Appendix "B"

Full Text

BI.    Conscience Research Group (CRG)

BI.1    The Conscience Research Group (CRG) was formed by Professor Carolyn McLeod of the University of Western Ontario with the assistance of a 2009 grant of over $240,000.00 from the Canadian Institutes of Health Research (CIHR).1  CIHR provided members of the group with another $24,500.00 in grants between 2010 and 2012.2

BI.2   The Group faculty includes euthanasia/assisted suicide advocates Jocelyn Downie and Daniel Weinstock.  It is headed by Professor Carolyn McLeod and supported by research associate Jaqueline Shaw and seven graduate students.3  

BI.3    A central goal of the Group is to entrench in medical practice a duty to refer for or otherwise facilitate contraception, abortion and other "reproductive health" services.  The Group advocates a coercive model policy on conscientious objection that would apply to any legal, publicly funded procedure, including assisted suicide and euthanasia.  They have been working to convince provincial Colleges of Physicians and Surgeons to enact the policy in order to achieve by force of law/regulation what they have been unable to achieve by persuasion.(Appendix "A")

BII.    CRG convenes meeting with College representatives

BII.1    It appears that the CRG organized a meeting in 2013 to advance their Model Concientious Objection Policy (Appendix "A").  According to Bryan Salte, the meeting was funded by a research grant (presumably the CIHR granted noted above) and included:

• Bryan Salte, LLB, Associate Registrar, College of Physicians and Surgeons of Saskatchewan
• Andréa Foti, Manager- Policy Dept., College of Physicians and Surgeons of Ontario
• Dr. Gus Grant, Registrar of the College of Physicians and Surgeons of Nova Scotia
• A representative of the Collège des Médecins du Québec
• ". . . representatives from the faculties of law, medicine and philosophy from academia and other invited individuals."4

BII.2    The CRG authors appear to refer to this meeting in the introduction to their model policy:

Feedback on the draft policy was also solicited from a number of relevant experts: academics who do research primarily in health law, biomedical ethics, medicine or other health professions; physician regulatory body members; and local community organizations dealing with women’s health, sexual health, and the health of more marginalized populations (e.g. rural populations, street youth, First Nations). . . (Emphasis added)5

BII.3    It is not unlikely that the various faculties were represented by CRG members, perhaps augmented by supportive colleagues.

BII.4    The goal of the meeting "was to develop a policy that could be adopted by Canadian Colleges of Physicians and Surgeons to guide physicians who have a conscientious objection to providing certain forms of health care." 

While that is most frequently experienced in issues pertaining to reproduction i.e. birth control, abortion and emergency contraception, it can arise in a number of other situations as well, such as the provision of blood products and end of life care.4

BII.4    According to Byran Salte, participants at the meeting agreed upon the text of what he subsequently called the "draft policy statement developed by the Conscientious Objections Working Group."6   This was almost an exact duplicate of what the CRG published later in 2013 as its Model Conscientious Objection Policy. However, because Mr. Salte continued to use and refer to the text of the former, he could, strictly speaking, claim that the CPSS draft, Conscientious Refusal was not "taken from" that the CRG Model.

BIII.   Meeting of Registrars of BC, Alberta, Saskatchwan, Manitoba and Ontario

BIII.1    On 5 May, 2014,7 the "draft policy statement developed by the Conscientious Objections Working Group" was discussed during a meeting of the Registrars of the Colleges of BC, Alberta, Saskatchewan, Manitoba and Ontario.  Associate Registrar Bryan Salte of Saskatchewan seems to have taken the lead:

I suggested that each of the Colleges consider whether the recommendations in the report of the conscientious objections working group are appropriate, and if so, to consider implementing them.  I understood each College agreed to consider doing that.8

BIII.2    According to Salte, the Registrars "appeared to have reached a consensus that the document developed by the working group. . . should be considered for possible adoption by Canadian Colleges of Physicians and Surgeons."4

BIII.3    Of interest here is that the reported consensus included the Registrar of the College of Physicians and Surgeons of Ontario, one month before the Ontario College launched its public consultation on Physicians and the Ontario Human Rights Code.9   

BIII.4    However, the Registrar of the College of Physicians of BC made no reference to the discussion or consensus when reporting to the College Board at the end of the month,7 and the Registrar of the College in Alberta seems not to have reported the discussion or consensus at the College's quarterly Council meeting at the end of May.10  Neither was the discussion or consensus mentioned by Bryan Salte at the CPSS Council meeting at the end of June, though he made numerous other reports.11

BIV.    Controversy about Alberta physician declining to prescribe contraceptives

BIV.1    On 2 July, 2014, the CPSS Registrar (or someone in her office) copied a newspaper article about a Calgary physician who was refusing to prescribe contraceptives for the information of College Council.12  This appears to have been done in anticipation of the next Council meeting in September.

BIV.2    It is noteworthy that the news reports were sparked by a patient who was offended by the physician's notice about her practice, not by someone who had been refused a birth control prescription, although this was not clear in the clipping selected.13  More significant, the final sentence in the story stated that CPSA policy required objecting physicians to "ensure the patient has access to another practitioner who will prescribe the drug."  The statement erroneously implied a policy of mandatory referral for morally contested services.

BIV.3    The Registrar of the Alberta College included the following remarks in a column sparked by the controversy.  He referred, in particular, to two paragraphs of the College's policy on Moral or Religious Beliefs Affecting Medical Care:

• 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.
• 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 must 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.14

BIV.4    He went on to say:

The first point I wish to make is that patients shouldn’t be denied access to a medically necessary service. Numbers 2 and 4 (especially #4) of the standard emphasize that point. The physician in this case responded by altering her sign, giving prospective patients specific information as to where (and from whom) they could receive information about birth control including, if appropriate, a prescription for oral contraceptive pills.15

BIV.5    This could be taken to imply that the policy means that a physician has a duty to refer for a morally contested service, and that the physician in question had complied with the policy.  However, the Registrar had previously refused to assert that the policy implied such a duty, and strongly denied that the policy should be understood to imply a duty to refer for abortion.16

BV.    Canadian Registrars advised to adopt uniform coercive policy

BV.1    Associate Registrar Bryan Salte wrote to all Canadian Registrars of Colleges of Physicians and Surgeons, in July, 2014.  Citing the consensus of the western registrars (BIII.2), he recommended that all Colleges in Canada adopt the "draft policy statement developed by the Conscientious Objections Working Group."

Physician-assisted suicide, in particular, has the potential to challenge Colleges of Physicians and Surgeons to provide guidance to its members. . .

I think it will be very helpful if all Colleges are able to adopt the same or a very similar document.  My perspective is that that topic has the potential to be very controversial.  My perspective is that ethical standards for medical practice should be very similar across Canada, and that it should be possible for Canadian Colleges to adopt a common approach.  Any College that is an outlier, either because it has adopted a different position than other Colleges, or because it has not developed a policy, will potentially be placed in a difficult position.4

BV.2    Note that the concern voiced here is with the provision of assisted suicide (and, presumably, euthanasia), not with birth control or abortion.  Obviously, if it is agreed that objecting physicians can be coerced to refer patients for euthanasia, it becomes difficult to explain why they should not be forced to refer patients for anything else. 

BVI.    Memo to College Council proposes policy on "ethical objection"

BVI.1    On 31 July, 2014, Mr. Salte prepared a memo for College Council asking "whether it will develop a policy or guideline for physicians who have an ethical objection to providing certain forms of care."17

BVI.2    He offered five examples of "issues which have resulted in controversy": abortion, birth control, assisted suicide, fetal sex identification and genetic testing.  He identified himself as "part of a group that was formed with a grant to study and provide recommendations to Canadian Colleges of Physicians and Surgeons" concerning "physicians who have a conscientious objection to providing certain forms of medical care."  He provided a copy of the "draft policy statement developed by the Conscientious Objections Working Group," a copy of his letter to the Registrars of Canadian Colleges and copies of Alberta, Saskatchewan, Manitoba and Ontario policies referring to similar issues.

BVI.3    The policy documents were supplemented by a newspaper article about the Ontario consultation.  It referred to the On-line poll conducted by the College of Physicians and Surgeons of Ontario, which was actually of doubtful value.  However, the article concluded with an interview of ethicist Arthur Schafer, who insisted that objecting physicians have an obligation to refer patients to a colleague who will provide the services they refuse to provide.18

BVI.4    Mr. Salte also included an article from an American professional journal, "Conscientious Refusal in Family Medicine Residency Training."  The article described the results of a survey completed by 154 physicians in a university faculty, less than half of those polled. Like the article quoting Schafer, the conclusion of the journal article generally favoured the draft policy he was proposing:

This study is the first to demonstrate the prevalence of moral objection to legally available medical procedures among family medicine residents and faculty.  The survey responses demonstrate that conscientious objection exists and that there is support for physicians exercising moral objection in clinical practice, provided they engage in appropriate patient education and referral.19

BVI.5    However, the author added that the results were "unique to the residents and faculty in the University of Wisconsin Department of Family Medicine and limit generalizability of the findings" and that "the complexity of the subject matter may also limit the respondents' ability to give a complete answer by requiring a yes or no response."19

BVII.    College Council approves formation of committee

BVII.1    At the College Council meeting on 19 September, 2014, Mr. Salte presented his report and the newspaper clipping about the Calgary physician (BIV.).

BVII.2    The Council approved the formation of a committee to study "Conscientious Objection to Providing Medical Care."  Members of the committee were Mr. Salte, Council President Dr. Mark Chapelski, and public members Susan Halland and Marcel de la Gorgendiere. Dr. Susan Hayton of the Department of Academic Family Medicine of the University of Saskatchewan was also a committee member.20   In January, 2014 she completed a Master's thesis on Accommodation of Religious and Cultural Differences in Medical School Training.21

BVIII.    Committee meeting

BVIII.1    The committee met once; no minutes were kept.22  Dr. Chapelski was not present.  Committee members were Registrar Karen Shaw, Associate Registrar Bryan Salte, Deputy Registrar Dr. Michael Howard-Tripp, Dr. Hayton, Susan Halland and Marcel de la Gorgendiere.  The group agreed that the "draft policy statement developed by the Concientious Objections Working Group" was generally satisfactory, but suggested minor changes for the sake of clarity.  The only notable changes:

• Statements concerning disciplinary consequences were removed because they were thought superfluous.
• A statement to the effect that physicians should not promote their own beliefs was added.23

BIX.    Council approval in principle

 BIX.1    Mr. Salte presented a report based on the committee meeting to Council, recommending that there should be a consultation about the document  because of its"potentially contentious nature."24 On 20 January, 2015, Council unanimously approved the policy in principle and authorized a consultation.25

Notes

1. 

2.

3.  Let their conscience be their guide? Conscientious refusals in reproductive health care. (Accessed 2014-11-21)

4.  Letter from Bryan Salte to the Registrars of Colleges of Physicians and Surgeons in Canada.  Redacted in Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 8.

5.  Downie J.  McLeod C. Shaw J.,"Moving Forward with a Clear Conscience: A Model Conscientious Objection Policy for Canadian Colleges of Physicians and Surgeons." Health Law Review, 21:3, 2013, p. 29 (Accessed 2015-02-24)

6.  Document 200/14, College of Physicians and Surgeons of Saskatchewan, Report to Council from the Registrar, 31 July, 2014, p. 4, listed as the first of the attached documents, identifying the text reproduced on pages 5 to 7 of the report.  The few differences between the documents are largely editorial and are compared below.

7.  College of Physicians and Surgeons of British Columbia, Minutes of Board Meeting 30 May, 2014, p. 2. The Registrar reported the date of the meeting and four agenda items, but did not mention the discussion concerning physician freedom of conscience. (Accessed 2015-02-23)

8.  Document 200/14, College of Physicians and Surgeons of Saskatchewan, Memo from Bryan Salte to Council dated 31 July, 2014 Re: Possible Policy or Guideline - Physicians who have an ethical objection to provide certain forms of medical services., p. 3.

9.  "Physicians and the Ontario Human Rights Code."  Protection of Conscience Blog, 4 June, 2014.

10.  College of Physicians and Surgeons of Alberta, Council Highlights, May, 2014. (Accessed 2015-02-23)

11.  College of Physicians and Surgeons of Saskatchewan, Agenda, Open Session and  Executive Summary, Council Meeting 20-21 June, 2014 (Accessed 2015-02-23) He did provide a report on a Federation of Medical Regulatory Authorities, but the report is confidential.

12.  Document 185/14, College of Physicians and Surgeons of Saskatchewan, "Alberta doctor refuses to prescribe birth control over her morality."  Tristan Bronca, The Medical Post, 30 June, 2014.

13.  Leung M.  "Calgary doctor refuses to prescribe birth control due to personal beliefs."  CTV News, 28 June, 2014. (Accessed 2015-02-25)

14.  College of Physicians and Surgeons of Alberta, Moral or Religious Beliefs Affecting Medical Care. (Accessed 2015-02-13)

15.  College of Physicians and Surgeons of Alberta, "Trevor's Take on. . . Moral or Religious Beliefs Affecting Medical Care." The Messenger, 3 July, 2014 (Accessed 2015-02-24)

16.  Protection of Conscience Project Submission to the College of Physicians and Surgeons of Ontario Re: Professional Obligations and Human Rights (20 February, 2015) Appendix "B", BII.2.9

17.  Document 200/14, College of Physicians and Surgeons of Saskatchewan, Memo from Bryan Salte to Council dated 31 July, 2014 Re: Possible Policy or Guideline - Physicians who have an ethical objection to provide certain forms of medical services.

18.  Document 200/14, College of Physicians and Surgeons of Saskatchewan, Memo from Bryan Salte to Council dated 31 July, 2014 Re: Possible Policy or Guideline - Physicians who have an ethical objection to provide certain forms of medical services., p. 19-20.

19.  Document 200/14, College of Physicians and Surgeons of Saskatchewan, Memo from Bryan Salte to Council dated 31 July, 2014 Re: Possible Policy or Guideline - Physicians who have an ethical objection to provide certain forms of medical services, p. 21-24.

20.  College of Physicians and Surgeons of Saskatchewan, Minutes of Council Meeting, 19 September, 2014.

21.   Hayton S.  Accommodation of Religious and Cultural Differences in Medical School Training.  A Thesis Submitted to the College of Graduate Studies and Research In Partial Fulfillment of the Requirements For the Degree of Master of Laws In the College of Law
University of Saskatchewan Saskatoon (January, 2014) (Accessed 2015-02-24)

22.  Document 23/15, College of Physicians and Surgeons of Saskatchewan, Memo to Council from Bryan Salte, Re: Draft Policy-Conscientious Objection (9 January, 2015 ), p. 2. Email from the Office of the Registrar, College of Physicians and Surgeons of Saskatchewan, to the Administrator, Protection of Conscience Project, 24 February, 2015, 7:14 AM.

23.  Document 23/15, College of Physicians and Surgeons of Saskatchewan, Memo to Council from Bryan Salte, Re: Draft Policy-Conscientious Objection(9 January, 2015 ), p. 2-3

24.  Document 23/15, College of Physicians and Surgeons of Saskatchewan, Memo to Council from Bryan Salte, Re: Draft Policy-Conscientious Objection (9 January, 2015 ), p. 2.

25.  College of Physicians and Surgeons of Saskatchewan, Minutes of Council Meeting, 16 January, 2015, p. 11.

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