urgent situations.

The standard does not adequately address the continuing effects of criminal law. The College has no basis to proceed against physicians who, having the opinion that a patient does not fit one of the criteria specified by Carter, refuse to do anything that would entail complicity in homicide or suicide. College policies and expectations are of no force and effect to the extent that they are inconsistent with criminal prohibitions.

While the standard is satisfactory with respect to freedom of conscience, the fundamental freedoms of physicians in Nova Scotia will remain at risk as long as the College Registrar and others persist in the attitude and intentions demonstrated in his presentation to the Special Joint Committee on Physician Assisted Dying.


I.    Outline of the submission

II.    Avoiding foreseeable conflicts

II.1    Failed assisted suicide and euthanasia
II.2    Urgent situations
II.3    Project recommendations

III.    SPPAD and criminal law

IV.    Remarks of the Registrar

IV.1    The Registrar before the Special Joint Committee on Physician Assisted Dying
IV.2    The Registrar, the Conscience Research Group, and “effective referral”
IV.3    The Registrar’s intentions
IV.4    The Registrar’s complaint
IV.5    An ethic of servitude, not service

V.    Conclusion

Appendix “A”    Supreme Court of Canada, Carter v. Canada (Attorney General), 2015 SCC 5

A1.    Carter criteria for euthanasia and physician assisted suicide
A2.    Carter and the criminal law
A3.    Carter and freedom of conscience and religion

Appendix “B”    Conscience Research Group

B1.    Attempts to coerce physicians: abortion
B2.    Plans to coerce physicians: assisted suicide and euthanasia
B3.   Plans to coerce physicians: the CRG Model Policy
B4.    CRG convenes meeting with College representatives


The doctors’ dilemma

National Post (Editorial)

The College of Physicians and Surgeons of Ontario recently voted to require doctors who refuse to provide certain services for reasons of conscience to provide referrals to doctors who will.

The new policy, enacted over the objections of the Ontario Medical Association, is a marked departure from the old. It paints medicine as a battlefield, with equal and opposite freedoms repeatedly colliding. Thus the college graciously agrees to limit physicians’ freedom of conscience in order to safeguard patients’ right of access.

The problem is that “right of access” is a college creation, while freedom of conscience is enshrined in the Charter of Rights. Doctors make informed decisions about treatment constantly. If they did not refuse to prescribe some treatments and suggest others, they would not be professionals. A patient storming into an office demanding amputation to treat a broken arm does not have “right of access.” . . . [Full text]

Access – or ethical cleansing?

Sean Murphy*

Despite a warning from the Ontario Medical Association that the quality of health care will suffer if people who refuse compromise their moral or ethical beliefs are driven from medical practice,1 the College of Physicians and Surgeons of Ontario plans to introduce a policy this year that will have that effect.2 The College is concerned that too many Ontario doctors are refusing to do what they believe to be wrong.

Ontario physicians may have more to say about this, since no other profession imposes an obligation to do what one believes to be wrong as a condition of membership. Indeed, it is extremely improbable that such a requirement can be found in the constitution of any occupational or community organization in this country – or any country.

On a more practical note, if the Supreme Court of Canada decides to legalize euthanasia and physician assisted suicide, the policies on human rights and end of life care that the College plans to enact this year will require physicians to kill patients or help them commit suicide, or direct them to someone who will: in the words of the draft policy, to make “an effective referral . . . to a non-objecting, available, and accessible physician or other health-care provider.”3

An undetermined number of physicians who don’t want to kill patients or assist with suicide themselves may, in fact, be willing to do this. But many physicians will not be willing to provide “an effective referral” because, in their view, to do that is morally equivalent to doing the killing themselves. In the words of the President of Quebec’s Collège des médecins, “[I]f you have a conscientious objection and it is you who must undertake to find someone who will do it, at this time, your conscientious objection is [nullified]. It is as if you did it anyway.”4

Physicians who think like this are the targets of the policy developed by Dr. Marc Gabel and his working group at the Ontario College of Physicians. Physicians who think like this, according to Dr. Gabel, should not be in family practice. He was not, of course, talking about euthanasia or assisted suicide. He was talking about abortion.

But the issue is exactly the same. Any number of physicians may agree to referral for abortion because they believe that referral relieves them of a moral burden or of a task they find disturbing or distasteful. However, for others, as Holly Fernandez-Lynch has observed, referral imposes “the serious moral burdens of complicity.”5 They refuse to refer for abortion because they do not wish to be morally complicit in killing a child, even if (to use the terminology of the criminal law) it is, legally speaking, “a child that has not become a human being.”6

Just as some physicians believe it is wrong to facilitate killing before birth by referring patients for abortion, they and other physicians believe it is wrong to facilitate killing after birth by referring patients for euthanasia or assisted suicide. Activists like Professors Jocelyn Downie and Daniel Weinstock disagree.

Both are members of the “Conscience Research Group.”7 The Group intends to entrench in medical practice a duty to refer for or otherwise facilitate contraception, abortion and other “reproductive health” services. Both were members of an “expert panel” that recommended that health care professionals who object to killing patients should be compelled to refer patients to someone who would,8 because (they claimed) it is agreed that they can be compelled to refer for “reproductive health services.”9

From the perspective of many objecting physicians, this amounts to imposing a duty to do what they believe to be wrong. But that is just what the Conscience Research Group asserts: that the state or a profession can impose upon physicians a duty to do what they believe to be wrong – even if it is killing someone – even if they believe it to be murder. And Dr. Gabel and his working group agree.

To make that claim is extraordinary, and extraordinarily dangerous. For if the state or a profession can require me to kill someone else – even if I am convinced that doing so is murder – what can it not require?

If the College’s real goal is to ensure access to services – not to punish objecting physicians – that goal is best served by connecting patients with physicians willing to help them. If the real goal is to ensure access – not ethical cleansing – there is no reason to demand that physicians do what they believe to be wrong.


1. Letter to the College of Physicians and Surgeons of Ontario from the Ontario Medical Association Section on General and Family Practice Re: Human Rights Code Policy, 6 August, 2014. (Accessed 2015-01-11)

2. College of Physicians and Surgeons of Ontario, “Professional Obligations and Human Rights (Draft)” (Accessed 2015-01-11)

3.  College of Physicians and Surgeons of Ontario, “Professional Obligations and Human Rights (Draft),” lines 156-160. (Accessed 2015-01-11)

4. “Parce que, si on a une objection de conscience puis c’est nous qui doive faire la démarche pour trouver la personne qui va le faire, à ce moment-là , notre objection de conscience ne s’applique plus. C’est comme si on le faisait quand meme.Consultations, Tuesday 17 September 2013 – Vol. 43 no. 34: Collège des médecins du Québec, (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle Marchand) T#154

5.  Fernandez-Lynch, Holly, Conflicts of Conscience in Health Care: An Institutional Compromise. Cambridge, Mass.: The MIT Press, 2008, p. 229.

6.  Criminal Code, Section 238(1). (Accessed 2015-01-12).

7.  Let their conscience be their guide? Conscientious refusals in reproductive health care. (Accessed 2014-11-21)

8.  Schuklenk U, van Delden J.J.M, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011) p. 101 (Accessed 2014-02-23)

9.  Schuklenk U, van Delden J.J.M, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011) p. 62 (Accessed 2014-02-23)

Ethical Cleansing in Ontario

 Sean Murphy*

An Ontario College of Physicians official, Dr. Marc Gabel, says that physicians unwilling to provide or facilitate abortion for reasons of conscience should not be family physicians.1 The working group Dr. Gabel chairs wants the College to approve this policy.2 If it does, ethical cleansing of Ontario’s medical profession will begin this year, ridding it of practitioners unwilling to do what they believe to be wrong. Dr. Gabel claims that this is required by professional practice and human rights legislation.

It is not clear that the Ontario Medical Association (OMA) will agree. After all, it requires some effort to maintain that physicians are ethically or morally obligated to do what they believe to be unethical or immoral. Moreover, last August, the OMA’s General and Family Practice Section warned Dr. Gabel’s working group that the quality of medical care would suffer if only students willing to sacrifice their personal integrity were accepted in medical school. Moreover, “What about remote areas of practice?” the Section asked. “Will more prescriptive policies drive physicians to feel that they will have no choice but to practice in more urban settings?”3

In other words, is it really better that a pregnant woman in Gravel Roads Only should have no local obstetrical care rather than the help of a rural physician unwilling to recommend or refer for abortion?

The concern expressed by the OMA is understandable, but actually beside the point. In truth, concern about access to services is not really what is behind the drive for ethical cleansing. That was made abundantly clear in Ottawa last year, after it was learned that an Ottawa physician was refusing to prescribe or refer for contraceptives. The story hit the front page of the Ottawa Citizen.

The Citizen did not report the mere facts: that a young woman had to drive around the block to get The Pill. That might have been dismissed as a first world problem. No: the Citizen had more ominous news. It had discovered, lurking in the nation’s capital, not just one, but three physicians who would not prescribe or refer for contraceptives or abortion.4 There was pandemonium. An activist group began preaching a crusade against the dissenters, a vitriolic feeding frenzy erupted on Facebook,5 vehement denunciations appeared elsewhere6 and the story became the subject of a province-wide CBC broadcast.7

One of the Facebookers helpfully suggested that the objecting physicians should move elsewhere, “maybe Dubai,” where they could be among their “own kind,”8 while others raged that they had “no business practicing family medicine”9 and “[did] not deserve to practice in Canada. PERIOD.”10

To find such comments on Facebook is not surprising. But it is surprising – and regrettable – that the comments offered by Dr. Gabel reflect the same attitude.

Now, there are about 4,000 physicians practising in the Ottawa area,11 and contraceptives and abortion referrals are so widely available in the city that the Medical Officer of Health says that it is cause for celebration.12 Thus, the wildly disproportionate reaction to news that 0.08% of Ottawa area physicians do not prescribe or refer for contraceptives cannot be explained as a rational response to a problem of supply and demand.

The crusade against the three physicians, now expanded by Dr. Gabel and his working group to a crusade for the ethical cleansing of the entire medical profession, is not driven by merely practical concerns about access to services. It is driven by an a markedly intolerant ideology masquerading as enlightened objectivity.

That is why the OMA’s concern that objecting physicians might be restricted to practising in urban centres is understandable, but misplaced. Ontario physicians must come to grips with the fact that, once ethical cleansing gets underway, dissenting physicians will have no refuge in big cities, even if it takes the crusaders longer to find them there.

Nor, if assisted suicide and euthanasia are legalized, will there be refuge for physicians who don’t want to participate in killing patients. The College’s draft policy on end of life care “requires physicians to sensitively respond to a patients wishes or requests to hasten death”13 and insists that physicians who “limit their practice on the basis of moral and/or religious grounds” must comply with College policy on human rights.14 If the law is changed, and Dr. Gabel and his working group get their way, this policy will require physicians who refuse to kill patients to help them find someone who will.

Physicians will be expected to prescribe, abort or refer, to lethally inject or refer, or get out of medicine – or get out of the country.


1. “Catholics doctors who reject abortion told to get out of family medicine.” The Catholic Register, 17 December, 2014 (Accessed 2014-12-19)

2. College of Physicians and Surgeons of Ontario, “Professional Obligations and Human Rights (Draft).” (Accessed 2015-01-11)

3. Letter to the College of Physicians and Surgeons of Ontario from the Ontario Medical Association Section on General and Family Practice Re: Human Rights Code Policy, 6 August, 2014. (Accessed 2015-01-11)

4. Payne E. “Some Ottawa doctors refuse to prescribe birth control pills.” Ottawa Citizen, 30 January, 2014 (Accessed 2014-02-08)

5. Murphy S. “NO MORE CHRISTIAN DOCTORS.” Protection of Conscience Project.

6. “Some Ottawa doctors refusing to prescribe birth control, cite ‘ethical concerns and religious values.’” Reddit Ottawa (Accessed 2015-01-10)

7. CBC Radio, “Should doctors have the right to say no to prescribing birth control?” Ontario Today, 25 February, 2014 (Accessed 2015-01-10)

8.  T___ M___, 29 January, 2014, 6:56 pm

9.  A___ M___ 29 January, 2014, 7:41 pm

10. R___ V___, 29 January, 2014, 7:52 pm

11. College of Physicians and Surgeons of Ontario, All Doctor Search (Accessed 2014-07-29)

12.  Levy I. (Medical Officer of Health, Ottawa) and Abdullah A. (President, Academy of Medicine, Ottawa), Letter to the Ottawa Citizen, 1 February, 2014.

13.  College of Physicians and Surgeons of Ontario, Planning for and Providing Quality End of Life Care: Key Features of the Draft Policy (Accessed 2015-01-11)

14. College of Physicians and Surgeons of Ontario, Planning for and Providing Quality End of Life Care (Draft), lines 363-365. (Accessed 2015-01-11)

‘Frightening’: Life and family leaders react to Ontario College of Physicians’ draft policy

LifeSite News

Pete Balinski

Numerous life-and-family groups have slammed a draft policy from Ontario’s College of Physicians and Surgeons that threatens to force doctors into providing abortions and contraceptives in some circumstances, calling it “inimical to living in a free society” and “frightening.”

“We can say goodbye to a slew of good doctors in Ontario [if the policy passes],” Andrea Mrozek, executive director of Institute of Marriage and Family Canada, told LifeSiteNews. “If I were one, with a young family, I’d leave. Who wants to live under the threat of constant legal action for doing what you believe is good care?”

The College Council approved the draft policy last week. The policy would force doctors who are “unwilling to provide certain elements of care due to their moral or religious beliefs” — such as abortion — to refer the patient “in good faith” to another doctor who would provide the service.

If there is nobody to whom the patient can be referred, then the doctor “must provide care that is urgent or otherwise necessary to prevent imminent harm, suffering, and/or deterioration, even where that care conflicts with their religious or moral beliefs.”

“Although physicians have [freedom of conscience and religion] under the Charter, the Supreme Court of Canada has determined that no rights are absolute,” the draft policy states, adding that the “right to freedom of conscience and religion can be limited.”

The College’s former president, Marc Gabel, has stated that doctors who fail to comply will face disciplinary action. . . [Full text]

The Globe and Mail: bullying from a bully pulpit

Re: Globe and Mail Editorial, 11/12 December, 2014

Will Johnston

If Tommy Douglas had foreseen that the public funding of  Medicare  would one day be the excuse to savagely persecute doctors with minority opinions about the birth control pill,  he might have been taken aback.  When Douglas was fighting for Medicare, the Pill had barely been invented though hundreds of women had already died from clots caused by that Pill’s high estrogen doses. Modern pills use a tiny fraction of the estrogen dose of the first generation Pill, but still result in side effects ranging from depression (common)  to fatal embolism (rare) in some users.   Modern birth control pills cause some breast cancer but prevent some ovarian and uterine cancer.  They can harm.

A minority of doctors, following  their own medical judgment, and soberly ignoring  edicts  from cranky Globe and Mail editorialists,  decide not to associate themselves with the Pill just as they and the majority would not refer a young woman whose family insists on clitoridectomy.  Some doctors do not prescribe antidepressants,  preferring other therapies for depression.  Few doctors would refer for or perform the removal of a healthy limb (yes, there is an activist group who clamor for that “service” too). Public funding doesn’t mean that doctors should discard their judgment.   Referring for something means approving of it.

If you tell a nasty stormtrooper where to go to find some refugees, but don’t personally persecute anyone, you are still implicated in the persecution.  If you tip off an addict as to where to get his drugs, but don’t personally sell the drugs, you are still complicit in the addict’s self-harm.  If you arrange the sale of a gun to a murderer, you become a link in the chain of responsibility for the consequences.

So we are left with some  questions:

1. What harm is there in forcing some doctors to refer to other doctors who have no principles  likely to   frustrate  the patient’s desires?  None, if you have no problem insisting that some doctors do what they think is wrong.

2.  Should the doctor’s disinclination to refer for some item on some politician’s list, promptly and obediently,  justify a quick end to the doctor’s career? Yes, if you want the medical system to end by serving the powerful and not the people.

3. In what way is referring a patient for an abortion like selling a murder weapon, abetting self-harm, or betraying the hiding place of a refugee ?  In each way, for those with eyes to see.

The Globe editorial is a bully’s cry demanding that the authorities hurt certain doctors with minority  opinions about controversial medical care.  These doctors  are to be hurt by being pulled away from the patients they have laboured to serve and by having their livelihoods destroyed.

The authors of the Globe editorial appear to have no idea who bequeathed  them the freedom to express themselves . Strident opinions can’t land them in jail or get them murdered by the police because this is not Iran or Russia. Their irritable and intemperate attack on a few earnest doctors betrays  an  impulse to coerce which, if not exposed and ridiculed, must end in totalitarianism.   We had better not let it.


Freedom of Conscience Protected in Virginia

American Center for Law and Justice

Edward White

The American Center for Law & Justice (ACLJ) recently represented a pharmacist in Virginia who was the subject of a formal complaint and investigation owing to her refusal to fill prescriptions for oral contraceptives due to their abortifacient properties. We are glad to report that the investigation has been resolved in her favor.

While oral contraceptives are intended to prevent ovulation, they also have a secondary mechanism of action that attempts to end pregnancy after fertilization occurs. Many individuals, including many pharmacists, believe that this post-fertilization action is immoral because it intentionally ends a human life, and also believe that its morally impermissible to personally facilitate such activity.

Earlier this year, an individual contacted our client to request a refill for oral contraceptives. The pharmacist said that the individual could have the prescription filled two days later by someone else, but she was not comfortable dispensing it herself due to the drug’s abortifacient properties (acting post-fertilization). The pharmacist felt that it was her professional obligation to make sure that the individual was aware of how the prescribed drug works in light of the fact that many women object on religious or moral grounds to taking it once they understand how it works.

Shortly thereafter on the same day, the individual’s father called our client and angrily questioned her about her refusal to fill the prescription. He also claimed that oral contraceptives never act post-fertilization and warned her that he was going to make her life “a living hell.” . . . [Full Text]

Ontario physicians college draft policy would trample conscience rights

Canadian Catholic News

Deborah Gyapong

OTTAWA – The College of Physicians and Surgeons of Ontario’s draft human rights policy would trample religious freedom and freedom of conscience, say groups defending those rights.

“Prominent academics and activists want to force objecting physicians to provide or refer for abortion and contraception,” said a news release from the Protection of Conscience Project.

“They and others have led increasingly strident campaigns to suppress freedom of conscience among physicians to achieve that goal. The College’s draft policy clearly reflects their influence.”

While the draft policy does not require doctors to perform treatments that violate their consciences or religious beliefs, it does require them to refer patients to doctors who will. . . [Full Text]

Hobby Lobby Case and What It Says About Corporations With a Conscience

 If people want to deny corporations a conscience, how can they ever again demand that corporations act morally, conscientiously?

Paul De Vries*

The Supreme Court was right to allow corporations to be exempt from the mandate to pay for abortion pills or contraception when their leaders have established religious reasons against them. Moral issues can stand as questions for the liberty of conscience – whether individual conscience or corporate conscience.

That liberty of conscience empowers individuals, religious institutions, and corporations – as the Supreme Court just now made clear on the last day of June! The protections of the liberty of conscience for years have allowed people with a track record of pacifism to be exempt from military service and also for hospital nurses and doctors who object to abortion to be scheduled for other surgeries only. “Conscientious objectors” have had a long, distinguished, respected, empowered history in America.

Oddly, those who attack a corporate right to choose allege that it is obvious that corporations do not have consciences – and so that they cannot be “conscientious objectors.” How are those attackers so blind?  [Full text]