Submission to the College of Physicians and Surgeons of
Saskatchewan
Re: Conscientious Refusal (as revised)
5 June, 2015
Full Text
Abstract
Council has been given no evidence that anyone in Saskatchewan has ever been unable to
access medical services or that the health of anyone in Saskatchewan has
ever been adversely affected because a physician has declined to provide or
refer for a procedure for reasons of conscience.
The conclusion that objecting physicians "should not be obligated to
provide a referral to a physician who will ultimately potentially provide
the service" is entirely satisfactory. It is a tacit admission that such a
policy would be an unacceptable assault on freedom of conscience.
Conscientious Refusal as revised attempts to nullify the alleged
'bias' of physicians who object to a procedure for reasons of conscience by
requiring them to refer patients to a non-objecting colleague. This proposal
is not sound, since, if it is to be applied fairly and consistently, the
'bias' of physicians who do not object to a procedure should be
nullified in the same way. This would simply exchange one kind of alleged
'bias' for another, inconvenience patients and provide them with no better
care.
The more sensible course is to require all physicians to provide patients
with sufficient information to satisfy the requirements of informed medical
decision making. Physicians must advise patients at the earliest
reasonable opportunity of services or procedures they decline to recommend
or provide for reasons of conscience, advise
affected patients that they may seek the services elsewhere, and ensure that
they have sufficient information to approach other physicians, heath care
workers or community organizations. They must not promote their own
moral or religious beliefs when interacting with a patient.
Physicians unwilling to abide by these requirements must promptly arrange for a patient to be seen by another physician or
health care worker who is able to do so.
If the College is determined to enact a policy on conscientious refusal,
it should ensure that the policy adopted is sufficiently flexible to
accommodate physicians with respect to all procedures or services.
Otherwise, Council should reject Conscientious Refusal as revised and
postpone policy development until after the Carter decision comes into force
in 2016.
TABLE OF CONTENTS
I. Revision of draft policy -
Conscientious Refusal
II. Focus of this submission
III. Section 5.3
IV. Section 5.3: Suggested modification
V. Section 2: Scope
VI. Summary
Appendix "A" - Ontario
College briefing materials
Appendix "B" - Providing
Information
Appendix "C" -
Conscientious Refusal and assisted
suicide/euthanasia
I. Revision of draft policy - Conscientious
Refusal
I.1 The original text of Conscientious Refusal,
approved in principle by College Council on 20 January, 2015 (hereinafter "CR
No. 1"), was released for public consultation that generated "a very
significant return" of over 4,400 responses, almost all of which opposed the
policy.1
The first Protection of Conscience Project
submission was made during this consultation.2
I.2 CR No. 1 was revised and re-submitted to
Council on 20 March, 2015. This submission concerns the revised text
(hereinafter "Conscientious Refusal as revised").3
I.3 The Project’s first submission noted that neither
Mr. Salte nor the committee had provided any evidence
- that anyone in Saskatchewan has ever been unable to access
medical services because a physician has declined to provide or refer
for a procedure for reasons of conscience; or
- that the health of anyone in Saskatchewan has ever been adversely
affected because a physician has declined to provide or refer for a
procedure for reasons of conscience.
I.4 Since Mr. Salte would surely have drawn Council’s
attention to any evidence on either of these points produced by the
consultation, it appears that the "very significant return" produced no
evidence that such problems exist in Saskatchewan.
I.5 Council was provided with information from the
College of Physicians and Surgeons of Ontario concerning its new policy,
Professional Obligations and Human Rights, including the briefing note
provided to the Ontario College Council by its working group.4 Council is
cautioned that the Ontario College briefing note is "deficient, erroneous
and seriously misleading." (Appendix
"A")
II. Focus of this submission
II.1 The primary focus of this second submission is on three
elements in Conscientious Refusal as revised:
Section 5.3
- Deletion of the requirement to refer for a morally contested service
- Imposition of a requirement to refer patients for information
Section 2: Scope
- Non-applicability to assisted suicide and euthanasia
II.2 This submission notes that the deletion of the requirement to
refer for a morally contested service is entirely satisfactory and warrants
emphasis.
II.3 The imposition of a requirement to refer for information does
not, strictly speaking, have a direct adverse effect on the fundamental
freedoms of physicians, but it is problematic for other reasons relevant to
the exercise of freedom of conscience and the expectations of the Supreme
Court of Canada. For this reason, this submission treats this requirement at
greater length and recommends an alternative approach to ensure that
patients receive information necessary for medical decision making, without
compromising physician freedom of conscience.
II.4 This submission argues that the disclaimer that Conscientious
Refusal as revised will not apply to "physician assisted death" (i.e.,
physician administered euthanasia and physician assisted suicide) is
misleading and ill-advised. If the College is determined to enact a policy
on conscientious refusal, it should ensure that the policy adopted is
sufficiently flexible to accommodate physicians who are unwilling to do what
they believe to be wrong, not excluding direct or indirect participation in
killing patients or helping them commit suicide. If Council is uncertain how
this can be done, it should reject Conscientious Refusal as revised and
postpone policy development until after the Carter decision comes
into force in 2016.
III. Section 5.3
III.1 Deletion of requirement to refer for a morally
contested service
III.1.1 The revised policy no longer requires that a physician
unwilling to provide a service for reasons of conscience must facilitate the
procedure by referral to a colleague who will.
III.1.2 The revision is consistent with the committee's conclusion
that objecting physicians "should not be obligated to provide a referral to
a physician who will ultimately potentially provide the service."5
III.1.3 This is a tacit admission that the original demand that
objecting physicians must provide what the College of Physicians and Surgeons
of Ontario calls "effective referral" was an assault on freedom of
conscience, not a compromise.
III.1.4 The deletion of the demand for referral is entirely
satisfactory and the committee's conclusion is highly significant.
III.2 Imposition of requirement to refer patients for
information
III.2.1 Instead of a demand to facilitate a morally contested
service by referral, the revised policy imposes the following requirement
when patients seek a service to which a physician objects for reasons of
conscience:
. . . in such situations, [the physician] must make a
timely referral to another physician or other health care provider who can
meet the expectations of paragraph 5.2, who is willing and able to accept
the patient, and if the patient decides to receive a clinically appropriate
health service, that physician can either provide that treatment or refer
the patient to another physician or health care provider who can provide
that treatment.
III.2. Paragraph 5.2, to which this passage refers, concerns the
expectation that physicians will provide patients with the "full and
balanced" (Section 4) information needed to make informed decisions about
medical treatment. The accompanying memo to College Council included a
practical example of what is intended by the revision:
A physician with an ethical objection to referring a
patient for an abortion would not be obligated to refer a patient to an
obstetrician who will perform an abortion. Rather, the physician would be
obligated to refer the patient to another physician who can have an informed
discussion with the patient about abortion and, if the patient after that
discussion chooses to have a therapeutic abortion, refer the patient to an
obstetrician willing to perform the abortion.6
III.2.3 The revision presumes that, by virtue of moral opposition
to a service, a physician must be hopelessly prejudiced, duplicitous,
disrespectful and incapable of providing full and balanced information. In
light of Paragraph 5.2, the revision implies that physicians morally opposed
to a service (like abortion) will
- fail to advise a patient of its availability; and/or
- fail to advise a patient of diagnosis, prognosis, and clinically
appropriate treatment options; and/or
- provide false, misleading, intentionally coercive or materially
incomplete information; and/or
- fail to communicate in a manner likely to be understood by a
patient; and/or
- communicate or otherwise behave in a manner that demeans the patient
or the patient's beliefs, lifestyle, choices or values; and/or
- promote their own religious beliefs.
III.2.4 This is not an attack on freedom of conscience. It is,
however, an attack on the character and competence of objecting physicians.
This confirms of one of the central points made in the
Project's first submission to Council:
medicine is an inescapably moral enterprise.
. . . [E]very decision concerning treatment is a moral
decision, whether or not the physician specifically adverts to that fact.
[VII.5.1]
. . . Hence, the demand that physicians must not be
allowed to act upon beliefs is unacceptable because it is impossible; one
cannot act morally without reference to beliefs, and cannot practise
medicine without reference to beliefs. . .[VII.5.4]
. . . Morality and ethics are actually intrinsic to
[the practice of medicine]. Of course, some moral or ethical views may be
erroneous, but that is a different matter that must be addressed by
explaining why they are erroneous. It will not do to pretend, for example,
that the claim that best medical practice in some circumstances means
killing a patient does not involve at least implicit moral or ethical
judgements.[VII.5.5]
III.2.5 Nor will it do to pretend that the claim that best medical
practice means providing an abortion does not involve at least an implicit
moral or ethical judgement. On the contrary: the revised policy is not an
ethically or morally neutral statement. It demonstrates that committee
members believe that abortion (for example) is morally or ethically
acceptable and may be provided. Recall one of
the conclusions reached about the original policy in the Project's first
submission:
Conscientious Refusal is not a compromise
between opposite views about morally contested procedures or professional
responsibilities. It is an assertion of a preference for one of the opposing
views and an authoritarian attempt to compel others to conform to that
preference, masked by the pretence of neutrality.[VI.5.9]
III.2.6 The revised policy does not compel objecting physicians to
conform to the committee's ethical viewpoint, but, solely on the basis of
their beliefs, it effectively prohibits
them from communicating with their patients about morally contested
procedures. This demonstrates that the above
conclusion was correct, and that the policy, even as revised, attempts to advance moral
or ethical views masked by the pretence of neutrality.
III.2.7 While Project Advisor Jay Budziszewski calls this "bad
faith authoritarianism,"7 it may be more
appropriate, in this case, to describe it as merely unreflective
authoritarianism. It is possible that committee members are so intent upon
the 'bias' they perceive in those
with whom they disagree that they are unaware that they are similarly 'biased'
by their own moral/ethical viewpoint.
III.2.8 Nonetheless, suppose that College Council believes that it should nullify the
'bias' of physicians who object to a procedure for reasons of conscience by
prohibiting them from communicating with their patients about morally
contested procedures, requiring them, instead, to refer patients to a
non-objecting colleague.
III.2.9 However, if this approach is sound, the
College must go a step further. It must also nullify the 'bias' of
physicians who do not object to a procedure. It must also prohibit
physicians who do not object to abortion (for example) from
communicating with their patients about it, and require them to refer
patients to colleagues who do object to it.
III.2.10 As this exercise demonstrates, this
approach is not sound. It does nothing more than 'protect' patients
from one kind of alleged 'bias' by exposing them to another. Of course, this outcome
could be avoided by allowing physicians who do not object to abortion (for
example) to communicate with their patients about it, on the condition that
they then refer the patient to a colleague who does object to abortion, and
vice-versa. The respective physician 'biases' would then cancel each other
out.
III.2.11 However, this is also unsatisfactory. It would, at a
minimum, inconvenience patients, delay treatments, provide no better
outcomes, double the costs of providing health care and antagonize
physicians on all sides of any issue.
III.2.12 To repeat: this approach is not sound. The assumption
underlying the recommendation is that a physician who has a moral viewpoint
is incapable of properly communicating with a patient. But all physicians
have moral viewpoints. Thus, if applied as now written, the policy would simply exchange one kind of 'bias' for
another. If applied fairly and consistently, the
results would be ludicrous.
III.2.13 The committee's recommendation is not sound because
medicine is a moral enterprise, yet the committee would have the College
control for or eliminate the exercise of bona fide moral judgement. The
College cannot do that fairly and consistently without grotesquely deforming
medical practice. It can only do it unfairly and inconsistently by an
authoritarian suppression of moral viewpoints selected arbitrarily, or
selected on the basis of their unpopularity with those in positions of power
and influence.
III.2.14 Such selective authoritarianism by medical regulators is a
practice that squarely contradicts the repeated and eventually unanimous
assertion of the full bench of the Supreme Court of Canada: that, in a free
and democratic society, "the state will respect choices made by individuals
and, to the greatest extent possible, will avoid subordinating these choices
to any one conception of the good life."8
III.2.15 The recommended requirement to refer for information is
offensive to objecting physicians for the same reasons that it would be
offensive if it were applied to non-objecting physicians, but it does not,
strictly speaking, immediately and adversely affect the exercise of freedom
of conscience or religion.
III.2.16 However, the mindset perpetuated by such a policy is
inimical to fundamental freedoms because its natural tendency is in the
direction of oppression, as illustrated by developments in the College of
Physicians and Surgeons of Ontario between 2008 and 2015. It is also
inconsistent with the expectations of the Supreme Court of Canada concerning
the accommodation of different world views. For these reasons (in addition
to those noted in III.2.10 to 13) , the Project
recommends that the requirement for referral for information be modified.
IV. Section 5.3: Suggested modification
(See Appendix
"B")
IV.1 Physicians must provide patients with sufficient information
to make them aware of relevant treatment options so that they
can make informed decisions about accepting or refusing medical treatment
and care. The information must be communicated respectfully and in a way
likely to be understood by the patient.9
IV.2 Physicians must disclose whether or not their religious, ethical
or other conscientious convictions influence their recommendations or practice
or prevent them from providing certain procedures or services.10 If medical
judgement rather than moral/religious conviction is the primary
consideration, it is still prudent to disclose pertinent religious or moral
beliefs. The patient is also entitled to know whether or not the physician's
medical opinion is consistent with
the general view of the medical profession.11
IV.3 Physicians should inform patients of treatments or services
that they will not provide for reasons of conscience, and notify them when
their views change. Notice should be given as soon as it would be apparent
to a reasonable and prudent person that a conflict is likely to arise
concerning treatments or services the physician declines to provide, erring
on the side of sooner rather than later. In many cases - but not all - this
may be when a patient is accepted. The same holds true for notification of
patients when a physician's views change significantly.
IV.4 Physicians must not promote their own moral or religious
beliefs when interacting with a patient. Unless the patient questions the
physician, asks for further explanation, or otherwise indicates a lack of
understanding, a physician need not and probably should not expand upon the
basis for his conscientious convictions.
IV.5 A physician who declines to recommend or provide services or
procedures for reasons of conscience must advise affected patients that they
may seek the services elsewhere, and ensure that they have sufficient
information to approach other physicians, heath care workers or community
organizations.
IV.6 Physicians who are unable or unwilling to comply with this
section must promptly arrange for a patient to be seen by
another physician or health care worker who can comply with this section.
V. Section 2: Scope
V.1 Purported non-applicability of
policy to assisted suicide and
euthanasia
V.1.1 College Council
has been asked to include a disclaimer in Conscientious Refusal as revised. The
disclaimer states that the policy will not apply to "physician assisted
death or physicians' conscientious objection related to a potential
physician assisted death"12 (i.e., physician administered euthanasia and
physician assisted suicide).
V.1.2 The ostensible reason for this is "that this is
currently an issue which is in a state of development and may be revisited
by the College at a later time."13
V.1.3 Mr. Salte offered a more detailed explanation:
There is considerable uncertainty associated with
physician-assisted death following the Carter decision. There may
be legislation by the Federal or Provincial Government which addresses the
issue before February 2016 when the Carter decision will come into
effect if no new legislation is passed. The ethical implications of
physician-assisted death have not been fully explored.
The situation of physician-assisted death can be
revisited later, when it is clearer whether there will be legislation that
addresses the issue and, if there will be, what the legislation will state.14
V.1.4 Committee member Dr. Susan Hayton explicitly
supported this, noting that "the boundaries of this whole area are very grey
at the moment."15
V.1.5 However, this disclaimer is inconsistent with the
origin of the policy and with previous statements by its proponents (V.2).
It is also inconsistent with previous arguments associating the provision of
abortion/contraception with the provision of euthanasia/assisted suicide (V.3). Further, almost all of the
principles introduced into the revised policy are as supportive of
euthanasia and assisted suicide as they are of abortion and contraception
(Appendix "C").
V.2 Disclaimer inconsistent with
origin of policy and previous statements
V.2.1 The policy first proposed by Mr. Salte originated
with the Conscience Research Group (CRG) and was virtually identical to it.
The slightly modified text, approved in principle by College Council in
January, 2015 as Conscientious Refusal (hereinafter "CR No.1")
was also a nearly verbatim copy of the CRG policy.
V.2.2 The CRG includes two euthanasia activists. One of
them - Professor Jocelyn Downie - co-wrote the CRG policy largely replicated
in CR No. 1. They were and are of the view that health care workers
unwilling to kill patients or help them kill themselves should be forced to
find someone else willing to do so.16 Thus, the CRG policy is meant to apply
to all "legally permissible and publicly funded health services" - which,
beginning in 2016,
will include euthanasia and assisted suicide.
V.2.3 Consistent with this, when,
in 2014, Mr. Salte urged the registrars of all Canadian Colleges of
Physicians and Surgeons to adopt a uniform coercive policy of the kind he
and the CRG were proposing, he did not refer to abortion or contraception.
Instead, he wrote, "Physician-assisted suicide, in particular, has the
potential to challenge Colleges of Physicians and Surgeons to provide
guidance to its members."17
V.2.4 Further, when - with a
virtual clone of the CRG group’s text in his back pocket, so to speak - Mr.
Salte proposed that the College adopt a policy on "ethical objection," he
identified assisted suicide as one of a list of "issues which have resulted
in controversy" - the others being abortion, birth control, fetal sex
identification and genetic testing.18
V.2.5 After the Carter decision,
anticipating the legalization of physician administered euthanasia and
physician assisted suicide, Mr. Salte stated publicly that CR No. 1 was
intended to apply "broadly,"not only to "birth control and abortion," but
"all other areas," not excluding physician assisted suicide and euthanasia.
He explicitly confirmed that doctors who disagree with assisted suicide
could "end up being disciplined," and "could . . . lose their jobs."19
V.2.6 The statement is not
surprising. Mr. Salte’s willingness to discipline and dismiss physicians who
refuse to participate in killing patients or helping them to commit suicide
reflects an attitude entirely faithful to the source of the policy. It is
also consistent with his explicit association of assisted suicide with the
policy from the very beginning, and his linking of assisted suicide with
abortion and birth control. Mr. Salte has said nothing to indicate that his
attitude will be any different once the Carter decision comes into effect.
V.2.7 The Canadian Medical Protective Association
(CMPA) took note of the CR No. 1 requirement that objecting
physicians actually provide "all health services that are legally available
and publicly funded" if referral were not possible or would cause a delay
jeopardizing a patient’s "health or well being." The CMPA understood this
would include providing euthanasia and assisted suicide once Carter came
into effect.20
V.3 Disclaimer inconsistent with
association of abortion/birth control and euthanasia/assisted suicide
V.3.1 It has been noted that the policy first proposed
by Mr. Salte and CR No.1 are nearly verbatim copies of the CRG policy,
produced by a group including two euthanasia activists, one of whom co-wrote
the CRG policy. They argue that health care workers unwilling to kill
patients or help them kill themselves should be forced to find someone else
willing to do so because (they claim) it is agreed that health care workers
who refuse to provide abortion and birth control can and should be compelled
to refer patients to someone who will.21
V.3.2 It should be obvious that this claim is sharply
contested, but it demonstrates clearly that arguments supporting a policy of
coerced participation in abortion and birth control also support a policy of
coerced participation in euthanasia and assisted suicide.
V.3.3 Consistent with this, when Mr. Salte proposed
that the College adopt a policy on "ethical objection," he explicitly
associated assisted suicide with abortion, birth control, fetal sex
identification and genetic testing when indicating the potential scope of
the policy (V.2.4). After the Carter decision, he again
explicitly associated abortion and birth control with euthanasia and
physician assisted suicide (V.2.5).
V.4 Dissecting the disclaimer
V.4.1 The reasons offered to support the disclaimer are unsatisfactory.
V.4.2 In the first place, almost every one of the
principles that has been added to Section 1 of the revised policy has
already been used to support demands that physicians should be forced to
facilitate euthanasia and assisted suicide (Appendix "C"). Certainly,
arguments based on those principles are disputed. However, one would have to
be hopelessly naive, boundlessly optimistic or simply disingenuous to
suggest that the principles cannot or will not be used to
support coerced involvement in euthanasia and assisted suicide.
V.4.3 Second, when Mr. Salte proposed the coercive
policy in July, 2014, it was well known that the Supreme Court of Canada
might well legalize physician assisted suicide and euthanasia. That
possibility had become a widespread prediction by the time the committee
returned CR No. 1 to Council for approval in principle in January,
2015, but there was no reference to the "very grey" areas later discovered by Dr. Hayton. And Mr.
Salte continued to advocate for the coercive policy even after the ruling in
Carter.
V.4.4 Recall that, when Mr. Salte urged the registrars
of all Canadian Colleges to adopt a policy forcing objecting physicians to
refer for
morally contested procedures, he specifically noted its importance in
relation to physician-assisted suicide (V.2.3). He did
not then express concern that "the ethical implications of physician
assisted dying [had] not been fully explored." Why not?
V.4.5 Again, when Mr. Salte proposed that the College
adopt a policy on "ethical objection," he included assisted suicide among
the list of controversial services (V.2.4). He did not
then suggest that the College wait to see "whether there will be legislation
that addresses the issue and, if there will be, what the legislation will
state." Why not?
V.4.6 After the Supreme Court of Canada ordered the
legalization of euthanasia and physician assisted suicide, Mr. Salte stated
publicly that CR No. 1 was intended to apply "broadly," to all
areas of practice, not excluding physician assisted suicide and euthanasia.
He did not then worry that there was "considerable uncertainty associated with
physician-assisted death." He did not then say, "This is currently an issue
which is in a state of development." On the contrary, he defended the
proposition that physicians should be disciplined or fired if they refuse to
at least help to find someone willing to kill patients or help them commit
suicide (V.2.5, V.2.6). Why so
bold then, so cautious now?
V.5 Explaining the disclaimer
V.5.1 The timing of the shift in attitude suggests an answer. All of
the concerns about "ethical implications," "grey areas," "considerable
uncertainty," and lack of legislation arose suddenly in March, 2015 -
that is, just after Mr. Salte and the committee were confronted by
overwhelming opposition to CR No. 1.
V.5.2 The introduction of the disclaimer could be seen
as a mere tactical withdrawal: an attempt to secure passage of the policy,
at least in some form, by defusing opposition that has been amplified by the
pending legalization of assisted suicide and euthanasia. Supporters of
CR No. 1 may simply be prepared to wait, expecting to have an easier
time imposing a policy that will force physicians to do what they believe to
be wrong once physicians and the public have become as comfortable with
assisted suicide and euthanasia as they are with abortion and contraception.
V.5.3 On the other hand, a less Machiavellian
explanation is available. The disclaimer may indicate that committee members
have begun to realize that if the College can force physicians to do what
they believe to be wrong with respect to abortion and contraception, there
would seem to be no reason why the College should not also be able to force
physicians to do what they believe to be wrong with respect to killing
patients and helping them commit suicide. That would explain Mr. Salte’s
suggestion that the Council "may wish to consider whether there is something
different about physician assisted death that should result in it being
addressed differently than other issues of conscientious objection."22
V.6 Disposing of the disclaimer
V.6.1 Mr. Salte appears to be inviting College Council
to declare that objecting physicians need not facilitate euthanasia and
physician assisted suicide because killing patients is morally contentious,
but objecting physician must facilitate abortion, contraception, fetal sex
selection (and perhaps other procedures) because they are morally acceptable
and contrary views are erroneous.
V.6.2 Council should decline the invitation because
declarations of that kind are beyond its competence, and enacting policies
that give effect to such dogmatic positions would be an abuse of its
authority. For the same reasons, it would be unacceptable to propose a
policy to limit the exercise of freedom of conscience with respect to some
procedures or services and not others.
V.6.3 In view of V.2,
V.3. V.4 and
Appendix "B," it is unrealistic to believe that Conscientious
Refusal as revised will not be applied to physician administered
euthanasia and physician assisted suicide, either directly, after a certain
length of time, or indirectly, as a paradigm for further policy development.
V.6.4 Including the disclaimer in the policy is thus
misleading and ill-advised. If the College is determined to enact a policy
on conscientious refusal, it should ensure that the policy adopted is
sufficiently flexible to accommodate physicians who are unwilling to do what
they believe to be wrong, not excluding direct or indirect participation in
killing patients or helping them commit suicide. If Council is uncertain how
this can be done, it should reject Conscientious Refusal as revised
and postpone policy development until after the Carter decision
comes into force in 2016.
VI. Summary
VI.1 A public consultation that produced a very
significant return" produced no evidence that anyone in Saskatchewan has
ever been unable to access medical services because a physician has declined
to provide or refer for a procedure for reasons of conscience, or that the
health of anyone in Saskatchewan has ever been adversely affected because a
physician has declined to provide or refer for a procedure for reasons of
conscience.
VI.2 The revised policy has withdrawn the demand that
physicians unwilling to provide a service for reasons of conscience must
facilitate the procedure by referral to a colleague who will. This is
entirely satisfactory. It is also a tacit and significant admission that
compelling physicians to facilitate services to which they object for
reasons of conscience is an unacceptable assault on freedom of conscience.
The statement, "Objecting physicians should not be obligated to provide a
referral to a physician who will ultimately potentially provide the service"
should be included in the text of the policy itself.
VI.3 Conscientious Refusal as revised effectively
prohibits objecting physicians from communicating with their patients about
morally contested procedures. It presumes that, by virtue of moral
opposition to a service, a physician must be hopelessly prejudiced,
duplicitous, disrespectful and incapable of providing full and balanced
information. The suggested revision provides clear and convincing evidence
that the College committee continues to advance moral and ethical views
masked by the pretence of neutrality.
VI.4 The committee’s recommendation would have the
College control for or eliminate the exercise of bona fide moral judgement.
The College can only do that unfairly and inconsistently by an authoritarian
suppression of moral viewpoints selected arbitrarily, or because they are
unpopular. Such selective authoritarianism contradicts direction from the
Supreme Court of Canada that requires accommodation of different world
views.
VI.5 Physicians who, for reasons of conscience, are
unable or unwilling to provide patients with sufficient information to
satisfy the requirements of informed medical decision making must promptly
arrange for a patient to be seen by another physician or health care worker
who is able to do so.
VI.6 Physicians should inform patients of treatments or
services that they will not provide for reasons of conscience as soon as it
appears that a conflict is likely to arise. The same holds true for
notification of patients when a physician’s views change significantly.
VI.7 A physician who declines to recommend or provide
services or procedures for reasons of conscience must advise affected
patients that they may, if they wish, approach other physicians, heath care
workers or community organizations to obtain the services, and ensure that
they have sufficient information to do so.
VI.8 It is unrealistic to believe that a policy
concerning the exercise of freedom of conscience will not be applied to
euthanasia and assisted suicide. If the College is determined to enact a policy on conscientious
refusal, it should ensure that the policy adopted is sufficiently flexible
to accommodate physicians with respect to all procedures or services.
Otherwise, Council should reject Conscientious Refusal as revised
and postpone policy development until after the Carter decision
comes into force in 2016.
Notes
1. Salte BE.
Memorandum to Council re: Policy on Conscientious Objection, 9 March,
2015 (CPSS No. 38/15) p. 3.
2. Protection of Conscience Project,
Submission to the College of Physicians and Surgeons of Saskatchewan Re:
Conscientious Refusal, 5 March, 2015
3. Salte BE.
Memorandum to Council re: Draft Policy-
Conscientious Objection, 20 March, 2015 (CPSS No. 73/15) p. 10-17.
4. Salte BE.
Memorandum to Council re: Draft Policy-
Conscientious Objection, 23 March, 2015 (CPSS No. 75/15) p. 4-11.
5. Salte BE.
Memorandum to Council re: Draft Policy- Conscientious Objection, 20
March, 2015 (CPSS No. 73/15) p. 5.
6.
Salte BE.
Memorandum to Council re: Draft Policy-
Conscientious Objection, 20 March, 2015 (CPSS No. 73/15) p. 7
7. "The question of neutrality has been
profoundly obscured by the mistake of confusing neutrality with
objectivity... neutrality and objectivity are not the same... objectivity is
possible but neutrality is not. To be neutral, if that were possible, would
be to have no presuppositions whatsoever. To be objective is to have certain
presuppositions, along with the manners that allow us to keep faith with
them." Budziszewski J., "Handling Issues
of Conscience." The Newman Rambler, Vol. 3, No. 2, Spring/Summer 1999,
P. 4.
8.
R. v. Morgentaler (1988)1 S.C.R 30 (Supreme Court of Canada) p.
166. (Accessed 2015-02-26);
R. v. Salituro, [1991] 3 S.C.R. 654,
Québec (Curateur public) c. Syndicat national des employés de l'Hôpital
St-Ferdinand, [1996] 3 S.C.R. 211 (Accessed 2015-03-05).
9. Canadian Medical Association
Code of
Ethics (2004): "22. Make every reasonable effort to communicate
with your patients in such a way that information exchanged is understood."
(Accessed 2014-02-22)
10. Canadian Medical Association
Code of
Ethics (2004): "12. Inform your patient when your personal values
would influence the recommendation or practice of any medical procedure that
the patient needs or wants." (Accessed 2014-02-22)
11. Canadian Medical Association
Code of
Ethics (2004): "45. Recognize a responsibility to give generally
held opinions of the profession when interpreting scientific knowledge to
the public; when presenting an opinion that is contrary to the generally
held opinion of the profession, so indicate." (Accessed 2014-02-22)
12. Policy: Conscientious Refusal-2:
Scope. In Salte BE.
Memorandum to
Council re: Draft Policy, Conscientious Objection, 20 March, 2015
(CPSS No. 73/15) , p. 10-11,14-15.
13. Policy: Conscientious Refusal-2:
Scope. In Salte BE.
Memorandum to
Council re: Draft Policy, Conscientious Objection, 20 March, 2015
(CPSS No. 73/15) , p. 10-11,14-15.
14. Salte BE.
Memorandum to
Council re: Draft Policy, Conscientious Objection,, 20 March, 2015 (CPSS No. 73/15), p. 5.
15. Salte BE.
Memorandum to Council re: Policy on Conscientious Objection, 9 March, 2015 (CPSS No. 38/15) p. 12.
16. Professor Jocelyn Downie and Professor
Daniel Weinstock are members of the faculty of the "Conscience Research
Group" (CRG), the ulitmate source of the policy first proposed by Mr. Salte
(See Protection of Conscience Project,
Submission to the College of Physicians and Surgeons of Saskatchewan Re:
Conscientious Refusal, Appendices
"A"
and
"B."
With Udo Schuklenk and others, they were members of a Royal Society of
Canada panel of "experts" who recommended that health care workers unwilling
to provide euthanasia or assisted suicide should be compelled to refer
patients to someone who would do so. See 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). Referring to the Supreme Court of Canada
hearing in Carter, Shcuklenk noted the Project's joint intervention
asking the Court to "direct parliament to ensure that health care
professionals would not be forced to assist in dying if they had
conscientious objections." He commented, "I am not a fan of
conscientious objection rights anyway, so I hope the Court will ignore
this." Schuklenk U.
"Supreme Court of Canada heard arguments in Charter challenge to assisted
dying criminalisation." Udo Schuklenk's Ethx Blog, T, Thursday,
October 16, 2014 (Accessed 2015-02-22)
17.
Letter from Bryan Salte to the Registrars of
Colleges of Physicians and Surgeons in Canada. Redacted in Document
200/14, College of Physicians and Surgeons of Saskatchewan, Report to
Council from the Registrar, 31 July, 2014, p. 8.
18. Salte B.
Memorandum to Council re: Possible
Policy or Guideline - Physicians who have an ethical objection to provide
certain forms of medical services, 31 July, 2014 (CPSS No. 200/14).
19.
"Saskatchewan doctors could face discipline
over assisted suicide." Global News, 13 February, 2015
(Accessed 2015-05-30). Annotated transcription at Protection of Conscience
Project, Submission to the College of Physicians and Surgeons of
Saskatchewan, Re: Conscientious Refusal, Appendix "C": Interview of
Associate Registrar, College of Physicians and Surgeons of Saskatchewan Re:
CPSS Draft Policy Conscientious Refusal,
CI.2,
CI.3;
CIII.2 to
CIII.4,
CIV.1,
CV.1
20. Salte BE.
Memorandum to Council re: Policy on Conscientious Objection, 9 March, 2015 (CPSS No. 38/15) p. 9-10.
21. 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).
22. Salte BE.
Memorandum to Council re: Policy on Conscientious Objection, 9 March, 2015 (CPSS No. 38/15) p. 1.
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