Medical Assistance in Dying
Approved June, 2016 | Reviewed and Updated: July 2017, December 2018, April 2021

. . . Effective Referral: taking positive action to ensure the patient is connected² to a non-objecting, available, and accessible³ physician, other health-care professional, or agency.⁴ For more information about an effective referral, see the companion Advice to Profession document.Project Annotation (i)

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C. Conscientious Objection

The College recognizes that physicians have the right to limit the health servicesProject Annotation (ii) they provide for reasons of conscience or religion. For clarity, the College does not require physicians who have a conscientious or religious objection to MAID to provide MAID under any circumstances.¹³

However, physicians' freedom of conscience and religion must be balanced against the right of existing and potential patients to access care.Project Annotation (ii) The Supreme Court of Canada noted, in the Carter¹⁴ case, that the rights of physicians and patients would have to be reconciled in any regime governing MAID. The Court of Appeal for Ontario has confirmed that where an irreconcilable conflict arises between a physician's interest and a patient's interest, physicians' professional obligations and fiduciary duty require that the interest of the patient prevails.^{15, Project Annotation (iii)}

While the federal legislation does not address the conscientious objections of health care providers, the College has outlined expectations, set out below, for physicians who have a conscientious or religious objection to MAID. These expectations accommodate the rights of objecting physicians to the greatest extent possible,Project Annotation (iv) while ensuring that patients' access to healthcare is not impeded.

11. Consistent with the expectations set out in the College's Professional Obligations and Human Rights policy, physicians who decline to provide MAID due to a conscientious objection:
    1. must do so in a manner that respects patient dignity and must not impede access to MAID [Emphasis in original].
    2. must communicate their objection to the patient directly and with sensitivity, informing the patient that the objection is due to personal and not clinical reasons [Emphasis in original].Project Annotation (v)
    3. must not express personal moral judgments about the beliefs, lifestyle, identity or characteristics of the patient.
    4. must provide the patient with information about all options for care that may be available or appropriate to meet their clinical needs, concerns, and/or wishes and must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs [Emphasis in original].
    5. must not abandonProject Annotation (vi) the patient and must provide the patient with an effective referral [Emphasis in original].^{16,17,Project Annotation (vii)}  
       1. Physicians must make the effective referral in a timely manner and must not expose patients to adverse clinical outcomes due to a delay in making the effective referral [Emphasis in original]. Project Annotation (viii)

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MAiD Notes

2.  An effective referral does not necessarily, but may in certain circumstances, involve a 'referral' in the formal clinical sense, nor does it necessarily require that the physician conduct an assessment of the patient to determine whether they are a suitable candidate for the treatment to which they object (in the context of medical assistance in dying, this means that the physician is not required to assess whether the patient is eligible for medical assistance in dying prior to making the effective referral).

3.  'Available and accessible' means that the health-care provider must be in a location the patient can access, and operating and/or accepting patients at the time the effective referral is made.

4.  In the hospital setting, practices may vary in accordance with hospital policies and procedures.

13.  The College also does not consider a request for medical assistance in dying to be an emergency.

14.  Carter v. Canada (Attorney General), 2015 SCC 5

15.  See para. 187 Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393

16.  See the definition of effective referral provided in this policy and the companion Advice to the Profession document for more information and examples of what constitutes an 'effective referral'.

17. The Ministry of Health and Long-Term Care has established the Care Coordination Service (CCS) to allow clinicians, patients, and caregivers to access information about medical assistance in dying and end-of-life care options, and to connect patients with clinicians who provide medical assistance in dying. Clinicians seeking assistance in making an effective referral can call the CCS toll-free: 1-866-286-4023. If physicians have general questions about the CCS, or wish to register for the CCS as a willing provider, please contact the Ministry of Health and Long-Term Care at maidregistration@sasc.ca. The College expects physicians to make reasonable efforts to remain apprised of resources that become available in this new landscape.

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Advice to the Profession: Medical Assistance in Dying
Reviewed & Updated: October 2020, April 2021, May 2021

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Effective Referrals: What Physicians Need to Know

The College recognizes that physicians have the right to limit the health servicesProject Annotation (i) they provide for reasons of conscience or religion and so may choose not to be involved in assessing or providing MAID.Project Annotation (ii) In recognizing this right, the College does not require physicians to assess a patient's eligibility for MAID or provide MAID in any circumstances.

When physicians limit the health services they provide for reasons of conscience or religion, the College requires that they provide patients with an 'effective referral'.

What is an effective referral?

Physicians make an effective referral when they take positive action to ensure the patient is connected in a timely manner to a non-objecting, available, and accessible physicians, other-health-care professional, or agency that provides the service or connects the patient directly with a health-care professional who does.Project Annotation (iii)

The objective is to ensure access to care and respect for patient autonomy. An effective referral does not guarantee that a patient will receive a treatment or signal that the objecting physician endorses or supports the treatment.Project Annotation (iv) An effective referral also does not necessarily require that a referral in the formal clinical sense be made and does not require the physician to assess or determine whether the patient is a suitable candidate or eligible for the treatment to which the physician objects.

An effective referral involves taking the following steps:

1. The physician takes positive action to connect a patient with another physician, healthcare professional, or agency. The physician can take these steps themselves or assign the task to someone else, so long as that person complies with the College's expectations.Project Annotation (v)
2. The effective referral must be made to a non-objecting physician, healthcare professional, or agency that is accessible and available to the patient. The physician, healthcare professional, or agency must be accepting patients/open, must not share the same religious or conscience objection as the physician making the effective referral, and must be in a location that is reasonably accessible to the patient or accessible via telemedicine where appropriate.
3. The effective referral must be made in a timely manner, so that the patient will not experience an adverse clinical outcome due to a delay in making the connection. A patient would be considered to suffer an adverse outcome due to a delay if, for example, the patient is no longer able to access care (e.g., for time sensitive matters such as emergency contraception, an abortion, or where a patient wishes to explore MAID), their clinical condition deteriorates,Project Annotation (vi) or their untreated pain or suffering is prolonged.Project Annotation (vii)

What are some examples of an effective referral?

The following are examples of the steps physicians can take to ensure their patient is connected in a timely and appropriate manner. The examples provided are not exhaustive and the steps needed to ensure a connection is made depend on the patient's circumstances. Physicians will need to use their judgement, considering the patient's particular circumstances, when determining how to meet this obligation.

The physician or designate contacts a non-objecting physician or non-objecting healthcare professional and arranges for the patient to be seen or transferred².Project Annotation (iii)

The physician or designate connects the patient with an agency charged with facilitating referrals for the healthcare service, and arranges for the patient to be seen at that agency. For instance, in the MAID context, in appropriate circumstances an effective referral could include the physician or designate contacting Ontario's Care Coordination Service (CCS). The CCS would then connect the patient with a willing provider of MAID-related services.Project Annotation (viii)

A practice group in a hospital, clinic or family practice model identifies patient queries or needs through a triage system. The patient is directly matched with a non-objecting physician in the practice group with whom the patient can explore all options in which they have expressed an interest.Project Annotation (ix)

A practice group in a hospital, clinic or family practice model identifies a point person who will facilitate referrals or who will provide the healthcare to the patient. The objecting physician or their designate connects the patient with that point person.Project Annotation (iii)

For more information regarding physicians' right to freedom of conscience and religion and the basis for the College's expectations, please see the College's Advice to the Profession: Professional Obligations and Human Rights companion resource.

Advice to the Profession (MAID) Notes

2.  A transfer of care in this situation would be specific to the care to which the physician objects. A transfer is not equivalent to ending the physician-patient relationship. Physicians must not terminate the physician-patient relationship simply because the patient wishes to explore a care option to which the physician has a conscientious objection.