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Protection of Conscience Project

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Service, not Servitude
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Submission to the Canadian Medical Association

Re: 2018 Revision of the CMA Code of Ethics

2 April, 2018


Part VII.    CMA Plus: physician exercise of freedom of conscience
Introduction

VII.1    In Part VI a protection of conscience policy was proposed using almost entirely the CMA’s words. In this Part a more comprehensive policy is offered, based largely on CMA sources.

General

VII.2    It is in a patient's best interests and in the public interest for physicians to act as moral agents, and not as technicians or service providers devoid of moral judgement. While physicians must act in accordance with their conscientious convictions or moral commitments, they must always demonstrate respect for their patients by responding to their enquiries, requests or needs by providing information and appropriate support.

Supporting sources:

- Canadian Medical Association, Submission to the College of Physicians and Surgeons of Ontario (16 January, 2016)1

- Canadian Medical Association Code of Ethics (2018 Revision), C2 (App "A" Ref 049; + Ref 017, 019, 020, 037)

- Canadian Medical Association, Induced Abortion (1988)2

- Canadian Medical Association, Medical Assistance in Dying (2017)3,4,5,6

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)7, 8

Providing information to patients*

VII.3    Physicians must provide patients with sufficient and timely information, responsive to their needs or enquiries, to make them aware of relevant treatment options so that they can make informed decisions about accepting or refusing medical treatment and care.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) (App "A" C-IntroF, Ref 057, C8 Ref 063)

- Canadian Medical Association Code of Ethics (2004) para. 219

- Canadian Medical Association, Medical Assistance in Dying (2017)10

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)11,12

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Disclosure of information; Standard of disclosure.13

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.414

VII.4    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.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) (App "A" C8 Ref 063)

- Canadian Medical Association Code of Ethics (2004) para. 219

- Canadian Medical Association, Medical Assistance in Dying (2017)10

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)11,12

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Standard of disclosure.13

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.714

VII.5    Information is timely if it 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.

VII.6    Relevant treatment options include all legal and clinically appropriate procedures/interventions/services 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.

Supporting sources:

- Canadian Medical Association Code of Ethics (2004) para. 2315

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Some practical considerations about informed consent (4, 5)13

VII.7    Physicians whose medical opinion concerning a procedure/intervention/service  is not consistent with the general view of the medical profession must disclose this to the patient.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) C31 (App "A" Ref 102)

- Canadian Medical Association Code of Ethics (2004) para. 4516

VII.8    The information provided must be 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.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) C4, (App "A" Ref 052)

- Canadian Medical Association Code of Ethics (2004) para. 21,9 2217

- Canadian Medical Protective Association, Consent: A guide for Canadian physicians (4th ed) (June, 2016): Patient Comprehension13

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.414

VII.9    Physicians who are unable or unwilling to provide this information must promptly arrange for a patient to be seen by another physician or health care worker who can do so.

Exercising freedom of conscience

VII.10    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/interventions/services. Physicians must also give reasonable notice to patients if their views change.

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision), C3 (App "A" Ref 050)

- Canadian Medical Association Code of Ethics (2004) para. 12,18 219

- Canadian Medical Association, Induced Abortion (1988):19

- Canadian Medical Association, Medical Assistance in Dying (2017)20

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.1614

VII.11    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 procedures/interventions/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.

VII.12    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.

VII.13    Physicians who decline to recommend or provide a procedure/intervention/service for reasons of conscience or religion are not required to provide it, or to otherwise participate in it, or to refer or direct the patient to a physician or a medical administrator who will provide it, or to arrange a transfer for care for that purpose.  However, they must advise affected patients that they may seek the procedure/intervention/service elsewhere, and provide information about how to find other physicians or health care providers. Should the patient identify an alternative physician or provider, physicians must, upon the patient's request, effect a transfer of care or patient records to the physician or provider chosen by the patient. 

Supporting sources:

- Canadian Medical Association Code of Ethics (2018 Revision) (App "A" Ref 051)

- Canadian Medical Association Code of Ethics (2004) para. 219

- Canadian Medical Association, Medical Assistance in Dying (2017)21,22

- Canadian Medical Association, Principles-based Recommendations for a Canadian Approach to Assisted Dying (2015)8

-  CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) II.1014

VII.14    A physician's response under VII.13 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.

VII.15    In acting pursuant to VII.13, 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.

Supporting sources:

- Canadian Medical Association Code of Ethics (2004) para. 1923

- Canadian Medical Association, Medical Assistance in Dying (2017)22

- CMA, CHA, CNA, CHAC- Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care (1999) I.16, II.1114

VII.16    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/interventions/services that 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.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)24

VII.17    Physicians must not impede or block access to procedures/interventions/services to which they objection, nor make acceptance or retention of patients conditional upon their agreement not to request such procedures/interventions/services.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)19

No discrimination

VII.18    To enable physicians to adhere to such moral commitments without causing undue delay for patients requesting procedures/interventions/services, health systems will need to implement  mechanisms that allow patients to easily obtain direct access to them.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)25

VII.19    It is a responsibility of the community to ensure access, rather than placing the burden of finding services solely on individual physicians or patients.

Supporting sources:

- Canadian Medical Association, Submission to the College of Physicians and Surgeons of Ontario (16 January, 2016) 26

VII.20    Physicians' general employment or contract opportunities should not be influenced by their conscientious decisions to participate in, or not participate in, the delivery of procedures/interventions/services.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)27

- Canadian Medical Association, Induced Abortion (1988)

VII.21   Learners must be free to follow their conscience without risk to their evaluations and training advancement.

Supporting sources:

- Canadian Medical Association, Medical Assistance in Dying (2017)28

- Canadian Medical Association, Induced Abortion (1988)29


Notes

*  All references to "patients" include substitute medical decision-makers.

1.  "It is in fact in a patient's best interests and in the public interest for physicians to act as moral agents, and not as technicians or service providers devoid of moral judgement. At a time when some feel that we are seeing increasingly problematic behaviours, and what some view as a crisis in professionalism, we ought to be articulating obligations that encourage moral agency, instead of imposing a duty that is essentially punitive to those for whom it is intended and renders an impoverished understanding of conscience." Canadian Medical Association. Submission to the College of Physicians and Surgeons of Ontario [Internet]. 2016 Jan. 16.

2.  "A physician should not be compelled to participate in the termination of a pregnancy."Canadian Medical Association. Induced Abortion [Internet]. 1988 Dec 15 [cited 2018 Mar 15].

3.  "Rationale: . . .The CMA supports the right of all physicians to follow their conscience when deciding whether to provide or otherwise participate in assistance in dying as per the legislation governing medical assistance in dying. The CMA equally supports conscientious participation in and conscientious objection to assistance in dying by physicians." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

4.  "Relevant Foundational Considerations, 3. Respect for freedom of conscience: The CMA believes that physicians must be able to follow their conscience without discrimination when deciding whether or not to provide or participate in assistance in dying. The CMA supports physicians who, for reasons of moral commitments to patients and for any other reasons of conscience, will not participate in decisional guidance about, eligibility assessments for, or provision of medical assistance in dying." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

5.  "Relevant Foundational Considerations, 5. Duty of non-abandonment: Physicians have an obligation to respond to a request for assistance in dying, regardless of how their moral commitment is expressed. Patients should never be abandoned and must always be supported by their physician and other members of their care team." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

6.  "Relevant Foundational Considerations, 1. Respect for autonomy: The CMA upholds the importance of respect for decisional autonomy by competent patients — such persons are free to make informed choices and autonomous decisions about their bodily integrity, their personal aims and their care that are consistent with their personal values and beliefs." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

7.  "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." Canadian Medical Association.  Principles-based Recommendations for a Canadian Approach to Assisted Dying [Internet]. 2015; A2-1 to A2-6 at A2-2.

 8.  "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."  Canadian Medical Association.  Principles-based Recommendations for a Canadian Approach to Assisted Dying [Internet]. 2015; A2-1 to A2-6 at A2-6.

9.  "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 2018-03-24). Canadian Medical Association. Code of Ethics [Internet] 2004 [cited 2018 Mar 24].

10.  ". . .physicians are obligated to, regardless of their beliefs: i. provide the patient with complete information on all options available, including assistance in dying; . . ." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

11.   "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." Canadian Medical Association.  Principles-based Recommendations for a Canadian Approach to Assisted Dying [Internet]. 2015; A2-1 to A2-6 at A2-3.

12.  "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."  Canadian Medical Association.  Principles-based Recommendations for a Canadian Approach to Assisted Dying [Internet]. 2015; A2-1 to A2-6 at A2-6.

13.  Canadian Medical Protective Association. Consent: A guide for Canadian physicians. 4th ed. [Internet] 2016 Jun [cited 2018 Mar 23].

14.  Canadian Medical Association, Canadian Healthcare Association, Canadian Nurses' Association, Catholic Health Association of Canada. Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care [Internet]. 1999.

15.  "23. Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patient or to others. . ." Canadian Medical Association. Code of Ethics [Internet] 2004 [cited 2018 Mar 24].

16.  "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."Canadian Medical Association. Code of Ethics [Internet] 2004 [cited 2018 Mar 24].

17.   "22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood." Canadian Medical Association. Code of Ethics [Internet] 2004 [cited 2018 Mar 24].

18.   "12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants." Canadian Medical Association. Code of Ethics [Internet] 2004 [cited 2018 Mar 24].

19.  " A physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of this so that she may consult another physician."  Canadian Medical Association. Induced Abortion [Internet]. 1988 Dec 15 [cited 2018 Mar 15].

20.  "Addressing Adherence to Moral Commitments, (d) Physicians are expected to act in good faith. They are expected to never abandon or discriminate against a patient requesting assistance in dying and to not impede or block access to a request for assistance in dying. Physicians should inform their patients of the fact and implications of their conscientious objection. No physician may require a patient to make a commitment not to seek assistance in dying as a condition of acceptance or retention of the patient." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

21.  "Addressing Adherence to Moral Commitments, (a) . . physicians who choose not to provide or otherwise participate in assistance in dying are: i. not required to provide it, or to otherwise participate in it, or to refer the patient to a physician or a medical administrator who will provide assistance in dying to the patient. . ." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

22.  "Addressing Adherence to Moral Commitments, (a). . .physicians are obligated to, regardless of their beliefs: i. provide the patient with complete information on all options available, including assistance in dying;  ii. advise the patient on how to access any separate central information, counselling and referral service; and iii. transfer care of the patient to another physician or another institution, if the patient requests it, for the assessment and treatment of the patient’s medical condition and exploration of relevant options. The duty of non-abandonment still applies in all other aspects of the patient’s care." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

23.  "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." Canadian Medical Association. Code of Ethics [Internet] 2004 [cited 2018 Mar 24].

24.  "Additional Considerations: Physician Duties, 6. Duty to support interdisciplinary teams: The CMA advocates that physicians work within, and support other members of, interdisciplinary teams, pay close attention to the impacts of participation and non-participation in medical assistance in dying on their non-physician colleagues, and demonstrate solidarity with their team members as they navigate new legal and ethical territory together." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

25.  "Relevant Foundational Considersations, 3. Respect for freedom of conscience: . . . To enable physicians to adhere to such moral commitments without causing undue delay for patients pursuing this intervention, health systems will need to implement an easily accessible mechanism to which patients can have direct access. . ." Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

26.  ". . .it is a responsibility of the community to ensure access, rather than placing the burden of finding services solely on individual physicians."  Canadian Medical Association. Submission to the College of Physicians and Surgeons of Ontario [Internet]. 2016 Jan. 16.

27.  "Relevant Foundational Considersations, 3. Respect for freedom of conscience: . . . Further, the CMA believes that physicians' general employment or contract opportunities should not be influenced by their decisions to participate in, or not participate in, any or all aspects of medical assistance in dying with patients. . . " Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

28.  "Relevant Foundational Considersations, 3. Respect for freedom of conscience: . . . Learners should be equally free to follow their conscience without risk to their evaluations and training advancement."Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [cited 2018 Mar 12].

29.  "No discrimination should be directed against doctors who do not perform or assist at induced abortions. Respect for the right of personal decision in this area must be stressed, particularly for doctors training in obstetrics and gynecology, and anesthesia.  No discrimination should be directed against doctors who provide abortion services."  Canadian Medical Association. Induced Abortion [Internet]. 1988 Dec 15 [cited 2018 Mar 15].

 

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