ELOM20 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Physician Responsibilities Regarding Death

• physicians are required by law to complete a medical certificate of death unless the coroner needs

notification;failure to report death is a criminal offence

Coroner'

s Act,1990 (specific to Ontario,similar in other provinces) requires physicians to notify a

coroner or police officer if death occurs:

• due to violence, negligence, misconduct, misadventure, or malpractice

during pregnancy or is attributable to pregnancy

suddenly and unexpectedly

from disease which was not treated by a legally qualified medical practitioner

from any cause other than disease

undersuspicious circumstances

death from MAID

• coroner investigates these deaths, as well as deaths that occur in psychiatric institutions, jails,foster

homes, nursing homes, hospitals to which a person was transferred from a facility, institution or

home,etc.

• in consultation with forensic pathologists and otherspecialists, the coroner establishes:

• the identity of the deceased

where and when the death occurred

the medical cause of death

the means of death (i.e. natural, accidental,suicide, homicide, or undetermined)

• coroners do not make decisions regarding criminality or legal responsibility

• while the Supreme Court of Canada noted that nothing in the Carter v. Canada decision compelled

a physician to participate in MAID, the College of Physicians and Surgeons of Ontario mandatory

referral policy, which has been upheld by the courts, requires physicians in Ontario to provide an

effective referral if the physician conscientiously objects to MAID

the impact of MAID on religious institutions’obligation towards patients is not yet clear

Notify coroner if death occurs due to:

• Violence, negligence, misconduct

• Pregnancy

• Sudden or unexpected causes

• Disease not treated

• Cause other than disease

• Suspicious circumstances

. MAID

Physician Competence and Professional Conduct

CanMEDS Competencies (Ethical/Policy Statement)

•a framework of professional competencies established by the Medical Council of Canada (MCC) as

objectives for the MCC Qualifying Exam

• further information on Medical Council of Canada objectives can be found at www.mcc.ca

Legal Considerations

• physicians’conduct and competence are legally regulated to protect patients and society via

mandatory membership to provincial governing bodies(e.g. the CPSO)

• physicians are legally required to maintain a license with the appropriate authority, and are thus

legally bound to outlined policies on matters of conduct within their medical practice

• the ultimate constraint on physician behaviour with regards to unprofessionalism is‘conduct

unbecoming a physician,'

such as inappropriate behaviour with colleagues, conflicts of interest,

untruthfulness, unethical billing practices, and sexual impropriety with patients

Common Policies on Physician Conduct

• physicians must ensure that patients have knowledge of/access to on-call coverage and are never

abandoned

physicians are required to comply with the law, including human rightslaws

• sexual conduct with patients, even when consented to by the patient can lead to accusations of battery

and professional misconduct by the provincial governing body. Important notes on this topic include:

inappropriate sexual conduct includes intercourse, undue touching, inappropriate and unrelated

references to sexual matters,sexual jokes, and physician presence when capable patients undress

or dress

• in specific situations, physicians may have a personal relationship with a patient provided a year

has passed since the last therapeutic contact

physicians are permanently prohibited from personal relationships with patients whom they saw

for psychotherapy

in Ontario, physicians must report any colleagues of whom they have information regarding

sexual impropriety (as per CPSO Policy on Boundary Violations)

• physicians must maintain adequate records for each patient, which include:

• demonstration that care has been continuous and comprehensive

minimalstandardsfor record-keeping, including readability,diagnosis,differential diagnosis,

appropriate tests and referrals, and a coherent patient record, including drugs, a cumulative

patient profile, and all aspects of charting that are required for safe patient care (fullstandards

available at www.cpso.on.ca).Another physician should be able to take over the safe care of the

patient based on the record

• records stored for 10 yr in most jurisdictions, though this ought to be verified with one’s

provincial governing bodies

although the medical record is the property of the physician or an institution:

the patient or the patient’s delegate must be allowed full access to information in the medical

record

CPSO Policy:Treating Self and Family

Members

Physicians will not diagnose or treat

themselves or family members e xcept

for minor conditions or in emergencies,

and only it no other physician is readily

available

ft

CPSO Policy:Ending the PhysicianPatient Relationship

• Discontinuing servicesthat are

needed is an act of professional

misconduct

• Ex ceptions include patient request,

alternative services arranged,or

adequate notice has been given

CMA Code of Ethics

Report any unprofessional conduct by

colleaguesto the appropriate authority

CanMEDS Competencies

• Communicator

• Collaborator

• Health Advocate

• Leader

• Professional

. Scholar

• Medical Expert

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EL0M21 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

• the patient or delegate must obtain access within a reasonable period of time, usually upon a

written request

the physician can charge a reasonable fee for thisservice

•in the hospital, physicians must ensure their own competence, respect hospital by-laws and

regulations, practice only within the limits of granted privileges, cooperate with other hospital

personnel, and maintain hospital records

Research Ethics

Guiding Principles for Research Ethics

There are a number of principles that are

important to research ethics -the three

listed are primary ones that are typically

cited,but this list is non-exhaustive.

• Respect for persons:informed

consent

. Beneficence:harm vs.benefit

• Justice:avoid exploitation/unjustified

exclusion criteria

•involves the systematic analysis of ethical dilemmas arising during research involving human subjects

to ensure that:

study participants are protected

study participants are treated in accordance with relevant research ethics norms, including but

not limited to:respect for persons, concern for welfare, and justice

clinical research is conducted to serve the interests of the participants and/orsociety as a whole

• the protection of research participants is of the utmost importance when conducting clinical research

• a Research Ethics Board (REB) is responsible for reviewing and approving proposed human research.

REB approval isrequired prior to commencing a research study involving humans

• an ethical dilemma arises for physician researchers when their obligation to patients as their physician

comes into conflict with research obligations and/or incentives as a researcher.Physicians pursuing

research should not be the primary point of contact responsible for recruiting and consenting their

own patients due to the possibility of therapeutic misconception and/or feelings of undue influence/

lack of voluntariness

• REB offices located within hospitals may have requirements about who can/cannot recruit and/or

consent patients for their possible participation in research

• the Human Research Standards Organization (HRSO) develops and publishes nationalstandards

for those interested in overseeing,conducting, and/or participating in human research activities in

Canada. All published nationalstandards can be accessed here: https://www.hrso-onrh.org

• in order to become aware of all relevant research ethics principles and norms, of which there are many

(the above-mentioned principles and norms are far from an exhaustive list), it is recommended that

you read Declaration of Helsinki, the Belmont Report, and complete theTri-Council Policy Statement

Ethical Conduct on Research Involving Human Subjects (TCPS2) online training. The TCPS 2 (2018)

can be accessed here:Tri-Council Policy Statement:Ethical Conduct for Research Involving HumansTCPS 2 (2018) (ethics.gc.ca)

Ethics on Research with Indigenous People

• the Ownership, Control, Access, and Possession (OCAP) principles are “a set of standards that

establish important ground rules about how Indigenous peoples'

data should be collected, protected,

used,orshared”

• OCAP principles are:

control: Indigenous peoples, their communities, and representatives have the right

aspects of “research and information management processes that impact them"

access: “Indigenous peoples must have access to information and data about themselves and their

communities regardless of where it is held"

possession:Indigenous peoples are stewards of the data. As they possess the data, it is within

their jurisdiction and control

• researchers working with Indigenous communities are expected to uphold OCAP principles in their

research

• First Nations, Inuit. and Metis (FNIM) communities are self-determining, and as such, may have

their own version of OCAP.Investigatorsshould respect each community’s autonomy with respect to

research, data collection, analysis, interpretation, and knowledge transfer

• Chapter 9 of the TCPS2 discusses and provides considerations regarding research involving FNIM

Peoples of Canada.This chapter can be accessed here:Tri-Council Policy Statement:Ethical Conduct

for Research Involving Humans- TCPS 2 (2018)

- Chapter 9: Research Involving the First Nations,

Inuit and Metis Peoples of Canada (ethics.gc.ca)

The First Nations Principles of OCAP '

[Internet],Akwesasne (ON):First NationsInformation Governance Centre (FNIGC):2020|cited 2020 Apr12],Available

from:www.f NIGC.crVOCAP. OCAP'

is a registered trademark olthe First Nations Information GovernanceCentre [FNIGC)

Informed Consent for Research

• Purpose of study

• Expectations of the research

participant

• Name and probability of harm and

benefits

• whether and/or how participants

can withdraw their consent to

participate

• confidentiality (e.g.how will it

be maintained? Arc participants

going to be deidentified and

anonymized?)

• privacy (e.g. for how long will

participants' data be stored?)

• Nature of physician's participation

including compensation

. Proposals for research must be

submitted to a Research Ethics Board

(REB)

to control all CMA and CPSO Guidelines for Ethically

Appropriate Physician-Industry

Relations

• The primary goal should be the

advancement of the health of

Canadians

• Relationships should be guided by

the CMA Code of Ethics

• The physician's primary obligation is

to the patient

• Physicians should avoid any selfinterest in their prescribing and

referral practices

• Physicians should always

maintain professionalautonomy,

independence, and commitment to

the scientific method

Physician-Industry Relations

• healthcare delivery in Canada involves collaboration between physicians and the pharmaceutical and

healthcare supply industriesin the areas of research, education, and clinical evaluation packages (e.g.

productsamples)

• however, unlike physicians, pharmaceutical and healthcare supply industries do not have a fiduciary

duty to patients and are profit-driven. There exists a motive for pharmaceutical companies, which

extends beyond your responsibility as a physician

literature is clear that our decision-making is influenced by items such as gifts provided by the

pharmaceutical and healthcare supply industries (e.g. pens with brand names inscribed, free

lunch and learn sessions)

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ELOM22 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

accepting such offers(e.g.saying “yes” to a lunch and learn session being offered by a

pharmaceutical company, personal injury law firm, etc.) can directly influence physician

practices and beliefs in favour ofsuch promoted products. This influence can result in, for

instance, the prescription of medicationsfor reasons other than their efficacy and safety profile,

recommending particular law firms to patients (which is outside of one’sscope)

ultimately, there is a reason asto why the pharmaceutical and healthcare supply industriesspend

money to build relationships (namely, to influence decision-making in favour of the company)

the dissemination of free product samples by pharmaceutical companies is associated with

increased patient preference for new drugs that are often more expensive, thusincurring a greater

long-term cost for patients and the healthcare system

• new pharmaceutical products are not always more effective than previousstandard of care and

may have less robustsafety evidence by virtue of being new

• physicians must ensure that their participation in any collaborative efforts with pharmaceutical and

healthcare supply industriesis in keeping with their duties to their patients and society; however,

physicians often struggle to properly identify situations in which a conflict of interest is present, it is

recommended that clinicians who want support in identifying and navigating potential conflicts of

interest gain bioethicssupport

• gifts or free productsfrom the pharmaceutical industry are usually inappropriate:

sponsorship for travel and fees for conference attendance may be accepted only where the

physician is a conference presenter and not just in attendance

physicians receiving such sponsorship must disclose this at presentations and/or in written

articles; it is important to note, however, that the disclosure of conflicts does not eliminate the

potential influence that the conflict may have on physician behaviours

Resource Allocation

• definition: the distribution of any resource to programs and people (e.g. goods and services)

• if healthcare resources arc clinically indicated, physicians must make such resources available

to patients in a manner that takes into consideration equity, potential biases, and possible

discriminatory motivation of offering/not offering such resources

a person’s and/orsociety'

s need for and benefit of certain resources are morally relevant criteria

for determining allocation, particularly if resources are scarce

gender identity,sex,sexual orientation,religion, level of education,socioecnomic status, or age

alone are morally irrelevant criteria in and of themselves (i.e. one must not prevent a patient from

accessing a scarce resource exclusively on the basis of age)

• factors determining whether and/or how resources ought to be allocated must be balanced

against each other and weighed on a case-by-case,situation-by-situation basis. Tor instance, there

may be some cases where one’

s age is relevant to determining how much a patient is expected to/

not to benefit from a particular resource,but in other cases, age may be entirely irrelevant

• ethical dilemmas that may arise when deciding how best to allocate scarce resources:

favouring best outcome vs. giving all patientsfair access to limited resources (e.g. transplant list

prioritization)

• aggregation problem: providing modest benefits to many individuals vs.significant benefits to

few individuals

decision-making framework considerations:when to rely on a fair democratic process to arrive at

a decision, what does a ‘fair’processlook like?

Choosing WiselyCanada isthe national

voice for reducing unnecessary tests

and treatments in healthcare Refer

to https://choosingwisclycanada.org/

recommendations/for a comprehensive

list of recommendationsto assist in

decision making as healthcare stewards

Guidelines for Appropriately Allocating Resources

• protect and promote the welfare and best interests of patients

• enable informed, autonomous, and voluntary decision-making

• choose interventions known to be beneficial based on evidence of efficacy

• seek the test(s) or treatment(s) that will be most likely to accomplish the diagnostic or therapeutic goal

with minimal expected harms

• advocate for one'

s patients, but do not manipulate the system to gain unfair advantage

• resolve conflicting claims for scarce resources justly and equitably, on the basis of morally relevant

criteria such as need and benefit, using fair and publicly defensible procedures. Consult with external

resources(e.g. bioethicsteam) to help reduce potential biases in decision-making processes

• if appropriate,sensitively inform patients of the impact of cost constraints on care/the healthcare

system

• seek resolution of unacceptable shortages at the level of hospital management or government

Conscientious Objection rt

LJ

Patients Refusing Treatment

• in accordance with the principle of autonomy,it is generally acceptable for capable patients to make an

informed decision to refuse medical interventions, although exceptions may occur

• it is important to determine justification for refusal of recommended treatment, to ensure decisionmaking is informed, etc., particularly if the risks of such refusal are significant

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ELOM23 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

• if SDMs make decisions that are not in the best interests(or, if known, previously expressed wishes)

of an incapable child, physicians may have grounds for administering treatment, depending on the

acuity of the clinical situation.It is best to consult with Legal Counsel, Bioethics, and one’

sCollege if

you are considering the administration of treatment without consentsince applications to gain this

permission (via the Consent and Capacity Board in Ontario,for instance) may be essential

in high-acuity scenarios(e.g. refusing blood transfusion based on religious groundsfor a child in

hemorrhagic shock), physicians have a stronger obligation to act in the child’

s best interests

in lower acuity scenarios(e.g. refusing childhood immunization in a developed nation), there is a

stronger obligation to respect the autonomy of the decision-makers

Working with Vaccine-Hesitant Parents:

An Update

Canadian feediatric Society 2018

1. Understanding the health provider's

key role in parental decision-making

and not dismissing vaccine refusers

from practice

2. Using presumptive and motivational

interviewing techniques to identify

specific vaccine concerns

3. Using effective and dear language

to present evidence for disease

risks and vaccine benefits fairly and

accurately

4. Managing pain during immunization

5. Reinforcing the importance of

parental responsibility for community

protection

Physicians Refusing to Provide Treatment

• it isthe case that with justification provided, physicians may refuse to provide a desired treatment

(e.g. a treatment that is not clinically indicated and may cause harm) and/or discharge/discontinue

relationships with patients (e.g. if there is no therapeutic relationship or trust due to a series of

conflicts),but must ensure these patients can access services elsewhere by way of referring the patient

to an available and willing practitioner

Implicit Bias

• implicit bias involves: implicit attitudes, thoughts, and/or feelings that may exist outside of conscious

awareness and are therefore difficult to acknowledge and control

there exist varioustypes of (implicit) biases(e.g.related to age,race,sex,sexual orientation,

gender identity,socioeconomic circumstances)

• negative attitudes towards certain patients based on implicit biases may contribute to disparities

in quality of healthcare received

• these negative attitudes caused by implicit biases reflect constant pervasive exposure to

stereotypical portrayals of members of different “social groups"

• bias and stereotypes can be lethal

• on September 21, 2008, Brian Sinclair, an Indigenous man, presented to a Winnipeg emergency

department with a blocked catheter. His presence was not recorded by triage

while he waited in the emergency department waiting room, he lost consciousness, but was not

checked on by healthcare staff

after being in the waiting room for 34 h, he passed away without having received any medical

attention

• later, an inquest found that healthcare staff thought he was intoxicated or homeless

• a Manitoba court stated that Brian Sinclair'

s race, and consequently the stereotypesstaff held

leading to the assumption that he was intoxicated, were relevant factorsin his tragic and

preventable death

Suggestions for Noticing Implicit Bias

• before a clinical encounter, physicians are advised to check-in with themselves

• physicians may want to ask themselves:

• how are they feeling?

what are they worried about?

• what do they notice in their body?

• what is their intention for the interaction?

what do they need to feel more grounded and supported before going into the clinical space?

• how can they leave some of their assumptions and fears in the hall, instead of bringing them into

the examination room?

Clinical Informatics and Ethical Considerations

Key Terms

Health Informatics

• is the study of information design and use in healthcare

Clinical Informatics

• is the application of health informatics knowledge in the clinical setting to promote quality care. It has

three domains: collection of longitudinal personal health information for direct patient care, exchange

of health information between services and locations, and aggregation of health data for analysis

using analytics, artificial intelligence, and machine learning

Digital Health

• is the use of information technology and electronic communication tools,services, and processes to

deliver healthcare services

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ELOM24 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Overview of Digital Health Technologies

Table 6. Overview of Digital Health Technologies and Relevant Ethical Considerations

Digital Health

Technologies

Definitions Ethical Considerations

System of electronically stored patient health informationin a

digital format

EMR (Electronic

Medical Record)

Impact of threats to healthcare information

Privacy and confidentiality

Security breaches

System implementation

Oata entry inaccuracies

EHR (Electronic Health Digital collection of medical information(e.g.patient'shealth

Record) history,allergies,immuniiations.treatment plans

LIS (laboratory Computer software that processes,stores,and manages data from

InformationSystem) all stages of medical processes and tests

Computet software providing storage and access to images from

multiple modalities

PACS (Picture

Archiving and

Communication

System)

Indigenous Health

Overview of the History and Impact of Colonialism

•the Indigenous health crisis that exists today is a result of many factors, including the impact of

colonial laws, oppression, and genocide

• Indigenous health is deeply connected to the land and freedom that have been systematically stolen

from its people

• physicians can consider how oppressive legislation plays a role in precluding many Indigenous

patients from experiencing health

• you might find thistimeline outlining "Key Moments in Indigenous History"

helpful: http://education.

historicacanada.ca/files/426/Key_Moments_in_lndigenous_History_Timeline.pdf

• long before the arrival of European newcomers, Indigenous peoples lived on and cared for T urtle

Island (now known as North America). This history is richly steeped in culture, relationship, and a

holistic worldview. The Indigenous peoples had a nourishing trade, complex social and legal systems,

and scientific knowledge about astronomy, ecology, agriculture, and medicine. Despite hundreds of

years of adversity,Indigenous peoples and their rich cultures persist and thrive today - an indication

of the resilience and tenacity of Indigenous peoples and communities

• upon European arrival, Indigenous and non-lndigenous people formed friendships based on mutual

respect. These relationships were formalized through treaties. Treaties provided a framework for

relationships and the sharing of Indigenous landsin a peaceful and respectful way

• one example of how treaties were documented and enacted was through wampum belts. Wampum

belts are intricate visual displays made from clam shells.These beltsserve as a living record of

agreements. The two-row wampum belt is particularly important for understanding the relationship

between Indigenous peoples and Europeans

• in 1613, Kanienkehaka (Mohawk) peoples noticed that settlers were using and living on their

traditional lands. The Haudenosaunee Confederation met and discussed now they could live and work

together peacefully on the land. Through these discussions, they learned much about one another and

the two-row wampum was created: “In one row is a ship with our White Brothers’ways; in the other

a canoe with our ways. Each will travel down the river of life side by side. Neither will attempt to steer

the other’

s vessel.” This wampum represented three principles:friendship, peace, and the concept of

forever

• soon after these treaties were forged,greed and colonial policies began to erode these relationships.

• the treaties and the rightsthey established with Indigenous peoples became an inconvenience to the

expanding European empire, and consequently, they began to he ignored, as they continue to be today

• the Doctrine of Discovery'was the piece of colonial law that let European explorers‘discover’lands

previously occupied for thousands of years. This doctrine arose from a series ofstatementsfrom the

Hope, which morally and legally justified the dispossession of lands from their Indigenous inhabitants

(Terra Nullius)

• this justification is based erroneously on the supposed ‘inferiority’

of Indigenous peoples to their

‘superior’ European counterparts. This allowed monarchs to exploit North American land and

resources regardless of its original caretakers and use the power of this doctrine to extinguish

Indigenous rights. This doctrine continues to have devastating impacts on Indigenous peoples in

Canada

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ELOM25 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Figure 3. Image of a two row wampum belt. It represents friendship, peace, and the concept of forever

Boriupottc 0. the two Row Wampum Belt: An Akwvsune Tradition ol the Vesselrind Canoe (Internet;, [place unknown;: The People's Voice. 2005 Aug

5[cited 2020Apr 16J.Available from: htlpry/www.wampumchronides.com/tworowwampumbelLhtinl

•in 1763, King George 111 issued the Royal Proclamation that delineated the process of British

settlement of Indigenous lands. This proclamation gave ownership of North America to King George

111; however, it stated that Indigenous title existed and would continue to exist.Therefore, any land

would belong to the Indigenous people unless otherwise noted and agreed upon in a treaty. This

prevented European settlers from taking possession of land that was occupied by Indigenous peoples,

unless already purchased by the Crown

• this document unequivocally recognizes Indigenous rights, title, and self-determination.To this

day, no law has overruled the Royal Proclamation; therefore, it is still valid according toCanadian

law.Additionally,the notion of Indigenous rights is protected in section 25 of the Constitution Act.

Although Indigenous rights cannot be legally diminished or extinguished,theCanadian government

frequently disregardsthisfact

• in 1764, the year following the Royal Proclamation,the Treaty of Niagara would lay the foundation

for the relationship between the Crown and First Nations and their coexistence on Turtle Island. At

thisinstance, the Silver Covenant Chain of Friendship was affirmed and both Indigenous and British

sovereignty were recognized. The Treat)'of Niagara established a multinational familial relationship

between the Crown and the Indigenous nations

• over 2000 Indigenous dignitaries, representatives of 24 Indigenous nations across Turtle Island, were

present, and the 24-nation wampum belt was created. This wampum represents the relationship

between the Indigenous nations and the Crown

• the British North America (BNA) Act of 1867 (later renamed the Constitution Act,1982) gave the

Canadian government control over "Indians" (notably excluding lnuit and Metis peoples). This act

included New Brunswick, Nova Scotia, Ontario, and Quebec as a new self-governing federation. This

laid the foundation for Canada'

slaws and governance and the rights of those living in the territory

now defined asCanada.The BNA Actstated that the federal government had jurisdiction over

“Indians and lands reserved for Indians."

Indigenous peoples were not involved in conversations or

proceedings associated with the passingof this act

• in 1857, An Act for the Gradual Civilization of the Indian Tribes in Canada passed and later absorbed

under the larger umbrella of the Indian Act

• “it is desirable to encourage the progress of Civilization among the Indian Tribes in this Province, and

the gradual removal of all legal distinctions between them and Her Majesty'

s other Canadian Subjects,

and to facilitate the acquisition of property and of the rights accompanying it, by such Individual

Members of the said T ribes as shall be found to desire such encouragement and to have deserved it"

• this act encouraged the voluntary enfranchisement of Indigenous people.Enfranchisement is the

legal process of exterminating one’s “Indian" status and ancestral rights in order to gain Canadian

citizenship. Later, involuntary enfranchisement would be enforced, This would extinguish the status

of any Indigenous person who served in the armed forces, received a university degree, or became a

professional (e.g. lawyer, engineer, physician)

• this act depicts the deliberate intentions of Canadian parliament to erase Indigenous culture and

diversity from Canada. Other assimilatory programssuch as residential schools, the Sixties Scoop,

and Indian hospitals have been implemented over various time periods since Confederation. These

policies have created irreparable harm, and much of the poverty and current physical and mental

health crisesfacing Indigenous communities today can be traced back to these colonial injustices, as

well as ongoing colonialist policies

• a strong understanding of these historical factors can equip physicians to provide better care and

cultivate a more empathetic physician-patient relationship +

• the Indian Act (1876) allows theCanadian government to obtain complete control over First Nations,

status, and reserves.It precluded equal political and economic participation and actually made

cultural and spiritual practices illegal

ELOM26 Ethical, Legal, and Oiganizational Medicine Toronto Notes 2023

• the Indian Act still exists today but has morphed significantly since its establishment.This act has

taken total political control, imposed foreign governmental structures(band councils), and eliminated

the rights of Indigenous peoples to practice theirsacred cultural and spiritual beliefs.Indian agents

were government workers who enforced these laws and were given the power to prevent Indigenous

peoples from leaving their communities. In 1887, Sir|ohn A. MacDonald stated, “The great aim of our

legislation has been to do away with the tribalsystem and assimilate the Indian people in all respects

with other inhabitants of the Dominion asspeedily as they are fit to change”

• in terms of health, the Indian Act gives the Governor in Council control over the decisions made

surrounding regulations of public health and treatment. However, this act does not present any

obligation of the Canadian government to provide health servicesfor Indigenous peoples

• Section 141 of the Indian Act prevented Indigenous peoples from gathering and discussing their rights

or hiring legal representation to fight against this oppression

• )udge Alfred Scow describes the impact that this has had on his peoples:

“This provision of the Indian

Act was in place for close to 75 years and what that did was it prevented the passing down of our oral

history. It prevented the passing down of our values. It meant an interruption of the respected forms

of government that we used to have, and we did have forms of government be they oral and not in

writing before any of the Europeans came to this country. We had a system that worked for us. We

respected each other. We had ways of dealing with disputes"

• in 1951,some amendments were made to the Indian Act. The more oppressive sections were amended

or erased,such asthe outlawing of sacred practices, the inability to leave reserve without permission

of an Indian agent, the inability to hire legal counsel, and the inability of Indigenous women to vote in

Band Council elections

• the Indian Act continued to oppress Indigenous women uniquely by taking away theirstatusif

they married a non-lndigenous man. This means that a woman would have to leave her family and

community, and consequently lose her treaty and health benefits, including her right to be buried

on reserve with her ancestors.The opposite held true for Indigenous men, as it allowed for nonlndigenous women to gain Indian status through marriage

• in the 1970s-80s, Indigenous women began lobbying for equal rights and Bill C-31 was passed that

nullified thislaw, allowing many women to regain status. However,thislaw continues to pose

significant controversy as thisstatus is only allowed to be passed down to one generation

• Indian statusis defined under section 6 of the Indian Act and denotes who qualifies and therefore

becomes a ward of the government. This is a paternalistic legal relationship that creates two categories

of First Nationsstatus

6(1):this person can pass on theirstatusto their children regardless of their partner’s heritage

• 6(2):this person can only pass on their status if their partner is also Indigenous

• thisidea ofstatus complicates the identities of many Indigenous peoples (including non-status First

Nations, Metis, and Inuit peoples who do not fall under the Indian Act) who are prevented from

registering and therefore lose governmentsupport, their treaty, and health benefits.They also lose

their ability to:

• participate in community politics

partake in land claims

connect to their ancestral lands

• this displacement and the misconception that non-status peoples are “less Indian” is extremely

harmful and often serves as a platform for lateral violence. In this context,lateral violence refers to

when a member of an oppressed group behavesin a malicious or violent manner towards another

member of that same oppressed group or in a lower position of power, Lateral violence can be traced

back to the impact of colonialism

• Indigenous individuals are generally subject to full taxation, though individuals with status are

eligible forselect tax exemptionsthrough section 87 of the Indian Act. It is a pervasive and harmful

myth that Indigenous individuals do not pay taxes. For the most part, exemptions only apply to

financial matters located on-reserve, with complex and specific criteria to be met. Matters located offreserve are generally taxed in full. A summary of thisis available in Bob )oseph’s “Dispelling Common

Myths about Indigenous Peoples" https://www.ictinc.ca/hubfs/ebooks/ebooks%202019/Common%20

Myths%20eBook%20July%202019.pdf

• the Indian Act is a controversial piece of legislature because it undermines the nationhood and

sovereignty of Indigenous peoples. However,it is important to understand the Indian Act because it

also provides the basis for the historical and constitutional relationship between Indigenous peoples

and theCanadian government Therefore, it cannot be easily removed without having significant

ramifications

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ELOM27 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Movement Towards Reconciliation

• in 1991, the Royal Commission on Aboriginal Peoples (RCAP) wasformed to address the inequities

that exist, and to work to repair the relationship between Indigenous peoples and Canada. This

commission was brought about after the Oka Crisis. The Oka crisis (The Mohawk Resistance) arose

from a long-standing history of rejection and ignoring of Indigenous land rights by the Canadian

government, and resulted in a 78-day protest of a proposed golf course expansion onto sacred Mohawk

territory. The RCAP report (1996) detailed extensive research and recommendations needed to heal

and restructure the relationship between Indigenous and non-Indigenous peoples.The majority of

these recommendations have not been implemented and there continuesto be little government

interest in the constitutional issuesthat affect Indigenous peoples and communities

• in 2008, the Prime Minister of Canada apologized to all those who were affected by the residential

school system,where Indigenous children were forced into abusive schools(see Public Health and

Preventive Medicine.Colonization and Healthcare, PH7 ). The Truth and Reconciliation Commission

was born out of a settlement agreement between the government and residential school survivors. The

mission of this commission is to learn and tell the stories of those who attended these schools.This

commission hopes to bring about renewed relationships and healing based on mutual understanding

and respect. To achieve this goal, the commission put out 94 Calls to Action aiming to bring us closer

to reconciliation.These calls urge all levels of the Government of Canada to work together to address

systemic inequities by changing policies and programs that continue to oppress Indigenous peoples.

Under the category of health, the following recommendations are quoted below:

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 previous Canadian

government policies, including residential schools, and to recognize and implement the

healthcare rights of Aboriginal people as identified in international law, constitutional law, and

under the T reaties

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 nonAboriginal communities, and to publish annual progress reports and assess long-term 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

in order to address the 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, Inuit, and off-reserve Aboriginal peoples

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

we call upon those who can effect change within the Canadian healthcare system to recognize

the value of Aboriginal healing practices and use them in the treatment of Aboriginal patientsin

collaboration with Aboriginal healers and Elders requested by Aboriginal patients

• we call upon all levels of government to:

1. increase the number of Aboriginal professionals working in the healthcare field

2. ensure the retention of Aboriginal healthcare providers in Aboriginal communities

3. provide cultural competency training for all healthcare professionals

we call upon medical and nursing schools in Canada to require all students to 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

• going forward as healthcare professionals, we are uniquely responsible for knowing and

understanding the impact these historical and legal truths have on our patients. When addressing

health inequities that are disproportionately experienced by Indigenous peoples, we need to take into

account the impact of 500 years of colonialism. We need to understand how our patients and their

ancestors have experienced structural violence and trauma in order to address their physical, mental,

emotional, and spiritual health needs. Physicians need to understand that we are all treaty people,

and that the above legislation not only applies to Indigenous peoples, but to physicians as well, and all

those who benefit from these laws

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