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ELOM14 Ethical, Legal, and Organizational Medicine Ethical and Legal Issues in Canadian Medicine Toronto Notes 2019
The Tri-Council Policy Statement
1. Genetictreatmentaimedataltering germ cells is prohibited in Canada and elsewhere
2. Embryoresearchispermittedupto14d post-fertilization
3. Embryoscreatedforreproductive purposes that are no longer required may be used
4. Gameteprovidersmustgivefreeand informed consent for research use
5. No commercial transactions in the
creation and use of the embryos are
permitted
6. Creationofembryossolelyforresearch
purposes is prohibited
8. Humancloningisstrictlyprohibited
8. Risksofcoercionmustbeminimized(i.e.
the fertility treatment team may not be pressured to generate more embryos than necessary)
9. Onemayonlydiscusstheoptionofusing fetal tissue for research after free and informed choice to have a therapeutic abortion has been made by the patient
10. Physicians responsible for fertility treatment may not be part of a stem cell research team
Palliative Care – Not the Same As Euthanasia
Palliative care is an approach designed to improve symptoms and quality of life for the duration of a person's life, but unlike Medical AssistanceinDying, itdoesnotaimdirectly at or intend to end the person’s life. Many palliative care physicians are incorporating MAiD into their practice, though some may conscientiously object
MAID: Ethically Appropriate Actions
• Respect capable decisions to forgo treatment
• Provide appropriate palliative measures
• Try to assess reasons for such requests
from patients to see if there are ‘reversible factors’ (such as depression, pain, loneliness, anxiety) that can be treated
Ethical and Legal Concerns and Arguments
• inCanada,thereisnocriminalprohibitionregardingabortion
• itisawoman’smedicaldecisiontobemadeinconsultationwithwhomshewishes;thereisno
mandatory role for spouse/family
• 2ndandeven3rdtrimesterabortionsarenotillegalinCanada,butareusuallyonlycarriedoutwhen
there are serious risks to the woman’s health, or if the fetus has died in utero or has major malformations (e.g. anencephaly)
Prenatal/Antenatal Genetic Testing
• uses
1. to confirm a clinical diagnosis
2. to detect genetic predisposition to a disease
3. allows preventative steps to be taken and helps patient prepare for the future 4. gives parents the option to terminate a pregnancy or begin early treatment
• ethicaldilemmasarisebecauseofthesensitivenatureofgeneticinformation;importantconsiderations of genetic testing include:
■ the individual and familial implications
■ its pertinence to future disease
■ its ability to identify disorders for which there are no effective treatments or preventive steps ■ its ability to identify the sex of the fetus
■ ethical issues and arguments regarding the use of prenatal/antenatal genetic testing include:
◆ obtaining informed consent is difficult due to the complexity of genetic information ◆ doctor’s duty to maintain confidentiality vs. duty to warn family members
◆ risk of social discrimination (e.g. insurance) and psychological harm
Legal Aspects
• nocurrentspecificlegislationexists
• testingrequiresinformedconsent
• nostandardofcareexistsforclinicalgenetics,butphysiciansarelegallyobligatedtoinformpatientsthat
prenatal testing exists and is available
• aphysicianmaybeabletobreachconfidentialityinordertowarnfamilymembersaboutacondition
if harm can possibly be prevented via treatment or prevention. In general, the patient’s consent is required, unless the harm to be avoided is sufficiently serious to rise to the level of imminent risk of serious bodily harm or death (i.e. not a chronic condition, but an acute life-threatening condition)
Genetic Testing: Ethically Appropriate Actions
• thoroughdiscussionandrealisticplanningwithpatientbeforetestingisdone • geneticcounsellingfordeliveryofcomplexinformation
End-of-Life Care
Overview of Palliative and End-of-Life Care
• focusofcareiscomfortandrespectforpersonnearingdeathandmaximizingqualityoflifeforpatient, family, and loved ones
■ palliative care is an approach that improves the quality of life of patients facing life-threatening illness, through the prevention and relief of suffering, including treating pain, physical, psychosocial, and spiritual concerns
• appropriate for any patient at any stage of a serious or life-limiting illness • mayoccurinahospital,hospice,inthecommunity,orathome
• ofteninvolvesaninterdisciplinaryteamofcaregivers
• addressesthemedical,psychosocial,andspiritualdimensionsofcare
Euthanasia and Medical-Assistance in Dying (MAiD)
• euthanasia:knowinglyandintentionallyperforminganact,withorwithoutconsent,thatisexplicitly intended to end another person’s life where that person has an incurable illness
• medical-assistanceindying:theadministeringorprescribingforself-administration,byamedical practitioner or nurse practitioner, of a substance, at the request of a person, that causes their death
■ palliative sedation: the use of sedative medications for patients that are terminally ill to relieve suffering and manage symptoms. Though the intent is not to hasten death, this may be a foreseeable consequence
■ withdrawing or withholding life sustaining interventions (e.g. artificial ventilation or nutrition) that are keeping the patient alive but no longer wanted or indicated
Common Ethical Arguments/Opinions
• criminallyprohibitingassistanceindeath,forcessomewhowilleventuallybecometoounwelltoend their own lives at an earlier time and forces others to endure intolerable suffering.
• patienthastherighttomakeautonomouschoicesaboutthetimeandmanneroftheirowndeath
• beliefthatthereisnoethicaldifferencebetweentheactsofeuthanasia/assistedsuicideandforgoinglife-
sustaining treatments
• beliefthattheseactsbenefitterminallyillpatientsbyrelievingsuffering
• patientautonomyhaslimits