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Protection of Conscience Project

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Service, not Servitude
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Submission to the College of Physicians and Surgeons of Ontario
Re: Interim Guidance on Physician Assisted Death

Appendix "C"

Physician Exercise of Freedom of Conscience and Religion


C1.    Introduction

C1.1     To minimize inconvenience to patients and avoid conflict, physicians should develop a plan to meet the requirements of Parts C2 and C3 for services they are unwilling to provide for reasons of conscience or religion.

C2.    Providing information to patients

C2.1     This Part highlights points of particular interest within the context of the exercise of freedom of conscience. It is not an exhaustive treatment of the subject of informed consent.

C2.2     In exercising freedom of conscience and religion, physicians must provide patients with sufficient and timely information to make them aware of relevant treatment options so that they can make informed decisions about accepting or refusing medical treatment and care.

C2.3     Sufficient information is that which a reasonable patient in the place of the patient would want to have, including diagnosis, prognosis and a balanced explanation of the benefits, burdens and risks associated with each option.

C2.4     Information is timely if it is provided as soon as it will be of benefit to the patient. Timely information will enable interventions based on informed decisions that are most likely to cure or mitigate the patient’s medical condition, prevent it from developing further, or avoid interventions involving greater burdens or risks to the patient.

C2.5     Relevant treatment options include all legal and clinically appropriate procedures, services or treatments that may have a therapeutic benefit for the patient, whether or not they are publicly funded, including the option of no treatment or treatments other than those recommended by the physician.

C2.6 Physicians whose medical opinion concerning treatment options is not consistent with the general view of the medical profession must disclose this to the patient.

C2.7     The information provided must be responsive to the needs of the patient, and communicated respectfully and in a way likely to be understood by the patient. Physicians must answer a patient’s questions to the best of their ability.

C2.8     Physicians who are unable or unwilling to comply with these requirements must promptly arrange for a patient to be seen by another physician or health care worker who can do so.

C3.    Exercising freedom of conscience or religion

C31     In exercising freedom of conscience and religion, physicians must adhere to the requirements of Part CII (Providing information to patients).

C3.2     In general, and when providing information to facilitate informed decision making, physicians must give reasonable notice to patients of religious, ethical or other conscientious convictions that influence their recommendations or practice or prevent them from providing certain procedures or services. Physicians must also give reasonable notice to patients if their views change.

C3.3     Notice is reasonable if it is given as soon as it would be apparent to a reasonable and prudent person that a conflict is likely to arise concerning treatments or services the physician declines to provide, erring on the side of sooner rather than later. In many cases - but not all - this may be prior to accepting someone as a patient, or when a patient is accepted.

C3.4     In complying with these requirements, physicians should limit discussion related to their religious, ethical or moral convictions to what is relevant to the patient’s care and treatment, reasonably necessary for providing an explanation, and responsive to the patient’s questions and concerns.

C3.5     Physicians who decline to recommend or provide services or procedures for reasons of conscience or religion must advise affected patients that they may seek the services elsewhere, and provide information about how to find other service providers. Should the patient do so, physicians must, upon request, transfer the care of the patient or patient records to the physician or health care provider chosen by the patient.

C3.6     Alternatively, in response to a patient request, physicians may respond in one of the following ways, consistent with their moral, ethical or religious convictions: 

a) by arranging for a transfer of care to another physician able to provide the service; or

b) by providing a formal referral to someone able to provide the service; or

c) by providing contact information for someone able to provide the service; or

d) by providing contact information for an agency or organization that will refer the patient to a service provider; or

e) by providing contact information for an agency or organization that provides information the patient may use to contact a service provider; or

f) by providing non-directive, non-selective information that will facilitate patient contact with other physicians, heath care workers or sources of information about the services being sought by the patient.

C3.7     A physician’s response under C3.5 or C3.6 must be timely. Timely responses will enable interventions based on informed decisions that are most likely to cure or mitigate the patient’s medical condition, prevent it from developing further, or avoid interventions involving greater burdens or risks to the patient.

C3.8     In acting pursuant to C3.5 or C3.6, physicians must continue to provide other treatment or care until a transfer of care is effected, unless the physician and patient agree to other arrangements.

C3.9     Physicians unwilling or unable to comply with these requirements must promptly arrange for a patient to be seen by another physician or health care worker who can do so.

C3.10     Physicians who provide medical services in a health care facility must give reasonable notice to a medical administrator of the facility if religious, ethical or other conscientious convictions prevent them from providing certain procedures or services, and those procedures or services are or are likely to be provided in the facility. In many cases - but not all - this may be when the physician begins to provide medical services at the facility.

C4.    Reminder: treatments in emergencies

C4.1     Physicians must provide medical treatment that is within their competence when a patient is likely to die or suffer grave injury if the treatment is not immediately provided, or immediately arrange for the patient to be seen by someone competent to provide the necessary treatment.

C4.2     Physicians who fail to provide or arrange for medical treatment in such circumstances may be liable for negligence or malpractice.


Notes

1.  Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) (Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses’ Association, Catholic Health Association of Canada)  "I.1 Open communication, within the confines of privacy and confidentiality, is also required. All those involved in decision-making should be encouraged to express their points of view, and these views should be respectfully considered. Care providers should ensure that they understand the needs, values and preferences of the person receiving care. To avoid misunderstanding or confusion, they should make their communications direct, clear and consistent. They should verify that the person receiving care understands the information being conveyed: silence should not be assumed to indicate agreement. The person receiving care should be provided with the necessary support, time and opportunity to participate fully in discussions regarding care."

2.  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 2015-09-22.

3.  Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (May, 2006) Accessed 2015-09-15.

4.  Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2016) "Section 1.2: The attending physician must disclose to the patient information regarding their health status, diagnosis, prognosis, the certainty of death upon taking the lethal medication, and alternatives, including comfort care, palliative and hospice care, and pain and symptom control." Accessed 2016-01-09.

5.  Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2016) "Section 5.2: . . . physicians are expected to provide the patient with complete information on all options available to them, including assisted dying, and advise the patient on how they can access any separate central information, counseling, and referral service." Accessed 2016-01-09.

6.  Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) (Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses’ Association, Catholic Health Association of Canada) "I.7 Informed decision-making requires that the person receiving care or his or her proxy be given all information and support necessary for assessing the available options for care, including the potential benefits and risks of the proposed course of action and of the alternatives, including palliative care."

7.  Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (May, 2006): Standard of disclosure; Some practical considerations. Accessed 2016-01-09.

8.  Canadian Medical Association Code of Ethics (2004): "23. Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patient or to others. . ."  Accessed 2015-09-22.

9.  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 2015-09-22.

10.  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 2015-09-22.

11.  Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (May, 2006): Standard of disclosure; Some practical considerations. "3. A physician must answer any specific questions posed by the patient as to the risks involved in the proposed treatment. Always the patient must be given the opportunity to ask questions."  Accessed 2016-01-09

12.  Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2016) "Foundational Principle (6) Dignity: All patients, their family members or significant others should be treated with dignity and respect at all times, including throughout the entire process of care at the end of life."

13.  Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2016) "Foundational Principle (10) Mutual respect: There should be mutual respect between the patient making the request and the physician who must decide whether or not to perform assisted dying. A request for assisted dying is only possible in a meaningful physician-patient relationship where both participants recognize the gravity of such a request."

14.  Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) (Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses’ Association, Catholic Health Association of Canada) "I.16 . . . Health care providers should declare in advance their inability to participate in procedures that are contrary to their professional or moral values. . ."

15.  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 2015-09-22.

16.  Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) (Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses’ Association, Catholic Health Association of Canada) "II.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."

17.   Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) (Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses’ Association, Catholic Health Association of Canada)"II.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."

18.  Canadian Medical Association Code of Ethics (2004): "19. Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted; until another suitable physician has assumed responsibility for the patient; or until the patient has been given reasonable notice that you intend to terminate the relationship." Accessed 2015-09-22.

19.  Canadian Medical Association Code of Ethics (2004): "18. Provide whatever appropriate assistance you can to any person with an urgent need for medical care. " Accessed 2015-09-22

 

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