Ontario doctors fight law forcing them to help kill their patients

The Interim

Five doctors and three doctors’ groups were in an Ontario court June 13-15 arguing a policy from the College of Physicians and Surgeons of Ontario (CPSO) violates their Charter rights to freedom of conscience and religion. The CPSO forces doctors to refer patients for euthanasia and abortion, even when it violates their conscience or religion. Kathleen Wynne’s Liberal government intervened on behalf of the college.

The 2015 CPSO policy requires that doctors who object on religious or conscience grounds to providing certain procedures such as abortion and euthanasia must give patients seeking these practices an effective referral. This means directly handing over a patient to another colleague who will follow through with an abortion or euthanasia request. The doctors argue this implicates them in the immoral practices to which they object. . . . [Full text]

 

Understanding Freedom of Conscience

Policy Options

Brian Bird*

The year 2017 marks the 150th anniversary since Confederation and the 35th anniversary of the Canadian Charter of Rights and Freedoms. By virtue of a court case in Ontario that might go all the way up to the Supreme Court of Canada, 2017 may also be the year when freedom of conscience — until now a dormant Charter freedom — is brought to life.

In June, Ontario’s Divisional Court heard arguments in a case that challenges a policy in Ontario obliging physicians to provide an effective referral if they conscientiously object to performing a medical procedure. An effective referral means that the objecting physician must promptly direct the patient to a physician who will perform the procedure. In May, two of the lawyers representing the side that is challenging the policy outlined their position in Policy Options. In essence, they argue that the policy unduly infringes the freedom of conscience and religion of physicians who refuse on the basis of those Charter grounds to participate in medical procedures. . . [Full text]

 

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…)

 

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]

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]

 

To dispense or not to dispense…

Eastern Daily Press

Nick Conrad

I was drawn to a news story which snuck under the radar this week. This issue is a classic ‘contract’ versus ‘conscience’ battle facing some pharmacists, which was brilliantly highlighted on the BBC Radio Norfolk Sunday Breakfast programme.

I pen this week’s article with genuine interest, a will to impartially provoke a healthy debate rather than trying to influence opinion. In a U-turn on proposed policy, Britain’s pharmacy regulator has declared that pharmacists should not be forced to dispense medicine and substances against their consciences. This includes drugs such as the morning-after pill or even contraceptives. The pharmacist can object if it goes against their religious beliefs, forcing the customer to go elsewhere. . . [Full text]

 

Freedom for conscientious objectors needs protection

Waterloo Region Record

Stephen Woodworth

Last week five doctors and several rights groups were in Ontario’s Divisional Court challenging rules imposed by the College of Physicians and Surgeons of Ontario to punish doctors who refuse to help arrange assisted suicide. The Court reserved its ruling, which will be released at a later date.

Ontario’s new assisted suicide law amended various Acts in response to the federal legislation on assisted suicide. Pleas to guarantee freedom of conscientious objection for doctors who defy orders to provide “effective referral” were ignored by the legislature, so penalties imposed by the College of Physicians and Surgeons of Ontario against conscientious objectors remain in force.

Remarkably, in just two short years Canadians have gone from punishing those who helped arrange assisted suicide to punishing those who refuse to arrange assisted suicide. . . [Full text]