Category: Publications

Protection of Conscience Project publications

Project Submission to the College of Physicians and Surgeons of Ontario

Protection of Conscience Project

Re: Physicians and the Ontario Human Rights Code

Abstract [Français]

The Ontario Human Rights Commission made a serious error in 2008 when it attempted to suppress freedom of conscience and religion in the medical profession on the grounds that physicians are “providers of secular public services.” In its public perpetuation of this error, the Commission has contributed significantly to anti-religious sentiments and a climate of religious intolerance in Ontario. Both were on display earlier this year when it became front page news and a public scandal that three physicians had told their patients that they would not recommend, facilitate or do what they believed to be immoral, unethical, or harmful.

The physicians had followed the guidelines of the Canadian Medical Association and the College of Physicians and Surgeons of Ontario. Physicians must advise patients about treatments or procedures they are unwilling to recommend or provide for moral or religious reasons, so that patients can seek the services elsewhere. Physicians are not required help patients obtain services or procedures they believe to be wrong.

The arrangement is a compromise that safeguards the legitimate autonomy patients and preserves the integrity of physicians, but it has been continually attacked by activists who want to compel objecting physicians to provide or facilitate abortion and contraception, and, lately, euthanasia. Essentially, the activists assert that physicians have a duty to do what they believe to be wrong because they must not act upon their moral or religious beliefs.

However, it is incoherent to include a duty to do what one believes to be wrong in a code of ethics, the very purpose of which is to encourage physicians to act ethically and avoid wrongdoing. Moreover, one cannot practise medicine without reference to beliefs, whether they reflect a secular ethic or a religious one, and neither a secular ethic nor a religious ethic is morally neutral. Thus, demands that physicians must not act upon their beliefs or must practise medicine in a morally “neutral” fashion are unacceptable because they are impossible.

The demand that physicians must not act upon religious beliefs because medical practice is a secular profession is unacceptable because it is erroneous. The Supreme Court of Canada has acknowledged that a secular society is not faith-free; it includes both religious and non-religious believers, and rational democratic pluralism must make room for them all. The full bench of the Court has warned that to disadvantage or disqualify the exercise of religiously informed conscience in public affairs is an illiberal distortion of liberal principles that offers “only a feeble notion of pluralism.”

If it is legitimate to compel religious believers to do what they believe to be wrong, then it is equally legitimate to compel non-religious believers to do what they think is wrong; everyone would have a duty to do what is believed to be wrong.

Hence, the compromise worked out by the Canadian Medical Association not only safeguards the integrity of physicians and legitimate autonomy of patients, but protects the community against the temptation to give credence to a dangerous idea: that a learned or privileged class, a profession or state institutions can legitimately compel people to participate in what they believe to be wrong – even gravely wrong – even murder – and punish them if they refuse.

Freedom of conscience and freedom of religion are subject to reasonable limitations, but the mantra, “the freedom to hold beliefs is broader than the freedom to act on them”  is inadequate. More refined distinctions are required to address the difficulties that arise in a pluralist democracy. One of them is the distinction between the two ways in which freedom of conscience is exercised: by pursuing good and avoiding evil. There is a significant difference between preventing people from doing the good that they wish to do and forcing them to do the evil that they abhor.

As a general rule, it is fundamentally unjust and offensive to force 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 is a policy fundamentally opposed to civic friendship, which grounds and sustains political community and provides the strongest motive for justice. It is inconsistent with the best traditions and aspirations of liberal democracy.  And it is dangerous, since it instills attitudes more suited to totalitarian regimes than to the demands of responsible freedom.

This does not mean that freedom of conscience exercised to preserve personal integrity can never be limited. It does mean, however, that even the strict approach taken to limiting other fundamental rights and freedoms is not sufficiently refined to be safely applied here. Like the use of potentially deadly force, if the restriction of preservative freedom of conscience can be justified at all, it will only be as a last resort and only in the most exceptional circumstances.

When the College of Physicians and Surgeons of Ontario receives complaints from patients who have been unable to obtain services they want, the College should help connect the patients with willing service providers. That would be more helpful than attempting to suppress freedom of conscience and religion in the medical profession. [Full Text]

Demande à l’Ordre des médecins et chirurgiens de l’Ontario

Protection of Conscience Project

Objet : Les médecins et le Code des droits de la personne de l’Ontario

Résumé [En Anglais]

La Commission ontarienne des droits de la personne a commis une grave erreur en 2008 lorsqu’elle a tenté d’éliminer la liberté d’opinion et la liberté de religion de la profession médicale sous prétexte que les médecins sont des « fournisseurs de services publics laïcs ». Dans son interprétation publique de cette erreur, la Commission a largement contribué à la diffusion d’un esprit antireligieux et à la création d’un climat d’intolérance religieuse en Ontario. Ces deux phénomènes ont fait la manchette et ont été l’objet d’un scandale public plus tôt cette année lorsque trois médecins ont dit à leurs patients qu’ils ne recommanderaient, n’offriraient ou ne feraient pas ce qu’ils jugent immoral, contraire à l’éthique ou néfaste.

Ces médecins suivaient ainsi les directives de l’Association médicale canadienne et de l’Ordre des médecins et chirurgiens de l’Ontario. Les médecins doivent aviser leurs patients des traitements ou des procédures qu’ils refusent de leur recommander ou leur offrir pour motif moral ou religieux afin que ces derniers puissent recevoir des soins ailleurs. Les médecins ne sont pas tenus d’aider leurs patients à obtenir un service ou à suivre une procédure qu’ils jugent néfaste.

Ce compromis qui permet de protéger l’autonomie légitime des patients et de préserver l’intégrité des médecins est constamment attaqué par des activistes voulant contraindre les médecins à offrir ou à conseiller un avortement ou des moyens contraceptifs et, récemment, à pratiquer l’euthanasie alors qu’ils s’y objectent. Ces activistes croient essentiellement que les médecins ont le devoir de faire ce qu’ils tiennent comme étant mal, car ils ne doivent par agir en fonction de leurs convictions morales ou religieuses.

Il est toutefois incohérent d’inclure dans un code de déontologie le devoir de faire quelque chose considéré comme mal, puisque la nature même d’un tel code est d’encourager les médecins à agir de façon éthique et de prévenir les méfaits. De plus, il est impossible de pratiquer la médecine sans faire référence à des convictions, que celles-ci relèvent de l’éthique laïque ou religieuse, et ni une éthique laïque ni une éthique religieuse ne sont moralement neutres. Ainsi, demander que les médecins n’agissent pas en fonction de leurs convictions ou qu’ils pratiquent la médecine de manière moralement « neutre » est inacceptable, car cela est impossible.

Demander que les médecins n’agissent pas en fonction de leurs convictions religieuses puisque la médecine est une profession laïque est inacceptable, car cela est erroné. La Cour suprême du Canada a reconnu qu’une société laïque n’est pas sans foi; les personnes qui la composent peuvent avoir des convictions religieuses ou non, et un pluralisme démocratique rationnel doit accepter toutes ces personnes. La Court a mis en garde, en séance plénière, contre la défavorisation ou la suppression de la conscience au courant des aspects religieux des affaires publiques représente une distorsion mesquine des principes libéraux qui n’entraîne « qu’une piètre notion de pluralisme ».

S’il est légitime de contraindre des personnes ayant des convictions religieuses de faire ce qu’ils considèrent comme étant mal, il est donc également légitime de contraindre les personnes n’ayant pas de convictions religieuses à faire ce qu’ils considèrent comme étant mal. Ainsi, le compromis fait par l’Association médicale canadienne ne sert pas uniquement à protéger l’intégrité des médecins et l’autonomie légitime des patients, mais également à faire en sorte que la société ne soit pas tentée de croire en une idée dangereuse, à savoir qu’une classe, une profession ou une institution d’état privilégiée peut, de manière légitime, contraindre des gens à participer à des actes qu’ils jugent comme étant mal (même très mal, comme un meurtre) sous peine de représailles s’ils refusent.

La liberté d’opinion et la liberté de religion sont sujettes à des contraintes raisonnables, mais la maxime voulant que la liberté d’avoir des convictions soit plus large que la liberté d’agir en fonction de ces dernières est inadéquate. Il est nécessaire de faire appel à des distinctions plus précises pour affronter les difficultés d’une démocratie pluraliste. Une d’entre elles est la nuance entre les deux manières dont s’exerce la liberté d’opinion : en faisant le bien et en évitant le mal. Il existe une différence considérable entre le fait d’empêcher les gens à faire le bien qu’ils souhaitent faire et le fait de les contraindre à faire le mal qu’ils abhorrent.

De manière générale, il est fondamentalement injuste et offensant de contraindre des gens à soutenir, offrir ou participer à des actes qu’ils considèrent comme étant mal, et plus le méfait est grave, plus cette injustice ou cette offense est grave. Il s’agit d’une pratique fondamentalement opposée au civisme, lequel permet de maintenir une communauté politique et de favoriser une justice forte. Elle va à l’encontre des meilleures traditions et des aspirations d’une démocratie libérale.  Elle est de plus dangereuse, car elle encourage une attitude plus près de régimes totalitaires que des demandes qui caractérisent une liberté responsable.

Cela ne veut pas dire pour autant qu’il ne faille pas imposer de limites à la liberté d’opinion exercée pour préserver l’intégrité personnelle. Cela veut par contre dire que même l’approche stricte visant à imposer des limites à d’autres libertés et droits fondamentaux n’est pas assez précise pour pouvoir être appliquée sans danger ici. à l’instar de l’utilisation d’une force potentiellement mortelle, la restriction de la liberté d’opinion à des fins de protection ne peut être justifiée qu’en dernier recours et uniquement dans des circonstances exceptionnelles.

Lorsque l’Ordre des médecins et chirurgiens de l’Ontario reçoit des plaintes de patients qui n’ont pas pu obtenir les services qu’ils voulaient, il devrait aider ceux-ci à les mettre en contact avec des fournisseurs prêts à leur offrir ces services. Ceci sera plus constructif que de tenter d’éliminer la liberté d’opinion et la liberté de religion de la profession médicale. [Demande]

“NO MORE CHRISTIAN DOCTORS”

  Crusade against NFP-only physicians

“Religious beliefs should remain where they belong – in the private domain.”

 Sean Murphy*

Abstract

A 25 year old woman could not obtain a prescription for contraceptives at a clinic because the physician did not prescribe them for reasons of “medical judgment as well as professional ethical concerns and religious values.”  She obtained the prescription at a clinic two minutes away. A crusade was started against the physician and two colleagues with the same views. Crusaders argued that in a ‘secular’ state health care system, physicians should be forbidden to act on their moral or religious beliefs.

Physicians who refuse to prescribe contraceptives face a difficult challenge, since aggressive contraceptive promotion has left most people unaware of alternatives. Further, the social progress of women is widely attributed to contraceptives, so that failure to provide them risks an adverse reaction. Nonetheless, based on a respectful understanding of female fertility cycles and other factors, plausible reasons can be given to justify refusal to prescribe contraceptives and recommendation of Natural Family Planning.

The Supreme Court of Canada has acknowledged that secularists are believers, no less persons with religious beliefs. There is no legal warrant for the idea that a secular state must be purged of the expression of religious belief. The claim that a secular state or health care system is “faith-free” is radically false. Both religious belief and secularism can result in narrow dogmatism and intolerance, as demonstrated by the crusade against the physicians.

Since the practice of medicine is an inescapably moral enterprise, every decision concerning treatment is a moral decision. Since the practice of morality is a human enterprise, the secular public square is populated by people with many moral viewpoints. To discriminate against religious belief is a distortion of liberal principles. Moreover, if religious believers can be forced to do what they believe to be wrong, so can non-religious believers. This would establish a destructive and dangerous ‘duty to do what is wrong.’

It is essential to maintain the integrity of physicians and well-being of patients. After abortion was legalized, a difficult compromise emerged that safeguards both, while protecting the community against a purported ‘duty to do what is wrong.’ Nonetheless, some people are trying to entrench that duty in medical practice, moving from a purported duty to provide or facilitate abortion to a duty to kill or facilitate the killing of patients by euthanasia. It is unacceptable to compel people to commit or even to facilitate what they see as murder, and punish or penalize them if they refuse. It is equally unacceptable to insist that physicians must not act upon beliefs, because it is impossible; one cannot act morally without reference to beliefs. Such policies are inconsistent with the central place occupied by individual conscience and judgment in a liberal democracy.

Freedom of conscience can be adequately accommodated in a society characterized by a plurality of moral and political viewpoints if appropriate distinctions are made. The first of these is the distinction between the exercise of perfective freedom of conscience: pursuing an apparent good – and preservative freedom of conscience: refusing to participate in wrongdoing. The state can sometimes legitimately limit perfective freedom of conscience by preventing people from doing what they believe to be good, but it does not follow that it is equally free to suppress preservative freedom of conscience by forcing them to do what they believe to be wrong.

To force people to do something they believe to be wrong is always an assault on their personal dignity and essential humanity, and it always has negative implications for society. It is a policy fundamentally opposed to civic friendship, which grounds and sustains political community and provides the strongest motive for justice. It is inconsistent with the best traditions and aspirations of liberal democracy, since it instills attitudes more suited to totalitarian regimes than to the demands of responsible freedom. Even the strict approach taken to limiting other fundamental rights and freedoms is not sufficiently refined to be safely applied to limit freedom of conscience in its preservative form. Like the use of potentially deadly force, if the restriction of preservative freedom of conscience can be justified at all, it will only be as a last resort and only in the most exceptional circumstances.

That a young woman had to drive around the block to fill a birth control prescription does not meet this standard.

Part 1:  The Making of a Story

 

Impartiality, complicity and perversity

 Sean Murphy*

Impartiality, complicity and perversity

Benjamin Veness weighs in on behalf of the Australian Medical Students’ Association (AMSA) to demand that physicians who believe abortion is wrong should be forced to direct patients to a colleague willing to provide it (“Abortion need not be doctor’s dilemma too.” Sydney Morning Herald, 16 November, 2013).

He and medical students who share his views believe that Victoria’s abortion law is the model that ought to apply throughout Australia.  It follows from this that they believe that any Australian physician who refuses to help a patient find someone willing to do a sex selective abortion should be struck from the medical register or otherwise disciplined.

Mr. Veness correctly believes that this would be consistent with Victoria’s abortion law, and he is hardly alone in believing that physicians who refuse to facilitate abortion for reasons of conscience should be disciplined or expelled from the profession.

However, he and the students whom he represents are mistaken in their assumption that a physician who is morally opposed to abortion – whether in principle, or because he has more limited moral objections to practices like sex selective abortion – is not capable of providing information about the procedure and legal options available to a patient.  In fact, many physicians opposed to abortion are quite willing to do so for the very reasons given by Mr. Veness: that the patient may ultimately decide not to go ahead with it.

More remarkable is the fact that the outlook of Mr. Veness and the Australian Medical Students’ Association suggests that only people willing to do what they believe to be gravely wrong ought to become physicians.  Whether or not this is a condition for membership in the AMSA Mr. Veness does not say, but it is not a policy conducive to the ethical practice of medicine.

What is most striking is Mr. Veness’ belief that only physicians willing to facilitate or provide abortions are “impartial,” as if the judgement that an abortion ought to be provided does not involve a moral judgement.  A conviction that abortion is (or can be) a good thing is just as “partial” as the opposite conviction of an objecting physician.  Mr. Veness’ mistaken notion of what it means to be “impartial’ is evidence that he and the AMSA are anything but.

For some physicians, referral is an acceptable strategy for avoiding complicity in what they hold to be wrong or at least morally questionable.  Others find it unacceptable because they believe that referral and other forms of facilitation actively enable wrongdoing and make them parties to it.  Mr. Veness and the AMSA may dispute this, but it is hardly a novel idea.  It is reflected, for example, in Section 45 of the Australian Capital Territory’s Criminal Code (Complicity and common purpose).1

More relevant, perhaps, is the broad definition of “participation” developed by the American Medical Association in its prohibition of physician participation in capital punishment. This includes “an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned,” and even giving advice.2

Lest the connection with capital punishment be thought out of place here, Australian medical students and physicians should take note that the arguments used to compel objecting physicians to provide or facilitate abortion are the same ones used by euthanasia advocates who would  force physicians to lethally inject their patients, or help them find someone who will.  That has been obvious in Belgium from the beginning,3 and it has been equally evident in Canada,4 most recently in Quebec.5

What is gradually becoming clear is that policies and laws devised to ensure the “accessibility” of abortion by suppressing freedom of conscience among health care workers lead ultimately to a perverse conclusion: that one can be forced to do what one believes to be gravely wrong, even if that means killing someone else, or finding someone who is willing to do the killing.  That conclusion is profoundly inconsistent with principles that ought to inform the laws and policies of a liberal democracy.

[PDF Text]

Notes

1.  Australian Capital Territory, Criminal Code 2002. (Accessed 2013-11-15)

2.  American Medical Association, Policy E-2.06 Capital Punishment (June, 2000) (Accessed 2013-11-15)

3.  Murphy, Sean. Belgium: Mandatory referral for euthanasia.

4.  A panel of the Royal Society of Canada recommended legalization of assisted suicide/euthanasia. The panel stated that, since physicians who are unwilling to provide what it delicately termed “certain reproductive health services” are obliged to refer patients to others who will (a contested assertion), physicians who refuse to provide (legal) euthanasia or assisted suicide for patients “are duty-bound to refer them in a timely fashion to a health care professional who will.” Schuklenk U, van Delden J.J.M, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel:  End of Life Decision Making.  November, 2011, p. 61-62 (Accessed 2011-12-31).

5.  Hearings were held recently by a committee of the Quebec National Assembly concerning a bill to legalize euthanasia by physicians.  State regulators of the professions of medicine, nursing and pharmacy all stated that their codes of ethics (developed as a result of controversies about abortion and birth control) require objecting professionals to refer or find colleagues willing to provide the service(s) to which they object.  It is clear that they mean to apply the same rule to euthanasia, although it is equally clear that this causes some of them some discomfort.  See, for example, the statement of Charles Bernard on behalf of the College of Physicians of Quebec at Quebec National Assembly, Consultations & hearings on Quebec Bill 52: College of Physicians of Quebec. Tuesday 17 September 2013 – Vol. 43 no. 34, T#154

Australian regulator misrepresents physician obligations

Claim that practitioner codes require referral disproved by Australian Medical Association

Sean Murphy*

According to a report in The Examiner, a representative of the Australian Health Practitioner Regulation Association told a Tasmanian legislative committee that physicians who object to a procedure for reasons of conscience are obliged by professional codes of ethics to refer patients to another physician.  Lisa McIntosh was addressing the Committee concerning a proposed Reproductive Health Bill.

Her assertion is contradicted by a submission by the Australian Medical Association Tasmania, which protested the section of the bill that would force objecting physicians to facilitate morally contested procedures by referral.  The AMA Tasmania submission included quotes from the AMA Code of Ethics and a document from the Medical Board of Australia Good Medical Practice to demonstrate that the draft legislation information paper falsely claimed that there was a duty to refer.

The Committee also heard from Catholic Archbishop Adrian Doyle, whose concerns about the proposed bill included the mandatory referral provision.