Submission to the Canadian Medical Association

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Executive Summary

The CMA Code of Ethics Revision Task Force has proposed a substantial revision to the Association's Code of Ethics. The Project applauds the emphasis placed by the Task Force on the moral agency of both patients and physicians, on human dignity, and on the importance of integrity and freedom of conscience in medical practice.

However, the 2018 Revision adds a requirement quite inconsistent with that emphasis: that physicians provide a formal referral or initiate a transfer of care to facilitate procedures to which they object for reasons of conscience. This reverses the CMA's longstanding position against mandatory referral. It contradicts recently developed CMA policy, and it is inconsistent with a significant CMA position statement concerning freedom of conscience. Finally, it imposes a form of servitude that is offensive to human dignity, violates freedom of conscience and illicitly discriminates against physicians in a manner the CMA itself has rejected.

It is preferable to take a broad and principled approach that keeps the focus on the nature and importance of freedom of conscience, avoiding entanglement in controversies about the acceptability of morally contested procedures.  The Project proposes a serviceable stand-alone policy of this type that draws on past CMA statements, key elements of its submission to the CPSO on effective referral, and the revised CMA Medical Assistance in Dying policy. This ought to be fully acceptable to the Association, since the elements of the policy have already been considered and agreed upon.

Incidentally, the Project recommends deletion of a reference to torture incorporated into 2018 revision. Deleting the reference would not compromise patient interests nor detract from the revision, and would avoid potentially troublesome distractions.

TABLE OF CONTENTS

Executive Summary

Part I:          Seeking reconciliation

• Introduction
• Praise for the 2018 Revision
• Problematic elements
  • The codification of moral partisanship
  • Ethical incoherence
  • What is "necessary"?
  • Contradiction of CMA norms and policies
  • Servitude, not service
• Seeking reconciliation

Part II:        CMA against mandatory referral

• The first CMA "conscience clause"
• 1977-78: The first referral controversy
• No ethical obligation to do what is believed to be wrong
• 2006-2008: reaffirmation of the policy
• 1978-2018: forty years later, no ethical consensus
• 1978-2018: forty years later, no evidence
• Conclusion

Part III:      CMA: freedom of conscience

• 1988-2012: from abortion to euthanasia
• 2012-2014: 'neutrality' and conscience
• 2015: the Carter maelstrom
• 2016: The CMA and "effective referral"
• Conclusion

Part IV:      CMA Policy: Medical Assistance in Dying

• Physicians as moral agents
• Patient dignity
• Equality of patients and physicians
• Guidelines reflect the foundations

Part V:      Reconciling obligations

• Avoiding entanglement: the need for a broad and principled approach
• Avoiding authoritarian "neutrality"
• A stand-alone protection of conscience policy
• A stand-alone protection of conscience policy in the CMA's own words

Part VI:    In the CMA's words: a policy on physician freedom of conscience

• Introduction
• CMA Code of Ethics (2018)
• Supplementary Guidelines

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

• Introduction
• General
• Providing information to patients
• Exercising freedom of conscience
• No discrimination

Part VIII:    Postscript: torture

Appendix "A":   2004 Code and 2018 revision compared

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