Obligations for Services for Patients

Professional Standards Regarding Obligations for Services for Patients

Preamble

Physicians have the right to limit the health services they provide for legitimate reasons of conscience, religion, or scope of practice. When exercising this right, physicians must not discriminate against patients. The rights of patients are paramount, and their interests must prevail.

This document provides instruction to physicians on how to meet their obligations to patients when limiting services to patients for reasons of conscience, religion, or scope of practice.

Professional Standards

General Expectations

Physicians must:

act in their patients’ best interests. In doing so, physicians must strive to create and foster an environment in which the rights, autonomy, dignity, and diversity of all patients, or those seeking to become patients, are respected.

Human Rights, Discrimination, and Access to Care

Physicians must:

comply with the Nova Scotia Human Rights Act and the expectations of the College, when making any decision relating to the provision of health services. This means that physicians must not discriminate, either directly or indirectly, based on a protected ground under the Human Rights Act when, for example:

accepting or refusing individuals as patients;
providing existing patients with health care or services;
providing information or referrals to existing patients or those seeking to become patients; and/or
ending the physician-patient relationship

The Duty to Accommodate

Physicians must:

take reasonable steps to accommodate the needs of existing patients, or those seeking to become patients, where a disability or other personal circumstance may impede or limit their access to care. The purpose in doing so is to eliminate or reduce any barriers or obstacles that patients may experience.
make accommodations in a manner that is respectful of the dignity, autonomy and privacy of the person, unless the accommodation would:

subject the physician to the undue hardship or;
significantly interfere with the legal rights of others.

c. make reasonable efforts to ensure patients receive care in their preferred language.

Interpretation and Language Services

Nova Scotia Health

IWK

Limiting Health Services for Legitimate Reasons

The duty to refrain from discrimination does not prevent physicians from limiting the health services they provide for legitimate reasons (for instance, because the care is outside their clinical competence or contrary to their conscience or religious beliefs).

Physicians must:

when limiting health services they provide for legitimate reasons, do so in a manner that respects patient dignity and autonomy, upholds their professional duties to the patient, and does not impede equitable access to care for existing patients, or those seeking to become patients.

Clinical Competence

The duty to refrain from discrimination does not prevent physicians from making decisions in the course of practicing medicine that are related to their own clinical competence. The College expects physicians will always practice in their own knowledge, skill and judgment.

Physicians must:

provide patients with quality health care in a safe manner. If physicians feel they cannot appropriately meet the healthcare needs of an existing patient, or those who wish to become patients, they are not required to provide that specific health service or to accept that person as a patient. However, physicians must:

comply with the Human Rights Act, and College expectations, in so doing; and
make any decision to limit the provision of health services on the basis of clinical competence in good faith.

b. inform patients as soon as reasonable where clinical competence may restrict the type of services or treatments provided, or the type of patients a physician is able to accept. Physicians must:

communicate this information in a clear and straightforward manner to ensure that individuals or patients understand that their decision is based on an actual lack of clinical competence rather than discriminatory bias or prejudice, which will lessen the likelihood of misunderstandings; and
provide a referral to another appropriate healthcare provider for the elements of care the physician is unable to manage directly. In doing so, protect patients’ best interests and ensure that existing patients (or those seeking to become patients) are not abandoned.

Conscience or Religious Beliefs

The College recognizes that physicians have the right to limit the health services they provide for legitimate reasons of conscience or religion.

Physicians must:

when choosing to limit the health services they provide for reasons of conscience or religion, do so in a manner that respects patient dignity, ensures access to care, and protects patient safety;
communicate their objection directly and with sensitivity to existing patients, or those seeking to become patients, and inform them that the objection is due to personal and not clinical reasons;
in communicating their objections, not express personal moral judgments about the beliefs, lifestyle, identity, or characteristics of existing patients, or those seeking to become patients. This includes not refusing or delaying treatment because the physician believes the patient’s own actions have contributed to their condition;
not promote their own religious beliefs when interacting with patients, or those seeking to become patients, nor attempt to convert them;
provide information about all clinical options that may be available or appropriate to meet patients’ clinical needs or concerns;
not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs;
provide the patient with an effective referral;
not impede access to care for existing patients, or those seeking to become patients;
proactively maintain an effective referral plan for the frequently requested services they are unwilling to provide; and
provide care in an emergency, where it is necessary to prevent imminent harm, even where that care conflicts with their conscience or religious beliefs.

Definitions

Discrimination is an act, decision, or communication that results in the unfair treatment of a person or group by either imposing a burden on them, or denying them a right, privilege, benefit or opportunity enjoyed by others. Discrimination may be direct and intentional; it may also be entirely unintentional, where rules, practices or procedures appear neutral but have the effect of disadvantaging certain groups of people.

Effective referral is taking positive action to ensure the patient is connected to a non-objecting, available, and accessible physician, other healthcare professional, or agency.

Freedom of Conscience: The concept of freedom of conscience and religion is rooted in the Canadian Charter of Rights and Freedoms. This concept is open to court interpretation in the context of a particular factual situation, so it does not lend itself to a static definition. Physicians who are uncertain whether their reason for limiting health services is properly based on this Charter right should obtain legal advice to understand the most recent court rulings on the point. At the time of creating this Standard, the case of Christian Medical and Dental Society of Canada v College of Physicians and Surgeons of Ontario provides relevant guidance.

Resources

Canadian Medical Association

Code of Ethics and Professionalism

College of Physicians and Surgeons of Nova Scotia

Canadian Medical Protective Association

Nova Scotia Human Rights Act 2007 (Sections 4 and 5)

Acknowledgements

The College has incorporated excerpts from the College of Physicians and Surgeons of Ontario’s Professional Obligations and Human Rights in the development of this standard.

Document History

First approved by the Council of the College of Physicians and Surgeons of Nova Scotia: May 27, 2022

Date of next review: 2025