Nova Scotia’s doctor shortage may soon get worse, all because of recent policy changes from the College of Physicians and Surgeons of Nova Scotia (CPSNS). In fact, if the CPSNS insists on forcing physicians to make “effective referrals” for procedures that violate their consciences – like medical assistance in dying (MAID) – no one should be surprised to learn of more doctors retiring or moving to a different province. And it’s even possible fewer bright young people will consider medical careers in Nova Scotia. That’s the message that came from doctors and Dalhousie medical students in a letter and recent press conference. And rather than dismissing their concerns, the CPSNS should be taking them seriously.

‘Effective referrals’ When the CPSNS forces doctors to make “effective referrals” for MAID or other procedures, it can put those doctors in the position of participating – even if indirectly – in things that violate their conscience, their ethics, their morality, and-or their  professional discretion and judgment.

As described in an article in the Canadian Medical Association Journal, an effective referral in the case of MAID makes providers “complicit in the procedure. This is not mere semantics — to be blunt, the physician must ask another health-care provider to consider killing their patient.” So, do regulators (or patients) have the right to force doctors into making these requests, which could then weigh on doctors’ consciences for the rest of their lives?

So, if the CPSNS policy on referrals leads to Nova Scotia doctors deciding they can’t practise medicine without violating their conscience, significant and ongoing health staffing issues will only get worse.

More patients would struggle to access care and remaining medical personnel would face more difficult working conditions. Even before the CPSNS policy change, doctors and nurses were reporting burnout and raising the possibility of leaving their professions mid-career.

But the issue goes deeper than practical concerns about doctor shortages or other staffing issues. Freedom of conscience is central to who we are as people.

“Conscience… preserves who I am and what I stand for in a fundamental sense,” according to a Cardus paper. Betraying your conscience, inevitably compromises someone’s integrity and identity, which “can be a dreadful and inwardly divisive experience.” This is why conscience is one of the first protected freedoms in the Charter of Rights and Freedoms. Conscience violations lead to moral injury and distress.

Unfortunately, health-care institutions have had recent experiences showing the toll that moral injury and moral distress take on medical personnel. During the pandemic, physicians, nurses and others were placed in incredibly difficult situations due to resource scarcity, restrictions on in-person contact with patients, and more.

As articulated by the Canadian Medical Association, “when physicians are unable to uphold the oath they took to deliver the best care and put the needs of their patients first, they can experience moral injury.” Similarly, moral distress “occurs when one feels unable to take what they believe to be an ethically appropriate or right course of action, including avoiding wrongdoing or harm, because of institutionalized obstacles. With time, moral distress can lead to moral injury.”

By requiring doctors to violate their ethical framework and moral principles on issues like MAID, the CPSNS policy change on referrals results in moral injury and moral distress. Effective referrals require physicians to negate the very ethics and morals that inspired them to pursue medicine in the first place — to do no harm. It requires them to be complicit it what they see as contrary to the very purpose of medicine.

In so doing, moral injury and distress harm the mental health of doctors, reducing their ability to function at work and in their personal lives. This has very real effects on an already struggling health-care workforce, and the risk of being put in ethically compromising situations may drive doctors away from the field entirely.

It also has consequences for access and quality of health care in Nova Scotia generally — the college, the government and Nova Scotians should take note.

• Rebecca Vachon is Health Program Director at Cardus