EL0M3 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

2. Canada Health and Social Transfer Act (1996):federal government gives provinces a single

grant for healthcare,social programs, and post-secondary education; division of resources at

provinces’ discretion

History of the Canadian Healthcare System and CrownIndigenous Relations Pursuant to Healthcare

Europeansfirst arrive in Canada

• settlersfind healthy inhabitants with complex societies, cultures, and beliefsystems

• Indigenous peoples’ have specific knowledge of local environment and medicines

• early instance of medical practice occurs when local Indigenous nation

(Haudenosaunee) used cedar as a source of vitamin C to treat scurvy experienced by

European settlers

1534

Royal Proclamation

• identifiesIndian Country that was under British sovereignty but Indigenous possession

• sets out guidelinesfor European settlement of Indigenous territories in what is now

North America;statements include:Aboriginal title (a legal term for ancestral land

rights) has existed and continuesto exist, and that all land would be considered

Aboriginal land unless ceded by treaty

• forbids settlers from claiming land from the Indigenous occupants, unlessit wasfirst

bought by the Crown and then sold to the settlers

• only the Crown can buy land from first Nations

1763

1764 Treaty of Niagara

• the treaty is signed with 24 Indigenous Nations represented

• Indigenous peoples and the Crown agree to co-exist and build their relationship on

Turtle Island

British North America Act (now Constitution Act 1867)

• establishes Canada as a confederacy

• “establishment,maintenance, and management of hospitals” under provincial

jurisdiction

• gives the federal government control overlands reserved for “Indians”

Manitoba Act

• Metis land is protected and they are given an additional 1.4 million acres for their

descendants

• this act wassubsequently ignored and infringed upon as this land was given freely to

incoming settlers

1871-1921 Numbered Treaties

•transfer large tracts of Indigenous land to theCrown with various promises made to

Indigenous Peoples

• Treaty 6 explicitly includes medicine, while others contain agreements related to

social factors affecting health

1867

1870

Indian Act

•reinforces the federal government’s exclusive jurisdiction over Indians and lands

reserved for Indians

•gives complete control of “ Indian bands,"

status, and reserves to the Canadian

government

•enfranchisement (the process of terminating one'

s legal Indian Status, identity, and

ancestral rights in order to gain full Canadian citizenship) becomes legally compulsory

in many situations (such as becoming a physician)

•outlaws the practice of Indigenous culture and spirituality

•imposes band councils and “Indian agents"

1884-1996 Residential Schools and Indian Hospitals

•legislated genocide (see Public Health and Preventive Medicine. PH7)

Execution of Metisleader Louis Riel

•leader of the North-West Rebellion against the federal government due to infringement

on Metis ancestral lands, rights, and way of life

1876

1885 r1

L J

Court Decision Reference Re Eskimo rules that the federal government is hassimilar

responsibility for Inuit people as Indigenous Peoples

• following tnis decision the government developed policies that enforced assimilation

and benefited governmental goals, with disregard for Inuit wellbeing.Thisleadto

extensive harms,some of which are noted below:

1939

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EL0M4 Ethical,Legal, and Organizational Medicine Toronto Notes 2023

• coercive relocation to isolated and sedentary communities away from ancestral lands,

ending seasonally dynamic way of life

• sled dogs were killed, which discontinued the Inuit traditional way of life and forced

them to rely on government supplies

• discs, to be worn around the neck, were issued with numbers in lieu of Inuit

surnames and to ease bureaucratic workload

Royal Commission on Health Services(Hall Commission) recommendsfederal leadership

and financialsupport with provincial government operation

National Medical Care Insurance Act

•federal government'

sfirst legislation with the goal of free access to healthcare

•federal government to pay half of medicare costs in any province with insurance

plans that meet criteria of being universal, publicly administered, portable, and

comprehensive

•Indian Health Services budget is reduced under the guise of equality and social and

legal integration. Individuals can only receive support for healthcare servicesif they

prove they are Indigenous, have been refused fundsfrom their band, and can not obtain

provincial health services, financial limits are set to prevent “overuse” of services.

This createsfurther barriersto accessing healthcare, while reducing barriersfor nonIndigenous peoples

Canada Health Act is passed by federal government

• replaces Medical Care Act (1966) and Hospital Insurance and Diagnostic Services Act

(1957)

•provides federal funds to provinces with universal hospital insurance

•maintains federal government contribution at 50% on average, with poorer provinces

receiving more funds

•medical insurance must be “comprehensive, portable, universal, and publicly

administered”

•bans extra-billing by new fifth criterion:accessibility

Bill C-31

• the Indian Act forced Indigenous women who married non-lndigenous men to lose their

Indian status

•Bill C-31 attempted to stop the involuntary enfranchisement of Indigenous women (and

their children) who married non-lndigenous men

•Bill C-3 in 2011 and later cases ensured that eligible grandchildren of women who lost

status could regain it

1965

1966

1984

1985

Oka Crisis

•land dispute over ancestral Kanienkehaka (Mohawk) territory

•brought about the Royal Commission on Aboriginal Peoples (1996)

Canada Health and Social Transfer Act passed by federal government

•federal government gives provinces a single grant for healthcare,social programs, and

post-secondary education; division of resources at provinces’discretion

1990

1996

Royal Commission on Aboriginal Peoples

•established in the wake of the Oka Crisis.The Commission’s Report, the product of

extensive research and community consultation, was a broad survey of historical and

contemporary relations between Aboriginal and non-Aboriginal peoples in Canada

• recommendations made on how to repair the relationship between Indigenous peoples

and Canada

1996

Kirby and Romanow Commissions appointed

•Kirby Commission (final report,October 2002)

•examines history of the healthcare system in Canada, pressures and constraints of

current healthcare system, role of federal government, and healthcare systems in foreign

jurisdictions

2001

Romanow Commission (final report, November 2002)

•dialogue with Canadians on the future of Canada'

s public healthcare system

first Ministers' Meeting on the future of Health Care produces a lOyearplan

•priorities include reductions in waiting times, development of a national pharmacare

plan, and primary care reform

L

2004

+

Chaoulli v.Quebec,Supreme Court of Canada decision

• rules that Quebec’s banning of private insurance is unconstitutional under the Quebec

Charter of Rightssince patients cannot access the relevant services under the public

system in a timely manner

2005

EL0.M5 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Jordan'

s Principle

•Iordan Anderson was a First Nations child from Norway House Cree Nation born with

complex medical needs

•he spent two unnecessary years in hospital because provincial and federal governments

could not decide who was responsible for paying for the home-based care that Jordan

needed to be discharged.Consequently, he died in hospital at age 5 without ever going

home

2007

•Iordan'

s Principle is a legal obligation that promisesthat First Nations children will get

prompt and equitable access to healthcare and that payments (federal/provincial/local)

will be determined later

•in 2016, the Canadian Human Rights Tribunal found that the Canadian government was

racially discriminating against First Nations children and their families for its failure to

properly implement Jordan’s Principle,

lhe Tribunal issued legally binding orders that

Canada has an obligation to fulfill

First progress report by the Health Council reviews progress toward 2004 First Ministers’

10 year plan

•significant reductions in wait times for specific healthcare areas (such as cancer care,

joint replacements, and sight restoration), but may have inadvertently caused increased

wait timesfor other services

•despite large investments into EMRs,Canada continues to have low uptake, ranking

last in the Commonwealth Fund International Health Policy survey, with only 37% use

among primary care physicians

•minimal progress in creating a national strategy for equitable access to pharmaceuticals;

however,there has been some success in increasing pharmacists’

scope of practice,

reducing generic drug costs,and implementing drug information systems

•increase Funding to provinces at 6% per annum until the 2016-2017 nscal year; from

then onwards, increases tied to nominal GDP at a minimum of 3% per annum

2011

Second progress report by the Health Council reviews progress towards 2004 First

Ministers’ 10 year plan

•funding issufficient; however, more innovation is needed including incentivizing

through models of remuneration

•46 recommendations are made to address the lack of progress

Expiry of 10 Year Health Care Funding Agreement between federal and provincial

governments

•Canadian Doctors for Refugee Care v.Canada,the Federal Court of Canada rules that

the federal government could notsignificantly reduce/eliminate healthcare servicesfor

refugee claimants, as to do so would constitute “cruel and unusual treatment" contrary

to theCharter of Rights and Freedoms

Negotiations underway for a new Health Accord with a S3billion investment over four

years to homecare and mental health services by the elected Liberal government

'

lheTruth and Reconciliation Commission releases 94 “calls to action" (or

recommendations) to further reconciliation between Canada and Indigenous peoples

•the full list of calls to action can be found here:http://trc.ca/assets/pdf/Calls_to_

Action_English2.pdf, while health-specific calls and subsequent government actions

can be found here: https://www.rcaanc-cirnac.gc.ca/eng/15244990246l4/15575l 2659251

•the seven calls to action included under health are the following:

18. we call upon the federal, provincial, territorial, and Aboriginal governments to

acknowledge that the currentstate of Aboriginal health in Canada is a direct

result of previousCanadian government policies, including residential schools,

and to recognize and implement the health-care rights of Aboriginal people as

identified in international law, constitutional law, and under the Treaties

19. we call upon the federal government, in consultation with Aboriginal peoples,

to establish measurable goals to identify and close the gaps in health outcomes

between Aboriginal and non-Aboriginal communities, and to publish annual

progress reports and assesslongterm trends.Such efforts would focus on

indicatorssuch as:infant mortality, maternal health,suicide, mental health,

addictions, life expectancy, birth rates, infant and child health issues, chronic

diseases,illness and injury incidence, and the availability of appropriate health

services

20. in order to addressthe jurisdictional disputes concerning Aboriginal people

who do not reside on reserves, we call upon the federal government to recognize,

respect, and address the distinct health needs of the Metis, lnuit, and off-reserve

Aboriginal peoples

21. we call upon the federal government to provide sustainable funding for existing

and new Aboriginal healing centres to address the physical,mental, emotional,

and spiritual harms caused by residential schools, and to ensure that the funding

of healing centres in Nunavut and the Northwest Territories is a priority

2012

2014

2015

2015

LJ

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EL0M6 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

22. we call upon those who can effect change within the Canadian health-care

system to recognize the value of Aboriginal healing practices and use them in the

treatment of Aboriginal patients in collaboration with Aboriginal healers and

Elders where requested by Aboriginal patients

23. we call upon all levels of government to: i. Increase the number of Aboriginal

professionals working in the health-care field, ii. Ensure the retention of

Aboriginal health-care providers in Aboriginal communities,iii. Provide cultural

competency training for all healthcare professionals

24. we call upon medical and nursing schools in Canada to require allstudentsto

take a course dealing with Aboriginal health issues, including the history and

legacy of residential schools, the United Nations Declaration on the Rights of

Indigenous Peoples,Treaties and Aboriginal rights, and Indigenous teachings

and practices. This will require skills-based training in intercultural competency,

conflict resolution, human rights, and anti-racism

Canada’s Minister of Indigenous Affairs announces their fullsupport for the United

Nations Declaration on the Rights of Indigenous Peoples

•document describes individual and collective rights of Indigenous peoples and provides

guidance about how to maintain a relationship with Indigenous peoples based on

equality, partnership, good faith, and mutual respect

New 10 year Canada Health Accord is reached with a $11.5 billion federal investment

over 10 years to homecare and mental health services and a 3% annual rise in the Canada

Health Transfer (from 6% in the previous agreement)

Missing and Murdered Indigenous Women and Girls Inquiry Pinal Report and Calls for

justice

• reveals that persistent and deliberate human and Indigenous rights violations and

abuses amount to genocide and are the root cause behind Canada’sstaggering rates of

violence against Indigenous women,girls, and 2SLGBTQQ1A people

•the report calls for transformative legal and social changes to resolve the crisis that has

devastated Indigenous communities acrossthe country

2016

2017

2019

The federal government announces the creation of a national drug agency,

it will negotiate

prices on benalfof Canada’s drug plans, assess the efficacy of prescription drugs, and

2019

develop a national formulary

Healthcare Expenditure and Delivery in Canada

• the projected total healthcare expenditure in 2019 was expected to reach $265.5 billion, or $7064 per

person. Health spending was expected to comprise 11.5% of Canada’s GDP that year

Sources of Healthcare Funding

•69% of total health expenditure in 2018 came from public-sector funding with 65% coming from the

provincial and territorial governments, and another 5% from other parts of the public sector:federal

direct government, municipal, and social security funds. 31% is from private sources including out of

pocket (16%), private insurance (12%), and other (3%)

• public sector coversservices offered on either a fee for service, capitation, or alternate payment plan in

physicians'

offices and in hospitals

• fee-for-service is a payment model where services are unbundled and paid forseparately.This can

serve as an incentive for physicians to provide more services because payment is dependent on

the quantity of services provided

in Ontario, each service has a corresponding billing code defined by the Ministry of Health and

Long-term Care in the Physician Services under the Health Insurance Act

• capitation is a physician remuneration payment model determined by the number of patients

rostered

APP is a mutual agreement between a physician (or group of physicians) and their provincial

health authority.The agreement outlinesthe physician’

ssalary, incentives,and various after-hour

bonuses

• public sector does not cover services provided by privately practicing health professionals (e.g.

dentists, chiropractors, optometrists, massage therapists, osteopaths, physiotherapists, podiatrists,

psychologists, private duty nurses, and naturopaths), prescription drugs, OTC drugs, personal health

supplies, and use of residential care facilities

r T

cJ

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EL0M7 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Capital$243 /3.4%

Public HealthS384 / 5 4

:

r AdministrationS205 / 2.9%

OHS.Health Research S118 / 1.7%

OHS:Other Health Spending S351 / 7.8%

Other Professionals:

Other Health Professionals S171 / 2.4%

Hospital$1,880 / 26.6%

Other Professionals:

Vision Care $151 / 2.1%

Other Professionals:

Dental Services $45016.4%

Other Institutions S772 / 10.9%

DrugsPrescribed S918 13.0%

Physicians S1,064 / 15.1%

OHS.Other HealthSpending Drugs Non Prescribed$160/ 2.3%

Figure 1.Total health expenditure per capita by use of funds. Canada 2019 (dollars and percentage share)

Source:Canadian Institute for HealthInformation,NationalHealth Expenditure Trends.Total healthexpenditure per capita by health spending

category.Canada.2019 (dollars and percentage share),1975 to 2019.copyright 2020.Reprinted byPermission of CIHI

Delivery of Healthcare

•hospital services in Canada are publicly funded but delivered through private, not-for-profit

institutions owned and operated by communities, religious organizations, and regional health

authorities

•other countries have different systems of healthcare delivery,such as the United States (mix of public

and private funding, as well as private for-profit and private not-for-profit delivery), and the United

Kingdom (primarily public funding and delivery)

Physician Licensure and Certification

Table 2. Key Physician Certification and Licensing Bodies in Canada (and Ontario)

Certifying Body Description

Certifies physicians with the LMCC.LMCC acquired by passing the MCC Qualifying Examination PartsIandII

Certifies residents who complete an accredited residency program and pass the appropriate exam

Voluntary membership of the RCPSC is designated PRCPC or FRCSC

Certifies residents who complete an accredited family medicine residency program and pass the Certification

Examination in Family Medicine

13 provincial medicalregulatory (licensing)authorities

All postgraduate residents and allpractangphysicians must hold an educational or practice license from the

licensing body in the provincein which they study or practice

Membership to the provincial licensingauthority ismandatory

licensing authority functions include:

Provide non-transferable licensure tophysicians

Maintaining ethical,legal,and competency standards and developing policies to guide physicians

Investigating complaints against physicians

Disciplining physicians guilty of professional misconduct or incompetence

At times ol license investiture and renewal,physicians must disclose if they have a condition (such as HIV positivity,

drug addiction,or other illnesses) that may impact their ability to practice safely

MCC

RCPSC

CfPC

licensingBody

CPSO

•physician certification is governed nationally, while the medical profession in Canada self-regulates

under the authority of provincial legislation

•self-regulation is based on the premise that due to the advanced education and training involved in

the practice of medicine, the lay person is not in a position to accurately judge the standards of the

profession;the self-regulating colleges have a mandate to regulate the profession in the public interest

•the RCPSC and CFPC are responsible for monitoring ongoing CME and professional development

•certification by the LMCC plus either the RCPSC or CFPC is a minimum requirement for licensure by

most provincial licensing authorities

+

F.I.OMN Ethical. Legal, and Organizational Medicine Toronto Notes 2023

Role of Professional Associations

Table 3. Key Professional Associations

Advocacy and Diversity

• Similar to how the FMEQ represents

the interests of francophone medical

schools and the CFMS represents

those nation wide,other professional

associationsserve and advocate on

behalf of different communities

• These associations may serve

traditionally underrepresented

groups, underserved communities,

communities facing structural

barriers, and/or communities with

unique health needs

• Some examples of professional

associationsthat physicians or

medical students may join are:Gay.

Lesbian,Bisexual and Transgender

(GLBT) Medical Students of Canada:

the Black Medical Students

Association of Canada:Black

Physicians Association of Ontario

(BPAO): Muslim Medical Association

of Canada and the Indigenous

Physicians Association of Canada

(IPAC): Indigenous Medical/Dental

Students Association (IMDSA.

Alberta)

Association Description

CMA Provides leadership to physicians and advocatesfor access to high quality care in Canada

Represents physician and population concerns at the national level

Membership is voluntary

PTMAs (such as the Negotiates fee and benefit schedules with provincial governments

OMA)

Represents the economic and professional interests of physicians

Membership is voluntary

Provide physician health support

Physician-run organiration that protects the integrity of member physicians

Provides legal defense against allegationsof malpractice or negligence

Provides riskmanagement and educational programs

Membership is voluntary but all physicians must have some form of liability insurance

Upholds economic and professional interests of residents across Canada

Facilitates discussion amongst PHOs regarding policy and advocacy items

Medicalstudents are represented at their universities by student bodies, which collectively form the CFMS or f M (0

FMfO membership includes that of francophone medical schools

CMPA

RDoCand PHO

CFMSandFMFO

Ethical and Legal Issues in Canadian Medicine

Introduction to the Principles of Ethics s • ethics involves thinking about what the best course of action maybe in a specific case, including:

1. principles and values that help us consider what might be morally permissible and/or

impermissible in specific circumstances

2.rights, duties, and obligations of individuals and groups

• as a self-regulated profession, ethical and professional practice is guided by a shared code of conduct

(the CMA code of ethics), and by our provincial licensing bodies ( through policies)

• the physician-patient relationship significantly depends on trust, which is recognized in the concept of

fiduciary duty/responsibility of physician towards patient

• a fiduciary duty is a legal duty to act in another party’sinterest. Profit from the fiduciary relationship

must be strictly accounted for with any improper profit (monetary or otherwise) resulting in sanctions

against the physician and potential compensation to the patient, even if no physical harm has befallen

the patient

Autonomy vs.Competence vs. Capacity

Autonomy: the tight that patients have

to make decisions according to their

values, beliefs, and preferences

Competence:the ability to make

a specific decision for oneself as

determined legally by the courts

Capacity:the ability to make a specific

decision for oneself as determined by

the clinicians proposing the specific

treatment

Table 4. The Four Principles Approach to Medical Ethics

Principle Definition

Recogniics an individual'sright to make their own decisions in their own way(s) based on their wishes, beliefs, values,

and preferences

It may not be possible for a person to make a fully aulonomous decision and/or to have an autonomous decision

honoured in some circumstances. For instance,il an autonomous request for a medical intervention is deemed clinically

inappropriate from Ihe physician's perspective, then the physician need not offer it

Autonomy is nol synonymous with capacity

Obligation to provide benefit to Ihe patient, based on whal is considered lo be Ibeir best interests.Consideration of best

interestsshould consider Ihe patient's values, beliefs, and preferences, so far as these are known.Best interests extend

beyond solely medical considerations

May be limited by the principle of Autonomy (such aswhen differences exist between patient and clinician's conception

of best interests)

Paramount in situations where consent/choice isnot possible

Obligation to avoid causing haim:primum non nocere (“First, do no harm")

A limiting principle ol the Beneficence principle

Fail disliibufion ol benefils and harms within a community,regardless of geography,income, or other social factors

Concept ol fairness: Is the patient receiving whal they deserve -their fair share? Are they treated the same as equally

situaled patients? (equity) How does one set of frealmenl decisions impact others? (equality)

(quality and equity are different notions of justice,(quality involves providing Ihe distribution of resources lo all people

irrespective of differing needs, and equity involves distributing resources in a way that considers differing needs(such

as circumstance and social conlexl). Both concepts raise different considerations

Basic human rights,such asfreedom from perseculion and Ihe right to have one'sinterests considered and respected

Autonomy

Beneficence

Non-Maleficence

r t

Justice

+

Note:The four principles approach (i.e.principlism) is just one approach to medical ethics.Thereexist many other ethical principlesthat are also

relevant tomedicine fe.g.transparency,trust,etc.}.

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F.I.0M9 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

CMA Code of Ethics and Professionalism

• the CMA developed a Code of Ethics and Professionalism that providesstandards of ethical practice

to guide Canadian physicians,which covers virtues thatshould be exemplified by an ethical physician,

fundamental commitments of the medical profession, professional responsibilities,and the relation of

the physician to themselves, colleagues, and society

• the Code of Ethics and Professionalism is:

• prepared by physicians for physicians and applies to physicians, residents, and medical students

• informs ethical decision- making, especially where existing guidelines are insufficient or values

and principles come into tension

not exhaustive; it is intended to provide standards of ethical practice that can be interpreted and

applied in particularsituations

founded on other principles including the Hippocratic Oath, developments in human rights, and

recent bioethical discussions

• CMA policy statements addressspecific ethical issues/topics not mentioned by the code (e.g. abortion,

transplantation,and medical assistance in dying)

The CMA Code of Ethics and

Professionalism is a quasi-legal standard

for physicians;if the law sets a minimal

moral standard for physicians,the Code

seels to augments these standards

Table 5. CMA Code of Ethics and Professionalism

A.Virtues exemplified by the ethical physician

Compassion

Honesty

Humility

Integrity

Prudence

B.Fundamental commitments of the medical profession

Commitment to the well

-being of the patient

Com mitment lo respect for persons

Commitment lo justice

Commitment to professional integrity and

CMfetNK

Commitment to professional excellence

Commitment to self-care and peersupport

Commitment to inquiry and reflection

C. Professional responsibilities

Physicians and patients Patient-physician relationship

Decision -making

Patient privacy and the duty of confidentiality

Managing and minimizing conflicts of interest

Awareness of wellnessservices and promote health amongself

Seek support for professional and personal problems

Cultivate safe training and working environments

Treating colleagues with respect and dignity

lake responsibility for actions towards colleagues

Commitment tohigh quality healthcare services

Recognition of the social determinants of health

Supporting equitable accesslo healthcare resources, and building collaborative

relationships with marginalized groups

Physicians and the practice of medicine

Physicians and self

Physicians and colleagues

Physicians and society

Confidentiality

Overview of Confidentiality

• when determining legal and ethical issues surrounding patient information,start from the

foundational assumption point that all information given by the patient is both confidential (meaning

it cannot be disclosed to others) and privileged (meaning it cannot be used in court), then determine

whether exceptions to this exist

• the legal and ethical basis for maintaining confidentiality is that a full and open exchange of

information between patient and physician is central to the development and maintenance of a

therapeutic relationship

• privacy is a right of patients(which they may forgo), while confidentiality is a duty of physicians

(which they must respect barring patient consent or requirements of the law)

• patients have the right to the expectation that their personal information will receive proper

protection from unauthorized access (see Privacy of Medical Records, ELOMIO)

• if confidentiality is inappropriately breached by a physician, that physician can be sanctioned by the

hospital, court, or regulatory authority

• based on the ethical principle of autonomy, patients have the right to control their own health

information

• confidentiality may be ethically and legally breached in certain circumstances (e.g.child abuse)

• while physician-patient privilege exists, it islimited in comparison to solicitor-client privilege.

During conversations with patients about confidentiality, physiciansshould avoid promising absolute

confidentiality or privilege,asit cannot be guaranteed by law

• physicians should seek advice from their local health authority or the CMPA before disclosing HIV

status of a patient to someone else

• many jurisdictions make mandatory not only the reporting ofserious communicable diseases(e.g.

HIV), but also the reporting of those who harbour the agent of the communicable disease

• physicians failing to abide by such regulations could be subject to professional or civil actions

• legal duty to maintain patient confidentiality is imposed by provincial health information legislation

and precedent-setting court cases in the common law

Legal Aspects of Confidentiality

Advice should always be sought from

provincial licensing authorities and/or

legal counsel when In doubt

CMA Code of Ethics and

Professionalism

'Fulfill your duty of confidentiality to

the patient by keeping identifiable

patient information confidential;

collecting, using, and disclosing only as

much health information as necessary

to benefit the patient:and sharing

information only to benefit the patient

and within the patient's circle of care.

Exceptions include situations where

the informed consent of the patient

hasbeen obtained for disclosure or as

provided for by law”

n

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ELOMlO Ethical,Legal,and Organizational Medicine Toronto Notes 2023

Statutory Reporting Obligations

•legislation has defined specific instances where public interest overrides the patient'

s right to

confidentiality; varies by province,but may include:

1. suspected child abuse or neglect-report to local child welfare authorities(e.g.Children’

s Aid

Society)

2. fitness to drive a vehicle or fly an airplane -report to provincial Ministry of Transportation

(ieriatric Medicine.GM13)

3. communicable diseases-report to local public health authority (see Public Health and

Preventive Medicine, PH31)

4. improper conduct of other physicians or health professionals-report toCollege or regulatory

body of the health professional (sexual impropriety by physicians is required reporting in

some provinces)

5. vital statistics must be reported;reporting varies by province (e.g. in Ontario, births are

required to be reported within 30 d to the Office of Registrar General or local municipality;

death certificates must be completed by a physician then forwarded to municipal authorities)

6. reporting to coroners(see Physician Responsibilities Regarding Death, ELOM2Q )

•physicians who fail to report in these situations are subject to prosecution and penalty, and may he

liable if a third party has been harmed

Duty to Protect/Warn

•the physician has a duty to protect the public from a known dangerous patient; this may involve taking

appropriate clinical action (e.g. involuntary detainment of violent patientsfor clinical assessment),

informing the police,and/or warning the potential victim(s) if a patient expresses an intent to harm

•Canadian courts have not expressly imposed a mandatory duty to report, however, the CMA Code

of Ethics and some provincial/territorial regulator)'authorities may oblige physiciansto report

(mandatory reporting rather than permissive)

•concerns of breaching confidentiality should not prevent the physician from exercising the duty to

protect; however, the disclosed information should not exceed that required to protect others

•applies in a situation where:

1. there is an imminent risk

2. to an identifiable person or group

3. ofserious bodily harm or death

Ontario's Medical Expert Panel on Duty

to Warn

CMA J 1998;158(11):1473-1479

• There should be a duty to inform

when a patient reveals that they

intend to do serious harm to another

person(s) and it is more likely than

not that the threat will be carried out

• Where a threat is directed at a person

or group and there is a specific

plan that is concrete and capable

of commission and the method for

carrying it out is available to the

threatener.the physician should

immediately notify the police and.

in appropriate circumstances,the

potential victim. The report should

include the threat, the situation,

the physician's opinion, and the

information upon which it is based

• While Canadian courts have not

expressly imposed a mandatory

“duty to warn"on physiciansto alert

third parties of a danger posed by

a patient.Canadian supreme court

decisions have held that a physician

is permitted to warn (permissive vs.

mandatory)

(«e

CMA Code of Ethics and

Professionalism

• Protect the health information of your

patients

• Provide information reasonable

in the circumstances to patients

about the reasonsfor the collection,

use:and disclosure of their health

information

• Be aware of your patients'rights

with respect to the collection, use.

disclosure, and accessto their

health information;ensure thatsuch

information isrecorded accurately

Disclosure for Legal Proceedings

•disclosure of health records can be compelled by a court order, warrant, orsubpoena

Privacy of Medical Records

•privacy of health information is protected by professional codes of ethics, provincial and federal

legislation, the Canadian Charter of Rights and Ereedoms, and the physician'

s fiduciary duty

•the federal government created the P1PEDA in 2000 which established principles for the collection,

use, and disclosure of information that is part of commercial activity (e.g. physician practices,

pharmacies, and private labs)

•PIPEDA has been superseded by provincial legislation in many provinces,such as the Ontario

Personal Health Information Protection Act, which applies more specifically to health information

Duties of Physicians with Regard to the Privacy of Health Information

•inform patients of information-handling practices through various means (e.g. posting notices,