CONSULTATION 016

Code of Ethics

The Canadian Medical Association began a major renewal of its Code of Ethics in 2017 to address medical innovation, technological advances and how new patient expectations have led to considerable transformations in health care and how medicine is practised. The updated Code is the result of extensive research and consultation with physicians and stakeholders. CMA received over 6,000 comments that helped inform the revision.

After an extensive two-year consultation process, the CMA Board of Directors approved its new Code of Ethics and Professionalism in December 2018.

Key Highlights

1. Inclusion of “professionalism” in the title
The name of the Code has been updated to highlight the growing emphasis on medical professionalism and to make a distinction between the core values of the profession and its evolving responsibilities.

2. Reintroducing and emphasizing virtues
Virtues centre on the character of a physician; reintroducing them into the Code reaffirms the that they’ve long defined what it means to be an ethical physician. They also complement the fundamental principles outlined in the Code.

3. Articulating fundamental commitments
The new Code makes a distinction between professional responsibilities – which physicians are expected to enact, and which can evolve over time − and fundamental commitments, which define the profession, and which physicians should aspire to uphold.

4. Emphasizing the patient-physician relationship
The new Code reinforces the importance of the patient-physician relationship. It also addresses the changing nature of both this relationship and medical decision-making.

5. Emphasizing new commitments to oneself
The new Code introduces commitments to physician health and wellness, in response to growing evidence linking poor physician health and the impact on patient care.

More information on CMA’s consultation and amendment process can be found here.

Under Section 133 of the Health Professions Act, CPSA must consult with our members and stakeholders before adopting a new code of ethics. In accordance with Section 9 of the CPSA Bylaws, we must consult for at least 60 days prior to bringing the Code back to Council for adoption.

We will continue to use the 2004 version until consultation is complete and Council makes a decision regarding the adoption of the revised CMA Code.

Consultation is now open. Your feedback will help inform our recommendation to Council in May 2019.

61 + 1 =

The profession, stakeholders, other organizations and public members are invited to provide feedback between March 11-May 10. Council will consider non-nominal feedback when deciding upon adoption of the Code of Ethics & Professionalism at its May 2019 meeting.

All feedback is subject to the College’s Privacy Statement. The College reviews all comments before publication to ensure there is no offensive language, personal attacks or unsubstantiated allegations.

If you have any questions or require further assistance, please contact Chantelle.Dick@cpsa.ab.ca

Comments

The 2004 and the 2018 documents are very different codes in many respects. Personally I prefer the format of the 2004 document. The 2018 version does not provide much clarity in areas of tension. How does one respect the autonomy of a patient when their decisions are harmful to themselves? Surely I cannot enable that.
Why does the self-care portion of the document bother to mention physician physical, mental, and social well being, and not mention spiritual well being?
These are just two out of a number of statements that got my notice as being either unclear in practice, or unnecessarily directive, and not really providing an improvement over the 2004 document.
I know the CMA has been working on this for awhile, but without specifying their reasons for the overhaul, it is hard to say that the new document is better than the previous version.

Nancy Craig
12/03/2019
Alberta Physician

In general, the document is fairly well-written, although I would suggest it is a bit lengthy.

First, just a few nit-picky style points / definitional issues. On page 4, point 10., there is a description of "inhuman" procedures. I wonder if the authors instead mean "inhumane" ? Also, on page 2, section A. the definition of Integrity states that this is represented by consistency with professional expectations. I would argue that integrity generally refers to the consistency between one's actions and one's deeply held moral beliefs. I also note that "professional integrity" is referred to on the next page. I wonder if these two (arguably different) concepts might be confused or conflated as the current document is written?

Under section B. "Commitment to Justice" (alluding to social advocacy) is listed in parallel with other "Fundamental Commitments" of the Medical Profession, like being committed to the well-being of the patient, having professional integrity, and so forth. I believe that it is disingenuous to list virtues on an equal plane when they inevitably come into conflict with one another. Consider that some societies prioritize honesty over loyalty and others loyalty over honesty and how fundamentally differently they operate. I believe that "justice" as it pertains to physicians, mostly applies to the microlevel (i.e. treating your patients fairly and equally and not favouring some over others). There is no training in medical school that I am aware of that grooms physicians to take up their megaphones and make political comments to the general public. The gun control debate comes to mind. If called upon to provide a scientific opinion, then one can cautiously make statements within one's area of expertise. This is different than saying, "Therefore, handguns should be banned" or other such sweeping hubris.

Point #36 about "fostering team ... shared accountability" would be easier to swallow if nurses or social workers or physiotherapists were ever sued for malpractice. Except in extreme cases, the buck stops with the physician. Until that changes, it is probably appropriate that physicians act as quarterbacks.

Point #38 seems overstated to me. I prefer the phrase "social correlates of health," because to use more deterministic language erodes personal agency of my patients and becomes a form of bigotry / low expectation.

Point #43 seems vaguely out of place or even racist to me. I think we should treat patients with dignity and respect whether they are Indigenous, Caucasian, Black, Liberal, etc. I don't think Indigenous peoples should merit an extra bullet point. I doubt that similar documents in the United States have separate bullet points for African-Americans or make reference to Civil War era issues.

David Lounsbury
Family Physician
12/03/2019
Alberta Physician

Seems quite acceptable and doable. If all physicians read and contemplated would make things better.

Norman Schachar
Professor Emeritas University of Calgary Cumming School of Medicine
12/03/2019
Alberta Physician

This caught my eye: “Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the physician to refuse to accept a patient for legitimate reasons.
2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the patient has been given reasonable notice that you intend to terminate the relationship.”

These questions come to mind:

What would be legitimate reasons to refuse a patient? What would be a reasonable notice for termination?

Robert Drebit
Consulting Psychiatrist, Children’s Mental Health
12/03/2019
Alberta Physician

I have reviewed the revised CMA code of ethics and commend the authors of the document which addresses some current technological and cultural aspects of medical practice. The only specific comment I have relates to an item under commitment to respect for persons: That is: always respect the autonomy of the person. As a psychiatrist, we at times must hold patients against their will when they pose a danger to themselves or to others and suffer from a mental illness. This is one of the few circumstances when safety demands overriding the patients autonomy. It would be helpful if there was clarification provided about such circumstances as outlined in the Provincial Mental Health Act.

Janet Wright
12/03/2019
Alberta Physician

I agree with the new code of ethics

Stanley S Smith
Dr.
12/03/2019
Alberta Physician

In regards to Section B, sub-section "Commitment to justice":

I strongly object to using the word "justice". This is a socially in vogue use of the term justice that should be discarded so as to avoid creating a political document.

Furthermore, "social accountability" is a superficially vague term that is also politically popular but means something different than it implies. The WHO definition from 1995 is “the obligation [of medical schools] to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.” If this is what physicians should promote or aspire to do, then let's be more specific in the code of ethics.

Wesley D. Block
Radiologist
12/03/2019
Alberta Physician

Let's be clear- the CMA doesn't represent me or most other physicians. Only one province got to vote on who its president is. Same with the past and future presidents. That's three members of the board I don't get a vote for. As an Alberta physician, I get to vote for exactly one board member, and that member gets the same pull as the med student rep and the non-physician rep. I get literally no say. Its board regularly defies the will of its members, such as by secretly selling off MD Management and using the proceeds for a political slush fund.

So please, don't pretend the CMA has moral authority to tell me what is ethical and what isn't.

Paul Kirvan
Physician
12/03/2019
Alberta Physician

I think the new code is fine although a bit more wordy than the previous version.

Karen Lundgard
12/03/2019
Alberta Physician

2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the patient has been given reasonable notice that you intend to terminate the relationship.

This wording does not consider a situation when a patient becomes violent (e.g. declares intent to harm or kill the physician). There needs to be wording that explicitly indicates that the relationship is terminated when safety is a concern.

Donna Manca
University of Alberta
12/03/2019
Alberta Physician

In this statement of the Code of Ethics, under the section of "Commitment to Respect for Persons", the fourth line states "Never participate in or support practices that violate basic human rights". Article 3 of the UN Declaration of Human Rights states "Everyone has the right to life, freedom and security of person". If all of us have an inalienable right to life, then how is medical assistance in dying - in which a physician actively participates in the death of an individual, thus taking away that patient's life, acceptable according to this proposed Code of Ethics?

Earl Campbell
Earl A. D. Campbell Professional Corporation
12/03/2019
Alberta Physician

Please review the Hippocratic oath. It is far removed from the amoral thinking that is current.
What is ethical? Where can a REAL doctor act with empathy and true care without being hounded by some medical or other rules? It is with relief that I will retire very soon.

Paul Marner
FP
12/03/2019
Alberta Physician

I think this is an excellent modification to include attention to physician health and ability to reflect on the process of the relationship. This is very important to maintain a balanced approach towards the fiduciary relationship of Doctor patient.

TCR WILKES
Division Head of Child and Adolescent Psychiatry
12/03/2019
Alberta Physician

It would help to have access to a document that shows the differences between the 2004 and 2018 version of the code of ethics.

Thomas Raedler
13/03/2019
Alberta Physician

38. Recognize that social determinants of health, the environment, and other fundamental considerations that extend beyond medical practice and health systems are important factors that affect the health of the patient and of populations.

I don't buy into this idea of the social determinants of health. It seems to me a lazy way to blame society for poor health, rather than recognizing that good health is significantly more the result of good personal choices than it is the availability of health care resources. The same characteristics that predict poor health are those that predict poverty.

10. Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure.

Does this include ripping apart unborn children limb from limb? Does this include encouraging or facilitating genital mutilation (what some call sex-change) in kids under the age of 18? Puberty blockers despite overwhelming medical evidence that this is a bad idea? Last I checked, the CPSA doesn't take a firm stance against these terrible practices that have become common place for some physicians.

Matt
Dr
13/03/2019
Alberta Physician

I question why Medical Doctors accepted Minister Sarah Hoffman return of 90 Million Dollars , if Physicians controlled Healthcare Costs and were diligent and prudent when requesting Medical Testing . Reading the old Physicians Code of Ethics , this should be a blatant breach and viewed as an outside influence upon accepting these funds . Is it reasonable to believe that with be the promise of funds returned to Physicians , it would not unduly influence their decision making Process . I am glad the Code of Ethics and Proffessionlsim is be reviewed . Patient care depends on it .
Thank you

John Newton
14/03/2019
Public

The items in point #43, while socially relevant, appear to reduce the understandings of our professional obligations of care to a specific historically marginalized group in this instance. My concern is our perception that this is necessary, as we are all tasked with the moral and ethical obligations of providing unbiased care to all persons regardless of race, religion, creed, or need. I feel that we could place ourselves in the unnecessary position of identifying many other groups in specific ways (ie. LGBTQ/Immigration/etc.), whereas the core tenets and moral imperatives directing the expectations of the care we provide remain unchanged. As such, I feel that this item need not be included - not because it doesn't't reflect important considerations, but because they are not inherently specific to our medical considerations.

John
HRH
14/03/2019
Alberta Physician

Dear Colleagues
This is clearly an improvement. Over many years I have tried to apply the code to my practice and those who worked with me. What I found was that the wording is often highly philosophical and general I.e. not pragmatic. That is no surprise obviously because it would become a huge document otherwise. Therefore it is however subject to interpretation, and in the case of bad behavior subject to manipulative arguement. My main additional suggestion therefore is to identify where in the code one addresses the issue of the “disruptive physician”. It is not clearly spelled out in precise terms. Disruptive physician behavior is outlined by the HQCA document but only as a guideline to follow. This needs the authority of the college and the CMA Code so it may be enforced by small groups of physicians in their practices. In that way the college doesn’t end up dealing with corrosive but not flagrant bad behavior at a high level. Ie self governance by our groups at the most basic level of good conduct in the office. In many years of practice the broad issues described in the new code are much less of a problem then the softer issues of disruptive behavior, that sadly eventually lead to formal complaints to the college. But not without a lot of damage caused by the disruptive physician in the meantime. I would ask the registrar how we might add some teeth to the HCQA guidlelines in our community practices. Will this come with the CPSA move to start requiring all community practice groups to have proper and authorized Medical Director positions...across the province? I look forward to your response. Thomas F Szabo MD FCFP(EM)

THOMAS SZABO
Clinical Associate Professor U of Calgary
14/03/2019
Alberta Physician

It is about time that we, as a profession, move into the 21st Century. Re-writing the Code including the above changed accomplishes a large portion of the changes necessary to move us toward modernization.

JAY A DANFORTH
15/03/2019
Alberta Physician

INCLUSION THAT FELLOW PHYSICIANS SHOULD ALWAYS SPEAK POSITIVE ABOUT OTHER PHYSICIANS ESPECIAL APPARENT MISTAKES WERE MADE. (TO PREVENT UNDUE COMPLAINTS)

Peter Palma, MD
NLRHCtr
18/03/2019
Alberta Physician

Two comments:

-Should the CMA include a position on the emerging role of AI in medicine, and its potential impact on patients and physicians? What are the ethics around this that need to be codified?

-The CMPA has advised you have a duty of care to advocate for patients when government/hospitals do not provide appropriate resources. Ie, simply accepting a detrimental delay in diagnosis or treatment because your jurisdiction appears to lack access or resources does not meet the duty of care to an individual patient / plaintiff. The document mentions a stewardship role, but must cut both ways - physicians should be conserving resources where appropriate, but they must also be enabled to communicate the need for additional ones where required and advocate appropriately.

Robert Davies
18/03/2019
Alberta Physician

seems very acceptable

Ahmed Bani
physician
19/03/2019
Alberta Physician

I feel very strongly that every patient is equally entitled to evidence based high quality health care, free from social or political interference. By mandating advocacy for one or more special populations, we may inadvertently marginalize another group or neglect the fact that every patient has vulnerabilities whether or not they fit into a defined vulnerable population. In view of this I would ask the CPSA to refrain from including articles 43 and 44 and any other article which mandates advocacy for one particular group of patients.

Jennifer Norheim
19/03/2019
Alberta Physician

This is a great improvement!
I particularly like the emphasis on virtues.

Jack Bromley
physician
25/03/2019
Alberta Physician