Taking Credit for Others' Work

Conducting Personal Business on Compa while pointing out that two

members of the team did not pull their weight?
This is a thorny question. If employees single out their co-workers in a negative
light, it could foment resentment. The same thing could happen, however, if all
employees accept equal praise even though only a select few did the real work.
The best way to resolve this ethical dilemma is to not let it happen. Team
members should insist that all employees perform specific tasks to help
complete a project.

Common Ethical Employees often

work in teams to create marketing campaigns, develop new products or fine-tune

services, yet rarely does everyone in a group contribute equally to the final
product. If three members of a five-person team did all the work, do those three
members demand to receive proper credit

Workplace Dilemmas
ny Time
Because employees tend to spend so much of their weekday hours on the job,
they often are tempted to conduct personal business on company time. This can
include setting up doctor's appointments on company phone lines, making
vacation reservations using their employer's computers and Internet connections
or even making phone calls for a freelance side business while on company time.
At first glance, this ethical dilemma is fairly clear: It is an abuse of your employer
to conduct personal business on company time. But there are shades of gray
here. What if your spouse calls to tell you that your children are ill? Is it OK for
you to schedule a doctor's appointment? A good rule of thumb is for an
employee to check with his manager or human resources supervisors to clarify
what counts as an actionable offense in the company.

Common Ethical Workplace

Dilemmas
Conducting Personal Business on Company Time

Because employees tend to spend so much of their weekday hours on the job,
they often are tempted to conduct personal business on company time. This can
include setting up doctor's appointments on company phone lines, making
vacation reservations using their employer's computers and Internet connections
or even making phone calls for a freelance side business while on company time.
At first glance, this ethical dilemma is fairly clear: It is an abuse of your employer
to conduct personal business on company time. But there are shades of gray
here. What if your spouse calls to tell you that your children are ill? Is it OK for
you to schedule a doctor's appointment? A good rule of thumb is for an
employee to check with his manager or human resources supervisors to clarify
what counts as an actionable offense in the company.

Harassing Behavior
Employees often don't know what to do if they see one of their co-workers
harassing another employee, either mentally, sexually or physically. Employees
may worry for their jobs if they attempt to report a superior for harassment. They
may fret that they'll be labeled a troublemaker if they report co-workers who
display inappropriate behavior toward other employees.
The best way to resolve this ethical dilemma rests with the staff members who
develop the company's employee handbook. It is their job to include specific
language that spells out that employees won't be punished for reporting the
harassing behavior or inappropriate actions of their co-workers.
Accounting: Your supervisor enters your office and asks you for a check for
$150.00 for expenses he tells you he incurred entertaining a client last night. He
submits receipts from a restaurant and lounge. At lunch your supervisors
girlfriend stops by to pick him up for lunch and you overhear her telling the
receptionist what a great time she had at dinner and dancing with your
supervisor the night before. What do you do? Bank Teller: You have worked as a
bank teller for several months when one of the other tellers who has become a
good friend tells you that her daughter is extremely ill and that se must have an
operation to survive. She also tells you that she has no insurance and the
operation will cost $10,000. Sometime later you ask her about her daughter and
she tells you she is just fine now. She then confides in you that she took
$10,000.00 from a dormant account at the bank to pay for the operation. She
assures you that she has already started paying it back and will continue to do so
until it is all returned. What do you do?
Computers: In your spare time at work, you have developed a new spreadsheet
program on the personal computer in your office. It is even more powerful, yet
easier to sue than anything on the market. You share your new program with a
friend who encourages you to market it on your own because you could probably
make an incredible profit in a very short time. This is a very attractive option, yet

you developed it using company equipment and during time that you were at
work. What do you do?
Journalism/Advertising Your newspaper has published a report on a national
study, which concluded that bottled water has virtually no health advantages
over the tap water in more cities, including yours. The study included comments
from local health storeowners and water distributors challenging the study. The
AquaPure Bottled Water Company, advertising account worth over $75,000. a
year, has threatened to pull its account with your newspaper unless you run
another story of equal prominence, focusing on the benefits of bottled water.
What do you do?
Law Enforcement You are a rookie officer assigned to a training officer for the
first six months of your employment. The training officer is a 20-year veteran and
is a close friend pf thee Assistant Chief of Police and the brother-in-law of the
Watch Commander. The third day that you are working with him you respond to a
burglary call at a local convenience store. It is 2:30 am and the manager has
been notified. You are directed to wait 30-35 minutes for his arrival. A short time
later you observe your partner take a soda, candy and a bag of chips. He
consumes the soda and chips. When the manager arrives, the two of you depart.
What, if anything, should you do? Personnel Your company has a firm policy
regarding cases of theft of company property. Used company equipment is on a
table to be sold by bid each month. You see a valued employee who is 2 months
from retirement slip an electric drill from the table and put it in his car before the
day of the sale. What so you do?
Real Estate A lady from out of town calls you to list her deceased parents home
in Liberty. She is not sure what it is worth, but says she will be happy to get
$50,000.00 for the home. You look at the home and feel it is worth at least
$75,000, and re4laise it would be perfect for your brother. What do you do?
Retailing You are the buyer for a retail-clothing store. Your store has a policy of
not accepting gifts. However, over the years, salesmen have offered, and other
employees have accepted lunch, theater and baseball tickets. You arrive home
from the office and find a new TV and DVD player on you doorstep with a note
that says: A personal gift for out long standing friendship. Enjoy it with you
family in good health. The Jones Clothing Company What do you do?
Teacher You have a student who is from a single parent family. The student must
work to attend college. However, the job is interfering with the students
performance and several assignments have not been turned in. You have
determined that a D is all the student can make when a counselor informs you
that the student need a C to qualify for an academic scholarship. What do you
do?

A Colleague in Trouble

You are a physician who works in both urban and rural settings. Over the past six
months, the behavior of a colleague you have known for 10 years has changed.
The physician has:
o

become somewhat unreliable, showing up late for meetings and/or

procedures undergone personality changes

lacked attention to detail

occasionally smelled of alcohol

lacked judgment in some situations

responded negatively to colleagues who have attempted to

intervene

What would you do in this situation?

Responses, as published in the Messenger, to this issue:
I would first discuss with another colleague my observations and conclusions.
Hopefully we would then go together to address her/him in a friendly, candid
manner if we judged we had a reasonable chance of her/his seeking appropriate
help. (Dr. Cliff Nelson)
This situation should be handled in the same way as any person employed in a
position which would be considered a critical safety positionSince this is a
physician governed by the rules of a governing board, the College should be
notified. It would not be your role to treat or diagnose this situation. (Dr. Tim
Lepard)
The first step when encountering a case like the one described, is the recognition
that there exists a great likelihood of problematic substance use, which may not
be limited only to alcohol. Untreated substance use disorders in healthcare
professionals may have the potential of placing the public at risk, and where a
reasonable index of suspicion exists, notification of the local regulatory body is
indicated. This activates a protocol for full assessment, and if indicated, the
appropriate treatment.Exciting new treatment options are emerging for the
treatment of addiction and comorbid mental health concerns, and the
occupational, health, and social outcomes for impaired physicians are indeed
optimistic.The biggest dilemma physicians face is realizing that reporting of an
impaired colleague is in the best interest of the involved physician and his
patients, and in dispelling the perceived notion that staying silent protects our
colleague. Silence only maintains the disease. (Dr. Charl Els)

Accepting Patient's Gifts

You are a family physician with hospital privileges working in a large urban clinic.
Following hospitalization for pneumonia, one of your long-term patients gives you
a gift as a thank you for the care you provided. The gift is a $250.00 certificate to

a well-known local tailor who you know does excellent work. What would you do
in this situation?

Responses, as published in the Messenger, to this issue:

The physician-patient relationship is complex and matures with time. It is the

responsibility of the physician in this situation, therefore, to gauge the maturing
and appropriateness of the physician- patient relationship, and to determine the
appropriateness of accepting the gift. This is one aspect of our professionalism
that will not be able to be subjected to any blanket rule. (Dr. J. Fernandes)

It is never appropriate to accept monetary gifts or gifts of significant monetary

value from patientsI believe that personal gifts or tokens of appreciation, such
as Thank you cards or handmade gifts having more sentimental than monetary
value, are entirely appropriate, and in fact are a healthy form of interaction
between care providers and patients...Fundamentally, the issue devolves to this.
It is a reasonable expectation that treating physicians accept and recognize the
sentiment of gifts from patients. In order to retain an appropriate and healthy
relationship with ones patients, gifts which benefit the physician financially must
always be redirected or refused. Like any other interaction with a patient,
documentation is necessary. (Dr. M. Rose)

I recommend not accepting the gift because this could have problems down the
road. (Dr. H. Hoffman)

I feel that it would be wrong to categorically forbid gifts from patients. It is a

way in this society to express appreciation and affection. Gifts have to be
differentiated from bribes and that is not always easy. Gifts should also be
appropriate in size and a physician has to weigh whether there are expectations
attached to this before acceptance, as this may haunt the physician later. (Dr. E.
Schuster)

I dont know if ethical principles would make distinctions based on the size of
the gift but it strikes me that there is a difference between an appropriate gift
relative to service performed vs. something completely outrageousOf course,
there is another side to accepting gifts that should be considered. In accepting a
gift does this imply that a favour may need to be returned? Does this mean that
a physician will be expected to be more readily available, more easily convinced,
more likely to provide a requested letter, more apt to squeeze in an

appointment, etc, etc.The more I ponder on this gifting issue, the more
complex it becomes. (Dr. M. Joffe)

In general, a physician will feel uncomfortable if a gift from a patient has a

substantial value, as opposed to a modest one. However, this cannot be defined
by an exact dollar valuea $250 gift is not a modest one for most patients, but it
may be modest for an affluent patient, and perhaps this long-term patient is
trying to express his gratitude for years of service not necessarily just his
recent care. (Dr. S. Shafran)

Confidentiality and High Risk Patients

The parents of an adult child (age 23 years) come to you in your role as the
patients family physician with concerns that they are unable to obtain
information regarding their daughter.
She had received much attention from the health care community as a result of
diabetes mellitus and chronic pain, stemming from injuries sustained in a motor
vehicle accident four years previously. She had recently become increasingly
withdrawn.
What could you, as the usual treating physician, tell the parents? Is there an
ethical way of having them understand what transpired in your treatment plans?
Four months after their initial visit, the parents arrive at your office with a death
certificate, the will of their recently deceased daughter, and a toxicology report
indicating the presence of benzodiazpines and narcotics.
They are actively grieving and questioning why they were not included in the
treatment interventions. Does it make a difference to your obligations, if the
patient herself indicated she does not want her parents to know about her health
treatments?
If the patient did not expressly state a desire to keep her information
confidential, is there an obligation on your part to engage concerned parents in a
treatment plan that will assure this high-risk individuals safety?
Responses, as published in the Messenger, to this issue:
This is an unfortunate situation that needs lots of communication.... Maybe a
gentle suggestion (to the patient) that her parents are very worried and would
like a bit of information may give the doctor a bit of room to discuss it with
them... If the patient is competent and not a threat to herself or others then her
confidentiality is paramount. (Dr. J. Huang)
Trust is the foundation that grounds the physician-patient relationship.
Respecting the privacy of patients, and giving them a place where they know
their confidences will be protected, is key to the ongoing maintenance of that
trust. When family members approach physicians for information about the past

or current health status of patients, physicians are wise, not to mention

obligated, to respect confidentiality.
This should not mean a physician cannot speak to the parents of a 23-year-old
woman with concerns about their daughters health. On the contrary, the
presumption should be her parents are part of the support structure we hope
exists for all of our patients. (Mr. G. Goldsand, Clinical Ethicist)

Disparaging Comments

You are the training director for a residency program. Recently, several residents
have come to you reporting that a physician frequently makes disparaging
comments to residents and to patients about the work of other physicians.
The physicians latest comment was to a patient in which he said he would not
allow a particular physician to treat his pets.
Other comments attributed to this physician involved telling the residents that a
surgeon is a butcher and a psychiatrist a mindless twit.
The residents have attempted to speak to him about this practice to which the
physician responded by saying he only speaks the truth, adding that patients
and residents have a right to know.
The residents report the comments appear to be unwarranted and they seem to
be scaring the patients. Is this physician behaving unethically? Should physicians
question the work of their colleagues? How should this be done?
Responses, as published in the Messenger, to this issue:
Unfortunately, this is something we see or hear too often. It is my opinion that
this doctor is wrong and his behaviour is against the code of ethics. If a doctor
has something to say against someone elses practice, it should be done through
regular channels and this may go up to health authorities, governing bodies or
even a complaint to the CPSA. This resident is right and should report this doctor.
(Dr. M. Trudeau)
This doctor is ethically immoral and legally at risk of action for slander. He is
destroying the trust in the medical establishment of both patients and
colleagues. If he really believes what he says, then he should discuss his
concerns with the other doctors themselves, face to face, or Chief of Staff, or the
Ethical committee. (Dr. G. Stewart-Hunter)
Should physicians question the work of their colleagues? Absolutely - within the
realms of appropriateness, professionalism and courteousness, without malice or
ill intent, for the purpose of improving patient care and in the right setting.
Keep little things little, simple and straightforward, critique actions not people,
dont make it personal, do it for the right reasons, ensure that the correct person
does it in a private place with adequate warning.When done in this manner it

often has the best potential to be a building and growing experience. (Dr. L.
Clarke)

Elderly Patient's Autonomy

You are nearing the end of your practice career and many of your patients are
older. Several of them have developed mild dementia and youve been
discussing their wishes should they continue to lose mental capacity.
The other day, an elderly gentleman arrived for his appointment with his middleaged son who reported that his father is becoming increasingly forgetful. The son
would like to have his father moved to a facility rather than continue to live on
his own.
While examining your patient, you note he has multiple bruises on his upper
arms that suggest he has been grabbed by someones hand. When you discuss
with him the idea of moving to an assisted living facility, he becomes very upset
and says his son wants to get his hands on his money and that is why he wants
him to move from his own home.
The patients Mini Mental Status examination is within the normal limits and he
reports that his multiple bruises are the result of a friend grabbing his arm while
they were out walking.
You would like to respect your patients autonomy to make his own decisions but
have some concerns that he may be at risk. You are not sure what the ethical
principles are and approach your colleague for advice. What advice would you
give to this colleague if you were approached?
Responses, as published in the Messenger, to this issue:
As physicians, we are often trying to balance the autonomous rights of our
patients with the need to protect those who are vulnerable. Older patients,
whose capacity to make decisions is diminishing, can be vulnerable to abuses.
However, they can also display suspicious tendencies as a symptom of cognitive
decline.
In this case, it would be important to fully explore all aspects of the patients
history, assess his capacity, determine if he has a personal directive and who
would act for him if he lost capacity, and fully explore the potential for financial
or physically abusive situations. (Dr. J. Wright, CPSA Assistant Registrar)
Respecting the autonomy of patients has rightly become the central ethical
principle in the delivery of healthcare, and this case is no exception. The
physician is showing great respect for his/her patients with early dementia by
discussing the expected trajectory of the illness, and then charting any opinions
they convey about where they may eventually want to live, how they would like
decisions made, acceptable levels of risk, general attitudes about quality vs.
mere quantity of life, etc.

When we encounter patients whose own hopes and preferences appear to differ
from what their families may think, we should chart these observations and then
strongly recommend that they make a personal directive while they retain the
capacity to do so. We should offer to assist with this if need be, especially under
these circumstances. (G. Goldsand, Clinical Ethicist)

Managing your reputation

Dr. Smith is a family physician working in a small town with a population of about
5,000 and frequently refers her patients to a larger urban centre. She has
developed good working relationships with many of the specialists.
This week, she received a copy of a consultation letter from one specialist to
another that was very critical of the care she had provided to the patient.
Although she was upset by the criticism, she felt that the physician did not have
the full history, so she chose to disregard it.
Later that day, the patient in question came for an appointment. The patient was
very angry and reported that the specialist said that her incompetence had
delayed the diagnosis and worsened her prognosis significantly. Dr. Smith was
taken aback and had to spend a significant amount of time with the patient to
discuss the issue. In the end, she felt that they could continue to work together;
however, she was very upset with the specialists comments and wondered what
to do?
She notes that the Code of Ethics says, Avoid impugning the reputation of
colleagues for personal motives; however, report to the appropriate authority
any unprofessional conduct by colleagues. She comes to you to ask what she
should do?
Responses, as published in the Messenger, to this issue:
Poor Dr. Smith. She worked hard in a solitary practice in a small town with no
colleague to consult with. Then she sees an interprofessional consultation that is
critical of her care. One assumes her name specifically was used in the criticism.
First, review the charts. Was there any possibility of malpractice? Have a friendphysician who works away from her practice review the situation by phone.
(Dont mention the name of the patient concerned or the staffmans name in
your conversation.)
Next comes communication, and this can be tricky. First, talk to the staffman who
received the complaint about you. He/she will obviously be aware of the
criticism. He/she may identify what error may have been made, which would be
helpful. On the other hand he/she may be baffled by the complaint as well.
Now comes the difficult part. You have to confront the complainant, and the
phone would be a good way.
Call his/her secretary and ask if you could book a telephone appointment with
his/her boss. Ask the secretary to kindly dig out the chart at the appropriate

time. Do not discuss any matters pertaining with the secretary. Two things may
happen, either you dont hear back, or else he/she does call you. (...) see full
text (Dr. Mike Hancock, Edmonton)

The physicians primary responsibility is the patients well being. Any concern
about the maligning of the physicians reputation by the specialist is secondary.
In this case, the specialist caused direct and willful harm to the relationship
between the physician and her patient. This is a complex longitudinal
relationship that is built on mutual trust and respect and is central to the
patients care over the long term.
The criticism of one physician by another is often, as in this case, fueled by lack
of information and understanding and is often unprofessional. There are venues
to report truly incompetent care.
If the specialist presumed the right to criticize the physician, then the specialist
also had an obligation to ensure that his/her information was both correct and
complete before rendering an opinion to the patient.
In this case, the specialist did not attend to his/her responsibility to ensure that
he/she had complete and correct information prior to rendering an opinion to the
patient about the incompetence of the physician.(...) see full text(Dr. John
Fernandes, Calgary)

I read the Ethics 101 article in the latest issue of the "Messenger". I realize that
you are expecting opinions from within the profession but I think that as a lay
person I might have something to contribute. The danger of a well known
physician having undue pressure on his/her colleagues would indicate that
perhaps inviting these doctors to present at seminars supported by a
pharmaceutical company would be contraindicated in a self governing profession
that prides itself on it high standard of ethics and morality. These ethics must
not only be practised but they should be seen to be practised. A physician who
had been heavily involved in clinical studies and who was going to give an
objective report on those studies, carefully avoiding any temptation to encourage
the use of the treatment by others is probably an acceptable case.
I have done some research and I would like to submit some numbers which
might represent the cost to the company and benefit to the physician. I assume
that the company wants to make a good impression on the physician, the
amount of the honorarium is a guess as are allowances for meals and incidental
expenses.

Item

How

Calculated

Total

First class airfare Edmonton, New York return

airline
website

Small suite in Fairmont hotel

4 nights @
$935

Meals

4 days @
$200

$800

estimate

$500

Miscellaneous expenses taxis, limo's, laundry,

phone calls, etc,
Honorarium

estimate

Grand Total

$7,1
76
$3,7
40

$5,0
00
$17,
216

I have been the patient of an incredible physician for almost 27 years and from
what I understand if I were to give her a cheque for this amount she would have
to answer to the college for receiving a large gift from a patient, I have read of
such cases in the "Messenger". What is the difference from an ethical point of
view if the gift comes from a patient or a pharmaceutical company? If I have
overestimated the amounts of money I would appreciate a correction. (Paul S.
Hinman, Edmonton)

Working with industry representatives

While working in your office at a tertiary care hospital you agreed to meet with a
representative from a pharmaceutical company.
During that meeting, the pharmaceutical representative mentioned a meeting in
New York City where she will be discussing the release of a new product.
The company wants you to attend and participate in a educational session in
New York and offers to pay for your flight, hotel and an honorarium. You tell her
that you will think about it and get back to her. On reflection you are not sure
that this is appropriate and decide to consult one of your colleagues.
If you were the colleague, what advice would you provide?
Reponses, as published in The Messenger, to this issue:
In general, I would tell my colleague that decisions to participate in this sort of
event are personal decisions and each physician must make a decision with
which he or she is comfortable.

That said, it is important for my colleague to realize that there is frequently much
more going on with such events than initially appreciated.
Combining education with marketing is a very common strategy employed by
industry. While there may be a real educational benefit to the event, the reason
for including us is not altruistic.
As physicians, we are very attractive to pharmaceutical companies. We prescribe
medications for a third party. Convincing one physician to prescribe a
medication, may lead to dozens (or even hundreds) of prescriptions for long term
use. Moreover, convincing one high profile/opinion leader physician of the benefit
of a medication may lead to many physicians adopting a new treatment, thus
multiplying exponentially the potential number of prescriptions. So spending
$5,000-$10,000 on a physician can be money very well spent.
Of course, most of us will argue that just because we accept a dinner, or golf
game or trip to New York, does not mean we are going to adopt the companys
product. In fact, we argue that it is insulting to think we can be bought off by
such gimmicks. This argument is based on an important misconception. It is not
about being bought off or bribed. Even the most morally dubious physician would
have second thoughts about prescribing a medication just for a financial kickback.
What is actually going on in these scenarios is more subtle. Industry is exploiting
societal conventions regarding obligation and reciprocity. (...)* See full text. (Dr.
Wayne Rosen, Calgary)
The physician thinking about industry supported travel to New York might
consider several professional issues.
In a tertiary care environment, the physician should be careful about rolemodelling acceptance of largesse from industry. Medical trainees may come to
believe that thinly veiled marketing influence on prescribing choices is an
entitlement.
The physician in a tertiary care academic environment should read the book
The Truth About Drug Companies written by Dr. Marcia Angell, a former editor
of the New England Journal of Medicine. Also the physician should become
informed about the environment in New York and other parts of the United States
where drug industry largesse has become a societal concern.
United States Senate discussions stimulated by the 2009 Grassley-Kohl Physician
Payments Sunshine Act have caused embarrassment for some academic
physicians. The physician should read and consider the 2008 task force report of
the Association of American Medical Colleges (AAMC) on industry sponsorship of
medical education, and note the policies and guidelines on competing interests
and disclosure. The Association of Faculties of Medicine of Canada has been less
directive than its American counterpart, so far.

The finances of medical schools are currently under great stress, but there needs
to be a properly balanced approach to acceptance of industry support for
institutions vis-a-vis individuals.
If the physician has helped the drug company with legitimate clinical trials, he or
she is not a company employee and should be aware of potential competing
interests. And if the physician does accept support to attend the conference he
or she will need to consider what to tell patients when prescribing the new drug,
especially if there are reasonable alternative products. (...)* See full text. (Dr. Ray
Lewkonia, Calgary)

Obligation to the Community?

You have enjoyed practising family medicine for 10 years but have recently
received an offer to join a cosmetic practice.
The hours and remuneration would be much better than you currently enjoy, but
you are acutely aware of the shortage of family physicians that exists in your
community. Furthermore, you know your patients will have difficulty finding a
new physician.
Do you have an obligation to the community to continue providing care? Or
should you accept the offer, which will allow you to work less for significantly
more income?
Responses, as published in the Messenger, to this issue:
This society needs to decide what it values the most. If we allow cosmetic
surgery to be better remunerated than dedicated family practice, we take a
collective responsibility for this. Compared to other medical disciplines, the
comprehensive family doctor has not been valued as much in the past
(financially nor in societal status) and we are seeing the consequences in
recruitment and retention. (Dr. E. Schuster)
In this particular case, I think the physician has the right to change practices and
I would fight hard to defend that right. Whether the doctor should choose to do
so is another issue. Truth is that lots of doctors make this decision. If the
province wants doctors to stay in practice, theyd better make sure it is
reasonably attractive. (Dr. G. Barr)
The ethical dilemma is between exercising ones autonomous rights as a private
practitioner versus the violation of social obligations by creating hardship upon
ones own community of dependent patients. (Dr. N. Yee)
Family practice is possibly the most undervalued area of medicine with
physicians continually dealing with higher workloads, increasing overhead, and
inadequate remuneration. Continuing the status quo out of "obligation" is
endorsing a system that results in unhappiness, burnout and possibly poorer
patient care.

I believe the only way to have physicians (and perhaps specifically family
physicians) valued appropriately is for actions to occur which force a realization
of that value. (Dr. S. Kyle)
I believe that the hypothetical case, as presented, is a real-time dilemma
presenting to most of the newer family physicians, and, unfortunately, the lures
of "cosmetic medicine" and the "easier hours" and "better lifestyle" are going to
win in a substantial number of situations.
Why should a family physician feel "guilty" about crossing the line into
cosmetic medicine and "feel-good medicine" when a substantial number of
plastic surgeons and dermatologists and ophthalmologists have already made
the journey into such lucrative pursuits? (Dr. B. Fernandes)
This is an example of the Messiah syndrome thinking, that is, one person can
save the world. The reality of it is, that if this MD drops dead today, the patients
will be seeing another tomorrow. Life is short and you only get to go through
once.
As long as the MD is employed in or billing for providing care to those patients in
their care, they are ethically charged with the responsibility of caring for them to
the best of their ability. What physicians have to realize is there is a difference
between being self-serving and doing what is best for themselves. If this MD's life
would be better by them changing their practice then so be it. (Dr. G. Bolduc)
Why should I have any sense of community, if already five of my colleagues in
my city provide cosmetic services? Why should I care about community when all
community wants is timely service, e.g. Pharmacists prescribing, if I cant
respond yesterday? (Dr. P. Mah)
My taking the position in the cosmetic practice would not be a loss to the
community and therefore I would not be under the usual and customary
obligation to that community. I would be willing to accept the less work for
significantly more money. (Dr. M. Prowse)
Under ideal circumstances, ethically speaking, a physician does have an
obligation to the community to continue providing care if there is no one else
available. Unfortunately, this is an unrealistic expectation because ethical
physicians who start practices in many rural, underserviced areas could then
potentially be stuck there forever without relief. (Dr. M. Bozdech)

Maintaining confidentiality in a small community

You moved to a town of 5000 to join a family practice with two other physicians.
You are enjoying the town very much and find everyone friendly and welcoming.
The clinic staff seem to know everyone in town and often provide you with
background information about patients and their families. Your wife teaches at
the local school and one of her colleagues is married to one of your office staff.
Last week your wife overheard her colleague talking about a patient who has

been diagnosed with breast cancer and he said he learned about it from his wife
who works at the medical clinic.
You are wondering how to maintain confidentiality in a small close knit
community and what you should say to your office assistant about this possible
breach of confidentiality.
Response, as published in the Messenger, to this issue:
In dealing with this problem, several principles need to be respected.
It is not necessary to be specific about the third party information you have
received from your wife. The best way to approach this issue is to announce to
your staff that you will have regular (you set the frequency) meetings to
discuss matters of interest shared by staff and doctor(s). Plan the first meeting
soon, such as having a meal-brought-in lunch event. Tell your staff that the
issues to be discussed at each meeting relate to patient and staff issues with
patient concerns being of primary importance. The topics can be generated by
the doctors or staff, but should generally be provided in advance so that
everyone attending will know what to prepare for, and likely what participation is
expected from them, at each session.
Advise them that at this first session the agenda will be patient privacy and if
you wish, other basic administrative issues, such as dealing with requests for
charts or chart information as these items fall within the confidentiality issues of
patient information. The long-term aim of these meetings is to develop standard
policies on all important interpersonal and professional issues that doctors and
staff must respect within their medical practice. Interpersonal staff and medical
doctor issues can also be brought to this meeting, but the doctors intent is to
develop an agenda that emphasizes the needs of patient service and office
efficiency. Be sure that everyone in the office will be there no one gets to avoid
the planned meeting so that everyone participates in these events. At the end
of the first meeting, seek comments if none are offered, and then advise on the
time and topic of the next meeting.
At that meeting simply review approved policy relating to confidentiality of
patient clinical data, covering receiving and sharing (gossiping) patient
information as well as the need to protect contents of charts and other relevant
communication devices involved in your medical practice. It will be necessary at
this meeting to detail what penalties apply to those who are revealed to be
discussing patient issues outside of the medical practice. This obviously will
include the possibility of dismissal and the possibility of a civil suit by an
aggrieved individual who identifies gossip and locates its source within the
medical office. Further, health care policies on information handling should be
formally presented, including the guidelines of the Medical Associations, Colleges
and regulations established by government.
The meeting can be kept short by preparing an information report which details
the issue at hand and lists the reasons for the policy. This way, the added

penalties for breaking the policies also just become part of the general education
theme on this important issue. It would be convenient and useful to prepare a
similar document each time a meeting is held. These documents will become the
Office Procedures and Standards Manual, with guidelines to managing
interpersonal and health-related matters in the doctors office.
Should anyone miss the meeting, have the meeting secretary identify that
individual in the records and provide the meeting summary and related
important documents to that individual shortly after the meeting. In that
communication, have the recipient sign and send back the meeting documents,
indicating that they understand and respect the policies contained in the
statement. Once this routine is developed, it will be very uncommon for anyone
to avoid these meetings.
In this way no personal issues are ever presented. But, the importance and
problems that may develop should confidentiality not be respected will be clear
to all. This same impersonal technique should apply to all other office healthrelated issues dealt with at each of the subsequent meetings.
Should it become necessary to speak to an individual who continues to break the
principled rules, it should be done privately, quickly after the issue is identified,
and may involve severe reprimand, as the doctor can be held responsible for
being involved in this type of thing, should it not be totally controlled. (Rod
Morgan, MD)

Sub-Optimal Care

The May 2011 issue of The Messenger contained an article written by Dr. Dennis
Kendel, Registrar of the College of Physicians and Surgeons of Saskatchewan. In
the article, Dr. Kendel asserts physicians have a collective responsibility to
protect patients from receiving sub-optimal care and hold a position of great
public trust akin to the sentries on the great wall. His article calls on our
profession not to abrogate our sentry duty as protectors of patients from harm
associated with sub-optimal physician performance.
In this new scenario, you have completed a locum in a physicians office and
noted many significant concerns in the care of a large group of patients, ranging
from missed follow-up of investigations to misdiagnosis and poor management of
chronic diseases.
You already decided not to do another locum in this practice but are wondering
now if you should do something more. For example, do you have an ethical
obligation to report your concerns to someone and, if so, who this should be?
You approach a colleague to ask for advice. If you were this colleague, what
advice would you provide and why?
Responses, as published in the Messenger, to this issue:

Medical care is an ever-evolving, ever-changing entity requiring all of us as

clinicians to attempt to remain up-to-date on many varied conditions. In addition,
we are responsible for ever-increasing technology in record-keeping, lab and
imaging reporting and other diagnostics.
We must rely on our staff to assist us with appropriate follow-ups, alert us to
patients requiring attention, and correctly file records and reports.
It is the rare clinician who can say that he/she have never missed a diagnosis or
a follow-up report.
I also think its a rare clinician who would not appreciate the direct approach by a
colleague to give some constructive criticism about any of these matters. The
majority of us are interested in giving good medical care, keeping up with the
rapidly changing standards of care in medicine and learning better ways of
delivering care both clinically and from a practice perspective.
My advice would be to assist that physician or group of physicians with some
direct advice on betterment of the practice.
To have already decided not to do another locum in the practice is not helpful
unless clearly the physician in question is not interested in making a change
(which I think is unlikely).
To decide not to return makes no positive changes for the practice; education is
the answer. We should all feel responsible for helping our fellow physicians where
we can. Our roles as physicians include education for patients, students and
colleagues.
I think the College should be available to assist in a scenario that we cannot
resolve physician-to-physician, but self-governance can begin at a basic one-toone information exchange level.
- Sharisse Kyle MD CFPC(EM) Dip Sport Med
I would arrange to meet this colleague socially as soon as possible for a
debriefing session following the locum.
The colleague in my opinion suffers from burn-out and/or depression. There may
be substance abuse, marital problems, etc. I would guide the discussion and take
it from there. Naturally, I would aim for agreement to undertake steps for further
assessment and treatment (for instance through the AMAs Physician & Family
Support program), which I expect would involve a period of sick leave away from
work. (I wouldnt be surprised if I was approached to do another locum for this
colleague! )
In any case, I would ask for his/her permission to meet again for followup/support just to make sure the colleague and practice will be safe. If the
colleague disagrees with my assessment/suggestions, I would have to explain
the consequences, be more confrontational, touch on reporting, etc. The followup would still stand.

- Hans Berkhout (retired but in the process of re-activating his practice permit)
Talk to the colleague for which you are doing the locum. Offer helpful suggestions
re: the transformation of the clinic to one that you think will be better. DO NOT
BE JUDGEMENTAL. If your ego is not up to a personal confrontation, write a letter
offering suggestions for change. Offer to help with the suggested changes and
definitely offer to do another locum for him. (Perhaps he is ready to retire and
will offer you his practice - now that's a challenge.)
- Dr. Selby Frank

Personal health information

Your practice has a large number of older adolescents and young adults, and
your patients frequently say they do not want any information released to their
parents.
Yesterday, you saw a 19-year old woman who is suffering from depression, has a
history of binge-drinking and has had increasing thoughts of suicide. She reports
she would not act on these thoughts because it would hurt her family, but you
are worried about her. Her mother frequently brings the patient to her
appointments. You thought of speaking to the mother but decided against this
when your patient asked you not to.
This morning, you received notification that your patient was brought into
emergency last night following an overdose and was admitted to the ICU. You are
now wondering if you should have spoken with her mother about your concerns.
A colleague reports you could not talk to the mother because of privacy
legislation, but you wonder if this is correct, and even if so, should you have tried
to ensure your patients safety?
Response, as published in the June 2011 Messenger:
Under the Health Information Act (HIA), Albertas access and privacy law for the
health sector, custodians of health information such as physicians have a duty to
protect the confidentiality of patient information. At the same time,
the HIA affords custodians the discretion to disclose health information if, in the
professional judgment of the custodian, the disclosure is essential in the
circumstances.
Custodians have a duty under section 58(2) of the HIA to consider the expressed
wishes of patients as an important factor in deciding how much health
information they disclose about them. In this scenario, the patient asked you not
speak to her mother. While this expressed wish is an important factor in deciding
to disclose health information about the patient, clearly it is not the only factor.
Patient safety is of primary concern.
Under section 35(1)(b) of the HIA, custodians may disclose health information to
a person who is responsible for providing continuing treatment and care to the
patient.

In this case, the patient is an adult, but because her mother has attended
appointments with her there is some evidence to suggest the mother is involved
in your patients care. Based on your understanding of the care relationship
between mother and daughter, you may decide to disclose the daughters health
information to her mother.
There is another section of the HIA that would allow you to disclose health
information to the patients mother if the situation is more urgent. Under section
35(1)(m) of the HIA, you have the discretion to disclose health information to
anyone if you believe, on reasonable grounds, the disclosure will avert or
minimize an imminent danger to the health and safety of any person.
Custodians are not held to a standard of perfection under the HIA, rather a
standard of reasonableness. Therefore, if you reasonably believe that disclosing
your patients thoughts about suicide to her mother will avert the imminent
danger of her harming herself, you could disclose this information.
The HIA gives physicians the ability to exercise their professional judgment when
a patient is at risk. In making a decision to disclose your patients health
information to her mother, keep a record of your reasons for making the
disclosure and, of course, you should only disclose the amount of health
information essential to meet the intended purpose.
(Brian Hamilton, Director, Health Information Act, Office of the Information and
Privacy Commissioner)

Let's Make a Deal? A Pharmacy's Offer

At your last office staff meeting, the rising cost of rent and overhead was
discussed. One of your partners mentioned that he had been approached by a
large pharmacy chain with an offer of space adjacent to their new pharmacy that
is only one block from your current offices. The cost per square foot is half of
what you are currently paying and there was a suggestion that the rent could be
lowered if the volume of prescriptions from your office were substantial.
Although this offer is very tempting, you have reservations about the potential
conflict of interest. One of your partners is pushing to explore this option. You are
wondering if you could manage the conflict by refusing to engage in any
reduction in rent based on prescription volume but still take the space at the
reduced lease costs.
Another partner feels that this arrangement will compromise her autonomy and
feels that it will look as if the office is associated with the pharmacy even if it is
not. Everyone agrees that the overhead costs need to be reduced. What is the
right thing to do?
Responses, as published in the Messenger, to this issue:
1. Accept the offer to rent the space at a lower cost as there is no conflict of
interest in renting an office space.

2. Decline the offer of lowering the rent for a larger volume of prescriptions as
this arrangement would most likely bias the physicians to over prescribe. (Dr. J.
Tse)
Many physicians have come to experience "suggestions" from colleagues in the
pharmaceutical industry as a regular part of practicing medicine in this part of
the world. Physicians and drug makers are entwined in a necessary relationship,
each with vital roles in getting effective medicines to the right people in an
efficient manner.
But the fact that these two distinct parties physician and pharmaceutical
salesperson owe primary allegiance to two different realms physician to
patient, and drug representative to company and shareholder creates the
constant possibility of conflict of interest. (G. Goldsand, Clinical Ethicist)

Questioning your colleague's ability to practise safely

For ten years you have worked in a clinic with five family physicians. Everyone
gets along very well. The most senior member of the clinic, who founded it 40
years ago, has been a mentor and teacher to most of the other physicians. He
was planning to retire but changed his mind when he lost a significant
percentage of his retirement income in a stock market crash.
Over the past year, you have noticed he often forgets to do things, and his
charting has declined significantly. Any attempts to discuss this with him were
met with denial. The group decided to keep a close watch on him, hoping there
would be no further decline to his practice prior to his retirement.
When he announced that he was going to continue practising, the group
attempted to discourage him but he reported that he could not afford to retire for
another five years. His colleagues hold him in very high esteem and do not want
to hurt him, but they are concerned about his ability to care for patients.
The group met and a decision was made to approach him and insist that he sees
his physician about his memory problems. No one was sure what to do if he
refused, or if they continued to notice a decline in his functioning. The group
wondered at what point they would need to act to protect patients.
What would you do in this circumstance?
Responses, as published in the Messenger, to this issue:
Physicians who maintain open and communicative relationships with colleagues
and patients set the stage for being able to deal with the ethical dilemmas they
will inevitably face together. And while duties to patients are generally clear, it is
not so easy to know the extent of ones duties to colleagues. The group is correct
in having decided that someone needs to discuss the issue with their mentor
directly, however difficult that might be.
And while the extent of his cognitive decline is something he ought to discuss
with his physician, this scenario also raises the question of how physicians ought

to offer peer support and professional supervision to each other. While

professional autonomy and independence are positive features of a medical
career, if these are excessive, a practitioner can feel alone and abandoned. This
team of five physicians could consider a more formalized structure where honest
assessment of ones performance and development can be discussed. Talking
routinely with a trusted mentor or peer is beneficial for ongoing professional
development, and should be standard.
Wanting to spare the hurt feelings of their mentor is natural, but the member of
the group closest to this physician should sit down and engage in an open and
honest discussion. They should determine what insight he might have into his
own decline, consider whether he is still able to see patients safely, and explore
any face-saving alternatives that will enable him to complete his career with his
dignity intact, and his patients safe. When close and trusting relationships
already exist with colleagues, facing such dilemmas together will be far easier
than in situations where insufficient communication and excessive professional
politeness have rendered them unable to talk honestly with each other. (Gary
Goldsand, Clinical Ethicist, Edmonton)
As the original guy, now 26 years later with four colleagues, I must say that it
has occurred to me that I may be the individual in question. The answer is of
course: 1) Have a group intervention, 2) Advise the College if it does not go well!
(Dr. Rick Zabrodski, Prof. Corp.)

Treating a Family Member

You are a physician with a busy family practice in a mid-sized city. Recently, three
of your colleagues left the region to practice elsewhere, adding to the pressure to
take on more patients.
On top of this, your elderly father recently moved into the community and is
demanding of your time - particularly in looking after his medical needs. You
have refilled his prescriptions and examined him when he developed a cough but
have encouraged him to seek another family physician. He cannot find one
accepting new patients.
You ask a colleague for assistance but she feels she cannot accept another
patient with complex medical needs.
You continue to fill your fathers prescriptions but feel uncomfortable and wonder
about the ethical issues of treating a family member. You decide to approach a
senior colleague for advice.
What is the right thing to do?
Responses, as published in the Messenger, to this issue:
Ethics, in plain words, is simply a set of rules of conduct and, even though this is
a rather simplistic approach, it is my opinion that there should be room for
manoeuvre.The case in point illustrates quite well the dilemma facing the

practising physician. I have no doubt that the physician, in that particular

instance, must prescribe for his relative. (Dr. H. Jacobs)
The remedy is simple. Ensure that each Canadian has one GP (with allowance
made for locums and cover by associates) and one only. Pay the GP for having
the patient on their list (even if they dont need to see them). In return require
the GP to see them promptly when the need is there.
What if more people come into town than the doctors care to take on? In the long
run, the law of supply and demand will put this right. In the short run, medicare
physicians should be required to take on extra patients as a condition of the
provincial contract. (J. Blakiston, MD)
I cant tell from the case scenario how many physicians are left in the city. I feel
strongly that treating family members is a dangerous scenario. Certainly in a
complex case, there will be pressures on the child aka physician to do what his
parent wants. There needs to be a mutual/reciprocal agreement among members
in smaller communities of treating each others families to maintain professional
objectivity. (Dr. C. Hilbert)
The physician should report his unwilling colleagues to the College. It is simply
unacceptable to refuse to care for the family members of a colleague, no matter
how busy our practice.It is an honour to be asked to care for someone like that. I
absolutely will not even discuss health issues with my own family. They have a
wonderful family doctor who will attend to their needs. (Dr. J. Currie)
1.) In the present circumstances if you dont help out your elderly family
members no one else is likely to. Do what you can to help.
2.) At the same time, do your utmost to help them "acquire" a physician
(difficult) and minimize their dependence on you. (G. Hunter, MD)

Remaining Silent

You have been reading a lot about the patient safety movement and the
disclosure of errors to patients and their families. You cannot stop thinking about
the following incident that occurred while you were a resident.
While on call you were asked to see a woman whose labour was being induced
with oxytocin or syntocinin. The fetal pH was becoming unacceptable and after
consultation with your attending physician you elected to proceed with a CSection. Once the oxytocin or syntocinin was discontinued, the fetal pH returned
to normal so there was no urgency. You suggested an epidural be used but the
young anesthetist wanted to do an immediate general anesthetic.
This suggestion, as well as the anesthetists experience level concerned you, but
you said nothing. The young anesthetist did not recognize nor know how to
manage the womans extremely small mandible and you watched both the
mother and baby die.

At the inquiry you were called to testify but were not asked, nor did you
volunteer, information about this aspect of the tragedy.
You did not speak to the anesthetist despite having seen similar problems
without consequences in the past.
If you were faced with the same situation today, you are wondering what you
could have done differently and why you felt compelled to remain quiet then.
What could you have done then and what would you do today if faced with the
same situation?
Responses, as published in the Messenger, to this issue:
I am a FM resident, PGY1. I wouldnt be quiet as a resident or if I was a student. I
wouldnt talk to the family or the anesthesiologist - Id first explain the situation
to my preceptor. I trust his judgment to make sure my perception of what
happened is correct. Ill follow up with what my preceptor advises me or call
CCFP for further advice. (Dr. N. Khosrodad)
I think that the main fear is to appear judgmental towards colleagues standard
of practice. Young doctors need to still "practise" different techniques as they
find what approaches they are comfortable with. I can sympathize with
"remaining quiet" and hoping things work out. However, after seeing this pattern
multiple times, I think there is no more understanding for silence. (Dr. C. Hilbert)
In todays complex environment, we would expect the disclosure would have
occurred on perhaps multiple occasions. As always, comments about the
performance of an individual team member would be avoided.
It strikes me as quite difficult to address the decision made without questioning
competence, although if this were to become a finger-pointing exercise no one
would be well-served.
The second question I would have, in this case, is what support was given to the
anesthetist? This situation might (and more than likely) would be a career
altering event. Support from his/her colleagues and institution would be
crucial. (Dr. R. Johnston)
The easy answer would be to tell the physician that he should have spoken up
but speaking up can be very difficult. Many physicians are reluctant to speak up
and say to themselves "there but for the grace of God, go I." Admitting our own
errors is difficult and pointing out someone else's can be just as hard. However, it
can be easier if we recognize that we are human and we all make errors.
The patient safety movement calls for a shift in how we interact with each other
and with our patients to minimize errors. Medicine is experiencing a cultural shift
where it is not only acceptable but also expected that we will help our colleagues
when we see the possibility of an error occurring. Evaluation of a critical incident
looks at all the factors involved: fatigue, culture, hierarchy, equipment, etc.

When an error occurs we are encouraged to disclose in a compassionate and

honest fashion with our patients. (Dr. J. L. Wright)

Reporting Patients to the Police

You have been treating a 24-year-old man for many years in your family practice.
He has an anxiety disorder and had some trouble with substance abuse in his
teens but has been doing well and attending university.
After his last visit for a minor injury you noted that a prescription pad was
missing. A few weeks later you received a call from a pharmacy asking you to
verify a prescription for Lorazepam 1mg bid, 300 tablets and acetaminophen
with codeine 300 tabs written for this patient.
You report that this is a forgery and ask the pharmacy not to fill it. Your colleague
urges you to report this to the police and states this is allowed under the Health
Information Act. You are very angry with the betrayal of trust with your patient
but you have never reported a patient to the police and wonder what you should
do.
The CMA code of ethics advises you to keep patients personal health information
private and only consent to release to a third party with consent or as provided
for by the law, such as when the maintenance of confidentiality would result in a
significant risk of substantial harm.
You are wondering if your patient has a substance abuse problem and whether
he could be selling this medication. You have called the patient to come in for an
appointment but he has refused. Should you notify the police?
Responses:
The following are excerpts from some of the responses we received. The full text
of all letters is posted on the CPSA website at www.cpsa.ab.ca - look for Ethics
101 under publications/resources.
Theft and forgery are criminal activities. If there is ambiguity with respect to the
motive, let the judge decide.
I suppose I should add, at the risk of stating the obvious, that yes, I would call
the police. To amplify my comment, the patient has violated a boundary, crossing
from merely self-harming behavior into criminality; enabling this benefits no one,
least of all the patient.
The behavior typically represents the "tip of an iceberg." Anyone behaving in
such a fashion is plagued by serious issues and needs serious intervention,
heavy-handed as it may initially appear. The behavior is unlikely to self-correct.
(Dr. D. Fermor)
The doctor-patient professional relationship is complex, and must include
consideration of the patients welfare and secondarily that of society in general.
What constitutes "a significant risk of substantial harm?" Surely, except in

extreme cases such as the risk of murder or suicide, this is a matter of opinion. In
this young mans case, his continuing suspected actions may result in the ruin of
his life and that of others, but those possibilities do not yield an overwhelming
argument for breaching the confidentiality code, all things considered. (Dr. E.
Gingrich)
Patient privacy ethics are designed neither to foster abuse of medications nor
enable crimes against physicians. Clemency was offered but refused by the
patient; therefore, reporting the patient to police is acceptable. (I. Gebhardt, MD)
How can I know this persons motivations for his behaviour, particularly if he
wont return to discuss the issue? Do I understand addiction, dependence or the
patients underlying situation well enough to make a decision that may result in
consequences that permanently affect his life, such as acquiring a criminal
record? How can I come to an understanding that will allow me to make a more
informed, appropriate decision?
Given the nature of this situation, Id be very sure to contact the patient myself.
The importance of a face-to-face visit "to understand why this happened, and
what should be done about it" cannot be understated. A personal call from a
physician carries more weight than a call from the office staff, and also allows
the physician, in the case where the patient categorically refuses to discuss this
in person, to document, consider and act appropriately. (Dr. M. Rose)

Peformance enhancing drugs

A colleague has approached you for advice about a request he received from an
athletic club to provide human growth hormone to athletes. He is wondering if
there is any ethical reason not to proceed. He is aware of the prohibition by Sport
Canada to performance enhancing drugs but feels that as long as the athlete
freely chooses this option and is aware of all risks, medical and otherwise, then it
should be allowed.
What advice would you give your colleague and why?
No reponses were received for this scenario.

Prescribing for unnecessary treatments

A 40-year-old woman came in and requested a prescription for a medication that

was, in your opinion, contraindicated because of her co-morbid medical
conditions. She said she was aware of the risks and insisted that if she wanted to
proceed with the treatment, she should be allowed to do so. Furthermore, she
stated that you had no right to refuse to prescribe it for her.
You have always tried to act in accordance with the tenet do no harm and have
felt that you must make an independent decision as to the acceptability of a
treatment. One of your colleagues feels that if the patient is aware of the risks
then you should provide her with the treatment if she requests it. You are unsure
about this and wonder how best to sort this out. What should you do?

Responses, as published in the Messenger, to this issue:

This scenario is timely and realistic, especially for family doctors. We must
remember that the pharmaceutical industry is driven, like all big business, by
profit. They advertise to the public and physicians to advance this goal. And it
works, or they wouldnt be spending millions on it. Most importantly, we must
remember that this advertising (to both the public and doctors) is neither
objective nor necessarily accurate.
To that end, my answer to this patient would be a firm no. The analogy Id offer is
this: A Toyota salesman will never recommend an Accord, even if its better than
a Camry. I will not base my medical judgement on the advertising efforts of the
pharmaceutical industry. If this patient still has an issue with this, she should find
a new doctor. (Dale Cole, CCFP - Calgary)
While the patient has a right to the medication, the physician has an equal right
to refuse to prescribe treatment he or she believes to be on balance harmful. The
patient, however, deserves to be given a second opinion. So I would refuse to
prescribe the medication but would provide a referral to a colleague for a second
opinion regarding the risks vs. the benefits. I wonder what disease is supposed to
be treated by the medication the 40 year old patient is requesting? Is it an
urgent or even fatal condition? That would not change my position, but would
change the urgency of the referral. (Dennis Fong, CCFP - California)
When a patient is prescribed an antibiotic (clearly indicated for the patient at
that point) both the doctor and the patient are aware of any side effects and/or
adverse effects. The patient is given the prescription because the doctor clearly
outlines the benefits vs. adverse effects so that the patient feels the treatment is
justified.
In this scenario, the patient should be given a type of presentation that will
convince the patient to pick up the right prescription. This process may need a
physicians time, verbal expertise and a bit of patience. (Mira Parai, FRCPC,
Pathologist - Red Deer)

End-of-life care

Dr. Jones is an internist working in a tertiary care hospital. She covers the general
medical units on weekends and supervises residents. Last weekend, a resident
came to her with concerns about a patient who was receiving end of life care.
The patients family had been reading about the Quebec discussion on
euthanasia and expressed fears that the pain relief being offered to their mother
was designed to hasten her death. They were very opposed to this and wanted
the resident to reduce the amount of medication given.
The patient is unable to participate in these discussions and the resident is
concerned that the patient will suffer extreme pain if the dose is lowered.

Dr. Jones offers to speak to the family with the resident, but the conversation
with the family does not go well. She approaches you to discuss any suggestions
you might have to assist in discussions of end-of-life pain management and the
ethical considerations associated with end-of-life care.
How would you advise Dr. Jones?
Responses, as published in The Messenger, to this issue:
The patient hopefully has had a family physician - who probably is not involved in
the hospital care. I would recommend to Dr. Jones that she open the door for the
patients personal physician to review the situation and advise the family
accordingly. The communication block will hopefully be sidestepped to the
satisfaction of all.
(Warren Hindle MD )
The New York Times ran a terrific article on this called: When Morphine Fails to
Kill by Gina Kolata (July 23rd, 1997)1. While it is somewhat older than Id prefer it is still incredibly accurate. The article quotes Portenoy, Kathleen Foley, Lynn,
Mount, and others and is by far the best article Ive seen on this particular myth
about opioids. The article is rather North American centric in that it doesnt quote
Twycross, Bond, or others across the pond.
(http://www.nytimes.com/1997/07/23/us/when-morphine-fails-to-kill.html?
emc=eta1).
(Daniel Harries )
Find out if the patient has previously made her wishes known. An Advance
Directive or nomination of a decision-making agent would be best, but even
documented discussion with her family physician, or with hospital physicians
when making a decision about Goals of Care, would clarify what the patient
herself wished. If this can be established, the patients wishes are paramount,
and should be carried out, though this should be done as tactfully as possible. If
the patients wishes are not clear, I would suggest negotiating a written
agreement with the relatives. This might require insisting that one person speaks
for all. The agreement should acknowledge the relatives concern, then start
from the premise that on no account should the patient be allowed to suffer pain,
because this would be inhumane and unethical, and that the physician, with her
special knowledge in this area, should be the judge of when her unconscious
patient is in pain. She could explain about increased pulse-rate, blood-pressure,
sweating, restlessness. Then she could agree to reduce the analgesic dose
incrementally until the patient shows signs of pain, then increasing to the lowest
dose at which pain is no longer evident, a task that could be delegated to the
resident.
(Dr Robert Burn, Family Physician )

Responding to the College - your regulatory body

While at the hospital doing rounds a colleague approaches you in an agitated

state. She reports that she has been served a Notice to Practitioner from the
College and has been charged with unbecoming conduct.
She goes on to explain that she received a letter from the College six months
ago and was so busy she never got around to responding to it. She claims it was
a trivial matter relating to the failure to respond to a letter from a patients
insurance company and cant believe that the College would charge her.
You are surprised too and ask if this came out of the blue. She admits that she
was sent four reminder letters but that she had more important matters to
attend to - like caring for patients. When she asks you what you think about this
matter you are not sure what to say.
What would you say to your colleague? Is it important to respond to the College your regulatory body?
Responses, as published in the Messenger, to this issue:
I would have told her that, me and my scared ass wouldve responded
immediately. My shaking fingers and sweaty palms wouldve made the phone call
reluctantly but asap.
I have no empathy for this situation. Does she not stop her car when a police
officer approaches either? What is her sense of entitlement that she is above the
rules? (Dr. Nancy Blaney, Banff )
It is probably just as important to look after ones good health in respect of the
Registering Authority (College) as it is to look after ones personal good health.
Deterioration in either is going to negatively impact on our ability to service our
patients, if that is our raison detre. (Dr. Selby Frank, Vegreville)
I would be obliged to tell her this was a most serious mistake and I doubt if there
can be a satisfactory excuse!
I would also have to advise her that she had a responsibility to reply to the
insurance company in a reasonable time frame. Not to respond to a patents
request for information to be provided to a potential insurer could cause harm for
the patient and also create a liability for the physician.
I showed my son, who is a senior marketing consultant for a major Canadian
Insurance agency the ethics 101 case. He told me that getting replies from
physicians in a timely fashion is a major problem for the industry. (...)* See full
text (Dr. Keith Todd, Calgary)

Responsibilities during a Pandemic

You are a family physician working in a multi-physician practice. You and all of
your partners also provide in-patient care and emergency room coverage at a
local hospital.
The outbreak of H1N1 influenza was raised at the last staff meeting and
everyone is struggling to determine how the clinic and the hospital will manage
during a pandemic situation.
One of the physicians worked in Toronto during the SARS crisis and spoke about
how difficult this was for health care workers.
You do not have any children and one of your partners suggested that physicians
with young children should not be required to put themselves at undue risk.
What principles should your clinic consider as they make plans to prepare for a
pandemic?
Response, as published in The Messenger, to this issue:
In the scenario outlined, there are two components to the problem:
First is the risk of contracting and dying from infection, leaving possibly orphaned
children.
Second is the risk of acting as a carrier and infecting children who may have no
immunity.
I would draw your attention to another ethical dilemma. I am an older
anesthesiologist on the verge of retirement and not sure whether I will continue
practice for another year or not.
I am in the age group which appears to have some immunity to the current
threatening pandemic. Do I therefore have an ethical duty to renew my licence
so that I may make myself available in an emergency? Obviously I cannot be
forced to do so.
My spouse is currently on home oxygen therapy for incipient respiratory failure. If
I continue in practice can I ethically opt out of providing specialized airway care
during a pandemic due to the obvious extreme risk I would expose her to? (Name
withheld to maintain the confidentiality of personal health information)

Your Responsibilities During a Pandemic

The year is 2007; Toronto has declared an emergency pandemic situation and all
signs are that the cases in Alberta (and your community) are increasing rapidly.
You have two school age children and are responsible for aging parents. You work
in a multi-doctor family clinic and take some shifts as a hospitalist every month.
Your daughter has been sent home from school because she has been exposed
to influenza and you are scheduled to do a shift in the hospital. You are aware the
hospital is very busy, has many staff off sick and everyone is working to their
maximum.

What are your responsibilities to your family, the public, and your colleagues?
Responses, as published in the Messenger, to this issue:
Since there is no/or pathetic protection protocols for medical staff working during
a pandemic, ensuring basically that if you work during these time that you would
get infected as well as transmitting the virus to your own home, all medical staff
should stay home and tend their own families. Our first responsibility is to
ourselves and our families. (Dr. W.T. de Vos)
First and foremost, as a parent I am responsible for my children, both legally and
morally. All other considerations are secondary. If I do not care for my children
then no one else will Dont think that the powers in the Alberta Public Health
Act scare me either. Id rather get a $5,000 fine and have the judge throw me in
jail for contempt of court than to have two children at home dying alone. (Dr.
Padraic McCombe)
The main issue in whether physicians will respond to a pandemic is one of
personal safety. We do not ask others (i.e. paramedics) to enter an unsafe
burning building since they will turn from rescuers to casualties (remember 9/11
and the firefighters lost in the building collapse). Physicians should not be asked
to work in unsafe pandemic situations. Our ability to help others will be lost once
we are infected ourselves. The healthcare workers infected with SARS were
effectively removed from the response to SARS---and some died. (Dr. Warren
Thirsk)
I feel that in families where both parents work in the health care field, one parent
should be allowed to stay and take care of children. (Dr. Alexandra Noga)