Abstract

This review responds to a request from an associate member of the World Medical Association (WMA) for critical analysis of a revision to Paragraph 27 of the International Code of Medical Ethics (ICME) proposed by a WMA workgroup (WG Para 27). The commentary is provided for the use of the associate member in WMA discussion and proceedings.

The review finds WG Para 27 anomalous in relation to medical practice because it ignores the role of conscience in medicine and adopts an inadequate and prejudicial analytical framework. WG Para 27 does not attempt or even suggest how to accommodate physician integrity and patient requests when they conflict. It is also anomalous in relation to existing WMA policy and related functionally interdependent paragraphs in the proposed ICME.

The Project recommends amendments to WG Para 27 that

• reflect the role of conscience in medical practice;
• identify conduct morally relevant to participation in contested procedures;
• recognize the potential for conflict between physicians and state or other authorities;
• bring other provisions of the ICME into play;

The Project recommends that the ICME be supplemented by WMA policy on physician freedom of conscience. It strongly urges that the conference now scheduled for 4-5 July in Jakarta or Bali should be dedicated to the subject of conscience in medical practice, and that discussion of “conscientious objection” should occur within that context. Otherwise, the conference is likely to adopt the inadequate, prejudicial and anomalous approach reflected in WG Para 27.

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TABLE OF CONTENTS

I.    Introduction

II.    Conscience in medicine

III.    Paragraph 27: “Conscientious objection”

•  Inadequate, prejudicial analytical framework
•  Critical distinctions not recognized
•  Conflict with existing WMA policy on euthanasia/assisted suicide
•   Conflict with interdependent ICME provisions
•  Recommended amendments to Paragraph 27

APPENDIX “A”

• Project recommendations

APPENDIX "B"

• Personal and Professional Integrity in Medical Practice: An addition to WMA policy
  •  Protection of personal and professional integrity
  • Non-discrimination
  • Notice
  • Patient autonomy and decision-making
  • Declining to provide an intervention
  • Non-abandonment
  •  Regulatory, educational and civil authorities
• Comments on the text

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I.    Introduction

I.1    The Protection of Conscience Project is a non-profit, non-denominational initiative with an international scope that has advocated for freedom of conscience in health care since 1999. The Project does not take a position on the morality or acceptability of contested procedures or services.

I.2    This review responds to a request from an associate member of the World Medical Association (WMA) for critical analysis of a revision to Paragraph 27 of the International Code of Medical Ethics (ICME) proposed by a WMA workgroup (WG Para 27). The commentary is provided for the use of the associate member in WMA discussion and proceedings.

I.3    The review is notably informed by the impact of Canada’s legalization of assisted suicide and euthanasia (EAS) on practitioners opposed to the procedures, described in the World Medical Journal (WMJ) by Canadian physicians.1,2 It also draws on WMJ articles (co-authored by the Project Administrator) describing the origins of the Declaration of Geneva and the ICME3 and the relationship between the revised Declaration of Geneva and good medical practice.4

I.4    The following paragraphs from the draft ICME are functionally interdependent and relevant to the issue of conscience in medical practice. Discussion includes consideration of these provisions. (headings added here for convenience):

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II.    Conscience in medicine

II.1    The central role of conscience in medical practice was a prominent concern of the organizers of the WMA and the assemblies that first approved the Declaration of Geneva and ICME.5,6 In reviewing the origins of these documents, the Project Administrator and co-authors affirmed and applied the insight of the WMA founders:

[T]he practice of medicine is an inescapably moral enterprise. Physicians first consider the good of patients, always seeking to do them some kind of good and protect them from evils. Hence, moral or ethical views are intrinsic to the practice of medicine, and every decision concerning treatment is a moral decision, whether or not physicians consciously advert to it. To demand that physicians must not act upon moral beliefs is to demand the impossible, since one cannot practise medicine without reference to moral beliefs. (References omitted)7

II.2    Relevant here is an observation by Dr. Ewan Goligher, a WMA associate member and co-author of two of the WMJ articles cited herein. He notes that objections to conscientious objection in medicine claim that it

a) imposes doctors’s values on patients,

b) undermines professional standards, and

c) denies access to care.

Dr. Goligher points out that these claims are themselves "conscience-based ethical objections."

"The real question," he says, "is not whether conscience should be exercised, but rather which kinds of conscientious objections are appropriate and which kind are not."8

II.3    For example, no difficulty arises from the perspective of freedom of conscience when the only issue is clinical competence in relation to a service or procedure that the physician believes is in a patient’s best interests. Facilitating or arranging for the service to be provided by someone else is then a natural extension of the physician’s responsibilities to the patient and is consistent with the physician’s professional and personal moral integrity. Effective referral in this situation becomes an obligation, and refusing or failing to make an effective referral can be characterized as abandonment. This is the basis for ICME Paragraph 20.

II.4    On the other hand, physicians who refuse to provide or to make effective referrals for a treatment because evidence of efficacy is insufficient are acting in a manner consistent with their ethical obligations. Similarly, physicians who conclude that a treatment is medically contraindicated because it is harmful are ethically obliged to refuse to provide or facilitate that treatment. Both kinds of refusals can be properly described as examples of the exercise of conscience (or conscientious objection) based on clinical judgement. Again, Dr. Goligher:

In all these cases, I have not only a technical reason, but also a moral obligation, not to perform such interventions. As such, these are unavoidably conscience-based refusals; I can’t offer this treatment because it would be unethical for me to do so.9

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III.    Paragraph 27: "Conscientious objection"

III.1    The workgroup’s proposed text of Paragraph 27 (WG Para 27) ignores the role of conscience in medicine and adopts an inadequate and prejudicial analytical framework limited to "conscientious objection."  In so doing it fails to make distinctions that would, if recognized, suggest how both physician integrity and patient access to services can be accommodated.  For these reasons it is also anomalous in relation to existing WMA policy and undermines related functionally interdependent paragraphs in the proposed ICME.

Inadequate, prejudicial analytical framework

III.2    WG Para 27 undermines a physician’s obligation to conscientiously object in the circumstances described in II.4 because it ignores the role of conscience in medicine. For the same reason it does not and cannot provide coherent ethical guidance on conscientious objection by physicians. In that respect it is wholly inadequate.

III.3    Further, WG Para 27 clearly assumes that what an objecting physician refuses to do is morally/medically acceptable and necessary "care" or medical treatment. It uncritically accepts as a matter of fact the very point that is usually contested in these cases. It appears to be based on the premise that objecting physicians are mistaken in refusing to provide a contested procedure and characterizes “conscientious objection” as a “disruption to patient care.” This is not merely inadequate but a clearly prejudicial framework that lends itself to morally partisan abuse.

III.4    Finally, the WMA workgroup removed of the term “effective referral” from the original draft paragraph and replaced it with the definition of effective referral. This is not a “compromise”. The recommended text can be used to compel physicians who refuse to lethally inject their patients to arrange for them to be lethally injected by someone else.

WMA workgroup recommendation	Definition of “effective referral”
“. . . the physician must initiate, without delay, arrangements for the patient to consult with a suitably qualified physician or authorised health care professional who does not object to the treatment or procedure.”	“taking positive action to ensure the patient is connected to a non-objecting, available, and accessible physician, other health-care professional, or agency.”  (CPSO Policy: Medical Assistance in Dying10)

III.5    WG Para 27 requires a form of collaboration that many objecting physicians reasonably consider ethically unacceptable, and that the WMA also considers unacceptable in relation to unethical procedures. Indeed, in relation to unethical activities the WMA identifies a range of morally relevant conduct that physicians should avoid, including referral,11 countenancing, condoning, facilitating or aiding,12,13 providing skills, premises, supplies, substances or knowledge, including individual health information,14 planning, instruction or training, preparation of reports,15, 16 incitement17 and retrospectively affirming or supporting unethical practices.18 Thus, WG Para 27 is not only inadequate and prejudicial, but anomalous in relation to WMA policy.

Critical distinctions not recognized

III.6    Objecting practitioners are typically willing to work cooperatively with patients and others in relation to patient access to services as long as cooperation does not involve collaboration: an act that establishes a causal connection to or de facto support for the services to which they object. They are usually willing to provide patients with information to enable informed decision-making and contact with other health care practitioners.

III.7    The distinctions between cooperation and collaboration and providing information vs. providing a service enable an approach that accommodates both patients and practitioners. However, these critical distinctions are irrelevant within the analytical framework adopted in WG Para 27, so they are not recognized. As a result, WG Para 27 does not attempt or even suggest how to accommodate physician integrity and patient requests when they conflict.

III.8    On the other hand, avoiding, minimizing and satisfactorily managing such conflicts can be challenging, and WG Para 27 correctly identifies some of the issues that must be addressed, such as patient health and continuity of medical treatment. It does not follow, however, that they can be adequately addressed by the workgroup's text.  It may be that the shortcomings of WG Para 27 reflect an attempt to accomplish more than can actually be accomplished within the constraints imposed by the nature of the document.

Conflict with existing WMA policy on euthanasia/assisted suicide

III.9    Euthanasia and/or assisted suicide are considered to be part of medical practice in Belgium, Netherlands, Luxembourg, Switzerland, Canada, Colombia, Australia, New Zealand, parts of the United States and Spain. Some former and present constituent members of the WMA consider the procedures to be in accord with good medical practice. It seems likely that other countries and national medical associations will follow suit.

III.10    Some physicians in these countries, like the WMA, remain opposed to euthanasia and assisted suicide. Currently, physicians are nowhere required to personally provide euthanasia or assisted suicide, but two medical regulators in Canada demand that objecting physicians collaborate in killing their patients by effective referral. Notwithstanding opposition to effective referral by the Canadian Medical Association,19 the position of objecting physicians in Canada is difficult and tenuous.20,21 Physicians in other countries may eventually find themselves in a similar position.

III.11    The WMA clearly asserts that this is unacceptable: "No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end."22 In contrast, WG Para 27 purports to establish an ethical obligation to actively and deliberately collaborate in a procedure a physician believes to be unethical, not excluding planned and deliberate medical homicide and assisted suicide.

III.12    Here it is relevant to recall what motivated physicians to found the WMA:

National medical association delegates returning [to] London in September, 1946 were uneasy and ambivalent about plans to nationalize health care systems in Britain and the Continent. On the one hand, they welcomed the growing interest in medicine by governments around the world. On the other, they worried about the consequences of (as later expressed) transforming all physicians into “Civil servants controlled by the state.” They conceived an international medical association as support for national associations defending practitioners from government demands. (References omitted)23

III.13    Current WMA policy on euthanasia and assisted suicide supports objecting physicians in the manner intended by the founders of the Association. WG Para 27 not only abandons them, but can and most certainly will be used against them. To assert that WG Para 27 cannot be used in this way because the WMA considers euthanasia/assisted suicide unethical is utterly unrealistic.

Conflict with interdependent ICME provisions

III.14    WG Para 27 undermines all of the functionally interdependent provisions of the ICME associated with practising medicine with conscience. Specifically, if physicians are compelled by WG Para 27 to collaborate in procedures they reasonably believe to be contrary to good medical practice, harmful to patients, or otherwise unethical, it will be impossible for them

 • to maintain their "commitment to the ethical principles set forth" in the ICME; (Paragraph 1: Primacy of ethical principles)

 • to "practise with conscience, honesty, and integrity, while always exercising independent professional judgment and maintaining the highest standards of professional conduct;" (Paragraph 3: Personal and professional integrity)

 • to steadfastly maintain "their sound professional medical judgments" against "instructions from non-physicians" — including patients, legislators, regulators, ethicists etc. (Paragraph 8: Integrity of medical judgement)

 • to "commit to the primacy of patient health and well-being and . . .offer care in the patient’s best interest" (when, contrary to their views about health, well-being and best interest, physicians are compelled by WG Para 27 to collaborate even in killing their patients); (Paragraph 14. Patient-centred practice)

 • to ensure that "ethical principles are upheld when working in teams"; (Paragraph 30: Ethical collaboration)

• to "prevent national or international ethical, legal, or regulatory requirements that undermine" ethical obligations (since WG Para 27 provides a vehicle for national, international, ethical, legal and regulatory authorities to compel physicians to collaborate in procedures they reasonably believe to be contrary to good medical practice, harmful to patients, or otherwise unethical); (Paragraph 39: Resistance to legal subversion of ethics)

 • "to support fellow members in upholding" ethical responsibilities or "to take measures to protect them from undue influence, from violence and from oppression." (Paragraph 40: Collegial support and resistance to oppression)

Recommended amendments to Paragraph 27

III.15    The amendments to WG Para 27 recommended by the Project make three changes:

• The analytical framework is expanded so that the amended Paragraph 27 addresses the exercise of freedom of conscience within medical practice in relation to contested procedures or services.

• Consistent with recognized ethical principles and other WMA policies, providing, facilitating, recommending and supporting are identified as morally relevant conduct in relation to contested procedures or services.

• The amendment explicitly recognizes the potential for significant ethical disagreement between physicians and the state or other authorities and gives practical force to the functionally interdependent provisions of the ICME identified in I.4 and III.14.

III.16    A paragraph in the ICME can make key points but cannot comprehensively address this subject. The Project recommends that Paragraph 27 be supplemented by a stand-alone WMA policy on physician freedom of conscience "to help physicians defend their personal and professional integrity while providing medical services within the context of patient-centred practice."24 A draft policy is proposed in Appendix “B”.

III.17    For reasons that should be apparent from this commentary, the conference now scheduled for 4-5 July in Jakarta or Bali should be dedicated to the subject of conscience in medical practice, and that discussion of “conscientious objection” should occur within that context. Otherwise, the conference is likely to adopt the inadequate, prejudicial and anomalous approach reflected in WG Para 27.

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APPENDIX "A"

Project recommendations

WMA INTERNATIONAL CODE OF MEDICAL ETHICS: WG PARA 27 Deletions: lined-out	Recommended amendments /  Specific Comments Additions: bold/underlined ||  Comments: [italic]
The physician has an ethical obligation to minimise disruption to patient care. Conscientious objection must only be exercised if the individual patient is not discriminated against or disadvantaged and the patient’s health is not endangered.	The physician has an ethical obligation to refuse to provide, facilitate recommend or support interventions they reasonably consider inefficacious, harmful, discriminatory or otherwise unethical, notwithstanding contrary ethical, legal or regulatory requirements, norms or standards. Conscientious objection must be exercised in relation to such interventions. Physicians must continue to provide other necessary treatment and care to ensure the patient’s health is not endangered.
	[Minimising disruption to patient care is encompassed in the recommended amendment’s requirement to continue to provide necessary treatment and care. Prohibition of discrimination is explicitly included in the amendment. “Disadvantaged” is a broad term not necessarily associated with medical practice or health care and is likely to be polemically misused].
If a physician intends to exercise a conscientious objection to a specific treatment or procedure, the physician must inform the patient of this objection. If it is not practicable for the patient to see another physician who will perform the treatment or procedure, the physician must initiate, without delay, arrangements for the patient to consult with a suitably qualified physician or authorised health care professional who does not object to the treatment or procedure.	If a physician intends to exercise a conscientious objection to a specific treatment or procedure, the physician must promptly inform the patient. If the patient wishes to see another physician who will perform the treatment or procedure, the physician must promptly advise the patient how to connect with other suitably qualified physicians or authorised health care professionals.
	[The recommended amendment specifies that notice to the patient must be prompt. The autonomy of patients is respected and enabled by requiring an objecting physician to explain how they can connect with other physicians. Physician integrity is protected because physicians are not required to collaborate in what they reasonably believe to be inefficacious, harmful or otherwise unethical practices by arranging for them to be provided by someone else].
The physician must minimise distress for the patient and must not disrespect the patient on the grounds of the patient’s conviction. The physician must respect other physicians’ and health professionals’ conscientious objections provided they are in line with this Code.

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APPENDIX "B"

Personal and Professional Integrity in Medical Practice

An addition to WMA policy

Protection of personal and professional integrity

1.    Physicians shall resist pressure from the state or other actors to force them to support, promote, provide, collaborate in or facilitate procedures or services that violate their personal or professional integrity or judgement, and refuse to affirm what they believe to be false, misleading or harmful to others.25,26,27,28,29,30 

2.    In order to protect their personal and professional integrity, physicians may decline to recommend, encourage, provide, collaborate in or help to arrange for interventions that are contrary to their ethical, moral or religious convictions or professional judgement,31,32,33,34,35,36  and may refuse to affirm what they believe to be false, misleading or harmful to others.37 In so doing, physicians must acknowledge patient concerns, treat them kindly, compassionately and respectfully, and must not attempt to convince patients to adopt their ethical, moral or religious convictions.38

Non-discrimination

3. In protecting their personal and professional integrity, physicians must not discriminate against persons by reason of their race, national or ethnic origin, colour, religion, sex, sexual orientation, gender, age, marital status, mental or physical disability or political views.39

Notice

4.    Physicians must give reasonable notice to patients of ethical, moral or religious beliefs that prevent them from providing an intervention so that patients may, if they wish, consult other physicians or health care personnel. Notice is reasonable if it is given before or at the time physicians assume primary responsibility for a patient's care, or as soon as practicable after becoming aware that a patient may request an intervention they decline to provide. Notice should also be given to colleagues and institutions likely to be affected.

Patient autonomy and decision-making

5.    In responding to patients, physicians must always provide sufficient and timely information about all lawful and professionally appropriate interventions that may have a therapeutic benefit so that patients can make informed decisions about accepting or refusing treatment. Sufficient information means diagnosis, prognosis and a balanced explanation of the benefits, burdens and risks associated with each intervention. Information is timely if it is provided so as to enable interventions that are most likely to cure or mitigate the patient's medical condition, prevent it from deteriorating further, or avoid interventions involving greater burdens or risks to the patient.40,41 

Declining to provide an intervention

6.    Physicians who decline to provide an intervention must advise affected patients that they may seek the interventions elsewhere and explain how affected patients can contact other physicians or health care personnel. When appropriate, they must promptly communicate to a person in authority a patient's request for a transfer of care and cooperate in a transfer of care arranged by the patient or a person in authority. They must continue to provide treatment or care unrelated to the requested intervention unless physician and patient agree to other arrangements.42

7.    Upon the request of a patient, physicians who decline to provide an intervention may, if consistent with their conscientious convictions and professional judgement,

a) arrange for the patient to be seen by a physician or other health care personnel willing to provide the requested intervention; or

b) arrange for a transfer of care to a physician willing to provide the requested intervention; or

c) provide contact information for physicians or health care personnel who provide or facilitate the requested intervention; or

d) enable patient contact with health care personnel or services in the community or in institutional settings who can ensure that the patient has access to all available interventions.43

Non-abandonment

8.    When a patient is imminently likely to suffer death or permanent serious injury if an intervention is not immediately provided, physicians must provide the intervention if it is within their competence, or immediately arrange for available and competent physicians or health care personnel to do so, unless the intervention has been or is likely to be facilitated by causing death or serious permanent injury of another person.44

Regulatory, educational and civil authorities

9.    A professional regulatory body must not make a regulation, by-law, rule, decision, policy, directive, guideline or standard that requires physicians to recommend, encourage, provide, collaborate in or help to arrange for interventions that are contrary to their ethical, moral or religious convictions or professional judgement, or to make statements that they know or reasonably believe to be false, misleading or harmful, or that require them to affirm belief in or about something that they do not believe.

10.&10.    Physicians and medical students must not be liable to civil, administrative, disciplinary, employment, educational penalty or disadvantage solely because they are unwilling to violate their ethical, moral or religious convictions or professional judgement, or to make statements they know or reasonably believe to be false, misleading or harmful, or refuse to affirm belief in or about something that they do not believe.

Comments on the text

The suggested extended policy would assist in implementing the Project’s recommended revision of Paragraph 27 of the International Code of Medical Ethics (ICME). As the notes indicate, it is internally consistent with other provisions of the ICME and important WMA policy statements. The principles it expresses are also reflected in codes of ethics of some national medical associations: the Czech Republic,45 Ethiopia,46 Germany,47 Hong Kong,48 Israel49 and Spain,50 for example.

Physicians are instructed to resist pressure to act in ways reasonably thought to incur moral complicity and professional responsibility for procedures or services that, like the affirmation falsehood, are inconsistent with moral commitments essential to their personal and/or professional integrity. The statement cannot reasonably be understood to license unjust discrimination, indulge irrational preferences or pander to mere feelings of distaste or discomfort.

The statement and policy confront bullying by states, international agencies, corporations and other powerful or influential actors, but they do not reflect a confrontational attitude toward patients. Physicians must give patients adequate notice to avoid or minimize inconvenience, and provide information they need to make informed and timely decisions about medical treatment. In declining to provide or facilitate an intervention for reasons of conscience and/or professional judgement, physicians must acknowledge patient concerns — not dismiss them — and must demonstrate kindness, compassion and respect. They must not abuse their authority by attempting to convert patients to their moral or religious beliefs, something the Indonesian Code of Medical Ethics denounces as “despicable.” 51

The grave obligation to intervene to prevent imminent death or serious injury is universally accepted. National codes of ethics variously articulate the circumstances that trigger the obligation. Often, like the ICME, they refer generally to providing care in emergencies; sometimes they define an emergency as involving "urgent life saving treatments"52 or imminent threats to life, limbs or organs.53 The formulation offered here is informed by two considerations.

First, in often heated partisan disputes about morally contested interventions, what counts as an “emergency” can be distorted. For example, if complications arise in providing euthanasia or assisted suicide in a patient’s home, Canadian practitioners unable to obtain IV access or provide “intraosseous infusion emergently” are advised to call an ambulance and have paramedics insert an IV, or to transport the patient to hospital where the IV can be inserted by emergency ward staff if the attending practitioner does not have privileges.54 Hence, the recommended policy is more specific about what triggers the obligation to act.

The unfamiliar exception to the obligation (“unless the intervention has been or is likely to be facilitated by causing death or serious permanent injury of another person”) reflects the difficulty faced by health care personnel who are unwilling to transplant organs obtained through executions, euthanasia or assisted suicide. Their resistance may reflect principled objections to the procedures or grave moral reservations about inducing people to opt for euthanasia or assisted suicide. Without the exception included here, the traditional obligation to prevent imminent death could be invoked to compel them to participate in transplanting organs obtained by what they consider to be unethical or dubiously ethical means.

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Notes

1.    Rene Leiva et al, "Euthanasia in Canada: A Cautionary Tale" (2018 Sep) 64:3 World Med J 17.

2.    Leonie Herx, Margaret Cottle & John Scott, "The Normalization of Euthanasia in Canada: the Cautionary Tale Continues" (2020 Apr) 66:2 World Med J 28.

3.     Sean Murphy et al, "The WMA and the Foundations of Medical Practice: Declaration of Geneva (1948), International Code of Medical Ethics (1949)" (2020) 66:3 World Med J 2 [WMA Foundations].

4.    Sean Murphy et al, "The Declaration of Geneva: Conscience, Dignity and Good Medical Practice" (2020 Aug) 66:4 World Med J 43.

5.    WMJ Conscience, supra note 4 at 41.

6.    WMJ Foundations, supra note 3 at 3.

7.    WMJ Conscience, supra note 4 at 42.

8.    CMDA Canada, "Understanding Conscience in Health Care" (21 April, 2021),at 00h:04m:01s to 00h:04m:48s [Goligher].

9.    Ibid at 00h:05m:54s to 00h:07m:16s.

10.    College of Physicians and Surgeons of Ontario, “Medical Assistance in Dying” (June, 2016; updated April, 2021), CPSO (website).

11.    World Medical Association, "WMA Declaration on Euthanasia and Physician-Assisted Suicide" (13 November, 2019), WMA (website) [WMA Euthanasia].

12.    World Medical Association, "WMA Declaration of Hamburg Concerning Support for Medical Doctors Refusing to Participate in or to condone, the use of Torture and other Cruel, Inhuman or Degrading Treatment" (13 July 2020), WMA (website) at para 1.

13.    World Medical Association, "WMA Declaration of Tokyo: Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment" (25 May, 2020), WMA (website) at para 1, 5, 9.

14.    Ibid at para 2, 5.

15.    World Medical Association, "WMA Resolution on the Prohibition of Physician Participation in Capital Punishment" (6 October, 2018), WMA (website).

16.    World Medical Association, "WMA Resolution on Prohibition of Forced Anal Examination to Substantiate Same-Sex Sexual Activity" (17 October, 2017), WMA (website) at para 6.

17.    Ibid at para 2.

18.    World Medical Association, "WMA Statement on Organ and Tissue Donation" (21 August, 2020), WMA (website), at para 34–36.

19.    Canadian Medical Association, "Submission to the College of Physicians and Surgeons of Ontario Consultation on CPSO Interim Guidance on Physician-Assisted Death" (13 January, 2016), Protection of Conscience Project (website).

20.     Leiva et al, supra note 1.

21.    Herx et al, supra note 2.

22.    WMA Euthanasia, supra note 17.

23.    WMJ Foundations, supra note 3 at 2.

24.    WMJ Conscience, supra note 4 at 44.

25.    World Medical Association, “WMA Declaration of Lisbon on the Rights of the Patient” (7 August, 2018), WMA (website) [WMA Declaration of Lisbon] at para 1(b).

26.    World Medical Association, “WMA Resolution on the Relation of Law and Ethics” (28 November, 2019), WMA (website).

27.    World Medical Association, “WMA Resolution on Criminalisation of Medical Practice” (30 April, 2021), WMA (website) at para 1.

28.    WMA Declaration of Hamburg, supra note 12 at para 4.1 (“resist any pressure to act contrary to the ethical principles governing their [commitment to serve humanity”).

29.    Memo from ICoME Workgroup to WMA Medical Ethics Committee (21 February 2022) Document no: MEC 220/ICoME REV2/Apr2022 “Draft WMA International Code of Medical Ethics: Compromise version following comments received after October 2021.” [ICoME Workgroup Rev2] at para 1, 8, 9.

30.    ICoME Workgroup Rev2, supra note 29 at para 36.

31.    WMA Declaration on Euthanasia, supra note 11 at para 3 (participate or refer).

32.    WMA Declaration of Hamburg, supra note 25 at para 1 (countenance, condone, or participate).

33.    WMA Declaration of Tokyo, supra note 13 at paras 1, 2, 5, 9 (countenance, condone, participate, provide knowledge, facilitate).

34.    WMA Resolution on Capital Punishment, supra note 15 at para 4 (participate in any way, planning, instruction, training).

35.    WMA Resolution on Anal Examination, supra note 16 at para 2, 6 (participation, complicity, incitement, preparation of reports).

36.    WMA Statement on Organ Donation, supra note 17 at para 34–36 (retrospectively affirming or supporting unethical practices).

37.    ICoME Workgroup Rev2, supra note 29 at para 8.

38.    ICoME Workgroup Rev2, supra note 29 at para 19.

39.    ICoME Workgroup Rev2, supra note 29 at para 5, 30.

40.    WMA Declaration of Lisbon, supra note 25 at paras 3–7.

41.    ICoME Workgroup Rev2, supra note 29 at para 13, 16, 17, 26.

42.    WMA Declaration of Lisbon, supra note 25 at para 1(f).

43.    Ibid.

44.    ICoME Workgroup Rev2, supra note 29 at para 10

45.    "The physician should know the laws and binding regulations, which apply to the performance of the medical profession, and must adhere to them. With full knowledge of the personal risk involved, the physician does not have to feel bound by any such laws and regulations, if their contents or their consequences result in a breach of medical ethics or threaten basic human rights. A physician is required to be independent and responsible in all his or her professional decisions and under all circumstances." The Czech Medical Chamber, Professional Regulation 10 of the Czech Medical Chamber: The Code of Ethics, Prague: CLK, 2007 [Czech COE] at s 1 para 2.

46.    "The doctor shall at no time divest herself/himself of her/his professional freedom." Ethiopian Medical Association, Medical Ethics for Doctors in Ethiopia, Addis Ababa: EMA, 2016 [EMA 2016] at art 17.

47.    "Physicians practice their profession according to their conscience, the precepts of medical ethics and humaneness. They may not acknowledge any principles, or comply with any regulations or instructions, that are irreconcilable with their tasks or for whose observance they cannot answer." German Medical Association, (Model) Professional Code for Physicians in Germany, Berlin: GMA (2011) at art 2(1).

48.    "The patient’s clinical benefit is of the utmost importance. If a doctor, because of his own religious belief, has any objection to a procedure which is beneficial to the patient, he should give a full explanation to the patient and ask the patient to seek advice from another qualified doctor." Medical Council of Hong Kong, Code of Professional Conduct for the Guidance of Registered Medical Practitioners, Hong Kong: MCHK, 2016 at para 33.2.

49.    "The physician is not obligated to give medical treatment at the patient's request, if the treatment conflicts with the physician's conscience or his professional opinion or with general medical knowledge, even if the request results from the patient's faith." Israeli Medical Association, The Code of Medical Ethics, s 1(n)2, in Israeli Medical Association, The Ethics Board: Rules and Position Papers, Ramat Gan: IMA, 2018 [IMA 2018] at p 38.

50.    Organización Médica Colegial de España, Código de Deontología Médica, Madrid: OMC, 2016 at p 29–30.

51.    Ikatan Dokter Indonesia (Indonesian Doctors Association), Kode Etik Kedoktoran Indonesia , Jakarta: IDA, 2012 at art 15(3).

52.    IMA 2018, supra note 49 at p 85.

53.    Saudi Commissioner for Health Specialties, Code of Ethics for Healthcare Practitioners, Riyadh: SCHS, 2014 at p 47.

54.    F Bakewell, VN Naik, “Complications with Medical Assistance in Dying (MAID) in the Community in Canada: Review and Recommendations” (28 March 2019) Canadian Association of MAiD Assessors and Providers (website).