Appendix "B"

Full Text

Introduction

B.1    It seems to be common ground that physicians have an ethical obligation to 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. It is also agreed that information must be communicated respectfully, in a way likely to be understood by the patient, and in a manner that does not provoke justifiable concern about "preaching" or attempting to "convert" the patient to his opinion. Finally, it is agreed that, whenever possible, physicians should inform patients, in advance, of treatments or services that they will not provide for reasons of conscience.

B.2    Some further clarifications are needed.

Clarifications

Sufficient information

B.3    The requirement that physicians will provide patients with sufficient information in comprehensible form necessarily precludes statements that are "false, misleading, intentionally confusing, coercive or materially incomplete."

Relevant options

B.4    Relevant options will, of necessity, be legal and clinically appropriate. It does not follow that every possible legal and clinically appropriate option must be presented at the first opportunity, in the absence of questions or other indications from the patient.

B.5    For example, while woman who is pregnant might want an abortion or might want to put the child up for adoption, it would be insensitive, when confirming a diagnosis of pregnancy, to say, "You can have the child, put it up for adoption or have an abortion. Which would you prefer?" That would be College-centred practice, not patient-centred practice.

B.6    Similarly, it would be insensitive, when advising a patient of a diagnosis of paraplegia, to present the relevant treatment options of euthanasia or assisted suicide, even though he has become legally entitled to the procedures under the terms of Carter.

Disclosure

B.7    The physician must disclose whether or not his religious, ethical or other conscientious convictions influence his recommendations or practice or prevent him from providing certain procedures or services.1 If medical judgement rather than moral/religious conviction is his primary consideration, it is still prudent to disclose pertinent religious or moral beliefs.2 The reason for this is that the patient is entitled to be apprised of non-medical factors that may influence a physician’s medical judgement and recommendations. The patient is also entitled to know whether or not the physician’s medical evaluation of the contraceptive(s) in question is consistent with the general view of the medical profession.3

B.8    Disclosure and discussion related to it ought to be limited to what is relevant to the patient’s care and treatment. This should not be interpreted so strictly as to prevent a dialogue that is responsive to the needs of the patient.

Advance notice

B.9    Questions sometime arise about when such disclosures should be made. Holly Fernandez-Lynch insists that physicians fully disclose their objections to patients when they first accept them, reiterate them if they become relevant to treatment options, and notify patients if their views change.4

B.10    However, inflexible notification protocols do not serve the interests of either patients or physicians. For example: it would probably be unnecessary for a physician who accepts a 55 year old single woman as a patient to begin their professional relationship by disclosing objections to abortion, and it could well be unsettling for the patient if her medical history includes abortion. And, while it is possible that the woman might, six months after being accepted as a patient, ask for an embryo transplant, it does not follow that the mere possibility of such a request imposes a duty on the physician to disclose moral objections to artificial reproduction at their first consultation.

B.11    Similarly, it would likely be imprudent for a physician whose patient has just become paraplegic to give notice of an objection to euthanasia and assisted suicide simply because the patient has become legally entitled to the procedures under the terms of Carter.

B.12    Interests of patients and physicians are better served by open and continuing communication. On the part of the physician, this involves a special responsibility to be attentive to the spoken and unspoken language of the patient, and to respond in a caring and truthful manner. Within this context, it is reasonable to suggest that a physician should disclose his position when it would be apparent to a reasonable and prudent person that a conflict is likely to arise concerning treatments or services he declines to provide, erring on the side of sooner rather than later. In many cases - but not all - this may, indeed, be when a patient is accepted. The same holds true for notification of patients when a physician’s views change significantly.

Respectful/non-demeaning communication

B.13    The requirement that physicians will be respectful in communication necessarily precludes communication or behaviour that demeans the patient or the patient’s beliefs, lifestyle, choices or values. However, when a physician complies with disclosure requirements (B.7), patients will likely realize that a physician believes that a service or procedure is immoral. They may thus "feel judged" or "demeaned" by the physician, even if the physician’s judgement pertains to the morality of the procedure rather than the personal culpability of the patient. Physicians should not be harassed or disciplined because they have complied with disclosure requirements and the patient resents or is angered by their beliefs.

Notes

1.  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)

2.  Guidelines typically require disclosure when a recommendation or practice is or would likely be influenced by a belief. However, a physician’s decision or recommendation may be justified solely on medical grounds without reference to beliefs. The practical difficulty in a practice and disciplinary environment hostile to religious belief is that a failure to disclose a belief may invite the adverse inference that the physician failed to disclose beliefs that were ‘really’ shaping his decision making, especially if the medical grounds are contested by establishment opinion.

3.  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)

4.  Fernandez-Lynch H. Conflicts of Conscience in Health Care: An Institutional Compromise. Cambridge, Mass.: The MIT Press, 2008, p. 217-219, 222

Prev | Next