Opinion

Why Can Canadian Doctors Still Deny Access To Abortion—And Other Healthcare?

The practice of conscientious objection means doctors can refuse or deflect requests for a variety of services, including abortion—and in many provinces, they're not even obligated to provide a referral.

A vector silhouette illustration of a doctor reviewing a patient's symptoms with her.

(Image: iStock)

Chantal had already performed all the mental gymnastics.

About eight years ago, the then-23-year-old woman from southern Alberta had accidentally become pregnant, and weighed her options. She settled on having an abortion, the best choice for her in that moment of her life. She booked an appointment with her doctor, one of only a small handful in her community, to request a referral—a requirement in Alberta then. When the time came to meet, she sat in his office and laid her cards out.

“I’m not in a time, or a place… this is not… I can’t be pregnant,” she recalls telling him, becoming flustered in her retelling. This was before Mifegymiso—“the abortion pill”—became available in Canada in 2017. Like many women, Chantal turned to her primary care provider for guidance, in hopes he would refer her to local resources or, at least give her information on how to get an abortion out of town.

She needed her doctor’s help. Instead, she says, he told her to “mull it over, talk to your family, talk to this and talk to that.” She insisted. Finally, he jotted down a phone number on a piece of paper and slid it across the desk. “Well, you’re going to have to contact these people and figure it out,” she remembers him saying. Then he dismissed her, without any help for the bloodwork and ultrasound then required to get an abortion. When she dialed, she discovered the number was for an abortion clinic.

This is how many Canadians seeking abortions or birth control experience conscientious objection from healthcare providers. Most often, the objection isn’t a declarative statement of religious or moral beliefs, but deflections, shaming and attempts to change patients’ minds. At its core, it’s a refusal to perform medical services, which can range from medical aid in dying (MAiD), to gender affirmation procedures, to abortion.

One in three Canadian women will have an abortion in her lifetime. A February 2020 poll by Dart and Maru/Blue reported that nearly two-thirds of Canadians are actively pro-choice, and 71 percent believe a person should be able to get an abortion for any reason. But for an overwhelmingly pro-choice society, we are terribly complacent about protecting abortion rights, says Joyce Arthur, executive director of the Abortion Rights Coalition of Canada (ARCC). She says our ambivalence about conscientious objection in particular empowers anti-abortion groups to lobby for backdoor bans, whether past attempts at harsher punishments for killing pregnant women; to Alberta MP Cathay Wagantall’s recent private member’s bill to ban sex-selective abortions; to ongoing efforts to defund abortions in Canada, or as part of Canada’s international humanitarian aid.

We may soon have to decide how far we want medical objections to go. Conscientious objection is being legitmized on a larger scale because of MAiD—a procedure that, among provincial medical colleges, shares the same blanket set of rules as abortion. Canadian society is far more polarized on provisions around MAiD than on the right to abortion, and those attitudes could trigger the expansion of conscientious objection. To abortion advocates, this seems like another convenient, no-punishment escape hatch for doctors who don’t want to prescribe Mifegymiso for medical abortion or provide referrals for abortion care.

The MAiD dilemma enters the fray at a time when, despite widespread practice and support, abortion still remains on the fringes of social and political acceptability. Experts say it’s another hit—along with administrative and political inertia, vast geographic areas without adequate reproductive health care and a serious lack of abortion training at medical schools—that endangers women’s reproductive freedom.

Together, all these factors coalesce into a health crisis only half the population has to reckon with.

“Conscientious objection” was coined as a refusal to perform compulsory military service because of one’s religious or moral convictions. In the 1960s, Muhammad Ali famously objected to being drafted into the U.S. Army during the Vietnam War, telling reporters, “My conscience won’t let me go shoot my brother, or some darker people, or some poor hungry people in the mud for big powerful America.”

It was later that decade, against the backdrop of the sexual revolution and the dawning of the women’s liberation movement, that the idea of a “conscientious objector” made its medical debut in the U.K.’s 1967 Abortion Act, which gave practitioners the ability to decline an abortion. It has popped up in laws and medical college guidelines throughout the world since. (Some pro-choicers contend that anti-choice factions benefit from the term’s noble connections to wartime pacifism, and instead prefer the term “dishonourable disobedience,” but this article will use “conscientious objection” as it’s an internationally recognized term.)

Under current legislation and college rules, Canadian doctors can use conscientious objection to avoid participating in abortion, birth control, hormone therapy and gender affirmation surgery for transgender patients, and other treatments and procedures. That includes MAiD. In fact, many provinces’ medical colleges only drew up conscientious objection rules in reaction to MAiD, which became legal in 2016. Yet these rules often apply to a variety of other medical procedures, leading to MAiD objection being used as a shield to modify abortion objection.

It’s not known how often conscientious objection in Canada is used to block abortion: There is no registry of doctors who refuse to help patients who want abortions, and no documented process in place for tracking or reporting objections. Numbers rely on patients filing official complaints to medical colleges against doctors—figures that Arthur of ARCC says are skewed by an intimidating process with inherent power imbalances. In Ontario, for instance, a complaint triggers an investigation or mediation process in which the doctor can respond. Many patients may assume the doctor will “win” anyway, and wonder if it’s worth their time and trauma.

“Even in the few cases where patients have complained about conscientious objection-related things, the doctor usually gets off or just gets a slap on the wrist and just has to do something really minor, like post a notice in [their] waiting room,” says Arthur.

Arthur contends that Canadian medical colleges’ positions on conscientious objection lack guts. Every province except Ontario, as well as the Canadian Medical Association, allows conscientious objection without a referral. The College of Physicians and Surgeons of Ontario (CPSO), for its part, requires an “effective” referral to a “non-objecting, available and accessible” provider. But the system has gaping loopholes, says Arthur. “There’s no enforcement, no requirements, no monitoring—nothing, just this sort of expectation on the honour system, basically,” says Arthur.

In fact, the CPSO essentially admitted to having a toothless policy in 2017, when it was sued by two religious medical societies that objected to having to make effective referrals for MAiD. In court, the College argued that the lack of a “specific penalty” for failing to effectively refer meant the burden on physicians was “trivial or insubstantial.”

In Chantal’s case, her doctor in southern Alberta was the only one available to her (and five years later, he also refused to prescribe her an IUD). The only reason she was able to get her abortion was because she had the means and the method to get to Calgary, two-and-a-half hours away.

Her case highlights the great divide in Canadian reproductive healthcare: Women with money who live in or near cities will almost always have better access to abortion, as well as birth control and the morning-after pill, says Frédérique Chabot, the director of health promotion at Action Canada For Sexual Health and Rights. Low-income women, immigrants and undocumented people, non-English or French speakers, those living on reserves or in rural or remote areas, and trans people have the biggest barriers to reproductive healthcare and suffer the most in consequence.

“There are ramifications to blocking access to sexual health services, and they are not felt equally,” says Chabot. The effects on personal and public health can be devastating, she continues. Patients would be hard-pressed to find someone willing to do an abortion after the Canadian Medical Association’s defined maximum of 20 weeks. In fact, nine of the 13 provinces and territories don’t even permit surgical abortions after 16 weeks, while Mifegymiso’s clock runs out at nine weeks. American research, though, found that most women don’t realize they are pregnant until they’re at least five and a half weeks along.

“It’s so often the case that we speak to people who knew they were pregnant from early on wanted an abortion, but had to save up money for so long that…they have to change province by the time they have enough money to travel [because] they’re out of the gestational time available in their region,” Chabot says.

Barriers due to inequity are compounded when a doctor citing conscientious objection deflects, shames or attempts to change patients’ minds. Others intentionally lose patients in bureaucratic runarounds and ineffective referrals.

“In some cases, I’ve seen people who were in extremely early pregnancy, and would have totally been eligible for any form of abortion—through medication or aspiration—and were told that they were beyond the [provider limit] when they weren’t even close,” says Dr. Mei-ling Wiedmeyer, a family planning provider in Vancouver. “It’s not just the formal kind of, ‘I don’t believe in this, so we’re not going to talk about it. It’s actually misdirection or misinformation provided.”

This issue likely won’t be solved by medical schools. Six years ago, Chatelaine reported on how woefully little training medical students get in abortion—one student reported 35 minutes of theoretical training across her entire degree—and not much seems to have changed. Even the arrival of Mifegymiso, which was heralded as a new training opportunity, has fallen flat. Interesting cross-Canada research published in the medical journal Pilot and Feasibility Studies in 2019 indicated that Canadian physicians resisted the mandatory training required to prescribe the drug, especially because there was a lack of remuneration (a.k.a. specific billing codes that doctors use to receive payment for their services) for providing it.

Registered nurse Martha Paynter believes many doctors and nurses end up objecting because they don’t feel competent in performing, and sometimes even discussing, abortion. So, in fall 2020, she launched a first-of-its-kind abortion course at Dalhousie University designed to empower students in medicine, nursing and social work to handle abortion conversations themselves. “One of the issues with abortion education is that there isn’t necessarily the willingness to do this work. It’s just traditionally excluded from most of the health professional programs, and that exclusion is out of sync with the reality of the acceptability of abortion in Canada,” says Paynter, adding that sex education in general is also “not a routinized part of health professional education.”

Paynter’s class is an exception right now, though Medical Students for Choice, which lobbies for expanded education on reproductive health care including abortion, now has chapters in every Canadian medical school. The Association of Faculties of Medicine of Canada did not respond to a request for more information on what students are taught regarding abortion, Mifegymiso or conscientious objection.

Bernard Dickens, a professor emeritus of health law and policy at University of Toronto, has studied abortion rights since 1966. He challenges the idea that doctors exclusively object to abortion for religious or moral reasons, noting that sometimes they simply find it “distasteful,” or see “death” as a failure.

“Of course, one response is that they haven’t chosen the right profession,” Dickens says. Considering how many women seek abortions in Canada, and how many more seek birth control, going into family medicine as an objector to reproductive freedom almost guarantees a doctor will find themselves at odds with patients, he explains—yet so many doctors still put themselves in that position.

Dickens traces these tensions to the historic influence of the Catholic Church on abortion legislation. He says expansion of abortion rights has, in many jurisdictions, been flash-frozen in outdated policies considerably influenced by the Catholic Church, which has for many years threatened excommunication to performers, procurers and political supporters of abortion. “ And we haven’t moved beyond that, or have moved beyond it dragging our feet,” notes Dickens.

We can see it in action here in Canada. There is an unspoken rule in Parliament: don’t reopen the abortion debate. The aversion is not so much designed to protect Canadians’ reproductive rights as it is to protect parties from political annihilation. Even Conservative Party leader Erin O’Toole knows this, and is trying to play both sides: On one hand, he campaigned on a platform that explicitly promised to defend and expand conscience rights, making a pitch to a prominent anti-abortion lobbying group about how anti-choicers could support him in his bid. On the other, O’Toole also describes himself as pro-choice.

But pro-choice sentiment is nothing without pro-choice action. Fears of the Alberta government further prohibiting abortion access led Chantal and a group of local pro-choice supporters to create the Pro-Choice Society of Lethbridge & Southern Alberta. The three-year-old group just got its 24-hour hotline up and running, and will occasionally help abortion seekers out by bringing them to Calgary, despite meagre funding.

What’s clear is that conscientious objection, in Canada and elsewhere, isn’t purely a question of religious or moral convictions. Instead, as Dickens mentioned, it is wrapped up in doctor ego and discrimination in medicine. Barriers to adequate medical care have serious, documented health consequences. Yet, we can’t seem to shake the idea that doctors’ conscience rights and patients’ human rights are equal and can be balanced—especially on issues like MAiD and abortion.

Buying into that fantasy is the Canadian thing to do. But is it the right thing to do?

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