ETHICS

Reporting Colleagues:

Physician who is your patient:

1. Abuse: Eg: Alcohol
• No Rules in Canada
• Talk to colleague first, encourage to report himself
• If does not comply, report to Provincial Regulatory board OR CMPA(better as independent)
• Ontario must report unsafe driver - Eg: risk of drinking and driving

2.Alleged Sexual Impropriety:

• Obligated to report even if you have received the information from the physician (even if the physician is your
patient)

3.Communicable Disease:
• MUST REPORT

4.Health:
• Report only if impairing the physician and his ability to practice
• Eg: Refusing to take medication, exercise precautions etc

Note: It is important to inform your physician-patient of your decision to report

Physician who is not your patient:

1. Clinical Competency: Concerns regarding a colleague's pattern or care or behavior

• Report to Hospital Administration

2. Disruptive Behavior: Unprofessional behavior towards others

• Report to Chief of Department

3. Alleged Sexual Impropriety:

• MUST report

Physician with Communicable Diseases:

• Physicians who perform exposure prone procedures are obligated to undergo testing for blood borne diseases
• Infected physicians should consult with a Family Physician
• Infected physicians who perform exposure prone procedures are obligated to report to the Regulatory Board.

Exposure prone procedures: Digital palpation of a needle tip in a body cavity or simultaneous presence of Healthcare
Worker's finger & needle or other sharp instrument in a poorly visualized or highly confined anatomic site

HIV:
• HIV is reportable
• Family physician should report HIV status of Physician
• HIV status of physician does NOT need to be reported to the patient (even if performing procedure)
• If patient gets infected, needs to be notified about the infection but not the source/identity of the physician

Right to Medical Records:

• Medical records are the property of the Physician, can only give copy to others including patient.

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 • Medical records are the property of the Physician, can only give copy to others including patient.
• Physician can be compelled by the court through a warrant, court order or subpoena to disclose medical records.
• Patient has right to all medical records, even if it contains information from other doctors.
• If there is information regarding other people there, then the doctor can withhold that information if -
○ There is a patient confidentiality agreement with that person
○ Therapeutic privilege - information harms the patient or disclosure will cause physical or psychological harm
to others
• If records contain remarks other doctors, it should be disclosed if medically relevant or else can be left out. Eg: Can
leave out remarks like 'patient is hostile/aggressive

Releasing child medical report:

• Mature minor (adolescents who have demonstrated decision-making abilities in other areas of life and are capable of
fully appreciating the nature and consequences of medical treatment [and] can give legally effective consent) - Take
consent from patient
• Both full custody parent & access parent (parent who does not have custody but can visit the child) are entitled to child's
medical record
• Younger children can give assent or dissent.

Withholding information from Medical Records

• If information is not relevant to the CURRENT problem, can be left out. Eg: Current problem - Sinusitis, Previous
history - Sexual abuse.
• If it is related to the current problem it cannot be left out even if the patient asks.

Genetic Testing:

• Requires informed consent

• Physicians are legally obligated to inform patients the prenatal testing exists
• Physician can breach confidentiality to warn family members of genetic test results if harm can be prevented via
treatment. Eg: Familial adenomatous polyposis
• Genetic treatment to alter germ cells is prohibited

Research Ethics:

Research first needs to be approved by appropriate review body before participation

Patient participation should only occur after full informed consent by patient or SDM(substitute decision maker)
Doctor must inform patient about:
• purpose of study,
• its source of funding,
• the nature and relative probability of harm,
• nature of participation
• any compensation the doctor will receive
Physicians should disclose any ties the doctor has to the industry in situations where there could be perceived bias. Eg:
Doctor treating the patient is a shareholder in the pharma company funding the research.
Doctor can be remunerated to cover expenses and time. It must be approved by the ethics board and patient must be
informed
Finder's fee is paid to doctor who meets patient, discusses study and takes informed consent and then submits the
patient information
Cloning is prohibited in Canada, doctor can take part outside of Canada

Research results:
• Aggregate (combined findings): offer to the participant
• Individual: offer is significant findings, can reduce harm

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• Individual: offer is significant findings, can reduce harm
• Incidental findings should be informed to the patient as well

Research in Children:
• Need consent from mature minor or guardian
• Immature minor's assent is required
• Dissent of minor should be respected. Dissent can be overridden if too young, will jeopardize child's wellbeing or no
other alternatives
• Research in minors only carried out if same research is not possible in adults ( Duchenne Muscle Dystrophy - children die
before becoming adults, so research must be carried out in children)
• Less vulnerable minors should be selected first
• Minors should derive direct benefit from it
• Minors with life threatening diseases may participate if no other treatment available and will derive benefit from it
• Minors with life threatening diseases may participate if no direct benefit but minimal risk and will benefit others
• Impaired/abused minors are only included if research is directly related AND potential benefit
• Genetic testing can only be done in mature minors

Conflict of interest in research (COI)

• Researchers with significant financial interests in research projects should not be involved in that research
• Research should not take place in that hospital (Institutional COI)

Consent waiver in Research - When can consent be waived:

• Involves minimal risk
• Waiver unlikely to adversely affect subject
• Obtaining consent is impractical:
• Subject must be debriefed after study & it must not be a therapeutic intervention.
• In emergency if there is a serious threat, direct benefit, less risk than other treatment, no prior directive.

Embryo research:
• Embryo research is permitted up to 14 days post fertilization.
• Embryo created for reproduction that are no longer required may be used
• Creation of embryos only for research is prohibited
• NO COMMERCIAL TRANSACTION or service trade ( you cannot buy or sell embryos)
• Informed consent must be obtained from gamete provider
• Physician responsible for fertility treatment may NOT be part of stem cell research
• Discuss research option only after informed choice of abortion is made by the patient
• Maximum of 2 embryos can be taken at a time
• Both parents consent required before donating embryo for research even if sperm is not from husband (consent from
sperm donor not required as consent obtained at time of donation)

Embryo Disposal methods:

• Offer only those that the doctor wants (mention options before IVF)
• Patient can select receiver of donation
• If couple is divorced, don’t need ex-husband's permission if a donor sperm was used
• Need consent of ex-husband if husband's sperm was used

Note: Consent to research and consent for clinical procedure are TWO DIFFERENT THINGS

Canada prohibits performing any procedure to identify sex of in vitro embryo

Sperm/Ova donation
Couples cannot buy sperm/ova, only approved clinics can reimburse donors
All information of donor should be collected but CANNOT be shared with the children
Information is shared to Assisted Human Reproduction Agency and the can share information with children (except

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 Information is shared to Assisted Human Reproduction Agency and the can share information with children (except
identity, that requires consent from donor)
Children can access information about other children conceived by same sperm donor
Sperm donation is not allowed <18yrs old, unless to create a child to raise himself (Eg: Young patient receiving radiation)

End of life care:

Palliative care: specialized medical care for people with serious illness that is focused on providing patients with relief
from symptoms, pain, stress of serious illness (can be given at any time of treatment)

Hospice care: care during final months of someone's life when cure is no longer possible (given when only months to
live)

End of life medication - TPN (total parental nutrition) not used in palliative care

When to initiate End of Life Care discussion:

• Recent hospitalization for serious illness
• Severe progressive medical conditions
• Death expected within 6-12months
• Patient inquiries about it

Advanced Living Will

Specific order - Comply
If order not clear - discuss with patient if possible or SDM

MAiD (Medical assistance in Dying)

• Legal in Canada
• Doctor CAN refuse to do it
• No laws on whether referral needs to be done
• Doctor needs to gove resources and information if denying MAiD

MAiD criteria:
• Eligible for health services funded by the government
• At least 18 yr old and competent
• Grievous and irremediable medical condition
• Suffering intolerable
• Natural death is foreseeable

Note: Depression is NOT a criteria for exclusion from MAiD. It needs to be assessed by tools

MAiD requirements:

• Patient signs and dates a written request for MAID

• Two independent witness sign the written request.
• 10 clear days must elapse between the request and the day on which MAID is provided

Patients refusing treatment:

• Can refuse treatment if competent

• Exceptions are - Parents/SDM making bad decisions for incapable child. Eg: Jehovah's witness refusing blood transfusion
for child in hemorrhagic shock

Doctors can refuse to treat but must refer the patient (Eg: Doctor refusing to treat an unvaccinated child, refusing to do
abortion)

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 abortion)

Brain Death:

Criteria:
Known process capable of causing neurological death with unresponsive coma and motor responses absent bilaterally
Spinal reflexes may be present
Brain stem reflex, gag reflex and cough response, corneal response, pupillary response with pupils midsize or larger and
vestibulo-ocular responses must be absent bilaterally.
No respiratory effort by apnea test
All tests must be performed in ABSENCE of confounding factors. Eg: Shock, hypothermia, metabolic abnormalities,
muscle dysfunction or drug effects
If confounding factors are present - perform cerebral angiography or perfusion scintigraphy

Aboriginal Health:

• Discuss what they want to avoid in treatment

• If requesting smoke ceremony, you can say no because of smoke hazard but provide alternatives such as performing it
outside.
• Leading cause of Death - Suicide
• Diabetes is more prevalent amongst indigenous population due to social suffering and genetic predisposition

Note: NEVER chose to say NO to them, no matter what the request. If request is unreasonable give them alternatives
but never just deny the request

Continued Medical Education (CME):

• Activities such as seminars can be funded by companies, but you cannot advertise/identify the products of the company
• Funding should be in the form of a grant to the medical institution
• Use generic names along with trade names when mentioning products in CME activities
• Company representatives cannot take part in CME activities
• Physicians should not engage in peer selling. Peer selling occurs when a pharmaceutical or medical device manufacturer
or service provider engages a physician to conduct a seminar or similar event that focuses on its own products and is
designed to enhance the sale of those products.
• If specific products or services are mentioned, they should be mentioned with scientific information
• Faculty at CME events may accept reasonable honoraria and reimbursement for travel, lodging and meal expenses.
• Attendees cannot be reimbursed
• Doctors can accept samples but must record the amount
• Doctors cannot accept gifts
• Doctors can accept teaching aids (aids can carry logo of the company but not specific service or product)

Duties of Physicians with Regard to the Privacy of Health Information

Obtain the patient’s expressed consent to disclose information to third parties:

- The patient’s expressed consent need not be obtained to share information between health care team members
involved in the “circle of care.” However, the patient may withdraw consent for this sharing of information and may put
parts of the chart in a “lock box”

Circle of care: The "circle of care" is the group of healthcare providers treating a patient who need information to
provide that care. For example if family physician refers patient to psychiatrist, both family physician and Psychiatrist are
part of the circle of care and consent is not required to share information between the two.

Lock Boxes: The term “lock boxes” applies to situations where the patient has expressly restricted their physician from
disclosing specific aspects of their health information to others, even those involved in the patient’s circle of care. Note
that the Personal Health Information Protection Act (PHIPA) provisions denote that patients may not prevent physicians

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 that the Personal Health Information Protection Act (PHIPA) provisions denote that patients may not prevent physicians
from disclosing personal health information permitted/ required by the law

When is breach of confidentiality allowed?

• Risk of substantial harm to others or to patients themselves (includes communicable diseases - all communicable
diseases must be reported to Public Health)
Eg: HIV status can be revealed to sexual partner but -
First talk to the patient & try to convince them to disclose the status
Set a time limit
If does not comply, inform contacts
• Duty to warn - Eg: Patient confides the plan to harm someone else
Clear risk to identifiable persons
Risk of serious bodily harm or death &
Danger is imminent
• Child abuse - mandatory to report
• Fitness to drive - mandatory to report to Transport authority. Eg - epilepsy, drinking and driving
• Coroner report

Death notification:

When to notify the coroner?

• Violence, negligence, misconduct

• Sudden unexpected death
• Disease not treated
• Cause other than disease
• Suspicious circumstances

Management of a suicidal patient:

Least restrictive alternative (LRA)
1. Discharge patient with follow up, if support/supervision present & there is low risk of self-harm
2. Voluntary hospitalization, if relatively clear suicidal plan (I could just take all these pills), drinks a lot & is socially
isolated
3. Involuntary hospitalization

Abortion:

Elective:
Legal
2nd & 3rd trimester abortion is also legal but usually only carried out if there is serious risk to woman's health or the
fetus has major malformations (anencephaly)

Abortion in incompetent women:

Abortion can be induced by authority of guardian only if it is therapeutic

Disclosure:

All harmful incidents must be disclosed to the patient.

No harm incidents:
• a patient safety incident that reached the patient but no discernible harm resulted. Eg: wrong medication given to a
patient but did not affect the patient.
• It needs to be disclosed to patient

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• It needs to be disclosed to patient

Near miss incident:

• a patient safety incident that did not reach the patient and therefore no harm resulted. Eg: Wrong limb prepped for
surgery but surgeon noticed it in the file and did not operate.
• It does not need to be disclosed to the patient

Disclosure of trainee competency:

• Recent graduates need to disclose their qualifications to patients in order to obtain consent for treatment
• The graduate can cite the experience of the team to reassure the patient
• Attending should inform patient of all level of involvement of resident (Eg: Doing full/part of surgery)

Cannabis prescription:
Doctor should not prescribe cannabis to patients below 25yrs unless all other conventional treatment has been
attempted and failed

Taking blood samples for alcohol or marijuana testing

• Cannot be taken without patients' consent (even if you are asked by the police)
• Can be taken without consent if warrant is issued

Organ donation:
If patient wanted to donate organs but the family doesn’t agree, the doctor is not obligated to take permission from the
family but it is ethical to discuss with the family first

Contraindication to organ donation:

HIV - Can be given to other HIV patient
Active cancer (can donate if cured)

Vaccination:
If vaccination is necessary to preserve life of a child but parents refuse, call child protective services

Elder abuse:
• Mandatory reporting if patient resides in long term home
• Cannot give any information to the police without consent or warrant

Age of consent for sexual activity:

• Majority age is 18yrs (partner cannot be in a position of authority. Eg: Football coach)
• Age of consent for exploitive activity (prostitution) - 18yrs
• 14-15yr can have sexual relations with persons less than 5yrs older than them
• 12-13yr can have sexual relations with persons less than 2yrs older than them

Consent during surgery:

If surgeon decides to perform an extra procedure or step during surgery for which expressed or written consent was not
obtained beforehand, it is important to assess if it is an emergency
• Emergency - consent not required (Eg: Hysterectomy due to uncontrolled PPH during C-sec)
• Not emergent - wait till the patient wakes up and take consent

Substitute Decision Maker hierarchy:

Court appointed
Power of Attorney
Spouse/Partner

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 Spouse/Partner
Children > 16 yr or parent
Access parent
Siblings
Other relatives

Family dispute for treatment of member

Elderly - Obtain help from ethics committee. Eg: Children arguing about treatment of elderly mother (children are at the
same level of SDM hierarchy, so cannot chose to listen to any of them)

Children - both parent permission required if they are married. If doctor does not agree with the decision of the SDM,
contact child welfare society

Note: In case of any dispute always chose to first discuss & mediate, then go to ethics committee

Exceptions to truth telling: When information can be withheld from patient?

1. Waiving of right
Patient can waive off right to information
Doctor should still take consent
Document all information
2. Strong cultural component & no effect on patient
3. Patient may ask others to be informed
4. Therapeutic privilege - withholding of information by the clinician in the belief that disclosure of the information
would itself lead to severe anxiety, psychological distress, or physical harm to the patient

Request for induction/delayed labour

• Can be done if fetus not at risk

• If request is due to unreasonable belief (god wants the baby to come) send to psychiatry
• Women can refuse induction or delay of labour even if fetus suffers

Legal issues during Pregnancy

• If a woman is competent and refuses medical advice, her decision must be respected even if the fetus will suffer
• The fetus does not have legal rights until it is born alive and with complete delivery from the body of the woman
• A pregnant woman that is addicted to teratogenic substances cannot be detained and treated to protect the fetus
• A woman is permitted to refuse HIV testing during pregnancy, even if vertical transmission to fetus results
• A woman is permitted to refuse Caesarean section in labour that is not progressing, despite evidence of fetal distress

Exceptions to consent

• Emergencies - Eg: Treatment of incapable/unconscious person in emergency, where without treatment the patient is at
risk of harm
• Communicable disease
• Legislation
mental health legislation allows for the detention of patients without their consent
Public Health legislation allows medical officers of health to detain, examine, and treat patients without their consent
(e.g. a patient with TB refusing to take medication) to prevent transmission of communicable diseases

Treatment without consent = battery, including if NO consent or if WRONG procedure

Treatment with poor or invalid consent = negligence

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 (e.g. a patient with TB refusing to take medication) to prevent transmission of communicable diseases

Treatment without consent = battery, including if NO consent or if WRONG procedure

Treatment with poor or invalid consent = negligence

Notes:
• Psychiatry patients can be involuntarily detained (if risk of harm to self or others, incapable of self-care)
• Patient and rights advisor should be notified if being detained involuntarily
• Non treatment of neonate born alive is acceptable in<22wks old, 23-25wks old - discuss with parents, >25wks old - full
treatment
• Patient can refuse HIV testing (mandatory testing in prison & military)
• Physicians may have personal relation with patients if >1yr since last therapeutic contact (except psychotherapy -
permanently prohibited)
• Physicians can't treat themselves or family members except for minor conditions or in emergencies & only if no
physician is readily available
• Courts declare competency, physicians assess capacity (capacity is the ability to understand information relevant to a
treatment decision & appreciate the reasonably foreseeable consequences of a decision or lack of a decision)
• Subpoena - it is only a command to attend court. Cannot be compelled to breach confidentiality
• Witness - Doctors can get attendance money as an expert witness

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