Background

 The Alberta Committee for Conscience Protection is calling on us to write to the College of Physicians and Surgeons Alberta (CPSA) with comments on their Consultation on the current Standard of Practice on Conscientious Objection. This consultation is open until January 10, 2024.

The Conscientious Objection standard was last reviewed in 2016. Amendments to this standard are intended to better outline expectations for regulated members in navigating ethical dilemmas relating to personal beliefs and patient beliefs. The addition of a preamble, glossary and directions provide more context around when and how regulated members can decline to provide treatment and what must be provided for the patient to ensure they continue to receive high quality care.

What’s changed?

• Addition of a preamble and glossary to provide context for the standard and more detailed definitions;
• Inclusion of clarifying language to better communicate the balance between a regulated members’ right to limit health service based on reasons of conscience, cultural belief or religion and patients’ rights to timely access to safe, high-quality care;
• Section added to clearly break down permitted and prohibited actions with a focus on reducing risk of harm and maintenance of respect for patient;
• Expansion of the related standards of practice and addition of companion resources to better support regulated members.

One of the concerns expressed by the Alberta Committee for Conscience Protection is around "effective referral". The glossary of the Model Practice Standard proposed by Health Canada defines:

Effective referral: taking positive action to ensure the person requesting MAID is connected in a timely manner to a non-objecting, available, and accessible physician or nurse practitioner, other health-care professional, or [name of agency, program, office responsible for patient navigation] that provides the health service (eligibility assessments for, and provision of, MAID) or connects the person directly with a health-care professional who does. ‘Timely manner’ means such that the person will not experience an adverse clinical outcome or prolonged suffering due to a delay in making the connection. [Note to users: delete this definition if the regulatory authority uses wording of effective transfer of care instead of effective referral]

Effective transfer of care: a transfer made by one physician or nurse practitioner in good faith to another physician or nurse practitioner who is available to accept the transfer, accessible to the person requesting MAID, and willing to provide MAID to that person if the eligibility criteria are met. [Note to users: delete this definition if the regulatory authority uses the wording of effective referral instead of effective transfer of care]

For further information, please read the points below and the drafts at https://cpsa.ca/physicians/standards-of-practice/consultation/consultation-028/028-conscientiousobjection (you can also read comments from other Albertans there and add your own). Feedback may be provided via survey, email or the comment form on each page.

Alberta Committee for Conscience Protection

Talking Points on the College of Physicians and Surgeons of Alberta (CPSA)
Draft Standard of Practice on Conscientious Objection Consultation 028

As many of you are aware, the CPSA has invited comments on their Consultation on the current Standard of Practice on Conscientious Objection. This consultation is open to CPSA members, partner organizations, other healthcare professionals and Albertans until January 10, 2024. We are hoping that we can send a clear message to the CPSA Council that the introduction of the term “effective referral” that was added to the draft policy is not acceptable to many physicians and concerned members of the public. This new term is borrowed from the Model Practice Standard proposed by Health Canada, and in Alberta we already have a solid framework for patients to access services they are looking for without requiring an “effective referral.”

We propose the following revisions to the draft Standard of Practice:

• Section 1.f. could be revised as “Proactively maintain a non-judgmental approach and be aware of resources to provide for frequently requested services they are unwilling to provide.”
• Section 2.c. should be removed due to lack of clarity.  
  • If a patient were to experience pain while waiting for MAID, this could be claimed an adverse clinical outcome. Although the procedure sought out should not be impeded as in 2c, there are a lot of subjective possibilities that could emerge from so-called "exposures" from "delayed effective referral."
  • Specifically, “adverse clinical outcomes” and “delayed” are not objectively defined and are open to wide subjective interpretation. 
  • "Delayed"  is not clearly defined either and in many ways the seeking of care is dependent on what the patient decides to do after visiting a provider.
  • Many psychiatrists have warned that it will be extremely difficult for physicians to discern which patients are making a fully informed, consensual decision to pursue MAID and which are not. 

Other talking points

• It needs to be clearly stated, whether in this policy or for the understanding of the draft standard committee, that a member who declines to provide a service (e.g. MAID) or a referral for the same (while still providing resources) is doing so because they believe it is in the best interest of the patients.  Their care of the patient compels them down this path. A sober second thought on the part of a provider who wants to provide a variety of different perspectives may allow a patient to see their concerns from a new or different angle and can be a source of support for that patient.
  • Many from the disability community have called for safe spaces where they know the practitioner sees their life as worth living and wouldn’t agree to end their lives when they are at a low point.
  • Since "effective referral" has been introduced in other provinces, many providers have left, retired early, or sought registration in Alberta because of our more reasonable conscience objection standard. Adopting this language from other provinces potentially exposes our system to further loss of providers who would be frustrated with the addition of this wording.
  • It should be emphasized that the Supreme Court gave its assurance that nothing in its original ruling on the constitutionality of MAID “…would compel physicians to provide assistance in dying.” Participation through an effective referral would directly involve physicians in MAID to which many of us are opposed.
  • The government and College does not want to micro-manage the doctor-patient relationship but does expect non-judgmental professionalism adhering to obligations
  • Based on opinion polling, many Canadians are concerned about compelling physicians to do something they are not comfortable with, e.g. "54 percent of Canadians give “quite a lot” or a “great deal” of weight to the concern that the confidence of patients in doctors could be compromised, given that patients look to doctors “to heal, comfort, and fight for them.” Sixty-three percent of visible minorities share this concern.
  • This is not about competing rights but about mutual freedoms.  It is not about limiting access but about redirection to different resources.  In reality, patients' and physicians' rights are not opposed. The patient and physician work together as a team and navigate medical decisions in a shared decision making framework.  
  • Conscience is not an expression of a physician’s personal preference, it is a judgment based on what the physician feels is in the patient’s best interest.  Patients and physicians disagree on a regular basis on a large number of issues, and these usually do not come to the point of conflict; they are usually resolved in professional and friendly ways. 
  • Physicians are not solely responsible for ensuring access to medical assistance in dying.  CMAJ February 20, 2018 190 (7) E181; DOI: https://doi.org/10.1503/cmaj.180153
    • "The responsibility to ensure access to MAID does not rest with an individual physician, but with society. Recognizing this, most provinces have developed access programs for MAID... When it comes to MAID, balancing the rights of physicians and patients is not an easy task, but both deserve protection."While this standard emphasizes the right of a physician, it also needs to consider the fact that many patients want providers whose values fit with theirs, and a large group of patients want to be served by providers who decline to offer certain procedures like MAID. Finding the right physician fit requires a diverse medical system with a variety of different providers with different opinions.

The above talking points are for reflection and to help formulate comments in your own words, using resources and references that you are familiar with. Please complete the online form here (https://cpsa.ca/physicians/standards-of-practice/consultation/consultation-028/028-conscientiousobjection/), or by email on the same page.

– Alberta Committee for Conscience Protection