Canadian Healthcare Association; Canadian Medical Association; Canadian Nurses' Association; Catholic Health Association of Canada
Joint Statement on Preventing and Resolving Ethical Conflicts Involving
Health Care Providers and Persons Receiving Care (1999)
The needs, values and preferences of the person receiving care should be
the primary consideration in the provision of quality health care. Ideally,
health care decisions will reflect agreement between the person receiving
care and all others involved in his or her care. However, uncertainty and
diverse viewpoints sometimes can give rise to disagreement about the goals
of care or the means of achieving those goals. Limited health care resources
and the constraints of existing organizational policies may also make it
difficult to satisfy the person's needs, values and preferences.
The issues addressed in this statement are both complex and
controversial. They are ethical issues in that they involve value
preferences and arise where people of good will are uncertain of or disagree
about the right thing to do when someone's life, health or well-being is
threatened by disease or illness. Because everyone's needs, values and
preferences are different, and because disagreements can arise from many
sources, policies for preventing and resolving conflicts should be flexible
enough to accommodate a wide range of situations.
Disagreements about health care decisions can arise between or among any
of the following: the person receiving care, proxies,1
family members, care providers and administrators of health care
authorities, facilities or agencies. This joint statement deals primarily
with conflicts between the person receiving care, or his or her proxy, and
care providers. It offers guidance for the development of policies for
preventing and resolving ethical conflicts about the appropriateness of
initiating, continuing, withholding or withdrawing care or treatment. It
outlines the basic principles to be taken into account in the development of
such policies as well as the steps that should be followed in resolving
conflicts. The sponsors of this statement encourage health care authorities,
facilities and agencies to develop policies to deal with these and other
types of conflict, for example, those that sometimes arise among care
Good therapeutic relationships are centered on the needs and informed
choices of the person receiving care. Such relationships are based on
respect and mutual giving and receiving. Observance of the following
principles will promote good therapeutic relationships and help to prevent
conflicts about the goals and means of care.
- The needs, values and preferences of the person receiving care
should be the primary consideration in the provision of quality health
- A good therapeutic relationship is founded on mutual trust and
respect between providers and recipients of care. When care providers
lose this sense of mutuality, they become mere experts and the human
quality in the relationship is lost. When persons receiving care lose
this sense of mutuality, they experience a perceived or real loss of
control and increased vulnerability. Because persons receiving care are
often weakened by their illness and may feel powerless in the health
care environment, the primary responsibility for creating a trusting and
respectful relationship rests with the care providers.
- Sensitivity to and understanding of the personal needs and
preferences of persons receiving care, their family members and
significant others is the cornerstone of a good therapeutic
relationship. These needs and preferences are diverse and can be
influenced by a range of factors including cultural, religious and
- Open communication, within the confines of privacy and
confidentiality, is also required. All those involved in decision-making
should be encouraged to express their points of view, and these views
should be respectfully considered. Care providers should ensure that
they understand the needs, values and preferences of the person
receiving care. To avoid misunderstanding or confusion, they should make
their communications direct, clear and consistent. They should verify
that the person receiving care understands the information being
conveyed: silence should not be assumed to indicate agreement. The
person receiving care should be provided with the necessary support,
time and opportunity to participate fully in discussions regarding care.
- The competent person3 must be involved
in decisions regarding his or her care.
- The primary goal of care is to provide benefit to the person
receiving care. The competent person has the right to determine what
constitutes benefit in the given situation, whether with respect to
physical, psychological, spiritual, social or other considerations.
- Informed decision-making requires that the person receiving care or
his or her proxy be given all information and support necessary for
assessing the available options for care, including the potential
benefits and risks of the proposed course of action and of the
alternatives, including palliative care.
- The competent person has the right to refuse, or withdraw consent
to, any care or treatment, including life-saving or life-sustaining
- Although parents or guardians are normally the primary
decision-makers for their minor children, children should be involved in
the decision-making process to the extent that their capacity allows, in
accordance with provincial or territorial legislation.
- When the person receiving care is incompetent, that is, lacking in
adequate decision-making capacity with respect to care and treatment,
every effort must be made to ensure that health care decisions are
consistent with his or her known preferences. These preferences may be
found in an advance directive or may have been communicated orally. In
jurisdictions where the issue of decision-making concerning care and
medical treatment for incompetent persons is specifically addressed in
law, the requirements of that legislation should be met.
- When an incompetent person's preferences are not known and there is
no family member or proxy to represent the person, decisions must be
based on an attempt to ascertain the person's best interests, taking
- the person's diagnosis, prognosis and treatment options,
- the person's known needs and values,
- information received from those who are significant in the
person's life and who could help in determining his or her best
- aspects of the person's culture, religion or spirituality that
could influence care and treatment decisions.
- When conflicts arise despite efforts to prevent them, they should be
resolved as informally as possible, moving to more formal procedures
only when informal measures have been unsuccessful.
- In cases of disagreement or conflict, the opinions of all those
directly involved should be given respectful consideration.
- Disagreements among health care providers about the goals of care
and treatment or the means of achieving those goals should be clarified
and resolved by the members of the health care team so as not to
compromise their relationship with the person receiving care.
Disagreements between health care providers and administrators with
regard to the allocation of resources should be resolved within the
facility or agency and not be debated in the presence of the person
receiving care. Health care authorities, facilities and agencies should
develop conflict resolution policies for dealing with such issues and
monitor their use.
- When the needs, values and preferences of the person receiving care
cannot be met, he or she should be clearly and frankly informed of the
reasons for this, including any factors related to resource limitations.
- Health care providers should not be expected or
required to participate in procedures that are contrary to their
professional judgement4 or personal moral
values or that are contrary to the values or mission of their facility
or agency.5 Health care providers should
declare in advance their inability to participate in procedures that are
contrary to their professional or moral values. Health care providers
should not be subject to discrimination or reprisal for acting on their
beliefs. The exercise of this provision should never put the person
receiving care at risk of harm or abandonment.
- Health care providers have a responsibility to advocate together
with those for whom they are caring in order that these persons will
have access to appropriate treatment.
Health care organizations should have a conflict resolution process in
place to address problems that arise despite efforts to prevent them. There
may be need for variations in the process to accommodate the needs of
different settings (e.g., emergency departments, intensive care units,
palliative care services, home or community care, etc.).
The conflict resolution policy of a health care authority, facility or
agency should incorporate the following elements, the sequence of which may
vary depending on the situation. The policy should designate the person
responsible for implementing each element. That person should work closely
with the person receiving care or his or her proxy. Anyone involved in the
conflict may initiate the resolution process.
- Clarify the need for an immediate decision versus the consequences
of delaying a decision. If, in an emergency situation, there is
insufficient time to fully implement the process, it should be
implemented as soon as possible.
- Gather together those directly involved in the conflict; in addition
to the person receiving care and/or his or her proxy, this might include
various health care providers, family members, administrators, etc.
- If necessary, choose a person not party to the conflict to
facilitate discussions. It is imperative that this person be acceptable
to all those involved and have the skills to facilitate open discussion
- Identify and agree on the points of agreement and disagreement.
While ensuring confidentiality, share among those involved all relevant
medical and personal information, interpretations of the relevant facts,
institutional or agency policies, professional norms and laws.
- Establish the roles and responsibilities of each participant in the
- Offer the person receiving care, or his or her proxy, access to
institutional, agency or community resources for support in the conflict
resolution process, e.g., a patient representative, chaplain or other
- Determine if the group needs outside advice or consultation, e.g., a
second opinion, use of an ethics committee or consultant or other
- Identify and explore all options and determine a time line for
resolving the conflict. Ensure that all participants have the
opportunity to express their views; the lack of expressed disagreement
does not necessarily mean that decision-making is proceeding with the
support or consent of all involved.
- If, after reasonable effort, agreement or compromise cannot be
reached through dialogue, accept the decision of the person with the
right or responsibility for making the decision. If it is unclear or
disputed who has the right or responsibility to make the decision, seek
mediation, arbitration or adjudication.
- If the person receiving care or his or her proxy is dissatisfied
with the decision, and another care provider, facility or agency is
prepared to accommodate the person's needs and preferences, provide the
opportunity for transfer.
- If a health care provider cannot support the decision that prevails
as a matter of professional judgement or personal morality, allow him or
her to withdraw without reprisal from participation in carrying out the
decision, after ensuring that the person receiving care is not at risk
of harm or abandonment.
- Once the process is completed; review and evaluate: (a) the process,
(b) the decision reached, and (c) implementation of the decision. The
conclusions of the evaluation should be recorded and shared for purposes
of education and policy development.
Health care authorities, facilities and agencies are encouraged to make
use of an interdisciplinary committee to develop two conflict resolution
policies: one for conflicts among health care providers (including
administrators) and the other for conflicts between care providers and
persons receiving care. Membership on the committee should include care
providers, consumers and administrators, with access to legal and ethics
consultation. The committee should also develop a program for policy
The successful implementation of the policy will require an
organizational culture that encourages and supports the principles of the
therapeutic relationship as outlined in this joint statement. The
implementation program should include the education of all those who will be
affected by the policy with regard to both the principles of the therapeutic
relationship and the details of the conflict resolution policy. It should
also include measures to ensure that persons receiving care and their
families or proxy decision-makers have access to the policy and its use. The
policy should be reviewed regularly and revised when necessary in light of
relevant clinical, ethical and legal developments.
Because policies and guidelines cannot cover all possible situations,
appropriate consultation mechanisms should be available to address specific
issues promptly as they arise.
The term "proxy" is used broadly in this joint statement
to identify those people who are entitled to make a care and treatment
decision for an incompetent person (in some provinces or territories, the
definition of proxy is provided in legislation). This decision should be
based on the decision the person would have made for himself or herself, to
the best of the proxy's (substitute decision maker's) knowledge; or if this
is unknown, the decision should be made in the person's best interest.
2. The term "therapeutic relationship" is used broadly
in this document to include all professional interactions between care
providers, individually or as a team, and recipients of care.
3. Competence can be difficult to assess because it is
not always a constant state. A person may be competent to make decisions
regarding some aspects of life but not others; as well, competence can be
intermittent: a person may be lucid and oriented at certain times of the day
and not at others. The legal definition and assessment of competence are
governed by the provinces or territories. Health care providers should be
aware of existing laws relevant to the assessment and documentation of
incompetence (e.g., capacity to consent and age-of-consent legislation).
4. Professional judgement will take into account the
standard of care that a facility or agency is committed to provide.
5. On this matter, cf. Guiding Principle 6 of the
Joint Statement on Resuscitative Interventions (Update 1995),
developed by the Canadian Healthcare Association, the Canadian Medical
Association, the Canadian Nurses Association and the Catholic Health
Association of Canada, "There is no obligation to offer a person futile or
nonbeneficial treatment. Futile and nonbeneficial treatments are
controversial concepts when applied to CPR (cardiopulmonary resuscitation).
Policymakers should determine how these concepts should be interpreted in
the policy on resuscitation, in light of the facility's mission, the values
of the community it serves, and ethical and legal developments. For the
purposes of this joint document and in the context of resuscitation,
'futile' and 'nonbeneficial' are understood as follows. In some situations a
physician can determine that a treatment is 'medically' futile or
nonbeneficial because it offers no reasonable hope of recovery or
improvement or because the person is permanently unable to experience any
benefit. In other cases the utility and benefit of a treatment can only be
determined with reference to the person's subjective judgement about his or
her overall well-being. As a general rule a person should be involved in
determining futility in his or her case. In exceptional circumstances such
discussions may not be in the person's best interests. If the person is
incompetent the principles for decision making for incompetent people should
© 1999, Canadian Healthcare Association (CHA), Canadian Medical
Association (CMA), Canadian Nurses Association (CNA) and Catholic Health
Association of Canada (CHAC). Permission is granted for noncommercial
reproduction only. Comments or questions regarding the joint statement or
orders for the joint statement can be sent to: Customer Services, Canadian
Healthcare Association, 17 York Street, Ottawa ON K1N 0J6, 613 241-8005,
ext. 253, fax 613 241-9481; or Membership Services, Canadian Medical
Association, PO Box 8650, Ottawa ON K1G 0G8, 800 267-9703, ext. 2307, fax
613 236-8864; or Publication Sales, Canadian Nurses Association, 50 The
Driveway, Ottawa ON K2P 1E2, 613 237-2133, fax 613 237-3520; or
Publications, Catholic Health Association of Canada, 1247 Kilborn Place,
Ottawa ON K1H 6K9, 61 373-17148, fax 613 731-7797. Copies of this joint
statement are also available at the following web sites:www.canadian-healthcare.org