Canada
College of Physicians and Surgeons of New Brunswick
Freedom of conscience and religion
Annotated Extracts and Links
Comment: Moral Objections
November, 2002
[Original text-
Accessed 2014-12-30]
One of the most difficult dilemmas in the patient/physician relationship
occurs when the physician has a personal moral objection to a procedure or
treatment that the patient may request or inquire about. Such issues create
a conflict between the recognized autonomy of a competent patient to make
their own decisions regarding health care and the autonomy of physicians to
practice according to their own knowledge, experience and conscience.
It is the Council's view that the autonomy of both patients and
physicians can be respected, on the basis of physicians following the
principles of good medical practice, the Code of Ethics, and College
Regulations.
To that end, it is a basic obligation under the Code of Ethics and
College Regulations for physicians to advise patients when their personal
morality would influence any recommendation or practice they may make
regarding a patient. In other words, it would be improper to refuse a
patient's request without stating such. The basic requirement is that
patients should be informed as to why a physician is declining to provide
the service or treatment requested.
Council also feels that, while it is not an obligation to do so, it is
preferred practice for physicians who have such objections to refer the
patient to another where such objections may not arise. Nevertheless, if the
physician feels even that is unacceptable, Council does view it as an
acceptable alternative for the physician to provide information, upon the
patient's request, regarding resources which may be directly accessible to
the patient.
In any case, any discussions, should these issues arise, should be dealt
with in a manner which is neither judgemental, nor intimidating.
Physicians are also reminded that other factors may have some influence
here. In addition to the Code of Ethics and College Regulations, the
Human Rights Act prevents physicians discriminating in access to care
based on a number of factors, including specifically "race, colour,
religion, national origin, ancestry, place of origin, age, physical
disability, mental disability, marital status, sexual orientation or sex."
Finally, physicians are reminded that, should a complaint arise, any care
offered will be judged by accepted medical and scientific standards.
Project Annotations
In a 2001
bulletin, the Council noted "that no physician is obligated to participate in a treatment or process to which they morally object" and sought feedback about appropriate guidelines for situations in which physicians have moral or ethical
objections to a service or procedure wanted by a patient. The statement above was issued the next
year.
The identification of referral as a "preferred" but not a "required"
practice is not necessarily problematic. It prompts objecting
physicians to consider, in each case, whether or not referral is a
morally acceptable option, thus providing them with the opportunity to
refine and better articulate their ethical reasoning.
Moral Factors and Medical Care
April, 2012: Amended June, 2017
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Moral Factors and Medical Care
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Les Facteurs Ethiques et les Soins Medicaux
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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:
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Les médecins peuvent parfois recevoir des demandes d'un
traitement ou d'une intervention auxquels ils s'opposent en raison
de leurs convictions morales ou religieuses. Dans ce cas, les
médecins doivent s'appuyer sur le Code de déontologie qui recommande
ce qui suit :
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12. Inform your patient when your personal values would influence the
recommendation or practice of any medical procedure that the patient needs or
wants.
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12. Avertir le patient lorsque ses valeurs
personnelles influeraient sur la recommandation ou la pratique d'une
intervention médicale que le patient souhaite ou dont il a besoin.
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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.
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21. Fournir au patient les renseignements dont
il a besoin pour prendre des décisions éclairées concernant les
soins médicaux et répondre de son mieux à ses questions.
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Based on these principles, Council believes physicians should
respond to such situations as follows:
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En se fondant sur ces principes, le conseil estime que dans la
situation évoquée, les médecins doivent agir comme suit :
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(1) A physician must communicate clearly
and promptly about any treatments or procedures the physician
chooses not to provide because of his or her moral or religious
beliefs.
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(1) Un médecin doit faire connaître clairement
et promptement les traitements et les interventions qu'il choisit de
ne pas prodiguer en raison de ses convictions morales ou
religieuses.
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(2) A physician must not withhold information about the existence
of a procedure or treatment because providing that procedure or
giving advice about it conflicts with their moral or religious
beliefs.Project Annotation (i)
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(2) Un médecin ne peut pas refuser de donner
des renseignements sur l'existence d'une intervention ou d'un
traitement parce que le fait d'exécuter cette intervention ou de
donner des conseils s'y rapportant entre en conflit avec ses
convictions morales ou religieuses.
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(3) A physician must not promote their own moral or religious
beliefs when interacting with patients.
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(3) Un médecin ne doit pas promouvoir ses
propres convictions morales ou religieuses dans son interaction avec
les patients.
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(4) 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.Project Annotation (ii)
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(4) Lorsque les convictions morales ou
religieuses d'un médecin l'empêchent de fournir des renseignements
ou les moyens d'en obtenir concernant un traitement ou un service
médical ou chirurgical permis par la loi, ce médecin doit s'assurer
que le patient qui demande ces conseils ou ces soins médicaux a
accès en temps opportun à un autre médecin ou à d'autres ressources
qui lui fourniront des renseignements exacts sur toutes les options
médicales disponibles.
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Project Annotations
This guideline was adopted in 2012, "based on
an inititiative" by the College of Physicians and Surgeons of Alberta. It recognizes a key distinction
between providing information and providing or
facilitating a morally contested service or
procedure.
i. Physicians are expected to provide information
necessary to satisfy the requirements of informed
medical decision making, such as prognosis, the
treatments or procedures available, benefits and
burdens of treatment, risks, etc. The point here is to balance the desire of a physician to avoid
complicity in a wrongful act with the importance of informed
decision-making by the patient, which requires that the patient have all
of the information relevant for the purpose of choosing a course of
treatment. It is necessary to respect both the freedom of conscience of
the physician and the freedom and right of the patient to make a fully
informed choice.
ii. Only if a
physician is unwilling to provide this information
is an offer of "timely access" to another physician
or resource required. The purpose of arranging
timely access in this situation is to ensure that
the patient has information needed for
decision-making. Offering timely access
may be achieved in various ways.
Assistance in Dying (December, 2015)
[Full
Text]
3. In
accordance with prevailing guidelines, a physician may decline to assist a
patient in dying if the physician has a moral objection.
It is known there are
physicians who object to the concept of assisting a patient in dying and who
would resist offering any such assistance. As in other situations,
physicians are not obligated to participate in a process to which they have
a strong personal objection. Furthermore, some physicians would object
to any related activity including actively referring the patient to another
physician for purposes of accessing the patient for assistance in dying.
The current College policy does allow physicians to decline to participate,
even in a limited way such, as a direct referral.
That said, it should be remembered that a
referral by a physician does not mean the physician necessarily agrees with
the patient's chosen intervention. In many other situations, the
physician may not, but wishes to avail the patient of an opinion from a
suitable consultant regarding the issue at hand.Project Annotation (i) Similarly,in the
case of assistance in dying,Project Annotation (ii) the physician may refer the patient to an
appropriate practitioner, but still make it clear that the referring
physician is personally opposed.Project Annotation (iii) This will also offer that physician
the opportunity to provide information which will be useful in any
determination of whether the patient is eligible for assistance in dying,
including the specific diagnosis, prognosis, competence, and treatments
provided or not provided up to that point.Project Annotation (iv)
Even if the physician is
reluctant to provide an active referral, they remain obligated to provide
information to the patient regarding resources which may be directly
accessible. In other words, they cannot, by inaction, obstruct the
patient who wishes to be evaluated for this option.
Project Annotations
i.
What is assumed here is that euthanasia and assisted suicide are legitimate forms of medical treatment, an assertion that is generally rejected by objecting physicians.
ii. The analogy is faulty because it fails to recognize that there is a difference between a professional prudential judgement about the efficacy of a course of treatment and an ethical judgement that the treatment is itself immoral or contrary to medical ethics.
iii. If the purpose of the referral is to facilitate patient access to euthanasia or assisted suicide, many objecting physicians would insist that merely stating their opposition does not extinguish their moral responsibility for actively supporting such procedures and complicity in euthanasia that may follow from their referral.
iv. The discussion envisaged here could take place without the need for an objecting physician to help the patient arrange for euthanasia or assisted suicide.
The discussion of the possibility of referral is a reasonable invitation to reflection. It prompts objecting physicians to consider, in each case, whether or not referral is a morally acceptable option, thus providing them with the opportunity to refine and better articulate their ethical reasoning.
The policy recognizes a key distinction
between providing information and providing or
facilitating a morally contested service or
procedure. It also acknowledges that
physicians unwilling to provide a morally contested procedure for
reasons of conscience may also be unwilling to refer patients to
colleagues willing to provide it.