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Protection of Conscience Project

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Service, not Servitude
Project Submissions

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

Appendix "B"

Unreliability of Jurisdictional Review by College Working Group


BI.  Overview of deficiencies in briefing supplied to the Council

BI.1    In Appendix 3 to the briefing note on Professional Obligations and Human Rights,1 the Council was provided with an overview of policies on discrimination and conscientious objection in Canada, the United Kingdom, the United States, Australia and New Zealand, as follows:

CANADA

    Canadian Medical Association

    Society of Obstetricians and Gynecologists of Canada

    British Columbia
    - College of Physicians and Surgeons

    Alberta
    - College of Physicians and Surgeons

    Saskatchewan
    - College of Physicians and Surgeons

    Manitoba
    - College of Physicians and Surgeons

    Ontario
    - Pharmacists
    - Nurses
    - Midwives

    Quebec
    - Collège des Médecins du Québec

    New Brunswick
    - College of Physicians and Surgeons

AUSTRALIA

    GMC

     Australian Medical Association

    Australian Medical Students' Association

NEW ZEALAND

     General Medical Council

UNITED KINGDOM

    General Medical Council

UNITED STATES

    American Medical Association

     American College of Obstetricians and Gynecologists

     American Academy of Pediatrics

     America College of Emergency Physicians

BI.2    With respect to the issue of physician freedom of conscience and referral in particular,

a.  the accounts provided in Appendix 3 of the policies of the Canadian Medical Association were deficient; [BII.1]

b.  the accounts provided in Appendix 3 of the policies of the Colleges of Physicians of British Columbia, Alberta, Nova Scotia, Prince Edward Island, Newfoundland, New Brunswick and Quebec were deficient; [BII.2]

c.  the information provided in Appendix 3 concerning the Australian Medical Association was erroneous and seriously misleading; [BII.3]

d.  the information provided in in Appendix 3 concerning New Zealand was deficient and seriously misleading;[BII.4]

e.  the account provided in Appendix 3 concerning policies in the United States was deficient and superficial;[BII.5]

f.  the account provided in Appendix 3 concerning nursing policies in Ontario was deficient and misleading;[BII.6]

g.  the account provided in Appendix 3 concerning midwifery policies in Ontario was deficient;[BII.7]

h.  Appendix 3 failed to reference significant documents from Canadian authorities relevant to the issues.[BII.8]

BII.    Particulars of deficiencies in briefing supplied to the Council

BII.1    Deficient accounts of CMA policies

BII.1.1    Extracts from the CMA Code of Ethics and policy documents were provided on Appendix P. 7 (p. 348). However, the following sections were left out of the extract from the CMA Code of Ethics:

7. Resist any influence or interference that could undermine your professional integrity.

9. Refuse to participate in or support practices that violate basic human rights.2

BII.1.2    In addition, the following sections were left out of the extract from the CMA Policy on Induced Abortion:3

No discrimination should be directed against doctors who do not perform or assist at induced abortions. Respect for the right of personal decision in this area must be stressed, particularly for doctors training in obstetrics and gynecology, and anesthesia.

No discrimination should be directed against doctors who provide abortion services.

BII.1.3    The working group failed to include the following clarification of CMA policy provided in response to a claim that CMA policy required physicians to refer for abortions:

CMAJ April 24, 2007 vol. 176 no. 9 1310 . . . CMA policy states that "a physician should not be compelled to participate in the termination of a pregnancy." In addition, "a physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of this so that she may consult another physician." You should therefore advise the patient that you do not provide abortion services. You should also indicate that because of your moral beliefs, you will not initiate a referral to another physician who is willing to provide this service (unless there is an emergency). However, you should not interfere in any way with this patient's right to obtain the abortion. At the patient's request, you should also indicate alternative sources where she might obtain a referral. This is in keeping with the obligation spelled out in the CMA policy: "There should be no delay in the provision of abortion services."4

BII.1.4    The working group failed to include the following CMA policy document:

Joint Statement on Preventing and Resolving Ethical Conflicts involving Health Care Providers and Persons Receiving Care (1999) Para. 16. Health care providers should not be expected or required to participate in procedures that are contrary to their professional judgement or personal moral values or that are contrary to the values or mission of their facility or agency. Health care providers should declare in advance their inability to participate in procedures that are contrary to their professional or moral values. Health care providers should not be subject to discrimination or reprisal for acting on their beliefs. The exercise of this provision should never put the person receiving care at risk of harm or abandonment.5

BII.1.5    The working group failed to include the following from the CMA intervention in Carter v. Canada at the Supreme Court of Canada:

CMA Factum: 3) As long as such practices remain illegal, the CMA believes that physicians should not participate in medical aid in dying. If the law were to change, the CMA would support its members who elect to follow their conscience.6

CMA Factum: 9) . . .The CMA's policies are not meant to mandate a standard of care for members or to override an individual physician's conscience.6

CMA Factum: 16) It is acknowledged that just moral and ethical arguments form the basis of arguments that both support and deny assisted death. The CMA accepts that, in the face of such diverse opinion, based on individuals' consciences, it would not be appropriate for it to seek to impose or advocate for a single standard for the medical profession.6

CMA Factum: 27) In addition, if the law were to change, no physician should be compelled to participate in or provide medical aid in dying to a patient, either at all, because the physician conscientiously objects to medical aid in dying, or in individual cases, in which the physician makes a clinical assessment that the patient's decision is contrary to the patient's best interests. Notably, no jurisdiction that has legalized medical aid in dying compels physician participation. If the attending physician declines to participate, every jurisdiction that has legalized medical aid in dying has adopted a process for eligible patients to be transferred to a participating physician.6

CMA Counsel Harry Underwood, oral submission [Webcast 228:32/491:20]: With the profession now divided between the two positions, each defensible on the basis of established medical ethical considerations and compassion for the patient, the CMA has decided to accept that physician assisted death, if it should become legal, may properly be undertaken by physicians who can square their participation with their own consciences, without overriding the consciences of those who object to performing it.7

BII.2    Deficient accounts of Colleges of Physicians policies
British Columbia, Alberta, Saskatchewan, Nova Scotia, Newfoundland, PEI

BII.2.1    The Colleges of Physicians and Surgeons of British Columbia, Alberta, Saskatchewan, Nova Scotia, Newfoundland and Prince Edward Island have all adopted the CMA Code of Ethics.8  The working group failed to include this information in the briefing materials. The policies of these Colleges thus include the following:

12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.

18. Provide whatever appropriate assistance you can to any person with an urgent need for medical care.

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.

BII.2.2    Since these six Colleges have adopted the CMA Code of Ethics, one would expect them to subscribe to related CMA policies, subject to changes explicitly adopted by each College. These include:

No discrimination should be directed against doctors who do not perform or assist at induced abortions. Respect for the right of personal decision in this area must be stressed, particularly for doctors training in obstetrics and gynecology, and anesthesia.

No discrimination should be directed against doctors who provide abortion services.

British Columbia

BII.2.3    Extracts of the CPSBC policy document Access to Medical Care9 were provided in Appendix 3, P. 4 (p. 345). However, the working group failed to include a relevant passage in the policy. The working group also included one sentence from the text (italicized below) under the sub-heading "Referrals." The sub-heading does not exist in the original text. The complete text follows. The parts not included by the working group are in bold face.

Physicians are not obliged to provide treatments or procedures to patients which are medically unnecessary or deemed inappropriate based on scientific evidence and their own clinical expertise.

While physicians may make a personal choice not to provide a treatment or procedure based on their values and beliefs, the College expects them to provide patients with enough information and assistance to allow them to make informed choices for themselves. This includes advising patients that other physicians may be available to see them, or suggesting that the patient visit an alternate health-care provider. Where needed, physicians must offer assistance and must not abandon the patient.

Physicians in these situations should not discuss in detail their personal beliefs if not directly relevant and should not pressure patients to disclose or justify their own beliefs.

In all cases, physicians must practise within the confines of the legal system, and provide compassionate, non-judgmental care according to the CMA Code of Ethics.

BII.2.4    In response to queries from the Protection of Conscience Project, the Deputy Registrar of the CPSBC provided the following explanation of this document:

. . . Your concern focused on the paragraph dealing with conscientious objection and specifically our advice that "where needed physicians must offer assistance and must not abandon the patient." I would like to reassure you that we did not intend this sentence or the paragraph that preceded it to require physicians to provide any treatment that they believe to be either clinically inappropriate or unethical. We were trying to direct physicians to offer whatever assistance they feel professionally and ethically able to offer, and not to withdraw from the care of a patient when unable to provide what the patient is specifically requesting. . .

. . .It was our intention to support the position that all patients have a right to access appropriate medical care but cannot oblige physicians to provide treatments which they believe to be medically inappropriate or unethical.10

Administrator: Is Access to Medical Care to be understood to require physicians to do what they believe to be immoral or unethical?

Deputy Registrar: No.

Administrator
: Does the College propose to take disciplinary action against physicians who refuse to do what they believe to be immoral or unethical?

Deputy Registrar: No, unless the College considers that in those specific circumstances the physician abandoned the patient without providing an appropriate level of medical care.11

BII.2.5    In brief, the CPSBC document Access to Medical Care does not require that objecting physicians provide what the CPSO draft policy calls "an effective referral."

Alberta

BII.2.6    A copy of the CPSA policy document Moral or Religious Beliefs Affecting Medical Care12 was provided in Appendix 3, P. 4 (p. 345). The working group also included one sentence from the text under the sub-heading "Referrals." The sub-heading does not exist in the original text:

When moral or religious beliefs prevent a physician from providing or offering access to information about a legally available medical or surgical treatment or service, that physician must ensure that the patient who seeks such advice or medical care is offered timely access to another physician or resource that will provide accurate information about all available medical options.

BII.2.7    The working group was obviously unfamiliar with the development and meaning of Moral or Religious Beliefs Affecting Medical Care.

BII.2.8    This provision is part of the Standards of Practice adopted by the CPSA following public consultation in 2008. The original draft Standards included a section concerning the termination of pregnancy which included the statement, "ensure that the patient. . . is offered access to available medical options." In its submission to the College, the Project warned that the wording was likely to be interpreted to impose a duty to refer for or otherwise facilitate procedures or services the physician believes to be wrong, and that many objecting physicians would find that unacceptable.13

BII.2.9    Consistent with this warning, the Registrar of the College later stated:

Most respondents take exception with the draft, believing that the College will require physicians to refer patients for termination of pregnancy, or at the very least to be compliant in arranging a patient's abortion, contrary to the physician's personal beliefs. This is not true. . . .

. . . The College's current policy (in place for the past decade) states:

  • While recognizing the varied personal convictions of physicians it must still be the responsibility of physicians to ensure that pregnant women who come to them for medical care are provided with or are offered access to information or assistance to enable them to make informed decisions on all available options for their pregnancies including termination.

The points I wish to make are these: A Standard of Practice on this subject will not change the obligations of physicians that have been accepted by this College since 1991. The words are a little different, but the intent is not, as the principles underlying the standard have not changed over the past 20 years. (Emphasis in the original)14

BII.2.10    The section concerning terminations of pregnancy was deleted from the final version of the Standards and the policy Moral or Religious Beliefs Affecting Medical Care adopted.

BII.2.11    As a result of questions from physicians, the Project Administrator wrote to the Registrar of the College and was provided with the wording of the new policy,  Moral or Religious Beliefs Affecting Medical Care. The Administrator asked the Registrar to confirm that he correctly understood the policy:

I understand the expectation of referral . . . to hold in those cases in which a physician, for reasons of conscience, is unwilling to advise a patient that a procedure is legally available, or unwilling to explain precisely what is involved with the procedure, its purported risks and benefits, or provide other information a reasonable patient would need to have in order to decide whether or not to undergo an abortion (or assisted suicide, euthanasia, etc.).

In such cases, the physician is expected to direct the patient to another physician or resource who is willing to provide this information. It seems clear from the wording of all of these passages that they are meant to ensure that a patient has all of the information necessary to make an informed decision about treatment options. None of these passages imply that there is a duty to refer patients in order to facilitate abortion (or assisted suicide, euthanasia, etc.).15

BII.2.12    The Registrar responded:

You are correct in your understanding that it is a physician's obligation to ensure his or her patient has the necessary information to make an informed decision. It would be unacceptable behaviour for a physician to deny a patient access to such information.16

BII.2.13    The working group was not aware of this correspondence. However, it did not include the CPSA explanation of the policy that is available on its website to the same effect.17

BII.2.14    The correspondence and explanation make clear that the focus of the policy is the communication of information. If, for reasons of conscience, the physician cannot provide information about a treatment or service, the patient must be directed to a physician who can supply that information. Moral or Religious Beliefs Affecting Medical Care does not require an objecting physician to provide what the CPSO draft policy calls "an effective referral."

Newfoundland

BII.2.15    The working group made no reference to Newfoundland. In addition to subscribing to the CMA policies noted in II.2.1 and II.2.2, the College in Newfoundland has adopted the Physician's Charter "as forming part of the ethical foundation of medical practice in Newfoundland and Labrador." This includes the following statement:

Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.18

BII.2.16    The policies of the College of Physicians and Surgeons of Newfoundland and Labrador do not reflect the view that objecting physicians must provide what the CPSO draft policy calls "an effective referral."

Saskatchewan

BII.2.17    In addition to failing to note the CPSS adherence to the CMA Code of Ethics and related policies, the working group failed to note the College's guideline, Unplanned Pregnancy.19

BII.2.18    While it was still in preparation, media reports stated that the policy would require referral by objecting physicians.20 However, the Deputy Registrar stated that the College was merely clarifying the 1991 policy, not changing it,21 and the 1991 policy did not require objecting physicians to refer a patient to someone who would provide an abortion.22 As adopted, Unplanned Pregnancy is ambiguous with respect to referral.23

BII.2.19    The policies of the College of Physicians and Surgeons of Saskatchewan do not reflect the view that objecting physicians must provide what the CPSO draft policy calls "an effective referral."

New Brunswick

BII.2.20    An extract of the CPSNB policy document Moral Factors and Medical Care24 was provided in Appendix 3, P. 5 (p. 346).  However, the working group failed to note that it was based on the Alberta policy (BII.2.6) and failed to include the following relevant introductory paragraphs:

From time to time, physicians may be confronted with situations where they may be requested to provide a treatment or procedure to which they have an objection on moral or religious grounds. In that regard, physicians should be guided by the Code of Ethics, which advises as follows:

12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.

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.

BII.2.21    The preceding paragraphs provide the context for the direction extracted by the working group. The extract included one paragraph (reproduced below) under the sub-heading "Referrals" The sub-heading does not exist in the original text.

When moral or religious beliefs prevent a physician from providing or offering access to information about a legally available medical or surgical treatment or service, that physician must ensure that the patient who seeks such advice or medical care is offered timely access to another physician or resource that will provide accurate information about all available medical options.

BII.2.22    Moral Factors and Medical Care, like that of the College in Alberta upon which it is based, does not reflect the view that objecting physicians must provide what the CPSO draft policy calls "an effective referral."

Manitoba

BII.2.23    An extract of the CPSM policy document Discrimination in Access to Physicians25 was provided in Appendix 3, P. 1 (p. 342). However, the working group failed to include the paragraph following the extract provided:

The College has been advised that some physicians:

1. are refusing to provide care to existing patients in their practice in relation to medical issues that involve MPI, WCB or an insurance claim.

2. are refusing to accept new patients into their practice on the grounds that the patient needs assistance with respect to MPI, WCB, or an insurance claim or that the patient's care needs are too complex.

BII.2.24    Discrimination in Access to Physicians was issued as a result of a problem completely unrelated to the exercise of freedom of conscience by physicians. It does not reflect the view that objecting physicians must provide what the CPSO draft policy calls "an effective referral."

BII.2.25    The working group provide an extract of a CPSM document in Appendix 3, P. 4 (p. 345), incorrectly identified as Discrimination in Access to Physicians. The document in question is actually Members Moral or Religious Beliefs Not to Affect Medical Care.26 The extract included one paragraph (reproduced below) under the sub-heading "Referrals." The sub-heading does not exist in the original text.

If the moral or religious beliefs of a member prevent him or her from providing or offering access to information about a legally available medical or surgical treatment or service, the member must ensure that the patient who seeks such advice or medical care is offered timely access to another physician or resource that will provide accurate information about all available medical options.

BII.2.26    The wording is virtually identical to the wording of previously noted policies of the Colleges of Alberta (BII.2.6) and New Brunswick (BII.2.21). These policies are directed to ensuring that patients have information about all available medical options. They do not reflect the view that objecting physicians must provide what the CPSO draft policy calls "an effective referral."

Quebec

BII.2.27    An extract of Legal, Ethical and Organizational Aspects of Medical Practice in Québec (ALDO-Québec)27 concerning the Collège des Médecins du Québec Code of Ethics was provided in Appendix 3, P. 5 (p. 346). The extract included one sentence from the Code of Ethics under the sub-heading "Referrals" The sub-heading does not exist in the original text or Code of Ethics. ALDO-Quebec provides guidance on the interpretation and application of the Code of Ethics. The key passage included in the extract provided is:

For example, a physician who is opposed to abortion or contraception is free to limit these interventions in a manner that takes into account his or her religious or moral convictions. However, the physician must inform patients of such when they consult for these kinds of professional services and assist them in finding the services requested.

BII.2.28    This is the requirement for "effective referral" found in the CPSO draft policy.

BII.2.29    The working group did not explain that the President and Director General of the Collège des Médecins du Québec has publicly acknowledged that this nullifies freedom of conscience. This information was provided to the working group in the first Protection of Conscience Project submission.  The working group did not refer to it.  Dr. Charles Bernard told Quebec legislators:

[I]f you have a conscientious objection and it is you who must undertake to find someone who will do it, at this time, your conscientious objection is [nullified]. It is as if you did it anyway. / [Original French] Parce que, si on a une objection de conscience puis c'est nous qui doive faire la démarche pour trouver la personne qui va le faire, à ce moment-là , notre objection de conscience ne s'applique plus.  C'est comme si on le faisait quand même.28

BII.3    Erroneous and misleading accounts of Australian policies

BII.3.1    Extracts from a document identified as Information for GPs: Conscientious Objection to the Termination of Pregnancy were provided in Appendix 3 at P. 9 (p. 350). The extracts chosen by the working group purport to represent the position of the Australian Medical Association with respect to referral for abortion by objecting physicians. They do not.

BII.3.2    Conscientious Objection to the Termination of Pregnancy: Information for GPs is actually a document released in June, 2013 by the Australian Medical Association's branch in the state of Victoria (AMA Victoria).29 It does not represent the policy of the Australian Medical Association concerning referral for morally contested services. This is not evident from the extract provided because, in copying the extracts, the working group deleted information identifying the source.

BII.3.3    Conscientious Objection to the Termination of Pregnancy: Information for GPs pertains to the Abortion Law Reform Act of 2008 in the state of Victoria, not to national legislation. This is not evident from the extract provided because, in copying the extracts, the working group deleted the first paragraph, which identifies this Act as the focus of the document.

BII.3.4    The Abortion Law Reform Act of 2008 includes a provision that requires physicians who object to abortion for reasons of conscience or religion to refer patients to physicians who do not have such an objection.30 Contrary to the impression created by the extracts, AMA Victoria opposed the provision when the legislation was under consideration.

Victoria's doctor union has told the state government it cannot support forcing doctors who conscientiously object to abortions to refer patients on.

Their objection is the same one over which the Catholic Church has threatened to close its hospitals.

The Australian Medical Association (AMA) Victoria wrote to Premier John Brumby on September 1, telling him it could not support the conscientious objection clause of the Abortion Law Reform Bill.

The bill would legalise abortion at up to 24 weeks gestation and make it compulsory for doctors who conscientiously object to abortions to refer the woman to another health professional who has no objections.

The AMA said while it welcomed parliament legalising abortion, it could not support the conscientious objection clause and asked it to be removed or amended to reflect existing law.

"Doctors are currently not forced to provide a service they believe to be unethical or immoral," AMA Victoria president Douglas Travis said in the letter.

"AMA Victoria supports the existing law and ethical obligation to properly inform patients and ensure that services are elsewhere available.

"Respect for a conscientious objection is a fundamental principle in our democratic country, and doctors expect that their rights in this regard will be respected, as for any other citizen.". . .31

BII.3.5    Despite the opposition of AMA Victoria and others, the mandatory referral provision was retained. Conscientious Objection to the Termination of Pregnancy: Information for GPs was issued to help physicians in the state of Victoria avoid conflict with the law.  In fact, five months after AMA Victoria published it, the Association continued to lobby for the removal of the mandatory referral provision.32

BII.3.6    The actual position of the Australian Medical Association is set out in its Code of Ethics and in a supplementary policy on conscientious objection issued in 2013. Neither of these documents was included in Appendix 3 by the working group. The AMA Code of Ethics states:

1.1.p. When a personal moral judgement or religious belief alone prevents you from recommending some form of therapy, inform your patient so that they may seek care elsewhere.33

BII.3.7    Similar statements are included in two other AMA documents, neither of which were included in Appendix 3 by the working group.

Reproductive Health And Reproductive Technology (1998: Revised 2005)
6. When a personal moral judgement or religious belief prevents doctors from recommending some form of therapy, they should so inform their patients. They should also inform patients that such therapy may be available elsewhere.34

Ethical Issues in Reproductive Medicine (2013)
1.6. A doctor who chooses not to provide clinical services, or conduct research, in reproductive medicine should not be subject to discrimination or stigmatisation.

1.7. A doctor should not be expected to participate in clinical or research activities that conflict with his or her personal convictions. When a doctor faces these conflicts, they should inform their patients so that they may seek care elsewhere and should not impede access to care. In an emergency situation, doctors are required to continue care for the patient until their services are no longer required.35

BII.3.8    An explanation of this section of the Code within the context of the state of Victoria's abortion law was provided in 2009 by AMA Secretary General Francis Sullivan. He stated that the Code "does not mean that doctors have a duty to directly refer the patient for the specific treatment in question."  Further:

"Proponents for the bill argued that the existing Victorian law was not changing, and the inclusion of the referral clause for doctors exercising their conscience was no different to what doctors understood their Code to instruct. Their Code being the AMA Code. Now it's important to know that in actual fact the AMA Code does not say that doctors are obliged to refer."36

Conscience Laws & Heathcare Conference
Francis Sullivan from CDAV on Vimeo.

BII.3.9    The Australian Medical Association's lengthy position statement, Conscientious Objection was issued in 2013.37 Of particular relevance to the draft CPSO policy is the following:

1. Doctors (medical practitioners) are entitled to have their own personal beliefs and values, as are all members of society. There may be times, however, where a doctor's personal beliefs conflict with their peer-based professional practice. In exceptional circumstances, and as a last resort, a doctor may refuse to provide, or participate in, certain medical treatments or procedures that conflict with his or her own personal beliefs. [For the purposes of this position statement, 'participation' may include indirect actions such as referring the patient to another doctor who will provide the service.]

BII.3.10    Thus, the actual position of the Australian Medical Association on this point is exactly the opposite of what is implied in the materials supplied by the working group.

BII.3.11    The materials supplied by the working group in Appendix 3 do not advert to the position taken by AMA Tasmania when the state legislature was considering the Reproductive Health (Access to Terminations) Act (No. 72 of 2013). An early version of the bill included a provision like that in the Victoria law that would have required a physician who objected to abortion to refer a patient to a non-objecting physician. AMA Tasmania opposed this clause.

Mandating a conscientious objector to make a referral to another doctor could be viewed as denying that doctor the ability to live according to their beliefs (if the person considers providing a referral to be participating in an activity to which they object).38

BII.3.12    It is instructive to note that a representative of the Australian Health Practitioner Regulation Association reportedly told a Tasmanian legislative committee that physicians who object to a procedure for reasons of conscience are obliged by professional codes of ethics to refer patients to another physician. This was precisely the kind of misrepresentation described by Francis Sullivan with respect to the Victoria abortion law (BII.3.8). The AMA Tasmania submission disproved that claim, quoting the AMA Code of Ethics, the AMA position statement on Reproductive Health And Reproductive Technology, and the Medical Board of Australia Code of Conduct .39

BII.3.13    The Australian Medical Council is a national standards body for medical education and training.40 The extracts in Appendix 3, p. 9 (P. 350) attributed to a General Medical Council are from a draft code of conduct developed by the Council41 and subsequently adopted by the Medical Board of Australia.42

BII.3.14    Contrary to the impression created by the extracts in Appendix 3 at p. 9 (P. 350), the policies of the Australian Medical Council, Medical Board of Australia and the Australian Medical Association do not reflect support of a policy of "effective referral" proposed in the CPSO draft policy. In fact, the actual position of the Australian Medical Association on this point is exactly the opposite of what is implied in the materials supplied by the working group.

BII.4    Deficient and seriously misleading accounts re: New Zealand

BII.4.1    Extracts of the Medical Council of New Zealand policy document Good Medical Practice concerning "Personal Beliefs and the Patient"43  were provided in Appendix 3, P. 8 (p. 349). The extracts were accurate, but the working group failed to include reference to the Contraception, Sterilisation, and Abortion Act (1977)44 which provides for conscientious objection by health care workers, including physicians, nurses and pharmacists:

 46. Conscientious objection
(1) Notwithstanding anything in any other enactment, or any rule of law, or the terms of any oath or of any contract (whether of employment or otherwise), no registered medical practitioner, registered nurse, or other person shall be under any obligation-

(a) To perform or assist in the performance of an abortion or any operation undertaken or to be undertaken for the purpose of rendering the patient sterile:

(b) To fit or assist in the fitting, or supply or administer or assist in the supply or administering, of any contraceptive, or to offer or give any advice relating to contraception,

if he objects to doing so on grounds of conscience.

BII.4.2    The working group also failed to include reference to the Health Practitioners Competence Assurance Act 2003:45

174. Duty of health practitioners in respect of reproductive health services

(1) This section applies whenever -

(a) a person requests a health practitioner to provide a service (including, without limitation, advice) with respect to contraception, sterilisation, or other reproductive health services; and

(b) the health practitioner objects on the ground of conscience to providing the service.

(2) When this section applies, the health practitioner must inform the person who requests the service that he or she can obtain the service from another health practitioner or from a family planning clinic.

BII.4.3    The working group also failed to include reference to a 2010 decision of the High Court in Wellington, New Zealand, that considered both of these statutes. Mr. Justice Alan MacKenzie ruled that the General Medical Council could not force objecting physicians to provide what the draft CPSO policy calls "an effective referral" for abortion.46

BII.4.4    The failure to include the statutory provisions and outcome of Hallagan et al v. General Medical Council NZ in Appendix 3 is likely to leave a reader with the false impression that New Zealand has no guidelines concerning referral for morally contested procedures.

BII.4.5    Contrary to the impression that might be created by the extracts in Appendix 3, P. 8 (p. 349), GMC New Zealand policies do not reflect support of a policy of "effective referral" proposed in the CPSO draft policy. In fact, the law in New Zealand prohibits it.

BII.5    Deficient and superficial accounts re: United States

BII.5.1    A single sentence from an article in Virtual Mentor titled "Legal Protection for Conscientious Objection by Health Professionals" was provided in Appendix 3, P. 10 (p. 351) as representative of the position of the American Medical Association. Virtual Mentor (now the AMA Journal of Ethics) is a source of short essays about medical ethics that present a wide range of opinions on a variety of topics, including freedom of conscience in health care. They do not necessarily represent the position of the American Medical Association. In fact, the article was about conscientious objection among pharmacists, not about the policies of the American Medical Association concerning freedom of conscience in health care.47

BII.5.2    In November, 2014, the AMA House of Delegates adopted a new policy concerning physician exercise of freedom of conscience, which will be formally issued in June. The AMA website states, "Reports not available online (such as those recently adopted by the AMA and pending publication) are made available upon request by contacting CEJA staff."48

BII.5.3    A policy document of the American College of Obstetricians and Gynecologists was quoted at length in Appendix 3, P. 10 (p. 351). The Limits of Conscientious Refusal in Reproductive Medicine49 is a controversial document. It was discussed in hearings into "Conscience in the Practice of the Health Professions" held by the President's Council on Bioethics under the chairmanship of Dr. Edmund D. Pellegrino. Professor Robert P. George critiqued the document.

. . .The report . . . in its driving assumptions, reasoning, and conclusions is not morally neutral. . . It represents a partisan position among the family of possible positions debated or adopted by people of reason and goodwill in the medical profession and beyond. Indeed, for me, the partisanship of the report is its most striking feature. . .

. . .The report's "my way or the highway" view of the thing is anything but an acknowledgement of the widespread and thoughtful disagreement among physicians and society at large and the moral sincerity of those with whom one disagrees. Indeed, it is a repudiation of it.50

BII.5.4    The Limits of Conscientious Refusal in Reproductive Medicine and the response to it by critics is a practical introduction to the kind of serious conflicts underway in the United States concerning the exercise of freedom of conscience by health care workers. It is by no means an uncontested model policy.

BII.5.5    The recommendations of the American Academy of Pediatrics are quite different in tone and substance and largely unexceptionable. A duty of referral is generally recognized by objecting health care workers when failure to do so would result in death or serious injury to a patient, so the acceptability of the AAP assertion of a duty to refer to avoid "harm" to a patient depends entirely upon what the AAP means by "harm."51

BII.5.6    As in the case of New Zealand, Appendix 3 failed to refer to the existence of American laws that are relevant to the exercise of freedom of conscience by physicians. There are numerous federal laws protection of conscience laws, and almost every state has protection of conscience provisions in its laws.52

BII.5.7    For example: the new Patient Protection and Affordable Care Act, a federal law intended to provide health care insurance coverage, includes the following provision:

IN GENERAL -Nothing in this Act shall be construed to have any effect on Federal laws regarding-

(i) conscience protection;
(ii) willingness or refusal to provide abortion; and
(iii) discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion. (Emphasis added)53

In General- The Federal Government, and any State or local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made by this Act) or any health plan created under this Act (or under an amendment made by this Act), may not subject an individual or institutional health care entity to discrimination on the basis that the entity does not provide any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing. (Emphasis added)54

BII.5.8    Among state laws, Illinois' Health Care Right of Conscience Act is the most comprehensive. In force since 1998, it prohibits discrimination against individuals or facilities that refuse to "receive, obtain, accept, perform, assist, counsel, suggest, recommend, refer or participate in any way in any particular form of health care services contrary to his or her conscience." (Emphasis added)55

BII.5.9   As an outline of the situation in the United States relevant to the draft CPSO policy requiring "an effective referral," Appendix 3 is deficient and superficial.

BII.6    Deficient and misleading account of Ontario nursing policies

BII.6.1    A paragraph of the College of Nurses of Ontario policy document Ethics was provided in Appendix 3, P. 6 (p. 347). The paragraph appears in three places in the document. The first was taken from a discussion of conflict between client choice and a nurse's values. The context for the chosen paragraph was a discussion of a client's choice of risky behaviours. This was summarized in the sentence immediately preceding the chosen paragraph:

Nurses may believe that, as health care professionals, they know what is best for clients; however, clients have the right to choose a risky course of action.56

BII.6.2    The scenarios and behavioural directives provided in Ethics following the chosen paragraph confirmed the context: an competent 85 year old patient who likes to walk along a busy highway, and a patient with difficulty swallowing who insists on solid rather than puréed food.57

BII.6.3    The paragraph appears a second time under the heading, "Respect for life," the context for which was established in the preceding paragraph:

Health care professionals need to make every reasonable effort to preserve human life. Technology now allows life to be preserved longer. Many health care professionals and clients believe that some treatments that preserve life at all costs are unacceptable when the quality of life is questionable.58

BII.6.4    The scenario and behavioural directives provided in Ethics following the chosen paragraph concerned a case in which the health care team was considering the use of a feeding tube, contrary to direction given by a patient who has since become uncommunicative, subject to the consent of her spouse.59

BII.6.5    The paragraph appears a third time under the heading, "Maintaining commitments to oneself," the context for which was established in the preceding paragraph:

As people learn and grow, they develop their personal values and beliefs. Nurses need to recognize and function within their value system and be true to themselves. Nurses' values sometimes differ from those of other health care professionals, employers and clients, causing ethical conflict. Nurses must provide ethical care while at the same time remaining committed to their values.60

BII.6.6    The scenario and behavioural directives provided in Ethics following the chosen paragraph concerned a case in which a family had directed the withdrawal of a feeding tube from a comatose patient.61

BII.6.7    The working group selected the paragraph from Ethics provided in Appendix 3 without providing the context. The first case is not analogous to situations in which nurses decline to participate in treatment for reasons of conscience. The second and third scenarios do not involve situations in which a nurse is ordered to do something she believes to be wrong. More important, the problems presented in the latter scenarios can be resolved by referring to documents and legislation neglected by the working group.

BII.6.8    The working group did not provide relevant information from another College of Nurses policy document, Refusing Assignments and Discontinuing Nursing Services, more pertinent to situations in which nurses decline to provide treatment for reasons of conscience. According to this document, discontinuing nursing services constitutes patient abandonment when, having accepted an assignment, a nurse discontinues care without

  • getting the client's permission;
  • arranging a suitable alternative or replacement service; or
  • allowing a reasonable opportunity for alternative or replacement services to be provided.62 (Emphasis added)

BII.6.9    This almost exactly parallels the legal definition of professional misconduct in such circumstances defined by Ontario Regulation 799/93, which, in defining professional misconduct, includes the following:

5. Discontinuing professional services that are needed unless,

i. the client requests the discontinuation,

ii. alternative or replacement services are arranged, or

iii. the client is given a reasonable opportunity to arrange alternative or replacement services.63 (Emphasis added)

BII.6.10    Refusing Assignments and Discontinuing Nursing Services and the regulation both provide alternatives that would likely be acceptable to most objecting nurses (see boldface passages above), since they do not require an objecting nurses to actively find someone willing to do what they find objectionable. The alternatives they provide would resolve the problems presented in the scenarios presented in Ethics, without requiring the objecting nurse to arrange for the morally contentious treatment or procedure to be done by someone else, or forcing the objecting nurse to quit her job or leave the profession.

BII.6.11    Finally, the working group failed to include reference to the Code of Ethics of the Canadian Nurses Association:

 7. If nursing care is requested that is in conflict with the nurse's moral beliefs and values but in keeping with professional practice, the nurse provides safe, compassionate and competent ethical care until alternative care arrangements are in place to meet the person's needs or desires. If nurses can anticipate a conflict with their conscience, they have an obligation to notify their employers, or, if the nurse is self-employed, persons receiving care in advance, so that alternative arrangements can be made.64 (Emphasis added)

BII.6.12    This is considered in greater detail in Appendix "D" to the Code, which provides:

 4. When a moral objection is made, the nurse provides for the safety of the person receiving care until there is assurance that other sources of nursing care are available.65

BII.6.13    Note that the Code does not require the objecting nurse to find someone to provide morally contested treatment (see boldface passages above), and that this is consistent with one of the alternatives available in Refusing Assignments and Discontinuing Nursing Services and the Ontario regulation. This is consistent with the experience of an Advanced Practice Nurse commenting on the draft CPSO policy:

 I've always worked as a nurse on health care teams that respect diversity. If I were assigned the care of a patient who has a medication or procedure that I can't provide for reasons of conscience, I would continue to provide nursing care to her and alert my team that I couldn't provide the treatment as soon as the ethical dilemma arose. However, I wouldn't make "an effective referral" to a colleague the way the CPSO draft recommends.66

BII.6.14    The deficient information provided by the working group in Appendix 3 is likely to mislead readers by causing them to believe that nurses in Ontario are obliged to provide treatments to which they object for reasons of conscience, to find someone who will provide such treatments in their stead, or to quit their jobs or leave the profession. That is incorrect.

BII.7    Deficient account of Ontario midwife policies

BII.7.1    Three sections of the College of Midwives of Ontario Code of Ethics were provided in Appendix 3, P. 6 (p. 347). The working group included one section from the text under the sub-heading "Referrals." The sub-heading does not exist in the Code. The section states:

11. Assist clients to find appropriate alternate care if for any reason she finds herself unable to provide care.67

BII.7.2    Assuming that "unable" may include "unwilling for reasons of conscience," there is a conflict between the Code and the relevant regulation. Ontario Regulation 388/09 defines professional misconduct in such circumstances:

8. Discontinuing professional services respecting a client unless,

i. the client requests the discontinuation,

ii. alternative services acceptable to the client are arranged,

iii. there is no longer a relationship of trust and confidence between the midwife and the client and the client is given a reasonable opportunity to arrange alternative services, or

iv. the client requests services inconsistent with the standards of practice of the profession and the midwife has adhered to the standard of practice for discontinuing care in such circumstances.68

BII.7.3    The regulation provides alternatives that would likely be acceptable to most objecting midwives (see boldface passages above), since they do not require an objecting midwives to actively find someone willing to do what they find objectionable.

BII.7.4    There are two significant differences between the practice of midwives and other health professionals like nurses or physicians which reduce the probability of unreconcilable conflicts of conscience.

  • First: their scope of practice is restricted to "assessment and monitoring of women during pregnancy, labour and the post-partum period and of their newborn babies, the provision of care during normal pregnancy, labour and post-partum period and the conducting of spontaneous normal vaginal deliveries,"69 and to a limited number of activities or procedures specified by statute.70 On the surface, at least, none of these seem to involve morally contentious services.

  • Second: in order to ensure continuity, midwifery care is supposed to be delivered not by one but by a group of up to four midwives, one of whom is identified as the coordinating midwife,71 and two midwives must attend each birth.72 This would seem to allow accommodation of conscientious objections by individuals with minimal conflict, particularly in view of the options made available by regulation.

BII.7.5    It is thus doubtful that the Code of Ethics for midwives is a suitable model for comparison with the draft CPSO policy, but this is not apparent because the information provided by the working group in Appendix 3 was deficient.

BII.8    Neglect of significant documents from Canadian authorities

BII.8.1    A joint statement relevant to the subject of the draft CPSO policy has been produced by

  • the Canadian Medical Association
  • Canadian Healthcare Association
  • the 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)

Part I, Para. 16. Health care providers should not be expected or required to participate in procedures that are contrary to their professional judgement or personal moral values or that are contrary to the values or mission of their facility or agency. Health care providers should declare in advance their inability to participate in procedures that are contrary to their professional or moral values. Health care providers should not be subject to discrimination or reprisal for acting on their beliefs. The exercise of this provision should never put the person receiving care at risk of harm or abandonment.

Part II, Para. 10: If the person receiving care or his or her proxy is dissatisfied with the decision, and another care provider, facility or agency is prepared to accommodate the person's needs and preferences, provide the opportunity for transfer.

Part II, Para. 11: If a health care provider cannot support the decision that prevails as a matter of professional judgement or personal morality, allow him or her to withdraw without reprisal from participation in carrying out the decision, after ensuring that the person receiving care is not at risk of harm or abandonment.5

BII.8.2    The Supreme Court of Canada cited this document in Cuthbertson v. Rasouli as one of the statements of professional organizations that provide guidance to physicians.73 It is also cited by the Royal College of Physicians and Surgeons of Canada in its primer on conflict resolution.74

BII.8.3    The Royal College of Physicians and Surgeons of Canada has published a primer on conflict resolution.  It stresses that a collaborative approach is the preferred method that leads to "creative, durable outcomes."74

BII.8.4    The working group did not refer to either of these documents.   


Notes

1.  Council Briefing Note: Professional Obligations and Human Rights- Draft for Consultation. Appendix 3: Jurisdictional Review.

2.  Canadian Medical Association Code of Ethics (Update 2004) (Accessed 2015-02-16)

3.  Canadian Medical Association Policy: Induced Abortion (1988). (Accessed 2015-02-13)

4.  Blackmer J. "Clarification of the CMA's position concerning induced abortion." CMAJ April 24, 2007 vol. 176 no. 9 1310 (Accessed 2015-02-13)

5.  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)

6.  In the SCC on appeal from the BCCA, Factum of the Intervener, The Canadian Medical Association.

7.  Supreme Court of Canada Webcast, 15 October, 2014 [228:32/491:20] Harry Underwood (Counsel for the Canadian Medical Association) oral submission, (Accessed 2015-02-12)

8.  College of Physicians and Surgeons of British Columbia, Code of Ethics. (Accessed 2015-02-11); College of Physicians and Surgeons of Alberta, Code of Ethics. (Accessed 2015-02-11); College of Physicians and Surgeons of Saskatchewan, Code of Ethics. (Accessed 2015-02-12); College of Physicians and Surgeons of Nova Scotia, CMA Code of Ethics. (Accessed 2015-02-11); College of Physicians and Surgeons of Newfoundland and Labrador, By-Law 5: Code of Ethics (Amended) (Accessed 2015-02-11); College of Physicians and Surgeons of PEI, CMA Code of Ethics (Updated 2004) (Accessed 2015-02-11)

9.  College of Physicians and Surgeons of British Columbia, Access to Medical Care. (Accessed 2015-02-13)

10.  Letter from the Deputy Registrar of the College of Physicians and Surgeons of British Columbia to the Administrator, Protection of Conscience Project, dated 27 February, 2013.

11.  Letter from the Deputy Registrar of the College of Physicians and Surgeons of British Columbia to the Administrator, Protection of Conscience Project, dated 22 March, 2013.

12.  College of Physicians and Surgeons of Alberta, Moral or Religious Beliefs Affecting Medical Care. (Accessed 2015-02-13)

13.  Protection of Conscience Project, Submission to the College of Physicians and Surgeons of Alberta Re: CPSA Draft Standards of Practice (8 October, 2008), II.5.

14.  "Registrar's Report: Draft standard for termination of pregnancy." The Messenger, April, 2009, p. 3 (Accessed 2015-02-12)

15.  Letter from the Administrator, Protection of Conscience Project to the Registrar of the College of Physicians and Surgeons of Alberta, dated 17 August, 2009.

16.  Letter from the Registrar of the College of Physicians and Surgeons of Alberta to the Administrator, Protection of Conscience Project, dated 24 August, 2009.

17.  The Messenger, "Are you up to Standard? Moral or Religious Beliefs Affecting Medical Care." 5 December, 2013. (Accessed 2015-02-12)

18.  College of Physicians and Surgeons of Newfoundland and Labrador, Medical Professionalism in the New Millenium - A Physician's Charter. (Accessed 2015-02-11)

19.  College of Physicians and Surgeons of Saskatchewan, Guideline: Unplanned Pregnancy. (Accessed 2015-02-12)

20.  "Saskatchewan Updates Abortion Policy." Edmonton Sun, 9 February, 2011; Toronto Sun, 9 February, 2011 (Accessed 2011-02-09); Scissons, Hannah, and Boesveld, Sarah, "Anti-abortion Docs Must Provide Referrals." National Post, 9 February, 2011. (Accessed 2011-02-09)

21.  Scissons, Hannah, "Abortion Guidelines Updated: Rules clarify protocol for doctors unwilling to terminate pregnancy." Star Phoenix, 9 February, 2011 (Accessed 2011-02-09)

22.  Protection of Conscience Project, College of Physicians and Surgeons of Saskatchewan
1991 / 2010 Guideline compared
(2011-03-21)

23.  Murphy S. "Clarifying the Clarification: College of Physicians and Surgeons of Saskatchewan Guideline on Unplanned Pregnancy." Protection of Conscience Project.

24.  College of Physicians and Surgeons of New Brunswick, Moral Factors and Medical Care. (Accessed 2015-02-13)

25.  College of Physicians and Surgeons of Manitoba, Statement 173: Discrimination in Access to Physicians. (Accessed 2015-02-13)

26.   College of Physicians and Surgeons of Manitoba, Statement: Members Moral or Religious Beliefs Not to Affect Medical Care. (Accessed 2015-02-11)

27.   Legal, Ethical and Organizational Aspects of Medical Practice in Québec (ALDO-Québec): Conscientious Objection (Accessed 2015-02-13)

28.  Consultations, Tuesday 17 September 2013 - Vol. 43 no. 34: Collège des médecins du Québec, (Dr. Charles Bernard, Dr. Yves Robert, Dr. Michelle) T#154

29.  AMA Victoria, Abortion - conscientious objection template and information for GPs (26 June, 2013) (Accessed 2015-02-14)

30.  Murphy S. "State of Victoria, Australia demands referral, performance of abortions: Abortion Law Reform Act 2008." Protection of Conscience Project

31.  "Vic:AMA says that it is against abortion objector clause." Medical Search, 24 September, 2008 (Accessed 2015-02-14)

32.  Cook H. "Abortion law changes eyed as Dr Mark Hobart probed." The Age, 7 November, 2013 (Accessed 2015-02-19)

33.  Australian Medical Association Code of Ethics 2004 (Editorially Revised 2006)
(Accessed 2015-02-13)

34.  Australian Medical Association Position Statement: Reproductive Health And Reproductive Technology (1998: Revised 2005). (Accessed 2015-02-14)

35.  Australian Medical Association Position Statement: Ethical Issues in Reproductive Medicine (2013) (Accessed 2015-02-14)

36.  Sullivan F. "Freedom of Conscience and Good Medical Practice: The AMA's position." Conscience Laws and Healthcare Conference, 25 July, 2009.

37.  Australian Medical Association Position Statement: Conscientious Objection (2013) (Accessed 2015-02-14)

38.  Australian Medical Association Tasmania Ltd., Submission to the Tasmanian Government on the law governing termination of pregnancy, 5 April, 2013. [Extracts concerning freedom of conscience; Full text (Accessed 2015-02-14)]

39.  Murphy S. "Australian regulator misrepresents physician obligations: Claim that practitioner codes require referral disproved by Australian Medical Association." Protection of Conscience Project

40.  Australian Medical Council, About the Australian Medical Council (Accessed 2015-02-14)

41.  Australian Medical Council, Good Medical Practice: A Code of Conduct for Doctors in Australia. (2009) (Accessed 2015-02-14)

42.  Medical Board of Australia, Good medical practice: a code of conduct for doctors in Australia (March, 2014) (Accessed 2015-02-14)

43.  Medical Council of New Zealand, Good Medical Practice (April, 2013) (Accessed 2015-02-14)

 44.  Contraception, Sterilisation, and Abortion Act (1977)

45.  Health Practitioners Competence Assurance Act 2003

 46.  In the High Court of New Zealand, Wellington Registry, CIV-2010-485-222, Between Catherine Mary Hallagan, First Plaintiff, and New Zealand Health Professionals Alliance Incorporated, Second Plaintiff, and Medical Council of NZ, Defendant (2 December, 2010)

47.  Grady A. "Legal Protection for Conscientious Objection by Health Professionals." AMA Journal of Ethics/Virtual Mentor. May 2006, Volume 8, Number 5: 327-331.(Accessed 2015-02-14)

48.  American Medical Association, CEJA Reports (http://www.ama-assn.org/ama/pub/about-ama/our-people/ama-councils/council-ethical-judicial-affairs/ceja-reports.page?) Accessed 2015-02-17

49.  American College of Obstetricians and Gynecologists, ACOG Committee Opinion No. 385, The Limits of Conscientious Refusal in Reproductive Medicine. (Accessed 2015-02-15)

50.  The President's Council on Bioethics, Thursday, September 11, 2008. Session 3: Conscience in the Practice of the Health Professions. Professor Robert P. George

51.  American Academy of Pediatrics Committee on Bioethics, Physician Refusal to Provide Information or Treatment on the Basis of Claims of Conscience. Pediatrics Vol. 124 No. 6 December 1, 2009 pp. 1689 -1693 (doi: 10.1542/peds.2009-2222) (Accessed 2015-02-14)

52.  Protection of Conscience Laws - United States. Protection of Conscience Project

53.  Patient Protection and Affordable Care Act, Public Law 111-148, Sec. 1303(c)2(A)

54.  Patient Protection and Affordable Care Act, Public Law 111-148, Sec. 1553(a)

55.  Illinois Health Care Right of Conscience Act, Sections 5, 10

56.  College of Nurses of Ontario Practice Standard: Ethics, p. 6 (Accessed 2015-02-15)

57.  College of Nurses of Ontario Practice Standard: Ethics, p. 7 (Accessed 2015-02-15)

58.  College of Nurses of Ontario Practice Standard: Ethics, p. 9 (Accessed 2015-02-15)

59.  College of Nurses of Ontario Practice Standard: Ethics, p. 9-10 (Accessed 2015-02-15)

60.  College of Nurses of Ontario Practice Standard: Ethics, p. 10 (Accessed 2015-02-15)

61.  College of Nurses of Ontario Practice Standard: Ethics, p. 10 (Accessed 2015-02-15)

62.  College of Nurses of Ontario Practice Standard: Refusing Assignments and Discontinuing Nursing Services, p. 5 (Accessed 2015-02-15)

63.  Nursing Act, 1991, Ontario Regulation 799/93, Professional Misconduct (Accessed 2015-02-15)

64.  Canadian Nurses Association, Code of Ethics for Registered Nurses (2008) (Accessed 2015-02-15)

65.  Canadian Nurses Association, Code of Ethics for Registered Nurses (2008) (Accessed 2015-02-15)

66.  Helen McGee, Advanced Practice Nurse. Webcast on Ontario Physicians' Conscience Rights, [40:04- 40:32] (Accessed 2015-02-15)

67.  College of Midwives of Ontario, Code of Ethics (Accessed 2015-02-15)

68.  Midwifery Act, 1991, Ontario Regulation 388/09: Professional Misconduct
(Accessed 2015-02-15)Midwifery Act, 1991, Section 3 (Accessed 2015-02-15)

69.  Midwifery Act, 1991, Section 3 (Accessed 2015-02-15)

70.  Midwifery Act, 1991, Section 4 (Accessed 2015-02-15)

71.  College of Midwives of Ontario, Continuity of Care (Accessed 2015-02-15)

72.  College of Midwives of Ontario, The Ontario Midwifery Model of Care (January 2014)
(Accessed 2015-02-15)

73. Cuthbertson v. Rasouli, 2013 SCC 53, [2013] 3 S.C.R, para. 198 (Accessed 2015-02-16)

74.  Marshall P, Robson R.  "Conflict Resolution."  Royal College of Physicians and Surgeons of Canada.

 

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