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IX.    PROJECT RESPONSE

IX.1    Preliminaries

IX.1    It is one thing to limit freedom of conscience by enacting laws that prevent people from doing everything that they want to do. But to force people to do things that offend their conscientious convictions cannot be reconciled with the best traditions and aspirations of liberal democracy. It is, in principle, inconsistent with the most rudimentary principles of civic friendship, a serious assault on the essential foundation of fundamental freedom, and offensive to human dignity. It is a fundamental injustice that cannot be rectified or ameliorated by appeals to theories of justice or notions of equality.

IX.2   Thus, the Protection of Conscience Project, without denying the importance of freedom of conscience in its widest sense, restricts the scope of its activity to advocacy for freedom of conscience in its most essential and foundational sense. Simply put, those providing health care must not be forced to do what they believe to be wrong, or punished for refusing to do so.

IX.3    The Project does not take a position on the acceptability of euthanasia or assisted suicide.  From the perspective of the Project, legalization of euthanasia or assisted suicide or a change of WMA policy against the procedures is of concern only to the extent that legalization or change threatens to disadvantage or punish physicians who refuse to do what they believe to be wrong.

IX.2    The issue

IX.2.1    If the CMA/RDMA proposal were accepted, would it have adverse consequences for physician freedom of conscience?

IX.3    Relevant considerations

IX.3.1    Most physicians refuse

IX.3.1.1    The majority of physicians believe participation in euthansia or assisted suicide is irreconcilable with their ethical obligations.  Available evidence demonstrates that the overwhelming majority of physicians worldwide are opposed to the procedures and would refuse to participate (III.1.1), and that, even where the procedures are legal, relatively few physicians are directly involved in providing the services (VI.3.4). This is not denied by the CMA and RDMA. 

IX.3.1.2    Many physicians opposed to providing euthanasia and assisted suicide are also opposed to facilitating or collaborating in the procedures by referral or other means because they believe that doing so makes them complicit in wrongdoing.

IX.3.2    Physician obligation to provide or facilitate medical treatment

IX.3.2.1    Although euthanasia and assisted suicide can be provided by non-medical personnel if authorized by law, when the law authorizes physician administered euthanasia and physician assisted suicide, the procedures are usually thought to be medical services or forms of medical treatment, notwithstanding contrary views among those opposed to them.  Medical associations that approve physician participation in the procedures can be expected to take this position (IV.3.4, VII.4.3.4, B9.3, B10.7).

IX.3.2.2    Physicians are understood to have an ethical obligation to provide or facilitate access to medical treatment or services needed by their patients. When professional or public authorities classify euthanasia and assisted suicide as medical treatments, providing or facilitating homicide and suicide becomes the norm, and refusal to do so the exception that requires justification or excuse. (VII.4.2.3).

IX.3.2.3    Where the state undertakes to finance and provide or arrange for the delivery of medical treatment, physicians may come to be seen as state employees obligated to deliver or facilitate the delivery of all legal medical treatments and services as a condition of employment.1  This is complemented and supported by theories or models of social contract professionalism.

IX.3.2.4    Since relatively few physicians are willing to provide the services, patients must find a way to connect with willing physicians.  This leads to demands that objecting physicians faciliate access by referral or other means (VII.4.3.4, B.10.19).

IX.3.3    Rights claims

IX.3.3.1    The CMA/RDMA proposal asserts, by implication, that people have a right to euthanasia and assisted suicide (VI.3.2, VII.5.2).  This claim is increasingly common and consistent with the view that people have a right to health care and medical treatment.  Whatever the moral or legal merits of such claims, they provide a basis for demands that physicians provide or facilitate euthanasia.

IX.3.3.2    A more refined claim of a right to equitable access to health care is made for the same purpose. When joined to human rights laws prohibiting discrimination on the basis of disability, the claim of a right to equitable access can ground a complaint against a physician who provides euthanasia for the terminally ill, but not for the clinically depressed.  Hence, physicians who agree to provide euthanasia or assisted suicide for one legally eligible patient may find that they cannot legally refuse to provide the services for any legally eligible patient, regardless of the condition or circumstances.2

IX.3.3.3   In either case, to seek to enforce these claims with respect to euthanasia and assisted suicide would invoke the power of the state to compel unwilling individuals to become parties to homicide and suicide, and to punish or disadvantage them if they refuse. 

IX.3.4    Likelihood of conflict

IX.3.4.1    The foregoing considerations indicate that legalization of euthanasia and assisted suicide has the potential to cause serious difficulties for the overwhelming majority of physicians who are opposed to the procedures.

IX.3.4.2     Proportionate to death from all causes, relatively few patients die from euthanasia and assisted suicide (VII.5.8).  However, everyone dies.  Hence, where the procedures are legal, every physician in general practice and many in other specialities may be confronted with a request for euthanasia or assisted suicide, especially in specialties like oncology and palliative care (VII.3.6.3).  Everyone entering the medical profession will be faced with this issue.

IX.3.4.3    Euthanasia and assisted suicide rates provide some indication of the likelihood that  objecting physicians will encounter ethical conflicts with patients or colleagues where the procedures are legal.  However, the rate of requests for euthanasia and assisted suicide is a more reliable indicator, since it is the need to respond to a request for the procedures that may cause difficulties for objecting physicians.  Request rates are typically higher than euthanasia/assisted suicide death rates.

IX.3.4.4    Generally speaking, the broader the grounds for euthanasia and assisted suicide, the greater the likelihood that conflicts of conscience will arise.  For example: physicians willing to provide the services in the last days of a terminal illness may not be willing to provide them for chronic depression.

IX.3.4.5    Generally speaking, the wider the range of people legally entitled to authorize euthanasia, the greater the likelihood of conflicts of conscience.  For example: physicians willing to provide euthanasia at the request of competent patients may not be willing to provide euthanasia at the request of a family member for someone with dementia who is not otherwise ill.

IX.4    Response to the issue

IX.4.1    It is reasonable to believe that the CMA/RDMA proposal would, if accepted, encourage the legalization of physician administered euthanasia and physician assisted suicide around the world (VII.5.7).

IX.4.2    The proposal posits a right to euthanasia and assisted suicide that is unrestricted with respect to eligibility criteria and other conditions under which they might be provided.  For example, it does not limit provision of the procedures to terminal illness, does not preclude the procedures as a response to mental illness, disability, or chronic medical conditions, and does not require access to palliative care as a prerequisite.  It does not limit provision of the services to adults: adolescents, children and infants are not excluded.  It does not exclude euthanasia of incompetent patients authorized by advanced directives (VII.2.4).

IX.4.3    To the extent that legalization does occur in accordance with the proposal, particuarly in view of its unrestricted scope, the overwhelming majority the world's physicians represented by WMA members would be exposed to demands that could generate serious conflicts of conscience and ultimately place those unwilling to provide or cooperate in providing the services in serious professional jeopardy (IX.3.1.1, IX.3.4.4, X.3.4.5 ).

IX.4.4      The protection of conscience provisions in the proposal do not afford sufficient protection for objecting physicians, especially in light of the increased probability of conflict due to the virtually unrestricted scope of the proposal. The provisions are not well-grounded and  actually rejected by one of the co-authors of the proposal (VII.4).

IX.4.5    The experience of objecting physicians in Canada demonstrates that the WMA should not follow the example of the CMA by precipitously changing its policy without sufficient reflection and forethought.3

IX.4.6    Given the particular gravity of the consequences of invoking state power against objecting physicians with respect to participation in homicide and suicide, the WMA should not change its policy on euthanasia and physician assisted suicide without first establishing a sound and robust policy to protect physician freedom of conscience. 

IX.4.7    However, a sound policy concerning physician freedom of conscience cannot be developed within the narrow perspective afforded by controversies about particular procedures.  The Project recommends, instead, a broad and principled approach be taken to develop a single protection of conscience policy.

Notes

1.  Dr. Preston Zuliani (President of the College of Physicians and Surgeons of Ontario, Canada's largest state medical regulator).  "In our society, we all pay for this medical system to receive services.  And if a citizen or taxpayer goes to access those services and they are blocked from receiving legitimate services by a physician, we don't feel that's acceptable."  Laidlaw S. Does faith have a place in medicine? Toronto Star [Internet]. 2008 Sep 18 [Cited 2018 Sep 29].  The College now demands that objecting physicians provide "effective referrals" for all services, including euthanasia and assisted suicide, notwithstanding their moral or religious beliefs (VII.4.3.3).

2.  "[I]f a doctor willingly prescribes pain-relieving drugs to alleviate suffering - for arthritis,
back pain, cancer, stomach ulcer, et cetera - but selectively refuses to prescribe secobarbital
or pentobarbital to a patient who lawfully chooses to die, that differential denial of service
(i.e., prescribing vs. not prescribing) needs a satisfactoryjustification, or it is discriminatory and illegal."  Attaran A. The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v Canada. Health L Can 2016; 36(3)  86-98 at 87.

3.    Murphy S.  Canadian Medical Association and euthanasia and assisted suicide in Canada: Critical review of CMA approach to changes in policy and law [Internet]. Protection of Conscience Project; 2018 Sep 26 [Cited 2018 Sep29].