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On conscience-based medical exemptions

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Photo: Adrian Clark/flickr

The College of Physicians and Surgeons of Ontario is currently reviewing its Human Rights Code policy on conscience-based exemptions for medical professionals, and their effect on access to medical services.

This review was sparked by a number of news reports of doctors in Ontario and Alberta refusing to prescribe birth control because of their religious beliefs. In some of those cases, patients were refused in clinics where there was only one doctor on duty.

Concurrently, south of the border, the United States Supreme Court ruled in favour of a corporation's right to deny medical insurance to its employees when doing so would violate the owners' religious beliefs -- a case that was specifically about access to contraception. The Hobby Lobby case has been followed by several new attempts to widen the exemption, and calls to extend it to other sectors and in ways that would allow businesses to refuse service to LGBT people.

These events reflect a major shift in the way that conscience rights are being seen and applied in North America.  It is my hope that the experiences of trans* people in Alberta with conscience-based medical exemptions might provide some insights for those considering a conscience policy review in Ontario.

Alberta has had a policy for some time which allows a doctor to refuse to prescribe treatments that violate their religious beliefs in non-emergency situations. However, they are required to state that the refusal is because of their religious beliefs, and to provide a timely referral for patients to someone who will provide care, so that patients still receive service and experience a minimum of undue hardship (although to be fair, having to jump through referral hoops can be considered an undue hardship itself, especially when one factors in the difficulties in scheduling time off from work and other real-life concerns). Ontario's policy is similar, though not identical.

Alberta's policy was created to protect medical professionals from having to participate in any situation that might lead to an abortion. But in the past year, there has been an upsurge of discussion about the need for a religious or conscience-based exemption in every sector and every practice. Access to birth control is one of the pivotal issues in play in that discussion, although it is not the only one.

As an advocate for transsexual and transgender people, I've needed to assist a great number of people over the years who've been denied medical services because they're trans* under Alberta's conscience exemption policy. Sometimes people have even been denied services for things like urinary tract infections, routine checkups and cases of the flu. To be fair, the conscience exemption is not the only factor: denials are sometimes made by doctors who say they've never been trained in trans* health -- although this complaint is made not only in regard to trans-specific health concerns, nor does there appear to be a willingness to learn from many of those doing the refusing.

Most often, trans* people who are refused care are also not provided a referral to anyone else. This exploits the public's unfamiliarity with this part of the law, and that they're entitled to a referral. It is certainly not every medical professional who refuses to assist, but it occurs frequently enough that the trans* community has had to try to keep a list of "trans-friendly" doctors -- a list that is constantly plagued by doctors no longer being able to accept new patients, or making changes in their practice or habits. I'm always happy to add doctors to the list, with the only requirement being that they adhere to the WPATH Standards of Care (which is also the policy of Alberta Health Services). Two years ago, someone obtained a copy of our records and stormed into the offices of several listed clinics in Calgary, raising a ruckus about doctors' willingness to treat trans* patients, and this resulted in several requests to be removed from our list.

Although commentators sometimes note theoretical possibilities like a Jehovah's Witness practitioner denying blood transfusions, I can say from experience that conscience policies already can and do result in people being denied access to the care they need... and are not always given "timely" alternatives.

I am sensitive to a person's right to opt out of something because their conscience, and not just a religious-based conscience. However, in practical experience, exemptions tend to be abused, and marginalized people pay the heaviest price. If there is to be a conscience-based exception to medical care, a province also needs to have a much better way of coordinating timely and accessible care alternatives, and better enforce the responsibility to provide those alternatives. In Alberta, this is difficult, since there is no centralized means of communicating with medical professionals and providing some forms of training after they're already in the field, short of making laws -- so strengthening things at a policy level proves difficult.

With the recent shift of thinking among the religious right toward making provinces "abortion-free" and denying access to previously uncontroversial things like birth control, this issue will worsen in coming years. If there is to be a conscience-based exemption to medical care, provinces need to seek a solution to the policy quandaries this creates now. For example, if a walk-in clinic's only physician on duty will not prescribe contraception, then it's worth investigating what responsibility the clinic should have in providing a doctor who will, and in a manner that suits the patient's needs, rather than the doctor's.

Or what responsibility the province is taking upon itself by sanctioning health-care exemptions.

Crossposted to DentedBlueMercedes

Photo: Adrian Clark/flickr

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