Category: Ethical Commentary

Submission to the College of Physicians and Surgeons of Ontario

Evangelical Fellowship of Canada

Re: CPSO Policy #5-08: Physicians and the Human Rights Code

The Evangelical Fellowship of Canada (EFC) appreciates the ability to offer comments on this policy review. The EFC is a national association of denominations, ministry organizations, post-secondary educational institutions including seminaries, colleges and universities, and local churches. Some of our affiliates provide medical and health care in Canada and overseas, and many physicians are members of our affiliated denominations.

Having reviewed to policy, we note that while there is a strong emphasis on the duty not to discriminate in the provision of services, there is a lack of emphasis on the religious freedom and freedom of conscience guarantees and protections offered in Canadian law to individuals and, in this context, physicians.

We endorse the analysis and commentary in the written submission and covering letter of the Christian Medical Dental Society (CMDS) and the Canadian Federation of Catholic Physician Societies. The CMDS is an EFC affiliate, and we commend these documents to you.

Christianity has a long history of fostering and promoting medical care. It was and continues to be a distinctive of the Christian tradition, as documented by Gary Ferngren in his book Medicine and Health Care in Early Christianity (Johns Hopkins, 2009). Integrity of belief and practice is a core element of the Christian faith and respect for religious freedom is critical to the ability of individuals and groups to live out their faith in an integral way before God and in the service of others.

Evangelical Fellowship of 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

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]

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]