That might come as a shock in the year 2014, but it's almost certainly just the tip of the iceberg. A significant minority of Canadian doctors are anti-choice, most of whom probably follow the same practice when it comes to patients who request not just abortion, but contraception too. Both services are on the anti-choice blacklist as "immoral," to put it mildly.
When doctors refuse to provide these reproductive health-care services based on personal beliefs, most people call it "conscientious objection." I say it is the opposite of conscientious. It amounts to an unjustified veto of a patient's right to health care, and a negligent refusal to do the job one was hired and paid to do. It's an abuse of authority, harmful to patients, and discriminatory. It should be seen as a violation of professional obligations and medical ethics, and disciplined accordingly.
So-called "conscientious objection" (CO) in reproductive health care is a reflection of stigma against women's autonomy and sexuality, in spite of laws guaranteeing women's human rights and equality. It's like a vigilante action against the legality of abortion and contraception. The exercise of CO is widespread around the world and largely unregulated, including in Canada -- dubbed the "Wild, Wild North" in regards to its CO policies or lack of them.
The Canadian Medical Association does not even require objecting physicians to refer patients to doctors who will provide the requested service. The CMA Code of Ethics simply instructs doctors to "Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants."
The CMA Code of Ethics does have an anti-discrimination clause, however, warning physicians not to discriminate based on the usual categories (ethnicity, disability, etc.) -- as well as sex, marital status, and sexual orientation. Unfortunately, violations of the latter categories are not being redressed. Reproductive health care is largely delivered to women, so refusal rises to the level of discrimination on the basis of sex, as argued to no avail by the Ontario Commission of Human Rights back in 2008. In 2003, a doctor in Barrie, Ontario refused to prescribe birth control pills to unmarried women, thereby discriminating on the basis of both marital status and sex. Although the doctor was charged with professional misconduct, the charges were dropped and he was only required to post a letter about his discriminatory policy in his waiting room. Transgender men can also become pregnant or require contraception, so refusing them reproductive health care discriminates on the basis of sexual orientation as well as gender, yet trans* people still frequently face discrimination when accessing health care.
Contraception is essential and life-saving health care that virtually all women of child-bearing age use at some point in their lives, so doctors have no excuse to not provide it. Similarly, CO against providing abortions is based on a denial of the overwhelming evidence and historical experience that has proven the devastating harms of legal and other restrictions.
The exercise of CO is a violation of women's rights and endangers their health and lives. Globally, many health-care workers refuse to provide abortion or contraceptive services, and some will even provide misinformation or treat the patient judgmentally or disrespectfully (including in Canada), or even let a woman die rather than give her a legal abortion -- as occurred in Ireland in 2012, and in Poland in 2004.
'Conscientious objection' is dishonourable disobedience
In March 2014, the journal Woman - Psychosomatic Gynaecology and Obstetrics published a comprehensive article co-authored by myself and Dr. Christian Fiala, explaining why CO in reproductive health care is actually "Dishonourable Disobedience." Our criticism of CO uniquely delved into its underlying premises to show that it is fundamentally contradictory and unworkable. We also wrote a shorter follow-up article that criticized the acceptance of CO by secular medical and health organizations. We then responded to our critics with this piece: The CO debate: "Conscientious objection" is still dishonourable disobedience.
Here are some of our main arguments:
- Physicians have a monopoly on the practice of medicine, with patients completely reliant on them for essential health care. The medical profession fulfills a public trust, making doctors duty-bound to provide care without discrimination. CO allows health-care professionals to abuse their position of trust and authority by imposing their personal beliefs on patients.
- Doctors are in a privileged position. They chose and willingly trained for their profession, with the full understanding that it entails duties to patients and an obligation to provide safe and necessary medical care. The specialty of Obstetrics/Gynecology in particular carries with it the obligation to help women with unplanned pregnancies.
- It's not an issue of "competing rights" between doctor and patient. There is no "balance" when an authority figure is allowed to impose their beliefs on a dependent person. Women's right to life and health has no moral equivalency with doctors' supposed right to refuse them care.
- Like many other enterprises, medicine serves the public, so health-care workers have no right to deny services to women. Why should refusing to treat a woman or trans* person who needs reproductive care be accepted, when refusing to treat someone who is gay, black, or Muslim is considered discrimination?
- CO in reproductive health care does not represent true "freedom of conscience" because it has nothing in common with the military CO it was derived from. Objectors to military service must justify their stance, are often required to undergo a rigorous review process, and are punished. In contrast, health-care professionals usually face no obligation to justify their refusals, rarely face any disciplinary measures, retain their positions, and even have their objection protected by law and policy.
- The alleged parallel in terms of refraining from killing is turned upside down for CO in reproductive health care. Abortion and contraception preserve the health and lives of women, while those practicing CO put women's health and lives at risk. Denial of care inevitably creates at least some degree of harm to patients, ranging from inconvenience, humiliation, and psychological stress, to delays or inability to get care, unwanted pregnancy, increased medical risks, and death.
- Most medical professionals and health organizations support CO as long as the objecting physicians disclose their objection to patients, refer them to another provider who can deliver the service, impart accurate information on all options, and provide care in cases of emergency. However, the referral requirement is a fundamental contradiction of the principle of CO -- it tries to protect doctors' conscience up to the point where they are required to violate their conscience. Many if not most objectors will refuse to take any action that makes them feel "complicit" in abortion or contraception. Hence, such requirements are routinely abused.
A chance to change the policy on 'conscientious objection'
Besides the CMA, the other main medical bodies that oversee doctors in Canada are the provincial Colleges of Physicians and Surgeons, which have chapters in every province. Each College expects doctors to adhere to the CMA Code of Ethics, and some have their own ethics guidelines around CO, including British Columbia, Alberta, and Ontario.
The Ontario College (CPSO) recently embarked on a review process of their existing 2008 policy, Physicians and the Ontario Human Rights Code. It's possible the review was sparked by the media controversy about the three Ottawa doctors who refuse to prescribe or refer for contraception, abortion, or vasectomy. Similar to the CMA Code of Ethics, the Ontario College's policy allows doctors to object based on "moral or religious beliefs" but does not require referrals except vaguely "in some circumstances."
The anti-choice movement is quite panicked at this review process, which is hopefully a good sign. Unfortunately, scare-mongering and misinformation about the review process and the health risks of contraception are rampant. The Campaign Life Coalition is convinced that Ontario doctors are "facing the threat of being forced … to participate in procedures that violate their conscience, such as abortion" -- even though the CPSO has no control over the CMA's (outdated) policy on Induced Abortion, which says doctors "should not be compelled to participate in the termination of a pregnancy."
The worst example of hyperbolic misinformation is a blog on the website of the Campaign Life Coalition, falsely claiming that contraception is not health care, causes abortions, and is dangerous. The graphic accompanying the article shows a gun pointed at the head of a doctor -- a rather ironic choice considering the shooting rampage against abortion providers carried out by extremists in the "pro-life" movement during the 1990s. When called on it (by me), the blog author Jack Fonseca replied in the Comments: "The supporting graphic is a clear condemnation against the brute force that the CPSO is threatening to use against doctors," which he analogized to the "Nazi extermination of Jews."
Campaign Life Coalition is marshalling its supporters to make submissions to the College, which probably means it is being inundated with anti-choice letters. The deadline is August 5, so PLEASE -- go here to email the College, post a comment, or answer the online survey. Ask them to revise their policy to disallow CO in reproductive health care as a violation of human rights, and to implement enforcement measures. It's time for the misnomer of "conscientious objection" to be recognized as the dishonourable disobedience that it is.
Joyce Arthur is the founder and Executive Director of Canada's national pro-choice group, the Abortion Rights Coalition of Canada (ARCC), which protects the legal right to abortion on request and works to improve access to quality abortion services.
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