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ELOM18 Ethical, Legal, and Organizational Medicine Ethical and Legal Issues in Canadian Medicine Toronto Notes 2019
• ethicaldilemmasthatarisewhendecidinghowbesttoallocateresources
■ fair chances vs. best outcome: favouring best outcome vs. giving all patients fair access to limited
resources (e.g. transplant list prioritization)
■ priorities problem: how much priority should the sickest patients receive?
■ aggregation problem: modest benefits to many vs. significant benefits to few
■ democracy problem: when to rely on a fair democratic process to arrive at a decision
Guidelines for Appropriately Allocating Resources
• thephysician’sprimaryobligationisto:
■ protect and promote the welfare and best interests of his/her patients
■ choose interventions known to be beneficial on the basis of evidence of effectiveness
■ seek the tests or treatments that will accomplish the diagnostic or therapeutic goal for the least cost ■ advocate for one’s patients, but avoid manipulating the system to gain unfair advantage for them
■ resolve conflicting claims for scarce resources justly, on the basis of morally relevant criteria such as
need and benefit, using fair and publicly defensible procedures
■ inform patients of the impact of cost constraints on care, but in a sensitive way
■ seek resolution of unacceptable shortages at the level of hospital management or government
Conscientious Objection
Patients Refusing Treatment
• inaccordancewiththeprincipleofautonomy,itisgenerallyacceptableforcompetentpatientstorefuse medical interventions for themselves or others, although exceptions may occur
• ifparentsorSDMsmakedecisionsthatareclearlynotinthe“bestinterests”ofanincapablechild, physicians may have ethical grounds for administering treatment, depending on the acuity of the clinical situation
■ in high-acuity scenarios (e.g. refusing blood transfusion based on religious grounds for a child in hemorrhagic shock), physicians have a stronger obligation to act in the child’s best interests
■ in lower acuity scenarios (e.g. refusing childhood immunization in a developed nation) there is a stronger obligation to respect the autonomy of the decision-makers
■ in 2014, a child was found not to be “a child in need of protection” when her mother refused chemotherapy and pursued traditional Indigenous healing. While this decision purported to establish a new constitutional right to Indigenous healing, the decision was amended such that “the best interests of the child are paramount." These statements could be interpreted in contradiction with each other, so it is unclear what the current status of the law is. Hamilton Health Sciences v. DH
Physicians Refusing to Provide Treatment
• physiciansmayrefusetoprovidetreatmentordiscontinuerelationshipswithpatients,butmustensure these patients can access services elsewhere by way of referring the patient to a willing practitioner (e.g. a pediatrician who refuses to treat an unvaccinated child should refer the family to another practice)
Aboriginal Legal and Health Policy
• AboriginalpeoplescollectivelyreferstooriginalinhabitantsofCanadaandtheirdescendants:First Nations, Inuit, and Métis peoples defined in the Canadian Constitution Act, 1982
■ First Nations people encompasses most of geographic Canada and constitutes many distinct communities and languages
■ Inuit refers to original inhabitants of arctic regions including Labrador, northern Quebec, Nunavut, and Northwest Territories
■ Métis are Indigenous people of both First Nations and European heritage
■ Canada’s Indian Act, 1976, defined who is considered a “status Indian” and thus eligible for programs
and services by federal and provincial agencies. Non-Status First Nations, are Aboriginals who are
not a “Registered Indian” with the federal government
■ the Daniels Decision, 2013 Federal Court of Canada, deemed Métis and non-status be considered
“Indians” under Canadian Constitution Act
• AboriginalHealthPolicyinCanadaismadeupofacomplicated“patchwork”ofpolicies,legislationand
agreements between federal, provincial, municipal, and Aboriginal governments which is in a constant state of flux; reviewed by the National Collaborating Centre for Aboriginal Health (NCCAH): http:// www.nccah-ccnsa.ca/en/publications.aspx?sortcode=2.8.10&publication=28
■ while some Aboriginal health services are adequate, gaps and ambiguities created by complicated policy and jurisdictions have created barriers to health equity
■ for majority of Métis, off-reserve, and non-status Indians, health services are financed through the National Health Insurance plan administered at the provincial and territorial level
■ for on-reserve First Nations and Inuit, the federal government finances and administers health services through the First Nations and Inuit Health Branch (FNIHB)
■ the Indian Health Policy, 1979, and Health Transfer Policy, 1989, transferred control to individual communities to negotiate with the FNIHB varying levels of health care responsibility to the community or council level
■ treaties and Self Government Agreements define areas of jurisdiction for federal, provincial/ territorial, and Aboriginal governments
■ in general, multiple levels of authority and responsibility are involved with the general tendency towards delegating responsibility to local levels