Approved by Council: September 2008
Reviewed and Updated: March 2015, September 2023

Companion Resource: Advice to the Profession

Definitions

Discrimination: An act, communication, or decision that results in the unfair treatment of an individual or group, for example, by excluding them, 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 indirect and unintentional, where rules, practices, or procedures appear neutral but have the impact of disadvantaging certain groups of people.

Effective referral: Taking positive action to ensure the patient is connected to a non-objecting, available, and accessible¹ physician, other health-care professional, or agency.

Protected grounds under the Human Rights Code: The Ontario Human Rights Code prohibits actions that discriminate against people based on protected grounds in protected social areas (including goods, services, and facilities, such as hospitals and health services). The protected grounds include age; ancestry, colour, race; citizenship; ethnic origin; place of origin; creed; disability; family status; marital status; gender identity, gender expression; receipt of public assistance; record of offences; sex; and sexual orientation.²

For more definitions of key terms and concepts related to this policy, including anti-oppression, anti-racism, cultural humility, and cultural safety, see CPSO’s Equity, Diversity, and Inclusion Glossary.

Policy

Providing Safe, Inclusive, and Accessible Health Services

1. Physicians must take reasonable steps to create and foster a safe, inclusive, and accessible environment in which the rights, autonomy, dignity, and diversity of all people are respected, including by incorporating cultural humility, cultural safety, anti-racism, and anti-oppression³ into their practices.
2. Physicians must not:
   1. express personal moral judgments in a manner that is demeaning towards patients’ beliefs, lifestyle, identity, or characteristics or the health services that patients are considering;
   2. rely on stereotypes associated with one or more aspects of the patient’s identity to determine their needs;⁴
   3. refuse or delay the provision of health services because the physician believes the patient’s own actions have contributed to their condition;⁵ or
   4. promote or impose their own spiritual, secular, or religious beliefs when interacting with patients.

The Duty to Provide Services Free from Discrimination

3. Physicians must comply with the relevant legal requirements under the Human Rights Code⁶ and the Accessibility for Ontarians with Disabilities Act, 2005.
4. Physicians must not discriminate, either directly or indirectly, based on a protected ground under the Human Rights Code when making decisions relating to the provision of health services, including when:
   1. accepting or refusing individuals as patients;
   2. providing information to patients;
   3. providing or limiting health services;⁷
   4. providing formal clinical referrals and effective referrals; and
   5. ending the physician-patient relationship.

The Duty to Accommodate

5. Physicians must comply with their duty to accommodate the needs of patients arising from protected grounds under the Human Rights Code in a manner that respects the dignity, autonomy, privacy, and confidentiality of the person.⁸
6. In discharging provision 5, physicians must explore and implement accommodation measures up to the point that they would:
   1. subject the physician to undue hardship (e.g., excessive cost, health or safety concerns); or
   2. significantly interfere with the legal rights of others.
7. Where a patient requests to receive care from a physician with a particular identity (e.g., race, ethnicity, culture, religion, gender identity), physicians must:
   1. with appropriate consent,⁹ provide any emergent or urgent medical care the patient requires; and
   2. when the situation is non-emergent or non-urgent:
      1. take appropriate steps to accommodate the patient’s request, where resources are available, if the request is reasonable (e.g., the patient requests care from a physician who is of the same gender for religious reasons or based on a history of trauma); or
      2. determine the safe and appropriate steps to take with respect to the patient’s care if the request is not reasonable (e.g., the patient requests care from a physician of a certain race based on racist beliefs), which may include refusing to accommodate the request.¹⁰

Addressing Violence, Harassment, and Discrimination

8. If physicians see acts of violence, harassment (including intimidation), or discrimination occurring against patients, health-care professionals, and/or staff, they must take necessary¹¹ and reasonable steps to stop and/or otherwise address these acts (e.g., providing support) in a manner that does not compromise the safety of themselves or others.¹²

Health Services that Conflict with Physicians’ Conscience or Religious Beliefs

CPSO recognizes that physicians have the right to limit the health services they provide for reasons of conscience or religion. Physicians’ freedom of conscience and religion must also be balanced against the right of existing and potential patients to access care. The Court of Appeal for Ontario has confirmed that where an irreconcilable conflict arises between a physician’s interest and a patient’s interest, as a result of physicians’ professional obligations and fiduciary duty owed to their patients, the interest of the patient prevails.¹³

CPSO has expectations for physicians who have a conscientious or religious objection to the provision of certain health services. These expectations accommodate the rights of objecting physicians to the greatest extent possible while ensuring that patients’ access to healthcare is not impeded.

9. Where certain health services conflict with physicians’ conscience or religious beliefs in a manner that would impact patient access to those health services, physicians must fulfill their professional obligations and fiduciary duty to their patients by putting patients’ interests first.
10. Physicians must provide patients with accurate, complete, and unbiased information about all available and appropriate options to meet their clinical needs or concerns so that patients are able to make an informed decision¹⁴ about exploring a particular option.¹⁵
11. Physicians must not:
    1. withhold information about the existence of any relevant service, treatment, or procedure because it conflicts with their conscience or religious beliefs; or
    2. impede access to information and/or care.
12. When a particular service, treatment, or procedure is an option for a patient and conflicts with a physician’s conscience or religious beliefs in a manner that would impact patient access, physicians must:
    1. make any decisions to limit the provision of health services in accordance with the Human Rights Code;¹⁶
    2. inform the patient that they do not provide that service, treatment, or procedure;
    3. have a plan in place around how they will connect patients to the services that would typically be requested in their type of practice, but that conflict with their conscience or religious beliefs; and
    4. provide the patient with an effective referral in a timely manner to allow patients to access care and not expose them to adverse clinical outcomes due to a delay.
13. In discharging provisions 10 and 12, physicians must:
    1. communicate the necessary information in a clear, straightforward, non-judgmental, and understandable manner;¹⁷
    2. document in accordance with the expectations set out in the Medical Records Documentation policy and, where relevant, the Medical Assistance in Dying policy, and transfer any copies of records in accordance with the Medical Records Management policy; and
    3. where formal clinical referrals are provided, comply with the relevant expectations set out in the Transitions in Care policy.
14. Physicians must provide any necessary care in an emergency, even where that care conflicts with their conscience or religious beliefs.¹⁸

Endnotes

^1. “Available and accessible” means that the health-care professional must be operating and/or accepting patients at the time the effective referral is made, and in a physical location the patient can reasonably access, or where appropriate, accessible via virtual care. Additional information on effective referrals can be found in the Advice to the Profession.

^2. For more information on the protected grounds and protected social areas under the Human Rights Code, see the Ontario Human Rights Commission’s website.

^3. For definitions of cultural humility, cultural safety, anti-racism, and anti-oppression, see the Equity, Diversity, and Inclusion Glossary. Additional guidance and resources on how to incorporate these concepts into practice can be found in the Advice to the Profession.

^4. Stereotypes are generalizations about people based on assumptions about qualities and characteristics of the group they belong to. Stereotyping typically involves attributing the same characteristics to all members of a group, regardless of their individual differences. It is often based on misconceptions, incomplete information, and/or false generalizations.

^5. See the Ending the Physician-Patient Relationship policy for circumstances where physicians must not end the physician-patient relationship.

^6. The Human Rights Code has primacy over all other provincial legislation, including the Substitute Decisions Act, 1992; Health Care Consent Act, 1996; Mental Health Act; and the Accessibility for Ontarians with Disabilities Act, 2005. If there is a conflict between the Human Rights Code and another provincial law, the Human Rights Code prevails unless the other law includes a specific exception.

^7. This policy addresses limiting health services for reasons based on conscience or religion in the section ”Health Services that Conflict with Physicians’ Conscience or Religious Beliefs.” The Accepting New Patients policy sets out expectations for physicians limiting health services on the basis of clinical competence, scope of practice, and/or a focused practice area.

^8. A physician’s duty to protect the confidentiality of personal health information and the privacy of individuals with respect to that information is governed by the Personal Health Information Protection Act, 2004.

^9. See the Consent to Treatment policy for expectations on obtaining consent during emergencies.

^10. See the Ending the Physician-Patient Relationship policy for expectations when deciding to end the physician-patient relationship. Additional guidance around determining whether a request is reasonable can be found in the Advice to the Profession.

^11. Necessary steps include complying with applicable legislation (e.g., the Occupational Health and Safety Act) and any other relevant policies (e.g., the Professional Responsibilities in Medical Education policy), institutional codes of conduct, or by-laws.

^12. Physicians will need to take into consideration the mental and/or physical state of the patient or individual when determining reasonable steps, where at times their behaviour may be due to a health condition (e.g., severe mental illness, neurocognitive or neurodevelopmental disorder) and/or their current health status (e.g., intoxication, delirium).

^13.  See para. 187 Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393.

^14. In accordance with the Consent to Treatment policy and the Health Care Consent Act, 1996, physicians need to obtain valid consent in order to proceed with a particular treatment option. In order for consent to be valid, it must be related to the treatment, informed, given voluntarily, and not obtained through misrepresentation or fraud.

^15. For specific guidance related to medical assistance in dying (MAID), see the Advice to the Profession: Medical Assistance in Dying.

^16. Limiting health services on the basis of conscience or religion does not permit physicians to discriminate on the basis of a protected ground under the Human Rights Code and limit to whom they provide services they otherwise offer.

^17. Communicating in an understandable manner may involve addressing language and/or other communication barriers (e.g., due to neurodiversity or disability) and using the best available resources for interpretation.

^18. For clarity, MAID would never be a treatment option in an emergency.