Must Doctors Refer for Services They Oppose?

Ontario’s highest court has ruled that doctors there must provide referrals to patients for services they oppose on moral or religious grounds.

Recently the Ontario Court of Appeal upheld a lower court judgment requiring doctors to comply with the “effective referral requirement” of the province’s College of Physicians and Surgeons. An effective referral requires the doctor to make an effort to connect their patient with another willing, available, and accessible health care provider if they oppose the treatment or service the patient seeks. They are not required to make a formal referral by providing a letter and arranging an appointment with another physician, except in an emergency where it is necessary to prevent imminent harm to a patient. Rather, the physician can ask staff to handle the referral. Alternatively, the court suggested that physicians could choose to specialize in a type of medicine where the issue of referrals for treatments they oppose is less frequent.

The intent of the College’s effective referral policy is to ensure that patients are not left to find a willing physician on their own without any assistance from the physician from whom they first sought care. A group of individual physicians and organizations argued that the policy infringes on their freedom of religion and challenged its constitutionality. They believe that the effective referral requirements would make them complicit in performing the procedures that they oppose.

The medical procedures objected to include abortion, contraception, infertility treatment, prescription of erectile dysfunction medication, gender re-assignment surgery, and medical assistance in dying. As noted by the court, these are often the most private, emotional, and challenging issues for patients to raise and discuss, even with a trusted family physician. As well, some of these decisions frequently confront already vulnerable patients:  those with financial, social, educational or emotional challenges; those who are young, old, poor, or addicted to drugs; those with mental health challenges or physical or mental disabilities; those facing economic, linguistic, cultural or geographic barriers; and those who do not have the skills, abilities, or resources to navigate their way through a complicated health care system. Family physicians fulfill the important role as “gatekeepers” and “patient navigators” for health care services. Further, decisions concerning many of these procedures are time-sensitive. A delay in accessing these procedures due to the absence of a referral can prevent access to them altogether.

The court stated that the effective referral policy is a compromise between rights of physicians and interests of patients, but ultimately found that patients should not bear the consequences of physicians’ religious objections. The nature of the physician-patient relationship requires physicians to act at all times in the best interests of their patients and to avoid conflicts between their own interests and their patients’ interests. The court found that the “general information” model proposed by the doctors opposing the policy (in which doctors would provide information or resources, but the patient would assume the responsibility for finding a non-objecting physician) would not meet the needs of most patients seeking personal and urgent medical advice and care, as few procedures can be accessed without a referral from a physician. In smaller, non-urban settings, patients may have additional difficulty in identifying a non-objecting physician given the more limited range of providers.

The court noted that while the effective referral policy of the Ontario College is not a perfect one for all physicians, it is not a perfect one for their patients either: they will lose the personal support of their physicians at a time when they are most vulnerable. The court found, however, that the College’s policy represented the best compromise possible between both sides with the goal of promoting equitable access to health care.

The British Columbia College of Physicians and Surgeons agrees that patient well-being is the single most important factor in ensuring an effective referral consultation process. The BC College, however, does not go as far as Ontario in requiring an effective referral. While physicians may make a personal choice not to provide a treatment or procedure based on their values and beliefs, the BC College only expects them to provide patients with enough information and assistance to allow them to make informed choices for themselves. This includes advising patients that other physicians may be able to see them, or suggesting that the patient visit an alternate health care provider. Where needed, physicians must offer assistance and must not abandon the patient, and must always treat the patient with dignity and respect. The College states that physicians in these situations should not discuss in detail their personal beliefs if not directly relevant and should not pressure patients to disclose or justify their own beliefs. In all cases, physicians must practice within the confines of the legal system and provide compassionate, non-judgmental care. Physicians are not obliged to see all patients, but they are required to treat those in need of emergent or urgent medical care.

*image courtesy of University Health News – universityhealthnews.com