Project Administrator, Author at Protection of Conscience Project Library

(Correspondence) CMA’s “third way” may be a third rail

Responding to articles by CMA officials (BMJ 2019; 364)

Sean Murphy

British Medical Journal, BMJ — British Medical Journal

Extract
It is disconcerting to find that the CMA’s President-Elect thinks that Canadian law “does not compel any physician to be involved in an act or procedure that would violate their values or faith.” The state medical regulator in Canada’s largest province has enacted policies that do just that, requiring physicians who refuse to kill their patients to find a colleague who will. These policies do have the force of law, and objecting physicians were forced to launch an expensive constitutional challenge to defend themselves. The Protection of Conscience Project and others have intervened in the case to support them; the CMA has not.

Further, the Canadian Medical Association’s assertion that it has successfully adopted a “neutral” position on euthanasia and assisted suicide (EAS) is challenged in a World Medical Journal article by seven Canadian physicians. “For refusing to collaborate in killing our patients,” they write, “many of us now risk discipline and expulsion from the medical profession,” are accused of human rights violations and “even called bigots.” . . .

Murphy S. CMA’s “third way” may be a third rail. Rapid Response to articles by CMA officials (BMJ 2019; 364).

Conscientious objection to abortion, the law and its implementation in Victoria, Australia: Perspectives of abortion service providers

Louise Anne Keogh, Lynn Gillam, Marie Bismark, Kathleen McNamee, Amy Webster, Christine Bayly, Danielle Newton

Abstract
Background: In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause (‘Section 8’) was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria.

Methods: Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically.

Results: The majority of participants described Section 8 as a mechanism to protect women’s right to abortion, rather than a mechanism to protect doctors’ rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women’s access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported.

Conclusion: Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.

Keogh LA, Gillam L, Bismark M, McNamee K, Webster A, Bayly C et al.. Conscientious objection to abortion, the law and its implementation in Victoria, Australia: Perspectives of abortion service providers. BMC Medical Ethics. 2019 Jan 31;20(1).

Conscientious objection to abortion, the law and its implementation in Victoria, Australia: perspectives of abortion service providers

Louise Anne Keogh, Lynn Gillam, Marie Bismark, Kathleen McNamee, Amy Webster, Christine Bayly, Danielle Newton

Abstract
Background: In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause (‘Section 8’) was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria.

Methods: Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically.

Results: The majority of participants described Section 8 as a mechanism to protect women’s right to abortion, rather than a mechanism to protect doctors’ rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women’s access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported.

Conclusion: Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.

Keogh LA, Gillam L, Bismark M, McNamee K, Webster A, Bayly C, Newton D. Conscientious objection to abortion, the law and its implementation in Victoria, Australia: perspectives of abortion service providers. BMC Medical Ethics201920:11.

Why I decided to provide assisted dying: It is truly patient centred care

Sandy Buchman

Extract
Supporting conscientious objection and conscientious provision in the context of respecting physician autonomy is the essence of the CMA’s approach to MAID. Thus, the medical profession as a whole could participate actively throughout the drafting of the law and in the governance of medical assistance in dying. Respecting autonomy, for patients as well as for physicians, is the essential element in finding compromise to one of the most challenging question of medical ethics of our times.

Buchman S. Why I decided to provide assisted dying: It is truly patient centred care. BMJ (Online). 2019;364.

How the Canadian Medical Association found a third way to support all its members on assisted dying

Jeff Blackmer

Extract
The CMA recognised that its policy needed to evolve: if the law were to change, the organisation would support all its members, regardless of their views, in deciding whether to participate in MAID. This was a watershed moment, enabling the association to lead national discussions and to give evidence before Canada’s Supreme Court. . . .The court referenced the CMA’s position to provide equal support for conscientious participation and conscientious objection, stating, “Nothing . . . would compel physicians to provide assistance in dying. The declaration simply renders the criminal prohibition invalid.”.

Blackmer J. How the Canadian Medical Association found a third way to support all its members on assisted dying. BMJ (Online). 2019;364.

Systematic Review of Ovarian Activity and Potential for Embryo Formation and Loss during the Use of Hormonal Contraception

Donna Harrison, Cara Buskmiller, Monique Chireau, Lester A. Ruppersberger, Patrick P. Peung Jr.

Abstract
The purpose of this review was to determine whether there is evidence that ovulation can occur in women using hormonal contraceptives and whether these drugs might inhibit implantation. We performed a systematic review of the published English-language literature from 1990 to the present which included studies on the hormonal milieu following egg release in women using any hormonal contraceptive method. High circulating estrogens and progestins in the follicular phase appear to induce dysfunctional ovulation, where follicular rupture occurs but is followed by low or absent corpus luteum production of progesterone. Hoogland scoring of ovulatory activity may inadvertently obscure the reality of ovum release by limiting the term “ovulation” to those instances where follicular rupture is followed by production of a threshold level of luteal progesterone, sufficient to sustain fertilization, implantation, and the end point of a positive β-human chorionic gonadotropin. However, follicular ruptures and egg release with subsequent low progesterone output have been documented in women using hormonal contraception. In the absence of specific ovulation and fertilization markers, follicular rupture should be considered the best marker for egg release and potential fertilization. Women using hormonal contraceptives may produce more eggs than previously described by established criteria; moreover, suboptimal luteal progesterone production may be more likely than previously acknowledged, which may contribute to embryo loss. This information should be included in informed consent for women who are considering the use of hormonal contraception.

Harrison D, Buskmiller C, Chireau M, Ruppersberger LA,Peung PP. Systematic Review of Ovarian Activity and Potential for Embryo Formation and Loss during the Use of Hormonal Contraception. Linacre Quarterly. 2019 Jan 03; 85(4):453–469.

Medical Assistance in Dying (MAiD): Ten Things Leaders Need to Know

Rosanne Beuthin, Anne Bruce

Abstract
The provision of MAiD will be in flux for a few years, as legislative challenges are underway. This article addresses what leaders need to know and do to support nurses today and in the future regarding care of patients choosing MAiD. Drawing on complexity leadership theory and research into nurses’ experiences in caring for persons choosing MAiD, we share 10 simple yet foundational things a leader must know. Underpinning our key messages are current evidence and familiar nursing concepts such as end-of-life care, death trajectories, conscientious objection, scope of practice, ethics, sense-making and care cultures. These key messages are embedded in a framework of leadership practices where attention to inter-relationships, emergence and innovation are highlighted. They provide nurse leaders with concrete actions to inspire a team dynamic for creating inclusive cultures of quality care. Leadership is needed across healthcare settings where MAiD is being enacted.

Beuthin R, Bruce A. Medical Assistance in Dying (MAiD): Ten Things Leaders Need to Know. Nurs Leadersh (Tor Ont). 2018 Dec;31(4):74-81. doi: 10.12927/cjnl.2019.25753.

Not here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare

Eric Plemons

Extract
. . . Over the past five years, however, public and
private health insurance coverage for transition-related surgery has increased exponentially.2 As available funds have increased, so has demand for services.3 American institutions are now struggling to meet a growing demand for competent, efficient, and effective transgender
healthcare that they had denied for decades. . . . The rapid expansion of Catholic hospitals is a concern for transgender people, their advocates, and the insurers who provide their health coverage because Catholic hospitals do not provide transition-related care. . .

Plemons E. Not here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare. Crosscurrents. 2018 Dec; 68(4): 533-549.

Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

Lori Seller, Marie Eve-Bouthillier, Veronique Fraser

Abstract
Background Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

Methods A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

Results Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient’s death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

Interpretation We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians’ approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Seller L, Bouthillier M, Fraser V. Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations. J Med Ethics. 2019;45:106-111 .

Drawing the line on physician-assisted death

Lynn A Jansen, Steven Wall, Franklin G Miller

Abstract
Drawing the line on physician assistance in physician-assisted death (PAD) continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill that can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill.

Jansen LA, Wall S, Miller FG. Drawing the line on physician-assisted death. J Med Ethics. 2019;45:190-197.