Tag: Canadian Medical Association

Groups representing doctors, nurses call for mandatory vaccination of health-care workers

France, Italy and Greece will make vaccinations mandatory for health-care workers

Nick Boisvert

The Canadian Medical Association (CMA) and the Canadian Nurses Association (CNA) are jointly calling for COVID-19 vaccinations to be made mandatory for health-care workers.

The two organizations today joined a growing number of calls to make vaccines a mandatory condition of employment in the health care sector.

“As health providers, we have a fundamental duty of care towards our patients and the public. There is significant evidence that vaccines are safe and effective and as health professionals who are leading the vaccination campaigns, it is the right call and an appropriate step,” said CMA president Dr. Ann Collins. . . continue reading

Medical schools should deny applicants who object to provide abortion, assisted death: bioethicist

Global News

Rachel Browne

A bioethicist is calling for medical schools to eliminate applicants who would oppose providing medical services over objections to them based on their personal beliefs.

The call from Udo Schuklenk, a Queen’s University professor and the Ontario Research Chair in Bioethics, comes as the Alberta government grappled with a controversial bill that would have allowed health-care providers to refuse to provide medical care if they object to it on religious or moral grounds. . . [Full text]

Canadian Medical Association and euthanasia and assisted suicide in Canada

Critical review of CMA approach to changes in policy and law

Sean Murphy*

Abstract

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In December, 2013, the Canadian Medical Association (CMA) Board of Directors decided to shape the debate and law concerning euthanasia and assisted suicide and revisit CMA policy opposing physician participation in the procedures. By the summer of 2014 it was clear that the overwhelming majority of physicians supported the existing policy. However, it appears that the Board decided the policy should be changed before the Supreme Court of Canada decided the case of Carter v. Canada.

The Board sponsored an ostensibly neutral resolution affirming support for the right of physicians to follow their conscience in deciding whether or not to provide euthanasia/assisted suicide if the law changed. The resolution was overwhelmingly approved. Unnoticed at the time was that the resolution was not conditional upon eligibility criteria, such as decision-making capacity or terminal illness.

The CMA intervention at the Supreme Court of Canada in the Carter case emphasized that existing CMA policy against euthanasia and assisted suicide would be changed to reflect the resolution. It conveyed the message that the Association would support physicians who decided to participate in euthanasia or assisted suicide no matter how broadly the Court or legislatures might cast the rules governing the procedures.

The Board reversed CMA policy about two months before the Court ruled. It formally approved physician assisted suicide and euthanasia, subject only to legal constraints. The policy did not exclude minors, the incompetent or the mentally ill, nor did it limit euthanasia and assisted suicide to the terminally ill or those with uncontrollable pain. It classified both as “end of life care,” promising support for patient access to the procedures should they be legalized. Support for physicians refusing to participate in euthanasia or assisted suicide was qualified by the statement that there should be no “undue delay” in providing them. Implicit in all of this was a new ethical paradigm: that in some circumstances, physicians have a professional obligation to kill patients or to help them kill themselves.

The new policy effectively wrote a blank cheque for the Supreme Court of Canada to legalize euthanasia and physician assisted suicide on any terms acceptable to the judges. After the Court struck down the law CMA officials expressed concern about the criteria set by the Court. It was implied that the Supreme Court was to blame for anxiety and profound discomfort among Canadian physicians because it had imposed upon them an obligation to kill, contrary to centuries of medical ethics and practice.

However, the concerns voiced by CMA officials after the Carter ruling existed when the CMA intervened in the case, and the CMA did not raise them then. In fact, the Supreme Court gave legal effect to a policy the CMA had already adopted, and the criteria the Court set for the procedures were actually more restrictive than anything the CMA had proposed. The Court cannot be blamed because CMA leaders were ill-prepared to deal with the consequences of a ruling entirely consistent with their own policy.

The consequences fell most heavily upon physicians who refused, for reasons of conscience, to provide euthanasia and assisted suicide or to collaborate in providing the services by referral or other means. Since Carter, the debate in Canada has been largely about whether or under what circumstances physicians and institutions should be allowed to refuse to provide or facilitate the services. While it is generally agreed that physicians should not be compelled to personally provide them, there are strident demands that physicians unwilling to kill their patients or help them commit suicide should be forced to refer patients to someone who will.

This review demonstrates that the CMA Board of Directors focus in 2014 was on the role physicians would play in providing euthanasia and assisted suicide should the law change. The Board knew that the overwhelming majority of Canadian physicians would refuse to participate in euthanasia or assisted suicide. The fundamental conflict presented by imposing an obligation to kill upon unwilling physicians was foreseeable and had been foreseen by CMA officials. Attacks upon physician freedom of conscience, particularly with respect to referral, were predictable.

However, the Board failed to consider physician freedom of conscience in relation to assisted suicide and euthanasia except the extent that it could be used to further its policy goals. As a result, after the Carter ruling, CMA officials were quite unprepared to mount a cogent, articulate and persuasive defence of physician freedom of conscience, especially in relation to referral. They discovered that state authorities and the public were often unreceptive and even hostile to physicians unwilling to arrange for patients to be killed by someone else. Negotiating at a significant disadvantage of their own making, they were desperate to find a policy “acceptable to the regulators” and to objecting physicians whose fundamental freedoms they had rashly jeopardized.

The CMA has since produced a strong defence of physician freedom of conscience in relation to referral for euthanasia and assisted suicide, and sound protection of conscience provisions have been incorporated into a revised CMA policy on the procedures. However, by the time these statements appeared, objecting physicians were on the defensive in a treacherous and even hostile environment, compelled to launch an expensive constitutional challenge to defend fundamental freedoms of conscience and religion. The outcome of that case will determine if they will be able to continue to practise medicine if they refuse to collaborate in killing their patients.

The World Medical Association (WMA) national medical associations are free to decide to change their policies on physician participation in euthanasia or assisted suicide. This review demonstrates that they should not follow the example of the Canadian Medical Association if they wish to safeguard the fundamental freedoms of physicians and health care workers. [Full Text]

World Medical Association to consider policy changes on abortion, euthanasia, assisted suicide

Debate planned for ethics conference in October in Iceland

Sean Murphy*

Following a meeting of the WMA Council in Riga, Latvia, the WMA issued a statement noting that a revised version of the WMA abortion policy would be presented for approval at the WMA annual General Assembly in Reykjavik, Iceland.

In addition, the WMA has announced that there will be a further “open debate” on changing the Association’s policy against physician participation in euthanasia and assisted suicide.  The debate will occur during a WMA conference on medical ethics taking place at the same time and place.  Formal presentations on euthanasia and assisted suicide will be given on 4 October, 2018, but informal discussions among delegates are likely to be important.  The debate appears to be a consequence of lobbying by the Canadian and Royal Dutch Medical Associations to convince the WMA to drop its condemnation of the practices

It is not clear whether or not WMA members appreciate the relationship between abortion policy and euthanasia policy.  Compulsory referral for abortion is essentially a dress rehearsal for compulsory referral for euthanasia and assisted suicide, something clearly demonstrated in Canada.  Accusations of “patient abandonment” formerly aimed at those refusing to refer for abortion1 are now, in addition, being levelled at those who refuse to refer patients to someone willing to kill them or help them commit suicide.2

In 2011, a Royal Society of Canada panel of experts chaired by Udo Schuklenk  recommended legalization of assisted suicide and euthanasia.3  The experts insisted that health care professionals unwilling to provide euthanasia help patients commit suicide must refer them to someone willing to do so.4 This was justified, they said, because it was agreed that objectors are obliged to refer for “reproductive health services.”5  It really was not agreed: the Canadian Medical Association had, in fact, rejected this claim five years earlier6 after it was made by Jocelyn Downie,7 one of Schuklenk’s colleagues on the Royal Society Panel.

By 2015 Schuklenk was arguing that objecting physicians should not be accommodated at all. Among his arguments was that referring for abortion or euthanasia is not a compromise because it involves moral complicity in the act, “barely reduced” by the act of referral.8  This implied that physicians should be forced to provide abortion and euthanasia, notwithstanding religious or conscientious convictions to the contrary, a position Schuklenk explicitly adopted over the next two years.9, 10

At the same time, Ottawa law professor Amir Attaran was insisting that physicians should be forced to kill eligible patients themselves.11 He claimed that this was required by human rights law,12 describing effective referral as an unacceptable form of illicit discrimination.13

In considering changes to euthanasia, assisted suicide and abortion policies in October, WMA delegates will have to take great care to consider not only the most obvious ethical issues of life and death, but less obvious yet important issues like the distinction between acceptable cooperation and unacceptable collaboration, which play out in disputes about mandatory referral for abortion and euthanasia.

Notes
1.  “According to the prevailing norm of beneficence therefore, as well as those of trust, patient autonomy, and not abandoning patients, physicians should refer patients for abortions.”  McLeod C. Referral in the Wake of Conscientious Objection to Abortion. Hypatia, Vol. 23, No. 4 (October-December, 2008) at p. 36 (Accessed 2018-08-022).

2.  Cook M. Canadian court tells doctors they must refer for euthanasia. Mercatornet, 2 February, 2018

3. Schuklenk U, van Delden JJM, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011)[“Royal Society“] p. 96 (Accessed 2014-02-23).

4.  Royal Society, p. 69, 101.

5.  Royal Society, p. 62.

6.  Blackmer J. Clarification of the CMA’s position on induced abortion. CMAJ April 24, 2007 vol. 176 no. 9 doi: 10.1503/cmaj.1070035 (Accessed 2017-12-12).

7.  Rodgers S. Downie J. Abortion: Ensuring Access. CMAJ July 4, 2006 vol. 175 no. 1 doi: 10.1503/cmaj.060548 (Accessed 2017-12-12).

8.  Schuklenk, U. Conscientious objection in medicine: private ideological convictions must not supercede public service obligations (2015) 29:5 Bioethics ii, DOI: 10.1111/bioe.12167

9.  Schuklenk U, Smalling R. Why medical professionals have no claim to conscientious objection accommodation in liberal democracies (2016) 43:4 J Med Ethics 234, DOI: http://dx.doi.org/10.1136/medethics-2016-103560.

10. Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception (2017) 31:3 Bioethics 162, DOI: 10.1111/bioe.12288

11.  Though conceding that a lethal drug might be administered in the physician’s presence by a delegate, and that referral might be necessitated by technical incompetence. Attaran A. The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v Canada (2016 ) 36:3 Health L Can 86 [“Attaran“], p. 87-88, 96.

12.  “[W]hen a doctor refuses to assist a patient who is disabled by a ‘grievous and irremediable medical condition’, just because the patient wants death rather than something else, that arguably discriminates against the disabled patient.” Attaran, p. 89.

13.  Attaran, p. 91–93.

World Medical Association urged to change policy against euthanasia, assisted suicide

Canadian & Royal Dutch Medical Association want censure dropped

Sean Murphy*

The President of the World Federation of the Catholic Medical Associations has disclosed that the Canadian Medical Association (CMA) and Royal Dutch Medical Association (RDMA) have asked the World Medical Association to change its policy against euthanasia and physician assisted suicide.

The WMA issued a Declaration on Euthanasia in 19871 and a Resolution on Euthanasia  in 2002;2  they are now identical. The WMA Statement on Physician Assisted Suicide was made in 1992 and reaffirmed in 2005 and 2015:

Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical is a basic right of the patient, and the physician does not act unethically even if respecting such a wish results in the death of the patient.3

Writing to the President of the World Medical Association, Dr. John Lee stated that the CMA and RDMA suggested that existing policy be replaced with the following:

8. The WMA does not support euthanasia or physician assisted suicide, but WMA does not condemn physicians who follow their own conscience in deciding whether or not to participate in these activities, within the bounds of the legislation, in those jurisdictions where euthanasia and/or physician assisted dying are legalized.

9. No physician should be forced to participate in euthanasia or assisted suicide against their personal moral beliefs. Equally, no conscientiously objecting physician should be forced to refer a patient directly to another physician. Jurisdictions that legalize euthanasia or physician assisted suicide must provide mechanisms that will ensure access for those patients who meet the appropriate requirements. Physicians, individually or collectively, must not be made responsible for ensuring access.4

Dr. Lee also expressed opposition to a planned revision to the Declaration of Oslo concerning abortion, which, he said, would require objecting physicians to refer for abortions and even to provide them.  However, he commented at greater length on the proposed change to WMA policy on euthanasia and assisted suicide.

Based on the Canadian experience, acceptance of the ethical neutrality of medically-assisted death has resulted in almost immediate challenges for physicians who are unable to refer because of moral, religious, or ethical concerns. It is a serious problem, with physicians put in the impossible position of having to choose between their conscience and being allowed to continue to care for their patients.4

The Canadian roots of the CMA/RDMA proposal

Dr. Lee’s observations about developments in parts of Canada are accurate.  The text of paragraph 8 is very similar to the CMA resolution used by the CMA Board of Directors as the basis for reversing CMA policy against euthanasia and assisted suicide. . . [Full Text]