Professional Documents
Culture Documents
12 June, 2015
NUMBER
FROM:
Registrar
135/15
M E M O R A N D U M
DATE:
TO:
Council
FROM:
Bryan E. Salte
RE:
1. Decision Required
At the March meeting Council asked the committee to reconsider aspects of the draft
policy and to suggest changes to the policy. Council agreed that at the June meeting it
would approve a draft policy in principle and once again engage in a consultation process
to obtain input from physicians and the public. Council will then approve a final policy in
September after considering the response to the final consultation.
2. Council direction in relation to the draft considered at the March meeting (Info
73_15)
As I understand the direction of the Council from the March meeting, it was the
following:
1) There will be a policy approved by Council. Council approved the general
approach of the document from Info. 73_15;
2) The reference to Code of Ethics in the draft should be changed to Canadian
Medical Association Code of Ethics or CMA Code of Ethics
3) The 7th bullet in the draft states that Reasonable limits on a physicians ability to
refuse to provide care are appropriate unless there is a good legal reason that the
patients interests should not be accommodated, that should be changed so that it
refers to a legitimate clinical reason in addition to referring to a good legal
reason
4) The order of the paragraphs under Scope should be reversed so that it first states
that the policy does not refer to physician assisted death and then contains the
second paragraph that it refers to all medical services.
for the patient to ask questions about the proposed treatment and receive
appropriate information about the proposed treatment if the patient wishes.
5) What will be required to meet the obligation to provide information to a patient in
a specific fact situation may vary depending on the nature of the treatment under
consideration and the particular situation of the patient.
6) If a physician provides information to a patient about a proposed treatment, and if
the patient decides to obtain the treatment, the physician has an obligation to take
steps to ensure that the patient is able to access the service without unreasonable
delay and without unreasonable barriers.
7) The general viewpoint expressed was that the word refer is one which has a
specific meaning to physicians and should be avoided if possible. Not everyone
agreed that the word refer was inappropriate but alternative wording was not
strongly opposed if the effect of the alternative was to clearly express the
Colleges expectations for physicians.
There wasnt general agreement on the following:
1) What are the expected arrangements for a physician who has a conscientious
objection against providing information to patients about a possible treatment?
Must the arrangement be with another health care provider? If it must be to
another physician or other health care provider is it necessary for the physician to
specifically arrange with that person to see the patient and obtain that persons
agreement to do so? Is it acceptable to make an arrangement with some other
source of information such as an agency?
2) What are the expectations of a physician who has provided information to a
patient if the patient chooses a treatment to which the physician has a
conscientious objection? Must the physician provide the patient with contact
information for another health care provider who can facilitate the treatment?
Must the physician contact a health care provider who can facilitate the treatment
and make arrangements for the patient to be seen by that health care provider?
Can the obligation be met by providing the patient with information about an
agency that can arrange for the treatment?
One point of view expressed was that it is sufficient to provide the patient with
contact information so that the patient can make the necessary arrangements to
access the health service.
The other point of view expressed was that physicians who recognize that they
will not be able to provide full and balanced information about a particular service
or procedure, or are unwilling to directly facilitate patient access to a particular
service or procedure because of a conscientious objection, must arrange for a
Saskatchewan health practitioner to provide care in these areas should such an
eventuality arise. In the situation where transfer of care to a Saskatchewan health
practitioner is not possible, the physician must demonstrate why such transfer is
not possible and what alternative methods of provision of information/access to
services will be provided in lieu of such transfer.
Additionally, there was concern expressed that paragraph 5.4 was capable of being read
in a way that it requires a physician to provide treatment to a patient if it would be
inconvenient to the patient to seek treatment elsewhere, not only in a situation where
delay could have a significant impact on patient health.
There were two competing viewpoints in relation to paragraph 5.4. The first was that the
paragraph should be limited to what have generally been regarded as true emergencies
where the patients health is in immediate danger.
The other viewpoint was that the document should address both emergency situations and
situations where the patient wants a particular type of care that needs urgent access to
information and a provider the statement in the policy should focus on the patient and
that individuals choice at the time of initial consultation. It is not appropriate to define
the obligation in terms of avoiding harm to the patients health or well-being. If defined
as avoiding harm to the patients health or well-being, it will, for example, allow a
physician opposed to abortion to refuse to arrange for the morning after pill on the basis
that the physicians believes that he/she is preventing harm by allowing the patients
pregnancy to continue to term. Such a physician may argue that he/she has taken action
that will benefit the fetus and ultimately benefit the mothers psychological well being.
Patient autonomy;
the patient, or until the patient has been given adequate notice that you intend to
terminate the relationship.
Patients should not be disadvantaged or left without appropriate care due to the
personal beliefs of their physicians;
2. Scope
This policy does not apply to physician-assisted death or physicians conscientious
objection related to a potential physician-assisted death. The College recognizes that this
is currently an issue which is in a state of development and may be revisited by the
College at a later time.
This policy applies to all other situations in which physicians are providing, or holding
themselves out to be providing, health services.
3. Definitions
Freedom of conscience: for purposes of this policy is actions or thoughts that reflect
ones deeply held and considered moral or religious beliefs.
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It is important to provide medical care in a way that is consistent with The Saskatchewan
Human Rights Code and the CMA Code of Ethics. The College document PatientPhysician Relationships addresses the expectations of physicians who are considering
taking on a new patient.
The Canadian Medical Association Code of Ethics says:
17. In providing medical service, do not discriminate against any patient on such
grounds as age, gender, married status, medical condition, national or ethnic
origin, physical or mental disability, political affiliation, race, religion, sexual
orientation, or socioeconomic status. This does not abrogate the physicians right
to refuse to accept patients for legitimate reasons.
The above obligation does not prevent physicians from making bona fide decisions, or
exercising professional judgment, in relation to their own clinical competence. Physicians
are always expected to practice medicine in keeping with their level of clinical
competence to ensure that they safely deliver quality health care. If physicians genuinely
feel on grounds of lack of clinical competence that they cannot accept someone as a
patient because they cannot appropriately meet that persons health care needs, then they
should not do so and should explain to the person why they cannot do so.
The duty of a physician not to refuse to accept a patient based on the identified
characteristics does not prevent physicians from making bona fide decisions to develop a
non-discriminatory focused practice.
Where physicians know in advance that they will not provide specific services, but will
only arrange for the patient to obtain the necessary information from another source or
arrange for the patient to obtain access to a medical treatment from another source (in
accordance with paragraphs 5.2 or 5.3), they must communicate this fact as early as
possible and preferably in advance of the first appointment with an individual who wants
to become their patient.
The College expects physicians to proactively maintain an effective plan to meet the
requirements of paragraphs 5.2 and 5.3 for the frequently requested services they are
unwilling to provide.
5.2 Providing information to patients
Physicians must provide their patients with full and balanced health information required
to make legally valid, informed choices about medical treatment (e.g., diagnosis,
prognosis, and clinically appropriate treatment options, including the option of no
treatment or treatment other than that recommended by the physician), even if the
provision of such information conflicts with the physicians deeply held and considered
moral or religious beliefs.
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Physician is willing to
provide full and
balanced information to
the patient
Patient chooses a
medical service to which
the physician has a
conscientious objection
Patient chooses a
medical service to which
the physician does not
have a conscientious
objection
OR
Physician provides
patient with
information to allow
the patient to
arrange timely and
effective access to
the medical service
Physician contacts
another healthcare
provider who is willing
to arrange or perform
timely and effective
access to medical
service and makes
arrangements for the
patient to be seen by
that health service
provider