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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude
Project Submissions

Submission to the Canadian Medical Association

Re: 2018 Revision of the CMA Code of Ethics

2 April, 2018


Appendix "A"
2004 Code and 2018 revision compared

Ref
 
2004 Code of Ethics [Original Text]
 
2018 Revision [Original Text]

001

 

2004-Intro-1. This Code has been prepared by the Canadian Medical Association as an ethical guide for Canadian physicians, including residents, and medical students.

 

2018-Intro-1. The CMA Code of Ethics and Professionalism articulates the ethical and professional commitments and responsibilities of the medical profession.

002

     

2018-Intro-2. The Code guides high standards of practice in the interests of patients and the public to foster patient and public trust in physicians and the profession.

003

     

2018-Intro-3. The Code is founded on and affirms the core commitments to which the profession aspires and reflects the contemporaneous and changing landscape of medical practice.

004

 

2004-Intro-2. Its focus is the core activities of medicine –such as health promotion, advocacy, disease prevention, diagnosis, treatment, rehabilitation, palliation, education and research.

 

2018-Intro-4. In this Code, ethical practice is understood as a process of active and reflective inquiry and decision-making concerning what a physician's and the profession's practice is and ought to be.

005

 

From Intro-6.

 

2018-Intro-5. Ethical practice involves reflection on the reasons for a physician's actions, what a physician's actions ought to be, situations where existing rules, norms or guidelines are insufficient or are in tension, and a consideration of multiple perspectives in decision-making.

006

     

2018-Intro-6. The Code is not intended to provide specific guidance; it is a vehicle to guide ethical decision-making and ethical practice.

007

 

2004-Intro-3. It is based on the fundamental principles and values of medical ethics, especially compassion, beneficence, non-maleficence, respect for persons, justice and accountability.

 

2018-Intro-7. In this Code, medical ethics concerns the virtues, values and principles that ought to guide the medical profession, while professionalism is the embodiment or enactment of responsibilities arising from those norms through behaviours, standards and competencies.

008

 

From 2004-46.

 

2018-Intro-8. Each physician has a continuing responsibility to merit the privilege of professional-led regulation and support its institutions through enacting the commitments and responsibilities outlined in the Code.

009

 

2004-Intro-4. The Code, together with CMA policies on specific topics, constitutes a compilation of guidelines that can provide a common ethical framework for Canadian physicians.

 

2018-Intro-9. The Code provides a platform for a shared purpose and identity, by articulating a common understanding of what it means to be a medical professional and the profession's shared goals.

010

 

2004-Intro-5. Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions.

 

2018-Intro-10. Physicians should be aware of legal and regulatory requirements that govern medical practice in their jurisdiction.

011

 

2004-Intro-6. Physicians may experience tension between different ethical principles, between ethical and legal or regulatory requirements, or between their own ethical convictions and the demands of other parties.

 

Moved to Intro-5.

012

 

2004-Intro-7. Training in ethical analysis and decision-making during undergraduate, postgraduate and continuing medical education is recommended for physicians to develop their knowledge, skills and attitudes needed to deal with these conflicts.

 

Deleted.

013

 

Intro-8. Consultation with colleagues, regulatory authorities, ethicists, ethics committees or others who have relevant expertise is also recommended.

 

Deleted.

014

     

A. VIRTUES EXEMPLIFIED BY THE MEDICAL PROFESSION

015

     

A-Intro. Trust is the cornerstone of the patient–physician relationship and of medical professionalism and is central to providing the highest standard of care. By exemplifying the following, interconnected virtues in practice, physicians strive to enhance the trustworthiness of the profession:

016

     

COMPASSION. A compassionate physician recognizes suffering, understands and feels something of the unique circumstances of the patient, and is motivated to act, and does act, to alleviate suffering.

017

     

HONESTY. An honest physician is straightforward and forthright, respects the truth and does their best to find out the truth, to preserve it, and to communicate it sensitively.

018

     

HUMILITY. A physician who acts with humility understands the limits of their own knowledge and skills and is careful not to overstep them by recognizing the experiential knowledge of patients and communities and the limits of scientific knowledge, and seeks the skills, experience, and wisdom of colleagues when necessary.

019

     

INTEGRITY. A physician who acts with integrity demonstrates consistency of intentions and actions, and acts in a truthful manner, in accordance with professional expectations.

020

     

MORAL COURAGE. A physician who acts with moral courage communicates and does what they believe to be right and true even in the face of adverse consequences.

021

 

Fundamental Responsibilities

 

B. FUNDAMENTAL COMMITMENTS OF THE MEDICAL PROFESSION

022

 

1. Consider first the well-being of the patient.
(See also Intro-3.)

 

B1. Commitment to beneficence
Promote the well-being of, and take steps to prevent harm to, patients; take actions that serve the best interests of patients and communities through the provision of appropriate care and treatment across the care continuum - from prevention to palliation.

023

 

2. Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.

 

B2. Commitment to patient dignity and autonomy
Treat all patients with dignity and as persons worthy of respect.
Practise medicine in a manner that recognizes patients as autonomous, self-determining persons capable of choice and that preserves the dignity and autonomy of those who cannot choose for themselves.

024

 

Moved from 2004-9.

 

Respect and promote the inherent dignity and equal worth of all persons and refuse to participate in or support practices that violate basic human rights; never participate in or facilitate torture.

025

3. Provide for appropriate care for your patient, even when cure is no longer possible, including physical comfort and spiritual and psychosocial support.

Deleted.

026

 

4. Consider the well-being of society in matters affecting health.
(See also 2004-Intro-3)

 

B3. Commitment to justice
Promote the well-being of communities, populations, and society by: ensuring the fair and equitable distribution of resources, improving access to care, reducing health disparities and inequities; and through resource stewardship, social accountability, health care advocacy and leadership in system change.

027

 

5. Practise the art and science of medicine competently, with integrity and without impairment.
(See also 2004-15, 47)

  B4. Commitment to professional integrity and professional competence
Practise the art and science of medicine competently, safely and with integrity.
Engage in lifelong learning to maintain and advance your professional knowledge and skills, know when to apply new knowledge and recognize that acting beyond one's expertise can have harmful consequences.
Provide high-quality patient care and have a view to continuous quality improvement at the practice and system levels.

028

6. Engage in lifelong learning to maintain and improve your professional knowledge, skills and attitudes.

See B7.

029

 

7. Resist any influence or interference that could undermine your professional integrity.

 

Deleted

030

 

8. Contribute to the development of the medical profession, whether through clinical practice, research, teaching, administration or advocating on behalf of the profession or the public.

 

B5. Commitment to professional excellence
Contribute to the development of the medical profession through clinical practice, research, teaching, mentorship, leadership, administration or advocacy on behalf of the profession or the public.
Cultivate strong connections and relationships between, and meaningful interactions with, colleagues, including physicians in all specialties and other health professionals.

031

 

9. Refuse to participate in or support practices that violate basic human rights.

 

Added to the end of B2.

032

 

10. Promote and maintain your own health and wellbeing.

 

B6. Commitment to self-care and support for colleagues
Maintain personal health and well-being, including exhibiting self-awareness and managing personal influences as well as professional demands for a sustainable practice throughout the career life cycle.
Value and promote a professional culture that recognizes, supports and responds effectively to colleagues in need, including cultivating training and practice environments where physicians are empowered and encouraged to seek help and are supported in their maintenance of physical, mental and social well-being.

033

 

See 2004-6.

 

B7. Commitment to inquiry and reflection
Value and enable active and reflective inquiry, and collective reflection and self-reflection, to further medical science and facilitate ethical decision-making.
Foster curiosity and exploration to further your professional development and insight and be open to new knowledge, technologies, ways of practising, and learning from others.

034

     

C. PROFESSIONAL RESPONSIBILITIES

 

035

 

Responsibilities to the Patient

 

PHYSICIANS AND PATIENTS

036

 

General Responsibilities

 

Patient-physician relationship

037

     

C-IntroA. The patient–physician relationship is at the heart of the practice of medicine. It is characterized by reciprocal trust, need and understanding, and centres on a process of deliberation that recognizes that the physician and patient are each moral agents.

038

     

C-IntroB.  Physicians and their patients build relationships of trust that enable open and honest dialogue and foster the patient's willingness to share deeply personal information, often in conditions of vulnerability.

039

     

C-IntroC.  Physicians owe a duty of loyalty to the patient by protecting and furthering the interests of the patient using the physician's expertise, knowledge and appropriate clinical judgement.

040

 

11. Recognize and disclose conflicts of interest that arise in the course of your professional duties and activities, and resolve them in the best interest of patients.

 

Moved to C19.

041

 

12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.

 

Moved to C3.

042

 

13. Do not exploit patients for personal advantage.

 

Moved to C19.

043

 

14. Take all reasonable steps to prevent harm to patients; should harm occur, disclose it to the patient.

 

Deleted.

044

 

15. Recognize your limitations and, when indicated, recommend or seek additional opinions and services.

 

See B4.

045

 

16. In determining professional fees to patients for non-insured services, consider both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient.

 

Deleted.

046

 

Initiating and Dissolving a Patient-Physician Relationship

 

In the context of the patient–physician relationship:

047

 

17. In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status. This does not abrogate the physician's right to refuse to accept a patient for legitimate reasons.

 

C1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation or socioeconomic status).

048

 

18. Provide whatever appropriate assistance you can to any person with an urgent need for medical care.

 

Moved to C6.

049

     

C2. Act according to your conscience, and respect differences of conscience among your colleagues; always respond to a patient's medical request regardless of your moral commitments.

050

 

Moved from 2004-12.

 

C3. Inform the patient when your deeply held values may influence the recommendation, provision or practice of any medical procedure or intervention that the patient needs or requests, but never abandon the patient.

051

 

19. Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted; until another suitable physician has assumed responsibility for the patient; or until the patient has been given reasonable notice that you intend to terminate the relationship.

 

The duty of non-abandonment requires providing the patient with complete information on all clinical options available and, when necessary, a formal referral or a direct transfer of care. It also includes the transfer of the patient's records when requested by the patient.

052

 

See 2004-22.

 

C4. Communicate accurately and honestly with the patient in a way that can be understood and applied.

053

 

20. Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available; there should be no fee for such treatment.

 

Deleted

054

 

Communication, Decision Making and Consent

 

Decision making

055

     

C-IntroD.  Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making informed by the patient's experience and values and the physician's clinical judgment.

056

     

C-IntroE.  This deliberation involves discussion with the patient and, with consent, the patient's family members and significant others, and other health care professionals and experts involved in the patient's care.

057

     

 C-IntroF.  The physician provides appropriate medical information and helps the patient navigate available therapeutic options to determine the best course of action for the patient. In the process of shared decision-making:

058

 

21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.

 

See C8.

059

 

22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.

 

See C4.

060

 

23. Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patient or to others. If a service is recommended for the benefit of others, as for example in matters of public health, inform your patient of this fact and proceed only with explicit informed consent or where required by law.

 

C5. Recognize that inappropriate use or overuse of treatments or resources can lead to ineffective, and at times harmful, patient care.

061

 

Moved from 2004-18.

 

C6. Provide whatever appropriate assistance you can to any person with an emergency need for medical care.

062

 

Moved from 2004-40.

 

C7. When involved in research, obtain the informed consent of the research participant, and advise prospective participants that they have the right to decline participation or withdraw from the study at any time, without impacting their ongoing care.

063

     

C8. Practise shared decision-making and empower patients to gain the knowledge and understanding necessary to improve their health and make informed choices, including by having a full discussion of the relevant harms and benefits.

064

 

24. Respect the right of a competent patient to accept or reject any medical care recommended.

 

C9. Respect the values and decisions of a competent patient to accept or reject any medical care or treatment recommended.

065

 

25. Recognize the need to balance the developing competency of minors and the role of families in medical decision-making. Respect the autonomy of those minors who are authorized to consent to treatment.

 

C10. Recognize the need to balance the developing competency of minors and the role of families or caregivers in medical decision-making.

066

 

26. Respect your patient's reasonable request for a second opinion from a physician of the patient's choice.

 

Moved to C12.

067

 

27. Ascertain wherever possible and recognize your patient's wishes about the initiation, continuation or cessation of life-sustaining treatment.

 

Deleted

068

 

28. Respect the intentions of an incompetent patient as they were expressed (e.g., through a valid advance directive or proxy designation) before the patient became incompetent.

 

C11. Respect the values and intentions of a decisionally incompetent patient as expressed through advance care planning discussions or via a substitute decision-maker.

069

 

29. When the intentions of an incompetent patient are unknown and when no formal mechanism for making treatment decisions is in place, render such treatment as you believe to be in accordance with the patient's values or, if these are unknown, the patient's best interests.

 

070

 

30. Be considerate of the patient's family and significant others and cooperate with them in the patient's interest.

 

Deleted

071

 

From 2004-26.

 

C12. Respect the patient's reasonable request for a second opinion.

072

     

PHYSICIANS AND THE PRACTICE OF MEDICINE

073

 

Privacy and Confidentiality

 

Patient privacy and the duty of confidentiality

074

31. Protect the personal health information of your patients.

C13. Fulfill your duty of confidentiality to the patient by keeping identifiable patient information confidential, collecting health information only to benefit the patient and sharing information only for that purpose and within the patient's circle of care, unless the informed consent of the patient has been obtained to do otherwise.
See also C17.

075

 

32. Provide information reasonable in the circumstances to patients about the reasons for the collection, use and disclosure of their personal health information.

 

076

 

33. Be aware of your patient's rights with respect to the collection, use, disclosure and access to their personal health information; ensure that such information is recorded accurately.

 

077

 

34. Avoid public discussions or comments about patients that could reasonably be seen as revealing confidential or identifying information.

 

See C18.

078

 

35. Disclose your patients' personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or, in the case of incompetent patients, to the patients themselves. In such cases take all reasonable steps to inform the patients that the usual requirements for confidentiality will be breached.

 

See C13.

079

 

36. When acting on behalf of a third party, take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to the third party.

 

Deleted

080

 

37. Upon a patient's request, provide the patient or a third party with a copy of his or her medical record, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others.

 

C14. Consider both your duty to care and duty not to harm the patient when considering privacy requirements.

081

     

C15. Recognize and manage privacy requirements within clinical training environments, quality improvement initiatives and secondary uses of data for health system management.

082

     

C16. Appropriately manage privacy considerations that can arise from the use of new and emerging technologies in clinical contexts.

083

     

C17. Act as a data steward, controlling the extent to which information about the patient is protected, used or disclosed. As a data steward, you should use or disclose only the minimum amount of information necessary to fulfill the intended purpose.

084

 

See 2004-34.

 

C18. Avoid public discussions, including in public spaces or on social media, about patients that could reasonably be seen as revealing confidential or identifying information, or as being disrespectful to patients, their families or caregivers.

085

     

Managing and minimizing conflicts of interest

086

 

Moved from 2004-11, 13.

 

C19. Recognize and disclose conflicts of interest that arise, or are perceived to arise, in the course of your professional duties and activities, and resolve them in the best interests of patients. Never exploit patients for personal advantage.

087

     

C20. Be transparent about relationships and transactions that may give rise to a conflict of interest, including in practice, education and research.

088

 

Moved from 2004-49.

 

C21. Enter into associations, contracts and agreements only if you can maintain your professional integrity and safeguard the best interests of the patient and communities.

089

 

Moved from 2004-50.

 

C22. Avoid using your role as a physician to promote services or products to patients for commercial gain.

090

 

Research

   

091

 

38. Ensure that any research in which you participate is evaluated both scientifically and ethically and is approved by a research ethics board that meets current standards of practice.

 

C23. Ensure that any research in which you participate is evaluated both scientifically and ethically and is approved by a research ethics board that adheres to current standards of practice. Inform potential research participants about anything that may give rise to a conflict of interest, such as the source of funding and the nature of your participation including any compensation.

092

 

39. Inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of your participation including any compensation.

 

093

 

40. Before proceeding with the study, obtain the informed consent of the subject, or proxy, and advise prospective subjects that they have the right to decline or withdraw from the study at any time, without prejudice to their ongoing care.

 

Moved to C7.

094

     

C24. Recognize the potential for conflicts of interest between your role as a clinician and your organizational, administrative or leadership roles.

094

 

Responsibilities to society

 

Physicians and society

095

 

41. Recognize that community, society and the environment are important factors in the health of individual patients.

 

C25. Recognize that community, society and the environment are important factors that influence the health of the patient.

096

 

42. Recognize the profession's responsibility to society in matters relating to public health, health education, environmental protection, legislation affecting the health or well-being of the community and the need for testimony at judicial proceedings.

 

C26. Support the responsibility of the profession in matters relating to public and population health, health education, environmental protection, legislation affecting the health or well-being of the community and the need for testimony at judicial proceedings.

097

 

43. Recognize the responsibility of physicians to promote equitable access to health care resources.

  C27. Promote shared stewardship of system resources and recognize the responsibility of the profession to promote equitable access to health care resources.

098

 

44. Use health care resources prudently.

 

099

     

C28. Contribute to and collaborate with others in leading system change to improve health care delivery and address systemic health issues that impact public and population health.

100

     

C29. Recognize that medical tourism raises complex systemic and resource issues.

101

     

C30. Recognize that new and emerging technologies are changing the nature and role of medical practice and the social role of physicians.

102

 

45. Recognize a responsibility to give generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate.

 

C31. Provide opinions consistent with the accepted views of the profession when interpreting scientific knowledge to the public; indicate when presenting an opinion that is contrary to the accepted views of the profession.

103

 

See 2004-47

 

C32. Contribute to developing a more cohesive and integrated health system through inter-professional collaboration.

104

     

C33. Recognize the importance of reconciliation between the medical profession and Aboriginal communities by working towards reconciling relationships and establishing and maintaining respectful and healthy relationships.

105  

Responsibilities to the Profession

 

PHYSICIANS AND COLLEAGUES

106

 

46. Recognize that the self-regulation of the profession is a privilege and that each physician has a continuing responsibility to merit this privilege and to support its institutions.

 

Moved to 2018-Intro-8.

107

 

47. Be willing to teach and learn from medical students, residents, other colleagues and other health professionals.

 

See C32.

108

 

 48. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues.

 

See C40.

109

 

49. Be willing to participate in peer review of other physicians and to undergo review by your peers.

 

Deleted

110

  49. Enter into associations, contracts and agreements only if you can maintain your professional integrity and safeguard the interests of your patients.  

Moved to C21.

111

 

50. Avoid promoting, as a member of the medical profession, any service (except your own) or product for personal gain.

 

Moved to C22.

112

 

51. Do not keep secret from colleagues the diagnostic or therapeutic agents and procedures that you employ.

 

Deleted.

113

 

52. Collaborate with other physicians and health professionals in the care of patients and the functioning and improvement of health services.

 

Moved to C37.

114

 

 

Treat your colleagues with dignity and as persons worthy of respect.

 

 C34. Treat your colleagues, including physicians and medical learners, other health professionals, the health care team and staff, with dignity and as persons worthy of respect.

   

C35. Cultivate respectful, open and transparent dialogue and relationships. Engage in respectful communications in all mediums.

   

C36. Take responsibility for promoting civility and confronting incivility within and beyond the profession. Assume responsibility for your personal actions and behaviours that may contribute to negative workplace and training culture.

115

 

See 2004-52.

 

C37. Promote patient-, family- and caregiver-centred, team-based, collaborative models of care across and within specialties, and with other health professionals. Support multidisciplinary teams and practices to bolster collaboration, and a shared accountability for patient care.

116

 

See 2004-47.

 

C38. Value the exchange of knowledge and experience and be willing to teach and learn from medical and other colleagues.

117

 

See 2004-47.

 

C39. Promote and enable formal and informal mentorship and leadership opportunities across all levels of training, practice and health system delivery.

118

 

See 2004-48.

 

C40. Know and follow relevant reporting requirements and expectations placed on you by regulatory authorities.

119

 

Responsibilities to Oneself

 

Physicians and self

120

 

53. Seek help from colleagues and appropriately qualified professionals for personal problems that might adversely affect your service to patients, society or the profession.

 

C41. Seek help from colleagues and appropriately qualified professionals for personal problems that might adversely affect your health and your services to patients, society or the profession.

121

 

54. Protect and enhance your own health and wellbeing by identifying those stress factors in your professional and personal lives that can be managed by developing and practising appropriate coping strategies.

 

C42. Be aware of what health and wellness services and other resources are available to you and colleagues in need.

   

C43. Cultivate an environment of physical and psychological safety, conducive to challenging the status quo, as well as encouraging help-seeking behaviours.

   

C44. Advocate for cultural and systemic change to remove individual- and system-level barriers to health and wellness.

   

C45. Take steps to maximize meaningful co-existence of professional and personal life, recognizing that prioritizing opportunities for adequate rest, exercise, healthy eating and leisure will support professional and personal life.

   

C46. Actively model healthy behaviours.

 

 

 

 

 

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