Ethics Archives - Page 60 of 85 - Protection of Conscience Project News

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

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 6: Participation in Killing

Abstract

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 6: Participation in Killing

It appears that, even where euthanasia or assisted suicide is legal, the majority of physicians do not actually provide the services. However, by establishing a purported legal “right” to euthanasia, ARELC generates a demand that physicians kill their patients, despite the high probability that a majority of physicians will not do so.

Often for purely pragmatic reasons, euthanasia supporters do not usually insist that an unwilling physician should be compelled to personally kill a patient. Thus, the difficulty created by the law can be addressed by administrative measures that connect patients looking for euthanasia with the minority of physicians willing to provide it. Nonetheless, physicians who object to euthanasia for reasons of conscience will likely be expected to facilitate access to the procedure by helping the patient find a colleague willing to provide it.

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. This includes actions that indirectly support or facilitate it. Hence, it is likely that most of the attacks on freedom of conscience resulting from ARELC will be preciptated, not by a refusal to kill directly, but by this kind of refusal to participate indirectly in killing.

The Criminal Code demonstrates that a physician who refuses to facilitate the killing of a patient because he does not want to be a culpable participant in killing is acting well within well-established moral and legal norms reflected in our criminal law. Further, the polices of professional medical organizations that forbid physician participation in capital punishment, torture, and female genital cutting indicate that it is not unreasonable for objecting physicians to refuse to facilitate euthanasia even indirectly.

On the contrary: refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is not aberrant behaviour. It is the response expected of physicians by professional bodies and regulators in order to avoid physician complicity in such procedures. [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]