Source: https://consciencelaws.org/law/commentary/legal030-001.aspx
Timestamp: 2019-04-18 10:35:48+00:00

Document:
Responding to Cook RJ, Dickens BM, "In Response". J.Obstet Gyanecol Can 2004; 26(2)112; Cook RJ, Dickens BM, Access to emergency contraception [letter] J.Obstet Gynaecol Can 2004; 26(8):706.
. . . the arguments of Professors Cook and Dickens for mandatory referral are unsupported and even contradicted by their own legal and ethical references. Regulatory officials with the power to enforce the views of Cook and Dickens are unlikely to discover this in the pages of the Journal, since, by editorial fiat, the discussion was terminated with the publication of their 'final word' on the subject. Here, then, is the postscript to the discussion, supplemented by developments in the United Kingdom and Belgium that have a bearing on the issue. . .
Nonetheless, Cook and Dickens stuck to their claim. "Physicians who feel entitled to subordinate their patient's desire for well-being to the service of their own personal morality or conscience," they stated, "should not practise clinical medicine"3 (Emphasis added).
The assertion that a patient's desire should be an ordering principle in the practice of medicine has little to recommend it. More important, the arguments of Professors Cook and Dickens for mandatory referral are unsupported and even contradicted by their own legal and ethical references. Regulatory officials with the power to enforce the views of Cook and Dickens are unlikely to discover this in the pages of the Journal, since, by editorial fiat, the discussion was terminated with the publication of their 'final word' on thesubject.4 Here, then, is the postscript to the discussion, supplemented by developments in the United Kingdom and Belgium that have a bearing on the issue.
The only authority cited by Professors Cook and Dickens to support their avowal that courts "continue" to demand referral was a less than contemporary ruling inZimmer v. Ringrose, a 23 year old case from the Alberta Court ofAppeal.5 The published letter from the Project pointed out that Zimmer addressed the failure to obtain informed consent to silver nitrate sterilization and failure to provide adequate follow-up care, not referral. The authors countered that the Administrator had misrepresented legal cases because he had failed to consider "historical background jurisprudence" that shapes court decisions. Summarizing what they believed to be the "continuing relevance of the Zimmer case," they claimed that failure to refer for abortion is "negligence close to abandonment."
Concluding the review of Zimmer, one can argue that a physician who urgently recommends a procedure to a patient has a duty to do all that he reasonably can to help the patient obtain it, but Zimmer does not speak to a case in which a physician, for reasons of conscience, refuses to recommend a procedure at all.
In other words, that the physician patient relationship is fiduciary for the purpose of disclosing patient records does not imply that it is fiduciary for the purpose of suppressing the conscientious convictions of the physician.
Finally, the court in McInerney accepted the characterization of the physician-patient relationship as "the same . . . as that which exists in equity between a parent and his child, a man and his wife, an attorney and his client, a confessor and his penitent, and a guardian and his ward."16Pursuing the analogy, no one has ever suggested that the fiduciary obligations of parents, husbands, attorneys, confessors, and guardians require them to sacrifice their own integrity to the "desires" of others. McInerneydoes not even remotely imply that physicians have such a duty.
The authors also insist that "in the event of differences between a physician and a patient regarding the patient's care, the patient's religious convictions prevail." Here they refer to Malette vs. Shulman, the case of a physician who was found liable for assault and battery because he deliberately ignored the prior written instructions of a Jehovah's Witness patient and gave her an emergency blood transfusion to save her life.17 The court ruled that medical treatment may not be forced upon a patient if it is contrary to his religious convictions, but it did not rule that a physician may be forced to provide or refer for treatment that is contrary to his. The case demonstrates that respect for patient autonomy may prevent a physician from doing what he believes to be good, but it does not create a duty to do or facilitate what the physician believes to be evil.
It is remarkable that Professors Cook and Dickens continue to cite these three cases, since they do not support their claims, and McInerney arguably contradicts them.
What of their reference to 'transcendent ethical duties'?
But the CMA Code of Ethics does not require that notice be given at a particular time, nor, necessarily, when a patient is first accepted. It is impossible for a physician to anticipate every demand that a patient might make of him, and both physicians and patients may, over the course of a relationship, change their respective views on a number of subjects. Moreover, technological developments may introduce new issues into an established relationship.
â€¢ A physician should not be compelled to participate in the termination of a pregnancy.
One looks in vain here for any evidence of the authors' alleged "fiduciary duty to refer."
The authors also argue from the physician's obligation "to put first the well-being of the patient," the first principle in the CMA Code of Ethics.
From this they conclude - yet again - that objecting physicians "must refer their patients to those who do not object to serve the patients' wishes." But this presumes that the Code is self-contradictory. It ignores the fact that the principle "to put first the well-being of the patient" co-exists with other sections of the Code and related policies that clearly do not expect referral by conscientious objectors.
Even if the Code were ambiguous on the subject of referral, such ambiguity would be insufficient to conclude that it requires referral in the service of the "well-being" of the patient - especially "well-being" unilaterally and subjectively defined by the patient. For it is one thing to say that patients are the best judges of what constitutes or contributes to their own well-being, and quite another to say that they may force physicians to serve the ends that they have chosen, regardless of the physicians' conscientious convictions: to force physicians to live their lives and make moral choices in obedience to the wishes, desires and demands of someone else. That is servitude, not service. Nonetheless, the authors cite Nancy B v Hotel Dieu deQuebec24 as legal authority for this line of ethical reasoning.
The Nancy B. decision is not relevant to the question of conscience in relation to pharmaceutical or medical practice because the autonomous views of one person are not what is at issue in "emergency contraception" situations where a pharmacist or physician do not wish to be involved in their prescription.
. . . this conflict cannot be settled by reference to one person's autonomy because two people's views or wishes (central to autonomy) are involved. That one of the people is the potential provider of the service sought is but one factor to take into account. To put the matter very clearly, let us look at what was and was not at issue in the Nancy B. decision.
Nancy B. had Guillain-Barré syndrome and was dependent upon a respirator. She wanted her respirator shut off. None of the physicians objected to what she wanted but sought the court's decision on whether such a course was legal. This is not what is relevant to the question of conscience or religious objection to "emergency contraception." Had a physician in the Nancy B. case refused to be involved, say, in turning off the respirator, then the issue would have been raised in a relevant form. But such a factual "issue" was not present in Nancy B. and that case fails to provide any light on the question of the duties that exist with respect to a pharmacist who does not wish to prescribe a particular drug or physician who does not wish to perform a particular procedure or nurse who does not wish to assist with a particular course of treatment.
Turning to the issue of accommodating conscientious objectors, Benson reminds the reader that the practice of medicine "is always a two-way street."
Yes, the patient or "client" has his or her autonomy; but so, too, does the practitioner. There is no good reason (except perhaps one grounded in an anti-religious bias) to advocate that a patient's autonomy should trump the autonomy of the professional health-care worker just because the two views conflict. What is needed . . . is an examination of how to accommodate conscience and religious views within the contemporary technocratic and often implicitly anti-religious paradigm of certain aspects of modern medicine.
For present purposes it is unnecessary to explore the ramifications of medical practice based on satisfying patient desires rather than meeting patient needs. It is enough to notice that, in the passage quoted, Chief Justice Dickson was addressing himself only to the meaning to be given to the phrase "the security of the person" in Section 7 of the Charter of Rights and Freedoms. The passage does not provide the key to resolving a conflict between a patient demanding an abortion and a physician unwilling to facilitate the procedure for reasons of conscience.
In fact, in R v. Morgentaler neither Chief Justice Dickson nor Mr. Justice Lamer, who joined in his reasons for judgement, considered principles associated with freedom of conscience, nor did Justices McIntyre and La Forest. But other judges did, and it is regrettable that Professors Cook and Dickens overlooked their opinions in their attempt to explain how R v. Morgentaler should be applied in cases of conscientious objection to medical procedures.
Madame Justice Bertha Wilson reflected more broadly on the nature and importance of freedom of conscience, arguing that "an emphasis on individual conscience and individual judgment . . . lies at the heart of our democratic political tradition."29 Wilson held that it was indisputable that the decision to have an abortion "is essentially a moral decision, a matter of conscience."
This is hardly a stepping stone to the kind of simplistic 'your wish is my command' solution advocated by Professors Cook and Dickens. Indeed, it is ironic that Madame Justice Wilson's reasoning in R v. Morgentaler so eloquently undermines their position. Following Madame Justice Wilson, for a regulatory authority or professional association to endorse and enforce the conscientiously-held view of the patient at the expense of physicians is to deny freedom of conscience to physicians, to treat them as means to an end, to deprive them of their "essential humanity."
This paper is confined to a review of the cases cited by Professors Cook and Dickens and their reasoning from them on the subject of referral for morally controversial procedures. Apart from brief reference to recent Belgian and British developments, no attempt has been made to marshal cases and arguments that offer support for the position of physicians who refuse to refer for services to which they object. Nonetheless, even this limited review of the subject leads to a number of conclusions.
â€¢ Zimmer v. Ringrose is not authority for the proposition that failure to refer a patient for reasons of conscience almost amounts to abandonment.
â€¢ McInerney v. MacDonald is not authority for the view that physicians have a fiduciary duty to refer patients for treatment to which they object for reasons of conscience.
â€¢ Malette vs. Shulman does not create a duty to do or facilitate what the physician believes to be wrong.
â€¢ The ruling in Nancy B v Hotel Dieu de Quebec is respectful of "the caregiver's comfort and conscience, empowering without ordering the physician to act;"it does not impose a duty to refer for morally controversial procedures.
â€¢ R v. Morgentaler did not establish the 'desire of the patient' as a fundamental principle governing the practice of medicine. The only references to freedom of conscience in Morgentaler support the view that physicians should not be forced to refer for services that they find morally objectionable.
â€¢ The authors' claim that "prior notice" is valid only if given when a patient is accepted is excessively rigid and inconsistent with the Canadian Medical Association's Code of Ethics.
â€¢ The first principle in the CMA Code of Ethics, "to put first the well-being of the patient,"co-exists with other sections of the Code and related policies that clearly do not expect referral by conscientious objectors. It cannot be taken out of context to fabricate a duty to refer for morally controversial procedures.
â€¢ The rejection by the British parliamentary committees of the compulsory referral provision in Lord Joffe's euthanasia bill supports the view that compulsory referral is an unjustifiable violation of freedom of conscience.

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