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Protection of Conscience Project

Service, not Servitude


Part 4: A difficult compromise


Part 1 described how a story that might have had a happy ending was eclipsed by the preaching of a crusade against three NFP-only physicians. Based on a letter from one of the physicians, Part 2 explored possible grounds for medical judgement and professional ethical concerns that might lead a physician to adopt NFP-only practice. Part 3 explained the common standing of a physician's religious beliefs vis-á-vis non-religious beliefs within a secular public square. It introduced but not elaborate upon the subject of freedom of conscience, making note that those attacking freedom of conscience for health care workers are, in their focus on a so-called "problem of conscientious objection," attempting to establish a 'duty to do what is wrong'.[CommentSince the Project does not take a position on the morality of morally contested procedures, a ‘duty to do what is wrong’ refers, in this paper, to ‘wrong’ as understood from the perspective of the person on whom the duty is purported to lie.]

Such an attempt was made in Canada in the years following the legalization of abortion.  It was rejected by members of the medical profession, who refused to support the attack on physician freedom of conscience.  The rejection was the condition necessary to sustain the compromise that allowed physicians who refused to participate in abortion to continue to preserve their integrity in practice even as abortion rates increased dramatically.  The story begins, ironically, with high praise for freedom of conscience.

Early promises of tolerance

Abortion law reform advocates frequently portrayed themselves as champions of freedom of conscience. In 1965, for example, the Globe and Mail demanded liberalization of the law "to enable doctors to perform their duties according to their conscience and their calling."1

Two Private Members Bills on abortion were introduced in1967.2 M.P. Grace MacInnis, sponsor of one of the bills, assured the committee that "nobody would be forcing abortion procedures on anybody else," suggesting that abortion should be up to the individual conscience.3

The Omnibus Bill introduced in 1967 included what later became Canada's new abortion law. It did not include a protection of conscience clause. Nonetheless, the Canadian Welfare Council stated:

At the risk of labouring the obvious, no woman will be required to undergo an abortion, no hospital will be required to provide the facilities for abortion, no doctor or nurse will be required to participate in abortion.4

Nor was the Catholic Hospital Association concerned:

We note that there is no question of [our hospitals] being obliged to change their present norms of conduct. On the contrary, proponents of a 'liberalized' abortion law admit that it should exempt those who object to being involved in procuring abortions.5

A protection of conscience clause was proposed when the Omnibus Bill returned to the Commons the following year.6 Justice Minister John Turner responded that the conscience clause was unnecessary because the proposed law

  • imposed no duty on hospitals to set up committees,
  • imposed no duty on doctors to perform abortions,
  • and did not even impose a duty on doctors to initiate an application for an abortion.7

The protection of conscience clause was rejected, and abortion was legalized and regulated.8 If health care workers and institutions and people objecting to the procedure had not been promised or led to believe that they would not be compelled to provide abortions, it is highly doubtful that the abortion law would have passed in 1969.

Broken promises

However, beginning in 1970, the promises made by abortion law reform advocates concerning respect for freedom of conscience began to be broken.9 Five years after the abortion bill passed, the Globe and Mail (that erstwhile champion of freedom of conscience) complained:

. . . hospital boards should never have been allowed a choice in the matter. The Government should . . . require hospitals which receive public grants to establish abortion committees.10

It appears that the change of attitude was caused by a dramatic yearly increase in abortion rates which continued for a decade, and an expansion of the grounds for abortion to include non-medical social reasons. The broadened grounds for abortion and continuing increases in the abortion rate increased the likelihood of conscientious objection to the procedure. It also brought raging controversy. This is the background for the development of Canadian Medical Association (CMA) policies on abortion and freedom of conscience for physicians, described in detail in Appendix "F."

Preserving physician integrity

When the law passed, the CMA's response was based on the premise that physicians would be permitted to provide abortions, but would not be forced to do so. This was reflected in the 1970 revision of its Code of Ethics. A new section, made necessary by the legalization of abortion, required physicians to disclose personal moral convictions that might prevent them from recommending a procedure to patients, but did not require the physician to refer the patient or otherwise facilitate the morally contested procedure. The arrangement preserved the integrity of physicians who did not want to be involved with abortion, while making patients aware of the position of their physicians so that they could seek assistance elsewhere.

Very likely in response to increasing demand for abortion, and perhaps influenced by a lobby convinced that all physicians were obliged to facilitate it, for a brief period the Association modified the 1970 policy by adding a requirement that an objecting physician "advise the patient of other sources of assistance." This move toward mandatory referral survived only a year. The 1970 wording was restored in June, 1978, because of the backlash from members of the Association who refused to accept the principle that they could be ordered to violate their conscientious convictions.

Since that time, in the face of repeated efforts to impose a 'duty to do wrong' on physicians, the Canadian Medical Association has maintained the position summed up by Dr. John R. Williams, then CMA Director of Ethics and now Director of Ethics for the World Medical Association:11 "[Physicians are] under no obligation to do something that they feel is wrong."12

Patient-centred medical practice and health care

While maintaining the personal and professional integrity of the physician is essential, it is equally essential to attend to the well-being of the patient. The years immediately following the legalization of abortion were particularly challenging, since objecting physicians and other health care workers had to find ways to adapt their practices to respond to both the expectations of their patients and of their professions.

What has emerged over the years can be described as a difficult compromise: "difficult" because it has had a difficult birth, and difficult because it requires continuous effort. It safeguards the legitimate autonomy of the patient by giving effect to the principle of informed medical decision making. "Legitimate" here refers to a limit placed on patient autonomy: physicians cannot be made to do what they believe to be wrong. This safeguards not only the physician, but the community, since it would be dangerous to adopt the principle that a community, a profession or the state can force people to do what they believe to be wrong.

While the difficult compromise was developed because of conflicts caused by legalization of abortion, it provides a template for a response to conflicts in relation to other morally contested procedures. Here we return to the patient, though not specifically to the young woman who had to drive around the block for her birth control pills. The subject here is how a physician who has ethical, moral or religious reasons for refusing to prescribe contraceptives can respond to patients who, given the dominant contraceptive mindset, are likely to be looking for and expecting to be provided with hormonal contraceptives or sterilization.


Everything that might be said in support of the preservation of personal integrity and protection of conscience in health care presumes a competent, caring, patient-centred approach to medical practice and health care. This must be emphasized and occasionally re-emphasized, since a continuing emphasis on developing and articulating a defence of freedom of conscience for health care workers can inadvertently encourage an inappropriate defensive attitude toward patients. Of course, crusades of the type launched in Ottawa and suggestions that women should fabricate complaints against objecting physicians are unhelpful in establishing the relationship of trust that ought to characterize physician-patient relationships.

What follows is provided to facilitate reflection and discussion about how physicians who decline to provide or facilitate contraception for reasons of conscience can respond ethically to patients seeking assistance with fertility control. Actual professional and legal requirements will vary from one jurisdiction to another and obviously take precedence over anything suggested here. The references provided are not offered as definitive authorities, but as illustrations of the compatibility of the suggested approach with professional expectations.

Finally, it is impossible to anticipate all of the situations and personalities a physician may encounter in his practice, so it is impossible to make hard-and-fast rules about what should or should not be said, or to provide a script to be followed.

Physician preparation

The physician should keep up to date on subjects related to birth control through continuing medical education (formal and informal).13 This is necessary because new information may cause him to modify his position. Moreover, the subject may come up in relation to the clinical management of contraceptive methods of birth control prescribed by others. Finally, he must be in a position to adequately explain the options available to a patient in order to satisfy the principle of informed consent.

The physician should be prepared to provide and articulate and cogent rationale for his practice policies, should the need arise, and to re-evaluate his position in light of new information or the circumstances of a particular patient.


If a complaint arises in connection with a physician's refusal to provide certain services or procedures for reasons of conscience, it is frequently caused by a failure to communicate effectively. This includes not only the communication of information, but conveying a sense of respect and caring that is consistent with competent, patient-centred medical practice.14 A failure in communication is not necessarily the fault of the physician, since the patient is a partner in dialogue and shares responsibility for its success. However, it is presumed that the physician normally has a greater responsibility for the success of a physician-patient conversation.15 The physician should consult with like-minded colleagues. They may be able to suggest communication strategies that have proved successful in different circumstances.

Clinical settings

A family physician has the opportunity to discuss limits to his practice when he accepts a patient. Continuing contacts while providing medical care provide the opportunity for physician and patient to get to know one another, and for the patient to develop trust in the physician in response to practical demonstrations of the physician's interest in her welfare. This kind of established relationship is less likely to break down if a difference of opinion arises over treatment. A walk-in clinic is more likely to bring together a physician and patient who have different views about the morality of some procedures or services, and who have not had the opportunity to develop a relationship that will sustain successful communications if these differences become an issue.


It is common ground that conflicts should be avoided - especially in circumstances of elevated tension - and that they often can be avoided by timely notification of patients, erring on the side of sooner rather than later. However, it is unreasonable to expect physicians to anticipate, in advance, every conceivable request that might be made by patients.

The interests of patients and physicians are best served by open and continuing communication, not inflexible notification protocols. On the part of the physician, this involves a special responsibility to be attentive to the spoken and unspoken language of the patient, and to respond in a caring and truthful manner. Notice should be given when it would be apparent to a reasonable and prudent physician that a conflict is likely to arise.16 In some cases - but not all - this may be when a patient first presents or is accepted. The same holds true for notification of patients when a physician's views change significantly.

However, it is more important in walk-in clinics to make some kind of notice available in the waiting room to advise patients of practice limitations.17 This minimizes inconvenience to patients, who may immediately decide to go elsewhere if they wish to avail themselves of services not available from the physician. It also minimizes the likelihood of misunderstandings between a walk-in clinic physician and a patient who do not have an established relationship. The notice should be in the languages common among patients attending the clinic. Suggestions for increasing the effectiveness of notices are included in Appendix "G".

Consultations and informed consent

While advance notice to patients and screening by receptionists make it less likely that an NFP-only physician will be consulted by patients seeking contraceptives, the subject may come up in relation to the clinical management of contraceptive methods of birth control prescribed by others. Further, a patient who has made an appointment because of an initial interest in NFP may, in the course of the consultation, decide against it. Finally, a variety of circumstances may lead patients using NFP to consider other options.

To simplify matters, assume that a physician who declines to provide contraceptives is consulted by a woman seeking assistance with birth control who is not aware of the physician's practice limitations.

Presumably, discussion of birth control would follow the taking of a medical history, and would begin with an assessment of the patient's awareness of the various methods of birth control available, and any initial preference she might have.

Much of what follows depends upon the patient's knowledge. Physicians are expected to provide patients with accurate information about all legal options available to them, the effectiveness of the methods, adverse effects or risks associated with each, benefits associated with each, and other information that someone in the position of a patient would reasonably want to know. In some cases the physician might have to provide a great deal of information; in others, it may simply be a matter of filling in some gaps in what the patient knows.18 In all cases, the physician must take care to present the information in a form comprehensible to the patient.19

The physician must disclose whether or not his religious, ethical or other conscientious convictions influence his recommendations or practice or prevent him from providing certain procedures or services. If medical judgement rather than moral/religious conviction is his primary consideration, it may still be prudent to disclose pertinent religious or moral beliefs.20 The reason for this is that the patient is entitled to be apprised of non-medical factors that may influence a physician's medical judgement and recommendations. The patient is also entitled to know whether or not the physician's medical evaluation of the contraceptive(s) in question is consistent with the general view of the medical profession.21

The physician should invite questions from the patient at different stages in the consultation to ensure that he has been correctly understood.22 The goal is to ensure that the patient has sufficient information and understanding to make an informed decision about what kind of birth control she wishes to use. With respect to any reference to his conscientious convictions, unless the patient questions him, asks for further explanation, or otherwise indicates that she does not understand his position, the physician need not and probably should not expand upon the basis for his own position. To do so would likely invite the accusation that he is "preaching."23

Anatomically accurate, life-size or scale models, graphics, charts or tables may facilitate communication. The physician might prepare a pamphlet to give the patient during or after a discussion. This would help the patient to recall the conversation accurately if she wishes to give the matter further thought.

It is up to the patient, following the consultation, to decide whether or not she wishes to accept the physician's recommendation to use a natural family planning method. If she prefers to use a contraceptive method, she must be advised that she may approach other physicians or seek them from other sources, such as public health clinics.24

An objectionable approach

It is instructive to compare this approach with one described by one of the commentators on the 'pro-choice' Facebook page:

My doctor has told me to my face that it is my womanly duty to have children and she will never condone me to prevent the birth of a child in any way. She also said she would not sign the vasectomy papers for my husband to get one. . .She lectures me often when I go in. She has 3 or 4 kids and says she is not done.25

Assume, for present purposes, that this brief narrative is an essentially accurate summary of the physician's conduct. Assume, as well, that the physician has religious or moral objections to contraception, abortion, and contraceptive sterilization, all of which are morally contested procedures that she may decline to provide or facilitate. Finally, assume that the physician believes, for moral or religious reasons, that women should have many children.

Nonetheless, what is described here is conduct unacceptable in ethical medical practice. While a physician is obliged to disclose the existence of moral or religious convictions that would influence her recommendations or preclude the provision of certain procedures, the disclosure must be respectful of the patient and must not take the form of "preaching" or "lecturing." Such a disclosure is meant to be about what a physician will not do and why, not about what the patient should do. Further: while it is not inconceivable that, in some circumstances, a physician might disclose some personal information or experience in a manner supportive of a patient, to set oneself up as a kind of role model ('you should have as many children as I do') is highly objectionable.

Sustaining the compromise

While the exercise of freedom of conscience by physicians and other health care workers must be supported and defended, it is equally necessary to support and defend patient-centred practice and respect for the principle of informed medical decision-making. The fulfilment of this dual obligation requires patience, perseverance, honesty and good will, and it may sometimes entail difficulty or misunderstanding.


1.  "Free the Doctor",Globe and Mail, 18 May, 1965. Quoted in de Valk A. Morality and Law in Canadian Politics: The Abortion Controversy. Dorval, Quebec: Palm Publishers, 1974, p. 18 Two years later an editorial in the Globe stated that the Government had decided "that where religious moralities conflict, the State should support none, but leave the choice to individual conscience. It is a policy that should also be followed with abortion." "Now the job is to be done, let it be done right", Globe and Mail, 21 December, 1967. Quoted in de Valk, supra, p. 56

2.  One of these had a conscience clause almost identical to that in the British Abortion Act. Standing Committee on Health and Welfare, Minutes of Proceedings and Evidence, Appendix "QQ": Brief submitted by the Catholic Hospital Association of Canada . . . on the Matter of Abortion. February, 1968, P. 679, paragraph 19.

3.  Quoted in de Valk, supra, p. 44-45

4.  Standing Committee on Health and Welfare, Minutes of Proceedings and Evidence, Appendix "SS": Canadian Welfare Council Statement on Abortion to the House of Commons Standing Committee on Health and Welfare. February, 1968, p. 707

5.  Standing Committee on Health and Welfare, Minutes of Proceedings and Evidence, Appendix "QQ": Brief submitted by the Catholic Hospital Association of Canada . . . on the Matter of Abortion. February, 1968, p. 676

6.  The Progressive Conservatives and Creditistes put forward seven amendments intended to guarantee the right of conscientious objection to individuals or institutions. It was agreed that debate on one amendment would dispose of all seven. The clause had been proposed M.P. Robert McCleave, who was in favour of legalizing abortion. (Hansard- Commons Debates, 28 April, 1969, p. 8069)

What was then debated was to the following effect:

  • Nothing in the new law shall be construed as obliging any hospital to establish a therapeutic abortion committee, or any qualified medical practitioner to procure an abortion, or any member of a hospital staff to assist in abortion. (A sub-amendment was added to the original amendment. The paraphrase reflects the effect of both. (See Hansard-Commons Debates, April 28, 1969, p. 8056, 8063)

7.  Hansard-Commons Debates, April 28, 1969, p. 8058-8059

8.  Hansard- Commons Debates, 28 April, 1969, p. 8087. Senator Haidasz had long since achieved a strong pro-life reputation.

9.  A little over a year after abortion was legalized, British Columbia Health Minister Ralph Loffmark told the Annual General Meeting of the British Columbia Medical Association that "all hospitals which ban abortions on religious grounds may be forced to change their policies." The chairman of the BCMA hospital committee said that he believed most of his colleagues would support the requirement, but it was acknowledged that the law permitted but did not require provision of abortions. B.C.M.A. Annual Meeting. CMAJ November 21, 1970, Vol. 103, 1223 (Accessed 2014-02-22)

A 1975 biography of Dr. Henry Morgentaler described how he and his staff performed an abortion on a shouting, squealing 16 year old severely retarded girl who could not understand what was happening. Pelrine EW.  Morgentaler: The Doctor Who Couldn't Turn Away. Gage Publishing, 1975, p. 55. Over twenty years later, as if demonstrating that Dr. Morgentaler was just a little ahead of his time, a Quebec Court ordered the abortion and sterilization of a mentally ill woman who was not capable of requesting or consenting to the procedures. Murphy S. Conscience or Contempt of Court? Court orders abortion of woman. Protection of Conscience Project. 

Between 1977 and 1984, nurse Linda Bradley was denied employment at four British Columbian hospitals because she did not want to assist with abortions. Desperate, she sacrificed her convictions to get a job at the Richmond General Hospital. She lost it after refusing to assist at the hysterotomy of a mother, five and a half months pregnant. Murphy S. Nurse Refused Employment, Forced to Resign: A Two Tiered System of Civil Rights.

BC welfare worker Cecilia Moore was fired in 1985 for refusing to authorize payment for an abortion that would have been illegal under the law as it then stood. Murphy S. Insubordination. Protection of Consience Project.

Three transition house workers in Ontario were fired - with the government's approval - for refusing to refer women for abortions. Kennedy, Frank, "Sweeney Defends Firings:Transition house workers fired, denied benefits for 'misconduct'". The Interim, March, 1989

In 1992, BC Health Minister Elizabeth Cull ordered 33 British Columbian hospitals to perform abortions. Hawkins, Anthony, "BC stamps out choice: Orders hospitals to do abortions; taxpayers to fund them." The Interim, 20 April, 1992. (Accessed 2010-05-18)

Over thirty years after the promises were made, postpartum nurses at Foothills Hospital in Calgary were told that they would have to be involved with late term abortions, regardless of their moral convictions. Ko M. "Personal Qualms Don't Count: Foothills Hospital Now Forces Nurses To Participate In Genetic Terminations." Alberta Report, April 12, 1999.

10.  Globe and Mail, 18 January 1974. Quoted in de Valk, supra, p. 137

11.  Carleton University, Centre on Values and Ethics. John R. Williams, Curriculum Vitae. (Accessed 2014-02-22)

12.  Mackay B. Sign in office ends clash between MD's beliefs, patients' requests. CMAJ January 7, 2003 vol. 168 no. 1 (Accessed 2014-02-16)

13.  Canadian Medical Association Code of Ethics (2004): "6. Engage in lifelong learning to maintain and improve your professional knowledge, skills and attitudes." (Accessed 2014-02-22)

14.  College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). "Treat patients or individuals who wish to become patients with respect when they are seeking or requiring the treatment or procedure. This means that physicians should not express personal judgments about the beliefs, lifestyle, identity or characteristics of a patient or an individual who wishes to become a patient. This also means that physicians should not promote their own religious beliefs when interacting with patients, nor should they seek to convert existing patients or individuals who wish to become patients to their own religion." (Accessed 2014-02-22)

15.  Canadian Medical Association Code of Ethics (2004): "22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood." (Accessed 2014-02-22)

College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). "The College expects physicians to communicate decisions they make to end a physician-patient relationship, refrain from providing a specific procedure, or to decline to accept an individual as a patient, and the reasons for the decision in a clear, straightforward manner. Doing so will allow physicians to explain the reason for their decision accurately, and thereby avoid misunderstandings." (Accessed 2014-02-22)

16. Canadian Medical Association Code of Ethics (2004): "12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants." (Accessed 2014-02-22)

College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). "Communicate clearly and promptly about any treatments or procedures the physician chooses not to provide because of his or her moral or religious beliefs."(Accessed 2014-02-22)

17.   Mackay B. Sign in office ends clash between MD's beliefs, patients' requests. CMAJ January 7, 2003 vol. 168 no. 1 (Accessed 2014-02-16)

18.  Canadian Medical Association Code of Ethics (2004): "21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability." (Accessed 2014-02-22)

College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). "Provide information about all clinical options that may be available or appropriate based on the patient's clinical needs or concerns. Physicians must not withhold information about the existence of a procedure or treatment because providing that procedure or giving advice about it conflicts with their religious or moral beliefs." (Accessed 2014-02-22)

Murray B. "Informed Consent: What Must a Physician Disclose to a Patient?" American Medical Association Journal of Ethics, Virtual Mentor. July 2012, Volume 14, Number 7: 563-566. (Accessed 2014-02-22)

19.  See note 15.

20.  Guidelines (like those below) typically require disclosure when a recommendation or practice is or would likely be influenced by a belief. However, a physician’s decision or recommendation may be justified solely on medical grounds without reference to beliefs. The practical difficulty in a practice and disciplinary environment hostile to religious belief is that a failure to disclose a belief may invite the adverse inference that the physician failed to disclose beliefs that were ‘really’ shaping his decision making, especially if the medical grounds are contested by establishment opinion.

Canadian Medical Association Code of Ethics (2004): "12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants." (Accessed 2014-02-22))

College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). "Communicate clearly and promptly about any treatments or procedures the physician chooses not to provide because of his or her moral or religious beliefs."(Accessed 2014-02-22)

21.   Canadian Medical Association Code of Ethics (2004): "45. Recognize a responsibility to give generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate." (Accessed 2014-02-22)

22.  See note 15.

23.  College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). ". . .physicians should not promote their own religious beliefs when interacting with patients, nor should they seek to convert existing patients or individuals who wish to become patients to their own religion." (Accessed 2014-02-22)

24.  Canadian Medical Association Code of Ethics (2004): "24. Respect the right of a competent patient to accept or reject any medical care recommended. 26. Respect your patient's reasonable request for a second opinion from a physician of the patient's choice." (Accessed 2014-02-22)

College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008). "Advise patients or individuals who wish to become patients that they can see another physician with whom they can discuss their situation and in some circumstances, help the patient or individual make arrangements to do so." (Accessed 2014-02-22)

25.  L___ S___, 30 January, 5:39 pm & 5:46 pm

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