Refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is the response expected of physicians by professional bodies and regulators. It is not clear that Quebec legislators or professional regulators understand this.
A principal contributor to this lack of awareness – if not actually the source of it – is the Code of Ethics of the Collège des médecins, because it requires that physicians who are unwilling to provide a service for reasons of conscience help the patient obtain the service elsehere. The President of the Collège was pleased that law will allow physicians to shift responsibilty for finding someone willing to kill a patient to a health system administrator, avoiding an anticipated problem caused by the requirement for referral in the Code of Ethics. However, the law does not displace the demand for referral in the Code, and can be interpreted to support it.
The Collège des médecins Code of Ethics demand for referral conflicts with the generally accepted view of culpable indirect participation. Despite this, it continues to be used as a paradigm by other professions, notably pharmacy. It is thus not surprising that the College of Pharmacists also anticipates difficulty over the issue of referral. Like the Collège des médecins, the College of Pharmacists would like to avoid these problems by allowing an objecting pharmacist to shift responsibility for obtaining lethal drugs to a health systems administrator.
Nurses cannot be delegated the task of killing a patient, it is not unreasonable to believe that nurses may be asked to participate in euthanasia in other ways. Thus, there remain concerns about indirect but morally significant participation in killing. Their Code of Ethics imposes a duty to ensure both continuity of care and “treatment,” which is to include euthanasia. However, under ARELC, an objecting nurse is required to ensure only continuity of care. This should not be interpreted to require nurses to participate in euthanasia, though they may be pressured to do so.
As a general rule, it fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence. It was a serious error to include this a requirement in code of ethics for Quebec physicians and pharmacists. The error became intuitively obvious to the Collège des médecins and College of Pharmacists when the subject shifted from facilitating access to birth control to facilitating the killing of patients.
A policy of mandatory referral of the kind found in the Code of Ethics of the Collège des médecins is not only erroneous, but dangerous. It establishes the priniciple that people can be compelled to do what they believe to be wrong – even gravely wrong – and punish them if they refuse. It purports to entrench a ‘duty to do what is wrong’ in medical practice, including a duty to kill or facilitate the killing of patients. To hold that the state or a profession can compel someone to commit or even to facilitate what he sees as murder is extraordinary.
Quebec’s medical establishment can correct the error by removing the mandatory referral provisions of their codes of ethics that nullify freedom of conscience. This would prevent objecting physicians and pharmacists from being cited for professional misconduct for refusing to facilitate euthanasia or disciplined for refusing to facilitate other procedures to which they object for reasons of conscience, including contraception and abortion. This would almost certainly antagonize consumers who have been conditioned to expect health care workers to set aside moral convictions.
It remains to be seen whether the Quebec medical establishment will maintain the erroneous provisions, preferring to force objecting health care workers to become parties to homicide rather than risk occasionally inconveniencing people, such as the young Ontario woman and her supporters who were outraged because she had to drive around the block to obtain The Pill. [Full Text]