World Medical Association to consider policy changes on abortion, euthanasia, assisted suicide

Debate planned for ethics conference in October in Iceland

Sean Murphy*

Following a meeting of the WMA Council in Riga, Latvia, the WMA issued a statement noting that a revised version of the WMA abortion policy would be presented for approval at the WMA annual General Assembly in Reykjavik, Iceland.

In addition, the WMA has announced that there will be a further “open debate” on changing the Association’s policy against physician participation in euthasnasia and assisted suicide.  The debate will occur during a WMA conference on medical ethics taking place at the same time and place.  Formal presentations on euthanasia and assisted suicide will be given on 4 October, 2018, but informal discussions among delegates are likely to be important.  The debate appears to be a consequence of lobbying by the Canadian and Royal Dutch Medical Associations to convince the WMA to drop its condemnation of the practices

It is not clear whether or not WMA members appreciate the relationship between abortion policy and euthanasia policy.  Compulsory referral for abortion is essentially a dress rehearsal for compulsory referral for euthanasia and assisted suicide, something clearly demonstrated in Canada.  Accusations of “patient abandonment” formerly aimed at those refusing to refer for abortion1 are now, in addition, being levelled at those who refuse to refer patients to someone willing to kill them or help them commit suicide.2

In 2011, a Royal Society of Canada panel of experts chaired by Udo Schuklenk  recommended legalization of assisted suicide and euthanasia.3  The experts insisted that health care professionals unwilling to provide euthanasia help patients commit suicide must refer them to someone willing to do so.4 This was justified, they said, because it was agreed that objectors are obliged to refer for “reproductive health services.”5  It really was not agreed: the Canadian Medical Association had, in fact, rejected this claim five years earlier6 after it was made by Jocelyn Downie,7 one of Schuklenk’s colleagues on the Royal Society Panel.

By 2015 Schuklenk was arguing that objecting physicians should not be accommodated at all. Among his arguments was that referring for abortion or euthanasia is not a compromise because it involves moral complicity in the act, “barely reduced” by the act of referral.8  This implied that physicians should be forced to provide abortion and euthanasia, notwithstanding religious or conscientious convictions to the contrary, a position Schuklenk explicitly adopted over the next two years.9, 10

At the same time, Ottawa law professor Amir Attaran was insisting that physicians should be forced to kill eligible patients themselves.11 He claimed that this was required by human rights law,12 describing effective referral as an unacceptable form of illicit discrimination.13

In considering changes to euthanasia, assisted suicide and abortion policies in October, WMA delegates will have to take great care to consider not only the most obvious ethical issues of life and death, but less obvious yet important issues like the distinction between acceptable cooperation and unacceptable collaboration, which play out in disputes about mandatory referral for abortion and euthanasia.


Notes
1.  “According to the prevailing norm of beneficence therefore, as well as those of trust, patient autonomy, and not abandoning patients, physicians should refer patients for abortions.”  McLeod C. Referral in the Wake of Conscientious Objection to Abortion. Hypatia, Vol. 23, No. 4 (October-December, 2008) at p. 36 (Accessed 2018-08-022).

2.  Cook M. Canadian court tells doctors they must refer for euthanasia. Mercatornet, 2 February, 2018

3. Schuklenk U, van Delden JJM, 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)[“Royal Society“] p. 96 (Accessed 2014-02-23).

4.  Royal Society, p. 69, 101.

5.  Royal Society, p. 62.

6.  Blackmer J. Clarification of the CMA’s position on induced abortion. CMAJ April 24, 2007 vol. 176 no. 9 doi: 10.1503/cmaj.1070035 (Accessed 2017-12-12).

7.  Rodgers S. Downie J. Abortion: Ensuring Access. CMAJ July 4, 2006 vol. 175 no. 1 doi: 10.1503/cmaj.060548 (Accessed 2017-12-12).

8.  Schuklenk, U. Conscientious objection in medicine: private ideological convictions must not supercede public service obligations (2015) 29:5 Bioethics ii, DOI: 10.1111/bioe.12167

9.  Schuklenk U, Smalling R. Why medical professionals have no claim to conscientious objection accommodation in liberal democracies (2016) 43:4 J Med Ethics 234, DOI: http://dx.doi.org/10.1136/medethics-2016-103560.

10. Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception (2017) 31:3 Bioethics 162, DOI: 10.1111/bioe.12288

11.  Though conceding that a lethal drug might be administered in the physician’s presence by a delegate, and that referral might be necessitated by technical incompetence. Attaran A. The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v Canada (2016 ) 36:3 Health L Can 86 [“Attaran“], p. 87-88, 96.

12.  “[W]hen a doctor refuses to assist a patient who is disabled by a ‘grievous and irremediable medical condition’, just because the patient wants death rather than something else, that arguably discriminates against the disabled patient.” Attaran, p. 89.

13.  Attaran, p. 91–93.

Canadian court tells doctors they must refer for euthanasia

Will they be hounded out of their profession?

Mercatornet

Michael Cook

For years bioethicists of a utilitarian cast have argued that conscientious objection has no place in medicine. Now Canadian courts are beginning to put their stamp of approval on the extinction of doctors’ right to refuse to kill their patients.

The Superior Court of Justice Division Court of Ontario ruled this week that if doctors are unwilling to perform legal actions, they should find another job.

A group of five doctors and three professional organizations were contesting a policy issued by Ontario’s medical regulator, the College of Physicians and Surgeons of Ontario (CPSO), arguing it infringed their right to freedom of religion and conscience under Canada’s Charter of Rights and Freedoms.

However, Justice Herman J. Wilton-Siegel wrote on behalf of a three-member panel:

“the applicants do not have a common law right or a property right to practise medicine, much less a constitutionally protected right.

“Those who enjoy the benefits of a licence to practise a regulated profession must expect to be subject to regulatory requirements that focus on the public interest, rather than the interests of the professionals themselves.”

At issue is the policy of “effective referral”. A doctor who objects to participating in euthanasia cannot be forced to do it. But he is expected to pass the patient to another doctor who will. The CPSO argues that effective referral is necessary “to protect the public, prevent harm to patients and facilitate access to care for patients in our multicultural, multifaith society, by guiding all physicians on how to uphold their professional and ethical obligations of non-abandonment and of patient-centred care within the context of Ontario’s public health-care system.”

Without the policy of effective referral, equitable access would be “compromised or sacrificed, in a variety of circumstances, more often than not involving vulnerable members of our society at the time of requesting services,” Justice Herman Wilton-Siegel wrote. People in remote communities might request euthanasia. If their doctor refused, they might suffer needlessly and taxpayers would have to foot the bill to subsidise the refusnik’s conscience.

It is remarkable how closely Justice Wilton-Siegel’s text hews to the arguments of bioethicists who have been chipping away at the right to conscientious objection for years.

In 2005 American legal scholar Alta Charo described conscientious objection as “an unfettered  right to personal autonomy while holding monopolistic control over a public good … an abuse of the public trust—all  the worse if it is not in fact a personal act of conscience but, rather, an attempt at cultural conquest’.

In 2006 Oxford’s Julian Savulescu argued in the BMJ that “when conscientious objection compromises the quality, efficiency, or equitable delivery of a service, it should not be tolerated”.

More recently, Canadian bioethicist Udo Schuklenk and a colleague contended in the BMJ that

“If at any given time a doctor is unable to continue practicing due to their—ultimately arbitrary—conscience views, nothing would stop them from leaving the profession and taking up a different vocation. This happens across industries and professions very frequently. Professionals can be expected to take responsibility for the voluntary choices they make.”

Responding to the ruling, Larry Worthen, executive director of the Christian Medical and Dental Society of Canada, said: “We heard from our members and other doctors with conscientious objections over and over again that they felt referral made them complicit and that they wouldn’t be able to live with themselves or stay in the profession if effective referral is still required.”

The case is sure to be appealed, but if the doctors championing conscientious objection fail, the consequences will be dire.

Throughout Canada, doctors would be required to refer for euthanasia. If they refuse, they will be hounded out of their profession, or, at best, shunted into specialties where the question will not arise, like pathology or dermatology.

This ruling shows how quickly tolerance vanishes after euthanasia has been legalised. In the Carter decision which legalised it, Canada’s Supreme Court explicitly stated that legalizing euthanasia did not entail a duty on the part of physicians to provide it. Now, however, 18 months and more than a thousand death after legalisation, conscientious objection is at risk.

It also shows how vulnerable religious-based arguments can be. The plaintiffs contended that referring patients violated their right to religious freedom. While this is true, is this the main ground for conscientious objection? As several doctors pointed out in the Canadian Medical Association Journal last year, “Insofar as all refusals of therapy are ultimately justified by the ethical belief that the goal of therapy is to provide benefit and avoid harm, all treatment refusals are matters of conscience.”


This article is published by Michael Cook and MercatorNet under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to MercatorNet. Commercial media must contact MercatorNet for permission and fees.

Doctors who morally object to treatments must refer patients elsewhere

CTV News

Paolo Lorrigio, The Canadian Press

Ontario doctors who have a moral or religious objection to treatments such as assisted dying, contraception or abortions must refer patients to another doctor who can provide the service, after a court found it is necessary to guarantee that vulnerable patients can access the care they need.

A group of five doctors and three professional organizations had launched a legal challenge against a policy issued by the province’s medical regulator, arguing it infringed on their right to freedom of religion and conscience under the Charter of Rights and Freedoms.

The group — which includes the Christian Medical and Dental Society of Canada, the Canadian Federation of Catholic Physicians’ Societies and Canadian Physicians for Life — said the requirement for a referral amounted to being forced to take part in the treatment. . . [Full Text]

Canadian nurse forced out for refusing to participate in euthanasia

Lifesite News

Pete Baklinski

PALMER RAPIDS, Ontario, June 14, 2017 (LifeSiteNews) — A Canadian nurse no longer has her job helping the sick and the elderly after she was told that she must either assist patients who wanted to kill themselves using the country’s new euthanasia law, or resign.

Mary Jean Martin, a Registered Nurse who worked in middle-management as a Homecare Coordinator in Ontario, said she became a nurse in the late 1980s to help the “vulnerable and the struggling,” not to be a link in a chain that would ultimately lead to a patient’s death.

“Can you imagine being a nurse and being told that you have to help kill someone? That’s so against the philosophy of nursing and it’s so against the heart of the healthcare person,” she told LifeSiteNews in an exclusive interview. . . [Full text]

 

Health care workers bring case for conscience rights to Ontario legislature

Catholic Register

Michael Swan

Armed with letters of support from religious community leaders, plus the official positions of the Ontario, Canadian and American Medical Associations, health care professionals descended on Queen’s Park May 18 in support of a Progressive Conservative private members’ bill that would shield doctors from punishment by the College of Physicians and Surgeons and other regulatory bodies if they refuse to refer for medically assisted suicide.

As the doctors entered the provincial legislature at 9 a.m., security staff warned the doctors they would not be allowed to sit in the public gallery that rings the law makers if they wear their scrubs, as that would be considered a form of protest.

Wearing her scrubs, Concerned Ontario Doctors president Dr. Kulvinder Gill made the case for Conservative health critic Jeff Yurek’s Bill 129 at a 9:45 a.m. press conference. . . [Full text]

 

On assisted suicide, let’s remember that doctors have rights too

Waterloo Region Record

Luisa D’Amato

Physicians are supposed to save lives, not hasten death.

So it’s not surprising that some doctors are having problems seeing how they fit into Canada’s new law that legalizes physician-assisted suicide for some patients.

It turns out that conscientious objectors like Sandra Brickell, a physician who works in Kitchener hospitals, are not protected.

“When somebody wants to end their life, it goes against what we’ve been trained to do,” she said at a meeting Friday with several other doctors, Kitchener-Conestoga MP Harold Albrecht and Kitchener-Conestoga MPP Michael Harris. . . [Full Text]

 

Doctors needed. Leave your conscience at home

 National Post

Marni Soupcoff

In a new paper, two prominent bioethicists suggest that all doctors should be required to see to it personally that any medical procedure — including abortions and assisted suicides — be performed for patients who request and qualify for them.

This should be the case, the authors argue, despite any personal moral or religious qualms the doctors may have about the operations or prescriptions in question. Sadly for devout Catholics, evangelical Protestants or others with deep religious or moral convictions, the prospect of medical school itself would be completely off the table if co-authors Udo Schuklenk and Julian Savulescu had their way; they argue that medical students should be screened for over-active consciences when it comes to things like contraception, abortion and euthanasia. Apparently those for whom these issues are anything but no-brainers shouldn’t be considered acceptable physician material at all. . . [Full text]

 

Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception

Abstract:  In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors’ personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: (1) removing a right to conscientious objection; (2) selecting candidates into relevant medical specialities or general practice who do not have objections; (3) demonopolizing the provision of these services away from the medical profession.

Savulescu J, Schuklenk U.  (2016) Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics. doi:10.1111/bioe.12288

Ban conscientious objection by Canadian doctors, urge ethicists in volatile commentary

National Post

Tom Blackwell

Authorities should bar doctors from refusing to provide such services as abortion and assisted death on moral grounds, and screen out potential medical students who might impose their values on patients, leading Canadian and British bioethicists argue in a provocative new commentary.

The paper by professors at Queen’s and Oxford universities, who are also editors of two major bioethics journals, throws rocket fuel onto a debate already inflamed by the new law allowing assisted death.

They argue that physicians have no right to opt out of lawful medical services — from abortion to prescribing contraceptives — that are requested by a patient and in the person’s interest.

Those who let conscientious objection affect patient care are clearly unprofessional, say Udo Schuklenk and Julian Savulescu.

“Doctors must put patients’ interests ahead of their own integrity,” they write in the journal Bioethics. . . [Full text]

    

Unacceptable to force doctors to participate in assisted dying against their conscience: CMA head

National Post

Sharon Kirkey

No physician in the country should be forced to play a role in any aspect of assisted dying against their moral or religious beliefs — including referring patients to another doctor willing to help them die, the Canadian Medical Association says.

Legalized physician-assisted death will usher in such a fundamental change in practice “we simply cannot accept a system that compels physicians to go against their conscience as individuals on something so profound as this,” CMA president Chris Simpson said in an exclusive interview.

The unanimous Supreme Court of Canada ruling legalizing assisted dying would not compel doctors to help patients end their lives when the historic decision takes effect next year.

But the justices were more guarded on the issue of mandatory referral, saying the Charter rights of both patients and doctors will need to be reconciled.

Dr. Simpson said that many doctors who conscientiously object to assisted dying feel the very act of referral “is contrary to their personal ethics or moral or religious beliefs.” . . . [Full text]