Conscientious ObjectionMONICA BRANIGAN

Hastened death: multiple ways of participating

Administer a lethal injection Provide a lethal prescription Attend a hastened death Act as a consultant as part of the approval process Provide a referral to a willing provider Provide information about accessing the service Exploring a request to hasten death

Referral: what do doctors think? Cross sectional survey of 2000 US physicians 57% agreed MD must refer for a legal service that they find morally wrong Most important value in Medicine

66 % beneficence 24% autonomy10% justice

The meaning of referral= approval and initiating the act

Combs et al [1]

Criteria for acceptance of CO1. serious damage to HCP moral integrity

2. objection plausible moral or religious rationale

3. treatment is not an essential part of the health professional work

4. burdens to patient are acceptably small

5. burdens to colleagues and institutions acceptably small

AND objection strengthened if:

1. objection is founded in Medicine’s own values

2. service is new or of uncertain moral statusMagelssen [2]

Importance of moral integrity of physicians

Trustworthiness at the heart of doctor- patient relationship Burnout, moral distress if ignored Moral integrity is a good to all persons

Reasons to accommodate CO Protect clinician’s moral integrity Respect clinician autonomy Improve quality of care at population level Identify practices in need of re-appraisal

American Thoracic Society [3]

Reasons to not accommodate CO

Professional commitment to patient autonomy and non-abandonment To protect vulnerable patients who cannot go elsewhere or make choices based on information about CO

Prevent excessive hardship on other colleagues or institutions Avoid invidious discrimination

American Thoracic Society [3]

Balance equality of access and physician conscience

An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.”

CPSO Professional Obligations and Human Rights The conversation should be about effective access Duty to refer puts whole burden on physician to find services This is the responsibility of the community-

and the team- which opens up much more options

What about institutions? Can an institution have a conscience- what about mission and values? Apply the same criteria to institutions as physicians How to balance institutional values and patient access?

Separate parallel access process Model after transplant organizations “Patient advocate” position or consultation services [4] [5] Provide

◦ Information- including palliative care◦ Counselling◦ Referrals◦ Registry of willing and trained providers◦ Assist in monitoring process for adherence etc

Importance: ◦ supports opting out institutions, professionals with conscientious

objection and under resourced areas◦ hastened death seen as distinct from palliative care

So will we have an access issue? Deaths in Ontario [6]

◦ 100,327 annual ◦ 275 daily average

Estimated hastened death 3% [7]◦ 3010 annual ◦ 8 daily

Estimated inquiries (completed deaths represent 20-40% of all inquiries) [4] [7]◦ 7525-15050 annually◦ 20-40 daily

Estimated physicians willing to be involved◦ Conservative: 25 % [4] ◦ Family physicians 65% [8]◦ # Physicians in Ontario 2014 = 28087 [9]◦ 7022 – 18257 willing physicians

Access NOT AN ISSUE with an effective system to link patients to appropriate services Potentially an issue if the burden falls to physicians to find willing providers Duty to refer is inadequate- who does one refer to? Duty of effective access to separate parallel system likely more effective, sustainable and fair

References1. Combs et al. Conscientious refusal to refer: findings from a national physician survey. J Med

Ethics 2011; 37(7): 397-410

2. M. Magelssen. When should conscientious objection be accepted? J Med Ethics 2012; 38: 18-21

3. Lewis- Newsby et al. Managing conscientious objection in intensive care medicine. American Thoracic Society. Am J Respir Crit Care Med 2015; 191 (2) : 219-227

4. Loggers et al. Implementing a Death with Dignity program at a comprehensive cancer centre. NEJM 2013; 268: 1417-1424

5. Van Wesemael et al. Establishing specialized health services for professional consultation for euthanasia. BMC Health Services Research 2009; 9:220

6. Statcan, accessed November 27, 2015

http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo07a-eng.htm

7. Steck N. Euthanasia and Assisted Suicide in Selected European Countries and US States: Systematic Literature Review. Medical Care 2013; 51: 938-944

8. College of Family Physicians of Canada e-panel #2- accessed November 27, 2015

http://www.cfpc.ca/uploadedFiles/Health_Policy/_PDFs/ePanel_psa_results_EN.pdf

9. Ontario Physician Human Resources Data Centre- accessed November 27, 2015

https://www.ophrdc.org/Public/Report.aspx?owner=pio