Codes of Ethics Archives - Page 7 of 10 - Protection of Conscience Project News

Canadian Medical Association softens stand on assisted suicide

Globe and Mail

André Picard

The Canadian Medical Association, which has a long-standing policy saying doctors should not participate in euthanasia or assisted suicide, is substantially softening its stance.

Delegates to the organization’s general council decided Tuesday that the CMA now “supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying.”

The carefully crafted position is an acknowledgment that, while assisting death is still a crime in Canada, the attitudes of Canadians, including those of physicians, are changing quickly, and so is the law.

While the group’s official policy has not changed, “it’s only a matter of time,” said Louis Francescutti, outgoing president of the CMA. Dr. Francescutti said the “conscience” resolution, which was adopted by an overwhelming 91 per cent of delegates, means that the CMA supports a doctor’s right to refuse to hasten the death of a terminally ill patient, but it will also support a doctor’s right to hasten death if the law allows.[Full text]

Canadian doctors want freedom to choose whether to help terminal patients die

CMA to revisit issue of doctor-assisted death after delegates pass motion supporting physician’s right to ‘follow their conscience’

canada.com

Sharon Kirkey

Canada’s doctors say they should be free to choose whether to help terminally ill patients kill themselves if the federal ban outlawing euthanasia is overturned.

Delegates at the Canadian Medical Association‘s annual general meeting in Ottawa overwhelmingly passed a motion Tuesday supporting the “right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying.”

The CMA is formally opposed to euthanasia – a stance its leaders indicated would now be revisited as the emotionally charged issue takes on new urgency in Canada.

The Supreme Court of Canada is set to hear a constitutional challenge of the criminal ban on doctor-assisted death in October, while Quebec has introduced Bill 52, legislation allowing doctors help end the lives of terminal patients suffering “unbearable physical or psychological pain.”

The CMA defines “medical aid in dying” as euthanasia or physician-assisted death.[Full text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 9: Codes of Ethics and Killing

Abstract

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 4: The Problem of Killing

Abstract

The original text of Bill 52 did not define “medical aid dying” (MAD), but it was understood that, whatever the law actually said, it was meant to authorize physicians to kill patients who met MAD guidelines. The Minister of Health admitted that it qualifed as homicide, while others acknowledged that MAD meant intentionally causing the death of a person, and that its purpose was death. Various witnesses in favour of the bill referred explicitly to lethal injection and the speed of the expected death of a patient.

Given the moral or ethical gravity involved in killing, it is not surprising to find serious disagreement about MAD among health care workers. Conflicting claims made about the extent of opposition to or support for euthanasia within health care professions are difficult to evaluate, but a review of the transcripts of the legislative committee hearings into Bill 52 is instructive.

One physician member of the committee was shocked by the assertion that there is no moral, ethical, or legal difference betwen withdrawing life support and lethally injecting a patient. Hospices and palliative care physicians rejected participation in euthanasia. Sharp differences of opinion among other health care workers were reported. Support for killing patients by lethal injection was likened to support for the death penalty; that is, many more agreed with the act in principle than were willing to do the actual killing. So marked was the evidence of opposition to euthanasia that doubts were raised about the possiblity of implementing the law.

Since the law was passed as a result of assurances from the Quebec medical establishment that it could be implemented, a committee member who is now a minister of the Quebec government warned that they would be called to account if it is found that few physicians are willing to participate. This political pressure is likely to provide an additional incentive for the medical establishment to secure the compliance of Quebec physicians.

The introduction of euthanasia into Quebec’s health care system is to be accomplished using the structures and powers established by other Quebec statutes that govern the delivery of health care in the province, which have established a multi-layered and overlapping bureaucracy of committees, councils, commissions, boards, directors, examiners, coordinators, syndics and commissioners. Physicians and other health care providers who object to euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system, a prominent feature of which is an emphasis on patient rights.

Everyone authorized to enact or supervise adherence to policies or standards can become a MAD functionary, using codes of ethics, protocols, guidelines, directives, etc. to normalize euthanasia. Similarly, every disciplinary and complaints procedure can be used to force participation in MAD services. Those who openly advocate refusal to provide or facilitate euthanasia can be fined from $1,500.00 to $40,000.00 per day under Quebec’s Professional Code if they are deemed to have helped, encouraged, advised or consented to a member of a profession violating the profession’s code of ethics. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 1: Overview

Abstract

An Act Respecting End-of-Life Care (“ARELC”) is intended to legalize euthanasia by physicians in the province of Quebec. It replaces the original Bill 52, the subject of a previous commentary by the Project. The original text of the Bill 52 did not define medical aid in dying (MAD), but ARELC now makes it clear that Quebec physicians may provide euthanasia under the MAD protocol. In addition, substitute decision makers can order legally incompetent patients who are not dying to be starved and dehydrated to death. This practice, identified here as Euthanasia Below the Radar (EBTR), is completely unrestricted and is not even reportable.

Neither ARELC nor MAD guidelines can abolish the criminal prohibition of euthanasia, so physicians who kill patients in the circumstances contemplated by the new law would still be liable to prosecution. However, the Quebec government has promised that it will refuse to prosecute physicians who kill patients in accordance with MAD guidelines, thus circumventing the criminal prohibition. Beyond that, Quebec general practitioners have asked for immunity from prosecution for failing to conform to MAD guidelines. Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, and some physicians may be unwilling to provide euthanasia without it.

The introduction of euthanasia will require the complicity of thousands of health care workers and administrators. Many are likely to comply because official representatives of the legal and medical establishments of Quebec have formally declared their support for the new law. On the other hand, palliative care physicians, hospices and an undetermined number of other physicians and health care workers are opposed to euthanasia and assisted suicide.

Section 4 of ARELC states that eligible patients have a right to “end-of life-care,” which includes euthanasia and palliative care. The statutory declaration of a “right” is the most powerful weapon in the legal arsenal likely to be used to enforce compliance with ARELC and to attack freedom of conscience among those who refuse to facilitate the procedure.

It appears that, even where euthanasia or assisted suicide is legal, the majority of physicians do not actually provide the services. The Act may lead to discriminatory screening of physicians unwilling to kill patients, effected by denying them employment in their specialties and denying them hospital privileges.

However, objecting physicians not only refuse to kill patients, but also often refuse to do anything that they believe makes them morally responsible for the killing. Hence, it is likely that most of the attacks on freedom of conscience resulting from ARELC will be precipitated by refusal to participate indirectly in killing.

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 administrator, 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.

The protection of conscience provision in ARELC distinguishes physicians from other health professionals, providing less protection for physicians than for others. Physicians may refuse only “to administer” euthanasia – a very specific action – which seems to suggest that they are expected to participate in other ways.

Palliative care hospices and a single Quebec hospital 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 exemptions were provided for purely pragmatic and political reasons. The exemptions have been challenged by organizations that want hospices forced to kill or allow the killing of patients who ask for MAD. Hospice representatives rejected the first demand and gave mixed responses to the second. A prominent hospice spokesman predicted that hospices refusing to provide euthanasia will operate in an increasingly hostile climate.

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 elsewhere.

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 a code of ethics. 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 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.

Since ARELC explicitly authorizes physicians to kill patients deemed eligible for MAD by the Act, the federal government can go to court to have the statute declared unconstitutional. However, it is possible that the federal government will take no action until after the Supreme Court of Canada ruling in Carter v. Canada and after the 2015 federal election.

It seems unlikely that Quebec physicians who provide euthanasia under MAD guidelines will be prosecuted even if the prohibition of assisted suicide and euthanasia is maintained by the Supreme Court of Canada, and even if ARELC is ultimately struck down as unconstitutional. The continued de facto decriminalization of euthanasia in Quebec would probably generate considerable pressure in other provinces to follow suit.

Those who refuse to provide or facilitate euthanasia for reasons of conscience will likely find themselves in increasingly complicated and contentious working environments. In the end, freedom of conscience for Quebec health care workers who object to euthanasia may come to mean nothing more than the freedom to find another job, or the freedom to leave the province. [Full text]