Medicine, morality and humanity

Sean Murphy*

Medicine is a moral enterprise.

Medicine, morality and humanityThe practice of medicine is an inescapably moral enterprise precisely because physicians are always seeking to do some kind of good and avoid some kind of evil for their patients. However, the moral aspect of practice as it relates to the conduct and moral responsibility of a physician is usually implicit, not explicit. It is normally eclipsed by the needs of the patient and exigencies of practice. But it is never absent; every decision concerning treatment is a moral decision, whether or not the physician specifically adverts to that fact.

This point is frequently overlooked when a physician, for reasons of conscience, declines to participate in or provide a service or procedure that is routinely provided by his colleagues. They may be disturbed because they assume that, in making a moral decision about treatment, he has done something unusual, even improper. Seeing nothing wrong with the procedure, they see no moral judgement involved in providing it. In their view, the objector has brought morality into a situation where it doesn’t belong, and, worse, it is his morality. . .  [Full Text]


Statement on the Denial of Conscientious Objection from the “Effective Referral” Mandate

News Release

Catholic Civil Rights League

Toronto, ON May 15, 2019 – The Catholic Civil Rights League (CCRL) is disappointed with the decision released today of the Ontario Court of Appeal, in CMDS et al v. CPSO.

In its ruling, the unanimous three member panel of the Court of Appeal, comprised of Chief Justice George Strathy, and Appellate Justices Sarah Pepall and J. Michal Fairburn upheld a previous decision from Ontario’s Divisional Court, from January 31, 2018. That ruling denied conscientious exemption from the “effective referral” mandate of the College of Physicians and Surgeons of Ontario (CPSO) for doctors who morally objected to participating in objectionable procedures such as assisted suicide, gender re-assignment surgeries, or abortion.

By way of background, individual Catholic and Christian doctors and several organizations had challenged the CPSO, which over the course of the past four years changed its professional guidelines on professional conduct, forcing Ontario doctors who objected to morally objectionable procedures to provide an “effective referral” to a willing doctor for such services. Previously, doctors were relieved from any such obligation.

Ontario is the only provincial or territorial jurisdiction which has made demands to this extent with its doctors. Other jurisdictions have elected to recognize such conscientious objections, or have provided a means to allow other transfers of a patient’s file, without infringing such rights.

In 2018, the Ontario Divisional Court had ruled in favour of the CPSO, despite finding that the religious freedom of doctors had been infringed. The Applicants appealed.

At the appeal, the CCRL, the Faith and Freedom Alliance (FFA) and the Protection of Conscience Project (PCP), had argued in a joint submission as an intervener that such “effective referrals” made objecting doctors complicit in the provision of the objectionable procedures, such as abortion, or assisted suicide. We argued that the referral requirement imposed the values of the state upon individuals, forcing them to violate their own consciences, without adequate justification.

Our intervention wished to expand the arguments into the area of conscience protection, in addition to religious freedoms asserted by the appellants under s. 2a of the Charter, but those submissions were not pursued by the Court of Appeal.

The Court of Appeal accepted that there was an infringement on the s. 2a rights of the appellants, but that the infringement was justified as a reasonable limit on those rights (para. 187).

The Court of Appeal decision clarified that “non-compliance with the [CPSO] Policies is not an act of misconduct” under the College’s professional misconduct regulations (para. 16), but could be used as evidence of falling below a professional standard if a misconduct allegation were brought (para. 17).

The Court accepted that referrals could be made in a variety of ways, or even by a staff member as a triage engagement (paras. 24-27).

The decision also referred to the availability of other practice arrangements endorsed by the CPSO, to allow doctors to “avoid” the demand for an effective referral, such as working in a hospital setting, or a group practice, if others were prepared to engage in the objectionable treatment, or make the requested referral (paras. 176-187).

The acceptance of such arrangements in the Court’s decision presented a dichotomy. In recognizing the infringement of s. 2a rights, several proposed workarounds were accepted, such as working in a hospital context, or in a group practice where others would be willing to make the referral, or having employees make the referral. Other jurisdictions have avoided the original effective referral demand, or have allowed for conscientious objections outright, which a majority of Ontario doctors supported.

The Court was not persuaded that a demand to change practice or specialty areas constituted a sufficient intrusion into a doctor’s existing practice. That may be a challenge for the typical cancer specialist, or cardiologist, who may be confronted more often with a demand for medical assistance in dying, especially in the absence of available palliative care options. While not underestimating the individual sacrifices that may be required (paras. 186, 187), the court’s answer suggested that it was perhaps time to change one’s specialty, or submit.

The CCRL continues to support Christian or other doctors who have raised serious concerns over the “effective referral” mandate of the CPSO, and look forward to continuing discussions on how best to serve their interests.

Click here to view the written factum of the CCRL, FFA, and PCP, submitted in November 2018, which made reference to important principles of law and philosophy, quoting Martin Luther King Jr., Jacques Maritain, and others.

We submitted that moral rights are central to one’s sense of human dignity, and that it was unacceptable to marginalize objecting physicians as religious extremists. The Ontario Medical Association (OMA) likewise opposed the “effective referral” regime, as representatives of Ontario doctors.

Ontario doctors should be persuaded that it may be time to re-visit these demands with a future Council of the CPSO, for which hopefully conscientious physicians will seek to pursue.

Sometimes change is needed to be undertaken by the governed to secure justice.

Court challenge raises issue of “reasonable apprehension of bias”

Sean Murphy*

Documents filed in an important Canadian court case bring into question the value and purpose of “public consultations” held by medical regulators, at least in the province of Ontario.

In March, 2015, the College of Physicians and Surgeons of Ontario (CPSO) approved a highly controversial policy, Professional Obligations and Human Rights.  The policy requires physicians  to facilitate services or procedures to which they object for reasons of conscience by making an “effective referral” to a colleague or agency willing to provide the service.  A constitutional challenge to the policy was dismissed by  the Ontario Divisonal Court in 2018.[1] An appeal of that ruling will be heard by the Ontario Court of Appeal on January 21-22, 2019.

Among the thousands of pages filed with the trial court are a number dealing with the public consultation conducted by the CPSO from 10 December, 2014 to 20 February, 2015.  In response to its invitation to stakeholders and the public, the CPSO received 9,262 submissions about the proposal, the great majority of which opposed it.[2]

College officials  finalized the wording of the policy on 19 January, 2015,[3]   a month before the consultation ended; only about 565 submissions would have been received by then.[4]  727 submissions had been received  by the time the policy was sent to the Executive Committee on 28 January,[5]  which promptly endorsed it and forwarded it to the College Council for final approval.[6]

According to the briefing note supplied to the Council, by 11 February, 2015 the College had received 3,105 submissions.[7]  Thus, the final version of the policy was written and approved by the College Executive before about  90% of the submissions in the second consultation had been received.

Submissions received by CPSO from 10 Dec 2014 to 20 Feb 2015

During the first 40 days ending 11 February, the College received an average of about 18 submissions per day.  Assuming someone spent eight full hours every working day reading the submissions, about 22 minutes could have been devoted to each.  Three staff members dedicated to the task could have inceased this average to about an hour, so the first 700 submissions could conceivably have received appropriate attention.

Time available for analysis of submissions

However, this seems unlikely in the case of more than 8,000 submissions received later.

By 11 February about 183 submissions were arriving at the College every day, increasing to about 684 daily in the last ten days of the consultation – one every two minutes.   A College staffer working eight hours daily without a break could have spent no more than about two minutes on each submission, and only about one minute on each of those received in the last ten days  – over 65% of the total.

A minute or two was likely sufficient if College officials deemed consultation results irrelevant because they had already decided the outcome.  This conclusion is consistent with the finalization and approval of the policy  by the six member College Executive (which included the Chair of the  working group that wrote it [8]).  To do this weeks before the consultation closed was contrary to normal practice.  CPSO policy manager Andréa Foti stated that working groups submit revised drafts to the Executive Committee  after public consultations close[9] – not before.

One would expect government agencies that invite submissions on important legal and public policy issues would allow sufficient time to review and analyse all of the feedback received before making decisions. The CPSO’s failure to do so does not reflect institutional respect for thousands of individuals and groups who responded in good faith to its invitation to comment on the draft policy.  Rather, such conduct invites a reasonable apprehension of bias that is unacceptable in the administration of public institutions.

1. The Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2018 ONSC 579 (Can LII)  [CMDS v CPSO].

2. CMDS v CPSO, supra note 1  (Respondent’s Application Record, Volume 1, Tab 1, Affidavit of Andréa Foti [Foti] at para 121.

3.    Foti, supra note 2 at para 133.

4. Estimated daily average based on the total received by 28 January (727).

5. CMDS v CPSO, supra note 1  (Respondent’s Application Record, Volume 4, Tab WW, Exhibit “WW” attached to the Affidavit of Andréa Foti: Executive Committee Briefing Note (February, 2015) (CPSO Exhibit WW) at 1724.

6. CMDS v CPSO, supra note 1  (Respondent’s Application Record, Volume 4, Tab XX, Exhibit “XX” attached to the Affidavit of Andréa Foti: Proceedings of the Executive Committee – Minutes – 3 February, 2015) (CPSO Exhibit XX) at 1746-1748.

7. “Council Briefing Note: Professional Obligations and Human Rights – Consultation Report & Revised Draft Policy (For Decision)” [CPSO Briefing Note 2015].  In College of Physicians and Surgeons of Ontario, “Annual Meeting of Council, March 6, 2015” at 61.

8. Dr. Marc Gabel. See CPSO Exhibit WW, supra note 4 at 1722 (note 1), and CPSO Exhibit XX, supra note 5 at 1746.

9. Foti, supra note 2 at para 36.

Hawaii legalizes assisted suicide: Refusing to refer for suicide may incur legal liability

Sean Murphy*

Assisted suicide will become legal in Hawaii on 1 January, 2019, as a result of the passage of the Our Care, Our Choice Act. Introduced in the state House of Representatives only in January, it passed both the House and Senate and was approved by Governor David Ige on 5 April. Beginning next year, physicians will be able to write prescriptions for lethal medications for Hawaiian residents who are capable of informed consent, who are at least 18 years old, and who have been diagnosed with a terminal, incurable disease expected to result in death within six months.1

And beginning next year, Hawaiian physicians who refuse to facilitate assisted suicide by referring patients to a willing colleague may face discipline — including expulsion from the medical profession — or other legal liabilities. Hawaii could become one of only two jurisdictions in the world where willingness to refer patients for suicide is a condition for practising medicine.2 . . . [Full text]

Professor David Oderberg joins Protection of Conscience Project Advisory Board

News Release   

For immediate release

Protection of Conscience Project

The Protection of Conscience Project welcomes David S. Oderberg, Professor of Philosophy at the University of Reading, UK to the Project Advisory Board. Professor Oderberg joined the university after completing his doctorate at Oxford in the early 1990s. He is the author of many articles in metaphysics, ethics, philosophy of religion, philosophy of science, and other areas. He is also the author of several books including Moral Theory and Applied Ethics (Blackwell, 2000) as well as co-editor of collections in ethics such as Human Values: New Essays on Ethics and Natural Law (Palgrave, 2004) and Human Lives: New Essays on Non-Consequentialist Bioethics (Palgrave, 1997).

Prof. Oderberg has been working on freedom of conscience in health care over the last few years, with a recent article in the Journal of Medical Ethics on co-operation, and a forthcoming policy monograph to be published by the Institute of Economic Affairs. He is Editor of Ratio, an international journal of analytic philosophy, and Senior Fellow of the Higher Education Academy. In 2013 he delivered the Hourani Lectures in Ethics at SUNY Buffalo, and has a book forthcoming based on those lectures, to be called The Metaphysics of Good and Evil. [Faculty Profile] [Website]

Contact:
Sean Murphy, Administrator
Protection of Conscience Project
protection@consciencelaws.org


The Protection of Conscience Project is a non-profit, non-denominational initiative that advocates for freedom of conscience in health care. The Project does not take a position on the morality or acceptability of morally contested procedures. Since 1999, the Project has been supporting health care workers who want to provide the best care  for their patients without violating their own personal and professional integrity.