Category: Law

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]

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

Abstract

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 9: Codes of Ethics and KillingRefusing 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 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 8: Hospitality and Lethal Injection

Abstract

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 8: Hospitality and Lethal Injection

Under the Act Respecting End of Life Care (ARELC) palliative care hospices 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 government included another section of ARELC to provide the same exemption for La Michel Sarrazin, a private hospital.  The exemptions were provided for purely pragmatic and political reasons.

The exemptions have been challenged by organizations that want hospices forced to kill patients who ask for MAD, or at least to allow physicians to come in to provide the service.  Hospice representatives rejected the first demand and gave mixed responses to the second.  A spokesman for the Alliance of Quebec Hospices confirmed that palliative care hospices that provide euthanasia will not be excluded from the Alliance.

A prominent hospice spokesman predicted that the pressures would increase after the passage of ARELC, and that hospices refusing to provide euthanasia would operate in an increasingly hostile climate.

A former minister of health rejected the challenges to the exemptions and insisted that the policy of hospices be respected, appealing to the principles of autonomy and freedom of choice.  Consideration of freedom of conscience is irrelevant to this approach, and the description of the problem as a conflict of autonomy actually precludes a successful resolution by an appeal to the principle giving rise to it.

While the former minister of health wanted the autonomy of hospices explicitly set out in law, the only requirement in ARELC is that regional health authorities consult with institutions and palliative care hospices in their territories before making rules.  Mere consultation may be insufficient to protect the integrity of hospices in the long term. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 7: Refusing to Kill

Abstract

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 7: Refusing to KillIt is important identify problems that the Act poses for those who object to euthanasia for reasons of conscience, and to consider how objecting health care workers might avoid or respond to coercion by the government and the state medical and legal establishments.  The goal here is to ensure that conscientious objectors to euthanasia will be able to continue to work in health care without becoming complicit in what they consider to be wrongdoing.

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 adminstrator, 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.

It would be preferable to end the involvement of the objecting physician with refusal, accompanied by a suggestion that the patient will have to look for assistance from other sources.  This might be achieved if objecting physicians were to notify both executive directors and patients in advance that they will not provide or facilitate euthanasia.

A more sensitive problem attends the requirement that an objecting physician forward  a euthanasia request form to the designated administrator, since that is more clearly connected to the ulitmate killing of a patient.  Since the requirement to forward the request applies only if it has been given to the physician, this might be avoided if the objecting physician made his position clear in advance, and/or refused to accept such a request.  Such complications could avoided if administrators were to adopt a policy to the effect that a health care professional who witnesses and countersigns a euthanasia request to arrange for MAD services is responsible for arranging them.

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

Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands, even if they do not object to the procedure. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, which exceeds what was recommended by the Select Committee on Dying with Dignity, and some physicians may be unwilling to provide euthanasia without it.

Finally, as long as euthanasia remains a criminal offence, physicians or other entities responsible for issuing or administering MAD guidelines may respond to requests for euthanasia precisely as they would respond to requests to become involved in first degree murder: with total refusal to co-operate.  Even a partial  and scattered response of this kind would likely be administratively troublesome.

Patients may lodge complaints against physicians who refuse to provide or facilitate euthanasia with institutions and the regulatory authority, regardless of the reasons for refusal. [Full Text]