If you are reading this article, the chances are good that you are already familiar with the story of a medical student whose ordeal, during the 2003-4 academic year, set in motion the events which led to the formation of the Freedom of Conscience Committee of CMDS Canada. Picture yourself on the wards. You are a clinical clerk, within weeks of starting your last year of medical school, which so far has been a largely positive experience. Your preceptors rate your performance highly. You are known for your conscientious approach to patient care, and as for the academic side of things – well, let’s just say you are unusually bright, even for a medical student. Working in the gyne out-patient department one day, you see a patient who has come in requesting a script for an oral contraceptive. Having learned that the patient is single, you find yourself unable, in good conscience, to write out the script personally, and so you defer that decision and the task of writing the script to your preceptor. Neither the patient nor your preceptor seem, at the time, to take any offense at this.
In 2004, the Christian Medical and Dental Society of Canada established the Vigilance and Freedom of Conscience Committee. Our mission is to:
- Promote a high view of human life consistent with the Christian faith and the Hippocratic tradition;
- Educate CMDS members regarding their conscience rights;
- Publicize evidence that demonstrates the congruence between science and Christian ethics;
- Communicate our concerns regarding the freedom of conscience to governments and universities;
- Monitor for evidence of bias against Christians’ entry into medical and dental schools; and
- Support and advocate for colleagues who have been pressured by threat of discipline or dismissal to compromise their commitment to life-affirming care.
The committee is chaired by Dr. Joseph Askin. The other members of the committee include Drs. John Patrick, Arnold Voth, Mark Chandra, Catherine McCallum, and the author (Mark Kristjanson).
In an effort to define the nature and extent of coercion of Christian medical and dental students across Canada with respect to matters of conscience, the committee developed a questionnaire which was distributed to the students who attended the Western and Eastern 2007 Student Conferences. The responses indicated that slightly more than 50 percent of students had experienced either direct criticism or negative off-hand comments about their faith or their pro-life commitments, often from their professors. Two students reported having committed actions against their conscience because of a strong impression that they had no other options.
At CMDS Canada’s national conference in Ottawa, this year (May 10-13) the FCC teamed up with the Christian Legal Fellowship to conduct a workshop on the protection of conscience. Ruth Ross who, since 2000, has served as Executive Director for the CLF, and Joseph Hamon, who practices family law and who has also studied theology and philosophy at the University of St. Paul in Ottawa, joined this author in a panel discussion on May 12th. The discussion ran well overtime, thanks in part to the excellent (and very welcomed) participation of the audience, and the spirited discussion which followed the formal presentation. I am persuaded, both by the quality of the discussion we enjoyed with the audience, and by the immediate bond of kinship in Christ which Ruth, Joseph and I experienced during a time of prayer, just before the session, that our Lord’s Spirit was actively guiding our interactions. A brief round of introductions, at the start of the panel discussion, was followed by a sufficiently detailed review of the ordeal, of the above-mentioned medical student, to serve as a basis for further discussion. Some of the salient points raised during the discussion were to the effect that:
- The Canadian Charter of Rights and Freedoms states in Section 2, “Everyone has the following fundamental freedoms: (a) freedom of conscience and religion...”
- The Supreme Court of Canada has ruled explicitly on the issue of freedom of conscience stating that “subject to such limitations as are necessary to protect public safety, order, health, or morals or the fundamental rights and freedoms of others, no one is to be forced to act in a way contrary to his beliefs or his conscience.”
- The Canadian Medical Association, in policy document PD99-03 (Joint statement on preventing and resolving ethical conflicts involving health care providers and persons receiving care) states that “Health care providers should not be expected or required to participate in procedures that are contrary to their professional judgement or moral values (sic). Health care providers should not be subject to discrimination or reprisal for acting on their beliefs. The exercise of this provision should never put the person receiving care at risk of harm or abandonment.”
- CM A policy document PD06-02 on medical professionalism (update 2005) states that “physicians are not morally obliged to provide inappropriate medical services when requested by patients, despite their respect for patient autonomy.”
Our discussion also briefly touched upon correspondence with Manitoba’s and Alberta’s Colleges of Physicians and Surgeons regarding protection of conscience. On March 30, 2004, CMDS member and Calgary chapter president Christin Hilbert wrote to Dr. Bob Burns, then Registrar of the College of Physicians of Alberta, to confirm the College’s position on matters of conscience as previously articulated by Dr. Burns’ predecessor, Dr. Larry Olhauser in his written reply to questions posed by Dr. Hilbert in previous correspondence on this subject. Dr. Hilbert reminded Dr. Burns that Dr. Olhauser’s correspondence asserted the following:
“A patient has the right to access the information regarding various different treatment choices available for a certain medical problem. The practitioner needs to provide information on all of the options, thus enabling the patient to be fully informed. If one has an issue of conscience even discussing certain options, then arrangements must be made to somewhere where the patient can obtain all the information. However, the responsibility is only on providing information; there is no obligation for a practitioner to take part in the procedure which offends the practitioner’s conscience, including referring to (sic) that procedure. This also holds true for rural physicians (i.e. there is no obligation based on geography) as well as practitioners at any stage in their training.”
Dr. Burns replied to Dr. Hilbert in a letter dated April15, 2004. In it, he endorses the above statement as fairly reflecting the Alberta College’s position, and adds that the physician who declines on the grounds of conscience to make an abortion referral must also inform the patient “of their particular personal morality and why it precludes them from recommending or referring for the specific abortion.”
Dr. Rick Ross, a family physician practicing in Winnipeg, wrote to Dr. Bill Pope, the Registrar of the College of Physicians and Surgeons of Manitoba, in a similar effort to clarify the position of the Manitoba College. Dr. Pope did assert that a physician objecting on grounds of conscience to abortion referrals is obliged to support the patient in their efforts to procure an abortion. However, he indicated that this duty “is not tantamount to a requirement to identify another physician who will refer the patient to a physician who practices therapeutic abortion.” Rather, any obligation to “refer” is satisfactorily met if the objecting physician simply cooperates with the timely release of records to another physician, i.e. when and if the patient seeks the advice of another physician who in turn submits a request for release of records.
In a guest editorial published in CMAJ 2006, 175(1):9, lawyers S. Rogers and J. Downie erroneously asserted that physicians are required, as a matter of law and by CMA policy, to make abortion referrals. The Freedom of Conscience Committee, along with numerous other contributors to the debate, issued letters of rebuttal to this assertion. The CMAJ repeatedly refused to publish the letters submitted by the FCC, although correspondence from some other contributors did make its way into print. In fact, the response to the original guest editorial was so vigorous (on both sides of the debate) that the CMAJ eventually asked the CMA to clarify its position. Jeff Blackmer, Executive Director of the Office of Ethics for the CMA, in a letter entitled “Clarification of the CMA’s position concerning induced abortion” and published in the April 24, 2007 issue of the CMAJ, states “CMA policy states that ‘a physician should not be compelled to participate in the termination of a pregnancy.’ In addition, ‘a physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of this so that she may consult another physician.’
You should therefore advise the patient that you do not provide abortion services. You should also indicate that because of your moral beliefs, you will not initiate a referral to another physician who is willing to provide this service (unless there is an emergency).
However, you should not interfere in any way with this patient’s right to obtain the abortion. At the patient’s request, you should also indicate alternative sources where she might obtain a referral. This is in keeping with the obligation spelled out in the CMA policy: ‘there should be no delay in the provision of abortion services.’”
Although Jeff Blackmer affirms the CMA position that physicians have no obligation to refer for abortion, it is worth noting that he asserts the alleged “right” of the patient to abortion. A recurring theme in the panel discussion at the Ottawa conference was the concern that proponents of abortion are wilfully misleading physicians and students regarding the legal status of abortion in Canada. International medical graduates and medical students in particular are being fed the message that they have an ethical and a legal obligation to refer; ambiguity (and ignorance) regarding the legal status of abortion in Canada are part of the problem.
During the panel presentation, Ruth Ross pointed out that the Supreme Court Justices who struck down Canada’s abortion law in 1988 did not in fact discover any “right” to abortion in the Charter or anywhere else. Rather, because of the discrepancies in access to abortion which existed across Canada, they found that the provision in the law, for access on grounds of medical necessity to an otherwise illegal procedure, violated the Charter guarantee of security of the person. Rather than strike down only that component of the legislation which granted legal access to abortion under such “exceptional” circumstances, the Supreme Court struck down the entire law, with the intent that Parliament re-write the relevant legislation. Given that Parliament has never gotten around to passing any law to replace the old one, abortion simply has no legal status in this country. The justices of the Supreme Court did acknowledge in their majority opinion that the state does in fact have an interest in protecting the life and rights of the foetus.
Joseph Hamon proposed a practical check list to guide the response of a physician who finds him- or herself in conflict with secular authorities over an ethical matter. Before a problem ever arises, we need to be in prayer over matters of medical ethics and regarding our relationships with our patients. We need to inform our patients, in advance whenever possible, of our stance on controverted medical ethical issues, and to sufficiently inform our patients of our beliefs and our commitments so that they will know when such beliefs will influence the advice we give them regarding the investigation or treatment of a clinical problem. Mr. Hamon provided the group with the example of a physician in Ontario who has posted a sign in his waiting room explaining in brief his commitment to Christ and his corresponding refusal to prescribe Viagra or birth control pills to unmarried patients, and his stance regarding the sanctity of the life of the foetus. That physician has been careful in his wording of the sign to avoid proselytizing, but at the same time indicates his openness to further dialogue with the patient on these matters should the patient so desire.
Should a problem arise, Mr. Hamon again advises that we start by committing the matter to God in prayer, and by seeking His guidance. A rational consideration of the issue should be followed by contemplation as to whether or not reasonable accommodation without compromising conscience might be possible. He recommends planning for a successful resolution of the issue by:
- enlisting prayer support from others;
- discussing all sides of the issue with a trusted colleague;
- calling or e-mailing the Christian Legal Fellowship for information or guidance.
Exercising discernment with respect to whether enlisting assistance from secular bodies might be appropriate, e.g. calling Jeff Blackmer of the CMA Office of Ethics.
With specific reference to the abortion issue, Mr. Hamon reminded the group to advise the patient of the time-sensitive nature of the matter, so that she may conduct herself accordingly.
On May 8th, the National Abortion Federation (based in the US but also representing Canadian abortion providers) sent a letter to the CMA urging it to change its position with respect to conscientious objection to abortion. During the question and answer portion of the discussion in Ottawa, Rene Leiva made the group aware that the College des medicines du Quebec specifically requires of physicians that in the instance where a patient is demanding/requesting an action or therapy contrary to the conscience of the physician, the “physician must then offer to help the patient find another physician”. This policy clearly runs contrary to the protection of conscience provisions in the Charter and in CMA policy. Unfortunately, this policy is part of a larger document dealing with the stance of the College on ethics which has also been endorsed by Quebec’s provincial government.
Dan Hardock urged that we be proactive in educating IMGs and medical students about their conscience rights, especially in light of the ongoing efforts by some university faculty, ethicists, and lawyers to deceive our physicians-in-training on these matters.
At the close of the session, we spoke briefly of the possibility that the Freedom of Conscience Committee, which has taken over responsibility for the Hippocratic Registry, could establish therein a legal defence fund for those practitioners or students who are facing disciplinary measures or dismissal as a consequence of adhering to a life-affirming ethic of care.
My heartfelt desire is that all CMDS members will devote earnest prayer to these matters. The Freedom of Conscience Committee of CMDS Canada seeks to minister on Christ’s behalf to those members of His body who are experiencing harassment, coercion, or even (at times) persecution for taking a principled stand, in His name, on medical ethical issues in the context of their clinical practices or in medical school or residency. It is clear to me from my interactions with Ruth Ross and Joseph Hamon that the Christian Legal Fellowship is every bit as dedicated to such a ministry, and they are available to co-labour with us in proactively influencing policy where possible, and in providing spiritual support and legal counsel to oppressed practitioners and students whenever needed. You can reach the CLF by contacting Ruth Ross at
ross.clf@primus.ca. On behalf of the FCC, I welcome your feedback, and encourage readers of Focus to send their comments.
In Christ,
Mark Kristjanson
May 21, 2007
Mark Kristjanson is Chair of the Steering Committee of the Manitoba Chapter of CMDS, and a member of the Freedom of Conscience Committee.
