Dr. Jillian Demontigny keeps a rainbow bracelet wrapped around the stethoscope that she drapes across her neck. It’s her signal to any LGBTQ patient who arrives at her clinic: you are welcome here.
Dr. Demontigny is one of 13 physicians working at the Taber Clinic, a family medicine clinic in a southern Alberta town of 8,500 people. Over her 14 years in Taber, she has expanded her practice to offer extra supports for patients looking for the kind of health care that can be hard to access in this rural, conservative region, where anti-abortion billboards are posted along the highway.
She prescribes the medical-abortion drug Mifegymiso. She devotes one day a week to transgender patients and operates an opioid dependency clinic in Lethbridge, 50 kilometres away. “It’s kind of simple, basic care but I think makes a big difference to the community,” Dr. Demontigny says.
However, she’s concerned that the kind of care she offers may be endangered if members of Alberta’s United Conservative Party government pursue legislation to extend doctors’ conscience rights.
Rural and vulnerable patients already face barriers to accessing contentious procedures such as abortion and medical assistance in dying, “even though I think the majority of health-care providers aren’t using their beliefs as a reason to deny care,” Dr. Demontigny says.
In November, UCP backbencher Dan Williams tabled a private member’s bill that would grant protection to doctors and other health-care providers who morally object to medical treatments or procedures such as abortion, contraception, medical assistance in dying (MAID) and gender-affirming care. They would not be required to discuss treatments or procedures with patients, or refer patients to providers who would perform those acts of health care.
The bill was voted down at committee with several UCP members voting against it. It did not get a final vote before the legislature session wrapped up last year, which meant the bill will effectively die on the order paper.
But some physicians and patients in Alberta say they are concerned a similar bill could be proposed in 2020.
If physicians do not have to refer patients for types of health care that they object to, it will “make it even harder on patients and they will have no recourse,” Dr. Demontigny said. (She added that her views do not represent those of her partners at her clinic.)
Danielle Rose Gallant, a trans woman in the northern Alberta hamlet of Fort Vermilion, had mental-health issues before she transitioned and sought help at a hospital emergency department. “They just drew a blank.” They told her she could call or visit physicians in Edmonton, nearly 800 kilometres away. “There are no other doctors here. It’s only one hospital and there’s only one doctor on duty at that hospital at any time. So it puts us in a very, very difficult situation,” Ms. Gallant said.
The bill’s critics point out that physicians and pharmacists in Alberta already have conscience rights. They can opt out of performing treatments and procedures but, according to the code of practice set out by the Alberta College of Physicians and Surgeons, they must inform patients about the acts that they will not provide based on their conscience or religion, and they must help patients get timely access to other physicians who will provide the service or to a centralized resource that will give information.
Pharmacists have a similar ethical obligation to help patients obtain appropriate services when they have a conscientious objection, according to the Alberta College of Pharmacy.
No physician or pharmacist in the past five years has faced disciplinary action in Alberta for refusing to refer, according to both regulators.
Physicians who support Bill 207 say the act of referral – even to a centralized referral service available by phone – makes them participants in acts they object to. It is, they say, a violation of their Charter rights.
Kiely Williams, a family doctor in Calgary, said Bill 207 would have protected Alberta physicians from having to make effective referrals – connecting patients directly to physicians who will perform these health-care acts, as is now required in Ontario.
The College of Physicians and Surgeons of Ontario’s requirement that doctors provide such referrals was upheld last year by the province’s Appeal Court. Dr. Williams said she worries that the Alberta regulator will follow suit.
“A direct referral makes you complicit in the act,” she said. She cited the example that the physicians are not allowed to refer patients for female genital mutilation (FGM) because they would be complicit. FGM is not a health-care treatment or procedure approved in Canada. It is considered a form of violence and a criminal offence.
She said some physicians in Alberta might leave the province or reduce their scope of practice if they have to make referrals for things such as assisted dying or abortion.
Many patients and advocates feel Bill 207 put physicians’ beliefs ahead of patients’ needs, and would create additional barriers for people who are already struggling to access care.
Small communities in Alberta have fewer physicians and health-care services – meaning fewer places for patients to turn, particularly for things such as abortion, contraception, assisted dying and LGBTQ care.
Patients in cities have more options, said Jillian Ratti, a family physician who spoke against Bill 207 at the committee deliberations and has become a vocal critic of the UCP government. When Dr. Ratti gives a patient a prescription for the medical-abortion pill, she tells them which local pharmacies will not provide the medication.
“We are very careful to try and send our patients to places that are not going to judge them in a time when they're feeling vulnerable and scared.”
Some remote communities in the province have only one nurse or physician, and patients lack the means to travel elsewhere for care, she said. In some places, other physicians or pharmacists may be more than an hour away by car, and patients, especially younger or poorer patients, might not have access to a vehicle.
Fiona Mattatall, a Calgary obstetrician and gynecologist, says she worries that an expansion of physician conscience rights will harm Indigenous and First Nations communities where services are limited. Indigenous patients’ health outcomes already lag behind the rest of the province, she said.
“That's a population already struggling and I wonder if one person with an agenda could further provide barriers.”
Dr. Mattatall performs gender-affirming surgery for trans patients in Calgary. They wait about four months to see her and another eight for their surgery. She’s one of several surgical specialists they will see throughout transition.
Some of her patients spent years avoiding the health-care system after negative experiences with physicians who did not provide supportive care, she said. She operated on one man in his 30s who went nearly two decades without a doctor – despite multiple suicide attempts – after one suggested he undergo conversion therapy.
Dr. Mattatall said that doctors can step away from providing treatments they’re conscientiously opposed to, but they “have a responsibility and a duty to guide that patient to someone who can provide the service.”
“That's how it was universally taught to us in medical school. That’s ethics 101.”
Trans people in Alberta already face dangerous delays in care because of a lack of trained providers and a widespread distrust of the health-care system, said Dr. Kristopher Wells, Canada Research Chair for the Public Understanding of Sexual and Gender Minority Youth.
“Many people believe that we’re at a crisis point in Alberta when it comes to gender-affirmative care,” he said.
Many physicians aren’t familiar with transgender care, so they default to a mode that excludes rather than welcomes trans patients, he said. Patients become uncomfortable and avoid seeking care. By the time they do, “it’s often an emergency situation and, unfortunately, it’s far too late,” he said.
When B Adair, a paramedic who goes by the initial B, came out as trans, he could not find anyone locally to help him with mental health. “It was so hard for me to gather up that strength and courage to approach somebody and talk about stuff, and then to literally have them turn around, say, ‘I don’t know what to do with you, sorry.’”
Small gestures from physicians and nurses made an enormous difference, he said. His new family doctor recently asked B and his partner for their pronouns, the first in his experience to do so.
Steve Buick, press secretary to the Minister of Health, pointed out that Bill 207 was a private member’s bill, not UCP government legislation. Policies regarding gender reassignment services remain the same as under the previous government, he said.
The College of Physicians and Surgeons of Alberta provided suggestions to Mr. Williams for proposed amendments to Bill 207, which the regulator said would bring the new bill in “greater alignment” with its standard of practice. In a statement, the CPSA said they believe their current standard “sufficiently protects access to care” while respecting the rights of physicians.
Cheryl Mack, a bioethicist and palliative care physician at the University of Alberta, says she believes the CPSA’s code achieves a reasonable balance between doctors’ personal conscience rights and their professional obligations to patients. Doctors must refer and provide information – a step that acknowledges doctors are both the providers of care and gatekeepers to the system of care, she said.
Physicians must pay attention to the needs of the patients in front of them, she said. “The College asks us to do that – to think about, ‘who is harm going to be situated with in these instances?’ And it’s kind of hard not to see that it is situated with the patient.”
Patients who can’t travel, who are homeless or lack a cellphone or internet access, or have literacy or language barriers will face more difficulties accessing care, she said. Physicians need to take that into account when weighing what to do.
Dr. Demontigny was altered by a meeting with a patient in 2015 who caused her to change her position. That year, a young woman arrived at her clinic, depressed and suicidal after an abortion. She’d put off seeking help because she feared what a doctor might say.
It was then Dr. Demontigny decided to go public with her beliefs. She started her own pro-choice march in Taber, showing up on the same day and street as the local anti-abortion march.
Some of her colleagues asked that she stop protesting, and asked her to consider removing personal tokens, such as the rainbow flag bracelet, that could be considered political or offensive.
Remembering this, she lost her voice for a few seconds. Then she added, “But the patient needing health care – that’s the vulnerable position.”