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ARCC's Submissions to the Saskatchewan College of Physicians and Surgeons

By Joyce Arthur, Executive Director of Abortion Rights Coalition of Canada  

In March, June, and August of 2015, ARCC made the three following submissions to the Saskatchewan College of Physicians and Surgeons.



First Comment on "Conscientious refusal" policy

Friday, March 06, 2015 (by email)

Dear College of Physicians and Surgeons of Saskatchewan,

I’m writing on behalf of the Abortion Rights Coalition of Canada to provide feedback on your draft policy “Conscientious Refusal,” in particular to how it relates to delivery of reproductive healthcare, in particular abortion and contraception.  (Please excuse me for emailing you, but my submission is quite long.) 

Thank you for this opportunity, and congratulations on your new draft policy. There are many positive aspects to it, including the Principles under which doctors have obligations to patients, including providing patients with accurate and full health information needed to make informed choices, regardless of the physician’s moral or religious beliefs; to make a timely referral to another healthcare provider if they don’t wish to deliver care to which they object; and to provide urgent care as necessary, despite conflicts with their personal beliefs.

Summary

First, I will provide arguments against allowing any degree of conscientious objection (CO) in reproductive healthcare specifically (it should not even be allowed on condition of a referral), on the basis that such refusals do not stem from genuine freedom of conscience. They are a violation of medical ethics, an abuse of authority, and an unjust veto of a patients’ right to healthcare. They impose a doctor’s personal beliefs onto the patient, in effect giving them the “right” to discriminate. Most reproductive healthcare is delivered to women, so refusals amount to discrimination on the basis of sex, a contravention of your policy and the Saskatchewan Human Rights Code

Second, I will provide arguments against the typical compromise that requires doctors to refer appropriately, because it is contradictory, unworkable, and will be systematically ignored by many if not most objecting doctors.

Third, if the Saskatchewan College does choose to implement this new draft policy with the duty to refer, I ask the College to implement robust monitoring and enforcement measures against those who will disobey your conscientious refusal policy, including disciplinary measures and financial and legal liability for any patient harms.

The Problem of “Conscientious Objection”

Reproductive healthcare is the only field in medicine where freedom of conscience is accepted as an argument to limit a patient‘s right to a legal medical treatment. It is the only example where the otherwise accepted standard of evidence-based medicine is overruled by faith-based actions. So-called “‘conscientious objection” (CO) to contraception and abortion is a misnomer because it is actually an abuse of authority on the part of healthcare professionals who refuse to provide this care. I believe it is actually “dishonourable disobedience” to medical ethics and codes, and that it represents incompetence or negligence that should be disciplined accordingly.

Refusals by healthcare professionals to provide certain types of reproductive healthcare is a growing concern around the world. Most recently, religious organizations and secular companies in the United States have been launching lawsuits – and often winning them – to defend their “religious freedom” to not offer medical insurance to their employees that covers contraception. Around the world, CO is routinely abused and policies and regulations around it are not enforced. Not only do many healthcare workers refuse to provide abortion or contraceptive services, some also refuse to refer appropriately, or even to provide emergency care. As a result, women’s health and lives are being endangered.

As women are by far the primary recipients of contraception and abortion care, CO against those services rises to the level of gender discrimination, undermining women’s self-determination and liberty. In Canada, women are protected from discrimination by the Charter of Rights and Freedoms, the Canadian Human Rights Act, and provincial human rights codes, as well as ethical codes and policies from the Canadian Medical Association and the provincial Colleges of Physicians and Surgeons. Further, since transgender men can also become pregnant or require contraception, refusals of reproductive healthcare also discriminate on the basis of sexual orientation as well as gender. 

CO in reproductive healthcare violates the principle of public accommodation, which requires the discounting of individual conscience within a profession to prevent discrimination. In the same way that the U.S. Civil Rights Act prohibits business owners from refusing to serve black people, a healthcare provider’s right of conscience while “on the job” should be limited to prevent discrimination and protect the rights of others. In the 2001 Supreme Court decision Trinity Western University v. BC College of Teachers, the court ruled that teachers who adhere to certain religious beliefs are free to hold those beliefs, but could not act on them in the classroom if it would result in discriminatory conduct. Likewise, doctors are free to hold personal beliefs against abortion and contraception, but would be guilty of discrimination if they acted on those beliefs in their practice by imposing them onto dependent patients. 

CO in reproductive health care is actually a reflection of stigma against abortion (and contraception) and women’s autonomy and sexuality. It is like a “vigilante” action against the law and women’s rights. It is an attempt to claw back the legality of abortion and return women to their traditional roles of wife and mother, producing soldiers and citizens for the state. Such an ideology has no place in modern healthcare.

Why CO in Reproductive Healthcare Is Not Conscientious

CO amounts to a veto of a patient’s right to healthcare, and an unjustified refusal to do the job one was hired and paid to do. CO allows healthcare professionals to abuse their position of trust and authority by imposing their personal beliefs on patients. But physicians have a monopoly on the practice of medicine, with patients completely reliant on them for essential health care. The medical profession fulfills a public trust, making doctors duty-bound to provide care without discrimination. 

Freedom of conscience is a fundamental human right, but CO in reproductive healthcare does not reflect genuine freedom of conscience. It has nothing in common with the military CO it was derived from – or more accurately, falsely appropriated from by religious and right-wing groups who oppose self-determination for women. I argue it is more correct to call CO “dishonourable disobedience”. 

In western countries that protect CO for military service, objectors must justify their stance, are often required to undergo a rigorous review process, and are frequently punished. In contrast, healthcare professionals usually face no obligation to justify their refusals, rarely face any disciplinary measures, retain their positions, and even have their objection protected by law and policy. 

In a military context, CO is generally invoked by ordinary citizens drafted into compulsory service, while healthcare workers are in a privileged position. They chose and willingly trained for their profession, with the full understanding that it entails duties to patients and an obligation to provide safe and necessary medical care. The specialty of Obstetrics/Gynecology in particular carries with it the obligation to help women with unplanned pregnancies. 

The alleged parallel in terms of refraining from killing is turned upside down for CO in reproductive healthcare, because abortion and contraception preserve the health and lives of women, while those practicing CO put women’s health and lives at risk. Denial of care inevitably creates at least some degree of harm to patients, ranging from inconvenience, humiliation, and psychological stress, to delays or obstructions to care, unwanted pregnancy, increased medical risks, and even death. 

Most CO policies, including your new draft policy, represent an attempt to balance the rights of physicians with the rights of patients. But there can be no “balance” in the situation of refusals of care, because an authority figure is being allowed to impose their beliefs on a powerless person who needs the services that only the person in power can provide. It’s the patient who pays the price and bears the burden of CO in reproductive healthcare, not the healthcare provider (another reversal of military CO). Moreover, the presumption about the need to balance rights has a false premise – that a patient’s need for basic medical care is morally equivalent to protecting a healthcare provider’s personal beliefs. The idea that women’s right to life and health “competes with” or should be “balanced” with doctors’ supposed right to refuse them care trivializes the health and lives of women. It assumes that women’s human rights are negotiable and dispensable as soon as someone disagrees with them. But why should the refusal to treat a woman who needs reproductive care be accepted, when the refusal to treat someone who is gay, black, or Muslim would be considered discrimination? Like many other enterprises, medicine serves the public, which means healthcare workers have no right to refuse certain services to women.

In addition to the right to life and health, patients also have a Charter right to conscience and liberty, as well as equal protection, privacy, dignity, and other basic rights. These may all be denied in addition when a doctor vetoes their healthcare. Even if the exercise of CO was true CO (which it isn’t), the sole right of freedom to conscience cannot possibly outweigh or be balanced against this long list of fundamental human rights. 

In Canada, doctors’ incomes are paid from taxpayer dollars, which raises serious questions about whether doctors should be able to pick and choose the services they provide, or have the freedom to refuse care or deliver sub-standard care – not to mention whether medical organizations should support these dubious practices by allowing CO. 

As you mention on your website, self-regulation is a privilege granted to physicians by the Medical Profession Act. More broadly, it is a privilege granted by the public itself, and is based on public trust, which means this privilege can be revoked if abused. If we cannot trust certain physicians to fulfill their professional obligations by providing the most appropriate care that is available and legal, then those doctors do not deserve an unencumbered right to self-regulation. This should apply especially for doctors who object to providing common, medically required treatments they personally disagree with. (I’m referring to reproductive healthcare primarily; I would not include doctor-assisted euthanasia as that would be far less commonly requested and perhaps considered elective).

Referral Requirement Is Contradictory and Unrealistic

Most medical professionals and groups support what I call “limited CO,” which generally allows physicians to refuse to provide a particular medical service, but requires them to disclose their objection to patients, refer them to another provider who can deliver the service, impart accurate information on all options, and provide care in cases of emergency. An example of the consensus that supports this compromise is a special supplement called “Conscientious Objection to the Provision of Reproductive Healthcare,” published by the International Journal of Gynecology and Obstetrics (IJGO) in December 2013. 

One of the papers in this supplement was a comprehensive “white paper” by three physicians from Global Doctors for Choice. The authors present all the various laws, regulations, and policies on CO around the world, revealing a huge variation in requirements and standards and almost no enforcement against the abuse of CO. Here in Canada, Jocelyn Downie and Jacquelyn Shaw have shown the near-total lack of consistency or enforcement around CO, with their January 2014 article in Bioethics: “Welcome to the Wild, Wild North: Conscientious Objection Policies Governing Canada's Medical, Nursing, Pharmacy, and Dental Professions.” 

My co-author Dr. Christian Fiala and I describe in our major paper why limited CO is a fundamental contradiction and consequently cannot work. Attempts to regulate CO are ignored and abused worldwide because the objectives of the requirements imposed on refusers are entirely at odds with the refusers’ own objectives. The only reason healthcare workers invoke CO is to hinder their patients from a certain action, such as using contraception or having an abortion. But limited CO assumes that objecting healthcare personnel will now make the required rational compromise even though their deeply-held beliefs have already been deemed strong enough to invoke CO. 

In effect, the referral requirement is a fundamental contradiction of the principle of CO – it tries to protect doctors’ conscience up to the point where they are required to violate their conscience. Naturally, many objectors will refuse to take any action that they feel makes them “complicit” in abortion or contraception, which they strongly feel are immoral. Some objectors will even provide misinformation or treat the patient judgmentally or disrespectfully (see this Canadian study from 2003), or even let a woman die rather than give her a legal abortion (as occurred in Ireland in 2012, and in Poland in 2004). 

You have probably received many submissions from anti-abortion individuals to this effect, including doctors who say they will refuse to refer. Many in the anti-abortion movement believe that the new draft policy – and also the Ontario College’s new draft policy – will “drive pro-life doctors out of practice”, or to other provinces. This belief rests on insider knowledge that most such doctors will indeed refuse to refer or provide emergency care for services they oppose. I completely agree with this assessment, based on my almost 30 years of monitoring the anti-abortion movement. However, while it’s possible that some doctors may move or shift careers, and some may even agree to refer, I predict that most will simply flout the policy, and continue refusing to refer or provide care with which they disagree. 

Since a significant proportion of objectors, perhaps even a majority, will never agree to abide by restrictions on CO, especially those who believe that abortion is murder, limited CO is seriously inadequate to mitigate the harms of CO. Moreover, it places extra burdens on healthcare systems and non-objecting colleagues, burdens they should not have to shoulder. It is inappropriate for healthcare systems to spend resources to help employees shirk their duties, deny legitimate care to patients, transfer their workload to colleagues, and involve other staff in facilitating these violations.

The requirement to refer should be eliminated from CO regulations, not because doctors should not refer when necessary, but because it is contradictory and unworkable in the context of CO for religious or moral reasons. Instead, CO in reproductive healthcare should be generally banned. Healthcare professionals who are requested or expected to provide reproductive healthcare should be required to provide that care or accept punishment. Referrals should only be necessary if the provider is professionally unqualified to provide that care, or for other legitimate non-CO reasons. (Please see Point #7 in our rebuttal article for examples of legitimate CO by doctors.)

Importance of Monitoring and Enforcement

I fear that the CPSS does not currently have an inadequate complaints and enforcement process to handle objecting doctors. Currently, enforcement of CPSS policies relies on a complaint-driven process.  However, most patients, even when treated unjustly by doctors, are probably not going to file a complaint because of the time and hassle involved, and the loss of privacy. This is especially the case for women seeking birth control or abortion, which are felt to be very private and confidential services. Further, when a patient (or someone on their behalf) files a complaint, the doctor is informed of the particulars and learns the patient’s identity, which can jeopardize the doctor/patient relationship. What patient wants to go back to a doctor she’s filed a complaint against?  She would more likely choose to not file a complaint at all, especially given the difficulty of finding a new family doctor or Ob/Gyn. Finally, many patients are unaware they even have a right to complain, much less how to go about it.

If the CPSS goes ahead with this policy, I believe it will fail to protect patients because most objecting doctors will choose to quietly disobey the policy, and most patients won’t complain. However, it may work more effectively if the CPSS also embarks on an education program for objectors, modifies its enforcement policy, and implements additional monitoring and discipline. You would know best how to accomplish this, but may I please suggest some possible strategies? 

  1. Implement a training program on the need for reproductive healthcare services and why women request them, expose doctors to patients requesting the services, impart knowledge of the negative effects of CO on patients, and provide a clear understanding of the fiduciary duty to patients.
  2. Require all objecting doctors to register so they can be monitored. You could start building the registry based on all the doctors you already know are objectors.
  3. Require all objecting doctors to file a report (e.g., a form to complete) every time they refuse services based on their moral or religious objections, including description of the patient and encounter (no identifying info necessary), the services refused, and the referral made or action taken. Investigate any inadequate or problematic reports. 
  4. Randomly conduct regular audits on objecting doctors, whether or not they have filed any reports.
  5. Discipline those who violate the policy, and develop a more comprehensive policy around this.
  6. Make the complaint process easier – e.g., create a simpler complaint form for patients that is made prominently available in paper form at all doctor’s offices, clinics, and hospitals; is easy to complete and file; and provides the option of patient confidentiality going forward.
  7. Implement an alternate investigative procedure for complaints, which prevents the doctor from learning or discerning the complainer’s identity.
  8. Engage in public advocacy about the right to complain when doctors refuse care or referrals – eg, place your brochure in doctors’ offices, publish an op-ed, write a position paper for your website, and keep a permanent prominent link to it on your home page, etc. 
Regarding suggestions 2-4, this level of regulation of doctors may seem unreasonable given the high value placed upon doctor discretion and autonomy. However, as I mentioned earlier, physicians’ right to self-regulation is a privilege given to them by Canadians on the basis of trust. Refusals of care violate that trust, so refusing physicians should be monitored and required to justify themselves.

Conclusion

I ask the Saskatchewan College to seriously consider amending its draft policy to prohibit or strongly discourage the practice of conscientious objection for contraception and abortion. General practitioners should be required to dispense contraception if requested, and perform abortions if they have the skills and capacity or else refer appropriately. All Obstetricians/Gynecologists should be expected to dispense birth control and perform abortions as part of their practice (unless there is a legitimate medical or professional reason not to). Treating women who wish to delay or prevent childbearing is an integral and common part of the job of an Ob/Gyn.

CO in reproductive health care should be dealt with like any other negligent failure to perform one’s professional duty: through enforcement and disciplinary measures, including possible dismissal or loss of license, as well as liability for costs and any negative consequences to victims. Those who would refuse to provide or refer for abortion or contraception because of a personal or religious objection should not be allowed to enter disciplines that deliver that care, including family medicine and the Obstetrics/Gynecology specialty.

Several countries already do not allow CO at all, including Sweden, Finland, and Iceland. In Sweden last year, a midwife was denied work because the hospital jobs she applied for required her to perform abortions and she refused. Sweden’s Equality Ombudsman denied her complaint because even though her freedom of religion had been infringed upon, the public interest of having safe and accessible abortion care was deemed more important. In the United Kingdom, the Faculty of Sexual and Reproductive Healthcare (FSRH) issued a statement that FSRH Diploma Trainees must complete the full syllabus, including a willingness to prescribe all forms of hormonal contraception regardless of personal beliefs. Last March, the medical student association in Norway.

I urge the Saskatchewan College to set a progressive and landmark precedent in Canada by following in the footsteps of other countries and medical organizations that ban or oppose CO in reproductive healthcare in order to protect the rights and health of women. Alternatively, I ask you to please withstand pressure from the social conservative lobby and implement your new policy, but with new safeguards in place to ensure that objectors are identified and educated, and then monitored and disciplined appropriately as required, and that the enforcement process not depend solely on patient complaints.


Thank you.
Sincerely,

Joyce Arthur
Executive Director
Abortion Rights Coalition of Canada (ARCC)
POB 2663, Station Main
Vancouver, BC, V6B 3W3


Second Comment on "Conscientious refusal" policy

Sunday, June 14, 2015 (by email)

Dear College of Physicians and Surgeons of Saskatchewan,

I’m writing to follow up on the detailed submission I sent you on March 6 regarding your draft policy on “Conscientious Refusal” (copy below). I understand that you will be having a meeting on this topic on June 19. May I provide some input and share some concerns about the process so far?  I hope you will please share this with the committee, thank you very much in advance. 

According to this article from an anti-abortion source, the College has been intimidated by the large number of anti-abortion letters and submissions.  Although this source may well be inaccurate, please allow me to stress that the sheer number of responses you received against your draft policy should NOT factor into your decision. The anti-abortion movement is well-organized and far more motivated than those who don’t object to the policy and would therefore not even bother to write you. In fact, most of the anti-abortion letters were form letters, as it was part of an orchestrated campaign against you. 

Instead, I ask you to please consider the content and quality of the submissions, above all. My own March 6 submission details clearly all the problems with “conscientious objection,” including the primary problem you are now facing – that anti-abortion doctors will not obey your policy and will refuse to refer. That’s why my submission included a section on the importance of establishing monitoring and enforcement measures.

I’ve also read the March 20 memo from Brian Salte to the College Council regarding the recommendations on the CO policy. Please allow me to address a few issues in this memo. 

First, the ONLY possibly good point that the objectors have (including the SMA) is that implementing the policy may negatively affect the ability of the College to recruit doctors. Saskatchewan is a conservative province so I can understand this dilemma. However, the answer is not to capitulate to anti-abortion doctors who would discriminate against women of child-bearing age, but to educate all current doctors on the basic need for family planning and abortion services. In addition, the curriculum in all Canadian medical schools should be improved to teach students about this basic need, and impress upon them the importance of providing these services. 

Although the Ontario College’s policy is currently subject to a lawsuit by a Christian group of anti-abortion doctors, this suit is unlikely to succeed and should not be a barrier to the Sask. College implementing its own policy. I’ve studied the anti-choice movement for 25 years and have been party to some of their court actions, and I can assure you they do not have a firm grasp on legal realities because of their blinkered bias in favour of fetuses at the expense of women. In Canada, the anti-choice movement has ultimately lost every single abortion-related court case they’ve been involved in.  In the current Ontario case, they are overwhelmingly focused on doctors’ rights and fail to recognize patients’ rights, which is their Achilles heel. As Salte’s memo mentions, over 80% of respondents to an Ontario poll said that physicians should be required to provide a referral in cases of CO. Salte also noted that the Ontario College’s legal counsel said its policy would survive a Charter challenge. 

Salte’s memo recommends adding this sentence: “Provide whatever appropriate assistance you can to any person with an urgent need for medical care” to the current draft statement about the obligation to provide care in cases where the patient’s health may be jeopardized. But this added sentence waters down and pretty much contradicts the draft statement. It gives leeway to any anti-abortion doctor to refuse services because they will have their own idea of what “appropriate” assistance is – which can easily mean none at all!  And the new added statement may allow them to get away with it. Please do not underestimate the misguided beliefs and intentions of anti-abortion doctors, which do NOT align with evidence-based medicine or patient-directed care. 

Next, the memo recommends that the policy be amended to state that the provider only needs to refer to another provider who can provide “balanced and appropriate information.”  This is very wrong, for several reasons. First, it would allow anti-abortion doctors to refer patients to anti-choice “counselling” agencies, staffed by religious fundamentalist volunteers who urge women not to have abortions and who provide scare-mongering misinformation. Unfortunately, many anti-abortion doctors would consider that “balanced and appropriate”.  Second, patients have no duty to run around to two or three or more healthcare providers just to access basic routine services. The policy would allow a potentially endless series of referrals to providers who can’t actually help the patient!  This delays important care, and inconveniences and humiliates the patient.  Third, such running around is often impossible for people who are low-income or who are living dysfunctional or chaotic lives. So not only does it delay care, it puts it out of reach for some people. Any policy that ends up discriminating against disadvantaged people is a very bad policy – especially when done in order to privilege doctors’ power over them.

In the case of abortion in particular, there is no need for any obfuscation or vagueness in the case of referrals. To my knowledge, there are only four places to refer women to in Saskatchewan – the two hospitals in Regina and Saskatoon that perform abortions, and the two centres that help women with unbiased info and referrals: Planned Parenthood Regina and the Sexual Health Centre in Saskatoon. Doctors should be informed about those 4 specific places and be required to refer to them for abortion care, or directly to a doctor who provides abortions. I recommend that the Sask College please issue a memo or bulletin regarding this to inform both doctors and women, and also warn doctors against referring to “pregnancy care centres” run by anti-abortion groups. 

In summary, I recommend that you return to the gist of your original policy, and reject all suggested changes that would continue to privilege doctors’ personal beliefs over patients’ rights. 

Thank you very much for your consideration,

Regards,

Joyce Arthur
Executive Director
Abortion Rights Coalition of Canada (ARCC)
POB 2663, Station Main
Vancouver, BC, V6B 3W3


Third Comment on "Conscientious refusal" policy

Friday, August 07, 2015 (by email)

Dear College of Physicians and Surgeons of Saskatchewan,

May I please submit the following comment regarding your draft policy on “Conscientious Refusal.” I also made a detailed submission (by email) on March 6, and a follow-up submission on June 14 in response to your newly revised policy.  I stand by everything in these submissions, which are even more relevant to your current draft. 

In some respects, your new draft policy is an improvement on the original one, for example, by the inclusion of a list of principles relating to the physician-patient relationship (under 1. Purpose).  Under section 4. Principles, I see you’ve added several related to physicians’ freedom of conscience. This is where some problematic aspects of your revised policy come into play:

“Physicians’ exercise of freedom of conscience to limit the health services that they provide should:
-        not impede, either directly or indirectly, access to legally permissible and publicly-funded health services.
-        be done in a manner that respects patient dignity, facilitates access to care, and protects patient safety.” 

Although you recognize that these “obligations and freedoms can come into conflict”, and your policy is a valiant attempt to mitigate that conflict, unfortunately the policy does not do so. The policy itself will fail in practice because it rests on several fundamental errors or contradictions. 

First, it is a contradiction in terms to ensure patients’ access to services, while allowing physicians to exercise their “freedom of conscience” to limit those services.  That is, you cannot pretend that any doctor can respect patients’ right to prompt access to quality healthcare by allowing them to refuse prompt access to quality healthcare. ANY degree of refusal harms patients. For example, even a timely referral to an accessible doctor who can provide the services will inconvenience the patient at the very least. But since you no longer even require a timely referral, the harms caused may be even more severe, such as humiliation and loss of dignity, delays to care, and increased medical risks. 

Second, “conscientious objection” (CO) in healthcare is not genuine CO. It is more aptly called “dishonourable disobediencebecause CO is an unjust refusal of care, a violation of patients’ rights and medical ethics, and an abuse of authority. The exercise of CO imposes a doctor’s personal beliefs onto the patient, in effect giving them the “right” to discriminate. By mistakenly accepting this refusal of care as if it was genuine CO, the Sask. College is setting up its policy for failure. The term “conscientious objection” is a misnomer – it was introduced into healthcare by the Catholic Church and other religious groups to provide a legitimate-sounding excuse for anti-abortion doctors to flout laws and policies by refusing to provide contraception and legal abortion to women.  The paper on “dishonourable disobedience” linked above was written by myself and Dr. Christian Fiala, and also describes how CO in reproductive healthcare is a wolf in sheep’s clothing because it has nothing in common with the military CO from which it was supposedly derived. 

Third, the policy tries to protect patient rights by compromising the physician’s “right” of CO.  That exposes a fatal contradiction – you are illogically trying to respect doctors’ freedom of conscience up to the point where you require them to violate it. This will fail because many or most objecting doctors will refuse to violate their conscience in any way. Your policy will also fail because it’s an attempt to harmonize “faith-based” care with evidence-based medical practice. The two are entirely incompatible. Further, once religious belief is allowed to dictate medical decisions, it’s impossible to draw the line and stop the expansion of refusals, or even police the ones that are happening. 

The key changes to your draft policy illustrate the errors and contradictions above:

1. Under 5.2 (Providing information to patients), you state that physicians must provide their patients with “full and balanced health information…” etc. “…even if the provision of such information conflicts with the physician’s deeply held and considered moral or religious beliefs,” but that physicians can meet this obligation by referring the patient to someone who can provide this information. 

2. Under 5.3 (Providing or arranging access to health services), you state that objecting physicians must “make an arrangement” for the patient to obtain the required health services by “arranging for the patient to meet with another physician or other health care provider who is available and accessible and who can either provide the health service or refer that patient to another physician or health care provider who can provide the health service.”

Both changes mean that instead of providing the information themselves, or making a timely referral to someone who can provide the required treatment, doctors must at least refer the patient to someone who can refer them to someone (who in turn can refer them to someone) who can provide the info or services. As mentioned in my June 14 submission, patients have no duty to run around to two or three or more healthcare providers just to access basic information or services. The revised policy would still allow a potentially endless series of referrals to providers who can’t actually help the patient, thereby delaying important care, inconveniencing and disrespecting the patient, and possibly precluding care entirely for disadvantaged people who can’t manage all that running around.  Finally, whether at one arm’s length or two (or three), ANY referral that might lead to a patient getting an abortion would be anathema to many anti-abortion doctors.

Indeed, many objecting doctors will NOT honour the revised policy any more than they would the original policy. The following is from the right-wing news site, LifeSiteNews, July 31: 

“Larry Worthen, lawyer and Executive Director of the Christian Medical and Dental Society of Canada, told LifeSiteNews that a number of doctors simply don’t want to take part in procedures or practices they consider to be harmful and unethical.  ‘Essentially, the physicians we represent don't want to do anything that is going to make them facilitators of procedures that they consider to be harmful to the patient. The idea of actually ‘making arrangements’ is kind of another way of explaining what ‘referral’ actually is. Because when you refer someone, you are basically connecting the patient with a physician who will actually do the procedure that you cannot do for ethical reasons.’ ”

Therefore, trying to put the referral at arm’s length is a futile attempt to appease the unappeasable. Even if a few more doctors would come on board with the policy by agreeing to refer patients to a “middleman,” the main accomplishment of that change would be to further jeopardize and delay patients’ access to healthcare. 

Therefore, I urge the Saskatchewan College to rewrite its policy to completely prohibit CO. Failing that, could you please return to your original policy requiring doctors to make a timely referral to another physician who can provide the service. In the latter case, robust monitoring and enforcement measures are essential to prepare for the many doctors who will disobey your conscientious refusal policy. These measures should include disciplinary measures and financial and legal liability for any patient harms. My March 6 submission to the College contained a comprehensive list of suggested strategies for monitoring and enforcement, as well as possible disciplinary measures, and strategies to reduce the impact and number of objectors in reproductive healthcare over time. 

Thank you very much for your consideration.

Joyce Arthur
Executive Director
Abortion Rights Coalition of Canada (ARCC)
POB 2663, Station Main
Vancouver, BC, V6B 3W3