Category: Canada

Submission to the College of Physicians and Surgeons of Ontario

General Practice Section, Ontario Medical Association

Re: Human Rights Code Policy

Dear College of Physicians and Surgeons of Ontario,

The Section on General and Family Practice appreciates the opportunity to provide  comment on the College’s Physicians and the Ontario Human Rights Code policy that is currently being reviewed.

This policy provides important guidance to physicians on sensitive matters and has generated a great deal of interest and discussion amongst our members since it has come up for review. Overall, the Section feels that the policy in its current form seems to strike a reasonable balance between the moral and religious beliefs of physicians and the legal obligations and professional expectations related to the medical services they provide and has served the profession well since it was approved in 2008.

Essentially, the Section feels that we as physicians are professionals. We communicate with our patients on the complex issues they bring to us and we use our best judgement in making decisions around care together with our patients. The system and communities that we work in have well established networks with our other provider colleagues that enable us to provide the care our patients require when that need falls outside of our ability to provide that care as individual physicians.

Since this policy has come up for review, there have been significant concerns raised amongst our members that tighter guidelines will be placed upon physicians requiring them to provide types of care that conflict with their own personal morals and beliefs. This has led to a number of concerns being raised as to the possible outcomes related to any potential changes to this policy that would be more onerous on physicians. Questions that have come to our attention from our members include the following.

  • Are we slowly heading to a system where individuals looking to enter the medical profession will be required to leave their moral and religious beliefs behind when they accept entry?
  • What about more remote areas of practice? Will more prescriptive policies drive physicians to feel that they will have no choice but to practice in more urban settings?
  • What happens if a physician becomes fearful for safety in their office due to the extreme nature of a particular patient’s behaviour or uncomfortable with a patient who refuses to respect the rules of a physician’s office that may or may not be related to an underlying medical condition? Will the physician lose the ability to end the doctor-patient relationship?
  • Will a stricter policy make it more difficult to manage inappropriate patient demands such as those for narcotic pain medications as it may be construed by some patients as a denial based on discrimination.

College policies can have far-reaching impact above and beyond regulation of physicians in practice. As such, they need to be carefully thought out. A more strict approach to Physicians and the Human Rights Code could lead to situations where well qualified students are, in a sense, denied entry into medical school because of a potential inability to honour their personal, socially accepted religious beliefs due to patient demand. The Section believes it is important to ensure that the public continues to have access to care from the best and brightest minds and we are concerned that quality could suffer if we only accept medical students who are willing to compromise their personal values. At the same time, the Section is well aware of recent items in the media that might compel the College to consider changes to the current policy that would place more onerous expectations upon physicians to personally provide any and all treatment even when it is in direct conflict with their own personal morals and beliefs. However, the Section is not aware that there has been a pattern of complaints that relate to this matter that would document a more significant underlying or systemic problem in this area. As such, it would seem that the policy in its current form is adequate.

An area that was identified as a potential area to be improved upon is in regards to the definition of “disability” within the context of this policy. Mental illness has been raised as an example of a medical condition or disability that has a wide range of expression. It is felt that there may be some room to better define disability or provide some guidance to allow for the use of professional judgement when it comes to disability and a physician’s ability to safely and appropriately provide care in their work environment.

Finally, a significant area for consideration has been raised about the importance of having clarity in regards to complaints being dealt with through the Ontario Human Rights Commission and the role of the College. Physicians are always exposed to the risk that the decisions they make will be challenged by a complaint to the OHRC. If there is a complaint against a physician to the OHRC, this should be allowed to run its course without necessitating involvement of the College. The College should not become involved in additional areas outside of its jurisdiction. For complaints that come to both the OHRC and the College, the College policy should clarify when the College steps aside and waits to assess whether issues of professional conduct remain after the OHRC has made its decision.

The Section feels that the policy in its current form seems to give appropriate guidance to physicians in regards to our legal obligations and our professional expectations but also does not place physicians in an unreasonable position of being forced to provide certain care if it conflicts with their own moral and religious beliefs. The ability for physicians to say “no” without retribution must be preserved as long as those decisions are not based on discrimination. In the rare instance that an individual physician’s professional conduct is felt to clearly fall outside of what is deemed to be reasonable, then the policy in its current form has sufficient substance to be able to deal with those individual situations.

The Section understands that this request for feedback is a preliminary consultation that is meant to assist the College as it begins its work to update this policy so we look forward to the opportunity to review the outcome of this work and once again provide input when it is recirculated for further comment.

General Practice Section
Ontario Medical Association

Ethics should colour doctor’s decisions

Wrong to ask MDs to leave their values at their exam room doors

Hamilton Spectator

Reproduced with permission

Lea Singh

In a recent column, Martin Regg Cohn throws spears in all directions as he attacks doctors who refuse to prescribe or refer for birth control pills. Cohn wants the College of Physicians and Surgeons of Ontario, which is reviewing its human rights guidelines, to clamp down on these doctors and force them to participate in treatments they consider unethical or risk losing their jobs.

First off, Cohn rejects the possibility that there could be sound medical judgment behind the decision not to prescribe birth control pills. He is wrong; birth control is not Tylenol. Popular pain relievers are very safe when used according to directions; their main danger comes from accidental overdose.

In contrast, a regular “safe” daily dose of birth control pills will nearly triple a woman’s risk of deadly blood clots, and newer pills like Yasmin further double or triple that risk. Last year, Yasmin was linked to the deaths of 23 Canadian women. This year, a major French report revealed that blood clots caused by birth control pills have killed about 20 French women per year since 2000. Many women who survived their blood clots have been left paralyzed, blind and otherwise disabled.

Yes, pregnancy also increases blood clot risks. Blood clots kill more pregnant women than any other cause in the developed world. But pregnancy only lasts nine months, while many women are on the pill for years or even decades, often with little monitoring.

And what about the fact that the World Health Organization has classified birth control pills as “carcinogenic to humans?” The WHO is hardly trying to promote a religious agenda, but in a 500-page report it found “sufficient evidence” that birth control pills increased the risk of breast cancer and cancers of the cervix and liver.

But medical judgment aside, should doctors have the right to opt out of treatments they believe to be deeply unethical? Cohn argues that doctors should leave their religious values and personal ethics out of their workplace.

This is a new and dangerously totalitarian way of thinking. In the past, we have always respected every person’s right to live according to their own moral and religious precepts. This is why our Charter says that “Everyone has the following fundamental freedoms: (a) freedom of conscience and religion.”

Living out our values is the essence of true freedom. In dictatorships, everyone is still free to think, but they cannot act on their beliefs. In democracies like Canada, citizens have the right to conform their actions to their deepest values.

Cohn would take away this Charter protection from doctors, to save patients from the inconvenience and annoyance of having to go elsewhere. But is minor inconvenience really too high a price to pay for the fundamental freedom of our doctors, or any citizens? Ontario patients have plenty of alternative venues from which to get their prescriptions, such as public health clinics and emergency rooms. Abortions don’t even need a referral in Ontario.

If the medical profession is different from other professions, it is because ethics are so much more important in the field of medicine. Doctors hold our health and our lives in their hands. For centuries, we have insisted that doctors promise to do no harm, because we know that internal ethical limits make doctors far more responsible in the use of their medical powers. If doctors become mere machines that take orders without question, patients will ultimately be far less safe.

How can we trust doctors who leave their personal ethical limits at the door of their workplace? To really undermine confidence in our health care system, populate it with morally schizophrenic doctors who won’t mind performing procedures they admit are deeply unethical.

The law is too rough, corruptible and imperfect to prevent doctors from playing God. What will hold back doctors if the law permits any unethical procedures? Is it wise to place all our faith in regulations as our only safeguard when the scalpel looms over us?

We will reap what we sow. Perhaps we have truly become so dogmatic that we can no longer tolerate any dissent from the mantra of reproductive and sexual rights, and freedom is the next casualty. But freedom is a mighty tree that should not be cut down lightly. Our pluralist, democratic society lives in its branches, and the aftershocks of such a fall will be felt by all of us.

Lea Singh is a blogger, writer and lawyer who resides in Ottawa. Her blog is at http://leazsingh.blogspot.ca/.

Submission to the College of Physicians and Surgeons of Ontario

Christian Legal Fellowship

RE: Physicians and the Ontario Human Rights Code Consultations

The College of Physicians and Surgeons of Ontario (“CPSO”) has invited feedback from al 1 stakeholders in regard to its review of Policy Statement #5-08. Physicians and the Ontario Human Rights Code (”the Policy”). In particular, the CPSO has asked if the Policy provides useful guidance, whether the Policy fails to address any issues, and any other ways in which the Policy should be improved. The Christian Legal Fellowship (“CLF”) appreciates the opportunity to participate in this discussion, as we did in the prior CPSO consultation on Human Rights in September of 2008, and makes the following introduction and submissions.

The CLF is a national charitable association that exists to strengthen the spiritual life of its members, and encourage among Christians in the vocation of law the integration of faith with contemporary legal, moral, social and political issues. The CLF’s membership consists of approximately 550 lawyers, law students, professors, and others who support its work; with approximately one third of its members in the Province of Ontario. It has 14 chapters in cities across Canada and student chapters in most Canadian law schools. While having no direct denominational affiliation, CLF’s members represent more than 30 Christian denominations working in association together. As an association of Christian professionals, we welcome the opportunity to address the issues which the CPSO have raised in this consultation process.

The CLF has intervened in numerous legal cases relating to matters of conscience and religious freedom at the appellate and Supreme Court level. The organization also engages in policy consultations raising issues that impact, among other things, religious freedom and human rights. CLF is therefore knowledgeable and well-positioned to comment on this CPSO policy.

In reviewing the Policy, there are three broad areas of concern for CLF. First, we submit that the Policy fails to recognize that physicians have the right to freedom of religion and conscience. Second, the Policy fails to recognize that the law protects physicians with religious beliefs from engaging in activities that violate their religious beliefs, their moral beliefs and their conscience. Third, the Policy obligates physicians, in “some circumstances” to actively refer a patient for services which violate the beliefs or conscience of the physician.

(l)        Physicians have the right to freedom or religion and conscience.

In its current format, the Policy mentions “personal beliefs and values and cultural and religious practices are central to the lives of physicians and their patients”. This description fails to acknowledge the legal status of beliefs and religion. In fact, conscience and religion, thought, belief, opinion and expression are protected as fundamental freedoms by the Charter of Rights and Freedoms.1  Further, the Human Rights Code2 upon which the Policy is based, protects from discrimination on the basis of creed.3

The Policy also precludes physicians from sharing their religious beliefs with patients: “physicians should not promote their own religious beliefs when interacting with patients, nor should they seek to convert existing patients or individuals who wish to become patients to their own religion”. While this conduct may not be appropriate in all circumstances, a blanket prohibition is problematic and a clear violation of freedom of religion and expression.

Religion as a protected freedom is more than the right to privately think or believe certain ideas and principles. It is broadly defined and demands robust protection. Freedom of religion encompasses the right to entertain religious beliefs of one’s own choosing, the right to declare religious belief openly and without fear of hindrance or reprisal, the right to manifest those beliefs by worship and practice, by teaching and dissemination.4It precludes forcing an individual to act [lacuna] conscience. Under the law, physicians must be afforded the ability to align their practices with their conscience in these controversial areas and others, and that right must be made clear in the CPSO Policy.

CLF therefore urges the CPSO to modify its Policy to reflect the principles outlined above, ensuring it accurately reflects physicians’ rights pursuant to the Charter and the Human Rights Code.

Please note the endorsements that follow. CLF would be pleased to provide further assistance in any way the CPSO believes would be appropriate. Thank you for your consideration of our submissions.

Christian Legal Fellowship

Notes
1. The Constitution Act1982, Schedule B to the Canada Act 1982 (U.K.), 1982, c. 11.

2. Ontario Human Rights Code,R.S.O. 1990, e. H .19.

3. Ontario Human Rights Commission: Policy 011 Creed and the Accommodation of Religious Observances, October 20, 1996. While creed is not a defined term in the Code, the OHRC has adopted the following definition of creed in its Policy: “Creed is interpreted to mean “religious creed” or “religion.” Tt is defined as a professed system and confession of faith, including both beliefs and observances or worship. A belief in a God or gods, or a single supreme being or deity is not a requisite … The existence of religious beliefs and practices are both necessary and sufficient to the meaning of creed, if the beliefs and practices are sincerely held and/or observed. “Creed” is defined subjectively. The Code protects personal religious beliefs, practices or observances, even if they are not essential elements of tne creed provided they are sincerely held.” Policy page 4-5. ” In the case of discrimination in the workplace, both management and the union have a duty to accommodate. In Central Okanagan School District No. 23 v. Renaud the Court noted that although the principle of equal liability applies, the employer has charge of the workplace and will be in a better position to formulate measures of accommodation. The employer, therefore, can be expected to initiate the process of taking measures to accommodate an employee. Nevenhelcss, the Court also noted that they will not absolve a union of its duty if it fails to put forward alternative measures that are available. In short, when a union is a co-discriminator with an employer it shares the obligation to remove or alleviate the source of the discriminatory effect.” Policy page 9. “Conclusion: Religious pluralism poses a challenge in any multicultural society, especially one as diverse as ours. Although the law is developing rapidly in this area, an informed spirit of tolerance and compromise is indispensable to any civil society, as well as to its capacity to make opportunities available to everyone, on equal terms, regardless of creed [or other protected right].” Policy page 16. “R v. Rig M Drug Mart l 1985] I SCR 295 at336-337

Submission to the College of Physicians and Surgeons of Ontario

Freedom of Professional Judgment

Canadian Physicians for Life

I would like to thank the CPSO for inviting comment about its Policy Statement #5-08, “Physicians and the Ontario Human Rights Code.”

The CPSO policy is fair and should not change.

Some, and I would hope most,  Canadian physicians wish to practice as professionals in a free country,  and to use their hard-won medical wisdom in the service only of the patient who presents with the unique circumstances of an individual life. This excludes treating the patient as a means to an end, political or otherwise, but rather the doctor’s judgment should be fearlessly focused on the physical and mental integrity of the patient.

In recent years various activists have attempted to impugn certain medical decisions in controversial situations, notably requests for abortion or for  potentially abortifacient drugs.  The activists wish to portray their ideological opponents as driven by purely private (usually religious) prejudices which have no place in medical practice.

The CPSO  should decline to be used by such activists as an instrument to suppress their critics, for in reality that is all that is going on with demands that physicians be forced to refer for, or perform, certain acts.

If a physician has come to the conclusion that induced abortion would be bad for a certain patient and fatal for her child, the CPSO is in a good position to recognize this opinion  as resulting from the healthy application of medical judgment.  Some activists wish to malign such decisions  by casting them  as  creatures  of a whimsical  “conscience” as opposed to an obedience to  “professionalism.”

These activists have a debased understanding of  both concepts.  The free application of a  good conscience directs  the doctor to offer selfless professional judgment to each human being he or she has the honour to advise and treat.

The concept of “conscience” should never be used to cloak an agenda hidden from the patient, and the concept of “professionalism” should never be turned on its head to subjugate professional judgment to a political ideology or to persecute those who show  ethical courage.

I wish the CPSO endurance in resisting the erosion of its members’  freedom to do the right thing for their patients.

Yours cordially,

Will Johnston MD
President, Canadian Physicians for Life
495 West 40th Ave.
Vancouver BC V5Y 2R5

Related:

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]