More clarity on conscientious objection to physician-assisted death needed: professionals

[The ways the right to conscientious objection will be handled could vary considerably across the country, and even among different medical professionals in the same province. INTERNATIONAL BUSINESS TIMES]

The passage of Bill C-14 into law last week ended some of the uncertainty around physician-assisted death in Canada. But on the issue of conscientious refusal by medical professionals, uncertainty remains, particularly for pharmacists, registered nurses and nurse practitioners.

“The bill, which is now legislation, is very silent on questions of conscientious objection,” Joelle Walker, director of government relations for the Canadian Pharmacists Association (CPA), tells Yahoo Canada News.

That uncertainty could result in a situation where different provinces take different approaches to conscientious objection by medical professionals, Walker says.

The new federal law that legalized physician-assisted dying in Canada states that doctors have freedom of conscience on the matter and aren’t required to perform or assist in the provision of the procedure. The rights of other medical professionals aren’t specified in the bill, so their conscience rights have to be extrapolated from that statement.

The ways the right to conscientious objection will be handled could vary considerably across the country, and even among different medical professionals in the same province.

Physician colleges across the country have all addressed the issue of conscientious objection for doctors, but with varying recommendations and subtle differences in language.

In Alberta, for example, physicians have an “obligation” to give patients a timely referral to doctors who will provide medical assistance in death if they themselves are unwilling to do so. In Nova Scotia, it is “recommended” that doctors do so.

Manitoba and New Brunswick’s guidelines say a doctor can both refuse to perform the procedure and to provide a referral, but must give “timely access” to a resource that has the information on how a patient can access physician-assisted death.

Guidelines in Prince Edward Island state that physicians refusing to provide doctor-assisted death are obligated just to make a patient’s charts available to other practitioners.

Several professional groups representing more than 4,700 doctors across Canada are challenging in court Ontario regulations, which require them to effectively refer a patient seeking physician-assisted death to a willing physician.

The regulations for the College of Physicians and Surgeons of Ontario say that a doctor who is unable to provide assisted death for a patient has to provide an “effective referral” to an effective and available doctor or agency that will do so.

“A physician makes an effective referral when he or she takes positive action to ensure the patient is connected in a timely manner to another physician, health-care provider or agency who is non-objecting, accessible and available to the patient,” the colleges online factsheet says.

Some objecting physicians say that referring care to a doctor they know provides assisted death is still a violation of their conscience rights, because it means they are participating in some way in the procedure.

Other medical professionals

Not only physicians are involved in providing medical assistance in dying. Pharmacists, registered nurses, and nurse practitioners also play a role in the procedure.

Those professions will apply the conscience guidelines for doctors in the bill to their own role and then develop guidelines of their own, says Walker of the pharmacists association.

“Now that the legislation has passed, it’s going to allow the provinces and the various provincial regulators to actually develop practice guidelines to support the various professions, including pharmacy,” Walker says.

The CPA supports the right to conscientious objection for its members, Walker says, and that pharmacists should ensure continuity of care for their patients. However, that doesn’t necessarily mean referring patients to a pharmacist who will participate in physician-assisted death, she says.

“We don’t think they should have to refer directly to another pharmacist,” Walker says. A lot of pharmacists would see such a referral as equivalent to providing the medications themselves, she says.

With the legislation now in place, Walker says, and no specific protections or guidelines for pharmacists with conscientious objections included in C-14, the issue will go to the provincial regulatory boards.

“I think what we’re going to see, potentially across the country, are differences in regulatory provisions,” Walker says.

Carolyn Pullen, director of policy for the Canadian Nurses Association (CNA), agrees.

“We’re really seeing strong signs already, across the provinces, that all of the regulatory bodies are advocating and being supportive of protection for their professional groups,” Pullen says. “But not all the nursing regulatory bodies have released their standards for their nursing professions.”

Part of the CNA’s role will be bringing those bodies together to attempt to reach as much national consensus as possible on the matter, Pullen says.

“The CNA doesn’t have the authority or the intent to insist that everyone proceed the same way. What we try to do is facilitate the discussion,” Pullen says.

Nursing itself has a history of dealing with issues of conscience while ensuring continuation of care, Pullen says, in particular around abortion care. And the profession’s code of ethics means that nurses are required to continue caring for a patient until they’re able to transfer care to another professional who will provide it at the same level, she says.

Both the CNA and the CPA say that a national framework could be helpful for their medical professionals.

“Having provincial or even a national system or body who could help keep lists of pharmacists or other health-care providers, just maybe from a health-care standpoint, would be practical,” Walker says. Pharmacists with conscientious objections to participating in physician-assisted death could refer patients to such a resource, she says.

Pullen agrees that a national body to refer to for standards of care would be helpful. She says it’s already emerging that smaller provinces are working to establish which medical professionals are willing to participate in physician-assisted death.

“It’s going to evolve to a bit of a specialized practice where professionals will self-identify as willing to participate and will become the go-to professionals,” Pullen says.

In the meantime, work on harmonizing professional standards across Canada as much as possible will be important for patients and professionals alike, Pullen says.

“You don’t want differences in care from simply crossing a border,” she says.