Submission to the College of Physicians and Surgeons of
Saskatchewan
Re: Conscientious Objection
(5 August, 2015)
Appendix "C"
Conscientious Objection - 5. Physician
Obligations
Comment and Critque
Note:
This appendix contains three principal sections:
C1: A suggested alternative to Section 5 of
Conscientious Objection, presented as a whole;
C2: A side-by-side comparison of Conscientious
Objection with the Project alternative to identify the similarities and
differences, with references to explanations in C3;
C3: Commentary corresponding to the tables in
C2.
C1. 5. Obligations (Project alternative)
5.1 Taking on new patients
(To replace the 2nd last paragraph) Physicians must give notice of
religious, ethical or other conscientious convictions that influence their
recommendations or practice or prevent them from providing certain
procedures or services if it appears that a conflict is likely to arise in
relation to someone applying to be accepted as patient. In such
circumstances, the provisions of 5.3 (5) apply.
5.2 Providing information to patients
1. Physicians must provide patients with sufficient and
timely information to make them aware of relevant treatment options so that
they can make informed decisions about accepting or refusing medical
treatment and care. [Canadian Medical Association Code of Ethics
(2004) para. 211 ] [(CMA, CHA, CNA, CHAC- Joint Statement on Preventing
and Resolving Ethical Conflicts Involving Health Care Providers and Persons
Receiving Care (1999) I.42]
2. Sufficient information includes diagnosis, prognosis
and a balanced explanation of the benefits, burdens and risks associated
with each option. [Canadian Medical Association Code of Ethics
(2004) para. 211 ] [(CMA, CHA, CNA, CHAC- Joint Statement on Preventing
and Resolving Ethical Conflicts Involving Health Care Providers and Persons
Receiving Care (1999) I.72] [CPSS, Conscientious Objection (draft)]
3. Information is timely if it is provided as soon as
it will be of benefit to the patient. Timely information will enable
interventions based on informed decisions that are most likely to cure or
mitigate the patient's medical condition, prevent it from developing
further, or avoid interventions involving greater burdens or risks to the
patient.
4. Relevant treatment options include all legal and
clinically appropriate procedures, services or treatments that may have a
therapeutic benefit for the patient, whether or not they are publicly
funded, including the option of no treatment or treatments other than those
recommended by the physician. [Canadian Medical Association Code of
Ethics (2004) para. 233][CPSS,
Conscientious Objection
(draft)]
5. A physician whose medical opinion concerning
treatment options is not consistent with the general view of the medical
profession must disclose this to the patient. [Canadian Medical Association
Code of Ethics (2004) para.45]
6. The information must be responsive to the needs of
the patient and communicated respectfully and in a way likely to be
understood by the patient. Physicians must answer a patient's questions to
the best of their ability. [Canadian Medical Association Code of Ethics
(2004) para. 21, 221,5 ] [(CMA, CHA, CNA, CHAC- Joint Statement on
Preventing and Resolving Ethical Conflicts Involving Health Care Providers
and Persons Receiving Care (1999) I.42] [CPSS, Conscientious
Objection (draft)]
7. Physicians who are unable or unwilling to comply
with these requirements must promptly arrange for a patient to be seen by
another physician or health care worker who can do so.
5.3 Exercise of freedom of conscience and religion
1) To minimize inconvenience to patients and avoid
conflict, physicians should develop a plan to meet the requirements of
subsections 5.2 and 5.3 for services they are unwilling to provide for
reasons of conscience or religion.
2) In exercising freedom of conscience and religion,
physicians must adhere to the requirements of 5.2 (Providing information to
patients).
3) In general, and when providing information to
facilitate informed decision making, physicians must give patients
reasonable notice of religious, ethical or other conscientious convictions
that influence their recommendations or practice or prevent them from
providing certain procedures or services. Physicians must also give
reasonable notice to patients if their views change. [Canadian Medical
Association Code of Ethics (2004) para. 126][Canadian Medical
Association Code of Ethics (2004) para. 211 ] [(CMA, CHA, CNA, CHAC-
Joint Statement on Preventing and Resolving Ethical Conflicts Involving
Health Care Providers and Persons Receiving Care (1999) I.162]
4) Notice is reasonable if it is 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 prior to accepting someone as a patient,or when a
patient is accepted.
5) In complying with these requirements, physicians
should limit discussion related to their religious, ethical or moral
convictions to what is relevant to the patient's care and treatment,
reasonably necessary for providing an explanation, and responsive to the
patient's questions and concerns.
6) A physician who declines to recommend or provide
services or procedures for reasons of conscience or religion must advise
affected patients that they may seek the services elsewhere. Should the
patient do so, a physician must, upon request, transfer the care of the
patient or patient records to the physician or health care provider chosen
by the patient. [Canadian Medical Association Code of Ethics (2004)
para. 211] [(CMA, CHA, CNA, CHAC- Joint Statement on Preventing and
Resolving Ethical Conflicts Involving Health Care Providers and Persons
Receiving Care (1999) II.102]
7) In other cases, in response to a patient request, a
physician may respond in one of the following ways:
a) by providing a formal referral; or
b) by arranging for a transfer of care to another
physician; or
c) by providing contact information for someone who
is able to provide the service or procedure; or
d) by providing contact information for an agency or
organization that facilitates the service or procedure; or
e) by providing non-directive, non-selective
information that will facilitate patient contact with other physicians,
heath care workers or sources of information about the services being sought
by the patient.
8) In acting pursuant to (5) or
(6) above, a physician
must continue to provide other treatment or care until a transfer of care is
effected, unless the physician and patient agree to other arrangements.
[Canadian Medical Association Code of Ethics (2004) para.
197][Canadian Medical Association Code of Ethics (2004) para. 211]
[(CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving
Ethical Conflicts Involving Health Care Providers and Persons Receiving Care
(1999) I.16, II.112]
9) A physician unwilling or unable to comply with these
requirements must promptly arrange for a patient to be seen by another
physician or health care worker who can do so.
5.4 Necessary treatments to prevent harm to patients
1) Physicians must provide medical treatment that is
within their competence when a patient is likely to suffer serious harm if
the treatment is not immediately provided, or immediately arrange for the
patient to be seen by someone competent to provide the necessary treatment.
[Canadian Medical Association Code of Ethics (2004) para. 188]
2) Physicians who fail to provide medical treatment in
such circumstances may be civilly liable for negligence or malpractice,
whether or not the failure results from their moral or religious beliefs.
C2. Conscientious Objection
and Project alternative compared
Table A.
Note: To see the related comments, click on the link
(3.1, 3.2 etc.) in the middle column.
Conscientious Objection
5.1 Taking on new patients
|
C3# |
Project Alternative
5.1 Taking on
new patients
|
|
(2nd last paragraph) . . . Where physicians
know in advance that they will not provide specific services,
but will only arrange for the patient to obtain the necessary
information from another source or arrange for the patient to
obtain access to a medical treatment from another source (in
accordance with paragraphs 5.2 or 5.3 ), they must communicate
this fact as early as possible and preferably in advance of the
first appointment with an individual who wants to become their
patient.
|
3.1
|
Physicians must give notice of religious, ethical or other
conscientious convictions that influence their recommendations or
practice or prevent them from providing certain procedures or services
if it appears that a conflict is likely to arise in relation to someone
applying to be accepted as patient. In such circumstances, the
provisions of 5.3 (5) apply.
[From 5.3 Exercise of freedom of
conscience and religion]
5) In complying with these
requirements, physicians should limit discussion related to their
religious, ethical or moral convictions to what is relevant to the
patient's care and treatment, reasonably necessary for providing an
explanation, and responsive to the patient's questions and concerns.
|
|
(Last paragraph) The College
expects physicians to proactively maintain an effective plan
to meet the requirements of paragraph 5.2 and 5.3 for the
frequently requested services they are unwilling to provide.
|
3.2
|
[From 5.3 Exercise of freedom of
conscience and religion]
1) To minimize
inconvenience to patients and avoid conflict, physicians should
develop a plan to meet the requirements of subsections 5.2 and
5.3 for services they are unwilling to provide for reasons of
conscience or religion.
|
Table B.
Conscientious Objection
5.2 Providing information
to patients
|
C3# |
Project Alternative
5.2 Providing
information to patients
|
|
Physicians must provide their patients with full and balanced
health information required to make legally valid, informed
choices about medical treatment (e.g., diagnosis, prognosis, and
clinically appropriate treatment options, including the option
of no treatment or treatment other than that recommended by the
physician), even if the provision of such information conflicts
with the physician's deeply held and considered moral or
religious beliefs.
|
3.3
|
1. Physicians must provide patients with sufficient and timely
information to make them aware of relevant treatment options so that
they can make informed decisions about accepting or refusing medical
treatment and care.
2. Sufficient information includes diagnosis, prognosis and a
balanced explanation of the benefits, burdens and risks associated with
each option.
3. Information is timely if it is provided as soon as it will be of
benefit to the patient. Timely information will enable interventions
based on informed decisions that are most likely to cure or mitigate the
patient's medical condition, prevent it from developing further, or
avoid interventions involving greater burdens or risks to the patient.
4. Relevant treatment options include all legal and clinically
appropriate procedures, services or treatments that may have a
therapeutic benefit for the patient, whether or not they are publicly
funded, including the option of no treatment or treatments other than
those recommended by the physician.
5. A physician whose medical opinion concerning treatment options is
not consistent with the general view of the medical profession must
disclose this to the patient.
6. The information must be responsive to the needs of the patient and
communicated respectfully and in a way likely to be understood by the
patient. Physicians must answer a patient's questions to the best of
their ability.
7. Physicians who are unable or unwilling to comply with these
requirements must promptly arrange for a patient to be seen by another
physician or health care worker who can do so.
|
|
The obligation to inform patients may be met by
arranging for the patient to obtain the full and balanced
health information required to make a legally valid,
informed choice about medical treatment from another source,
provided that arrangement is made in a timely fashion and
the patient is able to obtain the information without undue
delay. That obligation will generally be met by arranging
for the patient to meet and discuss the choices of medical
treatment with another physician or health care provider who
is available and accessible and who can meet these
requirements. The physician has the obligation to ensure
that an arrangement which does not involve the patient
meeting and discussing choices of medical treatment with
another physician or health care provider is effective in
providing the information required by this paragraph.
|
3.4
|
[From 5.2 Providing information to
patients]
7. Physicians who are unable or unwilling
to comply with these requirements must promptly arrange for a
patient to be seen by another physician or health care worker
who can do so.
|
|
Physicians must not provide false, misleading,
intentionally confusing, coercive, or materially incomplete
information to their patients.
|
3.5
|
[From 5.2 Providing information
to patients]
1. Physicians must provide
patients with sufficient and timely information to make them
aware of relevant treatment options . .
2. Sufficient information includes diagnosis, prognosis and a
balanced explanation of the benefits, burdens and risks
associated with each option.
4. Relevant treatment options include all legal and
clinically appropriate procedures, services or treatments that
may have a therapeutic benefit for the patient, whether or not
they are publicly funded, including the option of no treatment
or treatments other than those recommended by the physician.
5. A physician whose medical opinion concerning treatment
options is not consistent with the general view of the medical
profession must disclose this to the patient.
|
|
All information must be communicated by the physician in
a way that is likely to be understood by the patient.
|
3.6
|
[From 5.2 Providing information
to patients]
6. The information must be
responsive to the needs of the patient and communicated
respectfully and in a way likely to be understood by the
patient. Physicians must answer a patient's questions to the
best of their ability.
|
|
While informing a patient, physicians must not
communicate or otherwise behave in a manner that is
demeaning to the patient or to the patient's beliefs,
lifestyle, choices, or values.
|
3.7
|
[From 5.2 Providing information
to patients]
6. The information must be
responsive to the needs of the patient and communicated
respectfully . . .
|
|
Physicians must not promote their own moral or religious
beliefs when interacting with a patient.
|
3.8
|
[From 5.3 Exercise of freedom of
conscience and religion]
5) In complying with
these requirements, physicians should limit discussion related
to their religious, ethical or moral convictions to what is
relevant to the patient's care and treatment, reasonably
necessary for providing an explanation, and responsive to the
patient's questions and concerns.
|
Table C.
Conscientious Objection
5.3 Exercise of freedom of
conscience and religion
|
C3# |
Project Alternative
5.3 Exercise of
freedom of conscience and religion
|
|
Physicians can decline to provide legally permissible and
publicly-funded health services if providing those services
violates their freedom of conscience. However, in such
situations, they must:
|
3.9
|
1) To minimize inconvenience to patients and avoid conflict,
physicians should develop a plan to meet the requirements of subsections
5.2 and 5.3 for services they are
unwilling to provide for reasons of conscience or religion.
2) In exercising freedom of conscience and religion, physicians must
adhere to the requirements of 5.2 (Providing
information to patients)
|
|
a) make an arrangement for the patient to obtain
the full and balanced health information required to make a
legally valid, informed choice about medical treatment as
outlined in paragraph 5.2; and,
|
3.10
|
3) In general, and when providing information to facilitate
informed decision making, physicians must give patients
reasonable notice of religious, ethical or other conscientious
convictions that influence their recommendations or practice or
prevent them from providing certain procedures or services.
Physicians must also give reasonable notice to patients if their
views change.
4) Notice is reasonable if it is 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 prior to
accepting someone as a patient, or when a patient is accepted.
|
|
|
3.11
|
5) In complying with these requirements, physicians should
limit discussion related to their religious, ethical or moral
convictions to what is relevant to the patient's care and
treatment, reasonably necessary for providing an explanation,
and responsive to the patient's questions and concerns.
|
|
b) make an arrangement that will allow the patient to
obtain access to the health service if the patient chooses.
|
3.12
|
6) A physician who declines to recommend or provide services
or procedures for reasons of conscience or religion must advise
affected patients that they may seek the services elsewhere.
Should the patient do so, a physician must, upon request,
transfer the care of the patient or patient records to the
physician or health care provider chosen by the patient.
|
|
Those obligations will generally be met by arranging for
the patient to meet with another physician or other health
care provider who is available and accessible and who can
either provide the health service or refer that patient to
another physician or health care provider who can provide
the health service.
|
3.13
|
7) In other cases, in response to a patient request, a
physician may respond in one of the following ways:
a) by providing a formal referral; or
b) by arranging for a transfer of care to another physician;
or
c) by providing contact information for someone who is able
to provide the service or procedure; or
d) by providing contact information for an agency or
organization that facilitates the service or procedure; or
e) by providing non-directive, non-selective information that
will facilitate patient contact with other physicians, heath
care workers or sources of information about the services being
sought by the patient.
|
|
|
3.14
|
8) In acting pursuant to (6) or (7) above, a physician
must continue to provide other treatment or care until a
transfer of care is effected, unless the physician and patient
agree to other arrangements.
|
|
If it is not possible to meet the obligations of
paragraphs a) or b), the physician must demonstrate why that
is not possible and what alternative methods to attempt to
meet those obligations will be provided.
|
3.15
|
9) A physician unwilling or unable to comply with these
requirements must promptly arrange for a patient to be seen by
another physician or health care worker who can do so.
|
|
This obligation does not prevent physicians from refusing
to arrange for the patient to obtain access to the health
service based upon the physician's clinical judgment that
the health service would not be clinically appropriate for
the patient. If the physician refuses to arrange for the
patient to obtain access to a health service based upon the
physician's clinical judgment, the physician should provide
the patient with a full explanation for the reason not to do
so.
|
3.16
|
|
|
While discussing a referral with a patient, physicians
must not communicate, or otherwise behave in a manner that
is demeaning to the patient or to the patient's beliefs,
lifestyle, choices, or values.
|
3.17
|
[From 5.2 Providing information
to patients]
6. The information must be
responsive to the needs of the patient and communicated
respectfully . . .
[From 5.3 Exercise of freedom of
conscience and religion]
5) In complying with
these requirements, physicians should limit discussion related
to their religious, ethical or moral convictions to what is
relevant to the patient's care and treatment, reasonably
necessary for providing an explanation, and responsive to the
patient's questions and concerns.
|
|
When physicians decline to provide a health service for
reasons having to do with their moral or religious beliefs, they
must continue to care for the patient until the new health care
provider assumes care of that patient. |
3.18
|
[From 5.3 Exercise of freedom of conscience and
religion]
8) In acting pursuant to (6) or (7) above, a
physician must continue to provide other treatment or care until a
transfer of care is effected, unless the physician and patient agree to
other arrangements. |
Table D.
Conscientious Objection
5.4 Necessary treatments to
prevent harm to patients
|
C3# |
Project Alternative
5.4 Necessary
treatments to prevent harm to patients
|
|
Physicians must provide medical treatment for a patient if
treatment is necessary to avoid harming the patient's health or
well-being. Accordingly:
a) Physicians must provide care in an emergency, where it is
necessary to prevent imminent harm, even if providing that
treatment conflicts with their conscience or religious beliefs.
b) When it is not possible to arrange for another physician
or health care provider to provide a necessary treatment without
causing a delay that would jeopardize the patient's health or
well-being, physicians must provide the necessary treatment even
if providing that treatment conflicts with their conscience or
religious beliefs.
Physicians must provide medical treatment for a patient
within the physician's competency where the patient's chosen
medical treatment must be provided within a limited time to be
effective and it is not reasonably possible to arrange for
another physician or health care provider to provide that
treatment.
|
3.19
|
1) Physicians must provide medical treatment that is within their
competence when a patient is likely to suffer serious harm if the
treatment is not immediately provided, or immediately arrange for the
patient to be seen by someone competent to provide the necessary
treatment.
2) Physicians who fail to provide or arrange for medical treatment in
such circumstances may be civilly liable for negligence or malpractice,
whether or not the failure results from their moral or religious
beliefs.
|
C3. Commentary corresponding to the
tables in C2
Table A
5.1 Taking on new patients
C3.1 It would be
improper for a physician to refuse to accept a patient because of race,
ethnic origin, religious beliefs, etc. However, conscientious objectors are
not concerned with the sex, marital status or "group status" of the patient.
They are concerned to avoid moral complicity in wrongdoing. Objections, if
they arise, are, for example, to abortion, even though only women can have
abortions: to premarital sex, even though only unmarried persons can have
premarital sex: to the amputation of healthy body parts, even though only
apotemnophiliacs are likely to request such surgery.
Since objections are specific to procedures or services, and simply
accepting a patient does not involve wrongdoing, it seems highly unlikely
that a physician would refuse to accept a patient for reasons of conscience
or religion.
It is unnecessary and unrealistic to require physicians to notify every
patient before or when the patient is accepted of all services that they
will not provide for reasons of conscience or religion. For example: there
would seem to be no reason for physicians opposed to contraception to notify
a 60 year old woman that they will not prescribe birth control pills. It
makes more sense to insist on notification when there is actually some
reason to believe that it is advisable to do so to avoid inconvenience to
the patient or conflict.
C3.2 It is
reasonable to expect that physicians will develop plans to minimize
inconvenience and conflict that might arise in relation to their refusal to
provide services for reasons of conscience or religion.
This would seem to be better addressed in the section of the policy
dealing with obligations related to the exercise of freedom of conscience
and religion, so the provision is found there in the Project alternative.
Table B
5.2 Providing information to patients
C3.3 Provisions in
this paragraph have been distributed among the 7 paragraphs in the Project
alternative, and somewhat modified.
In the Project alternative,
- the reference to "balanced health information" is
connected specifically to a balanced account of benefits, burdens and risks
associated with the various treatment options, which is its correct meaning;
- "full" information becomes "sufficient" information
in the Project alternative because, in reality, "full" information might
well be overwhelming and unhelpful. "Sufficient" is defined so as to capture
what was likely meant by "full";
- a specific requirement that information be "timely"
(with a definition) is added.
Note that the essential element of "timely" information is its benefit to
the patient. It is not always beneficial to present an "options menu" to a
patient at the first opportunity. In the case of a patient who has lost both
legs in a motor vehicle accident, it would probably not be beneficial to
present the options of assisted suicide and euthanasia the day after
surgery. Subject to the other elements in the definition of "timely," timing
must be left to the discretion of physicians.
The reference to physicians' beliefs is deleted in the Project
alternative because the provision of information in the manner indicated
here is expected of all physicians, and it has not been the experience of
the Project that objecting physicians are unwilling to provide information
sufficient to fulfil the requirements of informed medical decision-making.
Instead, the Project alternative proposes that physicians who are unable or
unwilling to provide information sufficient to fulfil the requirements of
informed medical decision-making must arrange for the patient to see someone
who can.
C3.4 Since the goal
in this situation is to provide timely information sufficient to ensure
informed medical decision making, the Project alternative recommends that
the patient be "promptly" directed to another physician or health care
worker. This avoids the need for the physician to ensure that a
non-physician/health care "source" provides the information as required.
C3.5 The
requirements in the Project alternative preclude the provision of false,
misleading, intentionally confusing, coercive, or materially incomplete
information and lack the offensive implications of the statement in
Conscientious Objection.
C3.6 The Project
alternative emphasizes the importance of ensuring that the information is
responsive to the needs of the patient.
C3.7 It is
sufficient to require respectful communication, which necessarily excludes
communication or conduct that is demeaning to the patient or to the
patient's beliefs, lifestyle, choices, or values.
Note that a patient may feel that his beliefs, lifestyle, choices or
values are demeaned for no other reason than that the physician refuses to
provide or facilitate a service because he believes it is wrong. However,
that cannot justify the suppression or restriction of physician freedom of
conscience.
C3.8 Granted that
physicians should not use clinical encounters as an opportunity for
proselytizing, some discussion of religious or moral issues may well be
necessary within the context of Conscientious Objection. The Project
alternative proposes practical guidelines that take this into account, while
accomplishing what was likely intended in Conscientious Objection.
Table C
5.3 Exercise of freedom of conscience and religion
C3.9 In this sub-section, the first paragraph of the
Project alternative, following Conscientious Objection, includes the
expectation that physicians will develop plans to minimize inconvenience and
the possibility of conflict.
The second paragraph sets out the expectation that physicians exercising
freedom of conscience and religion must provide patients with sufficient and
timely information concerning their medical care.
C3.10 Conscientious Objection, like
CR No. 2, clearly
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. Accordingly, the policy demands
that such untrustworthy physicians must be forced to refer patients seeking
a morally contested service to a purportedly "unbiased" party who can be
trusted to act honestly.
As the Project pointed out in Project Submission-CR No. 2, this is not an attack
on freedom of conscience. It is, however, an attack on the character and
competence of objecting physicians. Solely on the basis of their beliefs, it
implies that they are unacceptably biased and effectively prohibits
objecting physicians from communicating with their patients about morally
contested procedures.
The assumption underlying the demand is that a physician who has a moral
viewpoint is incapable of properly communicating with a patient. But all
physicians have moral viewpoints. To be against euthanasia is to have a
moral viewpoint; to be in favour of euthanasia is to have a moral viewpoint.
Conscientious Objection simply exchanges one kind of 'bias' for another.
To be fair and consistent, the College 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.
Even then, however, the purported 'problem' remains. Such a policy would
do 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.
However, this would be ludicrous. 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.
The solution proposed in the Project alternative is simple. All
physicians should be expected to to provide information sufficient to fulfil
the requirements of informed medical decision-making. When applicable, and
in accordance with the CMA Code of Ethics, physicians must disclose and give
reasonable notice of religious, ethical or other conscientious convictions
that influence their recommendations or practice or prevent them from
providing certain procedures or services.
Only physicians who are unable or unwilling to do this should be required
to refer patients to a colleague or health care worker who can do so.
C3.11 As noted in
C3.8, physicians should not use
clinical encounters as an opportunity for proselytizing, but some discussion
of religious or moral issues may well be necessary within the context of Conscientious Objection. The Project alternative proposes practical
guidelines that take this into account.
C3.12 A requirement that an objecting physician must
"make an arrangement that will allow the patient to obtain access" to a
morally contested service amounts to a demand that the physician help the
patient to do what the physician believes to be wrong. This is unacceptable
because it nullifies freedom of conscience.
The Project alternative adopts the language and approach of a resolution
at the 1971 CMA General Council concerning abortion:
4. That faced with a request for an abortion, a
physician whose moral or religious beliefs prevent him from recommending
and/or performing this procedure should so inform the patient so that she
may consult another physician.9 (Emphasis added)
The expectation that an objecting physician should advise patients that
they can see a different physician or seek the service elsewhere conforms to
the spirit of the motion and is respectful of patient autonomy. The transfer
of records pursuant to a patient-initiated transfer of care does not, in the
Project's experience, present a problem for objecting physicians. A
patient-initiated transfer of care is the procedure used to accommodate
objecting physicians in jurisdictions where assisted suicide and/or
euthanasia are legal.
C3.13 A patient may not initiate a transfer of care,
but may ask the objecting physician for other assistance. It is important to
recognize that the response of objecting physicians will vary according to
the beliefs and moral reasoning of the physician and the particular facts of
each case. Hence, the Project alternative offers physicians a choice from
among a range of responses that do not obstruct patient access to services.
"Non-directive, non-selective information" refers to what is sometimes
called "generic" or "non-specific" information that a patient can use to get
further information about how or where to obtain a morally contested
service, the provision of which is not perceived by objecting physicians to
make them morally culpable participants in what they believe to be
wrongdoing.
C3.14 Like Conscientious Objection, the Project
alternative expects an objecting physician to provide continuity of care,
but, unlike Conscientious Objection, specifies that this does not include
the morally contested procedure. The alternative also recognizes that the
patient and physician may agree to other arrangements.
C3.15 Only physicians unwilling or unable to comply
with these requirements are required by the Project alternative to promptly
arrange for the patient to be seen by a physician or health care worker who
can comply with them.
C3.16 The Project alternative makes no reference to clinical judgement
since there does not appear to be any dispute that physicians cannot be
expected to provide or facilitate procedures or services contrary to their
clinical judgement.
C3.17 The Project alternative includes an expectation
of respectful communication. As noted in C3.7, a patient may feel that his
beliefs, lifestyle, choices or values are demeaned for no other reason than
that the physician refuses to provide or facilitate a service because he
believes it is wrong. However, that cannot justify the suppression or
restriction of physician freedom of conscience.
C3.18 Like Conscientious Objection, the Project
alternative expects an objecting physician to provide continuity of care,
but, unlike Conscientious Objection, specifies that this does not include
the morally contested procedure. The alternative also recognizes that the
patient and physician may agree to other arrangements.
Table D
5.4 Necessary treatments to prevent harm to patients.
C3.19 Activists determined to suppress physician freedom of conscience
frequently employ vague terminology for that purpose, such as purported
risks to "health" or "well-being" and the tendentious classification of
morally contested procedures like euthanasia as "medical treatment."
To
avoid or at least minimize these problems, the Project alternative uses
simplified and more restricted terminology that is consistent with existing
ethical and legal expectations.
The Project has not encountered
physicians unwilling to provide medical treatment that is urgently needed to
prevent serious harm to patients. However, in the event that such an
allegation is made, the issues are likely to be contested and complex.
Hence, the Project alternative simply cautions physicians to be mindful of
their civil liability for malpractice or negligence.
Notes
1. Canadian Medical Association
Code of Ethics
(2004): "21. Provide your patients with the information they need to make
informed decisions about their medical care, and answer their questions to the
best of your ability." (Accessed 2015-08-07)
2.
Joint Statement on Preventing and Resolving
Ethical Conflicts Involving Health Care Providers and Persons Receiving Care
(1999) (Canadian Medical Association, Canadian Healthcare Association,
Canadian Nurses' Association, Catholic Health Association of Canada)
3. Canadian Medical Association
Code of Ethics
(2004): "23. Recommend only those diagnostic and therapeutic services that
you consider to be beneficial to your patient or to others. . ." (Accessed 2015-08-07)
4. 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 2015-08-07)
5.
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 2015-08-07)
6. 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 2015-08-07)
7.
Canadian Medical Association
Code of Ethics
(2004): "19. Having accepted professional responsibility for a patient,
continue to provide services until they are no longer required or wanted;
until another suitable physician has assumed responsibility for the patient;
or until the patient has been given reasonable notice that you intend to
terminate the relationship." (Accessed 2015-08-07)
8. Canadian Medical Association
Code of Ethics
(2004): "18. Provide whatever appropriate assistance you can to any person
with an urgent need for medical care. "(Accessed 2015-08-07)
9.
"Canadian Medical Association 104th
Annual Meeting, Halifax, Nova Scotia." CMAJ Volume 104(12) 1132-1134, June
19, 1971
(Accessed 2015-06-17).
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