CONSULTATION 016

Code of Ethics

Consultation Outcomes

After a 2-year consultation, the Canadian Medical Association (CMA) published an updated Code of Ethics and Professionalism in 2018 (read more about CMA’s consultation and amendment process here).

Per Section 133 of the Health Professions Act, CPSA is required to consult with our membership, the Minister of Health, and organizational partners before adopting a new code of ethics. Consultation ran March 11-May 10, and 57 regulated members provided feedback:

  • 45% of respondents agreed with the proposed adoption of the updated Code of Ethics
  • 20% of respondents voiced dislike of the new edition
  • Despite clear messaging that changes to this document were not possible, 35% of respondents provided suggested edits; however, only 2 respondents explicitly suggested CPSA create its own code of ethics.
  • The majority of questions or requests for clarification are addressed in current CPSA standards
  • 8 respondents do not believe singling out Indigenous people is appropriate
  • 6 respondents found the document too long in comparison to the 2004 version
  • 2 respondents do not view the CMA as representative of Canadian physicians

While CPSA was unable to make edits to CMA’s 2018 Code of Ethics and Professionalism based on feedback received during the consultation – unlike the other Standards of Practice – your input informed our recommendation to Council.

The recommendation to adopt the 2018 Code was based on the feedback of medical regulators across Canada provided to CMA through FMRAC and CMPA, which resulted in extensive conversations and significant edits to the original version. Additionally, the recommendation to adopt the 2018 Code was made in an effort to maintain consistency across the country for physicians who work in multiple provinces.

Many of the comments received questioning why various topics are not addressed in the 2018 Code (e.g., acceptable reasons to refuse a patient, referring patients to other physicians, etc.) highlighted areas of our standards to examine for deficiencies or ambiguity. A code of ethics is not designed every issue a physician may encounter, but to set out baseline expectations that provincial laws and regulatory standards may put into force that define the expectations of the rules in order to protect the safety of patients.

The profession, stakeholders, other organizations and public members were invited to provide feedback between March 11-May 10, 2019. Council considered 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

The College has turned a perfectly good code of ethics into a mean, petty, uninspiring document which is verbose and repetitive. It may not be exhaustive, but it is certainly exhausting. It needs an editor. The preamble needs to be stuffed into a footnote at the end. The code of ethics needs to be separated from the code of professionalism. If the college did that, it would be able to stuff as many petty little rules as it could think of into the code of professionalism and at least leave us with one brief inspiring document called a code of ethics.

What is the intended audience for this document? The public? The profession? Both? Who is going to actually read something so long-winded?

I suggest that the College contact a reputable Canadian publisher and seek advice from one of its senior editors. Failing that, it could contact several professors of English at an Alberta university for suggestions on a rewrite.

Winston Churchill was once asked how long his speech would be. “Rather long, I’m afraid,” he answered, “I didn’t have time to write a short one.”

Graham Hunter
MD
08/04/2019
Alberta Physician

I have commented previously that this document is “wordy”. I here provide an example.

Section 1.
Four different terms are used regarding sexual matters. These are: “gender identity”; “gender expression”; “sex” and “sexual orientation”.

Am I such a dinosaur that I do not realize that these refer to four distinct things? Or is this an example of lazy use of language? Is it really necessary to use “gender expression” when you already have “gender identity”. After all, people who identify in a certain way express themselves accordingly. Is it necessary to use both terms “sex” and “sexual orientation”. Does the use of the word “sex“ really add anything? What does it mean here? Would it not be as meaningful merely to use the two terms, “gender identity“ and “sexual orientation“? It seems to me that these terms cover pretty much everything from straight to gay to bisexual to transgender. Aren’t we trying to cover as much as possible in as few words as possible? Good editing usually involves the removal of words, not their insertion.

In the course of a fairly long career I have been the first point of contact for three people who transitioned and I helped them on their way until their needs exceeded my psychiatric and surgical skill. Therefore, I do not consider myself a dinosaur, Nor do I consider that my understanding of this vocabulary is faulty. If I am wrong, I would appreciate being corrected.

Graham Hunter
MD
08/04/2019
Alberta Physician

I dislike the mention of one particular ethnic/racial/cultural/native group not because I am opposed to that particular group - I am not and I have numerous patients who belong to that group and who are happy to come and see me - but I fear that specific mention of one group diminishes the group rather than enhances it. My argument is similar to that which has been used against the introduction of the “Islamophobia bill” by the Liberal government. Before this, there was never any specific protection for other minorities such as Jews (Does anybody remember anti-Semitism?) - anti-semitism used to be a word. You don’t hear it anymore. Now you hear Islamophobia.

So let’s stick to the general. Discrimination against people on the basis of race or religion is wrong. Period.

Graham Hunter
MD
08/04/2019
Alberta Physician

I find this document overly political. It reminds me of an editorial by a former registrar regarding a current US president. I think the College should stay away from political statements as much as possible. Stick to basics. Stay away from politics. The registrar was retiring at that time so he could say anything he wanted to. I don’t think that The Messenger should be used for such purposes. And I don’t think political matters should find their way into the code of ethics. The code of ethics should be brief and inspirational. It should “inspire”. This one does not.

By the way, though this so-called code of ethics and professionalism was instituted by the Canadian Medical Association; that is no seal of approval. The Canadian Medical Association has long since ceased to be a representative vehicle for many Canadian physicians. (But it has become very political. And its goals, and reasons for being, are entirely different from those of provincial regulatory bodies. We should not lose sight of that. I think the College HAS lost sight of that.)

Finally, let me say that it does not inspire me when the College states (as it has from time to time) that it has consulted with different groups such as Alberta Health Services. Alberta Health Services is not a sentient being. It is an enormous, anonymous organization. What I want to know is with whom did The College consult? With which human beings? With what credentials? Are these “consultants” willing to stand up and be counted? The College can say it “consulted” with any groups it wants but this does not lend credibility to the College. The College itself is not a sentient being. Any other organization could say “We consulted with the College of Physicians and Surgeons of Alberta.“ So what? With whom?

The College should quit trying to gain credibility by pretending that it has consulted with others. It does not matter whether you have consulted or not. What matters is the final document. This is the document that you are taking responsibility for. Consultation does not lend credibility. You have to take responsibility for the document yourselves. The College‘s consultants are not taking responsibility for this document. It is entirely the responsibility of the College. That is the end of it.

Graham Hunter
MD
08/04/2019
Alberta Physician

Why do you have to use such obtuse and academic language? Why do you have to say “articulates” instead of “says” , “states” or “lists”. No one in the general public “articulates” anything. They “say” what they have to say. They “state“ things.

I am presuming, of course, that you wish this document to be accessible to the general public and not just to the profession.

Graham Hunter
MD
08/04/2019
Alberta Physician

Despite the fact that this new code is so disappointing, so uninspiring, and so terribly prescriptive, I think I will be forced to support it, with regret, because of its multiculturalism aspect. The “heavy hand” of multiculturalism obviously underlies this document. “Common sense” is something that is taken for granted in different cultural groups. But “common sense” is not “common” at all “between” cultural groups. The Canadian physician population is now a heavily multicultural group. It is distressing to me, but apparently entirely necessary, that there be a very detailed code of ethics and professional responsibilities to which all these different groups should adhere. I guess this code is merely a reflection of the times.

I am disturbed, though, by what I consider “mission creep”. This is the gradual, progressive extension of regulatory authority that the College grants itself. I wonder how long it will be before people are disciplined for working too long, being overweight, or smoking. The section on physician health is disturbing. It would be far better if the College did something to assist physicians who are in difficult work situations rather than creating a framework in which punitive measures could be taken.

Graham Hunter
MD
08/04/2019
Alberta Physician

It's a bit hard to compare the 2004 and 2018 versions. The new version seems remarkably "vague" overall, possibly because of so many terms like "guide", "aspire to", "strive to", etc. It will probably be harder to decide whether a specific decision or action by a Canadian physician meets the new CMA Code or not. Although it's the "highest" point of reference for medical ethics/professionalism in Canada, in many ways it's too vague to be useful. An aspirational document might inspire those (few) docs who actually read it, but the gray zones are where a Code of Ethics/Professionalism is most needed, and I would suggest the new version is perhaps worse than the previous one at helping navigate those gray zones.

Many of the terms used aren't defined, although I'd hate to see the Code lengthened further! As one of many examples, I struggle with the inconsistent self-referencing of various terms in the following:
"In this Code, medical ethics concerns the virtues, values, and principles that should guide the medical profession, while professionalism is the embodiment or enactment of responsibilities arising from those norms through standards, competencies, and behaviours. Together, the virtues and commitments outlined in the Code are fundamental to the ethical practice of medicine." Maybe it's just me.

As far as specific comments go, here are a few:

Preamble
- for some reason, specifying that the Code outlines responsibilities related to "contemporary" medical practice seems jarring, and begs the question whether this Code needs yearly review to ensure that statement continues to apply?

Section A.
- "COMPASSION. A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient." An example of when aspirational language is simply confusing - what exactly is meant by "accompanies the suffering and vulnerable patient"? Accompany them home? Or to the bathroom? Accompany them in their "medical journey", somehow? It sounds fine on first reading, but seems to fall apart when one attempts to apply it.

Section B.
- "Provide appropriate care and management across the care continuum." Although (I think) I understand what this means, it seems to fall apart as soon as I try to think of practical examples. Does the "care continuum" refer to cradle-to-grave, or resuscitative/curative/palliative care, or care at home/in-hospital/in-clinic/other? Surely all physicians can't be expected to provide care across all, or even one, of these continuums?

Section C.
- Another example of vagueness to the point of impracticality: "Act according to your conscience and respect differences of conscience among your colleagues; however, meet your duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and requests whatever your moral commitments may be." How does "acknowledging and responding" to the patient's concerns and requests equate to fulfilling a "duty of non-abandonment"? Clearly this is aimed at referrals for morally-sensitive things like abortion or MAID, but as written it means I fall foul of the Code if I don't "respond" (presumably by acquiescing) to my patients' requests - I can think of ten examples off the top of my head where doing so would be blatant malpractice.

- "Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the profession." It's surely overly-optimistic to state that there is a single "accepted view of the profession" on contentious issues, where this guidance is likely to be most relevant? Is the CMA the arbiter of this "accepted view"? Not being paranoid, but realistic.

In some ways, the revised Code is a classic example of a shift from a somewhat objective (or at least codified) set of ethical principles, to a somewhat subjective ethics that flirts with relativism - it becomes much harder to say "do this" or "don't do this", but instead we're left looking at "the medical profession" in a mirror, and defining ethics and professionalism by what we see, or hope to see, there. It's perhaps not the CMA's fault, as we're only following general society in this respect, but it's worth a passing thought to where this road leads, given some historical examples where the profession's "accepted view" was, in hindsight, entirely wrong. In many ways, the revised Code makes a laudable attempt to update the way in which we view our responsibilities to patients and society, and a lot of the new content is wonderful, but I do feel the result is a document that is less practically useful and much more "open to interpretation" than the previous one. Whether this actually matters or not remains to be seen. I wonder whether the CMA Code of Ethics and Professionalism will ever be relied on by physicians themselves, the Colleges, or the courts, in determining anything that matters? Or if it's simply aimed at the court of public opinion?

Noel Corser
30/04/2019
Alberta Physician

It is very clear that we live in a different society compared to 15-20 years ago. Patients are demanding treatments, with the autonomy principle being overriding all the other rational and ethical values.
The code should have some protection against the demands for treatments that are not within the best interest of the patient or treatment for which the results would inevitable prolong the dying process. Without using the "futile" word (dangerous due to different interpretations), at least the "physiologic futility should be advocated as a parameter. A treatment that is known that will not be physiologically plausible.

We are moral agents – patients are not our properties, but also physicians are not “vending machines” who must act against what they think is medically advisable or which affronts their personal and idiosyncratic morality (except in emergencies). Treatments that will bring moral distress to the whole team as well.
(Eric Loewy, Theoretical Medicine & Bioethics 2005
Physicians do not “hang their own moral beliefs together with their coats on a coat hanger, and provide whatever services a patient wishes as long as they are within the confines of the contract and the law.
(Engelhardt “The foundations of Bioethics”.)

Daniel
Stollery Children's hospital, Peds Intensive Care Attending Phyician
10/05/2019
Alberta Physician

Thanks for the opportunity to have some input into this document; it seems very well thought out and thorough.

My input focuses on the conscience of the individual physician. We are all trying to do what is good and right for the patient, but inevitably there will be a diversity of opinion about this among doctors, among patients, and even within the membership of the governing bodies of our profession.
If there weren't diversity among the membership, that could be a sign of "group-think" or perhaps a reluctance to speak up for something different – not a good thing! Our ethical guidelines need to acknowledge that and do their level best not to force anyone to breach their own conscience.

Under the conscience consideration, I have two questions:
1. Do the guidelines give adequate consideration and protection to the ethnic and religious diversity among practicing physicians? I would include atheism in the word ‘religious’ for it is truly a religious viewpoint. For example, the paragraph on Prudence indicates a physician should make a decision “…in good conscience…”. The good conscience decision of one physician will be different from another based on, in many cases, diverse ethnic and religious viewpoints. Will one of those physicians be subject to discipline, and the other not, even if both made their decision absolutely based on good conscience, and good clinical and moral reasoning, etc. as the paragraph states? If so, then one physician’s conscience will have been protected, and the other's not. Will the result be that only the physicians whose conscience and therefore underlying worldview conform to the worldview of the governing body will be protected? Sometimes the minority is ‘right’, so we must allow them to stand on their conscience, even when the majority disagrees. Isn’t that how much of the progress on human rights and science has been achieved? Perhaps more explicit, stronger wording could be inserted to protect, if not encourage the independent expression and practice of diverse moral and religious consciences.

2. Do the guidelines offer adequate opportunity for expression of diversity and/or dissent by individual physicians vis-à-vis the public representations of their governing bodies? I’m thinking specifically of clause 41, which requires a physician to “Provide opinions consistent with the current and widely accepted views of the profession…” While allowance is made to “…clearly indicate when you present an opinion that is contrary to the accepted views of the profession” the previous wording seems to require a physician to ‘toe the party line’. If a physician is just sadly uninformed or stubbornly refuses to accept scientifically proven facts, this can be dealt with under competence requirements. Or does the proposed obligation to provide ‘opinions’ consistent with widely accepted ‘views’ refer to more than simply providing competent medical care? Given the competence requirements already in place to ensure good care, would anything be lost if clause 41 were deleted?

Both of these concerns go back to the truth of history, that not infrequently it is the ones who voice the dissenting view who have sometimes changed the world and medicine for the better – Galileo, Copernicus, etc. Let’s ensure they have a voice.

Thanks for your work.

Gisela Macphail
Infectious Diseases Physician, CUPS Liver Clinic
10/05/2019
Alberta Physician