PROFESSIONAL ETHICS

Code of Ethics Summary and Other Resources

  • Code of Ethics
  • End of Life / Assisted-Death
  • Opioid Prescribing
  • Articles & Videos
  • Disruptive Physician
  • Resources

Code of Ethics

CMA Code of Ethics - Download PDF (Last Updated 2004, Last Reviewed March,2015)
"This Code has been prepared by the Canadian Medical Association as an ethical guide for Canadian physicians, including residents, and medical students. Its focus is the core activities of medicine – such as health promotion, advocacy, disease prevention, diagnosis, treatment, rehabilitation, palliation, education and research. It is based on the fundamental principles and values of medical ethics, especially compassion, beneficence, non-maleficence, respect for persons, justice and accountability. The Code, together with CMA policies on specific topics, constitutes a compilation of guidelines that can provide a common ethical framework for Canadian physicians. Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions...." - CMA

Fundamental Responsibilities
1. Consider first the well-being of the patient.
2. Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.
3. Provide for appropriate care for your patient, even when cure is no longer possible, including physical comfort and spiritual and psychosocial support.
4. Consider the well-being of society in matters affecting health.
5. Practise the art and science of medicine competently, with integrity and without impairment.
6. Engage in lifelong learning to maintain and improve your professional knowledge, skills and attitudes.
7. Resist any influence or interference that could undermine your professional integrity.
8. Contribute to the development of the medical profession, whether through clinical practice, research, teaching, administration or advocating on behalf of the profession or the public.
9. Refuse to participate in or support practices that violate basic human rights.
10. Promote and maintain your own health and well-being.

General Responsibilities
11. Recognize and disclose conflicts of interest that arise in the course of your professional duties and activities, and resolve them in the best interest of patients.
12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.
13. Do not exploit patients for personal advantage.
14. Take all reasonable steps to prevent harm to patients; should harm occur, disclose it to the patient.
15. Recognize your limitations and, when indicated, recommend or seek additional opinions and services.
16. In determining professional fees to patients for non-insured services, consider 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.

Initiating and Dissolving a Patient-Physician Relationship
17. In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status. This does not abrogate the physician’s right to refuse to accept a patient for legitimate reasons.
18. Provide whatever appropriate assistance you can to any person with an urgent need for medical care.
19. Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted; until another suitable physician has assumed responsibility for the patient; or until the patient has been given
reasonable notice that you intend to terminate the relationship.
20. Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available; there should be no fee for such treatment.

Communication, Decision Making and Consent
21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.
22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.
23. Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patient or to others. If a service is recommended for the benefit of others, as for example in matters of public health, inform your
patient of this fact and proceed only with explicit informed consent or where required by law.
24. Respect the right of a competent patient to accept or reject any medical care recommended.
25. Recognize the need to balance the developing competency of minors and the role of families in medical decision-making. Respect the autonomy of those minors who are authorized to consent to treatment.
26. Respect your patient's reasonable request for a second opinion from a physician of the patient's choice.
27. Ascertain wherever possible and recognize your patient's wishes about the initiation, continuation or cessation of life-sustaining treatment.
28. Respect the intentions of an incompetent patient as they were expressed (e.g., through a valid advance directive or proxy designation) before the patient became incompetent.
29. When the intentions of an incompetent patient are unknown and when no formal mechanism for making treatment decisions is in place, render such treatment as you believe to be in accordance with the patient's values or, if these are unknown, the patient's best interests.
30. Be considerate of the patient's family and significant others and cooperate with them in the patient's interest.

Privacy and Confidentiality
31. Protect the personal health information of your patients.
32. Provide information reasonable in the circumstances to patients about the reasons for the collection, use and disclosure of their personal health information.
33. Be aware of your patient’s rights with respect to the collection, use, disclosure and access to their personal health information; ensure that such information is recorded accurately.
34. Avoid public discussions or comments about patients that could reasonably be seen as revealing confidential or identifying information.
35. Disclose your patients' personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or, in the case of incompetent patients, to the patients themselves. In such cases take all reasonable steps to inform the patients that the usual requirements for confidentiality will be breached.
36. When acting on behalf of a third party, take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to the third party.
37. Upon a patient’s request, provide the patient or a third party with a copy of his or her medical record, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others.

Research
38. Ensure that any research in which you participate is evaluated both scientifically and ethically and is approved by a research ethics board that meets current standards of practice.
39. Inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of your participation including any compensation.
40. Before proceeding with the study, obtain the informed consent of the subject, or proxy, and advise prospective subjects that they have the right to decline or withdraw from the study at any time, without prejudice to their ongoing care.

Responsibilities to Society
41. Recognize that community, society and the environment are important factors in the health of individual patients.
42. Recognize the profession's responsibility to society in matters relating to public health, health education, environmental protection, legislation affecting the health or well-being of the community and the need for testimony at judicial proceedings.
43. Recognize the responsibility of physicians to promote equitable access to health care resources.
44. Use health care resources prudently.
45. Recognize a responsibility to give generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate.
Responsibilities to the Profession
46. Recognize that the self-regulation of the profession is a privilege and that each physician has a continuing responsibility to merit this privilege and to support its institutions.
47. Be willing to teach and learn from medical students, residents, other colleagues and other health professionals.
48. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues.
49. Be willing to participate in peer review of other physicians and to undergo review by your peers. Enter into associations, contracts and agreements only if you can maintain your professional integrity and safeguard the interests of your patients.
50. Avoid promoting, as a member of the medical profession, any service (except your own) or product for personal gain.
51. Do not keep secret from colleagues the diagnostic or therapeutic agents and procedures that you employ.
52. Collaborate with other physicians and health professionals in the care of patients and the functioning and improvement of health services. Treat your colleagues with dignity and as persons worthy of respect.

Responsibilities to Oneself
53. Seek help from colleagues and appropriately qualified professionals for personal problems that might adversely affect your service to patients, society or the profession.
54. Protect and enhance your own health and well-being by identifying those stress factors in your professional and personal lives that can be managed by developing and practising appropriate coping strategies.

Source: CMA Code of Ethics

End of Life / Assisted-Death

According to the College of Physicians and Surgeons of Ontario:
Ontario's Medical Assistance in Dying Policy: Physicians are expected to manage all requests for medical assistance in dying in accordance with the expectations set out in this policy.

Criteria for Medical Assistance in Dying (MAID):
In accordance with federal legislation, for an individual to access medical assistance in dying, he/she must:
1.Be eligible for publicly funded health services in Canada;
2.Be at least 18 years of age and capable of making decisions with respect to their health;
3.Have a grievous and irremediable medical condition (including an illness, disease or disability);
4.Make a voluntary request for medical assistance in dying that is not the result of external pressure; and
5.Provide informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.
Physicians must use their professional judgement to assess an individual’s suitability for medical assistance in dying against the above criteria. The content that follows elaborates upon each element of the criteria for medical assistance in dying.

Phone Care Coordination Service (CCS):  1-866-286-4023 (new as of 2018)
For more details or to register as a provider:  MAIDregistration@sasc.ca (new as of 2018)

As of 2017/2018...

MOHLTC: Ontario MAID information page with clinician aids/forms for patients - download
MOHLTC Ontario's Medical Assistance in Dying Statute Law Amendment Act (2017) - This Bill 84 came into force upon Royal Assent. It addresses medical assistance in dying that fall under provincial jurisdiction. download

CPSO Policy Statement #4-16 "Medical Assistance in Dying" - download; More CPSO Details
CPSO: Planning for and Providing Quality End-of-Life Care - details

CMA Policy - Medical Assistance in Dying - download
CMA Education on Medical Assistance in Dying (2 course modules) - details

CMPA Perspective and Tips on Medical Assistance in Dying - details

CEP (Centre for Effective Practice) Ontario MAID Step-by-Step Pathway Guide for Health Providers - download

As of July 17, 2016...

Medical Assistance in Dying Legislation (MAID)  - Ontario Health Minister Eric Hoskins announced on June 17, 2016 that the federal gov't passed legislation on medical assistance in dying (MAID).  Bill C-14 was passed by vote with 190-108 in favour of the amended version and sent back to the Senate for further consideration, where upon the Senate then passed it 44-28.  Ontario along with all other provinces and territories were engaged on a number of technical issues to prepare for its implementation and will continue to work with Health Canada as it comes into force.  Patients who wish to access medical assistance in dying are told to confer with their health care provider, while Ontario's health regulatory colleges will offer guidance to physicians in providing appropriate medical assistance in dying to patients who request this option.  Ontario will also ensure that drugs required for this purpose will be available at no cost. 

MAID Referral List:  At this stage, it is unclear what physicians will be willing to provide medical assistance in dying (MAID).  If you are willing to be on this list or are in need of making an effective referral, the College advises physicians to utilize their professional networks to gain information.  Alternatively, the MOHLTC has established a toll free referral support line to help Ontario physicians to arrange referrals for patients requesting MAID: 
Phone Care Coordination Service (CCS):  1-866-286-4023 (new as of 2018)
For more details or to register as a provider:  MAIDregistration@sasc.ca (new as of 2018)

  • CBC (June 6, 2016) - "Ontario to create referral service, provide drugs at no cost for assisted dying", CP - download
  • Ontario Newsroom (June 17, 2016) - "Statement by Ontario's Minister of Health and Attorney General on the Federal Government's Medical Assistance in Dying Legislation ", MOHLTC - download
  • CBC (June 17, 2016) - "Liberals' assisted-dying bill is now law after clearing final hurdles", C.Tunney - download
  • CPSO (June 28, 2016) - "Medical Assistance in Dying (MAID): Frequently Asked Questions", CPSO - download

Other Sources:  CPSO;  CMPA;  OMA

HISTORY:

On February 6, 2015, the Supreme Court of Canada ruled in favour of allowing people with "grievous and irremediable medical conditions" to ask for doctor-assisted suicide.

What does this decision mean for physicians?
The CMPA (Canadian Medical Protective Association) would like physicians to be aware of the following:

  • Assisted Dying was Illegal until June 2016 - The Court suspended the decision for 12 months (until approximately Feb.2016) to give Parliament and the provincial legislatures time to enact legislation, and medical regulatory authorities (Colleges) and medical associations time to develop policies and guidelines.
  • Limited to patients who are competent adult persons who clearly consent to the termination of life - The patient must be suffering from “…a grievous and irremediable medical condition […] that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”
  • Definition of “grievous and irremediable medical condition” - The Court stated that the definition includes an illness, disease, or disability. Moreover, the term “irremediable” is not intended to require the patient to attempt treatments that the patient considers unacceptable.
  • Physician's Right to Refuse - The Court expressly recognized a physician’s right to refuse to assist a patient to die based on freedom of conscience. The Court deferred to Parliament, provincial legislatures, and Colleges to establish appropriate frameworks that reconcile the Charter rights of patients and physicians.
  • Provincial Guidelines are Coming - It is expected that Colleges and medical associations across the country will develop policies and guidance on physician-assisted dying. The CMPA will continue to work with stakeholders to ensure that physicians’ medico-legal interests are protected, and that physicians are aware of their responsibilities and rights in this area.

NOTE: The CMPA advises its members to contact the CMPA for case-specific medico-legal advice on such issues, including when there is disagreement with a patient, family member, or substitute decision-maker on the recommended treatment plan.

Resources: CMPA: Supreme Court decision on physician-assisted dying; CMPA: After the Diagnosis - How to communicate with terminally ill patients; CMPA Interim Guidance on Physician-Assisted Death and draft document.

Opioid Prescribing

CPSO Policy Statement: Prescribing Drugs - download
CPSO Opioid Prescribing Resources - details

2017 Canadian Guideline for Opioids for Chronic Pain (McMaster National Pain Centre) - details

CMPA/SAEGIS Safer Opioid Prescribing Skills Program - details

UofT Safer Opioid Prescribing Courses/Webinars - details

 

Articles & Videos

If you have more video/audio suggestions that would be helpful for this page, please let us know: info@oags.org .

  • Dec,2014: Apology Legislation & Physicians - CBC's The Current & CMPA
  • Sept,2014: The Doctor and the Disease: CBC Radio - White Coat, Black Art - A doctor's personal journey with his disease and the ethical implications of practising.
  • Sept,2013: Medicine's Big Fat Bias: CBC Radio - White Coat, Black Art
    The epidemic of morbidly obese patients in OR.
  • Sept,2013: Blowing the Whistle on Bad Medicine: CBC Radio - White Coat, Black Art
    Documentary interviews with whistle blower physicians - It's a difficult road for health care workers to do what's right, when things go wrong.
  • July, 2013: Controversial McMaster University Laparoscopic Study (Laparoscopy linked with bonuses): Medical Post Article... With feedback and letters to the editor from the OMA President Scott Wooder and other surgeons. (Also CBC article with comments.)
  • Sully's Lessons From the Cockpit to the OR: CBC Radio - White Coat, Black Art
    Documentary interview with Captain Sully Sullenberger from the US Airways Flt 1549 on the Hudson River and how principles of aviation safety can be applied to surgery.
  • Nov, 2012: Chronic Condition- Healthcare Crisis: TVO-The Agenda
    Interview with The Globe and Mail's Jeffrey Simpson on his new book, Chronic Condition, and panel discussion on the healthcare crisis.
  • Sept, 2012: Will operate for food? The unemployed doc paradox: CBC Radio - White Coat, Black Art
    Also...Complete interview with Dr. Lou Francescutti. Documentary on wait lists and unemployment in the medical profession.

Disruptive Physician

Together, the College of Physicians and Surgeons of Ontario and the Ontario Hospital Association published the "Guidebook for Managing Disruptive Physician Behaviour" (Download PDF) in 2008. Although it focuses on physicians, it can easily be applied to the behaviour of any healthcare worker. The guide defines disruptive behaviour and suggests a complaints procedure. General Surgeons should be aware of what the CPSO and OHA consider disruptive:

Inappropriate Words:

  • profane, disrespectful, insulting, demeaning or abusive language;
  • shaming others for negative outcomes;
  • demeaning comments or intimidation;
  • inappropriate arguments with patients, family members, staff or other care providers;
  • inappropriate rudeness;
  • boundary violations with patients, family members, staff or other care providers;
  • gratuitous negative comments about another physician’s care (orally or in chart notes);
  • passing severe judgment or censuring colleagues or staff in front of patients, visitors or other staff;
  • outbursts of anger;
  • behaviour that others would describe as bullying;
  • insensitive comments about the patient’s medical condition, appearance, situation, etc.;
  • jokes or non-clinical comments about race, ethnicity, religion, sexual orientation, age, physical appearance or socioeconomic or educational status.

Inappropriate Actions:

  • throwing or breaking things;
  • refusal to comply with known and generally accepted practice standards such that the refusal inhibits staff or other care providers from delivering quality care;
  • use or threat of unwarranted physical force with patients, family members, staff or other care providers;
  • repeated failure to respond to calls or requests for information or persistent lateness in responding to calls for assistance when on-call or expected to be available;
  • repeated and unjustified complaints about a colleague;
  • not working collaboratively or cooperatively with others;
  • creating rigid or inflexible barriers to requests for assistance/cooperation.

 

Resources