As my loyal readers (both of them) know, I happen to be a Trekkie. Permit me to digress a bit, and reflect on one of Captain Jean Luc Picard’s best speeches (Nerd Alert: from the Next Generation episode “The Drumhead”):
“With the first link, the chain is formed. The first speech censured, the first thought forbidden, the first freedom denied, chains us all irrevocably.”
Picard goes on to point out that these words served as wisdom and warning that the first time anyone’s freedoms are trodden upon, we are all damaged.
I think of his speech a lot with debate on Conscience Rights for health care workers being played out in the public. In particular, I think of the decision by the divisional court of Ontario, and then the Ontario Court of Appeal to deny physicians conscience rights. The courts claimed they struck a “reasonable balance”. But they also went on to expressly state in their ruling that the “referral requirement does infringe on doctors’ religious freedoms.” Make no mistake about this, rights and freedoms of certain individuals are being violated by this ruling.
In the 1980s, the hot button issue driving the desire for Conscience Rights was Abortion. In 2020, the main issue is Medical Assistance in Dying (MAID). Many physicians’ groups have expressed concern about being forced to make a referral for this service, in violation of their morals and ethics. This concern has been expressed not just by physicians of faith, but by secular groups like the Canadian Society of Palliative Care Physicians.
Let me be clear about this: Neither myself, nor the Ontario Medical Association will support any physician who actively impedes or prevents a patient from accessing any legal medical service (including MAID). Period. Full Stop. This includes statements like “If you want MAID, I will no longer be your doctor.” That’s just not on.
However, for physicians who feel that actively referring a patient for such a service violates their principles, surely there can be a work around. Turns out, that’s exactly the case in Ontario. If a patient wants MAID, they simply have to contact the MAID co-ordination service and the service will ensure the patient gets the appropriate assessments. Surely handing a patient the contact information (which is not a referral) and leaving it up to the patient to contact the service (which is the patient’s right) is sufficient. Physicians’ conscience rights are protected, and no patient is denied access to a service they want.
Some argue that there will be cases where this is insufficient for various reasons. I disagree. In order to access MAID, you have to be mentally competent. If you’re not competent enough to dial a phone number and ask for this service, you’re not going to qualify anyway. Forcing a physician to do a referral (which involves putting your signature indicating you support the request on a form, setting up the appointment, informing the patient of said appointment and more) in violation of their conscience, isn’t going to alter in any way whether the patient is an appropriate candidate for MAID.
For me however, there is a bigger picture that many people may be missing. We live in an era where technological advances are rapidly occurring. These advances are not just related to computers, and possible interfaces with humans – think ports at the back of your skull to download information directly into your brain – and no, that’s not just science fiction, Elon Musk (yikes!) and Facebook (double yikes!!) are exploring this today. However, the more stunning advances, and I believe the ones with the greatest potential for ethical dilemmas, are the ones in genetics.
Look what’s already happening thanks to gene editing by CRISPR. A scientist in China has edited babies genes. Designer babies (hair, eye colour on order, muscle and IQ per your specifications) are so within the realm of possibility that the ethics are already being debated. Rapidly progressing work is being done to identify the genes (it’s not just one gene, but likely a cluster of several) that link to autism, Asperger’s and, yes even sexual orientation.
To those physicians who are opposed to legal protection for Conscience Rights, let me ask you this. What would you do if a patient asked you for a referral to have only a blue eyed, blonde haired baby?
Becomes a moral quagmire doesn’t it?
Another Star Trek Captain, James T. Kirk, once said (Nerd Alert: The Original Series Episode: “A Private Little War”):
“There came a time when our knowledge grew faster than our wisdom, and we almost destroyed ourselves.”
This is why Conscience Rights protection is so essential in society. With the explosion of knowledge that is going to continue over the next few decades, it is essential that we handle these advances in fair, ethical, and yes, moral manner. In order to do that, we must allow health care workers the same freedoms as everyone else in society on matters of conscience.
The first link in the chain has been formed. It’s time to break that link with legislation that protects everyone’s fundamental freedoms.
justanoldcountrydoctor 
Disappointing, Sohail. “In order to access MAID, you have to be mentally competent. If you’re not competent enough to dial a phone number and ask for this service, you’re not going to qualify anyway.” Several of my MAID cases have come from people who were not in a position to pick up a phone and dial on their own for lack of knowledge, physical ability, social support and for lack of a doctor who would inform them. You need to fine tune that statement.
I get what you’re trying to say about conscience rights but you can’t compare asking for MAID to asking to revisit the Nazi eugenics movement. You’re defending the wrong section of the OMA, and the wrong side of history. I don’t want to look back at my organization in twenty years and see an out of touch relic. I want to see what I see now in ST:TNG – a forward thinking, relevant, and eerily prescient leadership.
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Hey Chris – appreciate your point of view. Would however, respectfully point out that considering the fact that there are many many ethical dilemmas coming our way given the rapid expanse of genetic treatments and AI/technology is forward thinking…….
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Excellent and thoughtful article, Sohail: trying to balance Patient Access to legal treatment vs Physician Conscience Rights. As usual, these difficult discussions devolve into the extremes arguing while “reasonable accommodation” works in most situations.
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Thank you so much for this thoughtful look at why conscience rights are an imperative. We need to keep moral burnout at bay, and keep doctors at their best, so that all patients can ultimately benefit from a system that’s working as it should.
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Appreciate the kind words.
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I’m very grateful for this blog!
Especially in this day and age, conscience rights are essential, coupled with government systems and collegial behaviour on all sides to provide our patients best care and to avoid physician burnout. Thanks Dr Gandhi for standing up for Ontario doctors!
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Appreciate this.
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I thank dr Gandhi for such a principled and balanced approach on a very difficult topic. At the end of the day, we often are the last stand to voice protection for the vulnerable patient. It is important to note that he is not alone in requesting this.
Other democracies with similar legislation have it (from Government sites):
“Physician not obliged to perform euthanasia
Physicians are not obliged to grant a request for euthanasia. A physician who does not want to perform the procedure himself should discuss this with the patient and may decide to refer him to another physician.”
https://www.government.nl/topics/euthanasia/is-euthanasia-allowed (Holland)
“L’euthanasie n’est cependant pas un droit : introduire une demande d’euthanasie ne garantit pas que celle-ci soit pratiquée. Même si toutes les conditions légales sont réunies, le médecin est libre d’accepter ou de refuser de pratiquer une euthanasie. S’il refuse, il est tenu d’en informer en temps utile le patient ou la personne de confiance éventuelle en précisant les raisons de son choix. Le patient peut alors se tourner vers un autre médecin.”
https://www.health.belgium.be/en/node/22874 (Belgium)
“Section 1553 of the Affordable Care Act states that the Federal Government, and any state or local government or health care provider that receives federal financial assistance under this Act (or an amendment made by this Act) or any health plan created under this Act (or an amendment made by this Act), may not discriminate against an individual or institutional health care entity because the entity does not provide any health care item or service that causes, or assists in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.
Health care entities include:
Individual physician and other health care professionals
Hospitals
Provider-sponsored organizations
Health maintenance organizations
Health insurance plans
Any other kind of health care facility, organization, or plan”
https://www.hhs.gov/civil-rights/for-individuals/refusal-provide-assisted-suicide-services/index.html (United States- enacted under Obama)
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Thank you for those links. I will have to review them.
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These are honest and true. Thank you for sharing this perspective. Let’s see a change in Ontario so we can keep more doctors in Canada!!!
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Thank you Dr. Ghandi. Your words and position give me hope that there may be positive change.
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The need for conscience protection is eloquently articulated here. Protecting conscience is not about protecting physician’s private beliefs, but rather about ensuring that patients are treated ethically. Just because a treatment is legal doesn’t mean its ethical. Just because some people think euthanasia is ethical doesn’t mean that it actually is ethical. Protect doctors’ consciences so that patients receive the kind of ethical medical care that honours their value and intrinsic worth.
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Hey, that’s a great point of view. Thanks!
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Thank you, Sohail for this excellent comment. Really heartens me as a practicing physician to know that you are in the corner that recognizes our right to freedom of conscience, recognized as one of our fundamental freedoms in the Canadian Charter of Rights and Freedoms. You are doing the right thing.
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Thanks. Much appreciated.
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Dr. Gandhi- thank you for providing us with an insightful, thoughtful and forward-looking article that considers future ethical dilemmas, in addition to the real and present ethical question of referral for MAID. Happy and relieved to see the leader of our medical association taking a stance on conscience rights for physicians as well as balancing issues of patient access! This is in line with the most recent World Medical Association declaration on euthanasia, which re-iterates the importance of conscience protection: “No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end.”
https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide/
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Dr. Gandhi, thank you! Your stance represents a balanced perspective on the topic of effective referral for MAID by allowing for patient access while respecting the conscience rights of practicing physicians in Ontario. Well done for your efforts in sticking up for physicians in Ontario!
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Thanks for you kind words!
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Thank you so much Dr. Gandhi for this refreshing and reasonable approach to such a difficult issue.
As an Ontario medical student, I am very concerned with what I am seeing in my education so far, with multiple small group discussion sessions about MAiD often degenerating into widespread one-sided support of MAiD with disregard, and even open disdain at times, for physician conscience rights under the Canadian Charter of Rights and Freedoms from my colleagues and teachers. I often feel betrayed that I was not informed when choosing medicine as a career that I would have to leave my conscience at the door, and I worry about which type of residency to pursue in the future.
On the other hand, what you propose with a dedicated “MAID co-ordination service” is extremely reasonable and, to my knowledge, has been successfully employed in provinces other than Ontario.
However, I must ask for clarification about your statement that “that’s exactly the case in Ontario.” As far as I know, this approach has not been instituted in any official capacity in Ontario as the accepted pathway for patients to access this MAiD, and in my limited experience, this information has not been adequately communicated to the medical students or our faculty. Is there any official statement or document which outlines this explicitly which would be protective in the extreme situation of potential litigation or professional misconduct allegations? And if not, is this in the works?
Without this protection in place, it will be very difficult for me to positively endorse a medical career in Ontario to my friends, and is making me consider moving my future practise elsewhere.
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Thanks for the kind words. There is a MAID co-ordination service in Ontario, along with a 1-800 number patients can call themselves. I’ve used it in the past.
The issue around protection in an extreme situation from litigation, or misconduct allegations is a problem. Currently, I’m not aware of any fool proof method. This is one of the reasons why I feel we need legislation to protect conscience rights.
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I would be most interested in hearing directly from you. There are resources on the Protection of Conscience Project website that you may find useful: For Students , Making Notes , Complainant Worksheet
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Dr. Ghandi
Thank you so much for your well reasoned and articulated statement!
At this time many physicians are feeling compelled to ask against their conscience because of our college’s effective referral policy. Moral distress and burnout are the fallout.
With the proposed expansion of MAiD criteria many more patients will be put at risk if they become suicidal. More physicians will be sidelined as well.
Thanks again — keep up the good work!
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Thank you for your reflections and your strong support for physicians who want to first do no harm. You are protecting the integrity of medicine itself when we encourage doctors to do what they believe is right, not because others agree or not or whether they will get in trouble but because they are convinced that what they want to be part of, is in the best interests of their patients. Some people still have problems with mercy killing. Others don’t. If its legal, let the people that want to do that have freedom and those that are troubled by it have the same freedom.
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Thank you so much, Dr. Gandhi, for this well-balanced view…demonstrating that it is indeed possible to ensure patients’ autonomy is respected, but also that physicians’ conscientiously held beliefs can be, too.
As a medical student in the throes of learning immense amounts of medical information and deciding on a medical speciality, it gives me great comfort to know that our OMA President cares about this matter and is committed to ensuring that students like myself will be protected in the future. As your title so aptly states – conscience rights do matter! Keep up the good work.
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Thank you for your well-articulated and reasonable thoughts on what has become such a contentious topic, Dr. Gandhi. This post is very much appreciated! It is extremely refreshing to hear that this is the opinion held by a person in a position of leadership, such as yourself. Your support of and advocacy on behalf of physicians who wish to practice medicine according to their moral compass, provides great hope and encouragement.
Indeed, I fear the burnout that is increasingly affecting physicians who are forced to ‘leave their conscience at the door.’ Conscience is not a coat that can be hung up and forgotten about, for many it is the deeply-rooted, guiding force that led physicians to seek a career in medicine, in the first place. It is the calling that pushes Ontario physicians to go the extra mile for their patients and provide high quality, ethical patient care. Your reference to future ethical issues serves as a reminder that the current issues around conscience will not be the last issues and that the time to develop well-formulated and sound approaches to the protection of conscience in medicine, is now.
Thank you again for the work that you do and your advocacy around this issue.
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Thank you for reflecting on this important cause. It is essential to recognize our right to freedom of conscience, while also balancing the rights of our patients. As a trainee, it is very distressing to see the direction in which this is headed. Thank you for your support.
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I think your point is very reasonable. I am reminded of Martin Niemoller. You many not have a problem with the things that you are being asked to do now but with all the genetic advances it is quite possible you will have a problem with something being asked for in the future. It is ironic that we are talking about disqualifying folks to practice medicine because they chose to believe certain things in the name of promoting choice.
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I’m going to have to read up on Martin Niemoller!
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Thank you so very much for standing up for conscience rights. This is what Canada needs and you articulated the reason why it is a problem to do away with the conscience rights of doctors.
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Thank you for taking this stand and making such a clear argument for it. I am baffled by the college’s unwillingness to support all their physicians when it is clearly possible to do so. The decisions by the courts are even more difficult to understand. We clearly have biased leaders. I appreciate the glimmer of hope your blog gives me.
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Thank you Dr Ghandi for this exposition for the importance of conscience rights! If we compel physicians to act against their conscience, then we erode the very integrity of the profession and the ethical framework in which physicians should operate.
Thank you for standing up for the right of freedom to follow our conscience!
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I really enjoyed this article. It’s nice to see such open-mindedness in our leadership!
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It’s very encouraging to see such thoughtful comments coming from our OMA leader. Conscience rights must be protected. I appreciate you writing this excellent post.
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This is certainly a refreshing perspective to hear from a physician-leader. Defending conscience rights is certainly not in vogue in the current political environment, but reflecting on future ethical challenges emerging as a result of new technologies is a strong approach to the discussion. Too often, militant opponents of conscience rights see the issue as a no-brainer because their personal ethical commitments just happen to coincide with what is legal and popular, and they are unable (or unwilling) to attempt to view issues through alternative lenses. Some may feel uncomfortable reading the examples in your post – that is exactly the point, and will hopefully encourage more open-mindedness on the importance of conscientious integrity in the physician community.
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Glad you are keeping this conversation going. There are doctors leaving medicine and students not going into medicine because we lost our conscious rights. We need to keep the pressure up on the government to allow health care workers to feel their conscious matters and it can be done without limiting patient access to legal procedures.
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Thanks Sandy. That’s really the point of the blog. Patients must be allowed to access what’s legal if they choose. But that should be done without infringing on conscious rights.
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Great Job! Keep up the great work and momentum! We need conscious rights and must not lose hope!
Dr Max
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Thank you Sohail for your courageous statement. It is interesting how the same people who agressively argue for people’s “rights” to new processes such as MAID cannot abide it when the competing human rights of others (i.e. the rights of doctors who object to participating in the killing of their patients) are raised in objection. The fact is, the Charter requires a balancing of rights (of which freedom of creed and conscience is one), and the MAID hotline functions to do exactly this. It is a matter of basic human respect that we try to understand and balance the rights of all parties in this debate. Forcing doctors to refer against their consciences does nothing to balance these rights and is a totally inadequate response to the problem. Most people who are choosing MAID are doing to for purposes of finding meaning and control at the end of their life. We do a grave disservice to physicians and other health care workers to trample on their own autonomy in the process.
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Thank you Dr. Gandhi for your thoughtful post! In addition to infringing on doctors’ basic right to freedom of conscience that all Canadians are entitled to, a system that requires doctors to do things they fundamentally believe are wrong ultimately puts patients, especially the most vulnerable, at great risk of harm. This is unconscionable. Keep up the good work Dr. Gandhi!
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Well written. Thanks Dr. Gandhi!
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Dr. Gandhi, many thanks for writing this important article in support of physician right of conscience. I dully concur, and hope we can still keep pressuring our government to do what is right and provide legislation to protect us – and our nursing / pharmacist colleagues.
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Thanks Sohail. A very well written article.
I will say that I have never been personally been bothered by the need to make an “effective referral” and struggled to understand the concept that making a referral makes one complicit in the act of MAiD. My rationale: when I refer a patient to a surgeon or oncologist, there is no guarantee they will get surgery or chemo, they will simply be assessed. Surgery or chemo may be part of the plan of care. The same goes for MAiD. A referral is a request for assessment. However, that is my personal opinion and I respect the fact that beliefs, religion, culture, etc. are highly personal.
Having said that, I do believe Ontario did the right thing by creating a patient self-referral mechanism to improve access and deal with the issue of “effective referrals.”
I believe strongly that palliative care and MAiD are separate entities. Palliative care is a holistic patient-centered approach to care for patients facing a life-limiting illness, ideally from the time of diagnosis until end of life care, including bereavement support for family and caregivers. MAiD is a procedure, albeit a very permanent and irreversible one.
What I lament most is the intense focus on MAiD to the detriment of improving palliative care, imho. When Quebec legalised MAiD a few years before Canada, they included boosting palliative care funding and supports in the legislation. No such boost was provided in the federal legislation to provide provinces with funding (through directed health transfers) or address unmet palliative care needs and barriers to access through other means (HHR, public education, etc). This is not a criticism of MAiD, which may be accessed by ~5% of decedents, but a criticism of the lack of support for a holistic patient-centered approach to end of life care that can benefit 100% of Canadians, at some point in their lives.
Thanks again, good topic, well handled. Opinions are my own.
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