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Article CommentaryCommentary

Emerging assault on freedom of conscience

Stephen J. Genuis
Canadian Family Physician April 2016, 62 (4) 293-296;
Stephen J. Genuis
Clinical Professor in the Faculty of Medicine at the University of Alberta in Edmonton.
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  • Precedent for Conscientious Objection Established in International Law
    Theodore Loewen
    Published on: 25 May 2016
  • Re:response to Dr. genuis' article April 2016
    Stephen J. Genuis
    Published on: 19 April 2016
  • Re:Patients deserve more than our conscience
    Stephen J. Genuis
    Published on: 18 April 2016
  • Re:Patients deserve more than our conscience
    Cristina Alarcon
    Published on: 18 April 2016
  • response to Dr. genuis' article April 2016
    Nancy L Naylor
    Published on: 17 April 2016
  • Patients deserve more than our conscience
    Brady M. Bouchard
    Published on: 15 April 2016
  • Published on: (25 May 2016)
    Page navigation anchor for Precedent for Conscientious Objection Established in International Law
    Precedent for Conscientious Objection Established in International Law
    • Theodore Loewen, General Practitioner

    Thomas Jefferson's quote, concerning the high value of conscience rights by Dr. Genuis -1-rang true as I recalled the significant "moral residue risk" -1- quantified after a night perusing internet connections on historical examples of euthanasia including Physicians transgressing Hippocratic oath principles. Consider with me the conflict of interest coming to practicing Physicians heretofore in good standing with their...

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    Thomas Jefferson's quote, concerning the high value of conscience rights by Dr. Genuis -1-rang true as I recalled the significant "moral residue risk" -1- quantified after a night perusing internet connections on historical examples of euthanasia including Physicians transgressing Hippocratic oath principles. Consider with me the conflict of interest coming to practicing Physicians heretofore in good standing with their College, should the bill on MAID be passed without a "notwithstanding clause" on conscientious objection. The mistaken belief of our Federal Government that our Colleges will be either willing nor able to ensure this, when precedents in "standards of conduct" are already contrary to conscientious objection in its truest sense, is indeed naive.

    "Those who can not remember the past are condemned to repeat it"- George Santayana-2-

    Of the 23 defendants at the Public Health Segment of Nuremberg trials only 7 were acquitted. 20 of the defendants were doctors. Some of the principles established were as follows. * "Any person who commits an act which constitutes a crime under international law is responsible therefore and liable to punishment. * The fact that internal law does not impose a penalty for an act, which constitutes a crime under international law, does not relieve the person who committed the act from responsibility under international law. * The fact that a person who committed an act, which constitutes a crime under international law acted as Head of State or responsible government official does not relieve him from responsibility under international law. * The fact that a person acted pursuant to order of his Government or of a superior does not relieve him from responsibility under international law provided a moral choice was in fact possible to him. * Complicity in the commission of a crime against peace, a war crime, or a crime against humanity as set forth ......is a crime under international law."-3-

    -3-Wikipedia.org/wiki/Nuremberg_principles

    Many practicing physicians have established their values by invoking the Hippocratic oath. The Declaration of Geneva augments and reaffirms that oath today. Point 3 declares; "I will practice my profession with conscience and Dignity". Point 4 declares; "The health of my patient will be my first consideration." Point 9 declares; "I will maintain the utmost respect for human life". Health refers to physical, emotional, social and spiritual wellness. -4-

    -4-Wikepedia.org/wiki/Declaration_of_Geneva

    Whereas the College of Physicians & Surgeons of Alberta (the College) has proposed a review of standards of practice concerning moral or religious beliefs affecting medical practice which currently attempts to restrict the application of a physician's moral beliefs in item 2; "A physician must not withhold information about the existence of a procedure or treatment because providing that procedure or giving advice about it conflicts with their moral or religious beliefs", and item 3; "A physician must not promote their own moral or religious beliefs when interacting with patients" , and compels him into complicity with the assisted suicide in item 4; "When moral or religious beliefs prevent a physician from providing or offering access to information about a legally available medical or surgical treatment or service, that physician must ensure that the patient who seeks such advice of medical care is offered timely access to another physician or resource that will provide accurate information about all available medical options". Therefore if not revised, there exists for the moral physician a conflict of values in this matter of conscientious objection. When legislation for physician assisted suicide is enacted, the physician will have to choose to be in conflict with his conscience and the Declaration of Geneva, or in conflict with the College in this matter. The principles reviewed above infer the latter choice for ethical and moral physicians. Therefore if enacted and enforced, in due course the only physicians left practicing in good standing with the college, would be at the very least unethical and immoral, as defined by judgement at Nuremberg. The non objecting physicians would be approved by the College as acting in a manner to uphold the standard of Conduct at the time. Later on if judged by a higher law they may also be guilty of criminal action, the legal absolution of the College mandate notwithstanding, and even Canadian law fading rapidly as an excuse. Ethical and moral physicians must be free to exercise their conscience and to keep that conscience well tuned via the ongoing practice of their moral and religious convictions. To deny the right of morality, religion and conscience to a moral and ethical practicing physician mandates an appeal to a higher standard and a higher law as established at Geneva. I am amazed and disappointed in Provincial Colleges of Physicians as I wonder with Dr. Genuis whether some regulatory bodies explicitly coerce physicians to break this oath. At least our Registrar in Alberta has assured us the language pertaining to our Standard of Conduct in the matter of conscientious objection does not require that an "effective referral" be made, as in Ontario. I appreciated his concerned and understanding response in hearing us out personally on this matter, but remained concerned at the lack of responsibility to lead the profession to counterpoint the coming edicts. -5-

    College of Physicians & Surgeons of Alberta -Standards of Conduct -Conscientious objection-2011-(under review).

    My patients have expressed to me their fear of "becoming infirm" under this new law where a power of attorney or next of kin may proceed with assisted suicide by proxy, despite their wish to die of natural (non suicide) causes. Once these principals are in place there is little to prevent such possible misuse of the system. Physicians by virtue of their Doctor Patient relationship and their commitment to a higher standard are obliged, if they desire to remain professionally ethical and moral as defined by the Hippocratic Oath and Geneva Convention, to oppose this at every level. At least by doing so we may escape the "moral residue" so well reviewed by Dr. Genuis in his article.-1-

    The option by volition to make a choice for death is available to all humans regardless of physician advice for or against. Would patients choose death to spare the suffering of their loved ones, or to meet their expectations for relief or financial gain? The physician may not be able to protect them from that greater influence and may even be deceived to think it is the patient's own choice. If the physician is not forced to assist at least he may escape that moral residue and save his energy for his ongoing practice, and so more likely avoid the burnout which Dr. Genuis alludes to when discussing the morale of palliative care physicians practicing in days to come. -1-

    I agree with Dr Genuis that "patient trust...and relationship"-1- is at risk, but submit that a further conflict of interest will be present when the physician must ("Succumb")-1- subject his knowledge and skill, "to regulatory demands"-1-, instead of looking only to what he believes is the patient's best interests by promoting health and not destruction. The moral and ethical physician who embraces the Declaration of Geneva has vowed to practice with conscience and dignity and to uphold respect of human life. This is best done with a singular focus on health promotion. The distrust of the physician, who sometimes comes to promote life, and sometimes death, is another erosion the profession would do well to avoid as Dr. Genuis describes.-1- I further wonder at the ipso facto terminale How much will we get paid to assist death? Will we be able to bill if we counsel otherwise? What happens when the cost of surviving becomes too much for the system to sustain, and Government has to make some "hard" decisions? Will a segment of the population who is infirm and costly be singled out for the "mercy killings" reminiscent of the history books? Will physicians get a kick back to compensate for the lost revenues of extended care with premature death or to help the patient arrive at a "reasonable decision"? Those who fail to learn from history are bound to repeat it.-2- Most physicians at Nuremberg were found guilty as charged by a law higher than that of their country or governing body. Most of them did not do the killing themselves, they only supervised it.

    If physicians are required to practice without morality they become a menace to society. There needs to be but one item in the standard of practice in this matter of conscientious objection. 1."A physician must communicate clearly and promptly about any treatments or procedures the physician chooses not to provide because of his or her moral or religious beliefs." -5- Cults notwithstanding, most humans do not follow a moral code nor value system of their own making. Truth is not invented, it is discovered and once found many act upon it. In medical practice we call this evidenced based medicine. In life we call it wisdom. Moral and religious values are NOT of our own making. They are discerned by volition, and explored by reason. When enlightenment facilitates insight, commitment may follow.

    A physician's role to cure sometimes, to relieve often and to comfort always as described By D. Edward Trudeau who ran a TB sanatorium in the 1800's, will be upheld by all Moral and Ethical physicians, who support the Declaration of Geneva. Let us never relinquish our hope, nor our patient's hope, nor abandon our patients to physicians who by default in passivity have been silenced into subjection to a legal process, which remains criminal when judged by the higher standard. Let us continue to care for them whatever their choices for as long as possible, always in hope. When they choose of their own volition to suicide let us support their loved ones through the process as we have always done. Let us respect their right to choose, but let us be their advocate for life when they come for help.

    The Registrar of our College taught me years ago that the main function of the college is to protect the public. Colleges of Physicians would do this best by ensuring physicians the protection of their College in a full and complete Conscientious objection with Morality and Ethics intact and no conflicts of interest between life and death. The counterpoint of conscientious physicians so supported may do well in the preservation of values long established in the Medical Profession. These values are tested to protect the public down through the centuries, whereas the new Government laws have not been proven in these matters. Most physicians who deal with these matters daily may not accept this burden from Government. It is not our role to destroy life, and the College's mandate is to protect the public. After all that is what many of us signed up for at the outset of our Mandate and our Oath is worthy of respect.

    If the Declaration of Geneva is not evidence enough, there is yet a higher code of conduct superseding but complemented by it. This applies to all men everywhere, since the evidence is plain to see. The most prolific treatise on social conduct in the history of man ( Over 5 billion copies sold, World sales 100 million per year)-6-7- , states simply "You Shall Not Murder".-8- The same treatise when reviewing accountability reminds us "...man is destined to die once and after that to face judgment".-9- Let the reader decide what would be logical for the moral and ethical physician to do in preparation for that day. The only item a human owns is his reputation. Everything else he leaves behind to others when he passes from this world. His reputation remains his own. Physician's reputations are at stake and we must act decisively if we are to avoid the reputation of the Physicians indicted at Nuremberg. Let us rekindle the values of this amazing profession. I look to my family of physician colleagues in hope. May we stand together in the declaration and protection of our values, as moral and ethical Physicians.

    I for one am thankful that physicians such as Dr. Genuis articulate so well a much needed counterpoint. Thank you for engaging this important topic in your Journal.

    1. Steven Genuis- Emerging Assault on Freedom of Conscience- Canadian Family Physician April 2016 2. George Santayana-en.m.wikipedia.org 3. Wikipedia.org/wiki/Nuremberg_principles 4. Wikipedia.org/wiki/Declaration _of_Geneva 5. College of physicians and Surgeons of Alberta-Standards of Practice- Conscientious Objection- (under review). 6. en.m.wikipedia.org>wiki>list 7. nowthinkaboutit.com>2012/06>why-t 8. Bible-Exodus 20:13, Deuteronomy 5:17, Matthew 5:21, Romans 13:9, James 2:11 9. Bible-Hebrews 9:27

    Conflict of Interest:

    None declared

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    Competing Interests: None declared.
  • Published on: (19 April 2016)
    Page navigation anchor for Re:response to Dr. genuis' article April 2016
    Re:response to Dr. genuis' article April 2016
    • Stephen J. Genuis, Clinical Professor

    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 acces...

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    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

    Show Less
    Competing Interests: None declared.
  • Published on: (18 April 2016)
    Page navigation anchor for Re:Patients deserve more than our conscience
    Re:Patients deserve more than our conscience
    • Stephen J. Genuis, Clinical Professor

    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 misrepresen...

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    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

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    Competing Interests: None declared.
  • Published on: (18 April 2016)
    Page navigation anchor for Re:Patients deserve more than our conscience
    Re:Patients deserve more than our conscience
    • Cristina Alarcon, pharmacist

    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 wor...

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    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

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    Competing Interests: None declared.
  • Published on: (17 April 2016)
    Page navigation anchor for response to Dr. genuis' article April 2016
    response to Dr. genuis' article April 2016
    • Nancy L Naylor, physician

    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 e...

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    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

    Show Less
    Competing Interests: None declared.
  • Published on: (15 April 2016)
    Page navigation anchor for Patients deserve more than our conscience
    Patients deserve more than our conscience
    • Brady M. Bouchard, Assistant Clinical Professor

    I thank Dr. Genuis for voicing his views on medical aid in dying (MAID)[1], and more generally on freedom of conscience in medicine, but I must disagree strongly with some of his conclusions. As Dr. Genuis mentioned, a majority of physicians at the CMA's General Council support the right of physicians (within the bounds of existing legislation) to follow their conscience with regard to providing MAID. But similarly, that...

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    I thank Dr. Genuis for voicing his views on medical aid in dying (MAID)[1], and more generally on freedom of conscience in medicine, but I must disagree strongly with some of his conclusions. As Dr. Genuis mentioned, a majority of physicians at the CMA's General Council support the right of physicians (within the bounds of existing legislation) to follow their conscience with regard to providing MAID. But similarly, that same General Council voted overwhelmingly (79%)[2] against recommending that physicians who oppose assisted dying be allowed to refuse to refer. From this we can gather that most physicians in Canada feel that, despite whatever one's own religious or moral beliefs, we have a duty to provide care (or refer for care) when patients feel it is necessary. Dr. Genuis has disregarded the important distinction here that most physicians in Canada agree with: directly providing a service is significantly different, both legally and morally, from providing a referral for said service.

    We've been through this before with the provision of abortion services, and the majority of the provincial Colleges expect physicians to provide necessary care for their patients, including referral. To quote from the College of Physicians and Surgeons of Saskatchewan as a typical example, "physicians must provide their patients with the health information required to make legally valid, informed choices about medical treatment [...], even if the provision of such information conflicts with the physician's deeply held and considered moral or religious beliefs."[3]

    Ultimately, it comes down to the fact 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."[4]. Furthermore, I find the cohort of "conscientious objectors" to be troubling in their own right, in that it implies that there is a group of physicians practicing in Canada who are either unable (or unwilling) to set aside their own beliefs and biases for the good of the patient.

    [1] : http://www.cfp.ca/content/62/4/293.short

    [2] : http://www.dyingwithdignity.ca/canadian_doctors_vote_against_abandoning_patients

    [3] : College of Physicians and Surgeons of Saskatchewan, Policy, Conscientious Refusal, September 2015. See also: College of Physicians and Surgeons of Ontario, Policy #2-15, Professional Obligations and Human Rights, updated March 2015.

    [4] :https://www.cma.ca/Assets/assets- library/document/en/advocacy/Canadian-Approach-Assisted-Dying-e.pdf

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Canadian Family Physician: 62 (4)
Canadian Family Physician
Vol. 62, Issue 4
1 Apr 2016
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Emerging assault on freedom of conscience
Stephen J. Genuis
Canadian Family Physician Apr 2016, 62 (4) 293-296;

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