Protection of Conscience Project
Protection of Conscience Project
www.consciencelaws.org
Service, not Servitude

Service, not Servitude

Submission to the College of Physicians and Surgeons of Saskatchewan (5 March, 2015)
Re:
Conscientious Refusal

Appendix "D"

Ontario, Alberta, Manitoba and Saskatchewan College Policies


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DI.    Introduction

DI.1    The information in this Appendix is relevant to the documents provided by Mr. Salte in his memo to Council dated 31 July, 2014 (See IV:Justification for the proposed policy).

DII.    College of Physicians and Surgeons of Ontario

DII.1    Physicians and the Ontario Human Rights Code (POHR) was adopted in 2008.  An earlier draft was withdrawn because of the opposition and public controversy it provoked, centred on the following passages:

. . .there will be times when it may be necessary for physicians to set aside their personal beliefs in order to ensure that patients or potential patients are provided with the medical treatment and services they require. (p. 4)

If patients or potential patients cannot readily make their own arrangements to see another doctor or health care provider, physicians must ensure arrangements are made, without delay, for another doctor to take over their care. (p. 6-7)1

DII.2   In POHR as adopted, these expectations were dropped.  In the event that a patient wants a procedure that a physician is unwilling to provide for reasons of conscience, the physician is expected to advise the patient "that they can see another physician with whom they can discuss their situation and in some circumstances, help the patient or individual make arrangements to do so."2

DII.3    Contrary to the impression that may have been created by its inclusion in Mr. Salte's memo, this does not amount to a requirement to refer a patient to a physician who will provide a morally contested procedure.  This conclusion is supported by the current attempt by a CPSO working group to convince the College Council to adopt a policy that does have such a requirement.

DIII.    College of Physicians and Surgeons of Alberta

DIII.1    A copy of the CPSA policy document Moral or Religious Beliefs Affecting Medical Care3 was provided by Mr. Salte.

DIII.2    Mr. Salte may have been unfamiliar with the development and meaning of the policy.

DIII.3    This provision is part of the Standards of Practice adopted by the CPSA following public consultation in 2008. The original draft Standards included a section concerning the termination of pregnancy which included the statement, "ensure that the patient. . . is offered access to available medical options." In its submission to the College, the Project warned that the wording was likely to be interpreted to impose a duty to refer for or otherwise facilitate procedures or services the physician believes to be wrong, and that many objecting physicians would find that unacceptable.4

DIII.4    Consistent with this warning, the Registrar of the College later stated:

Most respondents take exception with the draft, believing that the College will require physicians to refer patients for termination of pregnancy, or at the very least to be compliant in arranging a patient's abortion, contrary to the physician's personal beliefs. This is not true. . . .

. . . The College's current policy (in place for the past decade) states:

  • While recognizing the varied personal convictions of physicians it must still be the responsibility of physicians to ensure that pregnant women who come to them for medical care are provided with or are offered access to information or assistance to enable them to make informed decisions on all available options for their pregnancies including termination.

The points I wish to make are these: A Standard of Practice on this subject will not change the obligations of physicians that have been accepted by this College since 1991. The words are a little different, but the intent is not, as the principles underlying the standard have not changed over the past 20 years. (Emphasis in the original)5

DIII.5    The section concerning terminations of pregnancy was deleted from the final version of the Standards and the policy Moral or Religious Beliefs Affecting Medical Care adopted.

DIII.6    As a result of questions from physicians, the Project Administrator wrote to the Registrar of the College and was provided with the wording of the new policy,  Moral or Religious Beliefs Affecting Medical Care. The Administrator asked the Registrar to confirm that he correctly understood the policy:

I understand the expectation of referral . . . to hold in those cases in which a physician, for reasons of conscience, is unwilling to advise a patient that a procedure is legally available, or unwilling to explain precisely what is involved with the procedure, its purported risks and benefits, or provide other information a reasonable patient would need to have in order to decide whether or not to undergo an abortion (or assisted suicide, euthanasia, etc.).

In such cases, the physician is expected to direct the patient to another physician or resource who is willing to provide this information. It seems clear from the wording of all of these passages that they are meant to ensure that a patient has all of the information necessary to make an informed decision about treatment options. None of these passages imply that there is a duty to refer patients in order to facilitate abortion (or assisted suicide, euthanasia, etc.).6

DIII.7    The Registrar responded:

You are correct in your understanding that it is a physician's obligation to ensure his or her patient has the necessary information to make an informed decision. It would be unacceptable behaviour for a physician to deny a patient access to such information.7

DIII.8    An explanation of the policy to the same effect is available on the CPSA website.8

DIII.9    The correspondence and explanation make clear that the focus of the policy is the communication of information. If, for reasons of conscience, the physician cannot provide information about a treatment or service, the patient must be directed to a physician who can supply that information.  Contrary to the impression that may have been created by its inclusion in Mr. Salte's memo, Moral or Religious Beliefs Affecting Medical Care does not require an objecting physician to refer a patient to a colleague who will provide a morally contested service.

DIV.    College of Physicians and Surgeons of Manitoba

DIV.1    A copy of the CPSM policy document Members Moral or Religious Beliefs Not to Affect Medical Care.9

DIV.2    The wording is virtually identical to the wording of policy of the Colleges of Alberta.   It is directed to ensuring that patients have information about all available medical options, not to mandatory referral for a morally contested procedure.

DIV.3    This conclusion is supported by a review of the College's Code of Conduct:

8. Inform your patient when your personal morality would influence the recommendation or practise of any medical procedure that the patient needs or wants.10

DIV.4    This is virtually identical to section 12 of the CPSS Code of Ethics.11

DIV.5    Contrary to the impression that may have been created by its inclusion in Mr. Salte's memo, Members Moral or Religious Beliefs Not to Affect Medical Care does not require an objecting physician to refer a patient to a colleague who will provide a morally contested service.

DV.    College of Physicians and Surgeons of Saskatchewan

DV.1    The first section of the policy quoted in Mr. Salte's memo (IV.4) appears to be directed at physicians who refuse to continue a relationship with a patient who 'might contemplate' abortion. Physicians who take this approach must be extremely rare - if any can be found at all - so it is doubtful that the situation would ever arise. And while one can arrive at more than one interpretation of this passage, there is no requirement that the "available physician" be an abortion provider. Thus, the passage should not be understood to require referral for abortion.  

DV.2    Quoted in isolation, the second passage provided by Mr. Salte is potentially misleading.  The policy goes on to state that the patient is to be advised "of the availability of abortion services in the province, or elsewhere," and that the physician "should ensure that the patient has the information needed to access such services or make the necessary referral" (emphasis added).

DV.3   This does not require the physician to provide information that would direct a patient to an abortion provider, and, as the following comment by the then Deputy Registrar demonstrates, referral is clearly an alternative, not a requirement. 

The changes are intended to provide clarity, said Dr. Karen Shaw, the college's deputy registrar. They weren't prompted by any specific concerns, but were part of a regular review of college guidelines. The new guidelines were adopted at the council's most recent meeting on Friday.

"We didn't change the actual policy," she said. "It just made it clearer that people can state up front that they have difficulty with this and make a referral or they can assist the patient through all the steps they're comfortable with, until the point where they are more uncomfortable or the patient understands they're not willing to do the last step -which is to refer to someone they know will perform the abortion -but they must provide enough information."12

DV.4    When the Guideline on Unplanned Pregnancywas adopted in 2011, some of the major papers reported that the policy required objecting physicians to refer for abortion.  This was incorrect, and the error was noted and the source of the confusion identified in an article that was sent to the Registrar of the College at the time (Appendix "E").


Notes

1.  College of Physicians and Surgeons of Ontario, DRAFT: Physicians and the Ontario Human Rights Code (2008)

2.  College of Physicians and Surgeons of Ontario, Physicians and the Ontario Human Rights Code (2008).

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

4.  Protection of Conscience Project, Submission to the College of Physicians and Surgeons of Alberta Re: CPSA Draft Standards of Practice (8 October, 2008), II.5.

5.  "Registrar's Report: Draft standard for termination of pregnancy." The Messenger, April, 2009, p. 3 (Accessed 2015-02-12)

6.  Letter from the Administrator, Protection of Conscience Project to the Registrar of the College of Physicians and Surgeons of Alberta, dated 17 August, 2009.

7.  Letter from the Registrar of the College of Physicians and Surgeons of Alberta to the Administrator, Protection of Conscience Project, dated 24 August, 2009.

8.  The Messenger, "Are you up to Standard? Moral or Religious Beliefs Affecting Medical Care." 5 December, 2013. (Accessed 2015-02-12)

9.   College of Physicians and Surgeons of Manitoba, Statement: Members Moral or Religious Beliefs Not to Affect Medical Care. (Accessed 2015-02-11)

10.  College of Physicians and Surgeons of Manitoba, Code of Conduct (1 December, 2008) (Accessed 2015-02-27)

11.  College of Physicians and Surgeons of Manitoba, Code of Conduct (Accessed 2015-02-27)

12.  Scissons H.  "Abortion guidelines updated: Rules clarify protocol for doctors unwilling to terminate pregnancy." Saskatchewan Star Phoenix, 9 February, 2011

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