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

Service, not Servitude

Canada

College of Physicians and Surgeons of Prince Edward Island

Freedom of conscience and religion

Annotated Extracts and Links

Conscientious Objection to Provision of Service (4 November, 2019)
[Full Text]

The “Policy on Conscientious Objection to Provision of Service” has been developed by the College of Physicians and Surgeons of Prince Edward Island(the College)as a guidance document for physicians as to how to balance the ethical dilemmas that occur when one’s beliefs and ethics as a practicing physician conflict with the ethical beliefs of one’s patients. Communication is clearly vital in this situation.

**[Relevant Excerpts from the CMA Code of Ethics and Professionalism (2018)]**

Moral or Religious Beliefs Affecting Medical Care

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.

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.

3. A physician must not promote their own moral or religious beliefs when interacting with patients.

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 should 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.

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.

Project Annotations

The policy recognizes a key distinction between providing information and providing or facilitating a morally contested service or procedure. 

 The point 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.

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.  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.

The offer of "assistance" in certain circumstances should not be understood to imply facilitating a morally contested service by referral or other means, since some physicians refuse to do so because they believe that makes them complicit in the act that follows.


Medical Assistance in Dying (4 November, 2019)
[Full Text]

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**[Relevant Excerpts from the CMA Code of Ethics and Professionalism (2018)]**

Foundational principles used in developing this document:

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2)    Access: Individuals who seek information about medical assistance in dying should have access to unbiased and accurate information. To the extent possible, all those who meetthe criteria for medical assistance in dying and request it should have access to medical assistance in dying.[Emphasis in original.]

3)    Respect for physician values: Within the bounds of existing standards of practice and subject to the expectations in this document and the obligation to practice without discrimination as required by the CMA Code of Ethics and Professionalism (2018) and human rights legislation, physicians can follow their conscience when deciding whether or not to provide medical assistance in dying.

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8)    Duty to Provide Care: Physicians have an obligation to provide ongoing care to patients unless their services are no longer required or wanted or until another suitable physician has assumed responsibility for the patient. Physicians should continue to provide appropriate and compassionate care to patients throughout the dying process regardless of the decisions they make with respect to medical assistance in dying.

Standards:

Communication:

A physician who for conscientious reasons declines to provide medical assistance in dying must

a. Disclose that fact to the patient,

b. Continue to treat the patient with dignity and respect, and provide medical care until no longer required or wanted, or until another physician has assumed responsibility for the patient, and

c. Provide, or arrange to be provided, the patient's chart and sufficient medical information, with the patient's consent, to the patient or to other physicians or nurse practitioners involved in the process

i) To enable the patient to make his/her own informed choice and access all options for care, including palliative care

ii) To enable access to another physician, nurse practitioner or service

A physician, or delegate, must be respectful, must provide sufficient, timely medical information, and must not be confusing, coercive, or provide incomplete information.

A physician may delegate the responsibility for communication of information regarding medical assistance in dying to another person (who is competent to do so and for whom the physician is responsible), or to another agency.

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A Physician's Obligation

This section must be read in the context of relevant evolving federal and provincial legislation, which supersedes this Policy. . .

Medical assistance in dying has been declared a right under the amended Criminal Code.  Therefore it is important that each physician consider the pros and cons and decide in advance whether or not the physician would participate if ever called upon to do so.

Each physician may find him/her self in one of the 3 following situations:

1. The physician decides either for conscientious or religious reasons not to participate. The physician should advise all his/her patients of that fact, perhaps by posting a notice in the office.

If a request is received anyway, the physician must not act as a barrier to the patient requesting the services, solely on the basis of the physician's beliefs. The physician, or delegate, must provide a copy of the patient's chart and sufficient medical information, with the patient's consent, to the patient or to other physicians or nurse practitioners involved in the process. The provision of information on medical assistance in dying may be delegated to another person (who is competent to do so and for whom the physician is responsible), or to another agency. A recommended course of action might be to transfer the care of the patient to another physician, nurse practitioner or service.

Federal reporting is required by this physician only if the patient was referred or their care transferred to another physician/nurse practitioner or service for the purpose of requesting MAID.

2. The physician decides to participate, but only to the degree of providing information, assessing eligibility for medical assistance in dying and referring to another physician, nurse practitioner or agency who will carry out the procedure . . .

3. The physician plans to participate: to assess eligibility and to carry out the procedure . . .

Project Annotations

Under Foundational Principles the reference to human rights legislation is especially significant for physicians who decide to participate in euthanasia and assisted suicide.  It has been argued that physicians who provide the services for one class of patients (the terminally ill, for example) but who refuse to provide the services for others (those not terminally ill) violates human rights legislation by discrimination on the basis of disability, and cannot avoid being found guilty of discrimination even if they arrange for the patient to see a willing colleague. See Amir Attaran, The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v Canada (2016 ) 36:3 Health L Can 86.

The policy requires that an objecting physician provide the patient with the medical chart and information sufficient to allow informed medical decision making and access treatment options.  It suggests that a transfer of care might be appropriate, but it is not required.  These expectations should not be problematic.  Patient-initiated transfers of care are the norm for objecting physicians in jurisdictions outside Canada where euthanasia and/or assisted suicide are legal.

Under A Physician's Obligations the policy erroneously states that "medical assistance in dying" (euthanasia and assisted suicide) have been declared to be a right under the Criminal Code.  Section 241.1 of the Criminal Code provides definitions and sets out the circumstances under which a physician or nurse practitioner may provide euthanasia or assisted suicide without being prosecuted.  It does not establish a "right" to either.

Providing notice to patients in advance will prevent conflicts between patients seeking the services and physicians unwilling to  provide them.  In practice, many objecting physicians prefer to talk personally with patients who raise the issue.