Whose right?

The Duke of Norfolk: “… but dammit, Thomas, look at these names! Why can’t you do as I did and come with us, for fellowship!”

Sir Thomas More: “And when we die, and you are sent to heaven for doing your conscience, and I am sent to hell for not doing mine, will you come with me, for fellowship?

Robert Bolt, A Man for All Seasons

The College of Physicians and Surgeons of Ontario (CPSO) recently approved a policy, “Physicians and the Ontario Human Rights Code,” in response to changes to the Ontario Human Rights Code in June 2008.1 During the external consultation process, there was much discussion about components of the policy by the media, physicians, and nonphysicians. The most controversial draft section read as follows:

Personal beliefs and values and cultural and religious practices are central to the lives of physicians and their patients. However, as a physician’s responsibility is to put the needs of the patient first, there will be times when it may be necessary for physicians to set aside their personal beliefs in order to ensure that patients or potential patients are provided with the medical treatment and services they require.1

What did this mean for Ontario physicians if the draft had been accepted as written? If, for personal, cultural, or religious reasons, you refused patients treatments they believed were necessary and they proceeded with complaints against you, you might not have been supported by the CPSO. Interestingly, this also applied to potential patients with whom you did not have existing fiduciary relationships. As originally written, this policy could have made practising in Ontario difficult for family physicians with strong personal, cultural, or religious views on medical issues. The approved CPSO policy does not include the controversial paragraph referred to above.

Of course, it is essential that physicians treat patients with respect and courtesy even if they have differences of opinion. And it is possible to maintain healthy relationships in difficult situations without physicians having to act against their conscience. The principles of patient-centred interviewing, including understanding patients’ expectations and contexts and finding common ground, are key in situations where physician and patient views diverge.2,3

Why should this concern family physicians in other parts of Canada? If this policy had been accepted as originally written, it could have opened the door to similar policies elsewhere. Human rights codes are by nature open to ongoing revision. What is unacceptable today might be acceptable tomorrow—and vice versa.

In a qualitative study of rewards and challenges in family medicine, Manca et al found that family physicians identified flexibility, control, and security among 8 key rewards to practising family medicine.4 They point out that the 2004 National Physician Survey (NPS) results support this finding.5 But not all family physicians around the world have this freedom, and the authors highlight several international studies describing family physician frustration with lack of control.6,7 The CPSO draft policy had the potential to turn this key reward for Canadian physicians into a challenge. In this issue, we publish a follow-up study by Manca et al ( page 1434) on another challenge for family physicians: respect from other specialists. The study offers some solutions at the individual and organizational levels. Berta et al propose a framework to improve family physician–consultant communication, an important component of maintaining good professional relationships ( page 1432).

The NPS gives us a window into the practices, plans, and concerns of physicians across Canada. In this issue, Grava-Gubins and Scott describe the intricate methodology used to entice physicians to complete the 2007 NPS ( page 1424), and Cameron argues that the results are worth the time, effort, and expense the survey entails ( page 1357). The issue also includes a supplement focusing on interesting family physician findings from the 2007 NPS.

Challenges. Rewards. Control. Freedom. They are important to us all.

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