Emerging assault on freedom of conscience

Sincere thanks to Dr. Naylor for this important letter. The comments she makes are central to the discussion of conscience issues and portend what is to come if medical regulators persist in this attempt to jettison liberty of conscience among physicians.

A main rationale put forth in the policy discussion from medical regulators is the necessity to secure access to all legal medical procedures, including access for those in rural areas. Enforcing physician involvement, despite conscientious objection on the part of the doctor, would allegedly provide access and diminish inequality of access based on geographical location. Perhaps medical regulators, however, have not factored in the other side of the equation: if doctors are faced with regulations requiring participation in procedures they believe are harmful, unethical, or unwise, some will change the way they practice medicine, switch specialties, or leave their profession. What will be the result?

The professional body representing Canadian practitioners of palliative medicine did a survey of its membership in 2011 [1] and found that 83.3% of respondents were against legalization or decriminalization of euthanasia, and 90.6% would not participate in it; 80.6% opposed physician-assisted suicide, and 83.6% would not aid in it.[1] As Dr. Naylor has chosen to do, many have indicated they will stop providing palliative services if compelled by regulators to be involved with physician assisted death (PAD).

Availability of palliative medicine is already abysmal, with 70% of Canadians not having access to such care.[2] Rather than 'protecting the public' and thus securing access to these essential services for all, conscience infringement by regulators will produce a further scarcity of palliative medicine, particularly in rural areas. Dr. Naylor's letter is a very real testament to this reality. Who will be held to account when increasing numbers of suffering Canadians at the end stages of life lose access to adequate pain relief, support, and compassionate care? Who will answer to their families?

Furthermore, other medical specialty groups are also exploring the headlong push to compel physicians towards involvement in controversial interventions. For example, the March 2016 edition of the Canadian Journal of Anesthesia contains four papers on PAD.[3-6] As anesthesiologists possess specialized pharmacological knowledge and skills including extensive experience with drugs used for assisted death, many recognize they are "well-suited to play prominent roles in PAD."[3] Concern is expressed in one paper that recent legal decisions surrounding PAD enable government authorities to "regulate physicians directly in a manner that could seriously compromise the public good."[6] Many primary care physicians are also concerned about an obligation to refer for PAD and some are already tailoring their practices to limit or preclude taking on patients whom they are less familiar with. This will only create greater problems for the many Canadians who are without a primary care physician.[7]

I respectfully suggest that the colleges and political authorities involved in this issue respect freedom of conscience among physicians and abandon any requirement for mandatory provision or referral for contentious services that clash with the objectives, conscience, or morality of individual doctors. This would curb considerable apprehension within the healthcare profession and would also prevent exacerbation of the dearth of palliative care services. The few controversial medical services that might conflict with physician conscience could easily be co- ordinated through central agencies - with direction to willing providers for patients seeking such services.

As mentioned in the original commentary,[8] there are many challenges facing Canadian patients in the healthcare arena. Attention to these areas might be more fitting and in keeping with the 'protect the public' mandate of regulators - rather than diminishing essential services for patients and generating turmoil within the medical profession.

1. Canadian Society of Palliative Care Physicians. .Euthanasia survey results. accessed July 19, 2012 at [www.cspcp.ca /english /Survey%20Results%20-%20FINAL.pdf] 2012.

2. Barwich D. When and how to die. CMAJ 2012;November 6, 2012 vol. 184 no. 16 doi: 10.1503/cmaj.112-2077:112.

3. Herrick IA. Physician-assisted death in Canada: an imminent reality. Can J Anaesth 2016;63:241-5.

4. Mack C, Leier B. Brokering trust: estimating the cost of physician -assisted death. Can J Anaesth 2016;63:252-5.

5. Mottiar M, Grant C, McVey MJ. Physician-assisted death and the anesthesiologist. Can J Anaesth 2016;63:326-9.

6. Zivot JB, Arenson K. Lessons learned from physician participation in lethal injection: Is Carter v. Canada a death knell for medical self- regulation? Can J Anaesth 2016;63:246-51.

7. Bailey T. Waiting for a family doctor. Can Fam Physician 2007;53:579-82.

8. Genuis SJ. Emerging assault on freedom of conscience. Can Fam Physician 2016;62:293-6.

Conflict of Interest:

None declared

I would like to thank Dr. Bouchard for his letter and the important comments enclosed. Let me address each of his contentions.

First: Dr. Bouchard claims that the CMA "General Council voted overwhelmingly (79%) against recommending that physicians who oppose assisted dying be allowed to refuse to refer." This comment sourced from the pro-euthanasia website 'Dying with Dignity Canada' simplistically misrepresents the detailed Council proceedings. There were two votes on two different days at the Council and the results are in apparent conflict. On the first day, a straw poll was taken at the meeting where about 75 per cent of delegates agreed that physicians should provide information to patients on all end-of-life options available to them in a timely manner but should not be obliged to refer.

After the second day of proceedings, (the source of the 79% figure) debate ensued about the interpretation of an apparent reversal of position, with some attendees claiming they rejected a new resolution not requiring referral because they preferred the previous rendition which included the provision of credible information on all options in a timely manner. Subsequent to the General Council, the CMA summarized the position of Canadian physicians: "From the CMA's significant consultation with our membership, it is clear that physicians who are comfortable providing referrals strongly believe it is necessary to ensure the system protects the conscience rights of physicians who are not."[1]

Second: Dr. Bouchard asserts that "directly providing a service is significantly different, both legally and morally, from providing referral for said service." This dogmatic statement conflicts with the views of many others who contend that referral for an intervention makes one complicit in the act - a perspective that is reflective of broader Canadian values. For example, convicted prisoners located in Canada but originating and likely facing the death penalty in other jurisdictions are not extradited. Canada refuses to refer them back to their homeland because our nation chooses not to be complicit in their execution, and perhaps because the protection of life is morally more virtuous than acceding to the statutes of another jurisdiction. Although Dr. Bouchard may feel that 'referring' and 'providing' are morally extricable, many Canadians do not share his views.

Third: Dr. Bouchard quotes the policy of College of Physicians and Surgeons from Saskatchewan allegedly mandating referral. Saskatchewan policy requires the provision of information necessary to satisfy the requirements for informed consent but does not mandate referral at all - only Quebec and Ontario demand this. Furthermore, the Ontario mandate is now the subject of a court challenge that will likely go to the Supreme Court. A policy pronouncement from one or two colleges is hardly an imprimatur of transcendent truth, virtue, or scientific credibility - it is their view, a view which is vigorously disagreed with by many, including most Canadian physicians.

Fourth: Dr. Bouchard provides a quote that "failure to refer that patient on to an appropriate physician is inappropriate and unacceptable. Being a physician does not mean you get to force your patient to live their life in accordance with your personal choices." This quote is misleading because the reference could lead the reader to mistakenly believe that it expresses CMA policy. On the contrary, this quotation has been lifted from a CMA document and has been taken out of context. It does not reflect CMA policy or the position of most physicians. In fact, the CMA recently stated: "It is in fact in a patient's best interests and in the public interest for physicians to act as moral agents, and not as technicians or service providers devoid of moral judgement. . . . medical regulators ought to be articulating obligations that encourage moral agency, instead of imposing a duty that is essentially punitive to those for whom it is intended and renders an impoverished understanding of conscience."[1]

Finally: Dr. Bouchard finds troubling the concept of "conscientious objectors" in medicine - those who are either "unable (or unwilling) to set aside their own beliefs and biases for the good of the patient." This statement represents a fundamental failure to recognize that conscientious objectors are not endeavoring to subvert the good in the name of superstition, but rather subscribe to a different account of the good.

We all agree that physicians should always act 'in the best interests' of patients. Contrasting opinions in clinical situations, however, suggest that views on what is 'good for patients' or in their 'best interests', do not always align between health providers. Furthermore, the 'good of the patient' is not always what patients immediately choose for themselves. The epidemic of teen suicide suggests many teenagers choose to die - we counter their immediate inclination in order to act in what Canadian society and most medical professionals believe is in their best interests. Many patients requesting assisted death reverse this expressed desire when physical suffering is ameliorated through competent palliative care. From Hippocrates, the Father of Western Scientific medicine, to the Dutch medical community who refused to participate in Nazi medicine, conscientious objectors throughout the history of medicine have always taken their stance, right or wrong, in order to serve the best interests of patients, rather than seeking to fulfill some self-serving sense of moral righteousness. To this end, the CMA concludes "The argument that only mandatory referral puts patients' interests first or respects patient autonomy - and that not making a referral does not - is fundamentally erroneous...It is the CMA's position that there is no logical or ethical basis for this argument."[1]

I appreciate Dr. Bouchard's letter but our vigorous disagreement typifies the polarity within the profession. Sincere debate and discussion are good and welcome; the imposition of unilateral draconian values by regulatory bodies is another matter altogether.

1. Canadian Medical Association - Submission to the College of Physicians and Surgeons of Ontario. Consultation on CPSO Interim Guidance on Physician-Assisted Death.

Conflict of Interest:

None declared

Dr Genius has hit the nail on the head "Most doctors agree that physicians should never do what they believe is morally wrong, no matter what alleged experts say." We cannot always do all the good we would like to do, but we should never be forced to do that which is morally abhorrent. For to act against one's own conscience is to pervert it. As both a pharmacist and a patient, I want to know that the physician I am working with has utmost integrity. There can be no integrity without moral coherence. Let those who want to provide this assisted suicide do so, but please allow the rest of us to practice according to the tenets of our deeply held belief that life is sacred.

Cristina Alarcon, pharmacist in West Vancouver

Conflict of Interest:

None declared

I am writing in response to Dr. Genuis' article in CFP April 2016. I am very thankful he was so eloquently able to express the thoughts I have had on physician assisted death and the stance of the OMA and CPSO. To make a referral ( for physician assisted death) or performing it oneself, a mandatory requirement for physicians who oppose it for reasons of ethics or moral conscience I take as an assault on my integrity and ethics as a physician. He quotes a provincial college registrar as saying "patient rights trump our rights" and "patient needs trump our needs". When will this assault on physicians stop?

Our provincial ministry of health can arbitrarily stop contract negotiations and impose their will on our fee schedule. Now our provincial college takes the position that if we as physicians fail to refer a patient for euthanasia despite our moral objections we are not practising standard of care medicine and our licences are in jeopardy.

I refuse to let anyone or any organization dictate my moral code. For this reason I am not renewing my licence to practice medicine . I have practiced full scope family medicine , including palliative care for the past 37 years and solely palliative care for the past 3 years. I have no wish to stop. But I will not be told that I must go against my moral conscience to provide standard of care.

Thank you again Dr. Genuis for your article.

Nancy Naylor MD CCFP FCFP

Strathroy, Ontario

Conflict of Interest:

None declared