Dr. David Amies: When a doctor's conscience thwarts patients' access to care

In his latest entry for Dying With Dignity Canada's blog, Dr. David Amies revisits the topic of conscientious objection, and in particular, whether physicians should be allowed to refuse to provide referrals for patients who request assisted dying — even if that refusal could ultimately lead to a denial of care.

Professor Julian Savulescu, a professor of practical ethics at Oxford University, during a recent series of public talks and interviews in Australia, argued that health care professionals should not be allowed to deny patients legitimate treatment on the grounds of their conscientious objections to the treatment. He rightly points out that such objections lead to delay in treatment and are not in the best interests of the patient. He cites the instance in which a pharmacist refuses to dispense the “morning after” pill to a young woman and thereby puts her at risk of a pregnancy that she does not wish to have. He claims that such conscientious squeamishness can cause delays when a patient asks for physician-assisted death and so subjects the sufferer to additional distress while other more willing practitioners are found.

Savulescu’s talk has particular relevance for us in Canada in the light of the refusal of some physicians and other health professionals to participate in medical aid in dying, especially in smaller centres where there may well be no other available sources of help. Savulescu puts forward two main arguments. Firstly, when conscientious objection is allowed, patients are prevented from obtaining timely necessary and legal treatment and potentially put at risk through delay not occasioned by clinical reasons. 

Savulescu’s second argument is a moral one and he poses a difficult question. Why should the medical care to which patients are entitled depend upon the personal and religious values of the health professionals they happened to attend? He grants that practitioners are entitled to their own values but he wonders whether such entitlement can be allowed to trump the legitimate needs and rights of patients. He holds that the principles of law and ethics should determine what treatments patients may receive and not the personal values of providers. In other words, the interests and desires of patients must take precedence over the personal prejudices of practitioners.

Apparently, Sweden and Finland have made it illegal for doctors to impede patient access to care. Consequently, women, for example, can ask for and receive a termination of pregnancy if the circumstances of their cases warrant it. The practitioners involved are obliged to provide it or immediately refer them to another healthcare professional.

Consequences for assisted dying access in Canada

In Canada, by contrast, a doctor faced with a request for medical aid in dying is fully entitled to refuse to provide it or, in some jurisdictions, even to refer the request to a colleague. In large and relatively empty countries such as Canada and Australia, there will be circumstances in which the only available doctor or pharmacist in a small, isolated location, may well allow his or her personal views to obstruct the wishes and needs of a patient.

Savulescu finds that situation intolerable and postulates remedies. He suggests that practitioners should avoid occupying posts in isolated communities if their values are likely to run counter to the wishes of patients. More radically, he considers that entrants to training programmes should avoid specialties which frequently involve making controversial and morally charged decisions. Of course, that situation is especially pertinent to obstetrics and gynecology. But nowadays might also apply to palliative care, geriatrics and oncology. He goes so far as to suggest that committed Catholics who oppose certain reproductive rights are likely to encounter awkward situations if they take up gynecology because therapeutic abortion and contraception are an integral part of that specialty today. He wonders, controversially, whether they might do better to consider some other specialization.

A direct quote from Savulescu nicely encapsulates his view of this dilemma:

"I think medical boards and indeed medical schools should be encouraging doctors to take a 21st century view of the doctor–patient relationship where the patient is first and their own personal values are second. They can engage in discussion with the patient about the options and perhaps even their moral validity, but in the end they ought to be there serving the patient and providing a service. So if indeed we have a right of conscientious objection, we ought to be encouraging doctors only to exercise that right in the most extreme of circumstances."

Vancouver Island case

Shortly after I came across the views of Professor Savelescu, I encountered a startling situation existing in a small city on Vancouver Island, where the only available hospital is run by the Catholic Church. It is not surprising that this institution refuses to consider the performance of medical aid in dying on its premises. It has now gone further by insisting that patients may not even begin the process of applying for it while they remain in one of its rooms. Consequently, grievously ill patients, who wish to bring their lives to an end, as they are entitled to do under certain clearly defined circumstances by federal law, must decamp to some other institution in another city or to return home before they can even begin the process of applying. To go home may well not be possible or practical and moving elsewhere will involve considerable travel and distress.

The stance of the hospital management appears to me to be doctrinaire to a horrifying degree. Such adherence to dogma is totalitarian and more in keeping with attitudes in some ghastly third-world dictatorship or theocracy. For the managers of the institution involved, consideration for the patients’ welfare comes very low down on the list of priorities, but their consciences will remain unclouded. And this is happening in Canada in 2016! 

To hear more about his thoughts on this issue, listen to this Australian Broadcasting Corporation interview with Savulescu.

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