Ethics   competency based

CMA Code of Ethics

CMAJ series: Bioethics for Clinicians 1996-97

Canadian College of Family Physicians

Royal College of Physicians and Surgeons of Canada

Various national specialty and sub-specialty societies and associations

Quebec Code of Ethics of Physicians

Various provincial licensing bodies

Canadian Human Rights

Trust in doctor patient relationship

Patient’s right to confidentiality

Legal obligations to disclose to public authorities

Disclosure to third parties

	with consent of patient;
	duty to notify of planned or required disclosure; and
	incapacitated patient.

Rights of minors

Right to access information only of patients under care, and with consent of patient

Duty to warn (individuals discovered to be at risk through disclosures made in confidence)

 To explain the basis for the physician’s obligation to maintain confidentiality.

 To explain reasonable precautions to maintain confidentiality (verbal, telephone, fax or e-mail communication; charts, written or computer stored; and educational or research rounds or presentations).

 To recognize situations in which third parties have a legitimate interest and right to information:

	legal requirements in the interest of public health;
	legitimate interest of 3rd parties (e.g., Insurance companies); and
	duty to warn threatened individuals.

 To recognize reasonable limits to disclosure, and reveal only the relevant and necessary

information, in a situation requiring disclosure to a third party.

 To recognize duty to advise patients of known risks of voluntary disclosure (e.g., Risks of disclosure of HIV status).

 To recognize the need to advise patient of obligatory disclosure of information.

 To transmit required information in a timely fashion.

 To recognize and seek guidance where harm from disclosure balances harm of maintaining confidentiality.

 Expressed consent, oral or written

	current
	advanced directives

 Informed choice (disclosure of material risks and alternatives)

 Voluntariness (freedom from coercion)

 Consent for emergency treatment

 Capacity to give consent

	impairment
	consent by minors
	assessment of capacity

 Implied consent

 Substitute decision makers or proxies

 Refusal or revocation of consent

 Candidate will communicate with a patient or their legitimate delegate, so as to obtain their consent or refusal to a given investigation or treatment.

 To explain the legal and ethical basis for consent.

 To demonstrate awareness of process for the assessment of capacity to give consent, and be able to conduct such an assessment.

 To recognize factors which can alter capacity (e.g., disease, drugs, depression).

 To identify appropriate substitute decision maker, or the process to determine that individual.

 To communicate clearly information relevant to informed consent (what a reasonable person would want to know in a given circumstance).

 To identify reasonable steps to ensure understanding of information: can the patient explain the medical problem, and the proposed treatment or test.

 To determine free choice, and absence of coercion.

 To recognize the patient’s right to refuse or revoke consent without prejudice to subsequent treatment.

 To recognize and identify ways of determining the appropriate balance between the emerging autonomy of a minor with the legitimate interests of parents or child welfare authorities.

 To recognize legal requirements in such cases.

 To recognize the legitimacy of the intentions of impaired patients as they may have been expressed (advanced directives).

 To recognize the duty to provide necessary emergency care where consent is unavailable.

 To recognize the need to provide non-consensual treatment in the public interest; e.g., involuntary admission for patients whose conditions possess an unacceptable risk to themselves or others.

 To recognize the role of religious belief in obtaining patient consent and the provision of treatment.

 Ethical basis for a patient’s right to know

 Consequences of violating a patient’s right to know

 Disclosure of relevant information

 Prohibition from transmitting false information

 Incomplete disclosure

 Exceptions (cultural, potential harm)

 Candidates will recognize that their duty is to speak truthfully and appreciate that it may conflict with their duty to do no harm.

 To understand and explain the ethical and legal basis for truth telling:

	respect for patient’s autonomy;
	situations of inevitable disclosure;
	provision of support with disclosure of difficult news; and
	respect patient’s need to make realistic life decisions.

 To recognize reasonable right of patient to know relevant information:

	purpose and implications of investigations;
	diagnosis and prognosis of medical condition;
	risks and benefits of treatment; and
	health risks to which they are exposed.

 To respect patients right to not know, and ascertains a patient’s wishes:

	identify and respect valid exceptions to truth telling;
	seek consent for disclosure;
	awareness of personal and cultural context and how that may influence a patient’s choice; and
	respects a patient’s choice above that of family members.

 To recognize and seek guidance in situations of conflict between this and other ethical duties, particularly the duty to do no harm.

 Fair access to health care resources

 Obligation to seek best interest of patient

 Prudent use of health care resource

 To make health care resources available to patients in a manner which is fair and equitable, without bias or discrimination.

 To recognize situations in which allocation of resources is unfair, and seek resolution.

 To recognize or propose fair means of resolving disputes for resources:

	primary obligation to patient;
	rank known patients ahead of unknown or future patients;
	use morally relevant criteria in allocating resource; and
	consult hospital ethics committees or other responsible bodies.

 To choose interventions on the basis of best available evidence:

	known to be effective;
	anticipated cost benefit; and
	avoid marginally beneficial investigations or treatments.

 To inform patients of impact of cost restraint in a supportive way.

 To be prudent and avoid waste in the utilisation of scarce or costly resources.

 Scientific and ethical merits of research

 Conflict of interest

 Full disclosure to informed consent

 Right of non-participation or withdrawal without prejudice

 To ensure that any research study in which their patients are involved is scientifically and ethically sound, that their patient has had full disclosure of anticipated risks and benefits, and has made an informed choice free from coercion.

 To identify reasonable criteria for ethical approval of research involving patients.

 To identify or propose reasonable steps to ensure scientific rigour of research (peer review, expert opinion).

 To refuse to participate or enrol your patients in research which has not been scientifically and ethically evaluated.

 To recognize the need for fully informed and voluntary consent.

 To identify additional information which should be disclosed in the course of research, as opposed to clinical consent.

 To acknowledge and disclose any possible conflict of interest on the part of investigator.

 To recognize the legitimate obligation of the hospital to have all research approved through a research ethics committee.

Medical Research Council

National Council on Ethics in Human research

 Conflict of interest

 Place best interest of patient first

 Candidates should be aware of the existence of an ethical code which regulates the relationship between the profession and the pharmaceutical industry, and recognize situations which breach it.

 The primary obligation of the physician is to their patient. Relationships with industry are appropriate only if they do not impinge upon that responsibility.

 Any conflicts of interest arising from a relationship with industry must be resolved in favour of the patient.

 Physicians in their practice must preserve their professional autonomy. Any potential conflict of interest must be disclosed to the patient.

 Institutions and organizations in which a physician works or holds privileges may have additional requirements regarding disclosure of potential conflict of interest.

 If a conflict of interest cannot be resolved, the physician may recommend a second opinion, or refrain from offering an opinion.

PMAC Guidelines

Canadian Medical Association Guidelines

CMA policy statement on Physicians and Industry

Canadian Medical Association Journal 1994; 150:256A-256C

 Obligations and restrictions

 Conflict of interest, disclosure of personal or moral limitations

 Professional boundaries

 Physician’s and patient’s rights

 Care of friends and family

 To recognize and demonstrate the elements in current codes which define the doctor patient relationship.

 The physician will place the best interest of the patient first.

 To establish a relationship of trust between physician and patient.

 To follow through on undertakings made to the patient, in good faith.

 To accept or refuse patients requesting care:

	without consideration of race, gender, age, sexual orientation, financial means, religion or nationality;
	without arbitrary exclusion of any particular group of patients, such as those known to be difficult, or afflicted with serious disease; and
	except in emergency situations, in which case care must be rendered.

 Once having accepted a patient into care, the physician may terminate the relationship, providing:

	care has been transferred; or
	adequate notice has been given to allow the patient to make alternative arrangements.

 The physician will not exploit the doctor patient relationship for personal advantage; be it financial, academic or otherwise.

 To disclose the limitations to the patient where personal beliefs or inclinations limit the treatment a physician is able to offer.

 To maintain and respect professional boundaries at all times:

	including physical, emotional, and sexual boundaries; and
	regarding treatment of themselves, their families, or friends.

 Personal Conduct

	competence
	impairment

 Professional Conduct

 The candidate will be aware of the conduct expected of a physician and recognize their responsibilities if a colleague demonstrates unprofessional conduct.

 To conduct yourself in a professional manner, characterised by dignity, respect, integrity, and honesty:

	possess and maintain medical expertise; and
	practice competently without impairment by substances, ill health, or other incapacity.

 To recognize responsibility of the profession in self regulation:

	maintenance of appropriate standards of the profession; and
	participate in peer review.

 To participate in learning with peers and others which may include:

	students;
	health care professionals; and
	community or patient groups.

 To assist peers and others in achieving effective methods of care, in the best interests of patient well being.

Uninsured services, for this policy’s purpose, are:

	Those which are not covered under the provincial schedules of medical benefits as amended from time to time.
	Services to unregistered patients who are ineligible for provincial health coverage or for coverage under the reciprocal agreement among provinces.

 Consider, in determining professional fees, both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient.

 Avoid any personal profit motive in ordering drugs, appliances or diagnostic procedures from any facility in which the physician has a financial interest.

 The patient’s best medical interest must always be foremost.

 Euthanasia

 Physician assisted suicide

 Maternal-fetal conflict of rights

 Advanced reproductive technology

 Fetal tissue

 Abortion

 Genetic testing

 The candidate will be aware that they may be asked to comment on unresolved or controversial ethical issues, and will be able to name and describe relevant key issues and ethical principles.

 When confronted with such a situation, candidates will:

	discuss in a non-judgemental manner;
	ensure patients have full access to relevant and necessary information;
	identify if certain options lie outside their moral boundaries and refer to another physician if appropriate;
	consult with appropriate ethics committees or boards; and
	protect freedom of moral choice for students or trainees.