Part VII.    CMA Plus: physician exercise of freedom of conscience

Introduction

VII.1    In Part VI a protection of conscience policy was proposed using almost entirely the CMA’s words. In this Part a more comprehensive policy is offered, based largely on CMA sources.

General

VII.2    It is in a patient's best interests and in the public interest for physicians to act as moral agents, and not as technicians or service providers devoid of moral judgement. While physicians must act in accordance with their conscientious convictions or moral commitments, they must always demonstrate respect for their patients by responding to their enquiries, requests or needs by providing information and appropriate support.

Supporting sources:

- Canadian Medical Association, Submission to the College of Physicians and Surgeons of Ontario (16 January, 2016)1

- Canadian Medical Association Code of Ethics (2018 Revision), C2 (App "A" Ref 049; + Ref 017, 019, 020, 037)

- Canadian Medical Association, Induced Abortion (1988)2

- Canadian Medical Association, Medical Assistance in Dying (2017)3,4,5,6

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)7, 8

Providing information to patients*

VII.3    Physicians must provide patients with sufficient and timely information, responsive to their needs or enquiries, to make them aware of relevant treatment options so that they can make informed decisions about accepting or refusing medical treatment and care.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) (App "A" C-IntroF, Ref 057, C8 Ref 063)

- Canadian Medical Association Code of Ethics (2004) para. 219

- Canadian Medical Association, Medical Assistance in Dying (2017)10

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)11,12

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Disclosure of information; Standard of disclosure.13

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.414

VII.4    Sufficient information is that which a reasonable patient in the place of the patient would want to have, including diagnosis, prognosis and a balanced explanation of the benefits, burdens and risks associated with each option.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) (App "A" C8 Ref 063)

- Canadian Medical Association Code of Ethics (2004) para. 219

- Canadian Medical Association, Medical Assistance in Dying (2017)10

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)11,12

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Standard of disclosure.13

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.714

VII.5    Information is timely if it 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.

VII.6    Relevant treatment options include all legal and clinically appropriate procedures/interventions/services 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.

Supporting sources:

- Canadian Medical Association Code of Ethics (2004) para. 2315

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Some practical considerations about informed consent (4, 5)13

VII.7    Physicians whose medical opinion concerning a procedure/intervention/service  is not consistent with the general view of the medical profession must disclose this to the patient.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) C31 (App "A" Ref 102)

- Canadian Medical Association Code of Ethics (2004) para. 4516

VII.8    The information provided must be 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.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) C4, (App "A" Ref 052)

- Canadian Medical Association Code of Ethics (2004) para. 21,9 2217

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Patient Comprehension13

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.414

VII.9    Physicians who are unable or unwilling to provide this information must promptly arrange for a patient to be seen by another physician or health care worker who can do so.

Exercising freedom of conscience

VII.10    In general, and when providing information to facilitate informed decision making, physicians must give reasonable notice to patients* of religious, ethical or other conscientious convictions that influence their recommendations or practice or prevent them from providing certain procedures/interventions/services. Physicians must also give reasonable notice to patients if their views change.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision), C3 (App "A" Ref 050)

- Canadian Medical Association Code of Ethics (2004) para. 12,18 219

- Canadian Medical Association, Induced Abortion (1988):19

- Canadian Medical Association, Medical Assistance in Dying (2017)20

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.1614

VII.11    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 procedures/interventions/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.

VII.12    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.

VII.13    Physicians who decline to recommend or provide a procedure/intervention/service for reasons of conscience or religion are not required to provide it, or to otherwise participate in it, or to refer or direct the patient to a physician or a medical administrator who will provide it, or to arrange a transfer for care for that purpose.  However, they must advise affected patients that they may seek the procedure/intervention/service elsewhere, and provide information about how to find other physicians or health care providers. Should the patient identify an alternative physician or provider, physicians must, upon the patient's request, effect a transfer of care or patient records to the physician or provider chosen by the patient. 

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) (App "A" Ref 051)

- Canadian Medical Association Code of Ethics (2004) para. 219

- Canadian Medical Association, Medical Assistance in Dying (2017)21,22

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)8

-  CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) II.1014

VII.14    A physician's response under VII.13 must be timely. Timely responses 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.

VII.15    In acting pursuant to VII.13, physicians must continue to provide other treatment or care until a transfer of care is effected, unless the physician and patient agree to other arrangements.

Supporting sources:

- Canadian Medical Association Code of Ethics (2004) para. 1923

- Canadian Medical Association, Medical Assistance in Dying (2017)22

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.16, II.1114

VII.16    Physicians who provide medical services in a health care facility must give reasonable notice to a medical administrator of the facility if religious, ethical or other conscientious convictions prevent them from providing certain procedures/interventions/services that are or are likely to be provided in the facility. In many cases - but not all - this may be when the physician begins to provide medical services at the facility.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)24

VII.17    Physicians must not impede or block access to procedures/interventions/services to which they objection, nor make acceptance or retention of patients conditional upon their agreement not to request such procedures/interventions/services.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)19

No discrimination

VII.18    To enable physicians to adhere to such moral commitments without causing undue delay for patients requesting procedures/interventions/services, health systems will need to implement  mechanisms that allow patients to easily obtain direct access to them.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)25

VII.19    It is a responsibility of the community to ensure access, rather than placing the burden of finding services solely on individual physicians or patients.

Supporting sources:

- Canadian Medical Association, Submission to the College of Physicians and Surgeons of Ontario (16 January, 2016) 26

VII.20    Physicians' general employment or contract opportunities should not be influenced by their conscientious decisions to participate in, or not participate in, the delivery of procedures/interventions/services.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)27

- Canadian Medical Association, Induced Abortion (1988)

VII.21   Learners must be free to follow their conscience without risk to their evaluations and training advancement.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)28

- Canadian Medical Association, Induced Abortion (1988)29

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