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Should provinces permit medical professionals to refuse to provide controversial services? Think of some of the biggest hot-button, controversial issues in medicine today. How does a doctor respond to a request for an abortion or for various forms of contraception? Can a Christian hospital refuse to provide euthanasia? Or think of medical transitioning. What can a doctor do if a male patient says they want to ‘transition’ to become a woman?  Is it ok if the doctor only needs to refer the patient to another doctor who will provide the service?

Many of the conversations around conscientious objection have been around the issue of euthanasia and assisted suicide, ever since it was legalized in 2016. The conversation also extends to whether certain facilities can refuse to provide euthanasia. However, provincial conscience policies typically apply to any legally available medical procedure.  A few recent developments highlight some of the problems with how our healthcare system treats conscientious objection.

New Policy in Nova Scotia 

At the end of May, the College of Physicians and Surgeons of Nova Scotia released a new document regarding conscientious objection. The policy leaves no ambiguity about what services physicians must effectively refer for. At the outset of the College’s “Professional Standards Regarding Conscientious Objection,” the College clarifies that it applies to, but is not limited to, “Medical Assistance in Dying (MAiD), immunization, reproductive care and gender affirming care.”

Proponents of the policy will be quick to say that no medical professional is required to participate in providing a service they object to. Yet, the policy requires physicians to provide information (even if it conflicts with their conscience) and to facilitate a procedure by providing an effective referral. An effective referral is defined as “a referral made in good faith to a non-objecting, available, and accessible physician, healthcare professional, or agency or service that oversees the delivery of the care being sought.”

So, the physician must ensure that the patient is connected with a non-objecting physician or service, thereby placing the patient on the path towards receiving a service that the physician objects to. Many doctors believe they are complicit if they provide an effective referral. Although they are not directly providing the procedure, they are still required to facilitate it.

Currently, only Nova Scotia and Ontario directly require effective referral. But there is increasing pressure for other provinces to implement similar policies. Health Canada’s Model Practice Standard for MAiD recommends that all provinces implement effective referral policies, at least for euthanasia. The College of Physicians and Surgeons of Alberta tried to do this recently, but received enough pushback that they did not end up incorporating such language.

Some of the negative consequences of Nova Scotia’s new policy are already clear. Not only is it wrong to force doctors to violate their conscience, but doctors are ready to leave the province as a result. When the College was considering this new policy, CTV News Atlantic reported that at least 24 physicians in Nova Scotia indicated that they cannot follow the policy and may need to leave the province or retire early. Likely, there are more. As of June 2024, there were over 160,000 Nova Scotians on a wait list for a family doctor in the province. Losing more doctors will exacerbate Nova Scotia’s healthcare shortage.

MAiD-Free Health Care

In two other provinces, conscience protection in faith-based institutions continues to be targeted. In 2023, the National Assembly of Quebec passed a law which stated that no palliative care hospice may refuse to provide euthanasia. The Archbishop of Montreal, who leases property to a Catholic-supported hospice in Montreal, has launched a legal challenge against the law in Quebec. A Court decision responding to an exemption request stated that the public interest in ensuring access to euthanasia is of fundamental importance.  You can read more about that case here.

Meanwhile, in British Columbia, St. Paul’s Hospital also does not provide euthanasia. The hospital is operated by Providence Health, a Catholic organization that refuses to provide euthanasia in any of its 18 facilities. After public uproar when a woman was forced to transfer hospitals before she could be euthanized, the provincial government agreed with Providence Health to create a separate clinical space next to the hospital where patients would be able to access euthanasia.

Such a compromise was not enough for some patients. One woman was diagnosed with stage 4 cancer in 2023. Upon receiving that diagnosis, she wanted to die by euthanasia, but was being treated at St. Paul’s Hospital in Vancouver. She was heavily sedated to be transferred to another facility and died hours later. Her mother, along with a palliative care doctor who quit over Providence Health’s policy to not allow MAiD in its facilities, has launched a lawsuit against the province of British Columbia and Providence Health Care, alleging that the “forced transfer” caused “egregious physical and psychological suffering, and denied her a dignified death.”

In addition to the obvious concerns about forcing conscientious objectors to provide euthanasia, there are many patients who want health care that does not include euthanasia. This is, of course, true of those for whom euthanasia is immoral. But it is also true of those that may support euthanasia in principle, but do not want it for themselves.

Some disability advocates, for example, worry about ableism in health care and the idea that you are “better dead than disabled.” They worry about whether MAiD will be provided against their wishes or in a moment of weakness. They want care that never includes the killing of people with disabilities. Such advocates speak of safe spaces, or MAiD-free health care, where patients do not have to fear being euthanized.

Conscience protection more necessary than ever

Euthanasia has become entrenched in our society. It is increasingly seen as a right. It’s not simply something that is legal as a last resort, nor is it even one option among many that patients may choose. Rather, it is seen by some as an obligation that doctors must provide in order to avoid patient suffering. Meanwhile, palliative care as a means of relieving suffering is seen as less important.

Canadians must continue advocating for freedom of conscience in healthcare, not just for doctors but also for patients. Stay tuned for further developments and action items as they arise.