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Protection of Conscience Project

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Service, not Servitude
Background

"NO MORE CHRISTIAN DOCTORS"

Part 2: Medical judgement and professional ethical concerns


"I thought that was very weird."

The patient who said that she owed her life to the physician whom others were calling a disgusting, incompetent, unethical jerk considered him an excellent doctor. However, she was as puzzled as the crusading Facebookers by his refusal to prescribe contraceptives. She understood it to be related to his religious views, but it was, she thought, "very weird." However, having had a hysterectomy, she was not concerned about it and did not pursue it further.

Her reaction is hardly surprising.

The contraceptive culture

The birth control pill hit the market in about 1960 and became increasingly available as time went on. The advent of "the pill" was soon followed by an exponential increase in out-of-wedlock births and eventually by legalization of abortion, from which point the number of abortions also dramatically increased. (See Appendix "D"). Despite the fact that medical professionals involved in family planning had long known that contraception was associated with abortion rates,1 the demand for abortion following legalization caught the medical establishment off guard.2 It appears that many attributed the increase to the surfacing of patients who would otherwise have sought clandestine abortions.3

In any case, the continuing escalation of out-of-wedlock births and demands for abortion reinforced the establishment view that these problems could only be solved by the wider use of contraception. Hence, the pharmaceutical industry and medical establishments in the developed world have made a variety of contraceptives increasingly available and have marketed them so aggressively that most people are unaware that there are any alternatives. In fact, most people have been convinced that a failure to use manufactured contraceptives of some kind is highly irresponsible. In addition, the social progress made by women in the last decades, especially their greater participation the job market, is widely attributed to their use of manufactured contraceptives.

As a result, abortion is now widely viewed and officially recognized as a 'backup' for failed contraception, and both have been linked in many minds to the social and economic well-being of women,4 even as many people continue to advocate contraception because they claim it reduces abortion.

Challenging the culture

The consequence of all of this is that physicians or other health care workers who object to prescribing or dispensing contraceptives for reasons of conscience face an enormous challenge. Many people conclude that they are not only ignorant of the facts of life, so to speak, but also medically or scientifically ignorant and profoundly disrespectful of women. This largely explains the surprise of the young woman who had to drive around the block for her birth control pills and the vehement reaction of the Facebook crusaders. By and large, they have grown up in a culture shaped by the widespread and unquestioning use of manufactured contraceptives. They instinctively perceive any contrary viewpoint to be "very weird" - or worse.

This kind of insular upbringing affects not only patients, but colleagues, physician regulators, government officials, bureaucrats, lawyers and judges, many of whom may be called upon to respond to complaints about an objecting physician. They have no difficulty understanding that reasonable people may have moral or ethical objections to abortion, euthanasia, or the amputation of healthy body parts.  However, even the fairest and most well-intentioned of them may well be mystified when faced with a physician who challenges the acceptability of contraception. One might as well ask perennial desert dwellers for an opinion about what kind of snow is best suited for building igloos.

Introducing a different perspective

This affects the approach of the Protection of Conscience Project in responding to the attacks being made on the three physicians in Ottawa. The Project does not take a position on the morality of services or procedures, but focuses, instead, on supporting freedom of conscience. This works well enough when people appreciate the basis for the position taken by objectors on familiar contentious subjects, like assisted suicide.

However, this is insufficient when, as in the present case, an attack on freedom of conscience resembles a religious crusade, when, with supreme self-righteous confidence, people demand absolute conformity to dogmas like "the right to choose" or "secularism," when they urge the professional excommunication of dissenting physicians, and when they treat unfamiliar world-views as dangerous heresies that must be driven from the public square.

In this situation, what is needed at the outset is not a call to arms, but an invitation to consider a different perspective. That is the purpose of this part of the Project's response. The goal here is not to convince others that an objector's viewpoint is correct, but to demonstrate that it is sufficiently plausible to warrant the deference customarily accorded in liberal democracies to thoughtful and considered dissent.

In the beginning

The original story about the young woman who had to drive around the block for her birth control pills began with a letter, and the story that displaced the original and became an epic of sorts began with the same letter. Now that the dust of the crusading host has abated somewhat, we can return to the beginning of both stories and read the letter once again: this time, attentively.

The physician states that the only kind of birth control he provides is Natural Family Planning, and that he will not prescribe or refer for artificial contraception, abortion, vasectomies, or the morning after pill. He offers three reasons for his practice, not one: "medical judgement," "professional ethical concerns," and "religious values." Religious belief is not offered as the first reason, nor as the exclusive reason; none of the three reasons offered need exclude the others.

Since all of the services he declines to provide and the single kind of service he will provide all involve the control of human fertility, we must assume that the control of human fertility is the focus of the medical judgement, professional ethical concerns and religious values to which he refers.

Medical judgement

We will begin where the physician begins: with medical judgement pertaining to human fertility. The essentials are set out in general terms in Appendix "E."

The physician in this case implies that, in his medical judgement, Natural Family Planning (NFP) is not only preferable to contraception, but is the only medically appropriate means to control human fertility.  The physician’s mention of medical judgement was almost completely ignored by the Facebookers. Only one referred to it, and that was for the sole purpose of mockery - as if the very possibility of adverse medical judgement were absurd, and the reference to it by the physician a disingenuous subterfuge.5 This illustrates that, for them, as for most, belief in the necessity and goondess of manufactured contraceptives that has been encouraged by the state, pharmaceutical industry and medical establishment has assumed the character of unquestioned and even unquestionable dogma.  And that, in turn, suggests an explanation for the vehemence of their reaction.

Now, sound medical judgement begins with and remains focused on the patient and is exercised respectfully. It must be informed by correct science, avoiding or minimizing foreseeable risks or harm. It must seek a reasonably effective response to the needs of the patient, the anticipated benefits of which outweigh potential risks or harms. Medical judgement requires the reasonable exercise of discretion, which is shaped and refined by clinical wisdom born of experience. More could be added, but these elements are essential.

Relying on these criteria, we can ask the relevant question. Is there a plausible justification for the physician's medical judgement that NFP is preferable and that contraception should be avoided?

The patient and establishment practice

The majority of physicians favour the control of fertility by contraception, post-coital intervention and sterilization, and many recommend and facilitate abortion when these measures fail. It is instructive, at this point, to reproduce three of the charts from Appendix "E". (Click on chart to enlarge.)

Male reproductive lifetime fertility Female Reproductive Lifetime fertility Combined fertility

With these charts in view, note that women who do not wish to become pregnant are advised by most physicians that they should take a birth control pill every day or use some form of contraception every time they have sexual intercourse, and that if ever they have "unprotected" intercourse they should forthwith take the morning after pill. Notice the assumptions: that it is possible for a woman to become pregnant 365 days a year, and possible for a woman to become pregnant every time she has sexual intercourse.

The patient and alternative medical judgement

The comparative charts make it abundantly clear that these assumptions cannot possibly be derived from female physiology or fertility cycles. A woman can conceive only during a 12 to 24 hour period during each menstrual cycle, and she can become pregnant as a result of sexual intercourse during only about 25% of her reproductive lifetime, but she is advised to use contraceptive drugs or devices every day, 100% of the time, if she wishes to avoid pregnancy. Thus, the design and recommended use of contraceptives appear to reflect male physiology and fertility. Moreover, much of current contraceptive practice appears to reflect the assumption that normal, healthy female physiology and fertility present problems that have to be solved.

Beginning with a focus on the patient, one might propose a basic premise: women are not men.

If this premise is accepted, it implies that the human male is not the paradigm in whose likeness the human female ought to be remade for her own good or that of the community. From the fact that a man can never become pregnant from an act of sexual intercourse, it does not follow that a woman is defective because she can, and that medical intervention is required to correct the purported defect.

If this premise is accepted, it implies that a woman who comes to a physician should receive medical treatment and health care that reflects her physiology, including her fertility pattern. It implies that it is not appropriate to provide a woman with reproductive health care that is based on male reproductive physiology and fertility, nor to act as if female physiology and fertility are pathological conditions requiring treatment with drugs, medical appliances or surgery.

The principal Natural Family Planning methods - the Billings Ovulation Method, the Sympto-Thermal Method and Creighton Method - all demand that a physician recognize and respect a woman's actual physiology and fertility pattern, and not offer treatment or advice based on male physiology and fertility. NFP methods are unquestionably patient-centred, and do not treat women like men.

Science, establishment practice and alternative medical judgement

There is no doubt that contraception and related practices are well-grounded in science, but so, too, are the principal Natural Family Planning methods, so this element in the formation of medical judgement cannot be decisive in and of itself.

However, it should be noted that the principal NFP methods are not only informed by scientific investigation of human fertility and make use of its findings; practitioners communicate those findings to patients. This is what makes it possible for them teach women and men how to recognize the days when sexual intercourse may result in conception, so that they can avoid or achieve a pregnancy. Since the Society of Obstetricians and Gynaecologists acknowledges that most women are not well informed about their fertility cycles,6 a physician who opts for NFP rather than contraception can reasonably cite this as a factor influencing his medical judgement.

Avoiding harm, establishment practice and alternative medical judgement

It is widely recognized that the use of commonly recommended contraceptives entails a variety of side effects and health risks. A recently published paper7 identified six:

i) The BCP is a human carcinogen in women[125-127], in men [128] (through environmental contamination) and in offspring [129] (through vertical transmission).

ii) The BCP significantly increases the risk of cardiovascular events [130], hypertension [131, 132], and cerebrovascular disease [133].

iii) The BCP is a significant determinant of diminished and irreversible female sexual dysfunction [134, 135].

iv) The BCP exerts an adverse effect on mood in some women [136, 137].

v) The BCP is a widespread and escalating endocrine disrupting contaminant in the ecosystem and domestic water supply [128, 138, 139]

vi) Some BCPs increase the risk of adverse birth outcomes and allergy in offspring of users [140, 141]

Certainly, side effects and risks are associated with any medical intervention and have to be balanced against benefits for the patient. Moreover, the significance and probability of the side effects and risks associated with contraceptives may be disputed.

However, no health risks or adverse side effects are associated with the practice of Natural Family Planning. Of interest here are the comments in the guidelines of the Society of Obstetricians and Gynaecologists of Canada. The only identified "risk" is the "high probability of failure with all fertility awareness methods if they are not used consistently and correctly." On the other hand, the guidelines acknowledge "non-contraceptive benefits":

Women who monitor or chart their fertility signs often have greater awareness of their own gynaecological health and are better able to discern the difference between normal and abnormal cervical secretions. As well, charting fertility signs can alert women to factors that may contribute to infertility, such as anovulation. Incorporating this information into family planning programs generally would greatly benefit women.8

Thus, a physician might plausibly conclude that it is medically inappropriate to recommend procedures or treatments that are known to involve risks for the patient when there are reasonably effective alternatives that do not, and which, moreover, offer additional health benefits for patients.

Effectiveness, establishment practice and alternative medical judgement

The effectiveness of manufactured contraceptives is not disputed, but neither is the effectiveness of the principal Natural Family Planning methods, if used consistently and correctly. They compare favourably to the effectiveness of manufactured contraceptives, although "typical use" effectiveness is less well established for the Billings Ovulation Method (See Appendix "D2"). In fact, the Society of Obstetricians and Gynaecologists of Canada states that it is a "myth" that NFP is unreliable: "These methods can be quite reliable when used correctly."9

In addition, instruments that can accurately identify times when pregnancy can occur have been on the market for some time. Cost is a factor affecting their availability, but their effectiveness in birth control is comparable to that of manufactured contraceptives. One such instrument is included in Chart D2.1.1.

The effectiveness of NFP (correctly and consistently applied) is not widely known, as is reflected by one of the first comments on the 'pro-choice' Facebook page:

OMG. This is a recent letter?? The name for "Natural Family Planning" is "parenthood"!10

It is true that pregnancy can result if NFP methods are used, but that is also true of manufactured contraceptives, and more often than might be expected. A recent report states that 66% of women who had abortions in the United Kingdom were practising contraception; 40% of the contraceptors were using the birth control pill.11

This introduces another factor that might reasonably affect medical judgement. Acknowledged experts known to be supportive of contraception have repeatedly acknowledged that women who use contraceptives are much more likely to have abortions than women who do not.12 If a physician believes that abortions are medically undesirable (an issue well beyond the scope of this paper) this might tip an otherwise even balance against contraception.

Professional ethical concerns

While the physician's letter notes that he has "professional ethical concerns" that are related to the control of human fertility, the generality of the statement and the broad range of issues that might be covered by it preclude close consideration of all that this might entail.  Nonetheless, professional ethical concerns are usually connected to medical judgement, so we might usefully consider the first three sections of the Code of Ethics of the Canadian Medical Association in light of the foregoing discussion.13

#1. Consider first the well-being of the patient
What constitutes or contributes to the "well-being" of a patient is largely determined by a competent patient, not by a physician, though a physician may well contribute to the patient's decision. However, it does not follow that a physician is always obliged to agree with the patient's decision or to give effect to it. What happens in the case of such disagreements is largely dependent upon patient and physician concerned and their respective evaluations of what is at stake.

More relevant here is the obligation of the physician to offer the patient his best medical judgement about a recommended course of treatment or action, and, in so doing, select treatments that avoid or minimize health risks or adverse side effects. In light of the discussion about medical judgement, it is not unreasonable to think that professional ethical concerns related to the first section of the CMA Code of Ethics might be engaged in a decision by a physician offer Natural Family Planning and decline to offer contraceptive services.

#2. Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect
A physician who subscribes to this provision may well give effect to it by providing a woman with assistance in controlling her fertility that is informed and shaped by female physiology and fertility. Similarly, he might consider an attempt to treat female fertility according to the paradigm of male fertility a violation of this section of the Code.

#3. Provide for appropriate care for your patient . . .
What is expected here is that the physician should offer treatment and care that he deems to be appropriate. As indicated by the foregoing discussion, a physician might put this section of the Code into practice precisely by declining to provide contraceptive services and offering NFP instead.

Discrimination

In 2008, the Ontario Human Rights Commission attempted unsuccessfully to suppress freedom of conscience in the medical profession through the College of Physicians and Surgeons of Ontario.14 In view of the Commission's demonstrated hostility to freedom of conscience among health care workers and its inquisitorial powers,15 it is appropriate to consider one final point under this head: the ethical obligation of physicians to refrain from illegal discrimination.

It is occasionally alleged that refusing to prescribe, provide or refer for contraceptives constitutes illegal discrimination against women. Assuming that a physician is motivated by the kind of alternative medical judgement described above, such a claim in this context is not only implausible, but incoherent.

It would imply that a physician who offers medical advice and assistance to a woman that is guided by and fully respects her physiology and fertility cycles is treating her unfairly. It would imply that a physician who helps a woman to avoid or achieve pregnancy by helping her to understand her own reproductive physiology is failing to treat her as a unique individual. Ultimately, it would imply that a physician is a bigot if he insists that women are not men, and should not have to make do with fertility control techniques that assume the normative value of male reproductive physiology and treat female reproductive physiology as a birth defect.

Beyond the absurdity involved in such claims, they are also dangerous, because they invite human rights bureaucrats to substitute their opinions for those of medical professionals in medical decision-making.

Case study

Having reflected upon what might inform the medical and professional ethical judgement of an NFP-only physician, we can return to the letter that set activist drums beating in the nation's capital and consider the judgement passed upon it by one of their number:

Any female doctor who wrote this, as well as any MALE doctor who wrote this, as well as any other NON BINARY GENDER TYPE DOCTOR who would DARE send any patient this notice does not deserve to practice in Canada. PERIOD.16

They expect the College of Physicians and Surgeons of Ontario and other regulatory authorities across the country to compel NFP-only physicians to "stand and deliver" when patients demand contraceptives, or revoke their licences to practise. It seems that nothing short of that will satisfy them. This expectation can be considered within the context of a case study.

The accused

A physician entering practice in Ontario acknowledges that men and women may have reasons for avoiding pregnancy. He wishes to assist his patients in controlling their fertility, and considers the range of birth control measures available.

He observes that the design and recommended use of contraceptives appear to reflect male physiology and fertility patterns. He notes that officially recommended contraceptive practice seems to assume that normal, healthy female physiology and fertility present problems that have to be solved, if not pathological conditions. His research confirms that some of the most common and highly recommended contraceptives are associated with a variety of adverse side effects and health risks, though their frequency and significance are subjects of some dispute.

The physician believes that it is medically inappropriate and disrespectful to recommend or provide a woman with contraceptive methods that suppress her normal, healthy bodily functions. He believes that a physician's practice should reflect the fact that a woman is a woman, and not a man - let alone a defective man. He wishes to provide women with assistance with fertility control that is scientifically sound and effective, but also responsive to and respectful female reproductive physiology.

Having heard about Natural Family Planning as a result of a controversy in Ottawa, he researches the Billings Ovulation Method, the Sympto-Thermal Method and Creighton Method. He learns that all of the methods are responsive to and respectful of both male and female reproductive physiology, that they have a sound scientific basis, and that no health risks are associated with their use. He finds that, if used correctly and consistently, they are as effective as manufactured contraceptives.

The physician learns that NFP instructors teach women and men about human fertility and how they can recognize the days when sexual intercourse may result in conception, so that they can avoid or achieve a pregnancy. He knows that most women are not well informed about their fertility cycles, so he values the fertility awareness instruction offered by NFP. He also recognizes the non-contraceptive benefits associated with NFP that have been acknowledged by the Society of Obstetricians and Gynaecologists of Canada.

Based on all of this, he concludes that he will offer his patients only Natural Family Planning, and will not prescribe, recommend or refer for contraceptives. Knowing that this approach will be unexpected, he ensures that patients are aware of his position in advance and that potential patients are notified by means of a notice in his waiting room, a practice required of another physician by the College of Physicians and Surgeons of Ontario.17 While willing to explain his position during clinical encounters and to provide information about other forms of birth control, he understands that some patients may be inconvenienced and annoyed if they are told about his policy only after waiting for an appointment. He hopes the notice will minimize inconvenience for patients who want only manufactured contraceptives.

The accusers

One day, a young woman comes to his clinic to get a prescription for the birth control pill. She is surprised and annoyed by the notice posted in the waiting room. She crosses the street to get her prescription at another clinic, and then posts an account of her experience on Facebook. In short order, the physician learns that he is "jerk," a "complete anachronism," "disgusting," incompetent, "unethical and unprofessional," a "worthless piece of ____," a "crummy doctor," "an idiot," and a judgemental "goofball."

The College

The College of Physicians receives complaints that the physician's NFP-only policy and notice to patients is unacceptable, and demands that his licence to practise medicine be revoked.
For present purposes, it is sufficient to consider some of the questions raised by the complaints and demands of the accusers.

Is the physician in the case study a "jerk"? Is he "disgusting"? Is he an "idiot"? A "goofball"?

More specifically, within the context of the College's mandate, is the physician in the case study "unethical and unprofessional"? Is he a "crummy doctor"? Is there evidence that he is incompetent? Can the College demonstrate that his reasoning is unsound? That he is misinformed, or uninformed? Has the physician in the case study demonstrated conduct or attitudes unbecoming a member of the profession?

Is it fit, proper and right that the physician in the case study - and those like him - should be driven from the practice of medicine if they insist that their medical judgement, formed in the manner described here, should be respected, even if it differs from that of the establishment?

Diversity, respect and tolerance

At this stage there is no question of the accommodation of religious belief. We are simply considering how a different perspective might yield a different approach to fertility control and produce alternative medical and professional ethical judgements. Moreover, the case study has taken a bare-bones approach to the issue; in an actual case an accused physician would likely have much more to say.

However, the expectations and demands of the accusers notwithstanding, it appears that a medical judgement formed in the manner described here is sufficiently plausible to warrant the respect customarily accorded to divergent opinions and practice within the medical profession, and to the tolerance citizens of a liberal democracy have a right to expect.
We have not yet come to the issue of freedom of conscience. That cannot be taken up until we have considered the third reason offered by the Ottawa physician for his practice: "religious values."


Notes

1.  As early as 1932, a physician observed that women practising contraception seemed naturally to seek an abortion if contraception failed. He commented that he was "Contraceptive measures are undoubtedly one factor in lowering the incidence of demand for abortion, and within recent years I have been rather impressed with the attitude of mind of the woman, who has practised contraception and who has failed to attain her object. Such woman seems to feel that she has a right to demand the termination of an unwanted pregnancy. The criminal aspect of the matter does not appear to enter her mind at all." Whitehouse B. "A paper on indications for induction of abortion." Br Med J. 1932 August 20; 2(3737): 337–341. (Accessed 2014-02-14)

Four years later Dr. Raymond Pearl (for whom the Pearl Index is named) observed that frequency of abortion was "three to four or more times greater, generally speaking, among contraceptors than among non-contraceptors." and that "white married women . . .who practise contraception . . .resort to criminally induced abortions about three times as often proportionately as do their comparable non-contraceptor contemporaries." He concluded that perhaps three quarters of criminal abortions were attributable to the birth controllers and the current imperfections in the technique of their art." Pearl R. The Natural History of Population. London: Oxford University Press, 1939) p. 222, 240-241.

According to a study published in 1940 by Margaret Sanger's Clinical Research Bureau, 41 percent of the pregnancies of contracepting women were ended by abortion, but only 3.5 percent of non-contracepting women resorted to the procedure. Stix RK, Notestein F. Controlled Fertility: An Evaluation of Clinic Studies. Baltimore: William and Wilkins, 1940, p. 79-87. Cited in Whitehead KD, "Do Sex Education and Access to Contraception Cut Down on Abortion?" FCS Quarterly, Vol. 21, No. 3, Summer, 1998 (Accessed 2014-02-14)

By 1955, Planned Parenthood concluded that there was still no evidence that increased availability of contraception would reduce the illegal abortion rate. Dr. Alfred Kinsey reminded a Planned Parenthood conference that "we have found the highest frequency of induced abortion in the group which most frequently uses contraceptives." Calderone M. (Ed.) Abortion in the United States. New York: Harper and Row, 1958, p. 157. Cited in Whitehead KD, "Do Sex Education and Access to Contraception Cut Down on Abortion?"  FCS Quarterly, Vol. 21, No. 3, Summer, 1998  (Accessed 2014-02-14)

Almost thirty years later, Planned Parenthood officials acknowledged that pregnant women who use contraception were more likely to have abortions than those who were not, and associated an increase in contraceptive use with an increase in abortion. Tietze C. "Abortion and Contraception" in Sachev P. Abortion: Readings and Research. Toronto: Butterworths, 1981, p. 54-60. Potts M. "Abortion and Contraception in Relation to Family Planning Service" in Hodgson J. (Ed.) Abortion and the Politics of Motherhood. Berkeley: University of California Press, 1984, p. 112. Both quoted in Whitehead KD, "Do Sex Education and Access to Contraception Cut Down on Abortion?"  FCS Quarterly, Vol. 21, No. 3, Summer, 1998  (Accessed 2014-02-14)

2.   "Therapeutic abortion: Government figures show big increase in '71." CMAJ, 20 May, 1972, Vol. 106, 1131. Lewis TLT. The Abortion Act. Br Med J. 1969 January 25; 1(5638): 241–242 (Accessed 2014-02-14)

3.   Hordern A. Legal Abortion: The English Experience. Oxford: Pergamon Press, 1971, p. 102.

4.  Ann Furedi the chief executive of the British Pregnancy Advisory Service, told New Zealanders that abortion is required as a part of family planning programmes because contraception is not always effective. She noted that abortion rates do not drop when more effective means of contraception are available because women are no longer willing to tolerate the consequences of contraceptive failure. Abortion a necessary option: advocate. 18 October, 2010, TVNZ. (Accessed 2014-02-15)

Over twenty years ago, the U.S. Supreme Court stated that "for two decades of economic and social developments, people have organized intimate relationships and made choices that define their views of themselves and their places in society, in reliance on the availability of abortion in the event that contraception should fail. The ability of women to participate equally in the economic and social life of the Nation has been facilitated by their ability to control their reproductive lives." Planned Parenthood of Southeastern Pa. v. Casey - 505 U.S. 833 (1992), p. 856 (Accessed 2014-02-15)

5.  L__J__M___, 30 January, 2014, 10:15 am (Accessed 2014-02-10)

6.  Black A, Francoeur D, Rowe T. Canadian Contraception Consensus. SOGC Practice Guideline No. 143- Part 3 of 3 (April, 2004) Chapter 9, p. 365 (Accessed 2014-02-11)

7.  Genuis SJ, Lipp C. Ethical Diversity and the Role of Conscience in Clinical Medicine. Int J Family Med. 2013;2013:587541 (Accessed 2014-02-15)

8.  Black A, Francoeur D, Rowe T. Canadian Contraception Consensus. SOGC Practice Guideline No. 143- Part 3 of 3 (April, 2004) Chapter 9, p. 365 (Accessed 2014-02-11)

9.  Black A, Francoeur D, Rowe T. Canadian Contraception Consensus. SOGC Practice Guideline No. 143- Part 3 of 3 (April, 2004) Chapter 9, p. 365 (Accessed 2014-02-11)

10.  M___ L___, 29 January, 2014, 5:55 pm. (Accessed 2014-02-10)

11.  Women trying hard to avoid unwanted pregnancy, research shows. British Pregnancy Advisory Service news release, 4 February, 2014 (Accessed 2014-02-15)

12.  See notes 1, 4

13.  Canadian Medical Association, CMA Code of Ethics (Update 2004) (Accessed 2014-02-15)

14.  Protection of Conscience Project, Ethics: Resisting Ethical Aggression. Notable Challenges - Physicians and the Ontario Human Rights Code.

15.  Murphy S. The New Inquisitors. Protection of Conscience Project (31 August, 2008)

16R___ V___, 29 January, 2014, 7:52 pm (Accessed 2014-02-10)

17.   In 2002 the College formally approved a written notice to patients and directed that it be made available in the physician's waiting room. Citing the Canadian Medial Association's Code of Ethics, the notice conveyed in explict terms the physician's religiously based objection to providing or arranging for abortions, or for prescriptions for birth control for unmarried patients, or Viagra for unmarried men. Murphy S. Ontario College of Physicians and Surgeons accommodates Christian physician. Protection of Conscience Project, August, 2002

 

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