Protection of Conscience Project
Protection of Conscience Project
www.consciencelaws.org
Service, not Servitude

Service, not Servitude

Canada

College of Physicians and Surgeons of Alberta

Freedom of conscience and religion

Annotated Extracts and Links

Conscientious Objection (June, 2016)
Formerly Moral or Religious Beliefs Affecting Medical Care (In force January, 2010 - June, 2016)
[Full Text]

(1)  A regulated member must communicate promptly and respectfully about any treatments or procedures the regulated member declines to provide based on his/her Charter freedom of conscience and religion [Emphasis in original].i, Project Annotation (i)

(2)  A regulated member must not withhold information about the existence of a procedure or treatment because providing that procedure or giving advice about it conflicts with his/her Charter freedom of conscience and religion [Emphasis in original].Project Annotation (ii)

(3)  A regulated member must not promote his/her own moral or religious beliefs when interacting with patients [Emphasis in original].

(4)   When Charter freedom of conscience and religion prevent a regulated member from providing or offering access to information about a legally available medical or surgical treatment or service,Project Annotation (iii) the regulated member must ensure that the patient who seeks such advice or medical care is offered timely access to [Emphasis in original]:
  1. a regulated member who is willing to provide the medical treatment, service or information;Project Annotation (iv) or
  2. a resource that will provide accurate information about all available medical options.Project Annotation (v)
Conscientious Objection Notes

i.  Canadian Charter of Rights and Freedoms, Part I of The Constitution Act, 1982.

Project Annotations

The policy recognizes a key distinction between providing timely access to information and providing or facilitating a morally contested service or procedure.  Offering timely access to information may be achieved in various ways.

i.  Giving timely notice should help to avoid conflicts between physicians and patients.

ii.  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. 

iii.  Consistent with section (2), section (4) is concerned only with "providing or offering access to information," not providing a morally contested procedure. Only if a physician is unwilling to provide the information described in annotation (ii) is an offer of "timely access" to another physician or resource required.

iv.  An objecting physician may offer timely access to someone willing to provide the morally contested service OR to someone willing to provide information about it.  This does not oblige an objecting physician to connect a patient with someone who provides the contested service, though some may be willing to do so.

v.  That is, to someone willing to "provide accurate information," which need not be someone who provides a morally contested service.


Medical Assistance In Dying (June, 2016)
[Full Text]

1.  A regulated member who receives, considers or fulfils a written request for medical assistance in dying must do so in accordance with legislation [Emphasis in original].

***

3. A regulated member who receives an inquiry from a patient with respect to medical assistance in dying must ensure that contact information for the Alberta Health Services medical assistance in dying care coordination service is provided to the patient, or to another person identified by the patient, without delay [Emphasis in original].

4.  A regulated member who receives an oral or written request from a patient for medical assistance in dying and who declines for reasons of conscience or religion to provide or to aid in providing medical assistance in dying must ensure that reasonable access to the Alberta Health Services medical assistance in dying care coordination service is provided to the patient without delay. . .[Emphasis in original]

***

8.  In these standards, "medical assistance in dying" means:

a)  the administering by a regulated member of a substance to a person, at their request, that causes their death; or

b)  the prescribing or providing by a regulated member of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.

Project Annotations

The current legislation directly applicable is Section 241.1 of the Criminal Code and Alberta Order in Council  142/216 (10 June, 2016), Order respecting Medical Assistance in Dying Standards of Practice.  The latter is binding only in Alberta.  Sections 3 and 4 of the Order are reproduced as Sections 3 and 4 of the College standard partly reproduced above.

Section 3

Section 3 is limited to an inquiry from a patient, though the response may be directed to someone delegated by the patient.  "Inquiry" presumably means a question concerning euthanasia or assisted suicide that does not amount to a request.  This provision does not prevent a physician from responding to the question, but requires, in addition, that the patient (or delegate) be given the contact information for the Alberta Health Services medical assistance in dying care coordination service.

Section 4

Section 4 is limited to a request from a patient, and the response is to be provided to the patient.  It does not prevent an objecting physician from discussing options with the patient, including euthanasia and assisted suicide.  Although the section does not specify that the response may be provided to someone delegated by the patient, that would presumably be allowed as a matter of custom.

This provision does not require that the objecting physician provide specific contact information for the Alberta Health Services medical assistance in dying care coordination service, but "reasonable access" must be provided, which, presumably, includes sufficient information for the patient to be able to contact the service.

The patient - not the objecting physician - is responsible for contacting the service.  This is an important point, since objecting physicians frequently object to doing something that may facilitate what they perceive to be a wrongful act.

Alberta MAID Care Coordination Service (AMCCS)

The nature of the AMCCS is important because some objecting physicians are  unwilling to facilitate contact with a service primarily designed to deliver euthanasia and assisted suicide.  There is usually no objection to facilitating contact with a general end-of-life care co-ordinating service even if euthanasia and assisted suicide are among the options.

The Alberta MAID Care Coordination Service appears to have been primarily designed to deliver euthanasia and assisted suicide (EAS).  All of the information in the 2016 AMCCS web pages concerned EAS services.  None led to other end of life options like palliative care. All but one of 31 FAQ's concerned euthanasia and assisted suicide.  While the AMCCS web pages now include some links to other end-of-life options, current AMCCS web pages  (2020 Jan 28) demonstrate that it remains a euthanasia and assisted suicide service.

This is a barrier to compliance Order respecting Medical Assistance in Dying Standards of Practice by physicians unwilling to connect patients directly with an EAS agency.  On the other hand, Alberta's system continues to be cited by organizations representing objecting physicians as a model for other Canadian jurisdictions.  Further, there do not appear to have been complaints about non-compliance with the Order. How can one account for this?

Four factors are likely relevant.  First, the number of physicians who refuse to connect patients directly with EAS services is probably small.  Second, patients who have not been given direct contact information for the AMCCS may have been satisfied with the information they have received.  Third(related to the second), physicians who do not comply with the Order may supply patients with other information (such as contact information for Alberta Health Link) that is sufficient for their purposes.  Finally, providing AMCCS is required only in the case of an enquiry, but requests for EAS can be managed under section 4.

Note that the MyHealth.Alberta.ca website, also maintained by the provincial government and Alberta Health Services, includes resources for palliative and end of life care that do not reference euthanasia and assisted suicide.  There is no requirement in the Order in Council or College policy on euthanasia/assisted suicide to provide patients with contact information for this website or to ensure reasonable access to it, though physicians would be free to do so.  This may be because the Carter case was launched and decided so as to ensure access to euthanasia and  assisted suicide, not palliative care.