Tag: Canadian Medical Association

Canadian Medical Association and Referral for Morally Contested Procedures

Sean Murphy

Protection of Conscience Project
Protection of Conscience Project

Abstract
The Canadian Medical Association (CMA) has variously expressed support for physician freedom of conscience in codes of ethics, resolutions at successive General Councils and in policies concerning specific procedures. For over fifty years it has insisted that physicians should not be compelled to make referrals for procedures to which they object for reasons of conscience.

It appears that the great majority of CMA members support this position, but are unaware of its history. This paper revisits this history at a time when increasingly strident claims have culminated in demands that the state should force objecting physicians to collaborate in euthanasia and assisted suicide by referral.

The first CMA “conscience clause” was introduced into the Code of Ethics in 1970 following the reform of Canada’s abortion law. The provision did not mention conscience (or abortion) but was clearly intended to protect physician freedom of conscience. It was reaffirmed and more clearly articulated the following year by the CMA Annual General Council.

A dramatic increase in the demand for abortion resulted in pressure on health care workers and institutions. A 1977 amendment of the Code was widely interpreted to require objecting physicians to refer for abortion. This caused significant division within the Association and was removed in 1978.

The protection of conscience provision in the Code of Ethics remained unchanged after the Supreme Court of Canada struck down Canada’s abortion law in 1988. The CMA stressed that there should be no discrimination against physicians who refused or who agreed to participate in abortion.

Twelve years later the CMA Director of Ethics said there was “no ethical consensus” to support mandatory referral, adding subsequently that physicians were not obliged to do what they believed was wrong. This position was supported by the Canadian Psychiatric Association.

The CMA rejected claims by two law professors in 2006 that objecting physicians were required to refer for abortion, two years later reiterating its support for physicians who refused to do so. These skirmishes reflected a continuing and increasing threat, but do not appear to have caused the CMA to explore or develop the foundation of its commitment to protect physician freedom of conscience.

As the issue of euthanasia and assisted suicide (EAS) made its way to the Supreme Court of Canada in 2014, CMA leaders moved the Association from opposition to the procedures to purported “neutrality” and support for physician freedom of conscience. However, in expressing unconditional support for legal EAS, the changed policy potentially exposed many physicians to demands that could generate serious conflicts of conscience.

When the Supreme Court ruled in Carter the CMA leadership was ready to implement euthanasia and assisted suicide, but not to mount a cogent, articulate and persuasive defence of physician freedom of conscience. CMA leaders waffled on the issue of mandatory referral to EAS providers when it exploded in the months following the ruling. However, a substantial majority of CMA members opposed mandatory referral, and the CMA General Council approved a policy framework for implementing the Carter decision did not require it.

The first CMA statement addressing the subject of physician freedom of conscience at a foundational level was a 2016 submission opposing a state regulator’s plan to compel objecting physicians to make an “effective referral” to EAS providers. Important elements in the submission were incorporated into CMA policy Medical Assistance in Dying the following year.

In brief, the CMA expects physicians to notify patients of their objections to EAS and respond to patient requests for EAS by acknowledging them respectfully and providing information they need to exercise moral agency and give effect to their decisions. This includes information about how to access an appropriate health care network. Physicians are not obliged to provide or participate in EAS or to facilitate it by referral to a person or entity willing to provide the service. However, they must cooperate in a transfer of care initiated by the patient or others and transfer medical records upon request. While this policy is specific to euthanasia and assisted suicide, it can be applied to other procedures. There is no principled reason to suggest otherwise.

Relevant sections of the CMA’s new Code of Ethics and Professionalism adopted in 2018 are consistent with these requirements and reflect the position on referral that the CMA has now held for fifty years. The Code’s emphasis on professionalism does not imply that “professional expectations” override physician freedom of conscience, an implication inconsistent with the emphasis placed on moral agency, integrity and conscience in the Code and CMA policy statements. Further, claims about “professional expectations” are not neutral. Subordinating freedom of conscience to a dominant or purportedly “neutral” theory of professionalism will generate illicit discrimination and exacerbate rather than resolve conflict within the profession.

Informed by careful reflection about the role and importance of freedom of conscience in health care, a serviceable stand-alone policy on physician freedom of conscience could be drafted by drawing on past CMA statements, its submission to the CPSO on effective referral, and the revised CMA Medical Assistance in Dying policy. However, in doing so it is essential to avoid entanglement in controversies about the acceptability of morally contested procedures. Instead, a broad and principled approach is necessary, one that recognizes that freedom of conscience serves the fundamental good and dignity of the physician as a human person, not merely professional autonomy or independence.

TABLE OF CONTENTS
Introduction
1970: The first CMA “conscience clause”
1977-78: The first referral controversy
1988: Responding to R v Morgentaler
2000-2003: No ethical obligation to do what is believed wrong
2006-2008: Policy reaffirmed
2011: Referral for euthanasia, assisted suicide
2012-2014: Euthanasia, assisted suicide, ‘neutrality’ and conscience
2015: The Carter maelstrom
2016: The CMA and “effective referral”
2017: The CMA and euthanasia/assisted suicide
2018: CMA Code of Ethics and Professionalism
Looking ahead

(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).

L’euthanasie au Canada: une mise en garde

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott

World Medical Journal
World Medical Journal

Extract
Nous sommes des médecins canadiens consternés et concernés par les impacts – sur les patients, sur les médecins, sur la pratique médicale – de l’implantation universelle de l’euthanasie dans notre pays, définie comme un « soin de santé » auquel tous les citoyens ont droit (conditionnellement à des critères ambigus et arbitraires). Beaucoup d’entre nous sont si touchés par la difficulté de pratiquer sous ces nouvelles contraintes prescrites que nous pourrions être forcés, pour des raisons d’intégrité et de conscience professionnelle, d’émigrer ou de se retirer complètement de notre pratique. Nous sommes tous profondément inquiets du futur de la médecine au Canada. Nous croyons que ce changement sera non seulement nuisible à la sécurité des patients, mais également à la perception essentielle par le public – et par les médecins eux-mêmes – que nous sommes réellement une profession dédiée seulement à la guérison et au mieux-être. Nous sommes donc très inquiets des tentatives visant à convaincre l’Association Médicale Mondiale (AMM) de modifier sa position qui s’oppose à la participation des médecins à l’euthanasie et au suicide assist . . . . Continuer la lecture dans le World Medical Journal en anglais | Français

Euthanasia in Canada: a Cautionary Tale

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

World Medical Journal
World Medical Journal

Extract
We are Canadian physicians who are dismayed and concerned by the impact  – on patients, on doctors, on medical practice – of the universal implementation, in our country, of euthanasia defined as medical “care” to which all citizens are entitled (subject to the satisfaction of ambiguous and arbitrary qualifying criteria). Many of us feel so strongly about the difficulty of practicing under newly prescribed constraints that we may be forced, for reasons of personal integrity and professional conscience, to emigrate or to withdraw from practice altogether. All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public  – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide. . .

Leiva R, Cottle MM, Ferrier C, Harding SR, Lau T, Scott JF. Euthanasia in Canada: A Cautionary Tale. WMJ 2018 Sep; 64:3 17-23.

Emerging assault on freedom of conscience

Stephen J. Genuis

Canadian Family Physician
Canadian Family Physician

Extract
Discussion on physician autonomy at the 2014 and 2015 Canadian Medical Association (CMA) annual meetings highlighted an emerging issue of enormous importance: the contentious matter of freedom of conscience (FOC) within clinical practice. In 2014, a motion was passed by delegates to CMA’s General Council,and affirmed by the Board of Directors, supporting the right of all physicians, within the bounds of existing legislation, to follow their conscience with regard to providing medical aid in dying. The overwhelming sentiment among those in attendance was that physicians should retain the right to choose when it comes to matters of conscience related to end-of-life intervention. Support for doctors refusing to engage in care that clashes with their beliefs was reaffirmed in 2015. However, a registrar from a provincial college of physicians and surgeons is reported to have a differing perspective, stating “Patient rights trump our rights. Patient needs trump our needs.

Genuis SJ. Emerging assault on freedom of conscience.  Canadian Family Physician April 2016 vol. 62 no. 4 293-296.

(Correspondence) Clarification of the CMA’s position concerning induced abortion

Jeff Blackmer

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
Discussion:
CMA policy states that “a physician should not be compelled to participate in the termination of a pregnancy.” In addition, “a physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of this so that she may consult another physician.” You should therefore advise the patient that you do not provide abortion services. You should also indicate that because of your moral beliefs, you will not initiate a referral to another physician who is willing to provide this service (unless there is an emergency). However, you should not interfere in any way with this patient’s right to obtain the abortion. At the patient’s request, you should also indicate alternative sources where she might obtain a referral. This is in keeping with the obligation spelled out in the CMA policy: “There should be no delay in the provision of abortion services.”.

Blackmer J. (Correspondence) Clarification of the CMA’s position concerning induced abortion. Can Med Assoc J. 2007;176(9):1310.

Revision of Code of Ethics proving to be complicated procedure

Patrick Sullivan

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Abstract
Although the CMA Code of Ethics is only a 10-page booklet, revising it is proving to be complicated and time consuming. It is currently undergoing its first major revision in 25 years in an attempt to bring it up to date with changes within the medical profession and medical practice. The work was to have been completed in time for presentation to General Council during the 1995 annual meeting, but because of its complexity and the need for consensus the revised code will not be presented to council until August 1996.

Sullivan P. Revision of Code of Ethics proving to be complicated procedure. Can Med Assoc J. 1995;152(6):934-934. Available from:

(News) Kill the bill, CMA tells Senate committee studying abortion law

Patrick Sullivan

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
A “chilling effect” brought about by federal abortion legislation may be the reason almost 1 in 10 physicians who had been performing abortions in Canada in 1989 stopped providing the service in 1990, a CMA survey indicates. . . . The data also confirm an earlier CMA estimate that 50 to 80 physicians have stopped performing abortions since Bill C-43 was tabled . . . . “The Canadian Medical Association is unequivocally opposed to Bill C-43,” she said, noting that the CMA was not alone . . .

Sullivan P. Kill the bill, CMA tells Senate committee studying abortion law. Can Med Assoc J. 1991;144(4):496, 499.

(News) CMA brief slams abortion bill, says legislation not needed

Patrick Sullivan

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
The CMA has proposed an amendment that would make abortion an indictable offence “unless [it] is induced by or under the direction of a medical practitioner in accordance with generally accepted standards of the medical profession”. The association has also asked that a new section be added to protect patients, hospitals and physicians from the “threat and costs of unjustified, politically or harassment-inspired criminal charges”. That amendment would mean that no prosecution could be instituted under the new law without consent of an attorney general. The CMA thinks this would help eliminate the laying of frivolous charges by antiabortionists . . .

Sullivan P. CMA brief slams abortion bill, says legislation not needed. Can Med Assoc J. 1990;142(4):377-378.

(News) CMA board finalizes response to federal abortion bill

Patrick Sullivan

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
T he CMA Board of Directors has given final approval to a brief outlining the association’s stand on Bill C-43, the abortion legislation introduced by the federal government last fall. . . . It will restate physicians’ opposition to the placement of abortion – a medical procedure – in the Criminal Code. The CMA says abortion is the only medical procedure accorded such treatment. . . The brief will also address the problem of criminal and civil charges against doctors, and especially the harassment of physicians by those holding extremist views on this highly politicized issue. Many physicians are concerned this will happen if the bill passes in its original form.

Sullivan P. CMA board finalizes response to federal abortion bill. Can Med Assoc J. 1990;142(2):147-149.