1. Conscientious Objection MONICA BRANIGAN

2. 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

3. 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% autonomy 10% justice The meaning of referral= approval and initiating the act Combs et al [1]

4. Criteria for acceptance of CO 1. 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 status Magelssen [2]

5. 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

6. 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]

7. 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]

8. 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

9. 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?

10. 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

11. 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

12. 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

13. References 1.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

14. 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