Should doctors have the right to refuse to treat a patient?

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Canada's largest medical regulator is reviewing its policy on physicians and the human rights code, a document that wrestles with a thorny question: When can a doctor refuse to treat a patient on religious or moral grounds?

The review by the College of Physicians and Surgeons of Ontario (CPSO) is a regularly scheduled revisiting of the policy, which was last updated amid controversy in 2008.

But the checkup also comes a few months after word spread online and in the mainstream media of a form letter distributed by three Ottawa doctors who declined to prescribe birth control because of their "religious values," a rare example of physicians openly refusing – in writing – to provide services for religious reasons.

In another case that surfaced this week, a Calgary woman posted to Facebook a picture of a sign on the door of a walk-in clinic that read: "Please be informed the physician on duty today will not prescribe the birth control pill," although the sign did not explain why.

Both incidents throw into sharp relief an issue that medicine's self-regulatory bodies across Canada have tried to deal with in the abstract through policy statements that differ around the margins, but essentially protect physicians' rights to refuse treatment for religious or moral reasons in non-emergency situations.

The college's 2008 revision originally suggested physicians would have to park their values at the door or face possible discipline, but a backlash from doctors, including the Ontario Medical Association, persuaded the college to water down its proposal.

Marc Gabel, the president of the CPSO, said it's too early to say how the policy might evolve this time.

"While the world has changed, it doesn't necessarily mean that the policy will change if it still takes care of professional responsibilities in a way that serves the public of Ontario," Dr. Gabel said.

The college has opened its website for comments about the policy until Aug. 5, after which a working group will produce a revised draft policy by late this year or early next.

So far, the call for comments has prompted a fierce online debate, much of it centred on the Ottawa letter.

A picture of the letter began ricocheting around the Internet in February, when Kate Desjardins, a married 25-year-old supermarket clerk, posted it to a feminist group's Facebook page and then recounted the incident in a post on the website xoJane.

When Ms. Desjardins visited the Ottawa walk-in clinic where she had been refilling her birth control prescription for two years, she received a letter from the receptionist that read: "Please be advised that because of reasons of my own medical judgment as well as professional ethical concerns and religious values, I only provide one form of birth control, Natural Family Planning. In addition, I do not provide for vasectomies, abortions nor do I prescribe the morning-after pill or any artificial contraception."

The letter, signed by Dr. Edmond Kyrillos, went on to say patients looking for artificial contraception could see their family doctor or ask to be seen by another physician, but Ms. Desjardins said no other doctors were on duty at the clinic that day.

"I was in total shock when I read it," she recalled by e-mail this week.

"I think it is outrageous that doctors have the right to deny things like birth control. I believe if they plan on being in a profession that helps other people, they need to leave their morals at the door," she wrote.

Rene Leiva and Agnes Tanguay, two other doctors at CareMedics, a chain of Ottawa walk-in clinics, had also been refusing to prescribe birth control.

Meghan O'Brien, a lawyer with the firm Gowlings representing the three doctors, said by e-mail that the physicians have structured their medical practices to protect the best interest of their patients without sacrificing their own beliefs. "Their right to do so is protected by the Charter, as well as consistent with CPSO policy and [Canadian Medical Association] position statements. To require physicians to 'check their beliefs at the door' is unconstitutional."

The CPSO's current policy on physicians and the human rights code advises physicians to "proceed cautiously" when refusing a service on religious or moral grounds because doctors could run afoul of the Ontario Human Rights Code.

The CPSO has a set of "expectations" it asks physicians to meet when refusing treatment, including communicating clearly and promptly about their refusal to provide certain services; explaining all clinical options based on the patient's clinical needs and concerns; behaving respectfully to patients they decline to treat; and advising potential patients that they can see another doctor.

"The College will consider the extent to which a physician has complied with this guidance, when evaluating whether the physician's behaviour constitutes professional misconduct," the policy says.