Submission to the College of Physicians and Surgeons of Ontario
Re: Professional Obligations and Human Rights

Appendix "A"

Recommended General Policy

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Conscience, Religion, Clinical Judgement and Access to Services

Introduction

To minimize inconvenience to patients and avoid conflict, physicians should develop a plan to respond to requests for services they are unwilling to provide for reasons of conscience, religion or clinical judgement in accordance with this policy. [POHR, para. 16]

Definitions

"health care personnel" and "health care provider" include a member of a profession included in Schedule 1 of the Regulated Health Professions Act, 1991, S.O. 1991, c. 18.

"patient" includes persons seeking to be accepted as patients and persons lawfully designated to make a decision on the care to be provided to patients unable to express a decision.

A1.    General

A1.1    Physicians may encounter patients who are isolated or burdened by illness, physical or mental disability, language barriers, etc. and unable to connect with health care personnel or obtain medical treatment or other necessary services. Patients so debilitated or circumstantially handicapped are clearly at risk. 

A1.2    In all such cases, physicians should connect the patient to a responsible and reliable person who can address problems of isolation and neglect, help patients overcome circumstantial handicaps and enable them to obtain necessary assistance and navigate the health care system.  The helper could be a family member, friend, social worker, outreach worker, etc.

A2.    Notice

A2.1    Physicians must give reasonable and timely notice to patients of religious, ethical or other conscientious convictions that influence their recommendations or practice or prevent them from providing certain procedures or services so that patients may consult or seek services from other health care personnel. Physicians must also give reasonable notice to patients if their views change.52,53 [POHR, para. 9, 10]

a)    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. [POHR, para. 9,10]

b)    Notice is timely if it is provided as soon as it will be of benefit to the patient. Timely notice 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. [POHR, para. 9, 14(a), (b)]

c)    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. Physicians must not criticize or denigrate the beliefs, lifestyle, identity, or characteristics of patients. This should not be understood to preclude respectful discussion of beliefs or habits that may adversely affect a patient's health. [POHR, para. 11]

A2.2    Physicians who provide medical services in a health care facility must give reasonable notice to the facility of religious, ethical or other conscientious convictions that prevent them from providing procedures or 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. [POHR, note 3]

A3.    Informed decision making

A3.1    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 treatment or services.54,55,56,57 [POHR, para. 9, 12, 13]

a) 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.58,59,60,61[POHR, para. 12, 13]

b) 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.[POHR, para. 9, 14(a), (b)]

c) 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.62,63 [POHR, para. 9, 12, 13]

d) Physicians whose medical opinion concerning treatment options is not consistent with the general view of the medical profession must disclose this to the patient.64

e) The information provided 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.65,66,67,68 [POHR, para. 10]

f) 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. [POHR, para. 9]

A4.    Declining to provide services

A4.1    Physicians who decline to recommend or provide services or procedures for reasons of conscience, religion or clinical judgement must advise affected patients that they may seek the services elsewhere and provide information about how to contact other service providers. [POHR, para. 9, 15] ,

A4.2    If the patient appears to be unable to contact other service providers without assistance, physicians must ensure that the patient is connected with a family member or other reliable and responsible person who can assist [See A1.] [POHR, para. 9, 14, 15]

A4.3    When appropriate, physicians must communicate to a person in authority a patient's request for a complete transfer of care so that the person in authority can facilitate the transfer; [POHR, para. 9, 14, 15]

A4.4    Physicians must, upon request by a patient or person in authority, transfer the care of the patient or patient records to a physician or health care provider chosen by the patient.69,70 [POHR, para. 9, 14, 15]

A4.5    In addition, upon a patient’s request or enquiry, physicians may, if consistent with their conscientious convictions and clinical judgement,

a) arrange for the patient to be seen by a someone able and willing to provide the service; or

b) arrange for a transfer of care to health care personnel willing to provide the service; or

c) provide contact information for a person, agency or organization that provides or facilitates the service; or

d) enable patient contact with health care personnel or services in the community or in institutional settings who will ensure that the patient has access to all available treatment options, including services the physician declines to provide.[POHR, para. 9, 14, 15]

A4.6    Physicians unwilling or unable to comply with these requirements must promptly arrange for a patient to be seen by a physician or other health care provider who can do so. [POHR, para. 9, 14, 15]

A5.    Continuity of care

A5.1    Physicians must continue to provide services unrelated to the services they decline to provide unless a physician and patient agree to other arrangements.71,72

A6.    Non-abandonment

A6.1    When a patient is imminently likely to suffer death or permanent, serious physical injury if an intervention is not immediately provided, physicians must

a) provide the intervention if it is within their competence and no competent and willing health care personnel are available; or

b) immediately arrange for available, competent and willing health care personnel to provide the intervention, unless the intervention is facilitated by a service or procedure provided by health care personnel deliberately causing the death or serious permanent injury of another person.73 [POHR, para. 17]

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Notes

52.    Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses’ Association, Catholic Health Association of Canada, "Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care" (1999), Protection of Conscience Project (website) [Joint Statement] at I.16.

53.    CMA Code, supra note 38 at para. 4.

54.    Joint Statement, supra note 52 at I

55.    CMA Code, supra note 38 at para. 6, 11.

56.    CMPA: Consent, supra note 41.

57.    Canadian Medical Association, "Principles-based Recommendations for a Canadian Approach to Assisted Dying (January, 2016)", CMA (website) [CMA Recommendations], at 5.2, online:

58.    Joint Statement, supra note 52 at I

59.    CMA Code, supra note 38 at 6, 11.

60.    CMPA: Consent, supra note 41, Standard of disclosure; Some practical considerations.

61.    CMA Recommendations, supra note 57 at 1.2, 5.2.

62.    CMA Code, supra note 38 at para. 11.

63.    CMPA: Consent, supra note 41, Standard of disclosure; Some practical considerations.

64.    CMA Code, supra note 38 at para. 41.

65.    Joint Statement, supra note 52 at I.4.

66.    CMA Code, supra note 38 at para. 5, 11, 14.

67.    CMPA: Consent, supra note 41, Patient comprehension.

68.    CMA Recommendations, supra note 57, Foundational Principle (10).

69.    Joint Statement, supra note 52 at II

70.    CMA Recommendations, supra note 57 at 5.2.

71.    Joint Statement, supra note 52 at I.16, II.11.

72.    CMA Code, supra note 38 at para. 2.

73.    CMA Code, supra note 38 at para. 8.