In his latest blog post, Dr. David Amies grapples with conscientious objection and examines the delicate balancing act between a healthcare provider's professional obligations and personal morality.
Health professionals who cite reasons of conscience for not filling legal prescriptions or who assemble multiple administrative hurdles aimed at preventing access to legitimate procedures have taken a couple of recent hits.
- Get the facts: Court challenge to the CPSO's policy on effective referral
- Related: Balancing 'institutional conscience' and patient rights
- Related: On 'institutional conscience,' Part 2
The Secular Medical Forum (SMF) has advised the central body overseeing pharmaceutical practice in the United Kingdom as follows, “It is essential to place reasonable limits on the unrestricted expression of the personal views of trained health care professionals.” It cites the example of a woman being unable to obtain the Morning-After Pill from a pharmacy because of the objection of the pharmacist to dispense it on personal religious grounds. Furthermore, it holds that any pharmacists working single-handedly in a remote rural area should think carefully about occupying such posts lest similar patients be greatly incommoded by their religious beliefs.
In late June, the U.S. Supreme Court refused to hear an appeal from a family-owned pharmacy that gave religious reasons for its refusal to provide emergency contraceptive agents to women. The effect of this refusal leaves in place a state regulation that requires pharmacies to deliver all legal medications, including contraceptives, in a timely fashion. The American Civil Liberties Union praised the action of the Supreme Court and remarked, “When a woman walks into a pharmacy, she should not fear being turned away because of the religious beliefs of the owner or the person behind the counter.”
So, it appears that both in the United Kingdom and the United States, the religious views of some healthcare professionals are not going to be allowed to trump the legitimate requirements of patients seeking remedies in such controversial matters as abortion and medical aid in dying (MAID). Of course, these are delicate questions that require careful handling.
In Canada, following the enactment of Bill C-14, certain qualified patients have the legal right to ask for and to receive medical aid in dying. On the other hand, the Charter of Rights provides for freedom of religion, and some healthcare professionals will take refuge behind this to avoid having to be party to such proceedings. In larger population centres, it will be relatively easy to make alternative arrangements. Problems will arise in remote, smaller centres where no other willing doctors, nurses or institutions are available. We can only hope that irresistible forces will not come up against immovable objects, thereby allowing for sensible compromise. The new law concerning medical aid in dying is already being challenged by the British Columbia Civil Liberties Association, who regard it as being too restrictive. It is highly likely that there will be opposite challenges aimed at imposing other barriers along with provisions concerning the protection of healthcare professionals’ consciences.
I would now like to turn to the ethics of terminal sedation. Imagine the following scenario: an elderly woman is in the last stages of uncontrollable cancer. She has had mutilating surgery, which has left her with painful swollen upper extremities; radiotherapy, leaving behind large areas of damaged skin; and three courses of chemotherapy, which made her feel wretched and knocked a few points off her mental acuity. All this treatment has not eradicated her cancer, which continues to smolder, occasionally bursting into flames with yet another bony secondary. She is nauseated by her pain medications as well as being seriously constipated by them. She applies to her doctors for MAID, which they refuse on conscience grounds. Instead they offer her terminal sedation. MAID would involve the administration of a cocktail of drugs, which would bring her life to an end in a matter of minutes. On the other hand, terminal sedation would involve the administration of similar drugs in much smaller doses, which would induce coma. The medical team would then slowly withdraw artificial hydration and nutrition, and she would die during the course of 10 days or so. During this time, her family and friends could sit by her and watch her slow, but inevitable expiry — a truly daunting experience.
Of course, the medical team could argue that, by providing MAID, they would be giving drugs with the intention of killing her. With terminal sedation they could take refuge in the idea that the drugs used were meant to put her into a terminal coma, but not to end her life. It seems to me that the distinction is an exceedingly fine one since the outcomes are identical. Whereas I recognize that everyone has a right to believe in what they choose, I find it difficult to envisage a deity who would be happy with terminal sedation but outraged by MAID. Those who do not share my difficulty evidently have a greater mastery of sophistry — or should that be casuistry?
Dr. David Amies is a retired doctor in Lethbridge, Alta., and a member of DWD Canada's Physicians Advisory Council.
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