Conscientious objection to physician-assisted dying

The legislation regarding medical aid in dying (Bill C-14) was introduced by the federal government this week and to no one’s surprise has caused outrage from both those who support and those who oppose physician-assisted dying. One particular article from the Ottawa Citizen about the Catholic Health Alliance of Canada’s concern that the legislation didn’t do enough to specifically protect conscientious objectors is particularly galling. This group reiterates their belief that “referring someone who would assist in death would make them complicit” and argues that doctors should in no way be forced to refer patients on. I have stated my beliefs before that doctors refusing to even make a referral is a selfish act placing physicians own beliefs ahead of the real needs of sick and vulnerable patients. But this article got me to thinking about how a conversation would go between a dying patient and a physician that the Catholic Health Alliance is trying to protect.

Patient: Doctor, you have taken care of me for the last six years; I’m suffering from intractable pain and you just told me I only have a few weeks left to live. I would like to talk about medical aid in dying that I heard was just legalized.

Doctor: Sorry I can’t help you.

Patient: But it is legal now, right? I meet all the criteria for getting a prescription to allow myself to peacefully pass away and end my suffering.

Doctor: You do, but I’m sorry I disagree with the whole concept of a physician assisted death.

Patient: Ok then, can you help me find another doctor who could discuss it with me?

Doctor: No I can’t do that either.

Patient: Why not?

Doctor: Referring you to someone else would be just as bad as me writing the prescription myself. And my conscience won’t allow me to do that.

Patient: But you get paid in essence by the government don’t you? And the government made this a legal medical treatment?

Doctor: Yes, but I have the right to refuse to help you based on my own beliefs.

Patient: Can I please talk to another doctor about this?

Doctor: Go ahead.

Patient: Who would that be?

Doctor: I am not at liberty to say.

Patient: Is there an agency or service you can point me to?

Doctor: Sorry, I can’t.

Luckily, it sounds like a centralized database of physicians willing to provide medical aid in dying will be created in Canada to connect patients who are abandoned by their physicians. I would hope all doctors would be reasonable enough to at the least provide a phone number or website where patients could achieve timely access to a willing provider. The medical community is moving more and more towards patient-centered care; legislation that specifically allows doctors to refuse to refer patients for any medical intervention including medical aid in dying would be an unfortunate setback.

One thought on “Conscientious objection to physician-assisted dying

  1. Good article as always, Dr Detsky. However, I think it illustrates a problem that I often come into when thinking about modern Canadian healthcare. It’s not one that I’ve been easily able to reconcile myself with yet, despite thinking about it for a long time. It’s sure it’s extremely unpopular, and I’m not even sure I entirely agree with it 100%.

    Basically, it’s the idea (stated either explicitly or implicitly) that because the government pays doctors, doctors become nothing more than agents of the state. They are thus required to perform any and all acts that the state deems acceptable, regardless of professional or personal ethics (either individual or collective on the part of doctors’ professional organizations). And, because we can’t possible contemplate a “two-tier system,” no option exists for physicians to extract themselves from the system while still using their skills to provide medical care to those who need it.

    To borrow your hypothetical dialogue device, the progression I’m describing went as follows. Note that in this context, I use the word “government” in the broad sense, encompassing the totality of the legislative, executive, and judicial bodies/functions of Canadian government at all levels; “doctors” is also broad — encompassing individual doctors as well as collective associations like the OMA or CMA:

    Gov’t: We don’t like that not everyone can access health care. So we are going to institute universal public health insurance.
    Doctors: Ok, we can do that. We can still retain our professional independence.
    Gov’t: We don’t like that you are charging more than what we are willing to pay you for certain services. So we are going to make it illegal for you to charge patients privately and/or make more money than we are willing to give you.
    Doctors: Ok, we don’t love it, but we’ll do it. We can still retain out professional independence.
    Gov’t: Since we’re the ones that pay you, we get to decide what services you have to offer.
    Doctors: Hey, what happened to our professional independence?! I don’t like this system, can I opt out of it and just practice the way I want?
    Gov’t: Nope, sorry. It’s our way or the highway.

    As much as Canadians might think it is, the government is not in charge of medicine (in the sense of dictating how medicine should be practices), and I don’t think they should they be. Doctors are not mere state functionaries, we are educated professionals who act based on our own judgments, opinions, ethics, and morals.

    The following is certainly a glib example, but (to use your specialty as an example), I don’t want think the government should be telling radiation oncologists not to treat a stage III lung patient with IMRT when deemed medically appropriate or that certain patients must be treated aggressively when doctors feel the risks outweigh the benefits. If physician-assisted dying is a medical procedure, then I think it should be treated the same way.

    Of course I think patients should have access to medical services, but I don’t think it follows that doctors need to be forced to violate their ethics for that to happen. If the government, advocacy groups, regulatory colleges or whoever else want physician-assisted dying to be widely available, surely they have the means to do so without forcing doctors to violate their consciences. Things don’t stop existing or being available just because the government doesn’t force it to happen.

    There are surely enough physicians who have no issues with assisting death to create a viable, accessible system. Examples of ways to do this that I’ve though of in the last 5 minutes include: 1) maintaining publicly available registers of physicians who provide these services and ensuring that they are widely available online and through hospitals, hospices, public health clinics, phone-service lines, etc, 2) providing financial incentives to physicians who provide these services, 3) opening facilities that are publicly administered/run and directly employing physicians who will provide these services directly. I’m sure there are many smarter ways that people smarter than myself can think up.

    The cynical part of me thinks that the government knows this, but also knows that doing so will be unpopular either because it will be expensive or for some other reason. So it’s easier to just dump the issue onto doctors, since we aren’t politically strong or popular.

    Anyway, I’d love to hear your thoughts on this matter, as it’s a question I’ve struggled with often, in many different contexts.


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