Canada

Canadian Medical Association

Policies & statements relevant to freedom of conscience

CMA Code of Ethics and Professionalism (2018) [Extracts]

A. Virtues exemplified by the ethical physician

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Compassion: A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient.

Honesty: An honest physician is forthright, respects the truth, and does their best to seek, preserve, and communicate that truth sensitively and respectfully.

Humility: A humble physician acknowledges and is cautious not to overstep the limits of their knowledge and skills or the limits of medicine, seeks advice and support from colleagues in challenging circumstances, and recognizes the patient’s knowledge of their own circumstances.

Integrity: A physician who acts with integrity demonstrates consistency in their intentions and actions and acts in a truthful manner in accordance with professional expectations, even in the face of adversity.

Prudence: A prudent physician uses clinical and moral reasoning and judgement, considers all relevant knowledge and circumstances, and makes decisions carefully, in good conscience, and with due regard for principles of exemplary medical care.

B. Fundamental commitments of the medical profession

Commitment to the well-being of the patient

Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient. Provide appropriate care and management across the care continuum. Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm has occurred. Recognize the balance of potential benefits and harms associated with any medical act; act to bring about a positive balance of benefits over harms.

Commitment to professional integrity and competence

Practise medicine competently, safely, and with integrity; avoid any influence that could undermine your professional integrity. Develop and advance your professional knowledge, skills, and competencies through lifelong learning.

C. Professional responsibilities

Patient physician relationship

The patient–physician relationship is at the heart of the practice of medicine. It is a relationship of trust that recognizes the inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of loyalty to protect and further the patient’s best interests and goals of care by using the physician’s expertise, knowledge, and prudent clinical judgment. In the context of the patient–physician relationship:

3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and requests whatever your moral commitments may be.

4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or practice of any medical procedure or intervention as it pertains to the patient’s needs or requests.

8. Provide whatever appropriate assistance you can to any person who needs emergency medical care.

Decision making

Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making and is informed by the patient’s experience and values and the physician’s clinical judgment. This deliberation involves discussion with the patient and, with consent, others central to the patient’s care (families, caregivers, other health professionals) to support patient-centred care. In the process of shared decision-making:

11. Empower the patient to make informed decisions regarding their health by communicating with and helping the patient (or, where appropriate, their substitute decision-maker) navigate reasonable therapeutic options to determine the best course of action consistent with their goals of care; communicate with and help the patient assess material risks and benefits before consenting to any treatment or intervention.

Physcians and self

30. Cultivate training and practice environments that provide physical and psychological safety and encourage help-seeking behaviours.

Physicians and society

41. Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the profession.

Project Annotations

Like its predecessors, the CMA’s Code of Ethics and Professionalism does not provide detailed guidance about the exercise of freedom of conscience by physicians; the relevant provisions are expressed in general rather than procedure-specific terms. However, The relevant sections of the Code of Ethics and Professionalism adopted by the Association reflect the traditional position of the CMA. They support physicians who refuse to refer patients for procedures to which they object for reasons of conscience and/or professional judgement, while recognizing that they have other obligations to patients and colleagues.

Caution is warranted with respect to the emphasis on “professionalism” introduced into the new Code. Some prominent academics assert that “professionalism” demands that physicians must give such priority to patient “interests” (as defined by the patient or others) that physicians should be willing to serve those interests even by doing what they believe to be wrong.

However, while self-sacrifice might entail going to jail or even the loss of one’s life, it has never been understood to include the sacrifice of one’s integrity. It is thus important to note that a claim that “professional expectations” overrides physician freedom of conscience would contradict the emphasis placed on moral agency, integrity and conscience in the Code and CMA policy statements. Indeed, the Code explicitly states that it is “not exhaustive” and acknowledges the interdependence of the virtues of an ethical physician.

Further, claims about “professional expectations” are not neutral. Physicians may disagree profoundly about whether participation in a given morally contested procedure exemplifies professional commitment or professional corruption; euthanasia is only the most recent and obvious example. Requiring conformity to a dominant theory of professionalism that subordinates freedom of conscience to purportedly neutral “professional” obligations reflects an authoritarian mindset that will generate illicit discrimination and exacerbate rather than resolve conflict within the profession.

Project Submission to the Canadian Medical Association Re: 2018 Revision of the CMA Code of Ethics

Canadian Medical Association and Referral for Morally Contested Procedures