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We are writing to respond to the CMAJ editorial Physicians are not solely responsible for ensuring access to medical assistance in dying, by Dr. Diane Kelsall.
The College of Physicians and Surgeons of Ontario (CPSO) was at the forefront of policy development as the MAiD legislation was coming into force, providing much needed guidance to the profession on this important issue after consulting broadly with the public and the profession.
Dr. Kelsall has mischaracterized various aspects of the MAiD discussion, especially as it pertains to the effective referral provision of our Medical Assistance in Dying (MAiD) policy for doctors who object to MAiD on religious or other grounds, and the issue of what constitutes “complicity” when objecting doctors encounter grievously ill patients seeking help to end their lives. (Our effective referral provision is also captured, as the editorial notes, in our Professional Obligations and Human Rights policy.)
An effective referral is not synonymous with a direct referral, and there are a number of ways that objecting physicians could discharge their effective referral obligations without relying on a direct referral, as we have made quite clear in our MAiD policy’s accompanying fact sheet. Examples of these include (but are not limited to): objecting physicians can make the referral themselves or delegate the task to a staff member or colleague; the physician or a designate can connect the patient with an agency charged with facilitating referrals for the healthcare service (such as Ontario’s care coordination service for MAiD), and make arrangements for the agency to see that patient; doctors who work as part of a practice team can also establish triage systems that ensure the objecting physician would never have to see a patient seeking MAiD.
It is vitally important to also stress that an effective referral, in any clinical situation, does not guarantee a specific outcome for a patient. In order to receive MAiD, the patient must be found eligible for MAiD in accordance with criteria in the Criminal Code by two independent clinicians, must consent to MAiD, and all of the safeguards set out in the Criminal Code must be met. The chief goal of our effective referral provision is to help patients find a pathway to pursue their interest in MAiD and to get help in that regard.
It is unfortunate that Dr. Kelsall has chosen to frame the broader discussion as a “doctors vs. patients” scenario. The goal of the College’s policy is to respect patients and physicians. It seeks to ensure all patients – including the most vulnerable -- have equitable access to available healthcare services in Ontario, while respecting physicians’ beliefs and religious freedoms.
When it comes to medical encounters involving MAiD, we are not concerned simply with “the basics of physician professionalism.” Our policy is rooted in the core values of the medical profession, such as service, altruism, trustworthiness and compassion, articulated in our Practice Guide. Our effective referral provision is in place to ensure that objecting physicians do not abandon their patients, and so that even the most vulnerable members of society have equitable access to our public healthcare system. As Dr. Danielle Martin so succinctly expressed it in an affidavit quoted in the Divisional Court decision: “The need for family physicians to provide patients with information and meaningful referrals is especially important in the Canadian system because many citizens do not have other access points through which to enter the system, or are unaware of what other access points exist. … Thus, in the Canadian context, both the geographic and community-based nature of our primary care catchment makes access to care particularly dependent on the consistency of service provided by doctors.”
Doctors have a fiduciary responsibility to all of their patients no matter where they are in their life cycle, including those who are grievously and irremediably ill and wish to seek assistance in ending their lives. The CPSO was gratified that the court recognized the importance of effective referral for patients at the most challenging time of their lives.