Submission to the College of Physicians and Surgeons of Alberta

Full Text

Abstract

The Protection of Conscience Project is a non-profit, non-denominational initiative that advocates for freedom of conscience among health care workers. It does not take a position on the acceptability of morally contested procedures. Parts of the draft standard Conscientious Objection relevant to Project advocacy are the preamble, two sections that mention “effective referral” and an overbroad prohibition of practitioners’ expression.

The title and preamble focus on conscientious objection, which seems to imply that conscience is extrinsic to medicine and intrudes upon it only in relation to service refusal. On the contrary: conscience and moral/ethical judgement are integral to medical practice. The title and preamble should acknowledge this to provide the proper context for CPSA expectations.

The preamble implies that the CPSA will adjudicate between physician and patient moral/ethical beliefs, a task arguably beyond its authority and competence. It should, instead, focus on respectful management of patient requests for services practitioners decline to provide.

Two sections mention “effective referral” for contested services, but the standard does not require it, nor define the term. A policy of “effective referral” would contradict the CPSA’s longstanding position, notwithstanding contrary assertions by some CPSA officials since 2009. The CMA has opposed such a policy for over 50 years.

Even academics who advocate for “effective referral” admit that refusal to refer for immoral/unethical procedures is not only rationally defensible, but obligatory. Effective referral policies adopted in Ontario and Nova Scotia appear to originate in a model policy drafted for morally partisan purposes. However, incorporating moral partisanship into the regulation of medical practice is unacceptable. The references to “effective referral” thus invite confusion and controversy. They are also unnecessary.

The first section of concern should be revised to require practitioners to plan how to comply with the standard (which does not require “effective referral”). That done, the second section of concern becomes redundant and can be deleted.

The absolute prohibition of the expression of practitioner moral judgement is overbroad. It conflicts with requirements in  the standard and CMA Code of Ethics and impedes physician-patient communication, concordance and transparency. It is also open to partisan misuse.  A more specific provision is already in force in CPSA standards and is preferable.

TABLE OF CONTENTS

I.    Introduction

II.    Outline of this submission

III.    Purpose of the standard

• Recommendation

IV.    Effective referral

•  Definition
•  Mandatory effective referral contradicts longstanding CPSA policy
•  Mandatory effective referral contradicts CMA policy
•  Effective referral, complicity and moral partisanship
•  Reference to effective referral not needed
•  Recommendation

V.    Delayed effective referral

•  Subjective and redundant
•  Recommendation

VI.    Expression of moral judgement

•  Expectations are in conflict
•   Expectation contradicts CMA Code of Ethics
•  Expectation impedes patient enquiries
•  Expectation seems redundant
•  Expectation invites misuse
•  Recommendation

VII.    Conscience and medical practice

• Medicine: a moral enterprise
• Recommendations

Appendix “A”: Conscience in medical practice

• Morality in the secular public square
• Medicine: a moral enterprise

Appendix “B”: CPSA and referral for morally contested services (1991–2020)

Appendix “C”:  Recommended Changes to draft standard Conscientious Objection