Submission to the College of Physicians and Surgeons of Ontario
Re: Interim Guidance on Physician Assisted Death
Appendix "C"
Physician Exercise of Freedom of Conscience and Religion
Full Text
C1. Introduction
C1.1 To minimize inconvenience to patients and avoid conflict, physicians
should develop a plan to meet the requirements of Parts C2 and C3 for
services they are unwilling to provide for reasons of conscience or
religion.
C2. Providing information to patients
C2.1 This Part highlights points of particular interest within the
context of the exercise of freedom of conscience. It is not an exhaustive
treatment of the subject of informed consent.
C2.2 In exercising freedom of conscience and religion, physicians must
provide patients with sufficient and timely information to make them aware
of relevant treatment options so that they can make informed decisions about
accepting or refusing medical treatment and care.
C2.3 Sufficient information is that which a reasonable patient in the
place of the patient would want to have, including diagnosis, prognosis and
a balanced explanation of the benefits, burdens and risks associated with
each option.
C2.4 Information is timely if it is provided as soon as it will be of
benefit to the patient. Timely information will enable interventions based
on informed decisions that are most likely to cure or mitigate the patient’s
medical condition, prevent it from developing further, or avoid
interventions involving greater burdens or risks to the patient.
C2.5 Relevant treatment options include all legal and clinically
appropriate procedures, services or treatments that may have a therapeutic
benefit for the patient, whether or not they are publicly funded, including
the option of no treatment or treatments other than those recommended by the
physician.
C2.6 Physicians whose medical opinion concerning treatment options is
not consistent with the general view of the medical profession must disclose
this to the patient.
C2.7 The information provided must be responsive to the needs of the
patient, and communicated respectfully and in a way likely to be understood
by the patient. Physicians must answer a patient’s questions to the best of
their ability.
C2.8 Physicians who are unable or unwilling to comply with these
requirements must promptly arrange for a patient to be seen by another
physician or health care worker who can do so.
C3. Exercising freedom of conscience or religion
C31 In exercising freedom of conscience and religion, physicians must
adhere to the requirements of Part CII (Providing information to patients).
C3.2 In general, and when providing information to facilitate informed
decision making, physicians must give reasonable notice to patients of
religious, ethical or other conscientious convictions that influence their
recommendations or practice or prevent them from providing certain
procedures or services. Physicians must also give reasonable notice to
patients if their views change.
C3.3 Notice is reasonable if it is given as soon as it would be
apparent to a reasonable and prudent person that a conflict is likely to
arise concerning treatments or services the physician declines to provide,
erring on the side of sooner rather than later. In many cases - but not all
- this may be prior to accepting someone as a patient, or when a patient is
accepted.
C3.4 In complying with these requirements, physicians should limit
discussion related to their religious, ethical or moral convictions to what
is relevant to the patient’s care and treatment, reasonably necessary for
providing an explanation, and responsive to the patient’s questions and
concerns.
C3.5 Physicians who decline to recommend or provide services or
procedures for reasons of conscience or religion must advise affected
patients that they may seek the services elsewhere, and provide information
about how to find other service providers. Should the patient do so,
physicians must, upon request, transfer the care of the patient or patient
records to the physician or health care provider chosen by the patient.
C3.6 Alternatively, in response to a patient request, physicians may
respond in one of the following ways, consistent with their moral, ethical
or religious convictions:
a) by arranging for a transfer of care to another
physician able to provide the service; or
b) by providing a formal referral to someone able to
provide the service; or
c) by providing contact information for someone able
to provide the service; or
d) by providing contact information for an agency or
organization that will refer the patient to a service provider; or
e) by providing contact information for an agency or
organization that provides information the patient may use to contact a
service provider; or
f) by providing non-directive, non-selective
information that will facilitate patient contact with other physicians,
heath care workers or sources of information about the services being sought
by the patient.
C3.7 A physician’s response under C3.5 or
C3.6 must be timely.
Timely responses will enable interventions based on informed decisions that
are most likely to cure or mitigate the patient’s medical condition, prevent
it from developing further, or avoid interventions involving greater burdens
or risks to the patient.
C3.8 In acting pursuant to C3.5 or
C3.6, physicians must continue
to provide other treatment or care until a transfer of care is effected,
unless the physician and patient agree to other arrangements.
C3.9 Physicians unwilling or unable to comply with these requirements
must promptly arrange for a patient to be seen by another physician or
health care worker who can do so.
C3.10 Physicians who provide medical services in a health care facility
must give reasonable notice to a medical administrator of the facility if
religious, ethical or other conscientious convictions prevent them from
providing certain procedures or services, and those procedures or services
are or are likely to be provided in the facility. In many cases - but not
all - this may be when the physician begins to provide medical services at
the facility.
C4. Reminder: treatments in emergencies
C4.1 Physicians must provide medical treatment that is within their
competence when a patient is likely to die or suffer grave injury if the
treatment is not immediately provided, or immediately arrange for the
patient to be seen by someone competent to provide the necessary treatment.
C4.2 Physicians who fail to provide or arrange for medical treatment in
such circumstances may be liable for negligence or malpractice.
Notes
1.
Joint Statement on Preventing and Resolving
Ethical Conflicts Involving Health Care Providers and Persons Receiving Care
(1999) (Canadian Medical Association, Canadian Healthcare Association,
Canadian Nurses’ Association, Catholic Health Association of Canada)
"I.1 Open communication, within the confines of privacy and confidentiality,
is also required. All those involved in decision-making should be encouraged
to express their points of view, and these views should be respectfully
considered. Care providers should ensure that they understand the needs,
values and preferences of the person receiving care. To avoid
misunderstanding or confusion, they should make their communications direct,
clear and consistent. They should verify that the person receiving care
understands the information being conveyed: silence should not be assumed to
indicate agreement. The person receiving care should be provided with the
necessary support, time and opportunity to participate fully in discussions
regarding care."
2. Canadian Medical Association
Code of Ethics
(2004): "21. Provide your patients with the information they need to make
informed decisions about their medical care, and answer their questions to
the best of your ability." Accessed
2015-09-22.
3. Canadian Medical Protective Association,
Consent: A guide for Canadian physicians (4th ed) (May, 2006)
Accessed 2015-09-15.
4. Canadian Medical Association,
Principles-based Recommendations for
a Canadian Approach to Assisted Dying (2016) "Section 1.2: The attending physician must disclose to the patient
information regarding their health status, diagnosis, prognosis, the
certainty of death upon taking the lethal medication, and alternatives,
including comfort care, palliative and hospice care, and pain and symptom
control." Accessed 2016-01-09.
5. Canadian Medical Association,
Principles-based Recommendations for
a Canadian Approach to Assisted Dying (2016) "Section 5.2: . . . physicians are expected to provide the patient
with complete information on all options available to them, including
assisted dying, and advise the patient on how they can access any separate
central information, counseling, and referral service." Accessed 2016-01-09.
6.
Joint Statement
on Preventing and Resolving Ethical Conflicts Involving Health Care
Providers and Persons Receiving Care (1999) (Canadian Medical
Association, Canadian Healthcare Association, Canadian Nurses’ Association,
Catholic Health Association of Canada) "I.7 Informed decision-making
requires that the person receiving care or his or her proxy be given all
information and support necessary for assessing the available options for
care, including the potential benefits and risks of the proposed course of
action and of the alternatives, including palliative care."
7. Canadian Medical Protective Association,
Consent: A guide for Canadian physicians (4th ed) (May, 2006): Standard
of disclosure; Some practical considerations. Accessed 2016-01-09.
8. Canadian Medical Association
Code of Ethics
(2004): "23. Recommend only those diagnostic and therapeutic services that
you consider to be beneficial to your patient or to others. . ." Accessed
2015-09-22.
9. Canadian Medical Association
Code of Ethics
(2004): "45. Recognize a responsibility to give generally held opinions of
the profession when interpreting scientific knowledge to the public; when
presenting an opinion that is contrary to the generally held opinion of the
profession, so indicate." Accessed
2015-09-22.
10. Canadian Medical Association
Code of Ethics (2004):
"22. Make every reasonable effort to communicate with your patients in such
a way that information exchanged is understood." Accessed
2015-09-22.
11. Canadian Medical Protective Association,
Consent: A guide for Canadian physicians (4th ed) (May, 2006): Standard
of disclosure; Some practical considerations. "3. A physician must
answer any specific questions posed by the patient as to the risks involved
in the proposed treatment. Always the patient must be given the opportunity
to ask questions." Accessed 2016-01-09
12. Canadian Medical Association,
Principles-based Recommendations for
a Canadian Approach to Assisted Dying (2016) "Foundational Principle (6) Dignity: All patients, their family
members or significant others should be treated with dignity and respect at
all times, including throughout the entire process of care at the end of
life."
13. Canadian Medical Association,
Principles-based Recommendations for
a Canadian Approach to Assisted Dying (2016) "Foundational Principle (10) Mutual respect: There should be mutual
respect between the patient making the request and the physician who must
decide whether or not to perform assisted dying. A request for assisted
dying is only possible in a meaningful physician-patient relationship where
both participants recognize the gravity of such a request."
14.
Joint Statement
on Preventing and Resolving Ethical Conflicts Involving Health Care
Providers and Persons Receiving Care (1999) (Canadian Medical
Association, Canadian Healthcare Association, Canadian Nurses’ Association,
Catholic Health Association of Canada) "I.16 . . . Health care providers
should declare in advance their inability to participate in procedures that
are contrary to their professional or moral values. . ."
15. Canadian Medical Association
Code of Ethics
(2004): "12. Inform your patient when your personal values would influence
the recommendation or practice of any medical procedure that the patient
needs or wants." Accessed 2015-09-22.
16.
Joint Statement
on Preventing and Resolving Ethical Conflicts Involving Health Care
Providers and Persons Receiving Care (1999) (Canadian Medical
Association, Canadian Healthcare Association, Canadian Nurses’ Association,
Catholic Health Association of Canada) "II.10 If the person receiving care
or his or her proxy is dissatisfied with the decision, and another care
provider, facility or agency is prepared to accommodate the person's needs
and preferences, provide the opportunity for transfer."
17.
Joint Statement
on Preventing and Resolving Ethical Conflicts Involving Health Care
Providers and Persons Receiving Care (1999) (Canadian Medical
Association, Canadian Healthcare Association, Canadian Nurses’ Association,
Catholic Health Association of Canada)"II.11 If a health care provider
cannot support the decision that prevails as a matter of professional
judgement or personal morality, allow him or her to withdraw without
reprisal from participation in carrying out the decision, after ensuring
that the person receiving care is not at risk of harm or abandonment."
18. Canadian Medical Association
Code of Ethics
(2004): "19. Having accepted professional responsibility for a patient,
continue to provide services until they are no longer required or wanted;
until another suitable physician has assumed responsibility for the patient;
or until the patient has been given reasonable notice that you intend to
terminate the relationship." Accessed 2015-09-22.
19. Canadian Medical Association
Code of Ethics
(2004): "18. Provide whatever appropriate assistance you can to any person
with an urgent need for medical care. " Accessed 2015-09-22
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