Abortion in “rural” British Columbia

 Researchers include city of 85,000 as part of “rural” B.C.

 Sean Murphy*

Abstract: 

Two recent research papers based on a 2011 survey of physicians providing abortion in British Columbia assert that “rural abortion services are disappearing in Canada.”  However, what the papers contribute to an understanding of the “barriers” to abortion services in rural British Columbia is doubtful, for two reasons.  First: the analytical structure proposed (the urban-rural dichotomy as defined by the authors) is inadequate.  Second: the authors ignore the significance of an important variable: the nature of the facilities or institutions where abortions are performed.  Concerns expressed about “access” to abortion are frequently accompanied by demands that freedom of conscience for health care workers should be suppressed.  Given the weaknesses noted above, the authors would have been hard-pressed to justify such a suggestion.  To their credit, they do not do so.
[Full Text]

Redefining the practice of medicine – Part 3

Winks and nods and euthanasia in Quebec

Re:  Bill 52: An Act respecting end-of-life care (June, 2013)

Sean Murphy*

Part 3: Working in the MAD matrix

Abstract

“Medical aid in dying” in Bill 52 (An Act respecting end-of-life care) will be transformed into euthanasia using the structures and powers established by other Quebec statutes governing the delivery of health care. These laws have established a multi-layered and overlapping bureaucracy. If Bill 52 passes, health care providers and others who want no part of euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system.

The Minister for Social Services and Youth Protection may issue “policy directions” about euthanasia. Health care in every region in Quebec is delivered under the direction of a regional health and social service agency. In addition, local health and social services networks have been established. These will be expected to provide or facilitate euthanasia.

Almost all local community service centres, hospital centres or residential and long-term care centres will be required to offer euthanasia, as will rehabilitation centres, which serve developmentally disabled patients. Palliative care hospices and hospitals are not required to do so. Physicians associated with private health care facilities must not provide euthanasia unless authorized by a local health authority.

Policies, standards, codes of ethics, protocols, guidelines, directives, etc. can be used to normalize euthanasia, and disciplinary and complaints procedures can be used to force participation in it. Local complaints commissioners, the Health and Social Services Ombudsman and syndics (investigators) for professional orders could create considerable difficulty for objecting physicians.

Under Quebec’s Professional Code, the Physicians’ Alliance for Total Refusal of Euthanasia, the Euthanasia Prevention Coalition and other groups that oppose euthanasia might face substantial fines if they persist in encouraging or advising physicians not to participate in the procedure.

Physicians may refuse to provide euthanasia if the patient is legally ineligible, and for other reasons, including conscientious objection. Section 30 of the bill should be amended to avoid unnecessary conflict with objecting physicians. Section 44, the provision specific to conscientious objection, is inadequate. Further, patients may lodge complaints against physicians who refuse to provide or facilitate euthanasia with institutions and the regulatory authority, regardless of the reasons for refusal.

Despite the promise of immunity, some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands, even if they do not object to the procedure. Similar reluctance might arise in regional health agencies, councils of physicians or other entities responsible for issuing MAD guidelines. Some might deliberately and obstinately interpret “medical aid in dying” to exclude killing patients, on the ground that the Act does not explicitly require or permit euthanasia, and the criminal law precludes such an interpretation.

Finally, objecting physicians might be able to appeal to the Public Protector, who is empowered to intervene “whenever he has reasonable cause to believe that a person or group of persons has suffered or may very likely suffer prejudice as the result of an act or omission of a public body.” [Full commentary]

Redefining the practice of medicine – Part 2

Winks and nods and euthanasia in Quebec

Re:  Bill 52: An Act respecting end-of-life care (June, 2013)

Sean Murphy*

Part 1: Bill 52 in detail

Abstract

An Act respecting end-of-life care (Bill 52) purports to establish a right to euthanasia for a certain class of patients by including it under the umbrella of “end-of-life care.” Those seeking euthanasia may not be near the end of their lives and may not be terminally ill, but they are apparently classed as “end-of-life patients” because they have chosen to end their lives.

Section 25 introduces a term not used by the medical profession, “terminal palliative sedation” (TPS). By this the Quebec government means an irreversible procedure intended to kill the patient slowly. Any patient is eligible for TPS, and a proxy can consent to it on behalf of an incompetent patient.

Section 26 permits patients to be killed quickly by “medical aid in dying”(MAD) if they are competent adult Quebec residents suffering from an incurable serious illness, in an advanced state of irreversible decline and suffering from constant and unbearable physical or psychological pain. The patient need not be terminally ill and is free to refuse effective palliative treatments.

A qualifying patient must personally make a written request for MAD “in a free and informed manner.” It must be signed in the presence of professional, who must also sign the request. The attending physician must confirm the eligibility of the patient and the free and informed nature of the request. He must verify the persistence of suffering and a continuing desire for euthanasia, speak to other members of the health care team and see that the patient is able to discuss the decision with others. However, the physician cannot advise family members unless the patient so wishes. Thus a physician may kill a patient without the knowledge of the family. Finally, the attending physician must obtain a written opinion of an independent physician confirming eligibility for euthanasia.

Only physicians may provide euthanasia (MAD), and, having done so, must “take care” of a patient until he dies. Physicians who provide TPS or MAD must report the fact to institutional authorities. They must report all euthanasia cases to the Commission on End-of-Life Care.

The Act appears to assume that the regulators will establish “clinical standards” for euthanasia but does not assign them a central role, making institutional authorities primarily responsible for it.

Canadian criminal law is not affected by the Act. It continues to apply to the killing of patients by physicians, but also to any act or omission done for that purpose, including the making and distribution of MAD guidelines and protocols.

First degree murder is defined as murder that is “planned and deliberate.” A physician who does what the Act requires will have provided excellent evidence that the killing was intentional, planned and deliberate. Conforming to the Act respecting end-of-life care would seem to increase the likelihood that a physician – and anyone counselling, aiding, abetting his act – could be charged and convicted for first degree murder, for which the punishment is life imprisonment without parole for 25 years. [Full commentary]

Redefining the practice of medicine – Part 1

Winks and nods and euthanasia in Quebec

Re:  Bill 52: An Act respecting end-of-life care (June, 2013)

Sean Murphy*

Part 1: Overview

Abstract

An Act respecting end-of-life care (Bill 52) is intended to permit physicians, in defined circumstances, to kill their patients as part of the redefined practice of medicine. However, the procedure cannot become part of medical practice in Quebec unless the medical profession itself (broadly speaking) formally accepts it as a form of health care.

The strategy of the Quebec government includes three key elements:

a) A statute that authorizes and allows the regulation of “medical aid in dying” (MAD) but does not define the term, so as to avoid conflict with the criminal law and constitutional challenges to the law;

b) Compliant medical regulators, professionals and health care authorities who are expected to define MAD to include euthanasia, thus establishing it as a legitimate aspect of health care;

c) Refusal to prosecute physicians who kill patients in accordance with MAD guidelines, thus circumventing the criminal prohibition of euthanasia.

While the federal government could, in theory, appoint and pay lawyers to act as prosecutors to enforce the criminal law, this would be especially contentious in Quebec and would involve political and practical problems. If Bill 52 passes, it seems unlikely that Quebec physicians who provide euthanasia under MAD guidelines will be prosecuted. The province formerly refused to enforce Canada’s criminal law on abortion for over twenty years, so a policy of refusing to prosecute physicians providing euthanasia could have similar staying power.

Though Bill 52 does not actually require or authorize the killing of patients, from a practical perspective, the text of the statute is a “mere technicality.” Nonetheless, it is not a mere technicality that the medical establishment and not the statute will have directed that patients can be killed in order to relieve their symptoms.

On the contrary: it is profoundly significant. Having formally approved of euthanasia, the medical establishment (meaning all of those who collaborate in drawing up MAD guidelines and protocols) will be at particular pains to defend and enforce the decision. In the end, freedom of conscience for Quebec health care workers who object to euthanasia may come to mean nothing more than the freedom to find another job, or the freedom to leave the province.  [Full commentary]

A “medical misadventure” in Ireland

Deaths of Savita & Prasa Halappanavar

Galway, Ireland: 21-28 October, 2012

Sean Murphy*

Savita Halappanavar was a 31 year old woman who was 17 weeks pregnant when she presented at the University Hospital, Galway, on 21 October, 2012, with a miscarriage.  She spontaneously delivered a stillborn daughter, Prasa, on the afternoon of 24 October, and died from sepsis early on 28 October.  The circumstances of her death generated a hurricane of controversy in Ireland and around the world about Irish abortion law.  A coroner’s inquest held in Galway in April, 2013 resulted in the classification of Savita’s death as a “medical misadventure.”

What follows is a chronological account of Savita’s care and treatment from 21 to 28 October, drawn from newspaper reports of the evidence taken at the inquest.  [Read more . . .]

Related:

 

Uruguay’s Voluntary Termination of Pregnancy Act

 Protection of conscience provisions may be defined out of existence

Sean Murphy*

In the fall of 2012 the Uruguayan legislature passed the Voluntary Termination of Pregnancy Act, which legalized abortion in the country under certain circumstances.  By January, 2013, Reuters was reporting that the law was meeting “fierce opposition” among Uruguayan gynaecologists, with up to a third of them refusing to provide the procedure for reasons of conscience;1 in some locations, almost none will do so. . . Full Text

Ontario College of Physicians and Surgeons accommodates Christian physician

 Sean Murphy*

The Ontario College of Physicians and Surgeons has accepted a suggestion from Dr. Stephen Dawson that has resolved complaints lodged against him. Dr. Dawson, a Christian physician who practises in Barrie, Ontario, was charged for professional misconduct because he refused to prescribe birth control pills to four unmarried women.

Dr. Dawson now posts a policy statement in his waiting room that includes a statement that he will not prescribe birth control pills to unmarried women nor Viagra to unmarried men, nor will he arrange for abortions. He will not offer further information about his religious convictions except in response to queries from patients. [Full text]

 

Who is “imposing morality” in Barrie?

Winnipeg, Manitoba
5 April, 2002

Sean Murphy,  Administrator
Protection of Conscience Project

The Canadian Broadcasting Corporation (CBC) is Canada’s publicly funded state radio and television broadcaster. The following was sent to the CBC in Winnipeg, Manitoba, asking whether or not it would be accepted for broadcast in the same region where Dr. Goldman’s editorial was aired. The CBC did not  reply.

In an editorial broadcast on CBC Radio on 7 March, 2002, Dr. Brian Goldman criticized Dr. Frederick Ross of Winnipeg, Manitoba, and Dr. Stephen Dawson of Barrie, Ontario. Dr. Ross had told his patients to stop smoking or find another doctor, while Dr. Dawson had refused to prescribe birth control pills or Viagra to single patients.

It does not seem that Winnipeg’s Dr. Ross believes that treating smokers is wrong, nor that it would be wrong to refer a smoker to another physician. His public statements do not preclude the possibility that he would treat smokers on an ad hoc basis (while standing in for an absent partner, for example).

In contrast, Dr. Dawson refuses to help single patients obtain birth control pills and Viagra under any circumstances, because he believes that by doing so he would be a party to immoral activity (i.e.,extramarital sex). Dr. Goldman was more sympathetic to this position, but criticized Dawson because he would not refer patients to other physicians who would prescribe the drugs.

Dr. Goldman recognized that his colleagues were acting for different reasons, but in drawing his conclusions he failed to maintain this distinction or recognize its significance. It is one thing to refuse to do something because it is inconvenient, difficult, frustrating, or pointless; it is quite another to refuse to do something because it is wrong. Grasping this distinction is the key to understanding the difference between the case of Dr. Ross, which does not seem to involve conscientious objection, and that of Dr. Dawson, which plainly does.

What some characterize as Dr. Dawson’s inflexibility actually illustrates the normal human reaction to a request to do something wrong. For example, a fifty year-old man who wanted to have sex with a fourteen year- old girl might be refused the use a friend’s apartment for that purpose. Nor would it be surprising if the unco-operative  friend also refused to refer the lecher to a more ‘flexible’ apartment owner.

We see the same principle at work in criminal law. It is an offence not only to commit a crime directly, but to counsel, aid or abet a crime committed by someone else. Again: many people who engage in ‘ethical investment’ do so because they do not want to be implicated, even indirectly, in business practices to which they object for reasons of conscience, even if the practices aren’t illegal.

Now, no one is suggesting that consensual extramarital sex between adults is morally equivalent to criminal activity. But when Dr. Dawson refused to provide birth control for single patients, he reacted exactly as an ‘ethical investor’ might react if asked to purchase shares in a company that exploits child labour. He reacted exactly as an honest man would act were he asked to help someone lie or cheat. In other words, he  acted as if extramarital sex really is wrong, and that its wrongness is not merely a matter of opinion or taste. That, in truth, is what has upset many of his critics; he has disturbed their repose in their  comfortable pews.

Of course, one may criticize a physician for causing needless distress to a patient by offering a poorly articulated or inappropriate explanation of his moral position. But that was not Dr. Goldman’s concern. Instead, he complained that Dr. Dawson had acted upon his own beliefs.

In fact, Dr. Goldman does exactly the same thing. He believes that he does nothing wrong by providing single patients with contraceptives and Viagra, and he acts upon that belief by writing prescriptions. Why should Dr. Goldman be allowed to act upon his beliefs by writing prescriptions, while Dr. Dawson is forbidden to act upon his by refusing  to do so? Is it because “the true north strong and free” is afraid of religious believers?

A physician who refuses, for reasons of conscience, to do something he believes to be wrong – falsifying a diagnosis, amputating a healthy limb, or prescribing contraceptives – does not force a patient to conform to his moral code. He is not “imposing morality.” To see what  “imposing morality” really means, watch this month when the Ontario College of Physicians and Surgeons tries to force Barrie’s Dr. Stephen Dawson to give up his Christian convictions, on pain of professional excommunication.

Project Letter to Telegraph Journal

New Brunswick, Canada
24 February, 2002

Sean Murphy, Administrator
Protection of Conscience Project

Dr. Monica Brewer’s characterization of physician referral for morally controversial purposes as a “black and white” issue is the result of inadequate reflection.(“MD’s Morals Restricting Birth Control Access,” February 9, 2002) Her suggestion that doctors who object to the morning-after-pill and contraception “should pair with doctors to whom they can refer” is a suitable solution only for those whose objections are simply matters of professional judgement or personal preference.

For example: physicians who know that 94% of the women who are sold the morning-after-pill do not actually require it to prevent pregnancy (the numbers are provided by those who support its widespread use1) may be unwilling to prescribe it for that reason. However, they might well refer a patient who wants the drug to a doctor who will.

Similarly, some physicians believe that women’s health and social interests are better served by learning to recognize their natural fertility cycles, so that they need not be dependent upon physicians or drug companies to plan or avoid pregnancy. These physicians may not prescribe birth control pills for ‘ecological’ reasons, but probably wouldn’t object to referral.

Finally, an obstetrician who thinks that aborting Down syndrome infants is a good idea, but finds performing abortions a traumatic experience, would probably welcome the opportunity to refer a patient to another colleague.

The situation is quite different when physicians are asked to refer a patient for something to which they have grave moral objections. They believe that by referring patients they are themselves morally culpable for facilitating the wrong that is done. Strange? Not at all.

Consider Newsweek columnist Jonathan Alter’s suggestion that, since physical torture is “contrary to American values”, the US should turn terrorist suspects who won’t talk over to “less squeamish allies.”2 No one would seriously argue that this would relieve the US of moral complicity in torture.

Of course, moral complicity in abortion, contraception and the morning-after-pill are not issues for people like Dr. Morgantaler and his associate, Judy Burwell, who think these are good things, and that those who think differently are mistaken. But it is surprising that they view freedom of conscience as a problem to be solved by abolishing it, at least for those who don’t agree with them.

After all, Dr. Morgantaler justified his defiance of Canadian abortion law in a 1970 article titled, “A Physician and His Moral Conscience.” 3


Notes (provided for editorial verification)

1. “In 16 months of ECP services, pharmacists provided almost 12,000 ECP prescriptions, which is estimated to have prevented about 700 unintended pregnancies.” Cooper, Janet, Brenda Osmond and Melanie Rantucci, “Emergency Contraceptive Pills- Questions and Answers”. Canadian Pharmaceutical Journal, June 2000, Vol.133, No. 5, at p. 28. See also Valpy, Michael, “The Long Morning After”, Globe and Mail, 15 December, 2001)

2. Alter, Jonathon, “Time to Think About Torture”. Newsweek, 5 November, 2001, p. 45.

3. The article appeared anonymously in The Humanist. Quoted in Pelrine, Eleanor Wright, Morgantaler: The Doctor Who Couldn’t Turn Away.  Canada: Gage Publishing, 1975, P. 79

Project Letter to the National Post

Toronto, Ontario, Canada
23 February, 2002

Sean Murphy, Administrator
Protection of Conscience Project

A doctor caring for patients in four Ontario cities may be driven from the profession, or from the country,  because he refuses to practise medicine in accordance with the policies of Planned Parenthood (“MD under fire for denying birth control,” National Post, 22 February, 2002). Welcome to the world of single-issue ethics.

Professor Laura Shanner asserts her personal belief that a physician “absolutely must” help patients obtain drugs or procedures to which the physician objects for reasons of conscience. But there is no self-evident reason why her morality should be imposed upon dissenting physicians under threat of  professional excommunication. Nor do mantras like “standard of care” provide useful guidance when the morality of the ‘care’  itself is in issue. Dr. Morgantaler’s standard of care is, in some  respects, markedly different from that of Physicians for Life. The standard of care in Oregon includes assisted suicide, and in the Netherlands, euthanasia.

On the other hand, John Hof is mistaken in his suggestion that conscientious objectors may refuse to  prescribe contraceptives in order to meet the “spiritual needs” of their patients. People do not go to the doctor to  satisfy their spiritual needs, and physicians should not assume the role of spiritual director.

Conscientious objection arises from concern about one’s own moral culpability, not that of others. It is a matter of personal integrity, not an attempt to control someone else’s behaviour. The unfortunate situation in Barrie may be the result of an infelicitous explanation that failed to make this clear.