Physicians are not solely responsible for ensuring access to medical assistance in dying

We are writing to respond to Dr. Steven Bodley’s letter: “Just the Facts on Effective Referral.” Since beginning our medical training, we have encountered a variety of viewpoints on the subject of medical assistance in dying (MAiD). While some physicians strongly advocate for increased access to MAiD, many others are not comfortable with the thought of being implicated in, much less performing, this procedure. In our classes, we have been encouraged to make space for the multiple perspectives that exist in our diverse society. We are deeply saddened to see that this inclusivity does not extend to practicing physicians, specifically with respect to the protection of their consciences. The College of Physicians and Surgeons of Ontario’s (CPSO’s) effective referral policy for MAiD does not go far enough in protecting the religious freedom of physicians.

According to the CPSO’s policy (no.4-16) on MAiD, an effective referral is required to be made in “good faith to a non-objecting, available, and accessible physician, nurse practitioner or agency.” While Dr. Bodley insists that “an effective referral is not synonymous with a direct referral,” this does not change the fact that, regardless of the healthcare practitioner or agency to whom a physician is sending a referral, he or she is still doing exactly that. It is unfortunate that the CPSO does not acknowledge that the provision of an “indirect” referral still renders the referring physician complicit. Most, if not all, other jurisdictions in the world that have legislation on physician-assisted suicide do recognize this and do not demand an effective referral of objecting physicians. In fact, the Divisional Court of Ontario, itself, acknowledged that the policy breaches the religious freedom of physicians. All the more unfortunate is the fact that medical students training in Ontario must now seriously consider taking their skills and talents to another province or jurisdiction in which they can practice their vocation in a manner that upholds their integrity.

Clinical encounters with suicidal patients during our Psychiatry rotations have helped us to appreciate the sense of intolerable suffering with which these individuals live. We are disturbed by the notion that we may one day have to grapple with deciding which suicidal patients should be provided with suicide prevention and which should be assisted with suicide. This is particularly concerning as the legislation is currently being considered for expansion to provide access to mature minors and to patients solely with mental health concerns. However, we are rapidly learning that these experiences and concerns can lead to very inconvenient perspectives. It has been suggested by some, that those of us who hold these views, should steer clear from choosing specialties that require interaction with the elderly who may seek this service. Alternatively, we could have been prevented from entering the medical field all together. We hope that going forward, those in positions of power may be reminded that the existence of multiple viewpoints in medicine is not a liability, but simply a reflection of the diverse community of physicians in Canada – this is something to be protected, not eliminated.

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.

Dr. Kelsall's commentary on the recent Ontario court decision upholding the requirement for "effective referral" seems to mischaracterize the specifics of what the College of Physicians and Surgeons of Ontario (CPSO) requires of its members with regard to ensuring access to MAID and other contentious medical treatments. Specifically, she mentions the requirement to "refer patients requesting MAiD directly" to a non-objecting party. The CPSO has explicitly and repeatedly made clear that there is no requirement for an objecting physician to make a "direct referral" or a "formal referral." Instead, the College states that "a physician makes an effective referral when he or she takes positive action
to ensure the patient is connected in a timely manner to another physician, health care provider, or agency who is non-objecting, accessible and available to the patient." (https://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/PAD-Ef...) This could include providing contact information for the patient to self-refer to the provincial Care Coordination Service or a non-objecting physician. Alternatively, a physician can designate someone else to provide the patient with this information, or ask a colleague to take over care of the patient. This is a far cry from requiring that "the physician must ask another health care provider to consider killing their patient."

However, despite the availability of these quite reasonable alternative means of ensuring access to care, some physicians who were part of the court challenge objected even to providing _any_ information about MAID, including the information needed for a patient to make a self-referral. And, as Justice Wilton-Siegel rightly pointed out in his decision, there are often times when frail and vulnerable patients do not have the resources or abilities to self-refer, and do require the help of others to access MAID. Consider, for example, the bedbound senior in a nursing home with severe rheumatoid arthritis who cannot use a phone, let alone a computer. If his or her family, or the staff in the facility, object to facilitating the patient's access to MAID, it may indeed fall to the patient's most responsible physician to act on the request, and rightly so.

While I agree that physicians are not _solely_ responsible for ensuring access to MAID and other services that some find objectionable, they are often the last bastions of hope for those who have nowhere else to turn for assistance. Society's most vulnerable patients depend on their physicians to fulfill their fiduciary duty and respect their choices, even when those choices are difficult to accept. Physicians who, in their positions of relative authority and privilege, cannot even do the bare minimum to help their patients in this way should be prepared to face the appropriate consequences of their decisions.