Page 27 - TNFlipTest

Toronto Notes 2019 Ethical and Legal Issues in Canadian Medicine Ethical, Legal, and Organizational Medicine ELOM13
Legal Issues and Arguments
• thelawprotectsawoman’srighttolife,liberty,andsecurityofperson,anddoesnotrecognizefetal rights; key aspects of the mother’s rights include:
■ 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 (Winnipeg Child and Family Services (Northwest Area) v. G. (D.F.), [1997] 3 S.C.R. 925)
■ a fetus is not a “human being” within the meaning of the Criminal Code of Canada, thus medical negligence during delivery resulting in the death of a fetus that has not been born alive does not constitute criminal negligence causing death (manslaughter) and cannot attract criminal penalties (R v Sullivan)
Royal Commission on New Reproductive Technologies (1993) recommendations:
1. medical treatment must never be imposed upon a competent pregnant woman against her wishes 2. no law should be used to confine a pregnant woman in the interest of her fetus
3. the conduct of a pregnant woman in relation to her fetus should not be criminalized
4. child welfare should never be used to control a woman’s behaviour during pregnancy
5. civil liability should never be imposed upon a woman for harm done to her fetus during pregnancy
Examples involving the use of established guidelines
• awomanispermittedtorefuseHIVtestingduringpregnancy,evenifverticaltransmissiontofetus
results, however, once the baby is born, breastfeeding and even theoretical transmission of HIV may
attract criminal liability (this area of law is unsettled)
• a woman is permitted to refuse Caesarean section in labour that is not progressing, despite evidence of
fetal distress
Advanced Reproductive Therapies
• includesnon-coitalinsemination,hormonalovarianstimulation,andIVF • topicswithethicalconcerns:
■ donor anonymity vs. child-centred reproduction (i.e. knowledge about genetic medical history)
■ preimplantation genetic testing for diagnosis before pregnancy
■ use of new techniques without patients appreciating their experimental nature
■ embryo status – the Supreme Court of Canada maintains that fetuses are “unique” but not persons
under law; this view would likely apply to embryos as well
■ access to ART
■ private vs. public funding of ART
■ social factors limiting access to ART (e.g. same-sex couples) ■ the ‘commercialization’ of reproduction
Fetal Tissue
• pluripotentstemcellscancurrentlybederivedfromhumanembryonicandfetaltissue • potentialusesofstemcellsinresearch
■ studying human development and factors that direct cell specialization
■ evaluating drugs for efficacy and safety in human models
■ cell therapy: using stem cells grown in vitro to repair or replace degenerated/destroyed/malignant
tissues (e.g. Parkinson’s disease)
■ genetic treatment aimed at altering somatic cells (e.g. myocardial or immunological cells) is
acceptable and ongoing
Induced Abortion
• CMAdefinitionofinducedabortion:theactiveterminationofapregnancybeforefetalviability(fetus >500gor>20wkGA)
• CMApolicyoninducedabortion
1. induced abortion should not be used as an alternative to contraception
2. counselling on contraception must be readily available
3. full and immediate counselling services must be provided in the event of unwanted pregnancy
4. there should be no delay in the provision of abortion services
5. no patient should be compelled to have a pregnancy terminated
6. physicians should not be compelled to participate in abortion – if morally opposed, the physician
should inform the patient so she may consult another physician
7. no discrimination should be directed towards either physicians who do not perform or assist at
induced abortions or physicians who do
8. induced abortion should be uniformly available to all women in Canada and health care insurance
should cover all the costs (note: the upper limit of GA for which coverage is provided varies between
provinces)
9. elective termination of pregnancy after fetal viability may be indicated under exceptional
Neonate as Member of Society
Paediatr Child Health 2012;17(8):443-444
• Once outside the mother’s body, the
neonate becomes a member of society with all the rights and protections other vulnerable persons receive.
• Non-treatment of a neonate born alive is only acceptable if <22 wk GA
• 23-25 wk GA: treatment should be a consensual decision between physician and parents
• 25 wk GA and more: neonate should receive full treatment unless major anomalies or conditions incompatible with life are present
Advanced Reproductive Technologies: Ethically Appropriate Actions
• Educate patients and address contributors
to infertility (e.g. stress, alcohol,
medications, etc.)
• Investigate and treat underlying health
problems causing infertility
• Wait at least 1 yr before initiating treatment
with ART (exceptions – advanced age or
specific indicators of infertility)
• Educate and prepare patients for potential
negative outcomes of ART
Payment of gamete donors is currently illegal in Canada. The ART Act is currently not being enforced as it does not clarify whether ART falls under the jurisdiction of the federal or provincial government
Semen Regulations of the Food and Drug Act, 1996
No one under age 18 can donate sperm or eggs, except for the purpose of creating a child that the donor plans to raise himself/ herself (e.g. young patients receiving radiation therapy for cancer that may cause infertility)
Assisted Human Reproduction Act, 2004
Surrogate mothers cannot be paid or offered compensation beyond a reimbursement of their expenses
circumstances