Canadian Medical Association Annual General Meeting, 2014
Strategic Session No. 2: 19 August, 2014
End-of-life care issues in Canada (Committee of the Whole)
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Category: Euthanasia
Submission to the College of Physicians and Surgeons of Ontario
Dr. Marc Gabel
President
College of Physicians and Surgeons of Ontario
80 College Street
Toronto, Ontario
MSG 2E2
Dear Dr. Gabel:
Re: Policy Review ‘Physicians and the Ontario Human Rights Code’
As the College of Physicians and Surgeons of Ontario prepares to review its policy on physicians and the human rights code, we are deeply disturbed by the many negative voices that have been urging the College to force doctors to “check their ethics at the door”. It should be obvious that now, only weeks after Quebec legalized euthanasia, we have arrived at the worst possible time in Canadian history to turn doctors into mere mechanics whose duty is to blindly do the bidding of their clients.
With euthanasia legal in Canada’s second-largest province, the debate about euthanasia and assisted suicide on the national level and in other provinces will only intensify. It is crucial that we preserve the right of our doctors to refuse to participate in such services even if they are legal.
Euthanasia and assisted suicide continue to be regarded as deeply unethical by many world religions, including Christianity, Judaism and Islam.
What is legal is no longer necessarily moral, and we would be unwise to place all our trust in the law as our shield, or to train our doctors to disregard their own ethical limits. Indeed, the properly formed conscience of our physicians may sometimes be the last moral and ethical boundary that protects us and provides us with life-affirming options and alternatives that respect our human dignity.
Canadians pride themselves on being a society made up of many cultures, religions and ethnicities. The freedom and democracy that underpin our pluralist society lead us to affirm the right of all citizens to participate fully in roles of leadership and the professional life, including the medical profession. Any policy that would require doctors to contravene their consciences and to breach their most deeply held values would be outrageously exclusionary and unacceptable, as it would chase out of medicine those principled physicians who refuse to violate the central teachings of many of our largest and most ancient religions. For such doctors, referral for actions that they believe to be contrary to their medical judgement, ethical principles and religious beliefs would be as unacceptable as providing them, as it would be tantamount to outright cooperation with the action in question.
We refuse to believe that this is the kind of Canada that any of us would want to live in. The freedom of conscience is a basic human right recognized by many international agreements and protected by the Canadian Charter of Rights and Freedoms. It is essential to a truly democratic society and foundational for the protection of all other human rights, including the freedom of religion.
As such, we strongly encourage the College, as it reviews its policy on this matter, to continue to protect an authentic freedom of conscience for all physicians. No Canadian citizen, including any physician, should ever be disciplined or risk losing their professional standing for conducting their work in conformity with their most deeply held ethical or religious convictions.
Sincerely yours,
Rabbi Reuben Bulka
Congregation Machzikei Hadas, Ottawa
Terrence Prendergast, S.J.
Archbishop of Ottawa
Imam Sarni Metwally
Ottawa Main Mosque
CC:
President of the Ontario Medical Association
President of the Canadian Medical Association
President of the College of Family Physicians of Canada
Redefining the Practice of Medicine- Euthanasia in Quebec, Part 9: Codes of Ethics and Killing
Abstract
Refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is the response expected of physicians by professional bodies and regulators. It is not clear that Quebec legislators or professional regulators understand this.
A principal contributor to this lack of awareness – if not actually the source of it – is the Code of Ethics of the Collège des médecins, because it requires that physicians who are unwilling to provide a service for reasons of conscience help the patient obtain the service elsehere. The President of the Collège was pleased that law will allow physicians to shift responsibilty for finding someone willing to kill a patient to a health system administrator, avoiding an anticipated problem caused by the requirement for referral in the Code of Ethics. However, the law does not displace the demand for referral in the Code, and can be interpreted to support it.
The Collège des médecins Code of Ethics demand for referral conflicts with the generally accepted view of culpable indirect participation. Despite this, it continues to be used as a paradigm by other professions, notably pharmacy. It is thus not surprising that the College of Pharmacists also anticipates difficulty over the issue of referral. Like the Collège des médecins, the College of Pharmacists would like to avoid these problems by allowing an objecting pharmacist to shift responsibility for obtaining lethal drugs to a health systems administrator.
Nurses cannot be delegated the task of killing a patient, it is not unreasonable to believe that nurses may be asked to participate in euthanasia in other ways. Thus, there remain concerns about indirect but morally significant participation in killing. Their Code of Ethics imposes a duty to ensure both continuity of care and “treatment,” which is to include euthanasia. However, under ARELC, an objecting nurse is required to ensure only continuity of care. This should not be interpreted to require nurses to participate in euthanasia, though they may be pressured to do so.
As a general rule, it fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence. It was a serious error to include this a requirement in code of ethics for Quebec physicians and pharmacists. The error became intuitively obvious to the Collège des médecins and College of Pharmacists when the subject shifted from facilitating access to birth control to facilitating the killing of patients.
A policy of mandatory referral of the kind found in the Code of Ethics of the Collège des médecins is not only erroneous, but dangerous. It establishes the priniciple that people can be compelled to do what they believe to be wrong – even gravely wrong – and punish them if they refuse. It purports to entrench a ‘duty to do what is wrong’ in medical practice, including a duty to kill or facilitate the killing of patients. To hold that the state or a profession can compel someone to commit or even to facilitate what he sees as murder is extraordinary.
Quebec’s medical establishment can correct the error by removing the mandatory referral provisions of their codes of ethics that nullify freedom of conscience. This would prevent objecting physicians and pharmacists from being cited for professional misconduct for refusing to facilitate euthanasia or disciplined for refusing to facilitate other procedures to which they object for reasons of conscience, including contraception and abortion. This would almost certainly antagonize consumers who have been conditioned to expect health care workers to set aside moral convictions.
It remains to be seen whether the Quebec medical establishment will maintain the erroneous provisions, preferring to force objecting health care workers to become parties to homicide rather than risk occasionally inconveniencing people, such as the young Ontario woman and her supporters who were outraged because she had to drive around the block to obtain The Pill. [Full Text]
Redefining the Practice of Medicine- Euthanasia in Quebec, Part 8: Hospitality and Lethal Injection
Abstract
Under the Act Respecting End of Life Care (ARELC) palliative care hospices may permit euthanasia under the MAD protocol on their premises, but they do not have to do so. Patients must be advised of their policy before admission. The government included another section of ARELC to provide the same exemption for La Michel Sarrazin, a private hospital. The exemptions were provided for purely pragmatic and political reasons.
The exemptions have been challenged by organizations that want hospices forced to kill patients who ask for MAD, or at least to allow physicians to come in to provide the service. Hospice representatives rejected the first demand and gave mixed responses to the second. A spokesman for the Alliance of Quebec Hospices confirmed that palliative care hospices that provide euthanasia will not be excluded from the Alliance.
A prominent hospice spokesman predicted that the pressures would increase after the passage of ARELC, and that hospices refusing to provide euthanasia would operate in an increasingly hostile climate.
A former minister of health rejected the challenges to the exemptions and insisted that the policy of hospices be respected, appealing to the principles of autonomy and freedom of choice. Consideration of freedom of conscience is irrelevant to this approach, and the description of the problem as a conflict of autonomy actually precludes a successful resolution by an appeal to the principle giving rise to it.
While the former minister of health wanted the autonomy of hospices explicitly set out in law, the only requirement in ARELC is that regional health authorities consult with institutions and palliative care hospices in their territories before making rules. Mere consultation may be insufficient to protect the integrity of hospices in the long term. [Full Text]
Redefining the Practice of Medicine- Euthanasia in Quebec, Part 7: Refusing to Kill
Abstract
It is important identify problems that the Act poses for those who object to euthanasia for reasons of conscience, and to consider how objecting health care workers might avoid or respond to coercion by the government and the state medical and legal establishments. The goal here is to ensure that conscientious objectors to euthanasia will be able to continue to work in health care without becoming complicit in what they consider to be wrongdoing.
Physicians may refuse to provide euthanasia if the patient is legally ineligible, and for other reasons, including conscientious objection. ARELC requires physicians who refuse to provide euthanasia for any reason other than non-eligibility to notify a designated adminstrator, who then becomes responsible for finding a MAD physician. The idea is to have the institution or health care system completely relieve the physician of responsibility for facilitating the procedure.
It would be preferable to end the involvement of the objecting physician with refusal, accompanied by a suggestion that the patient will have to look for assistance from other sources. This might be achieved if objecting physicians were to notify both executive directors and patients in advance that they will not provide or facilitate euthanasia.
A more sensitive problem attends the requirement that an objecting physician forward a euthanasia request form to the designated administrator, since that is more clearly connected to the ulitmate killing of a patient. Since the requirement to forward the request applies only if it has been given to the physician, this might be avoided if the objecting physician made his position clear in advance, and/or refused to accept such a request. Such complications could avoided if administrators were to adopt a policy to the effect that a health care professional who witnesses and countersigns a euthanasia request to arrange for MAD services is responsible for arranging them.
The protection of conscience provision in ARELC distinguishes physicians from other health professionals, providing less protection for physicians than for others. Other health care professionals may refuse to “take part” (participate) in killing a patient for reasons of conscience. Physicians may refuse only “to administer” euthanasia – a very specific action – which seems to suggest that they are expected to participate in other ways.
Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands, even if they do not object to the procedure. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, which exceeds what was recommended by the Select Committee on Dying with Dignity, and some physicians may be unwilling to provide euthanasia without it.
Finally, as long as euthanasia remains a criminal offence, physicians or other entities responsible for issuing or administering MAD guidelines may respond to requests for euthanasia precisely as they would respond to requests to become involved in first degree murder: with total refusal to co-operate. Even a partial and scattered response of this kind would likely be administratively troublesome.
Patients may lodge complaints against physicians who refuse to provide or facilitate euthanasia with institutions and the regulatory authority, regardless of the reasons for refusal. [Full Text]