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Committee Appearance – Senate Legal and Constitutional Affairs Committee: Bill C-7 – An Act to Amend the Criminal Code (medical assistance in dying)

https://policybase.cma.ca/en/permalink/policy14380
Date
2020-11-23
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2020-11-23
Topics
Health care and patient safety
Text
Committee Appearance – Senate Legal and Constitutional Affairs Committee: Bill C-7 – An Act to Amend the Criminal Code (medical assistance in dying) November 23, 2020 Dr. Sandy Buchman Past President of the Canadian Medical Association Monday, November 23, 2020 Speaking Remarks ____________________________________________________________ Thank you, Madam Chair. I appear before the committee today as the past president of the Canadian Medical Association with the honour and responsibility of speaking for all our members - the frontline physicians. My name is Dr. Sandy Buchman. I am a palliative care physician in Toronto. I am also a MAiD Assessor and Provider. It is incumbent upon us now to consider the effects that the passing of Bill C-7 will have on patients, but also the effects on the medical professionals who provide medical assistance in dying - MAiD. When the original MAiD legislation was developed as Bill C-14, the CMA was a leading stakeholder. We have continued that commitment with Bill C-7. Having examined Bill C-7, we know that, in a myriad of ways, the results of our extensive consultations with our members align with the findings of the government’s roundtables. Nicole Gladu, whose name is now inextricably tied to the government’s decision on MAiD, spoke as unequivocally as perhaps anyone could when she affirmed that it is up to people like her, and I quote, “To decide if we prefer the quality of life to the quantity of life." Perhaps not everyone agrees with this sentiment. Few can argue, though, that it is a powerful reminder of the real stakeholders when it comes to considerations of this bill. This applies no less critically to those who are currently MAiD providers or those who will become providers. These practitioners are our members. But we can’t overlook the fact that there must be complete support of both patients and providers. Fundamentally, the CMA supports the government’s prudent and measured approach to responding to the Truchon-Gladu decision. This thoughtful and staged process undertaken by the government is consistent with the CMA’s position for a balanced approach to MAiD. Through our consultations however, we learned that many physicians felt there is a lack of overall clarity. Recent federal efforts to provide precision for physicians are exceedingly welcome. The CMA is pleased to see new non-legislative measures lending more consistency to the delivery of MAiD across the country. The quality and availability of palliative care, mental health care, and care and resources for those suffering from chronic illness, and for persons with disabilities, to ensure that all patients have access to other, appropriate health care services is crucial. The CMA remains firm on our convictions on MAiD from Bill C-14 to C-7. We believe that the choice of those Canadians who are eligible should be respected. We also believe that the rights of vulnerable Canadians must be protected. This demands strict attention to safeguards. And we believe that an environment must exist that fosters the insistence that practitioners abide by their moral commitments. Each of these three tenants is equally unassailable. Our members are in strong support of allowing advance requests by eligible patients who may lose capacity before MAiD can be provided. The CMA believes in the importance of safeguards to protect the rights of vulnerable Canadians and those who are eligible to seek MAiD. Expanding data collection to provide a more thorough account of MAiD in Canada is important. However, this effort must not create an undue administrative burden on physicians. The CMA views some of the language in the bill as precarious. The CMA recommends amending the language in section 2.1 which states “mental illness is not considered to be an illness, disease or disability” to avoid the unintended consequence of having a stigmatizing effect. The legislation should also clearly indicate that the exclusion is for mental illness as a sole underlying medical condition, not mental illness as a comorbidity. To be clear, the CMA is not recommending a revision to the legislative intent. We trust that Parliament will carefully consider the specific language used in the bill. Finally, the CMA endorses the government’s staged approach to carefully examine more complex issues. We must move forward, though, by ensuring that practitioners are given the tools that will be required to safely administer MAiD on a wider spectrum. Support for developing clinical practice guidelines that aid physicians in exercising sound clinical judgment are a prime example. Such guidance would also serve to reinforce consistency in the application of the legal criteria. In conclusion, Madam Chair, allow me to thank the committee for the invitation to participate in today’s proceedings. Sharing the perspective of Canada’s physicians is a privilege. That together we pursue a painless and dignified end-of-life is noble. The assurance that the providers of this practice are supported is an ethical imperative.
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Committee Appearance – Justice and Human Rights: Bill C-7 – Amending the Criminal Code Regarding Medical Assistance in Dying

https://policybase.cma.ca/en/permalink/policy14374
Date
2020-11-05
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2020-11-05
Topics
Health care and patient safety
Text
Committee Appearance – Justice and Human Rights: Bill C-7 – Amending the Criminal Code Regarding Medical Assistance in Dying November 5, 2020 Dr. E. Ann Collins President of the Canadian Medical Association Committee Appearance – Justice and Human Rights Bill C-7 – Amending the Criminal Code Regarding Medical Assistance in Dying ____________________________________________________________ Thank you, Madam Chair. It’s my honour to appear before you today. I’m Dr. Ann Collins. Over the past three decades practising medicine, I have taught family medicine, run a family practice, served with the Canadian Armed Forces and worked in nursing home care. Today, in my capacity as President of the Canadian Medical Association, I represent our 80,000 physician members. In studying Bill C-7, it is incumbent upon us now to consider the effects on patients that the passing of this bill will have, but also the effects on the medical professionals who provide medical assistance in dying - MAiD. When the original MAiD legislation was developed as Bill C-14, the CMA was a leading stakeholder. We have continued that commitment with Bill C-7. Having examined Bill C-7, we know that, in a myriad of ways, the results of our extensive consultations with our members align with the findings of the government’s roundtables. Fundamentally, the CMA supports the government’s prudent and measured approach to responding to the Truchon-Gladu decision. This thoughtful and staged process undertaken by the government is consistent with the CMA’s position for a balanced approach to MAiD. Nicole Gladu, whose name is now inextricably tied to the decision, spoke as pointedly as perhaps anyone could when she affirmed that it is up to people like her, and I quote, “To decide if we prefer the quality of life to the quantity of life." Not everyone may agree with this sentiment, but few can argue that it is a powerful reminder of the real stakeholders when it comes to considerations of this bill. This applies just as critically to those who are currently MAiD providers and those who will become providers. They are our members, but we can’t lose sight of the fact that we must all support both patients and providers. Through our consultations, we learned that many physicians felt that clarity was lacking. Recent federal efforts to provide greater clarity for physicians are exceedingly welcome. The CMA is pleased to see new non-legislative measures lending more consistency to the delivery of MAiD across the country. The quality and availability of palliative care, mental health care, care for those suffering from chronic illness, and persons with disabilities, to ensure that patients have access to other, appropriate health care services is crucial. The CMA holds firm on our convictions on MAiD from Bill C-14 to C-7. We believe firstly that the choice of those Canadians who are eligible should be respected. Secondly, we must protect the rights of vulnerable Canadians. This demands strict attention to safeguards. And lastly, an environment must exist that insists practitioners abide by their moral commitments. These three tenants remain equally valid. Our consultations with members demonstrate strong support for allowing advance requests by eligible patients who may lose capacity before MAiD can be provided. The CMA believes in the importance of safeguards to protect the rights of vulnerable Canadians and those who are eligible to seek MAiD. The CMA also supports expanding data collection to provide a more thorough account of MAiD in Canada, however, this effort must not create an undue administrative burden on physicians. The CMA views the language in the bill, which explicitly excludes mental illness from being considered an “illness, disease or disability,” problematic and has the potential to be stigmatizing to those living with a mental illness. We trust that Parliament will carefully consider the specific language used in the bill. Finally, the CMA endorses the government’s staged approach to carefully examine more complex issues. However, we must move forward to ensure practitioners are given the tools that will be required to safely administer MAiD on a wider spectrum, such as support for developing clinical practice guidelines which aid physicians in exercising sound clinical judgment. Such guidance would also serve to reinforce consistency in the application of the legal criteria. In conclusion, Madam Chair, allow me to thank the committee for the invitation to participate in today’s proceedings and to share the perspective of Canada’s physicians. The pursuit of a painless and dignified end-of-life is a noble one. The assurance that the providers of this privilege are supported is an ethical imperative.
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Taking action on drug shortages during Covid-19 - open letter

https://policybase.cma.ca/en/permalink/policy14261
Date
2020-08-13
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-13
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Dear Prime Minister, We are writing to you today to ask you to bring attention and resources to Canada’s drug supply challenges. These shortages have existed for the past decade but have been greatly exacerbated due to the COVID-19 pandemic. As frontline pharmacists and physicians, we have seen and heard of serious shortages of essential, critical medications. These drugs are often used simultaneously in ORs, ERs and palliative care wards, as well as ICUs. And while our ICUs are thankfully seeing fewer COVID-19 patients, the pandemic has been placing a heavy burden on their drug supply, where patients often require weeks’ worth of treatment on ventilators. The shortages of these drugs imperil the lives of patients seeking care all over the country. Currently, the vast majority (24/32) of the drugs on Health Canada’s own Tier 3 list, which represents drugs for which there are no suitable alternatives, are essential for treating COVID-19. With the likely upcoming second wave in Canada, the potential for further exacerbation of these shortages is inevitable unless we implement rigorous preparedness measures. At first glance, the federal government may conclude that this is a provincial and territorial area of jurisdiction. We can assure you, that there is a considerable role for the federal government to play on this issue of national concern if you so choose to take action. We believe you should. Many of these critical care drugs should be part of the National Strategic Emergency Stockpile. However, it is clear that Canada simply did not invest enough into its stockpiles to meet the demand during the COVID-19 pandemic. In order for the stockpiling strategy to be effective, it is vital that the federal, provincial, and territorial governments work closely with hospitals, long-term care facilities, hospices and primary care facilities nationwide to establish a 2 comprehensive list of critical medicines and develop a plan to procure medicines in a coordinated manner to prevent unintended competition for resources. The 2019 budget had earmarked funds for a new Canada Drug Agency which would have oversight over a national formulary. This proposed agency could similarly identify essential medicines to aid in an efficient stockpiling response, whether through stimulating domestic production or through importation and coordination of purchasing strategies to ensure that jurisdictions that have a greater need for medications gain access to them. We know that COVID-19’s impact on the health system across provinces and territories and within each and every jurisdiction was not equal or consistent. We appreciate the active efforts of Health Canada to resolve current or projected shortages of critical drugs through its Tier Assignment Committees. Furthermore, Ontario has a Critical Care COVID-19 Command Centre and has created a Critical Care Drug Shortage Task Team. Certainly, the short-term deficit will need to be resolved through this mechanism and importing from all available suppliers. However, to support the system at large, provincial and territorial governments will need national support, resources and (where welcomed by provinces) a certain level of national coordination. Regardless of well-established Federal-Provincial-Territorial dynamics, without concrete preventative action, Canada will perpetually face drug shortages. This is why we recommend that your government commit to working on a long-term solution involving a three-pronged strategy: 1. Stockpiling of a Critical Medications List which the government commits to ensuring are always in stock for long enough to meet the needs in an emergency (likely through the Canada Drug Agency). a. A Critical Medications List would allow the parties involved in addressing the drug shortages to have a clear picture of what drugs to monitor closely, and provides a more comprehensive approach to the problem. 2. A publicly owned generic, critical drugs manufacturer, or at the bare minimum, public support for spare capacity by Canadian-based and controlled drug manufacturers to be used for critical drugs. a. This manufacturer or manufacturers would specialize in manufacturing the critical drugs on the Critical Medications List, and would be primarily involved in satisfying significant portions of our national demands. 3. Greater transparency and communications to and from governments and the health sector around the essential drug supply. This would include efforts to 3 better track the supply of drugs in hospitals across the country and push notifications on shortages through the appropriate channels to frontline workers. We encourage your government to give this urgent issue attention and efforts now, so that Canadians can have the confidence that their healthcare system will be there when they most need it.
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CMA Pre-budget Submission

https://policybase.cma.ca/en/permalink/policy14259
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
Text
RECOMMENDATION 1 That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care. RECOMMENDATION 2 That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians. RECOMMENDATION 3 That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit. RECOMMENDATION 4 That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs. RECOMMENDATIONS 3 Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now. We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system. While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens. The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients. Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing. The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system. The health of the country’s economy cannot exist without the health of Canadians. INTRODUCTION 4 Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic. At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies. The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them. Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage. The CMA will provide the budget costing in follow-up as an addendum to this submission. RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund 5 It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care. During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual. The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access. A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet. The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service. Create a Digi-Health Knowledge Bank Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy. We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments. Pan-Canadian broadband expansion It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement. RECOMMENDATION 2 Embedding virtual care in our nation’s health care system 6 Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long. The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors. A demographic top-up to the Canada Health Transfer The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors. The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade. Seniors care benefit Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients. RECOMMENDATION 3 Ensuring that better care is secured for our seniors 7 The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short. The CMA recommends the following measures: 1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program. 2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions. 3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member. RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers 8 Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic. Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system. CONCLUSION
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Responding to the COVID-19 pandemic: Federal measures to recognize the significant contributions of Canada’s front-line health care workers

https://policybase.cma.ca/en/permalink/policy14211
Date
2020-05-28
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2020-05-28
Topics
Health care and patient safety
Text
During these unprecedented times, Canada’s physicians, along with all front-line health care workers (FLHCWs), have not only put themselves at risk but have made enormous personal sacrifices while fulfilling a critical role in life-threatening circumstances. The CMA recognizes and strongly supports the measures the federal government has taken to date to mitigate the health and economic impacts of COVID-19 on Canadians. However, given the unique circumstances that Canada’s FLHCWs face, additional measures are required to acknowledge their role, the risks to themselves and their families, and the financial burden they have taken on through it all. To gain a better understanding of this issue, the CMA commissioned MNP LLP (MNP) to conduct a thorough economic impact study. They assessed the effects of the COVID-19 pandemic on physician practices in Canada and identified policy options to mitigate these effects. This brief summarizes the findings, provides an overview of the impact of the COVID-19 pandemic on physician practices across the country and highlights targeted federal measures that can significantly mitigate the evident challenges physicians are experiencing. It is important to note that the recommended measured were developed through the lens of recognizing the important contribution of Canada’s FLHCWs. UNDERSTANDING HOW THE PANDEMIC IS IMPACTING PHYSICIAN PRACTICES Canada’s physicians are highly skilled professionals, providing an important public service and making a significant contribution to the health of Canadians, our nation’s health infrastructure and our knowledge economy. In light of the design of Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Like most small businesses in Canada, physician practices have been negatively impacted by the necessary measures governments have established to contain this pandemic. Under the circumstances of the pandemic, the provinces postponed non-emergent procedures and surgeries, indefinitely. According to data from the 2019 Physician Workforce Survey conducted by the CMA, approximately 75% of physicians reported practising in settings that would be expected to experience a reduction in patient volumes as a result of COVID-19 measures. This suggests “the vast majority of physicians in Canada anticipate declines in earnings as a result of COVID-19 restrictions.” Physician practices include a variety of structures, which relate to the practice setting or type. In their economic impact study, MNP estimates that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario. These two scenarios are in comparison to a baseline scenario, prior to the pandemic. The low-impact scenario is based on the reduction of physician services reported during the 2003 experience with the Severe Acute Respiratory Syndrome (SARS) while the high-impact scenario estimates more significant impacts, being approximately double those observed during SARS. Unlike salaried public sector professionals, such as teachers, nurses or public servants, most physicians operate as small business owners who are solely responsible for the management of their practices. They employ staff, rent office space and have numerous other overhead costs related to running a small business, which they are still responsible for regardless of decreased earnings. According to data published by Statistics Canada in 2019 there were 120,241 people employed in physician offices in Canada and an additional 28,054 employed in medical laboratories. Additionally, physicians manage significant overhead expenses that are unique to medical practice such as practice insurance, licence fees and continuing medical education. It’s important to understand that even hospital-based physicians may be responsible for significant overhead expenses, unlike other hospital staff. Like any small business owner grappling with drastic declines in revenue, physicians may be forced to reduce their staffing levels or even close their practices entirely in response to the COVID-19 pandemic. ADDRESSING THE GAPS: ENSURING THAT FEDERAL ECONOMIC PROGRAMS CAPTURE PHYSICIAN PRACTICES To reiterate, the CMA supports the federal government’s decisive and meaningful response to the pandemic, including delivering critical economic relief programs. However, more detailed analysis is revealing that segments of physician practices are not eligible for these critical economic programs, because of technicalities. At this time, the CMA has identified three key segments of physician practice models who may not currently be eligible for the economic relief programs because of technicalities. These are: 1. hospital-based specialists 2. physician practices that operate as a small business but may not meet technical criteria 3. physicians delivering locum medical care These technical factors reflect the complexity of the health system infrastructure in Canada. Although hospital-based specialists may receive some form of salary, they may still be structured as a small business and be responsible for paying overhead fees to the hospital. Many physicians may operate as a small business and remit a statement of self-employment, and they may not have a business number or a business bank account. As is common amongst other self-employed professionals, many physicians operate practices within cost-sharing structures. The CMA is deeply concerned that these structures are presently being excluded for the federal government’s critical economic relief programs. As a result, this exclusion is affecting the many employees of practices structured as cost-sharing arrangements. Finally, physicians providing care in other communities, known as locum practice, would also be responsible for overhead expenses. It is the CMA’s understanding that the federal government is seeking to be inclusive in delivering economic relief programs to mitigate the impacts of the pandemic, such as closures or unemployment. For physician practices, eligibility for federal economic relief programs would extend the reach of these mitigation measures to maintaining Canada’s critical health resources and services, as physician practices are responsible for a significant portion of health system infrastructure. As such, the CMA respectfully recommends that the federal government ensure that these critical economic programs be made available to all segments of physician practices. To this end, the CMA recommends that the federal government expand eligibility for the federal economic relief program to: 1. Include hospital-based specialists paying fees for overhead expenses to the hospitals (e.g., staff, equipment, space); 2. capture physician-owned medical practices using a “personal” banking account as well as those in cost-sharing structures to access programs; and, 3. include physicians who provide locum medical care. NEW FEDERAL TAX MEASURES TO SUPPORT AND RECOGNIZE FRONT-LINE HEALTH CARE WORKERS It is also important to note that the impact of COVID-19 on FLHCWs goes well beyond the financial impacts. All FLHCWs face numerous challenges trying to carry out their work during these difficult times. They put their health and the health of their families at risk. They make enormous sacrifices, sometimes separating themselves from their families to protect them. These risks and sacrifices can strain an individual’s mental health, especially when coupled with anxiety over the lack of proper personal protective equipment (PPE). A survey conducted by the CMA at the end of April showed that almost 75% of physicians who responded to the survey indicated feeling very or somewhat anxious about the lack of PPE. FLHCWs deserve to be recognized for their unique role during this pandemic. Given the enormous sacrifices and risks that FLHCWs are making every day, the federal government should enact measures to recognize their significant contributions during these unprecedented times. The CMA recommends that the federal government implement the following new measures for all FLHCWs: 1. An income tax deduction for FLHCWs put at risk during the COVID-19 pandemic, in recognition of their heroic efforts. All FLHCWs providing in-person patient care during the pandemic would be eligible to deduct a designated amount against their income earned. This would be modelled on the deduction provided to members of the Canadian Armed Forces serving in moderate- and high-risk missions. 2. A non-taxable grant to support the families of FLHCWs who die in the course of responding to the COVID-19 pandemic or who die as a result of an occupational illness or psychological impairment related to this work. The grant would also apply to cases in which the death of an FLHCW’s family member is attributable to the FLHCW’s work in responding to the pandemic. The CMA is recommending that access to the Memorial Grant program, or a similar measure, be granted to FLHCWs and their family member(s). 3. A temporary emergency accommodation tax deduction for FLHCWs who incur additional accommodation costs as well as a home renovation credit in recognition of the need for FLHCWs to adhere to social distancing to prevent the spread of COVID-19 to their family members. The CMA recommends all FLHCWs earning income while working at a health care facility or in a capacity related thereto (e.g., paramedics or janitorial staff) be eligible for the deduction and credit. 4. Provide additional child-care relief to FLHCWs by doubling the child-care deduction. The CMA recommends the individuals listed above be eligible for the enhanced deduction. It is important that any measures enacted be simple for the government to implement and administer as well as simple for FLHCWs to understand and access. The recommendations above will ensure that relief applies to a wide range of Canada’s FLHCWs who are battling COVID-19. More details on these recommendations are provided in Appendix A to this brief. INCREASING FEDERAL HEALTH FUNDING TO SUPPORT SYSTEM CAPACITY It is due to the action of the federal and provincial/territorial governments, together with Canadians, in adhering to public health guidance that our health systems have been able to manage the health needs of Canadians during the pandemic. However, as governments and public health experts consider how we may proceed in lifting certain restrictions, we are beginning to comprehend the enormity of the effort and investment required to resume health care services. During the pandemic, a significant proportion of health care services, such as surgeries, procedures and consults considered “non-essential” have been delayed. As health services begin to resume, health systems will be left to grapple with a significant spike in already lengthy waiting times. Further, all health care facilities will need to adopt new guidance to adhere to physical distancing, which may necessitate longer operating hours, increasing staff levels and/or physical renovations. Given these issues, the CMA is gravely concerned that Canada’s already financially struggling health systems will face significant funding challenges at a time when provincial/ territorial governments are grappling with recession economies. The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic continues. CONCLUSION As outlined in this brief, the overwhelming majority of Canada’s physician practices will be negatively impacted financially by COVID-19. The indefinite postponement of numerous medical procedures, coupled with restrictions related to physical distancing resulting in reduced patient visits, will have a material effect on physician practices, risking their future viability. As well, all FLHCWs will be severely impacted by COVID-19 personally, through risks to themselves and their families. Many families of FLHCWs will also be impacted financially, from increased child-care costs to, tragically, costs associated with the death of a loved one because of COVID-19. In light of these substantial risks and sacrifices, the CMA urges the adoption of the above-mentioned recommendations designed to recognize the special contribution of Canada’s FLHCWs during these extraordinary times.
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Emergency federal measures to care for and protect Canadians during the COVID-19 pandemic

https://policybase.cma.ca/en/permalink/policy14132
Date
2020-03-16
Topics
Health care and patient safety
  2 documents  
Policy Type
Parliamentary submission
Date
2020-03-16
Topics
Health care and patient safety
Text
It is with a sense of urgency that the Canadian Medical Association (CMA) submits the recommendations herein for emergency federal measures that, taken together, will ensure Canadians receive appropriate care and that supportive measures are implemented for public health protection during the COVID-19 pandemic. While Canada has made significant strides since SARS to establish and implement effective public health infrastructure, resources and mechanisms, the significant resource constraints across our health systems present a major challenge in our current response. Federal emergency measures must be developed in the context of the current state of health resources: hospitals across the country are already at overcapacity, millions of Canadians lack access to a regular family doctor, countless communities are grappling with health care shortages, virtual care is in its infancy, and so on. Another core concern is the chronic underfunding and ongoing budget cuts of public health resources and programming. Public health capacity and leadership at all levels is fundamental to preparedness to respond to an infectious disease threat, particularly one of this magnitude. It is in this context that the Canadian Medical Association recommends that the following emergency measures be implemented by the federal government to support the domestic response to the COVID-19 pandemic: 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 1) FEDERAL RECOMMENDATION AND SUPPORT FOR SOCIAL DISTANCING In this time of crisis, Canadians look to the federal government for leadership and guidance. The single most important measure that can be implemented at this time is a consistent national policy calling for social distancing. This recommendation by the federal government must be paired with the resources necessary to ensure that no Canadian will be forced to choose between financial hardship — whether by losing employment or not being able to pay rent — and protecting their health. The CMA strongly recommends that the federal government immediately communicate guidance to Canadians to implement social distancing measures. The CMA further recommends that the federal government deliver new financial support measures as well as employment protection measures to ensure that all Canadians may engage in social distancing. 2) NEW FEDERAL EMERGENCY FUNDING TO BOOST PROVINCIAL/ TERRITORIAL CAPACITY AND ENSURE CONSISTENCY It is the federal government’s role to ensure a coordinated and consistent national response across jurisdictions and regions. This is by far the most important role for the federal government in supporting an effective domestic response, that is, protecting the health and well-being of Canadians. The CMA strongly recommends that the federal government deliver substantial emergency funding to the provinces and territories to ensure health systems have the capacity to respond to the pandemic. Across the OECD, countries are rapidly stepping up investment in measures to respond to COVID-19, including significant investment targeting boosting health care capacity. In considering the appropriate level of federal emergency funding to boost capacity in our provincial/territorial systems, the CMA urges the federal government to recognize that our baseline is a position of deficit. New emergency federal funding to boost capacity in provincial/territorial health systems should be targeted to:
rapidly enabling the expansion and equitable delivery of virtual care;
establishing a centralized 24-hour national information hotline for health care workers to obtain clear, timely and practical information on clinical guidelines, etc.;
expanding the capacity of and resources for emergency departments and intensive care units;
coordinating and disseminating information, monitoring and guidance within and across jurisdictions; and
rapidly delivering income stabilization for individuals and families under quarantine. Finally, the inconsistencies in the provision and implementation of guidance and adoption of public health measures across and within and jurisdictions is highly concerning. The CMA strongly encourages the federal government enable consistent adoption of pan-Canadian guidance and measures to ensure the health and safety of all Canadians. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 3) ENSURING AN ADEQUATE SUPPLY OF PERSONAL PROTECTIVE EQUIPMENT FOR CANADIAN HEALTH CARE WORKERS AND ENSURING APPROPRIATE USAGE The CMA is hearing significant concerns from front-line health care workers, including physicians, about the supply and appropriate usage of personal protective equipment. It is the CMA’s understanding that pan-Canadian efforts are underway to coordinate supply; however, additional measures by the federal government to ensure adequate supply and appropriate usage are required. Canada is at the outset of this public health crisis — supply issues at this stage may be exacerbated as the situation progresses. As such, the CMA strongly recommends that the federal government take additional measures to support the acquisition and distribution throughout health systems of personal protective equipment, including taking a leadership role in ensuring our domestic supply via international supply chains. 4) ESTABLISH EMERGENCY PAN-CANADIAN LICENSURE FOR HEALTH CARE WORKERS In this time of public health crisis, the federal government must ensure that regulatory barriers do not prevent health care providers from delivering care to patients when and where they need it. Many jurisdictions and regions in Canada are experiencing significant shortages in health care workers. The CMA urges the federal government to support piloting a national licensure program so that health care providers can opt to practice in regions experiencing higher infection rates or where there is a shortage of providers. This can be accomplished by amending the Canadian Free Trade Agreement (CFTA) to facilitate mobility of health care workers. Specifically, that the following language be added to Article 705(3) of the CFTA: (j) A regulatory authority of a Party* shall waive for a period of up to 100 days any condition of certification found in 705(3)(a) - (f) for any regulated health care worker to work directly or indirectly to address the Covid-19 pandemic or any health care emergency. Any disciplinary matter emanating from work in any province shall be the responsibility of the regulatory authority of the jurisdiction where the work is performed. Each Party shall instruct its regulatory authorities to set-up a rapid check-in/check-out process for the worker. *Party refers to a signatory of the CFTA To further enable this measure, the CMA recommends that the federal government deliver targeted funding to the regulatory colleges to implement this emergency measure as well as targeted funding to support the provinces/territories in delivering expanded patient care. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 5) ESTABLISH AN EMERGENCY NATIONAL MENTAL HEALTH SUPPORT SERVICE FOR HEALTH PROVIDERS Health care providers may experience trauma and hardship in meeting the increasing health needs and concerns of Canadians in this time of crisis. The CMA strongly recommends that the federal government establish an emergency National Mental Health Support Services hotline for all health care providers who are at the front lines of patient care during the pandemic. This critical resource will ensure our health care providers have the help they may need as they care for patients, including helping them to deal with an increasing patient load. 6) IMPLEMENT A TARGETED TAX CREDIT FOR HEALTH PROVIDERS EXPERIENCING FINANCIAL LOSS DUE TO QUARANTINE In addition to supporting income stabilization measures for all Canadians who may benefit from support, the CMA recommends that the federal government establish a time-limited and targeted tax credit for health providers who may experience financial loss due to quarantine. Many health care providers operate independently and may face significant fixed expenses as part of their care model. As health care providers may have an increased risk of contracting COVID-19, this may result in significant financial loss. A time-limited tax credit to ease this loss may help ensure the continued viability of their care model. Further, the CMA supports extending the federal tax filing timeline in recognition of the fact that health care workers and all Canadians are focused on emergency matters. CLOSING The CMA’s recommendations align with the OECD’s call to action: “Governments need to ensure effective and well-resourced public health measures to prevent infection and contagion, and implement well-targeted policies to support health care systems and workers, and protect the incomes of vulnerable social groups and businesses during the virus outbreak.” Now is the time to ensure that appropriate leadership continues and that targeted investments are made to protect the health of Canadians.
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A Public Health Perspective on Cannabis and Other Illegal Drugs : CMA Submission to the Special Senate Committee on Illegal Drugs

https://policybase.cma.ca/en/permalink/policy1968
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Cannabis has adverse effects on the personal health of Canadians and the well-being of society. In making this submission to the Special Senate Committee on Illegal Drugs, the Canadian Medical Association (CMA) wishes to make it clear that any change to the criminal status of cannabis must be done so with the recognition that cannabis is an addictive substance and that addiction is a disease. The CMA believes that the government must take a broad public health policy approach to address cannabis use. Focusing on the decriminalization issue alone is inadequate to deal with the complexity of the problem. Changes to the criminal law affecting cannabis must not promote normalization of its use, and must be tied to a national drug strategy that promotes awareness and prevention, and provides for comprehensive treatment. Under such a multidimensional approach the CMA would endorse decriminalization. In this document, we primarily focus on the health effects of cannabis use. However, we also present information and recommendations on the use of other illegal drugs. While we understand that this goes beyond the intended scope of the Senate Committee's study, this information is important to the development of comprehensive policy, which we believe is required. We also recognize and welcome the fact that many of the CMA's recommendations will require a closer working relationship among health providers, justice officials and law enforcement. The CMA's recommendations are: Section 1: Illegal Drugs 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. This document also contains the policies and recommendations of the CMA affiliated association that has specific expertise in the field of substance use disorders the, Canadian Society of Addiction Medicine (CSAM). In addition, for an even broader health-sector perspective, the CMA has attached information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. A PUBLIC HEALTH PERSPECTIVE ON CANNABIS AND OTHER ILLEGAL DRUGS INTRODUCTION The Canadian Medical Association (CMA) welcomes the opportunity to participate in the deliberations of the Special Senate Committee on Illegal Drugs. This document was developed by the CMA's new Office for Public Health in consultation with our Affiliate Societies, in particular the Canadian Society of Addiction Medicine, and our 12 provincial and territorial divisions. The use of illegal drugs and relevant policies is an extremely broad, multi-disciplinary and at times, controversial subject. Considering the breadth of this subject, the limited time-lines and the areas of particular interest of the Committee, this document will focus on the following: * What are the known health effects of cannabis and other illegal drugs? * What experience has there been with the decriminalization of cannabis? * What has been the impact of law enforcement on illegal drug use? * What changes need to be considered in Canada's approach to illegal drug use including the potential decriminalization of drugs? In addition to the above, this document will provide an overview of the relevant policy position statements and recommendations regarding cannabis and drug policy from other key medical organizations from both Canada and the United States. PUBLIC HEALTH PERSPECTIVE ON DRUG USE There are many different perspectives on the use of drugs including ethical and moral frameworks. This paper is prepared from a public health perspective where minimizing any harms associated with use is of primary concern. 1 This requires consideration of health issues related not only to the individual user and the drug being used, but also the key social factors associated with use. Drug use is a complex behaviour that is influenced by many factors. It is not possible to identify a single cause for drug use, nor will the set of contributing factors be the same among different drug users and populations. Public health objectives will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using the drug (e.g. treatment, rehabilitation); and assisting those who intend to continue to use the drug to do so in such a manner as to reduce the risk of adverse effects (e.g. needle exchange program to reduce risk of HIV). To address this complexity, what is required is a public health strategy to combat drug use utilizing a comprehensive, multi-component approach. Public health strategies focus on the various predisposing, enabling, and re-enforcing factors that influence healthy behaviours and choices. 2 These sets of factors recognize the many influences upon individual behaviour including: individual and social attitudes, beliefs and values; skills; support, self-efficacy and re-enforcement. Public health actions can be grouped into the following major categories: 3 * Developing Personal Skills - education and skill-building (e.g. mass media, skill development to resist peer pressure, thinking skills); * Healthy Public Policy - policies, formal and informal that support health (e.g. school policy, substance use and driving, harm reduction initiatives); * Creating Supportive Environments - social and physical environments (e.g. adequate housing and food, community safety, non-chemical coping mechanisms); * Strengthen Community Action - community involvement in finding solutions (e.g. self-help, social support, community participation); * Health Services - range of services to meet needs (e.g. prevention, assessment, early intervention, treatment, rehabilitation, harm-reduction initiatives). This framework is useful in identifying the range of program components that need to be considered. Relative emphasis between components and the specific interventions selected will vary depending upon the target population (e.g. school students vs. injection drug users). The key is a balanced approach that will influence the factors contributing to less healthy behaviours with support for behaviour change and maintenance. CANNABIS Several commissions and task forces, in Canada and elsewhere, have addressed the issue of how to deal with cannabis use, although frequently their recommendations have not been implemented. 4, 5, 6 It has been suggested that "cannabis is a political football that governments continually duck...(but that) like a football, it bounces back." 7 This section of the paper will review current Canadian levels of use, health effects, law enforcement issues, and experience with decriminalization in other jurisdictions. Current Use The Ontario Student Drug Use Survey is conducted every two years in grades 7, 9, 11, and 13, although in 1999 all grades from 7-13 were surveyed. Use of cannabis within the preceding year increased from 11.7% of students in 1991, to 29.2% in 1999. 8 Increases were also observed for several other drugs during the same time period (tobacco, alcohol, glue, other solvents, hallucinogens, cocaine, PCP, and ecstasy). Increases in adolescent drug use have also been observed in the US, Europe and Australia through the 1990s. Compared with earlier cohorts, fewer students in 1999 reported early onset of cannabis use (before grade 7) compared with similarly aged students in 1997 and 1981. Past year drug use of cannabis, alcohol and tobacco by grade year is shown in Table 1. The proportion of students who have used one of these drugs increases with increasing grade level. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 - Past Year Drug Use (%) by Grade Level, Ontario Students, 1999 7 8 9 10 11 12 13 Alcohol 39.7 53.7 63.1 74.9 82.0 84.6 83.0 Tobacco 7.4 17.8 27.8 37.4 41.7 38.6 38.0 Cannabis 3.6 14.9 25.5 36.4 48.1 39.4 43.3 1999 Ontario Student Drug Use Survey 9 [TABLE END] The last national survey of illicit drug use in Canada was conducted in 1994. 10 At that time, 23% of Canadians, aged 15 and over, reported having used cannabis more than once during their lifetime with 7% having used it within the preceding year. Current use is much more common in those under the age of 25 and diminishes significantly with age, (Table 2). Most cannabis use is sporadic with the majority of adult and adolescent users using it less than once a week. 11 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 - Lifetime and Current Use of Cannabis in Canada, 1994 Age Lifetime Use (%) Current Use (%) (past 12 months) 15-17 30 24.0 18-19 32.9 23.8 20-24 37.7 19.0 25-34 38.2 9.6 35-44 32.9 5.7 45-54 14.8 1.4 55-64 3.7 - 65+ 0.8 - Canada's Alcohol and Other Drugs Survey: 1994 [TABLE END] Health Effects Our understanding of the health effects of cannabis continues to evolve. Hall summarizes the effects into acute and chronic effects and whether these are probable or possible (Table 3). 12 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 3 - Summary of Probable and Possible Health Effects of Cannabis Use Pattern of Use Acute Chronic Probable anxiety, dysphoria, panic, cognitive impairment, psychomotor impairment; chronic bronchitis, lung cancer, dependence, mild cognitive impairment, exacerbation of psychosis; Possible (possible but uncertain, confirmation required in controlled studies) increased risk of traffic accident, psychosis, low-birth-weight babies; cancers in offspring, impaired immunity From CMAJ 2000; 162: 1690-1692. [TABLE END] Tetrahydrocannabinol (THC) is the main psychoactive substance in cannabis. THC is inhaled in the mainstream smoke and absorbed through the lungs, rapidly entering the bloodstream. Effects are perceptible within seconds and fully apparent in a few minutes. Cannabis combines many of the properties of alcohol, tranquilizers, opiates and hallucinogens; it has anxiolytic, sedative, analgesic and psychedelic properties. 13 Its acute toxicity is extremely low, as no deaths directly due to acute cannabis use have ever been reported. The main feature of its use is that it produces a feeling of euphoria (or 'high'). Toxic dose-related effects include anxiety, panic, depression or psychosis.14 It should also be noted that a significant incident of co-morbid addiction occurs in those with physical and mental diseases. People with major mental illnesses such as schizophrenia are especially vulnerable in that cannabis use can provoke relapse and aggravate existing symptoms. A chronic lack of energy and drive to work in chronic users has been referred to as an "amotivational syndrome," which is currently believed to represent an ongoing intoxication in frequent users. 14 Cannabis slows reaction times, impairs motor coordination and concentration as well as the completion of complex tasks. 13 Due to the extended presence of metabolites in the bloodstream, it is difficult to correlate blood levels with acute impairment making interpretation of crash data difficult. However, it is generally accepted that cannabis use is associated with an increased risk of motor vehicle and aircraft crashes. Impairments of attention, memory and the ability to process complex information can last for prolonged periods of time, even years, after cessation of heavy, chronic cannabis use. A cannabis withdrawal syndrome similar to alcohol, opiate and benzodiazepine withdrawal symptoms exist. 14 Cannabis use increases heart rate and causes blood vessels to dilate. These present a risk for those with pre-existing cardiac disease. Smoke from cannabis preparations contains many of the same compounds as tobacco cigarettes including increased levels of tar. Chronic cannabis smoking is associated with bronchitis and emphysema. Chronic cannabis use may have risks of chronic lung disease and lung cancer comparable to cigarette smoking. With increasing study and experience, it is clear that cannabis, like other substances such as tobacco or alcohol, can have a number of adverse physical and psychological effects. 15 Law Enforcement The 1997 data is the latest year with national drug offences' data for possession, cultivation, trafficking and importation (Figure 1). 16 The proportion of drug incidents is heavily skewed towards cannabis. This is intriguing since the health concerns of cannabis are substantially less than those of heroin or cocaine. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1: Proportion of All Drug Incidents by Drug Type, Canada, 1997 [FIGURE END] Of the 66,500 drug incidents in Canada in 1997, over 70% (47,908) were cannabis related. Of these, over two thirds (32,682) were for possession. The rate of cannabis offences has increased 34% since 1991 with cannabis-possession rates increasing steadily from 1991-1996 with a slight drop in 1997. Most (86%) of those charged with cannabis offences were under 25 years of age. It has been estimated that about 2,000 Canadians are sent to jail every year for cannabis possession.17 Despite the current level of enforcement, cannabis use has been increasing with over 40% of grade 11, 12 and 13 students having used cannabis in the preceding year. While it is obvious that only a small percentage of users are being charged, thousands of teens and young adults are being charged every year, receiving criminal records that can impact future employment, future interactions with the justice system, and be a barrier to acquiring citizenship. 11 Findings from several studies indicate that perceived health risk and social disapproval were much more important disincentives to cannabis use than legal threats. 18 Experience with Decriminalization in Other Jurisdictions A number of other jurisdictions have implemented alternative enforcement approaches to the personal use of cannabis. While none of these experiences directly predict what would happen in Canada, they do provide information to address some of the issues raised when decriminalization is considered. Despite the obvious interest in the impact of these policy changes, there is a paucity of well-designed evaluations (i.e. evaluations which were designed and implemented prior to policy change, rather than post-hoc analyses on available data). United States In the 1970s, several US states reduced the legal sanctions for possession of small amounts of cannabis to a maximum penalty of a fine. Despite the substantial potential interest in the effects of such policy changes, evaluative studies were relatively sparse. The available data, though based upon national high school student survey data as well as evaluations in two states, indicated that there was no apparent increase in cannabis use that could be attributed to decriminalization. 19 The high school student national survey data showed that while use of cannabis had increased in those states that had decriminalized possession, the rates of use had increased by a greater amount with stricter laws. California was one of the states which decriminalized possession, and similar to other states, experienced a decrease in cannabis use during the 1980s which based upon student surveys appeared to be due to changing perceptions of health risks rather than changes in the legal status of the drug. 19 Netherlands The Netherlands is the most frequently identified example of a country that altered its approach to marijuana. The Dutch impose no penalties for the possession of small amounts of cannabis and allow a number of coffee shops to openly sell the drug. 20 This policy therefore is not simply removing the potential for criminal records and imprisonment with possession, but actually partially legalized cannabis sales. This process began in 1976 and coffee shops were not allowed to advertise, could not sell hard drugs, no sales to minors, no public disturbances, and no sales transactions exceeding certain quantity thresholds. Initially this threshold was set at 30 gm of cannabis, a rather large amount which was reduced to 5 gm in 1995. Attempts have been made to compare the prevalence of cannabis use in the Netherlands with other countries. Since cannabis use changes dramatically with age and over different time periods, surveys need to be of similar populations during similar time periods to be comparable. Differences in the wording of questions between surveys also make comparison difficult. A recent review by MacCouin et al makes 28 comparisons between the Netherlands and the US, Denmark, West Germany, Sweden, Finland, France and the UK.21 Overall, it appears that Dutch rates are lower than rates of use in the US but somewhat higher than those of some of its European neighbours. Cannabis use is higher in Amsterdam compared to other Dutch cities and is comparable to use in the US. A limited number of surveys appear to show that from 1984 to 1992, there was a substantial increase in adolescent (aged 16 - 20) use of cannabis that did not occur in other countries. The increases observed from 1992 to 1998 however, were similar to the increases observed in other countries including Canada. Overall, it appears that while the increases in Dutch adolescent use started earlier than other countries, their prevalence of use was much lower than comparison countries so that by the late 1990s they had comparable rates of use to the US and Canada. Australia From 1987 to 1995, three Australian states decriminalized the possession and cultivation of cannabis for personal use by replacing penal sanctions with fines. 22 The courts in other states have tended to utilize non-penal sanctions such as a fine or a suspended sentence with a criminal record. The limited number of surveys conducted in Australia has failed to find evidence of any large impact on cannabis use (some of the surveys had small sample sizes and the trend in usage has been upwards in Australian states which did not decriminalize as well as in other countries that continue to prohibit cannabis use). Interestingly, despite the decriminalization, the number of notices issued by police exceeds the number of cannabis offences prior to the change in law. Summary The preceding sections have suggested that cannabis use is relatively common (particularly in teens and young adults); most use is sporadic; its use is increasing; and it is not harmless. Because of these potential harms, one would not wish to encourage its use. There is however, no necessary connection between adverse health effects of any drug or human behaviour and its prohibition by law. 22 The issue is therefore whether there are less coercive ways to discourage its use. Despite the current criminal justice approach where the bulk of all illegal drug charges are cannabis-related and the majority of these are for possession, use is increasing with thousands of teens and young adults receiving criminal records for possession each year. The available evidence from other jurisdictions suggests that decriminalization would not result in a substantial increase in use beyond baseline trends. Considering current trends, a comprehensive approach to discourage current usage is required. OTHER ILLEGAL DRUGS Illegal drugs other than cannabis present a different set of issues and concerns. While these drugs are not the primary focus of the Special Senate Committee's study, we have included a few key issues to better put the cannabis issue in proper context. Current Use The Ontario Student Drug Use Survey of students in grades 7, 9, 11 and 13 has shown that following a lengthy period of decline in drug use during the 1980s, there has been a steady increase in adolescent drug use. 8 Past year drug use in 1999 was reported as follows: ecstasy (4.8%); PCP (3.2%); hallucinogens (13.8%), and cocaine (4.1%). By comparison, tobacco, alcohol and cannabis were 28.3%, 65.7%, and 29.2% respectively. Canadian survey data of those aged 15 and over in 1994 found that about one in twenty reported any lifetime use of LSD, speed or heroin, or cocaine. 10 Rates of use of these drugs within the preceding year were 1% and 0.7% respectively. Health Effects The adverse effects of drugs such as heroin and cocaine are related not just to the drugs themselves, but also increasingly to their method of intake, which is predominantly by injection. Injection drug use (IDU) is an efficient delivery mechanism of drugs, but is also an extremely effective means of transmitting bloodborne viruses such as hepatitis B, hepatitis C and HIV. The proportion of HIV infections attributable to IDU has increased from 9% prior to 1985 to over 25% by 1995. 23 IDU is also the predominant means of hepatitis C transmission responsible for 70% of cases. 24 The increasing use of cocaine, which tends to be injected on a more frequent basis, increases the subsequent exposure to infection. It has been estimated that up to 100,000 Canadians inject drugs (not counting steroids). 25 Transmission of bloodborne pathogens is not limited to injection drug users as the disease can then be further spread to sexual contacts, including the sex trade, and vertical transmission from infected mother to child. An epidemic of overdose deaths among injection drug users has been experienced in British Columbia with over 2000 such deaths in Vancouver since 1991. 17 Despite the seriousness of the potential adverse effects of illegal drug use and the potential for this situation to worsen with increasing transmission of bloodborne diseases, on a population basis, legal drugs (alcohol and tobacco) are responsible for substantially more deaths, potential years of life lost and hospitalizations. 26 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 4 - The Number of Deaths, Premature Mortality and Hospital Separations for Illicit Drugs, Alcohol and Tobacco, Canada, 1995. Deaths Potential Years of Life Lost Hospital Separations Illicit Drugs 805 33,662 6,940 Alcohol 123,734 172,126 82,014 Tobacco 34,728 500,350 193,772 From: Single et al. CMAJ 2000: 162: 1669-1675 [TABLE END] Expenditures on Illegal Drugs The direct costs associated with illicit drugs based on 1992 Canadian data are shown in the figure below: [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [FIGURE END] The vast majority of expenditures related to illegal drugs are on law enforcement. Considering the distribution of drug incidents, a substantial proportion of these are related to cannabis offences although health and other costs will predominantly be associated with other drugs. A substantial proportion of drug charges are for possession as compared with trafficking or importation (cocaine 42%; heroin 42%; other drugs 56%). 16 Despite illegal drug use being primarily a health and social issue, current expenditures do not reflect this and are heavily skewed towards a criminal justice approach. Unfortunately, prisons are not an ideal setting for treating addictions with the potential for continued transmission of bloodborne viruses. RECOMMENDATIONS The Need for Balanced, Comprehensive Approaches Reasons for drug use, particularly "hard drugs," are complex. It is not clear how a predominantly law enforcement approach is going to address the determinants of drug use, treat addictions, or reduce the harms associated with drug use including overdoses and the transmission of bloodborne viruses including HIV. Costs of incarceration are substantially more than the use of effective drug treatment. 27 It appears that there is an over dependence on the law when other models might be more effective in achieving the desired objective of preventing or reducing harm from drug use. 18 Aggressive law enforcement at the user level could exacerbate these harms by encouraging the use of the most dangerous and addictive drugs in the most concentrated forms, 28 because these are easier to conceal and the efficacy of injecting is greater than that of inhaling as drug costs increase in response to prohibition and enforcement. 29 There have been several recent sets of recommendations from expert groups regarding the need for a comprehensive set of approaches to address the public health challenges due to drug use, particularly those associated with injection drug use (IDU). 17, 25, 30, 31 Recommendations include the following components: * address prevention; * treatment and rehabilitation; * research; * surveillance and knowledge dissemination; * national leadership and coordination. Many of the recommendations will require close working relationships with justice/enforcement officials. Drug abuse and dependency is a chronic, relapsing disease for which there are effective treatments.32 A criminal justice approach to a disease is inappropriate particularly when there is increasing consensus that it is ineffective and exacerbates harms.33 The CMA's recommendations have been separated into two separate sections. The first set of recommendations is focused on policies affecting illegal drugs in general. While this goes beyond the intended scope of the Senate Committee's study, in our opinion, these recommendations are equally important for the Committee to consider. The second set of recommendations is specifically focused on cannabis. Our recommendations in this section take into consideration the health impact profile of cannabis, current levels of use, extent and impact of law enforcement activities and experience from other jurisdictions. Section 1: Illegal Drugs The CMA recommends: 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis The CMA recommends: 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. CANADIAN SOCIETY OF ADDICTION MEDICINE The Canadian Society of Addiction Medicine (CSAM), which was formed in 1989, is a national organization of medical professionals and other scientists interested in the field of substance use disorders. Vision The Society shares its overall goals with many other organizations and groups in Canada; namely, the prevention of problems arising from the use of alcohol and other psychoactive substances, and the cure; improvement or stabilization of the adverse consequences associated with the use of these drugs. This Society aims to achieve these goals through the fostering and promotion of medical sciences and clinical practice in this field in Canada, particularly by: * fostering and promotion of the roles of physicians in the prevention and treatment of alcohol and drug related problems; * improvement in the quality of medical practice in the drug and alcohol field through: establishment and promotion of standards of clinical practice; fostering and promotion of research; and fostering and promotion of medical education; * promotion of professional and public awareness of the roles that physicians can play in the prevention and treatment of alcohol and drug related problems; * fostering and promotion of further development of programs for the prevention and treatment of problems of alcohol and drug use in physicians; and * contributing to professional and public examination and discussion of important issues in the drug and alcohol field. Policy Statement The CSAM National Drug Policy statement requires that: Canada must have a clear strategy for dealing with the cultivation, manufacture, importation, distribution, advertising, sale, possession and use of psychoactive substances regardless of whether they are classified as legal or illegal. Drug possession for personal use must be decriminalized and distinguished from the trafficking or illegal sale/distribution of drugs to others that must carry appropriate criminal sanctions. The individual and public health impact of substance use, substance abuse and substance dependence must be taken into account at all times. An assessment to ascertain the extent of a substance use disorder and screening for addiction must be an essential part of dealing with someone identified as an illicit drug user or possessor. Appropriate funding must be made available for supply reduction and demand reduction of various psychoactive substances that carry an abuse or addiction liability. Recommendations 1. National policies and regulations must present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence regardless of the classification of "legal" or "illegal" 2. Prevention programs need to be comprehensively designed to target the entire range of dependence-producing drugs to enhance public awareness and affect social attitudes with scientific information about the pharmacology of drugs and the effects of recreational and problem use on individuals, families, communities and society. 3. Outreach, identification, referral and treatment programs for all persons with addiction need to be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 4. Law enforcement measures aimed at interrupting the distribution of illicit drugs need to be balanced with evidenced based treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate addiction and its related problems. 5. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: * access to young people and prevalence of use among youth; * prevalence of use in pregnancy and effects on offspring; * prevalence rates of alcoholism and other drug dependencies; * crime, violence and incarceration rates; * law enforcement and criminal justice costs; * industrial safety and productivity; * costs to the health care system; * family and social disruption; * other human, social and economic costs. 6. CSAM opposes * any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). All changes need to be gradual and carefully monitored. * any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 7. CSAM supports * public policies that would offer treatment and rehabilitation in place of criminal penalties for persons with psychoactive substance dependence and whose offense is possession of a dependence-producing drug for their own use. Those who are found guilty of an offense related to Addiction, proper assessment and treatment services must be offered as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. * an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. RELEVANT POSITION STATEMENTS OF OTHER MEDICAL HEALTH ORGANIZATIONS The purpose of this section is to provide the Special Senate Committee on Illegal Drugs with information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. Canadian Centre for Addiction and Mental Health34 The Centre for Addiction and Mental Health (CAMH) does not encourage or promote cannabis use. CAMH emphasizes that the most effective way of avoiding cannabis-related harms is through not using cannabis, and encourages people to seek treatment where its use has become a problem. Cannabis is not a benign drug. Cannabis use, and in particular frequent and long-term cannabis use, has been associated with negative health and behavioural consequences, including respiratory damage, problems with physical coordination, difficulties with memory and cognition, pre- and post-natal development problems, psychiatric effects, hormone, immune and cardio-vascular system defects, as well as poor work and school performance. The consequences of use by youth and those with a mental disorder are of particular concern. However, most cannabis use is sporadic or experimental and hence not likely to be associated with serious negative consequences. CAMH thus holds the position that the criminal justice system in general, and the Controlled Drugs and Substances Act (CDSA) specifically, under which cannabis possession is a criminal offence, has become an inappropriate control mechanism. This conclusion is based on the available scientific knowledge on the effects of cannabis use, the individual consequences of a criminal conviction, the costs of enforcement, and the limited effectiveness of the criminal control of cannabis use. CAMH thus concurs with similar recent calls from many other expert stakeholders who believe that the control of cannabis possession for personal use should be removed from the realm of the CDSA and the criminal law/criminal justice system. While harmful health consequences exist with extensive cannabis use, CAMH believes that the decriminalization of cannabis possession will not lead to its increased use, based on supporting evidence from other jurisdictions that have introduced similar controls. CAMH recommends that a more appropriate legal control framework for cannabis use be put into place that will result in a more effective and efficient control system, produce fewer negative social and individual consequences, and maintain public health and safety. An alternative legal control system for the Canadian context can be chosen from a number of options that have been tried and proven adequate in other jurisdictions. CAMH further recommends that such an alternative framework be explored on a temporary and rigorously evaluated trial basis, and that an appropriate level of funding be provided/maintained for prevention and treatment programs to minimize the prevalence of cannabis use and its associated harms. American Society of Addiction Medicine 35 The Society's 1994 policy which was updated September 2001 recommends the following: 1. National policy should present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence. 2. Reliance on the distinction between "legal" and "illegal" drugs is a misleading one, since so-called "legal" drugs are illegal for persons under specified ages, or under certain circumstances. 3. Prevention programs should be comprehensively designed to target the entire range of dependence-producing drugs as well as to produce changes in social attitudes. (See ASAM Prevention Statement.) 4. Outreach, identification, referral and treatment programs for all persons suffering from drug dependencies, including alcoholism and nicotine dependence, should be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 5. Persons suffering from the diseases of alcoholism and other drug dependence should be offered treatment rather than punished for their status of dependence. 6. The balance of resources devoted to combatting these problems should be shifted from a predominance of law enforcement to a greater emphasis on treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate drug dependence and its related problems. 7. Law enforcement measures aimed at interrupting the distribution of illicit drugs should be aimed with the greatest intensity at those causing the most serious acute problems to society. 8. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: a. prevalence of use in pregnancy and effects on offspring; b. prevalence rates of alcoholism and other drug dependencies; c. crime, violence and incarceration rates; d. law enforcement and criminal justice costs; e. industrial safety and productivity; f. costs to the health care system; g. family and social disruption; h. other human, social and economic costs. 9. ASAM opposes any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). Any changes should be gradual and carefully monitored. 10. ASAM opposes any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 11. ASAM supports public policies that would offer treatment and rehabilitation in place of criminal penalties for persons who are suffering from psychoactive substance dependence and whose only offense is possession of a dependence-producing drug for their own use. 12. ASAM supports public policies which offer appropriate treatment and rehabilitation to persons suffering from psychoactive substance dependence who are found guilty of an offense related to that dependence, as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. 13. ASAM supports an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. 14. In addition, scientifically sound research into public policy issues should receive increased support and be given a high priority as an aid in making such decisions. 15. Physicians and medical societies should remain active in the effort to shape national drug policy and should continue to promote a public health approach to alcoholism and other drug dependencies based on scientific understanding of the causes, development and treatment of these diseases. US Physician Leadership on National Drug Policy 32 The Physician Leadership on National Drug Policy (PLNDP) was started in 1997 when 37 senior physicians from virtually every medical society* met and agreed that the "current criminal justice driven approach is not reducing, let alone controlling drug abuse in America." Their extensive review of the literature found: * drug addiction is a chronic, relapsing disease, like diabetes or hypertension; * treatment for drug addiction works; * treating addiction saves money; * treating drug addiction restores families and communities; * prevention and education help deter youth from substance abuse, delinquency, crime and incarceration. In follow-up to an extensive review of the literature, their key policy recommendations are: * Reallocate resources toward drug treatment and prevention; * Parity in access to care, treatment benefits, and clinical outcomes; * Reduce the disabling regulation of addiction treatment programs; * Utilize effective criminal justice procedures to reduce supply and demand (e.g. community coalitions, community policing, drug courts); * Expand investments in research and training; * Eliminate the stigma associated with the diagnosis and treatment of drug problems; * Train physicians and (medical) students to be clinically competent in diagnosing and treating drug problems. REFERENCES 1 Mosher JF, Yanagisako KL. Public health, not social warfare: a public health approach to illegal drug policy. J Public Health Policy 1991; 12: 278-323. 2 Precede - proceed model of health promotion. Institute of Health Promotion Research. Available from: http://www.ihpr.ubc.ca/frameset/frset_publicat.htm. Accessed: Nov 27, 2001. 3 World Health Organization. Ottawa charter for health promotion. Ottawa: World Health Organization, 1986. 4 Dean M. UK government rejects advice to update drug laws. Lancet 2000; 355: 1341. 5 Curran WJ. Decriminalization, demythologizing, desymbolizing and deemphasizing marijuana. Am J Public Health. 1972; 62: 1151-1152. 6 Report of the Canadian Government Commission of Inquiry into the non-medical use of drugs. Ottawa, 1972. 7 Anonymous. Deglamorising cannabis. Lancet 1995; 346: 1241. (editorial) 8 Edlaf EM, Paglia A, Ivis FJ, Ialomiteanu A. Nonmedicinal drug use among adolescent students: highlights from the 1999 Ontario Student Drug Use Survey. CMAJ 2000; 162: 1677-1680. 9 Centre for Addiction and Mental Health. The 1999 Ontario Student Drug Use Survey - executive summary. Available from: http://www.camh.net/addiction/ont_study_drug_use.html. Accessed: October 15, 2001. 10 MacNeil P, Webster I. Canada's alcohol and other drugs survey 1994: a discussion of the findings. Ottawa: Health Canada, 1997. 11 Single E, Fischer B, Room R, Poulin C, Sawka E, Thompson H, Topp J. Cannabis control in Canada: options regarding possession. Ottawa, Canadian Centre on Substance Abuse, 1998. Available from: http://www.ccsa.ca/. 12 Hall W. The cannabis policy debate: finding a way forward. CMAJ 2000; 162: 1690-1692. 13 Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatr 2001; 178: 101-106. 14 Johns A. Psychiatric effects of cannabis. Br J Psychiatr 2001; 178: 116-122. 15 Farrell M, Ritson B. Br J Psychiatr 2001; 178: 98. 16 Tremblay S. Illicit drugs and crime in Canada. Juristat 1999; 19. 17 Riley D. Drugs and drug policy in Canada: a brief review and commentary. November, 1998. Available from: http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/ill-e/library-e/riley-e.htm. Accessed: October 15, 2001. 18 Erickson PG. The law, social control, and drug policy: models, factors, and processes. Int J Addiction 1993; 28: 1155-1176. 19 Single EW. The impact of marijuana decriminalization: an update. J Public Health Policy 1989; 10: 456-66. 20 MacCoun R. Interpreting Dutch cannabis policy: reasoning by analogy in the legalization debate. Science 1997; 278: 47-52. 21 MacCoun R, Reuter P. Evaluating alternative cannabis regimes. Br J Psychiat 2001; 178: 123-128. 22 Hall W. The recent Australian debate about the prohibition on cannabis use. Addiction 1997; 92: 1109-1115. 23 Centre for Infectious Disease Prevention and Control. HIV/AIDS among injecting drug users in Canada. May 2001. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/bah/epi/idus_e.html. Accessed Oct 17, 2001. 24 Hepatitis C - prevention and control : a public health consensus. Can Communic Dis Rep 1999; 25S2. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/99vol25/25s2/index.html. Accessed: Oct 17, 2001. 25 F/P/T Advisory Committee on Population Health et al. Reducing the harm associated with injection drug use in Canada: working document for consultation. March 2001. Available from: http://www.aidslaw.ca/Maincontent/issues/druglaws.htm. Accessed: Oct 14, 2001. 26 Single E, Rehm J, Robson L, Van Truong M. The relative risks and etiologic fractions of different causes of death attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2000: 162: 1669-1675. 27 Marwick C. Physician Leadership on National Drug Policy finds addiction treatment works. JAMA 1999; 279: 1149-1150. 28 Grinspoon L, Bakalar JB. The war on drugs - a peace proposal. N Eng J Med 1994: 330: 357-360. 29 Hankins C. Substance use: time for drug law reform. CMAJ 2000: 162: 1693-1694. 30 National Task Force on HIV, AIDS and Injection Drug Use. HIV/AIDS and injection drug use: a national action plan. Canadian Centre for Substance Abuse and Canadian Public Health Association. May 1997. Available from: http://www.ccsa.ca/docs/HIVAIDS.HTM. Accessed: Oct 15, 2001. 31 Canadian HIV/AIDS Legal Network. Injection drug use and HIV/AIDS: legal and ethical issues. Montreal: Network, 1999. 32 Physician Leadership on National Drug Policy. Position paper on drug policy. January 2000. Available from: http://center.butler.brown.edu/plndp/. Accessed: Nov 27, 2001. 33 The Fraser Institute. Sensible solutions to the urban drug problem. 2001. Available from: http://www.fraserinstitute.ca/publications/books/drug_papers/. Accessed: Nov 29, 2001. 34 Canadian Centre for Addiction and Mental Health. CAMH Position on the legal sanctions related to cannabis possession/use. April 2000. Available from: www.camh.net/position_papers/cannabis_42000.html. Accessed Oct 9, 2001. 35 American Society of Addiction Medicine. Public policy of ASAM. Adopted 1994. Updated Sept 29, 2001. Available from: www.asam.org. Accessed: Nov 27, 2001. ?? ?? ?? ?? A healthy population...a vibrant medical profession Une population en santé...une profession médicale dynamique A Public Health Perspective on Cannabis and Other Illegal Drugs Ottawa, March 11, 2002 Page 21 Canadian Medical Association
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CMA Letter to the Senate Committee on Legal and Constitutional Affairs regarding Bill C-2, An Act to amend the Criminal Code and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy9110
Last Reviewed
2020-02-29
Date
2008-02-19
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-02-19
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Senate Committee on Legal and Constitutional Affairs concerning its study of Bill C-2 (An Act to amend the Criminal Code and to make consequential amendments to other Acts). We will confine our comments to the portion of the proposed legislation that relates to impaired driving. Canada's physicians support measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. Published reports indicate that the prevalence of driving under the influence of cannabis is on the rise in Canada. We note that: * Results from the Canadian Addictions Survey suggest that 4% of the population have driven under the influence of cannabis in the past year, an increase from the 1.5% in 2003 and that rates are higher among young people.1 * It was estimated that in 2003, 27.45% of traffic fatalities involved alcohol, 9.15% involved alcohol and drugs, and 3.66% involved drugs alone while 13.71% of crash injuries involved only alcohol, 4.57% involved alcohol and drugs, and 1.83% involved drugs alone.2 * In a 2002 survey, 17.7% of drivers reported driving within 2 hours of using a prescribed medication, over-the-counter remedy, marijuana, or other illicit drug during the past 12 months. * These results suggest that an estimated 3.7 million Canadians drove after taking some medication or drug that could potentially affect their ability to drive safely. * The most common drugs used were over-the-counter medications (15.9%), prescription drugs (2.3%), marijuana (1.5%), and other illegal drugs (0.9%). * Young males were most likely to report using marijuana and other illegal drugs. * While 86% of the drivers were aware that a conviction for impaired driving results in a criminal record, 66% erroneously believed that the penalties for drug-impaired driving were less severe than those for alcohol-impaired driving. In fact, the penalties are identical. * Over 80% of drivers agreed that drivers suspected of being under the influence of drugs should be required to participate in physical coordination testing for drug impairment. However, only about 70% of drivers agreed that all drivers involved in a serious collision or suspected of drug impairment should be required to provide a blood sample.3 The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code. While our 1999 brief focused primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. In June 2007, the CMA provided comments to the Standing Committee on Justice and Human Rights of the House of Commons during their study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts) which was later incorporated in the omnibus Bill now before your Committee. Last year, the CMA published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles. It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs, the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues, with regard to Clause 20 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and the privacy of health information. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 25 of Bill-C2 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 25(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 25(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could concern individuals who are not actually convicted of an offence. One should query whether the Clause 25(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other privacy related issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 25(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 21, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 21) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.4 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.5 In our 1999 response to the Standing Committee on Justice and Human Rights' issue paper on impaired driving6 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 7 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. We also wanted to note our support for Clause 23 which addresses the issue of liability by extending the existing umbrella of immunity for qualified medical practitioners to the new provision under 254(3.4) 23. Subsection 257(2) of the Act is replaced by the following: (2) No qualified medical practitioner by whom or under whose direction a sample of blood is taken from a person under subsection 254(3) or (3.4) or section 256, and no qualified technician acting under the direction of a qualified medical practitioner, incurs any criminal or civil liability for anything necessarily done with reasonable care and skill when taking the sample. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-2, must be accompanied by a public awareness and education strategy. This constitutes the most effective long-term approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is caused by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Brian Day, MD President 1 Bedard, M, Dubois S, Weaver, B. The impact of cannabis on driving, Canadian Journal of Public Health, Vol 98, 6-11, 2006 2 G. Mercer, Estimating the Presence of Alcohol and Drug Impairment in Traffic Crashes and their Costs to Canadians: 1999 to 2003 (Vancouver: Applied Research and Evaluation Services, 2005). 3 D. Beirness, H. Simpson and K. Desmond, The Road Safety Monitor 2002: Drugs and Driving (Ottawa: Traffic Injury Research Foundation, 2003). Online: www.trafficinjuryResearch.com/whatNew/newsItemPDFs/RSM_02_Drugs_and_ Driving.pdf 4 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 5 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 6 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 7 Mann et al
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Standing Committee on Health’s study on violence faced by healthcare workers

https://policybase.cma.ca/en/permalink/policy14052
Date
2019-05-14
Topics
Health care and patient safety
Ethics and medical professionalism
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2019-05-14
Topics
Health care and patient safety
Ethics and medical professionalism
Health human resources
Physician practice/ compensation/ forms
Text
Re: Standing Committee on Health’s study on violence faced by healthcare workers Dear Mr. Casey: I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for consideration by the Standing Committee on Health (the Committee) as part of the study on violence faced by healthcare workers. The CMA is deeply concerned with the state of workplace safety in all health care settings, including hospitals, long-term care, and home care settings. As in all experiences of violence, it is unacceptable for healthcare workers to be victims of violence in the provision of care to patients. While there is limited data nationally to understand the incidence of violence against healthcare workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity. A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in the previous month, nearly one-third of respondents had been exposed to some form of aggressive behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family physicians in active practice are subjected to regular abuse from their patients or family members of their patients.”1 These concerns were brought to the CMA’s General Council in 2015, where our members passed a resolution calling for: “the federal government to amend the Criminal Code by making it a specific criminal offence to assault health care providers performing their duties.” The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a recognition of the role of the workplace, primarily health care settings, and safe working conditions as having an important influence of physician health and wellness. …/2 1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9). Mr. Bill Casey Addressing violence against providers in healthcare settings will require action from both federal and provincial/territorial governments. In light of the above, the CMA respectfully submits the following recommendations for consideration by the Committee in its study on violence against healthcare workers: 1) The CMA recommends that the Committee on Health support the call to amend the Criminal Code of Canada to introduce a new criminal offence for assault against a healthcare provider performing their duty. 2) The CMA recommends that the Committee on Health support establishing monitoring of violence against healthcare workers, that is consistent across jurisdictions, and have an active role in responding appropriately to trends. 3) The CMA recommends that the Committee on Health support federal leadership in a pan- Canadian approach to support workplace safety in healthcare settings, including collaborating with the provinces and territories to improve violence prevention. Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy to address growing incidents of violence against health care workers.” In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the Committee’s report on this topic and the opportunity to collaborate on federal and provincial/territorial action in this matter. Sincerely, F. Gigi Osler, BScMed, MD, FRCSC President c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health Don Davies, M.P., Vice Chair Standing Committee on Health
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Statement to the Canadian panel on violence against women Ottawa -September, 1992

https://policybase.cma.ca/en/permalink/policy11956
Last Reviewed
2019-03-03
Date
1992-09-15
Topics
Health care and patient safety
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1992-09-15
Topics
Health care and patient safety
Ethics and medical professionalism
Text
The CMA is pleased to have this opportunity to address the Canadian Panel on Violence Against Women. As a professional organization with a leadership role in societal issues affecting health, it is both appropriate and important for the CMA to be actively involved in addressing the problems associated with violence. The extremely high incidence of abuse, the associated severe physical, mental and psychological health problems and the significant role played by physicians in recognizing and caring for victims make this a priority for organized medicine. The CMA has significant experience and expertise in this field. In 1984, the CMA General Council passed a resolution stating: "That Health and Welfare Canada and the Provincial Ministries of Health and Education alert the Canadian public to the existence of family violence, including wife assault, child abuse, and elder abuse, and to the services available which respond to these problems, and that organized medicine (through such vehicles as professional journals, newsletters, conferences and formal medical education) alert the physicians of Canada to the problem and that all physicians learn to recognize the signs of family violence in their daily contact with patients and undertake the care and management of victims using available community resources." (Resolution #84-47) The CMA calls the Panel's attention to four major areas of concern: Recognition and Treatment, Education and Training, Protocol Development and Research. 1. Recognition and Treatment: Recognition includes acknowledging the existence and prevalence of abuse and identifying victims of violence. Violence against women is clearly a health issue and one that should be given a very high priority. Statistics indicate that nearly one in eight Canadian women will be subject to spousal violence in her lifetime and that one in five will be a victim of sexual assault. Violence against women is a major determinant of both short -and long-term health problems including traumatic injury, physical and psychological illnesses, alcohol/drug addiction and death. Furthermore, although it is critically important to recognize that abuse crosses all racial and socio-economic boundaries, there are strong indications that certain groups are particularly vulnerable to abusive acts (e.g., pregnant, disabled and elderly women). Recognition includes acknowledging and understanding the social context within which violence occurs. Violence is not an isolated phenomenon, but is part of the much broader issue of societal abuse of women. Physicians are often the first point of contact for patients who have been abused physically, sexually, mentally and/or psychologically. They have a vital role to play in identifying victims and providing treatment and supportive intervention including appropriate referral. Abuse is not always readily apparent, however, and may go undetected for extended periods of time. Numerous studies have shown that both physicians and patients often fail to identify abuse as an underlying cause of symptoms. Such delays can result in devastating and sometimes fatal consequences for patients. Even in those cases where abuse is apparent, both physicians and patients often feel uncomfortable talking openly about the abuse and the circumstances surrounding it. It is the physician's role and responsibility to create a safe and supportive environment for the disclosure and discussion of abuse. Furthermore, the lack of resources for support services or the lack of awareness of what services are available to provide immediate and follow-up care to patients in need may discourage physicians from acknowledging the existence of abuse and identifying victims. It is clear that improvement in the ability and the degree to which victims of abuse are recognized and given appropriate assistance by physicians and other caring professionals in a non-threatening environment is urgently required. Individuals who are abused usually approach the health care system through primary contact with emergency departments or other primary care centres. The care available in such settings is acute, fragmented and episodic. Such settings are not appropriate for the victims of violence. The challenge that we, as physicians, recognize is to be able to provide access in a coordinated way to medical, social, legal and other support services that are essential for the victim of violence. This integration of services is essential at the point of initial recognition and contact. The CMA has been involved with eight other organizations in the Interdisciplinary Project on Domestic Violence (IPVD), the primary goal of which is to promote interdisciplinary co-operation in the recognition and management of domestic violence. 2. Education and Training: The spectrum of abuse is complex; the victims are diverse; expertise in the field is developing. The current system of medical education neither provides health care personnel with the knowledge or skills nor does it foster the attitude to deal adequately with this issue. Some of CMA's divisions have played an active role in this area. For instance, the Ontario Medical Association has developed curriculum guidelines and medical management of wife abuse for undergraduate medical students. It is ,important that there be more involvement by relevant medical groups in developing educational and training programs and more commitment from medical educators to integrate these programs and resources into the curriculum. Programs must be developed and instituted at all levels of medical education in order that physicians can gain the requisite knowledge and skills and be sensitive to the diversity of victims of violence. The CMA believes that the educational programs must result in: 1) understanding of the health consequences of violence; 2) development of effective communication skills; and, 3) understanding of the social context in which violence occurs. Understanding of the social context in which violence occurs will require an examination of the values and attitudes that persist in our society, including a close consideration of the concepts of gender role socialization, sexuality and power. This is required in order to dispel the pervasive societal misconceptions held by physicians and others which act as barriers to an effective and supportive medical response to patients suffering the effects of violence. 3. Development of Protocols: The CMA recognizes the need for more effective management and treatment of the spectrum of problems associated with violence against women. Health care facilities, professional organizations and other relevant groups are challenged to formulate educational and policy protocols for integrated and collaborative approaches to dealing with prevention of abuse and the management of victims of violence. The CMA and a number of its divisions have been active in this area:
In 1985, the CMA prepared and published Family Violence: Guidelines for Recognition and Management (Ghent, W.R., Da Sylva, N.P., Farren, M.E.), which dealt with the signs and symptoms, assessment and management, referral assistance and medical records with respect to wife battering, child abuse and abuse of the elderly;
The Ontario Medical Association published Repons on Wife Assault in January 1991. This document, endorsed by the CMA, examines the problem of wife assault from a medical perspective and outlines approaches to treatment of the male batterer and his family;
The Medical Society of Nova Scotia has developed a handbook entitled Wife Abuse: A Handbook for Physicians, advising on the identification and management of cases involving the battering of women;
The New Brunswick Medical Society has produced a series of discussion papers on violence and in conjunction with that province's Advisory Council on the Status of Women, has produced a graphic poster depicting physical assault on pregnant women as a way of urging physicians to be alert for signs of violence against women; The Medical Society of Prince Edward Island has worked cooperatively with the provincial Department of Health and Social Services and the Interministerial Committee on Family Violence to produce a document entitled Domestic Violence: A Handbook for Physicians. The CMA encourages continued involvement by the medical profession in the development of initiatives such as these and welcomes the opportunity to work in collaboration with other professionals involved in this area. 4. Research The CMA has identified violence against women as a priority health issue. Like rriany other areas in women's health, there is a need for research focusing on all aspects of violence and the associated problems. More specifically, the CMA maintains that there should be more research on the incidence of abuse (particularly as it relates to particular groups), on ways to facilitate the disclosure by victims of abuse and on the effectiveness of educational and prevention programs. The CMA recognizes that the medical profession must show a greater commitment to ending abuse of women and providing more appropriate care and support services to those who are victims of violence. The CMA possesses unique skills and expertise in this area and welcomes the opportunity to work with the Panel on this challenging social and health problem.
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Putting Patients First : Comments on Bill C 6 (Personal Information Protection and Electronic Documents Act) : Submission to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy1979
Last Reviewed
2019-03-03
Date
1999-11-25
Topics
Ethics and medical professionalism
Health care and patient safety
Health information and e-health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1999-11-25
Topics
Ethics and medical professionalism
Health care and patient safety
Health information and e-health
Text
CMA commends the federal government for taking this important first step that begins the debate on privacy and the protection of personal information. The issues are complex and the interests at stake significant. CMA welcomes the opportunity to provide comments on Bill C-6 and hopes that its input will strengthen the Bill by ensuring that patient privacy and the confidentiality of medical records are adequately protected. CMA’s chief concern with Bill C-6 is the inadequacy of its provisions to protect the right of privacy of patients and the confidentiality of their health information. The right of privacy encompasses both the right to keep information about ourselves to ourselves if we so choose and to exercise control over what subsequently happens to information we confide in trust for the purpose of receiving health care. In recent years, this right, and the ability of physicians to guarantee meaningful confidentiality, have becoming increasingly threatened. Computerization of health information facilitates easy transfer, duplication, linkage and centralization of health information. Captured in electronic form, patient information is potentially more useful for the purpose of providing care. However, thus captured, it also becomes much more valuable and technically accessible to various third parties -- private and public, governmental and commercial -- wishing to use this information for other purposes unrelated to providing direct care. An additional concern is that the demand for health information, referred to by some commentators as ‘data lust’, is growing, partly as a consequence of ‘information hungry’ policy trends such as population health. There is also a disturbing tendency toward ‘function creep’, whereby information collected for one purpose is used for another, often without consent or even knowledge of the individual concerned and without public knowledge or scrutiny. Furthermore, initiatives concerning health information technology tend to be dominated by those who seek access to this information for secondary purposes. From this perspective, privacy may appear less as a fundamental right than as a hindrance or even roadblock. As we move further into the information age there is some danger that we will become so spell-bound by the promise of information centralization and database linkages that we lose sight of the patients who confided this information or reduce them to impersonal ‘data subjects’. To avoid this danger and the allure of the technology we need to ground the application of information technology and practices in well-tested, enduring principles. We need to put privacy first rather than treat it as a nuisance or impediment. Rules and regulatory regimes concerning health information should be based on the principle of patient privacy because ultimately health information technology is not about ‘bits and bytes’ or ‘data’ or even ‘data subjects’ but about patients, and patients deserve to be treated with respect and dignity and to have their wishes and choices valued and respected. If we are to put patients first the right of privacy must be given primacy in rules concerning health information. This does not mean that this right is absolute. What it does mean is that the burden of proof must rest with those whose purposes, however compelling they may be, encroach upon the right of privacy. It means that we value patient privacy at least enough to demand explicit justification of any proposal that would diminish privacy. Bill C-6 begins with the right premise: that “rules to govern information collection, use and disclosure” should recognize the “right of privacy”. However, it fails to recognize the special nature of health information and to tailor its provisions accordingly. In consequence there is confusion and uncertainty about Bill C-6's application to health care. Even more seriously, however, Bill C-6 fails to recognize that health information requires stronger or greater privacy protection than other types of information. The inadequacy of Bill C-6 for health care is not surprising because clearly it was not drafted with health information in mind. Rather, it is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. The world of health care is very different from that of commerce and consequently requires distinct rules that are more protective of privacy. Confiding information to your physician under the trust of the patient-physician relationship is not on par with giving your address to a salesclerk when you purchase a toaster or rent a movie. Health information is special by nature. Canadians know this. In a recent Angus Reid poll commissioned by CMA Canadians told us loudly and clearly that they regard their health information as especially sensitive. However, the obvious sensitivity of health information is not the only thing that makes it special and in virtue of which it warrants distinct rules to strengthen privacy protection. It is important to recognize that this information is typically collected under the trust patients vest in their physicians. Patients confide their information for the purpose of receiving care and in the expectation that it will be held in the strictest confidence. This purpose, and the preservation of this trust, should be given primacy in rules concerning health information. It is also important to recognize that the trust under which patients confide in their physicians is fundamental to the patient-physician relationship. If patients can not trust their physicians to protect their information and keep it secret they will not confide it as freely as they do. In consequence, the ability of physicians to provide the care needed would be severely diminished. Rules relating to health information must be developed in recognition of its special nature and the circumstances of trust and vulnerability in which it is initially collected or confided. Patients confide in their physicians for the purpose of receiving care. The potential that the information thus confided may subsequently be used for other purposes must not impede the therapeutic purpose or diminish the trust and integrity of the patient-physician relationship. In recent years the secondary use of information for purposes other than those for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. Putting patients first means ensuring that health information, in all but exceptional and justifiable circumstances, is used only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Moreover, a distinction must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Bill C-6 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The laxness and breadth of these exemptions as applied to health information is unacceptable. These uses, without the patient’s consent (or even knowledge), reduce the patient to a means to someone else’s end, however worthwhile that end may be. Moreover, the absence of consent (or even knowledge) undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. CMA has developed and adopted a Health Information Privacy Code (Appendix A) in recognition of the special nature of health information and to give primacy to patients and to the right of privacy. This Code begins from the same starting point as Bill C-6, the Canadian Standards Association (CSA) Code which the Bill includes as Schedule 1. However, unlike Bill C-6, the CMA Code tailors the CSA Code to the specific circumstances of health information. The CMA Health Information Privacy Code, therefore, is able to address issues specific to health information that Bill C-6 either fails to address or, even worse, exacerbates. In light of the clear deficits in Bill C-6 and the inadequate protection of patient privacy and health information confidentiality, CMA urges this committee to accept the recommendations put forward in this brief to strengthen the Bill’s provisions for protecting privacy and to accept the amendment (Appendix B) CMA has prepared to give effect to these recommendations. CMA believes that Canadians desire and deserve no less than this as concerns the right of privacy with respect to health information. I. Introduction The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 46,000 members and the Canadian public, CMA performs a wide variety of functions, including addressing the emerging issue of electronic health information and confidentiality and privacy. It is in this capacity that we present our position on Bill C 6, The Personal Information Protection and Electronic Documents Act. CMA commends the federal government for taking this important first step of beginning the debate on privacy and the protection of personal information. The issues are complex and the interests at stake significant. CMA welcomes the opportunity to provide comments on Bill C-6 and hopes that its input will strengthen the Bill by ensuring that patient privacy and the confidentiality of medical records are adequately protected. In preparing this brief CMA has had the benefit of the final report of the federal Advisory Council on Health Infostructure, Canada Health Infoway: Paths to Better Health: Final Report. (“Advisory Council Report”) Where appropriate, CMA cites the findings contained in the Report. CMA wishes to underscore the key themes of its brief: A. Health information is special by its nature. Rules relating to health information must be developed in recognition of its special nature. Ensuring protection of privacy and confidentiality of the patient record must take precedence over other considerations. Bill C-6 fails to do this. Bill C-6 is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. The world of health care is very different from that of commerce and consequently requires distinct rules. B. Typically, health information is confided in the context of the therapeutic relationship and under the trust upon which this relationship is built. Rules concerning health information -- and in particular its collection, disclosure and use for purposes unrelated to the provision of direct care -- must be consistent with the expectations of patients about confidentiality and must not exploit the trust patients have in their physicians or compromise the ability of physicians to earn and maintain this trust. C. Health information must, in all but exceptional and justifiable circumstances, be used only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Moreover, a distinction must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Bill C-6 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The laxness and breadth of these exemptions as applied to health information is unacceptable. These uses, without the patient’s consent (or even knowledge), reduce the patient to a means to someone else’s end, however worthwhile that end may be. Moreover, the absence of consent (or even knowledge) undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. D. The root of most of the problems in applying Bill C-6 to health care information is its failure to distinguish among purposes for the collection, use and disclosure of health information. In particular, the Bill fails to distinguish between the primary purpose, which is to deliver care to and for the benefit of an individual patient, and secondary purposes, which are not for the direct benefit of the patient (and indeed may even use the patient’s information to his or her detriment). Provisions to protect privacy should give recognition to the difference between these purposes and should not hinder the ability of physicians and others to provide care consistent with the patient’s wishes. Moreover, the Bill has no effective mechanism to distinguish legitimate purposes, which should be permitted, from illegitimate purposes, which should not, notwithstanding the limitation to “purposes that a reasonable person would consider are appropriate in the circumstances” in Section 5(3). E. In recent years the secondary use of information for purposes other than the purpose for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. This Brief will first look at the apparent rationale of Bill C-6 and its potential application to health information. The brief will then describe why CMA considers health information to be special in nature and worthy of special protection. Finally, the brief reviews the difference in approach between Bill C-6 and CMA’s Health Information Privacy Code to illustrate that Bill C-6 provides inadequate protection to patient privacy and medical confidentiality. II. Rationale and Scope of Bill C-6 A. Rationale of Bill C-6 The driving force behind Bill C-6 is the support and promotion of electronic commerce. The second part of the Bill is devoted to permitting electronic versions of documents and signatures to be legitimate or ‘originals’ if the provisions of the Act are followed. Part 2 of the Bill is quite distinct from Part 2 and both parts could stand alone as separate pieces of legislation. Part 2 simply allows electronic versions of documents and signatures to be recognized as legitimate. On its face, this has little to do with the protection of personal information except to the extent that storage of documents in electronic form provides greater ability to access, link and merge information. Certainly, the Bill appears to draw on this connection by including, in its statement of purpose, the provision of a right of privacy in an era in which technology increasingly facilitates the collection and free flow of information. Part 1 concerns all forms of personal information, electronic and otherwise. It gives some protection to personal information by requiring consent in some instances. In CMA’s view, a fundamental difficulty with Part 1 and with the Bill in general is that its goal is to promote commerce and thus all information is implicitly considered as falling within the ‘commercial’ realm. In the case of health information this is surely not the case or the only consideration. Moreover, this creates a clash of values when applied to a health care system that is a public system. The Advisory Council Report takes a firm stand on this issue and states that legislation respecting the privacy protection of health information, “should also contain a clear prohibition against all secondary commercial use of personal health information.”Moreover, Bill C-6 fails to distinguish and priorize different purposes for collecting, using and disclosing information and in doing so treats all purposes as more or less equal and subject to the same rules. CMA takes a quite a different view when it comes to health information and will expound its view throughout this brief. B. Scope - Application to Health Records CMA has argued from the outset that C 6 (and its predecessor C 54) will apply to some health information. This view now appears to be widely accepted. Nevertheless, it is unclear as to what extent Bill C 6 will apply to health records. The full name of the Act states, in part: An Act to support and promote electronic commerce by protecting personal information that is collected, used or disclosed in certain circumstances . . . . What are these circumstances? Section 4(1) states that Part 1 (the part protecting personal information) applies in respect of personal information that: (a) the organization collects, uses or discloses in the course of commercial activities; or (b) is about an employee of the organization and that the organization collects, uses or discloses in connection with the operation of a federal work, undertaking or business. The definition of commercial activity given in 2(1) that commercial activity Ameans any particular transaction, act or conduct or any regular course of conduct that is of a commercial character@ is circular and does nothing to clarify uncertainties concerning the Bill’s scope. There are two points to be made here as concerns the application of this Bill to health information. The first concerns clarity around where commercial ends and health care begins. Which health care settings that operate for profit are excluded from the Act? This question speaks to the difficulty of delineating what activity is considered health care and what activity is considered commercial. Moreover the increase in public/private partnerships and joint funding of endeavours within the health care sector, which the government appears to be promoting, may make it increasingly difficult to make this distinction; for example in the area of research. The second concerns the specification of different regimes for information protection and privacy rights, depending on whether the information is deemed to come under commercial activity. This is clearly not desirable. However, the solution to this problem is not to reduce the privacy rules for all health information to the lowest common denominator but to raise them to a higher level of protection than is afforded commercially acquired information. Subjecting all health information to the regime laid out in the CMA Health Information Privacy Code would achieve this objective. In preparing this brief CMA has assumed that the Bill will provide a scheme that applies to at least some health information. Three years after it is in force it will apply equally to activities that occur strictly within the provinces, unless there is legislation in the province that is substantially similar to the Bill (see sections 27(2)(b) and 30). No doubt the extent of the federal government’s ability to legislate in this area generally will be the subject of extensive debate. However, CMA has no comment on this debate and provides its opinion in the interests of ensuring that the rules that relate to health information are compatible with preserving the integrity of the patient physician relationship and the protection of patient privacy and health information confidentiality. The federal government has an opportunity to provide Canadians with strong privacy rights in health information. It is incumbent upon the government to do so. C. Scope - Government Excluded Bill C-6 expressly excludes a large part of government activity from its ambit. Although government activity is to some extent governed by the Privacy Act, R.S.C. 1985, P-21, the rules of this Act provide less protection than those of Bill C-6. Government should subject itself to at least the same rules that it requires of the private sector in so far as it is a collector and user of information. Indeed, government’s practices relating to the collection, storage, merging, transfer and use of health information should be subject to more stringent rules than those found in either the Privacy Act or Bill C-6. The Advisory Council Report also calls for the same rules to apply to the public and private sectors, rules that are more stringent than those found in the Privacy Act or Bill C-6. Therefore, CMA recommends: That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. III. Considerations Regarding Patient Privacy and Confidentiality: Medical Context Versus Commercial Context A. CMA’s Position The world of health care is very different from that of commerce and consequently requires distinct rules that are more protective of privacy. Confiding information to your physician under the trust of the patient-physician relationship is not on par with giving your address to a salesclerk when you purchase a toaster or rent a movie. Health information is special by nature. Canadians know this. In a recent Angus Reid poll commissioned by CMA Canadians told us loudly and clearly that they regard their health information as especially sensitive. However, the obvious sensitivity of health information is not the only thing that makes it special and in virtue of which it warrants distinct rules to strengthen privacy protection. It is important to recognize that this information is typically collected under the trust patients vest in their physicians. Patients confide their information for the purpose of receiving care and in the expectation that it will be held in the strictest confidence. This purpose, and the preservation of this trust, should be given primacy in rules concerning health information It is also important to recognize that the trust under which patients confide in their physicians is fundamental to the patient-physician relationship. If patients could not trust their physicians to protect their information and keep it secret they would not confide it as freely as they do. In consequence, the ability of physicians to provide the care needed would be severely diminished. Rules relating to health information must be developed in recognition of its special nature and the circumstances of trust and vulnerability in which it is initially collected or confided. Patients confide in their physicians for the purpose of receiving care. The potential that the information thus confided may subsequently be used for other purposes must not impede the therapeutic purpose or diminish the trust and integrity of the patient-physician relationship. In recent years the secondary use of information for purposes other than those for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. Putting patients first means ensuring that health information, in all but exceptional and justifiable circumstances, is used only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Moreover, a distinction must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Bill C-6 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The laxness and breadth of these exemptions as applied to health information is unacceptable. These uses, without the patient’s consent (or even knowledge), reduce the patient to a means to someone else’s end, however worthwhile that end may be. Moreover, the absence of consent (or even knowledge) undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. CMA has developed and adopted a Health Information Privacy Code (Appendix A) in recognition of the special nature of health information and to give primacy to patients and to the right of privacy. In commenting on this Code the Advisory Council Report notes: The Code represents an important contribution to the deliberations of Canadians and legislators on how to safeguard privacy across the health domain. In his 1998-99 Annual Report, the Federal Privacy Commissioner writes in support of the Health Information Privacy Code: Legislators looking for guidance on health information privacy law need not re-invent the wheel; the Canadian Medical Association’s Health Information Privacy Code is a comprehensive benchmark for achieving a high national level of protection for personal information. The Code could be the basis for drafting legislation. Given the grumblings that the Code sets the bar too high, perhaps some Health Infoway funds should be used to study the impact of its implementation. The patients at the heart of this system deserve no less. There are several key principles that guided the development of the Health Information Privacy Code and upon which it is based: 1. The provision of health care to all Canadians irrespective of social circumstances or health status is a highly regarded value in Canadian society. The system is publicly funded and universally accessible. 2. The right of privacy is fundamental to a free and democratic society. 3. Rules relating to health information must recognize its special nature. Health information has a high level of sensitivity and is confided or collected in circumstances of vulnerability and trust for the primary purpose of benefiting the patient. 4. The hallmark of the medical profession since the time of Hippocrates has been the willingness and ability to hold information confided secret. 5. The patient-physician relationship is one of trust. A central feature of this trust is the belief of patients that information confided in or collected by physicians and other health care providers will be kept secret. 6. Patients believe that the information they disclose or that is gathered as a result of their seeking health care will be used to provide them with health care. Use beyond the provision of health care without knowledge or consent goes beyond what a patient’s reasonable expectations were when information was confided or collected and therefore is a breach of the trust patients place in their physicians. 7. Except in very limited circumstances, consent is required for health information collection, use, disclosure or access for any purpose. 8. Information required to provide patients with the health care sought should be readily available to those who require it to provide an aspect of care as consistent with the wishes of the patient. 9. Uses of health information for purposes other than the provision of health care to the person seeking care should be subject to rules that: - protect and promote privacy and confidentiality; - generally require express consent; - can be justified according to specific criteria. 10. Patients should know the uses to which their health information may be put prior to disclosing it. 11. Patients may be reluctant to disclose information if they are concerned about the uses to which the information is put or the persons entitled to access it. B. Public Opinion To determine the public’s views on issues concerning privacy and health information, CMA commissioned Angus Reid to conduct research in two forms, quantitative (survey) and qualitative (focus groups), and has found the following: 1. Canadians believe that health information is the most sensitive type of information, and indeed more sensitive than their financial information. 1. 2. Canadians believe that their health information will be kept confidential and consider this to be important. 3. Canadians believe it important to know and control how their health information is shared with others. 4. Canadians do not want their health information released to third parties (including governments and researchers) without their knowledge and consent. 5. Canadians have concerns about the release of delinked or anonymous information to third parties without their consent. 6. Some Canadians are reluctant to confide information to their physicians due to concerns about it subsequently being disclosed to others without their consent. 7. Patients believe that privacy rules should apply equally to the public and the private sector. These findings are consistent with the published literature and other findings relating to the public’s concerns about privacy and confidentiality. The CMA Health Information Privacy Code was developed in consideration of these views. Once developed, its principles were subsequently tested with the public in a series of cross-country focus groups and it was found that the Code appears to enjoy considerable public support. C. The Advisory Council Report The Advisory Council Report relates to the electronic health record. However, given the direction towards the greater use of technology and the underlying principles informing the Advisory Council, its recommendations are generalizable to all health information. A key principle of the Advisory Council Report is that access by health care professionals should be based on a need-to-know basis under the strict control of the patient. The Council, like CMA, calls for scrutiny and justification of secondary uses of health information. The Council is opposed to the use of multipurpose identifiers on the grounds that it becomes too easy for government officials from one department to gain access to a person’s health record or to combine a number of records to assemble a comprehensive profile. (Anecdotal evidence suggests that this concern may be justified and that there are insufficient safeguards preventing the flow of health information among government departments.) The Council recommends that all governments ensure that they have legislation to address privacy protection specifically aimed at protecting personal health information through explicit and transparent mechanisms. Included in these mechanisms are: * The provision of a precise definition of free and informed consent, as well as a statement of principle that informed consent should be the basis for sharing personal health information; * Any exemption to the requirement of informed consent should be clearly set out in law. More specifically, legislative guidance should be provided on how to balance the right of privacy with the public good for research purposes to implement a coherent and harmonized pan-Canadian system for independent, ethical review. * There should be provisions regulating secondary uses of non-identifiable health information. These provisions should address privacy concerns surrounding the degree to which data might be linked back to an identifiable individual. * Legislation should set clear limits on access to and use of health information by third parties outside the health care system. To prevent the serious invasions of privacy that can result from the unrestricted linking of personal health information with other kinds of information on the same individual, the legislation should contain provisions prohibiting the use for any other purpose of unique personal identifiers in health information systems. D. The Approach in Bill C-6 Bill C-6 begins with the right premise: that “rules to govern information collection, use and disclosure” should recognize the “right of privacy”. However, it fails to recognize the special nature of health information and to tailor its provisions accordingly. In consequence, there is confusion and uncertainty about Bill C-6's application to health care. Even more seriously, however, Bill C-6 fails to recognize that health information requires stronger or greater privacy protection than other types of information. The Bill makes a cursory attempt at distinguishing among varying types of personal information and gives inadequate additional protection to information that is highly sensitive (such as health information), notwithstanding the provisions in Paragraph 4.3.4 of Schedule 1 concerning consent which do provide some latitude for more stringent requirements in the case of sensitive information. The Bill permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purposes. In the context of health information, these grounds should be subject to intense scrutiny to determine their relevance and legitimacy. Some of these grounds would not withstand scrutiny if subjected to the tests established in the CMA’s Health Information Privacy Code. E. Conclusion CMA believes that health information is special and deserves a higher level of privacy protection than other types of information. The Advisory Council Report also recognizes that distinct rules, more protective of privacy, are required for health information. The Council’s Report places strong emphasis on the protection of privacy, recognizes that, as a general rule, the flow of health information should be on a need-to-know basis and under the control of the patient through the exercise of free and informed consent, and requires limits on the secondary use of health information. The inadequacy of Bill C-6 for health care is not surprising because clearly it was not drafted with health information in mind. Rather, it is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. However, the world of health care is very different from that of commerce and distinct rules that are more protective of privacy. The CMA Health Information Privacy Code begins from the same starting point as Bill C-6, the Canadian Standards Association (CSA) Code which the Bill includes as Schedule 1. However, unlike Bill C-6, the CMA Code tailors the CSA Code to the specific circumstances of health information. The CMA Health Information Privacy Code, therefore, is able to address issues specific to health information that Bill C-6 either fails to address or, even worse, creates. It offers a template for the protection that should be specifically accorded to the right of privacy in health information, a template that appears to have considerable public support and is designed to uphold patient confidence in their physicians and the health care system. Amending Bill C-6 to incorporate the principles in the CMA Code would ensure adequate privacy protection. CMA recommends: That Bill C-6 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Health Information Privacy Code provide the basis of such provisions. CMA developed the Health Information Privacy Code in recognition of trends and developments that pose new threats to patient privacy and the trust of the therapeutic relationship. In recent years the secondary use of information for purposes other than the purposes for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. CMA’s Health Information Privacy Code provides a test to which legislation addressing health information should be subjected. This test (found in section 3.6 of the CMA Code) states: Any proposed or existing legislation or regulation made under legislative authority that permits or requires health information collection, use, disclosure or access shall be subjected to the following legislative test: (a) There must be demonstration that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public and has been duly considered prior to the introduction of legislation [section 3.5 of the Code provides guidance with respect to the patient privacy impact assessment]; (ii) collection, use, disclosure and access will be limited to the greatest degree possible to ensure that * the collection of health information by persons external to the therapeutic context will neither trade on nor compromise the trust of the patient-physician relationship; * patients are not likely to be inhibited from confiding information for primary purposes; * the ability of physicians to discharge their fiduciary duties to patients will not be compromised; and, * patient vulnerability will not be exploited; (iii) collection, use, disclosure and access will be restricted to what is necessary for the identified purpose(s) and will not impede the confiding or collection of information for primary purposes; (iv) provisions exist for ensuring that patients are provided with knowledge about the purpose(s) and that, subject to 3.6(b), patient consent is clearly voluntary; (v) the means used are proportionate and the collection will be limited to purposes consented to or made known to the patient; (vi) the patient’s privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to or made known to the patient; (vii) linkage of the health information will be limited; and (viii) unless clear and compelling reasons exist: * all reasonable steps will be taken to make health information anonymous; and * if it has been demonstrated that making health information anonymous would render it inadequate for legitimate uses, the information will be collected and stored in a deidentified-relinkable format. (b) When nonconsensual collection, use, disclosure or access is permitted or required by legislation or regulation that meets the requirements of the Code, the following conditions must also be met: (i) the right of privacy has to be violated because the purpose(s) could not be met adequately if patient consent is required; and (ii) the importance of the purpose(s) must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. (c) Any legislative provision or regulation that permits or requires health information collection, use, disclosure or access nonconsensually shall not, without compelling reasons, be applied retroactively to existing health information. In its current form, Bill C-6 would not pass the scrutiny of the test. Consequently, CMA recommends: That the proposed rules for health legislation be subject to the legislative test found in CMA’s Health Information Privacy Code and formulated in light of this process. IV. Specific Comments on Bill C-6 From the Perspective of CMA’s Health Information Privacy Code This section highlights some key distinctions between the approach taken by Bill C-6 and CMA’s Health Information Privacy Code. It uses examples to illustrate divergent approaches taken for the purpose of demonstrating that Bill C-6 is inadequate in the protection it accords health information and to show how the CMA Health Information Privacy Code would address the issues adequately. A. General Bill C-6 and CMA’s Health Information Privacy Code are based on the Canadian Standards Association’s Model Code for the Protection of Personal Information (CSA Code). Bill C-6 and the CMA Code also augment the CSA Code’s provisions where considered necessary. The need to extend the provisions of the CSA Code demonstrates that the CSA Code, being general in nature, provides inadequate protection to information in many instances. The CSA recognized this at the time it developed its Code and specifically issued additional, specific guidance for health information in the form of an appendix to the Workbook for applying the Code. The Workbook begins: Information regarding one’s health and health records may be among the most sensitive of all personal data. Individuals are concerned that inappropriate disclosure of such information could unduly affect their employment status or their lives in general. . . Some health information is obtained directly from health care providers who have been given a patient’s private information with the expectation that this information will remain as a private communication. Health care providers . . . in turn, feel that such concerns could influence individuals to withhold vital information or avoid treatment to ensure their private information remains as such. Implementation of privacy procedures that adhere to the principles in the CSA Code and rigid applications of such procedures are essential steps for organizations that require access to health information, to maintain an individual’s trust that sensitive personal information remains confidential. In designing and implementing such procedures, organizations should recognize the sensitive nature of such information and also the fact that the primary reason that health care providers maintain records is to ensure that safe and efficacious care is provided. The Workbook goes on to list 7 interpretative points to augment the CSA Code, providing additional privacy protection as it applies to health information, including the following: requirements for the individual’s knowledge and consent be rigidly followed. Consent to acquire and disclose health information should be undertaken with the individual’s full knowledge of the scope of information to be requested. Bill C-6 does not include these additional interpretive points. It does not give due recognition that health information, because of its high sensitivity, deserves even stronger protection than is provided in the CSA Code as appended in Schedule 1 of the Bill (which even the Committee that drafted the CSA Code recognized). Although Bill C-6 and the CMA Code are based on the CSA Code, each takes a different approach to the ultimate protection accorded information and to the right of privacy. This divergence demonstrates that there are many ways to resolve issues left unresolved by the CSA Code. In other words, it is not a foregone conclusion that basing provisions on the CSA Code will result in appropriate or adequate protection of information. Rather, resolution of issues requires thought and deliberation and will depend in some measure on the primacy given to certain values. Bill C-6 appears to have given access primacy in the pursuit of commerce, whereas CMA gives privacy protection primacy in the pursuit of the provision of health care in accordance with physicians’ fiduciary obligations to patients and the integrity of the patient-physician relationship. CMA did not develop its approach in a vacuum. It reviewed, and was inspired by, the report of the House of Commons Standing Committee on Human Rights and the Status of Persons with Disabilities, entitled Privacy: Where Do We Draw the Line? This report articulates and makes explicit many of the issues that should be informing the current debate on Bill C-6. In addition, the Report of the Advisory Council takes a very different approach than Bill C-6. The Report recognizes the need to pay more than lip service to protecting privacy and confidentiality and recommends specific measures aimed at doing this. B. Primacy of the Therapeutic Purpose The root of most of the problems in applying Bill C-6 to health care is its failure to distinguish among purposes for the collection, use and disclosure of health information. In particular, the Bill fails to distinguish between the primary purpose, which is to deliver care to and for the benefit of an individual patient, and secondary purposes, which are not for the direct benefit of the patient and indeed may even involve using the patient’s information to his or her detriment. Under Bill C-6, the same rules apply equally to both the primary and to secondary purposes. In other sectors this failure to distinguish different purposes and to fashion rules in light of salient differences may not pose problems. In the health care sector, however, the consequences could be quite serious. As applied to secondary purposes, the provisions in Bill C-6 fail to limit access appropriately. Access to information may occur in ways that are inappropriate and violate the privacy of patients. As applied to the primary purpose -- the use of a person`s information to provide that person with care -- the rules in the Bill, if rigidly construed, may inhibit access that would otherwise be appropriate and consistent with the patient`s right of privacy. For example, the consent provisions in the Bill could create impediments to information flow where various members of a ‘health care team’ require information about the patient in order to be effective for the patient’s benefit; the provisions in the Bill that seek to limit the extent of information collection could inhibit physicians from being as extensive as they sometimes are and should be in collecting information from patients for the purpose of providing care; the provisions in the Bill requiring that the patient`s request to review his or her record be in writing could in fact be a barrier to patient access which might otherwise be facilitated informally and consistently with the patient`s wishes by a simple verbal request. Such consequences no doubt would be unintended by the drafters of the Bill; the drafters might even argue that for someone to interpret the provisions mentioned above as potentially leading to these consequences would be to misinterpret them. Regardless, the fact is that the Bill, on these matters and others, is somewhat strained when its provisions are applied to health care. The CMA Health Information Privacy Code, however, is not. It begins from the same starting point as Bill C-6, which is the CSA Code. However, the CMA, recognizing (as the drafters of the CSA Code apparently also did) that the CSA Code would need to be tailored to deal adequately with health information, did so in drafting its Health Information Privacy Code. This document was written from the ground up not just with privacy first and foremost as a value but also with specific reference to the health sector. And it is based on the fundamental premise that not all purposes for the use of health care are equal and that the therapeutic purpose must be given primacy. Thus the CMA Health Information Privacy Code avoids the kind of problems identified above that might arise as Bill C-6 is applied to health information. For example, it specifies that the collection of health information for the primary purpose of providing care “may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context” (3.2) but that for any secondary purposes it should be “as minimal as necessary in recognition of the need to protect the patient’s right of privacy in the therapeutic context” (3.3.). As concerns consent, which CMA recognizes to be core to the protection of privacy, the CMA Code articulates rules for consent in recognition of the importance of timely information flow in the team context and as appropriate to meet the purpose for which the patient has confided the information in the first place, which is to receive care. It stipulates that consent for the primary purpose may therefore be implied, albeit with certain qualifications. Moreover, where consent is required, the provisions of the Code allow that “the conveyance of generic information is a reasonable means of providing knowledge” in most circumstances, which means that this requirement is unlikely to create unreasonable burdens that would diminish rather than strengthen the therapeutic relationship. Finally, the CMA Code limits itself to issues of principle concerning patient access to their records; Bill C-6, by specifying that requests must be in writing, could in fact be creating a barrier to patient access or an undue burden upon the patient-physician relationship as there may be instances when an informal request would be quite appropriate. C. Knowledge of Purpose Prior to Collection Bill C-6 Bill C-6 is ambiguous in its provisions relating to whether or not a person should know the purposes for which information will be used prior to disclosure. This is due in part to the use of the term “knowledge and consent” as one concept rather than distinguishing the knowledge requirement from the consent requirement. What a person should know in relation to the purposes for which information might be used or disclosed, prior to its being given, is distinct conceptually from whether the person must consent before information can be used or disclosed for a particular purpose. Schedule 1 of the Bill contains a number of principles. For the purposes of this Brief the schedule will be referred to in terms of the principles (and their subparagraphs). Principle 2 addresses the identification of purposes for which information will be used or disclosed. Provided a purpose is identified it becomes a legitimate purpose (this Brief recognizes that the addition of the “reasonable person” clause in 5(3) takes precedence and provides some grounds for distinguishing legitimate and illegitimate purposes). Subparagraph 3 states that the identified purposes should be specified at or before the time of collection. Section 5(2) of the Bill states that the use of ‘should’ in schedule 1 indicates a recommendation and does not impose an obligation. Therefore, according to subparagraph 3, it is recommended but is not obligatory that disclosure occur. On the other hand, principle 3 addresses consent and appears to impose an obligation by stating that the knowledge and consent of the individual are required for the collection, use, or disclosure of personal information, except where inappropriate. Similarly subparagraph 2 appears to create something of an obligation by stating, “organizations shall make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used.” Section 7(1)(a) permits the collection of information without knowledge and consent when collection is clearly in the interests of the individual and consent cannot be obtained. The intent of this section could be made clearer, particularly in terms of who determines the “interests of the individual.” Otherwise this exception could give undesirable licence to collect without knowledge or consent. The provision in section 7(1)(b) is more problematic. This section appears to favour withholding knowledge from an individual if such knowledge would compromise accuracy, defeat the purpose for collection or prejudice the use. In some instances it may well be that, if an individual is provided with knowledge of the purposes for which information is collected and the uses to which it will be put, he or she may choose to withhold information rather than disclose it, and in doing so would clearly compromise accuracy, defeat the purpose for collection or prejudice the use to which the information will be put. This is contrary to principle 4.4.2, which recognizes that information should not be collected by misleading or deceiving individuals. The intent of this section should be far clearer and circumscribed in such a way as to make it clear that it is not permissible to withhold knowledge or not seek consent simply on the basis that if a person had knowledge they would not wish to disclose information. Section 7(1)(c) allows collection without knowledge or consent for journalistic, artistic or literary purposes. This provision is totally inappropriate in the case of health information. CMA Health Information Privacy Code The CMA Health Information Privacy Code is considerably more restrictive that Bill C-6. It recognizes that, in the therapeutic context, health information is confided or collected under the patient’s presumption that it is necessary to meet his or her therapeutic needs. The potential that health information may be subsequently collected, used, disclosed or accessed for other purposes without patient consent should be made known to patients before information is confided or collected for the primary therapeutic purpose. Moreover, it is not acceptable to withhold knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. The CMA Health Information Privacy Code limits the nonconsensual collection of health information to circumstances where it is either permitted or required by legislation or ordered or decided by a court of law. In addition, the CMA Code gives explicit direction to legislators with respect to the conditions under which legislation should permit or require health information collection (see section 3.6 of CMA Code). In the case of nonconsensual collection, the following conditions are stipulated: 1. The right of privacy has to be violated because the purposes could not be met adequately if patient consent is required; and 2. The importance of the purposes must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. D. Use Without Knowledge Or Consent Bill C-6 Once information has been collected and despite the limits, inadequate though they be, placed on collection without knowledge or consent, it can be put to even greater use than for the purposes for which it has been collected (with or without knowledge or consent). Section 7(2) opens up dramatically the uses to which collected information may be put without either knowledge or consent. At a minimum, and with little additional administrative effort, the enumerated grounds of section 7(2) (and 7(3) should be made known to an individual prior to their disclosure of information, which would be in keeping with the principle of openness and explicitness. Section 7(2)(a) allows use in connection with the investigation of an offence. In the medical context this could be problematic, particularly if it is interpreted to impose an obligation. Generally, there is no obligation to assist in the investigation of an offence, and indeed the fiduciary duty between patient and physician and the duty of confidentiality owed to the patient by the physician would suggest that physicians not offer information, despite its usefulness. Section 7(2)(b) recognizes emergency situations. However, as worded, section 7(2)(b) would allow access to anyone’s information if it is for the purpose of acting in an emergency threatening the life, health or security of an individual. The implications of this section should be carefully thought through. It is not desirable to give such a broad licence to access anyone’s information on the basis of an emergency. There should be some limiting principle that takes into account the prevailing view that people generally are not required to go to the assistance of others (emergency or otherwise) and that information about oneself is considered worthy of protection against use or disclosure, despite its potential benefit to others (for example, genetic information or HIV or Hepatitis C status). Section 7(2)(c) is very problematic as it permits the use of “identifiable” information for a host of purposes, including statistical and research, when it is impractical to seek consent. Even though the Commissioner must be informed of the use before the information is used the Commissioner has no power to approve or reject the use. If the use is legitimate under the Bill there would be no grounds open to the Commissioner to cause an audit to occur. This section gives significant scope for the secondary use of information that has been collected without knowledge or consent; in the case of health information it is very problematic. CMA Health Information Privacy Code The CMA Code makes a clear distinction between the primary purpose for the collection and use of health information and secondary purposes for its use. The key distinction between these two categories is that primary purposes relates to the provision of the health care benefit sought whereas secondary purposes are ends or aims that are not directly related to the provision of care. The CMA Code divides secondary purposes into two categories: 1. Secondary legislated purposes are those purposes that have been subjected to the legislative test specified in the Code and have subsequently been written into law; 2. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of the CMA Code and the secondary nonlegislative test provided by the Code. The tests that the CMA Code requires of both relate to: 1. Impact on privacy. 2. Impact on the patient-physician relationship, especially confidentiality and trust. 3. Impact on the willingness of patients to disclose information. 4. Impact on patients’ ability to receive care. 5. Evidence of broad public support for the measure. 6. The use will not exploit or compromise the trust of the patient-physician relationship. 7. Patient vulnerability will not be exploited. 8. Under most circumstances patients will be fully informed of the purpose and patient consent will be clearly voluntary. 9. Patient privacy will be intruded upon to the most limited degree possible. 10. Linkage of health information will be restricted and consented to by patients. In other words, the CMA Code does not permit any and all secondary purposes for the use of health information. Rather, it requires justification for the secondary use and assurance that the secondary use will neither impede nor undermine the patient-physician relationship and the provision of health care to the patient. This test is much more privacy protective than the “reasonable person” test the Bill contains in Section 5(3). Moreover, the CMA Code only permits use without consent if it is permitted or required by legislation or when ordered or decided by a court of law. The Advisory Council Report Like the CMA, the Advisory Council Report makes distinctions among various types of uses. The Report calls for legislation to clearly prohibit all secondary commercial use of personal health information (in which respect the Advisory Council takes an even stronger position than the CMA). In addition, the Report recommends that there be provisions regulating secondary uses of non-identifiable health information and that such provisions should address privacy concerns surrounding the degree to which such data might be linked back to an identifiable individual. In this context, the Report recommends that legislation set clear limits on access to and use of health information by third parties outside the health care system. In addition the Report reviews the uses of health information for statistical and research purposes. In connection with research, the Report calls for a number of safeguards and restrictions: 1. Where the data sets used have a higher level of potential identifiability, “the general rule should be informed consent and stringent assurances about privacy protection and security arrangements are necessary before a researcher can have access to personally identifiable information.” 2. The Report recognizes that in some instances it may be impractical to obtain consent from patients. Whether in anonymous or identifiable form, the Report requires that notice be given about the use of the information. In the case of the use of identifiable information, the Report states that the research should be subject to independent ethics review with the onus on the person seeking to use the information without consent to demonstrate that: (a) a tangible public good of significant benefit will result; (b) consent is impossible to secure at a reasonable cost; (c) less identifiable data will not serve the same purpose; and (d) no harm can occur to any person directly or indirectly as a result of this use of his or her personal information. E. Disclosure Without Knowledge Or Consent Bill C-6 The comments found under C. and D. above apply equally here. Section 7(3) adds further instances when collected information can be disclosed to others without knowledge or consent. CMA Health Information Privacy Code In the case of secondary use of health information, the CMA Code takes a far more restrictive approach. As concerns use, disclosure or access, it states: The potential that health information, in whole or in part, may be subsequently collected, used, disclosed or accessed for other purposes without their consent, and what those purposes might be, must be made known to the patient by reasonable means before it is confided or collected for primary purposes. Moreover, the CMA Code recognizes that information disclosed by one organization is collected by another. The Code defines collection to mean: the act of accessing, receiving, compiling, gathering, acquiring or obtaining health information from any source, including third parties, and by any means. It includes information collected from the patient, as well as secondary collection of this information in whole or in part by another provider or user. The collecting organization should be bound by the provisions of the CMA Code, which generally requires consent for use for any purpose and always requires knowledge of the potential purposes that information will or must be put to prior to the information being disclosed. CMA’s Code states: Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Finally, the CMA Code explicitly recognizes that information can be retrieved from a variety of sources to formulate records. Any and all such practices and the composite form developed are given the same degree of protection as that accorded information collected directly from the patient. F. Consent Bill C-6 In those cases where consent for collection, use or disclosure are required, the provisions in Bill C-6 are inadequate as applied to health care. Schedule 1 distinguishes between express and implied consent. Express consent is not adequately defined and it appears that this is not equivalent to what in health care is called ‘informed consent’. For example, Principle 4.3.2. says that “organizations shall make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used”. In the health care context, the notion of ‘reasonableness’ with respect to the doctrine of informed consent applies not to the effort to advise or inform (that much is assumed or given) but rather to determinations regarding what information should be provided to the patient. In addition, the application of some of the means described in Principle 4.3.7 by which individuals can give consent, and in particular the ‘negative option’ checkoff box in (b), may be quite problematic in the health care context. The broad scope allowed to implied consent in the Bill is also worrisome as applied to the health care setting. Principle 4.3.6 says “implied consent would generally be appropriate when the information is less sensitive”. However, with implied consent the issue is not the sensitivity of the information but rather the wishes of the patient. It is appropriate to infer consent even when the information is very sensitive provided one has reason to believe this is grounded in the patients wishes; conversely, it is not appropriate to infer consent, even in the case of information deemed not to be sensitive, if there is reason to believe the patient would object if asked explicitly. CMA Health Information Privacy Code The CMA Code furnishes clear definitions for consent: “Consent” means a patient’s informed and voluntary agreement to confide or permit access to or the collection, use or disclosure of his or her health information for specific purposes. For purposes other than the provision of direct care, which is the purpose for which the patient presents in the first place, the consent must always be explicit or express since there is no logical connection between secondary purposes and the desire to achieve care. Therefore inferences cannot be made with any confidence. The Code defines express consent as follows: “Express consent” is given explicitly, either orally or in writing. Express consent is unequivocal and does not require any inference on the part of the provider seeking consent. The CMA Code defines implied consent to disallow the loose use of the term, which is increasing today, to justify access for purposes (secondary purposes in particular) that the patient may not wish to occur: Implied consent arises where agreement may reasonably be inferred from the action or inaction of the individual and there is good reason to believe that the patient has knowledge relevant to this agreement and would give express consent were it sought. The CMA Code also lays out clear rules for the use of the concept of consent and makes clear that consent can be inferred for primary purposes (i.e., the provision of health care to the patient) but not for secondary ones, which require express consent. The Code grounds the notion of implied consent not in the desire to subvert express consent and thereby gain access to information that might otherwise be denied but rather in the wishes of the patient and the importance of providing health care for therapeutic purposes as consistent with those wishes. Advisory Council Report In addition to being more stringent than Bill C-6 about exemptions to consent, the Advisory Council Report also gives greater importance to defining the term clearly and strictly. It says that any legislation concerning health information should: contain a precise definition of free and informed consent, as well as a statement of principle that informed consent should be the basis for sharing personal health information. Although not as precise and emphatic on the subject of consent as is the CMA Health Information Privacy Code, the Report is certainly more so than is Bill C-6. G. Information Flow Within Organizations Bill C-6 Bill C-54 defined use to include “the transfer of personal information within an organization.” Bill C-6 no longer defines use, which leaves it uncertain whether the definition of use quoted above from Bill C-54 would be a reasonable interpretation of Bill C-6. If so, this would create a problem. Interpreting use in this way could have the effect of inappropriately restricting the free flow of information within an organization. In the health care context this is not a reasonable or desirable outcome and would hinder, rather than promotes, the patient’s right of privacy. CMA Code The CMA Code recognizes that the free flow of health information is desirable to the extent that it furthers the provision of the health care benefit sought and that it occurs with patient consent. The Code defines the primary purpose to mean: (i) Primary therapeutic purpose is the initial reason for a patient seeking or receiving care in the therapeutic context, and pertains to the delivery of health care to a particular patient with respect to the presenting health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. (ii) Primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to the presenting health need or problem, in order to enhance ongoing care to that person. The Code goes on to state that: Health information collection, use, disclosure or access for the primary therapeutic and longitudinal purposes may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context. And further states that: Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. Finally, in addressing consent the Code states: Consent to health information collection, use, disclosure and access for the primary therapeutic purpose may be inferred. Consent to subsequent collection, use, disclosure and access on a need-to-know basis by or to other physicians or health providers for this purpose, and for this purpose alone, may be inferred, as long as there is no evidence that the patient would not give express consent to share the information. The principles in the CMA Code that give effect to the patient’s right to control what happens to his or her information are not incompatible with the free flow of information among members of a health team for the purpose of providing care to the patient. Indeed, they facilitate and enable this flow to the extent this is in keeping with the patient’s wishes. H. Information Protected Bill C-6 The Bill covers “personal information” which is defined to mean “information about an identifiable individual, but does not include the name, title or business address or telephone number of an employee of an oganization.” This definition raises a host of questions: 1. Does the Bill cover information that has been delinked to an identifiable individual but that could be relinked to identify them? 2. Does the Bill only exclude anonymous information - that is, information that could never be relinked to an identifiable individual? And if so, is there an unjustified assumption that information can, in all cases, be rendered truly anonymous? 3. In the case of delinked and anonymous information, who decides that information about an identifiable individual can be rendered delinked or anonymous? The holder of the information or the person to whom the information pertains? 4. Is it accurate or reasonable to assume that people have no interest in information emanating from them once it has been rendered delinked or anonymous? 5. Given that anonymous information is generated from personal information, is the act or process rendering personal information into anonymous form considered a use under the terms of the Bill, and if so does this use require consent? In considering these questions, it is important to keep in mind that the concept of “anonymity” means different things to different people. Moreover, there are no generally used or accepted standards that address what is required to render identifiable information truly anonymous. As a consequence, different people use different standards (of varying degrees of rigour), if they use a standard at all. It is also important to note that, in virtue of sophisticated techniques for identifying individuals from supposedly anonymous information, there is debate about the extent to which true anonymity can ever be achieved or guaranteed. CMA Health Information Privacy Code In light of issues concerning the definition of ‘personal information’ and in the interest of ensuring a thorough scrutiny of information practices, the CMA Code provides a broad definition of health information: Health information means any information about a patient that is confided or collected in the therapeutic context, including information created or generated from this information and information that is not directly or indirectly linked to the provision of health care. It includes all information formats. The CMA Code covers identifiable information, delinked information, anonymous information and any composite form that is produced when health information is linked to other information about the patient. CMA’s research indicates that patients have an interest in their information even when it is in delinked and in anonymous formats. This view has recently received support from a decision of the High Court of Justice in England that is particularly relevant in the context of the commercial use of health information (Source Informatics Ltd. v. Department of Health). The issue arose because a prescription database company sought judicial review of a Department of Health policy document that advised National Health Service GPs and pharmacists not to sell “anonymous” prescribing or dispensing information. The document contained the following analysis: Anonymisation (with or without aggregation) does not, in our view, remove the duty of confidence towards the patients who are the subject of the data. Apart from the risk of identification of a patient despite anonymisation, the patient would not have entrusted the information to the GP or the pharmacist for it to be provided to the data company. The patient would not be aware of or have consented to the information being given to the data company, but would have given it to be used in connection with his care and treatment and wider NHS purposes. Anonymisation of the data (with or without aggregation) would not obviate a breach of confidence. . . .The duty of confidence may in some circumstances be outweighed by the public interest in disclosure. However we have severe reservations that disclosure by GPs or NHS pharmacists of dispensing information to X or other data companies would be argued to be in the public interest. Indeed it might well be contrary to the public interest if the data company is further selling the information on doctors prescribing habits to the pharmaceutical industry. High Court Justice Latham upheld the policy document, arguing that the information in question, though anonymous, was nonetheless confidential. He also argued that consent to its release was necessary and could not be implied, and that the breach of confidentiality involved in selling this information could not be justified as being in the public interest: In my view, it is impossible to escape the logic . . . that the proposal involves the unauthorised use by the pharmacist of confidential information. . . . In my judgement what is proposed will result in a clear breach of confidence unless the patient gives consent, which is not part of the proposal at present. Nor is it suggested that the patient can be said to have given implied consent. . . . I recognize that, for some, the sensitivity, as they see would see it, of the information may be such that they would feel that any use of the information without their consent, would be unconscionable. In other words it would be a breach of trust which they were reposing in the pharmacist. . . I have come to the conclusion that . . . this [is] a type of situation . . . in which there is a public interest in ensuring that confidences are kept. It is important that those who require medical assistance should not be inhibited in any way from seeking or obtaining. As I have indicated, I believe that there may be some patients who will feel very strongly that the pharmacist should not give any information obtained from the prescription without their consent. In view of the fact that there is a growing industry in so-called anonymous health information, it is important to ensure that this information is protected as consistent with the duties of health care providers and the expectation patients have that their providers will keep their information confidential. Advisory Council Report The Advisory Council Report addresses this issue in a number of ways. In making recommendations concerning the definition of health information, the Report calls for legislation that embodies: a clear definition of health information, broad enough to incorporate health information collected in public and private systems and to ensure that equal obligations and penalties apply to both public and private sectors. The Report recognizes a spectrum of data formats: completely anonymous, linked to pseudo-identities, code linked and reidentifiable, completely identifiable. In terms of sensitivity, the Report notes that information that can be re-identified is somewhat more sensitive than completely anonymous data or anonymous data linked to pseudo-identities and that completely identifiable health information is the most sensitive type of health information. The Report also notes that there can be some degree of risk of re-identification of what was believed to be anonymous data through such processes as data matching and the results of analysis using small cells. In this light, the Report recommends that legislation should recognize: A definition of personal health information, which takes into account the spectrum of potential identifiability in the case of health information. Furthermore, in the case of secondary uses of health information, the Report notes that provisions regulating secondary uses of non-identifiable health information must form part of any comprehensive legislation. Such provisions should address privacy concerns surrounding the degree to which data might be linked back to an identifiable individual. The Report raises further issues relating to the use of delinked and anonymous data. The Report notes that there may be group interests and concerns regarding data collected and states: Privacy can also be a concern for groups such as Aboriginal and immigrant communities. These communities worry that research on their members could be released to the media without notice and used in a negative way. This emerging issue is growing in importance and, in the Council’s view, should be a serious consideration in the context of ethical reviews of proposed research projects. It is important to note that, in these instances, it is not the fact that data is linked to an identifiable individual that is of concern. Rather, it is the ability to accumulate, process and dissect information that has ramifications for an individual because they are part of a group segregated and identified by the research. Finally, the Report considers the use of person-oriented data (data linked to individuals in a form where personal identifiers have been replaced by a code) for statistical purposes and notes that this too raises concerns about privacy. The Report notes that: “These concerns have traditionally been seen as a tradeoff against data access for research and analysis in the public interest.” The Report restates this to provide a more positive view of privacy and states: the best way for analysts to maintain the public’s consent to use sensitive (but anonymous) health data is to show the public that privacy, confidentiality and security are being taken seriously. In view of the issues concerning the definition of personal information and in the interest of ensuring maximum scrutiny of practices concerning health information and maximum protection of the right of privacy with respect to health information, CMA recommends: That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite information produced when health information is linked to any information about a person from any other source. I. Individual Access Bill C-6 Bill C-6 restricts the right of individual access to personal information. The grounds for denying access to information are inappropriate in the health care context. CMA Code The CMA Code follows the prevailing case law as it relates to medical records. Primarily this gives patients a right of access to their record in all but very limited circumstances. These circumstances are when there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus lies on the provider to justify denial of access on these grounds. J. Accuracy and Amendment Bill C-6 Bill C-6 requires that information be as accurate, complete and up-to-date as possible and that it shall not be routinely updated unless this is necessary to fulfil the purpose for its collection. In so far as amendment is concerned, Bill C-6 permits amendment to the record in specified circumstances. CMA Code The CMA Code takes a different approach in light of the nature and purpose of health information. The Code recognizes that the recording of statements of fact, clinical judgements and determinations or assessments should reflect as nearly as possible what has been confided by the patient and what has been ascertained, hypothesized or determined to be true using professional judgement. In terms of amending the record in light of a patient’s request, the CMA Code seeks to preserve the original record but also provide for noting the patient’s concerns. To accommodate both requirements the CMA Code states: Patients who have reviewed their information and believe it to be inaccurately recorded or false have the right to suggest amendments and to have their amendments appended to the health information. K. Sensitivity Bill C-6 Schedule 1 recognizes that medical records have a high level of sensitivity attached. For this reason this information may warrant special attention concerning consent, reasonable expectations, individual access and the degree of security that is appropriate. CMA Code The CMA Code recognizes that, even as all health information is sensitive (when considered against other forms of information about individuals), there are also variations in the level of sensitivity in various aspects of the health record. The CMA Code defines the “sensitivity of health information” to refer to: the patient’s interest in keeping the information secret. It varies according to the nature of the information, its form, and the potential negative repercussions of its collection, use or disclosure on the patient’s interests. Under the Code’s consent provisions it is stated that: Although all health information is sensitive and should be treated as such, the more sensitive the health information is likely to be, given what is known about the circumstances or preferences of the patient, the more important it is to ensure that consent is voluntary and informed. With respect to security the Code states: The development of security safeguards with respect to levels of access for various users shall recognize the differences in the sensitivity of health information and permit access accordingly. Moreover, the Code recognizes that health information is special and therefore requires distinct rules that afford stronger privacy protection not just due to its sensitivity but also to the circumstances of vulnerability and trust under which it is initially confided or collected. These special circumstnaces, which include much more than sensitivity, are outlined in Principle 2 of the Code. Bill C-6, by contrast, fails to consider these other features that make health information a special case. In consequence its provisions are not adquately tailored to the special nature of health information and do not accord it the strong privacy protection it warrants. V. Conclusions The increased capacity to collect, store, transfer, merge and access information, coupled with trends that support increased use of and access to information, have the potential to erode our traditional understanding and protection of privacy and confidentiality. The issues are complex and the choices we must make are difficult. Nevertheless, these issues should be squarely on the table and the choices that we make must be clear, transparent and defensible. Of paramount importance is that the public is not mislead into believing that their information is being protected or kept confidential when in fact it is not. Therefore, even to refer to Bill C-6 as the “Personal Information Protection and Electronic Documents Act” should be the subject of debate. Is the Bill truly about information protection or is it actually about permitting access to information? The approach to rules for information in Bill C-6 is directed toward commerce and appears to have access, and not privacy, as its dominant value, notwithstanding the Bill’s reference to a “right of privacy”. In CMA’s view, the Bill’s approach is inadequate when applied to health information. Based on the evidence, it seems highly likely that the public would also find Bill C-6 inadequate. Bill C-6 was not developed with health information in mind. In consequence there is confusion and uncertainty about its application to the health care context. Even more seriously, however, Bill C-6 fails to recognize that privacy with respect to health information requires stronger or greater protection than other types of information. CMA presents a different approach, an approach that recognizes the special nature of health information; an approach that puts patients first and values privacy and the preservation of the trust and integrity of the patient-physician relationship. This approach appears to be well-grounded in the values that Canadians hold about privacy and would likely enjoy broad public support. In addition, the CMA approach draws support from the Federal Advisory Council Report, which like CMA recognizes the importance of preserving patient privacy and the confidentiality of the health record in an era of increased use of technology. Implicitly, the Report recognizes that the benefits of such technology cannot be realized if public support, based on respect for privacy, cannot be secured. The CMA’s Health Information Privacy Code does what Bill C-6 fails to do. Amending Bill C-6 to incorporate the principles in the CMA Code would ensure adequate privacy protection. In light of the clear deficits in Bill C-6 and the inadequate protection of patient privacy and health information confidentiality, CMA urges this Committee to accept its recommendations and the amendment that incorporates them. Nothing less would give Canadians the high level of privacy protection they desire and deserve when it comes to their health information. VI. Summary of Recommendations That Bill C-6 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Health Information Privacy Code provide the basis of such provisions; and That any proposed rules for health legislation be subject to the legislative test found in CMA’s Health Information Privacy Code and formulated in light of this process; and That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite information produced when health information is linked to any other information about a person from any other source; and That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. CMA has drafted an amendment to Bill C-6 (Appendix B) which, if accepted, would achieve all of these recommendations and adequately give Canadians the kind of privacy protection with respect to their health information that they deserve and desire.
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Listening to our Patient's Concerns : Comments on Bill C 54 (Personal Information Protection and Electronic Document Act) : Submission to the House of Commons Standing Committee on Industry

https://policybase.cma.ca/en/permalink/policy1980
Last Reviewed
2019-03-03
Date
1999-03-18
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1999-03-18
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
Text
Over the last year, CMA has become increasingly concerned that debate on the issues concerning health information have been framed in terms of access to information with an attendant erosion of privacy and confidentiality. This one-sided approach comes at a time of expansion in our capacity to collect, store, merge, transfer and access information, coupled with trends both in the health care sector and generally related to the use of information To address these concerns and to ensure that privacy and confidentiality in the medical context are valued, protected and preserved, CMA developed and adopted a Health Information Privacy Code. This Code should form the basis of all legislation governing the collection, use and disclosure of health information. Health information is special by its nature. Rules relating to health information must be developed in recognition of its special nature. Ensuring protection of privacy and confidentiality of the patient record must take precedence over other considerations. Bill C-54 fails to do this. Bill C-54 is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. CMA considers the world of health care to be very different from that of commerce and consequently requiring distinct rules. Health information use must, in all but exceptional and justifiable circumstances, occur only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Bill C-54 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The evident lack of protection accorded health information based on such ground, is unacceptable. The absence of protection undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. Moreover, distinctions must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Not all purposes for the collection and use of health information are equal. Collection and use beyond the therapeutic context should be subjected to rigorous scrutiny before they are permitted to occur. Bill C-54 fails to make such a distinction and treats all purposes that could be identified for information collection or use as equal. Moreover, the Bill has no mechanism to distinguish legitimate purposes, which should be permitted from illegitimate purposes, which should not. In light of the clear deficits in Bill C-54 and the inadequate protection of patient privacy and health information confidentiality, CMA makes the following recommendations: That Bill C-54 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Code provide the basis of such provisions; and That the proposed rules for health legislation be subject to the legislative test found in CMA’s Code and formulated in light of this process; and That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite form produced when information is linked to any information about a person from any other source; and That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. I. Introduction The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including addressing the emerging issue of electronic health information and confidentiality and privacy. It is in this capacity that we present our position on Bill C 54, The Personal Information Protection and Electronic Documents Act. CMA commends the government for taking the first, important step of beginning the debate on the protection of personal information. The issues are complex and the interests at stake significant. CMA welcomes the opportunity to provide comments on Bill C-54. CMA hopes that its input will strengthen the Bill by ensuring that patient privacy and the confidentiality of medical records are adequately protected. In preparing this brief CMA has had the benefit of the final report of the federal Advisory Council on Health Infostructure, Canada Health Infoway: Paths to Better Health: Final Report. (“Advisory Council Report”) Where appropriate, CMA cites the findings contained in the report. CMA wishes to underscore the key themes of its brief: A. Health information is special by its nature. Rules relating to health information must be developed in recognition of its special nature. Ensuring protection of privacy and confidentiality of the patient record must take precedence over other considerations. Bill C-54 fails to do this. Bill C-54 is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. CMA considers the world of health care to be very different from that of commerce and consequently requiring distinct rules. B. Health information use must, in all but exceptional and justifiable circumstances, occur only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Bill C-54 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The evident lack of protection accorded health information based on such ground, is unacceptable. The absence of protection undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. Moreover, distinctions must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. C. Not all purposes for the collection and use of health information are equal. Collection and use beyond the therapeutic context should be subjected to rigorous scrutiny before they are permitted to occur. Bill C-54 fails to make such a distinction and treats all purposes that could be identified for information collection or use as equal. Moreover, the Bill has no mechanism to distinguish legitimate purposes, which should be permitted from illegitimate purposes, which should not. This brief will first look at the apparent rationale of Bill C-54 and its potential application to health information. The brief will next describe why CMA considers health information to be special in nature and worthy of special protection. Finally, the brief reviews the difference in approach between Bill C-54 and CMA’s Health Information Privacy Code to illustrate that Bill C-54 provides inadequate protection to patient privacy and health record confidentiality. II. Rationale and Scope of Bill C-54 A. Rational of Bill C-54 The driving force behind Bill C-54 is the support and promotion of electronic commerce. The second part of the Bill is devoted to permitting electronic versions of documents and signatures to be legitimate or ‘originals’ if the provisions of the Act are followed. Part two of the Bill is quite distinct from part one and both parts could stand alone as separate pieces of legislation. Part two simply allows electronic versions of documents and signatures to be recognized as legitimate. On its face, this has little to do with the protection of personal information except to the extent that storage of documents in electronic form provides greater ability to access, link and merge information. Certainly, the Bill appears to draw on this connection by including, in its statement of purpose, the provision of a right of privacy in an era in which technology increasingly facilitates the collection and free flow of information. Part one concerns all forms of information, electronic and otherwise. It gives some protection to personal information by requiring consent in some instances. In CMA’s view, a fundamental difficulty with part one and the Bill in general is that it’s goal is to promote commerce and thus all information is implicitly considered as falling within the ‘commercial’ realm. In the case of health information this is surely not the case or the only consideration. Moreover, this creates a clash of values when applied to a health care system that is a public system. The Advisory Council Report takes a hard line on this issue and states that legislation respecting the privacy protection of health information, “should also contain a clear prohibition against all secondary commercial use of personal health information.” Because all information is subjected to similar rules, there is no attempt within the Bill to distinguish some purposes for collecting information from other purposes. The Bill takes the approach that the purposes should be known and documented. While not stated explicitly, the assumption is that all purposes identified are legitimate and are permitted. CMA has quite a different view when it comes to health information and will expound its view throughout this brief. B. Scope - Application to Medical Records CMA is uncertain whether or to what extent Bill C-54 will apply to health records. The full name of the Act states, in part: An Act to support and promote electronic commerce by protecting personal information that is collected, used or disclosed in certain circumstances.... What are these circumstances? Section 4(1) states that Part 1 (the part protecting personal information) applies in respect of personal information that: (a) the organization collects, uses or discloses in the course of commercial activities; (b) the organization collects, uses or discloses interprovincially or internationally; or (c) is about an employee of the organization and that the organization collects, uses or discloses in connection with the operation of a federal work, undertaking or business. It should further be noted that three years after the Act is in force it will apply equally to activities that occur strictly within the province unless there is legislation in the province that is substantially similar to the Bill (see sections 27(2)(d) and section 30). The first issue is the provision of section 4(1)(a) - collection, use and disclosure in the course of commercial activities. There seems to be an assumption on the part of government that this automatically excludes health records, (although the Act fails to define what is meant by commercial activity). Is this accurate or does the assumption fail to recognize that there is not a clear, unambiguous distinction between what might constitute commercial activity or other activity? There are two points to be made here. The first concerns clarity around where commercial ends and health care begins. Which health care settings that operate for profit are excluded from the Act? This question speaks to the difficulty of delineating what activity is considered health care and what activity is considered commercial. Moreover it recognizes that the increased encouragement to public/private funding of endeavours within the health care sector may make it increasingly difficult to make this distinction; for example in the area of research. The second concerns the movement of health information from the health care setting (recognizing that this is not easily distinguished from the commercial setting) to the commercial setting; for example, health information provided to insurance companies. When health care information is collected in a health care setting and transferred to a commercial setting, which rules apply - Bill C-54 or no rules? In CMA’s view, there is no clear way of distinguishing commercial activity from health care activity in a way that ensures that the health care record is subject to different rules than those pertaining to other records. Moreover, the dilemma for government is that even if such distinction could occur, would it be desirable that health records be subject to no rules? Put in another way, will those organizations that currently collect health care information be entitled to claim that since the information forms part of the health record they are not subject to the provisions of C-54? Under such a regime health care records would be subject to an even lower standard than that provided for information collected in the commercial context. In terms of the provisions of 4(1)(b) - interprovincial and international transfer of information. This appears to apply to all information. In the existing environment and developments such as the “health information highway,” interprovincial transfers of information, the capacity for the central collection and storage of information, mechanisms such as telephone and cable to transfer information and general trends related to population health, it seems likely that interprovincial traffic will grow rather than diminish. The significance of this section, therefore, cannot be underestimated. Finally, the provisions of 4(1)(c) may well contain health information about the employee. In preparing this brief CMA has assumed that the Bill will provide a scheme that applies to some health information. No doubt the extent of the federal governments ability to legislate in this area generally will be the subject of extensive debate. However, CMA has no comment on this debate and provides its opinion in the interests of ensuring that the rules that relate to health information are compatible with preserving the integrity of the patient-physician relationship and the protection of patient privacy and health information confidentiality. CMA considers that the government has an opportunity to provide Canadians with strong privacy rights in health information. Indeed, CMA believes that it is incumbent upon the government to do so. C. Scope - Government Excluded Bill C-54 expressly excludes a large part of government activity from its ambit. While government activity is to some extent governed by the Privacy Act, R.S.C. 1985, P-21, the rules of this act provide less protection than those of Bill C-54. Government should subject itself to at least the same rules that it requires of the private sector in so far as it is a collector and user of information. Moreover, CMA is of the view that government’s practices relating to the collection, storage, merging, transfer and use of health information must be subject to more stringent rules than those found in either the Privacy Act or Bill C-54. The Advisory Council Report also calls for the same rules to apply to the public and private sectors, rules that are more stringent than those found in the Privacy Act or Bill C-54. Therefore, CMA recommends: That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. III. Considerations Regarding Patient Privacy and Confidentiality: Medical Context Versus Commercial Context A. CMA’s Opinion Over the last year, CMA has become increasingly concerned that debate on the issues concerning health information have been framed in terms of access to information with an attendant erosion of privacy and confidentiality. This one-sided approach comes at a time of expansion in our capacity to collect, store, merge, transfer and access information, coupled with trends both in the health care sector and generally related to the use of information To address these concerns and to ensure that privacy and confidentiality in the medical context are valued, protected and preserved, CMA developed and adopted a Health Information Privacy Code, which is appended to and forms part of this brief. In commenting on this Code the Advisory Council Report notes: The code represents an important contribution to the deliberations of Canadians and legislators on how to safeguard privacy across the health domain. There are a number of principles underpinning the Health Information Privacy Code: 1. The provision of health care to all Canadians irrespective of social circumstances or health status is a highly regarded value in Canadian society. The system is publicly funded and universally accessible. 2. The right of privacy is fundamental to a free and democratic society. 3. Rules relating to health information must recognize its special nature. Health information has a high level of sensitivity, it is confided or collected in circumstances of vulnerability and trust for the primary purpose of benefiting the patient. 4. Physicians now and historically promise that they will keep their patients’ information secret; this is a hallmark of the profession. 5. The patient-physician relationship is one of trust and a central feature of this trust is the belief in patients that information confided in or collected by physicians and other health care providers will be kept secret. 6. Patients believe that the information they disclose or that is gathered as a result of their seeking health care will be used to provide them with health care; uses beyond the provision of health care without knowledge or consent go beyond what a patient’s reasonable expectations were when information was disclosed or gathered and is a breach of the trust patients place in their physicians. 7. Except in very limited circumstances, consent is required for health information collection, use, disclosure or access for any purpose. 8. Information required to provide patients with the health care sought should be readily available to those who require it to provide an aspect of care. 9. Uses of health information for purposes other than the provision of health care to the person seeking care should be subject to rules that: - protect and promote privacy and confidentiality; - generally require express consent; - can be justified according to specific criteria. 10. Patients should know the uses to which their health information is put prior to their disclosure of it. 11. Patients may be reluctant to disclose information if they are concerned about the uses to which the information is put or the persons entitled to access it. B. Public Opinion To determine the public’s view on these issues, CMA commissioned Angus Reid to conduct research in two forms, quantative (survey) and qualitative (focus groups), and has found the following: 1. Patients believe that their health information will be kept confidential and consider this to be important. 2. Patients believe it important to know and control how their health information is shared with others. 3. Patients do not want their health information released to third parties (including governments and researchers) without their knowledge and consent. 4. Patients may have concerns about the release of delinked or anonymous information to third parties without their consent. 5. Patients may be reluctant to confide information as a result of concerns related to its use or disclosure. These findings are consistent with general findings relating to the public’s concerns about privacy and confidentiality. C. The Advisory Council Report The Advisory Council Report relates to the electronic health record. However, given the direction towards the greater use of technology and the underlying principles informing the Advisory Council, CMA believes that the recommendations are generalizable to all health information. A key principle of the Advisory Council is that access by health care professionals should be based on a need-to-know basis under the strict control of the patient. The Council, like CMA calls for scrutiny and justification of secondary uses of health information. The Council is opposed to the use of multipurpose identifiers on the grounds that it becomes too easy for government officials from one department to gain access to a person’s health record or combine a number of records to assemble a comprehensive profile. (Anecdotal evidence suggests that this concern may be justified and that there are insufficient safeguards preventing the flow of health information among government departments) The Council recommends that all governments ensure that they have legislation to address privacy protection specifically aimed at protecting personal health information through explicit and transparent mechanisms. Included in these mechanisms are: * The provision of a precise definition of free and informed consent, as well as a statement of principle that informed consent should be the basis for sharing personal health information; * Any exemption to the requirement of informed consent should be clearly set out in law. More specifically, legislative guidance should be provided on how to balance the right of privacy with the public good for research purposes to implement a coherent and harmonized pan-Canadian system for independent, ethical review. * There should be provisions regulating secondary uses of non-identifiable health information. These provisions should address privacy concern surrounding the degree to which data might be linked back to an identifiable individual. * Legislation should set clear limits on access to and use of health information by third parties outside the health care system. To prevent the serious invasions of privacy that can result from the unrestricted linking of personal health information with other kinds of information on the same individual, the legislation should contain provisions prohibiting the use for any other purpose of unique personal identifiers in health information systems. D. The Approach in Bill C-54 Bill C-54 is inadequate in its protection of health information. The Bill makes a meagre attempt at distinguishing among varying types of personal information and gives no additional protection to information that is highly sensitive (such as health information). The Bill permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purposes. In the context of health information, these grounds should be subject to intense scrutiny to determine their relevance and legitimacy. In CMA’s view and according to the tests established in the CMA’s Code, some of these grounds would not withstand such scrutiny. E. Conclusion CMA’s Code offers a template for the protection that should be accorded health information, a template that appears to have some public support and that strives to retain patient confidence in their physicians and the health care system. The Report of the Federal Advisory Council also recognizes that special rules are required for health information. The Council’s Report places strong emphasis on the protection of privacy, recognizes that as a general rule the flow of health information should be on a need-to-know basis and under the control of the patient through the exercise of free and informed consent and requires limits on the secondary use of health information. In CMA’s view, Bill C-54 should incorporate specific rules relating to health information and CMA’s Code should form the basis of these rules. CMA recommends: That Bill C-54 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Code provide the basis of such provisions. In addition, CMA’s Code provides a test that legislation addressing health information should be subjected to. This test (found in section 3.6 of the CMA Code) states: Any proposed or existing legislation or regulation made under legislative authority that permits or requires health information collection, use, disclosure or access shall be subjected to the following legislative test: (a) There must be demonstration that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public and has been duly considered prior to the introduction of legislation [section 3.5 of the Code provides guidance with respect to the patient privacy impact assessment]; (ii) collection, use, disclosure and access will be limited to the greatest degree possible to ensure that * the collection of health information by persons external to the therapeutic context will neither trade on nor compromise the trust of the patient-physician relationship; * patients are not likely to be inhibited from confiding information for primary purposes; * the ability of physicians to discharge their fiduciary duties to patients will not be compromised; and, * patient vulnerability will not be exploited; (iii) collection, use, disclosure and access will be restricted to what is necessary for the identified purpose(s) and will not impede the confiding or collection of information for primary purposes; (iv) provisions exist for ensuring that patients are provided with knowledge about the purpose(s) and that, subject to 3.6(b), patient consent is clearly voluntary; (v) the means used are proportionate and the collection will be limited to purposes consented to or made known to the patient; (vi) the patient’s privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to or made known to the patient; (vii) linkage of the health information will be limited; and (viii) unless clear and compelling reasons exist: * all reasonable steps will be taken to make health information anonymous; and * if it has been demonstrated that making health information anonymous would render it inadequate for legitimate uses, the information will be collected and stored in a deidentified-relinkable format. (b) When nonconsensual collection, use, disclosure or access is permitted or required by legislation or regulation that meets the requirements of the Code, the following conditions must also be met: (i) the right of privacy has to be violated because the purpose(s) could not be met adequately if patient consent is required; and (ii) the importance of the purpose(s) must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. (c) Any legislative provision or regulation that permits or requires health information collection, use, disclosure or access nonconsensually shall not, without compelling reasons, be applied retroactively to existing health information. In its current form, Bill C-54 would not pass the scrutiny of the test. Consequently, CMA recommends: That the proposed rules for health legislation be subject to the legislative test found in CMA’s Code and formulated in light of this process. IV. Specific Comments on Bill C-54 From the Perspective of CMA’s Health Information Privacy Code This section highlights some key distinctions between the approach taken by Bill C-54 and CMA’s Health Information Privacy Code. The purpose of this section is to illustrate through examples the divergence of approaches taken with the ultimate aim of demonstrating that Bill C-54 is inadequate in the protection it accords health information. A. General Bill C-54 and CMA’s Health Information Privacy Code are based on the Canadian Standards Association’s Model Code for the Protection of Personal Information (CSA Code). Bill C-54 and the CMA Code also augment the CSA Code’s provisions where considered necessary. The need to extend the provisions of the CSA Code demonstrates that the CSA Code, being general in nature, provides inadequate protection to information in many instances. Although Bill C-54 and the CMA Code are based on the CSA Code, each takes a different approach to the ultimate protection accorded information. This divergence demonstrates that there are many ways to resolve issues left unresolved by the CSA Code. In other words, it is not a foregone conclusion that basing provisions on the CSA Code will result in appropriate or adequate protection of information. Rather, resolution of issues requires thought and deliberation and will depend in some measure on the primacy given to certain values. Bill C-54 appears to have given access primacy in the pursuit of commerce, whereas CMA gives privacy protection primacy in the pursuit of the provision of health care in accordance with physicians fiduciary obligations to patients and the integrity of the patient-physical relationship. CMA did not develop its approach in a vacuum. It reviewed and was inspired by the report of the House of Commons Standing Committee on Human Rights and the Status of Persons with Disabilities, entitled Privacy: Where Do We Draw the Line? This report articulates and makes explicit many of the issues that should be informing the current debate on Bill C-54. In addition, the Report of the Advisory Council takes a very different approach to Bill C-54. The Report recognizes the need to pay more than lip service to protecting privacy and confidentiality and recommends specific measures aimed at doing this. B. Information Protected Bill C-54 The Bill covers “personal information” which is defined to mean “information about an identifiable individual that is recorded in any form.” This definition raises a host of questions: 1. Does the Bill cover or not information that has been delinked to an identifiable individual but that could be relinked to identify them? 2. Does the Bill only exclude anonymous information - that is, information that could never be relinked to an indentifiable individual? And if so, is there an unjustified assumption that information can, in all cases, be rendered truly anonymous? 3. In the case of delinked and anonymous information, who decides that information about an identifiable individual can be rendered delinked or anonymous? The holder of the information or the person to whom the information pertains? 4. Is it accurate or reasonable to assume that people have no interest in information emanating from them once it has been rendered delinked or anonymous? CMA Health Information Privacy Code The CMA Code provides a broad definition of health information: Health information means any information about a patient that is confided or collected in the therapeutic context, including information created or generated from this information and information that is not directly or indirectly linked to the provision of health care. It includes all information formats. In addition, the CMA Code covers identifiable information, delinked information, anonymous information and any composite form that is produced when health information is linked to other information about the patient. CMA’s research indicates that patients may have an interest in their information when it is in delinked and anonymous formats. Advisory Council Report The Advisory Council Report addresses this issue in a number of ways. In making recommendations concerning the definition of health information the Report calls for legislation that embodies: a clear definition of health information, broad enough to incorporate health information collected in public and private systems and to ensure that equal obligations and penalties apply to both public and private sectors. The report recognizes a spectrum of data formats: completely anonymous, linked to pseudo-identities, code linked and reidentifiable, completely identifiable. In terms of sensitivity, the Report notes that information that can be re-identified is somewhat more sensitive that completely anonymous data or anonymous data linked to pseudo-identities and that completely identifiable health information is the most sensitive type of health information. The Report also notes that there can be some degree of risk of re-identification of what was believed to be anonymous data through such processes as data matching and the results of analysis using small cells. In this light, the Report recommends: A definition of personal health information, which takes into account the spectrum of potential identifiability in the case of health information. Furthermore, in the case of secondary uses of health information, the Report notes that provisions regulating secondary uses of non-identifiable health information must form part of the legislation. Such provisions should address privacy concerns surrounding the degree to which data might be linked back to an identifiable individual. The Report raises further issues relating to the use of delinked and anonymous data. The Report notes that there may be group interests and concerns regarding data collected and states: Privacy can also be a concern for groups such as Aboriginal and immigrant communities. These communities worry that research on their members could be released to the media without notice and used in a negative way. This emerging issue is growing in importance and, in the Council’s view, should be a serious consideration in the context of ethical reviews of proposed research projects. It is important to note that in these instances it is not the fact that data is linked to an identifiable individual that is of concern. Rather, it is the ability to accumulate, process and dissect information that has ramifications for an individual because they are part of a group segregated and identified by the research. Finally, the Report considers the use of person-based data but not people’s names, for statistical purposes and notes that this too raises concerns about privacy. The Report notes that: “These concerns have traditionally been seen as a tradeoff against data access for research and analysis in the public interest.” The Report restates this to provide a more positive view of privacy and states: “the best way for analysts to maintain the public’s consent to use sensitive (but anonymous) health data is to show the public that privacy, confidentiality and security are being taken seriously.” Recommendation That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite form produced when information is linked to any information about a person from any other source. C. Knowledge of Purpose Prior to Collection Bill C-54 Bill C-54 is ambiguous in its provisions relating to whether or not a person should know the purposes for which information will be used prior to disclosure. This is due in part to the use of the term “knowledge and consent” as one concept rather than distinguishing the knowledge requirement from the consent requirement. What a person should know in relation to the purposes information might be used or disclosed for, prior to its being given is distinct conceptually from whether the person must consent before information can be used or disclosed for a particular purpose. Schedule 1 of the Bill contains a number of principles. For the purposes of this brief the schedule will be referred to in terms of the principles (and their subparagraphs). Principle 2 addresses the identification of purposes that information will be used or disclosed for. Provided a purpose is identified it becomes a legitimate purpose under the Bill. Subparagraph 3 states that the identified purposes should be specified at or before the time of collection. Section 5(2) of the Bill states that the use of ‘should’ in schedule 1 indicates a recommendation and does not impose an obligation. Therefore, according to subparagraph 3, it is recommended but is not obligatory that disclosure occur. On the other hand, principle 3 addresses consent and appears to impose an obligation by stating that the knowledge and consent of the individual are required for the collection, use, or disclosure of personal information, except where inappropriate. Similarly subparagraph 2 appears to create something of an obligation by stating, “organizations shall make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used.” The relationship between these sections should be clarified and made consistent. CMA is pleased to note that principle 3 has been modified to define when, and only when, organizations may collect information without knowledge or consent. Section 7(1)(a) permits the collection of information without knowledge and consent when collection is clearly in the interests of the individual and consent cannot be obtained. The intent of this section could be made clearer, particularly in terms of who determines the “interests of the individual.” Otherwise this exception could give undesirable license to collect without knowledge or consent. The provision in section 7(1)(b) is more problematic. This section appears to favour withholding knowledge from an individual if such knowledge would compromise accuracy, defeat the purpose for collection or prejudice the use. In some instances it may well be that if an individual is provided with knowledge of the purposes for which information is collected and the uses to which it will be put, they may choose to withhold information rather than disclose it, and in doing so would clearly compromise accuracy, defeat the purpose for collection or prejudice the use the information will be put to. This is contrary to the principle found in principle 4.1 which recognizes that information should not be collected by misleading or deceiving individuals. The intent of this section should be far clearer and circumscribed in such a way as to make it clear that it is not permissible to withhold knowledge or not seek consent simply on the basis that if a person had knowledge they would not wish to disclose information. Section 7(1)(c) allows collection without knowledge or consent for journalistic, artistic or literary purposes. This provision is totally inappropriate in the case of health information. CMA Health Information Privacy Code The CMA Code is considerably more restrictive that Bill C-54. It recognizes that in the therapeutic context, health information is confided by or collected from patients under the patient presumption that it is necessary to meet his or her therapeutic needs. CMA also believes that the potential that health information may be subsequently collected, used, disclosed or accessed for other purposes without patient consent should be made known to patients before information is confided or collected for the primary therapeutic purpose. CMA further notes that it is not acceptable to withhold knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. CMA limits the circumstances the nonconsensual collection of health information to those: 1. Permitted or required by legislation; 2. When ordered or decided by a court of law. Moreover, the CMA gives explicit direction to legislators with respect to the conditions under which legislation should permit or require health information collection (see section 3.6 of CMA Code). In the case of nonconsensual collection, the following conditions are stipulated: 1. The right of privacy has to be violated because the purposes could not be met adequately if patient consent is required; and 2. The importance of the purposes must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. While Bill C-54 is clearly enabling the collection of information, it does not, in CMA’s opinion put sufficient emphasis on or provide protections that preserve privacy and confidentiality, especially in the medical context. D. Use Without Knowledge Or Consent Bill C-54 Once information has been collected and despite the, albeit inadequate, limits placed on collection without knowledge or consent, it can be put to even greater use than the purposes it has been collected for with or without knowledge or consent. Section 7(2) opens up dramatically the uses to which collected information may be put without either knowledge or consent. At a minimum and without little additional administrative effort, the enumerated grounds of section 7(2) (and 7(3))should be made known to an individual prior to their disclosure of information, which would be in keeping with the principle of openness and explicitness. Section 7(2)(a) allows use in connection with the investigation of an offence. In the medical context this might be problematic particularly if it is interpreted to impose an obligation. Generally, there is no obligation to assist in the investigation of an offence and indeed the fiduciary duty between patient and physician and the duty of confidentiality owed to the patient by the physician would suggest that physicians not offer information despite its usefulness. Section 7(2)(b) recognizes emergency situations. However, as worded, section 7(2)(b) would allow access to anyone’s information if it is for the purpose of acting in respect of an emergency threatening the life, health or security of an individual. The implications of this section should be carefully thought through. Do we really intend to give such a broad licence to access anyone’s information on the basis of an emergency. In CMA’s view there should be some limiting principle that takes into account the prevailing view that people generally are not required to go to the assistance of others (emergency or otherwise) and that information about oneself is considered worthy of protection against use or disclosure despite its potential benefit to others for example, genetic information or HIV, Hepatitis C status. Section 7(2)(c) is very problematic as it permits the use of “identifiable” information for a host of purposes, including statistical and research, when it is impractical to seek consent. Even though the Commissioner must be informed of the use before the information is used the Commissioner has no power to approve or reject the use, and since the use is legitimate under the Bill provided the Commissioner has been notified there would be no grounds open to the Commissioner to cause an audit to occur. This section gives significant scope to use information that has been collected without knowledge or consent and certainly in the case of health information is problematic. CMA Health Information Privacy Code The CMA Code makes a clear distinction between the primary purpose for the collection and use of health information and secondary purposes for its use. The key distinction between these two categories is that primary purposes relates to the provision of the health care benefit sought whereas secondary purposes are ends or aims that are not directly related to the provision of care. The CMA Code divides secondary purposes into two categories: 1. Secondary legislated purposes, those purposes that have been subjected to the legislative test specified in the Code and have subsequently been written into law; 2. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of the CMA Code and the secondary nonlegislative test provided by the Code. The tests that CMA requires both to go through relate to: 1. Impact on privacy. 2. Impact on the patient-physician relationship, especially confidentiality and trust. 3. Impact on the willingness of patients to disclose information. 4. Impact on patients’ ability to receive care. 5. Evidence of broad public support for the measure. 6. The use will not exploit or compromise the trust of the patient-physician relationship. 7. Patient vulnerability will not be exploited. 8. Under most circumstances patients will be fully informed of the purpose and patient consent will be clearly voluntary. 9. Patient privacy will be intruded upon to the most limited degree possible. 10. Linkage of health information will be restricted and consented to by patients. In other words, CMA is not satisfied that any and all secondary purposes for the use of health information should be permitted. Rather, CMA seeks justification for the secondary use and assurance that the secondary use will neither impede nor undermine the patient-physician relationship and the provision of health care to the patient. Moreover, the CMA Code only permits use without consent if it is permitted or required by legislation or when ordered or decided by a court of law. The Advisory Council Report Like CMA, the Advisory Council Report makes distinctions among various types of uses. The report calls for legislation to clearly prohibit all secondary commercial use of personal health information. In addition, the Report recommends that there be provisions regulating secondary uses of non-identifiable health information and that such provisions should address privacy concerns surrounding the degree to which such data might be linked back to an identifiable individual. In this context, the Report recommends that legislation set clear limits on access to and use of health information by third parties outside the health care system. In addition the Report reviews the uses of health information for statistical and research purposes. The Report’s findings with respect to statistical use have already been discussed. In connection with research, the Report calls for a number of safeguards and restrictions: 1. Where the data sets used have a higher level of potential identifiability, “the general rule should be informed consent and stringent assurances about privacy protection and security arrangements are necessary before a researcher can have access to personally identifiable information.” 2. The Report recognizes that in some instances it may be impractical to obtain consent from patients. Whether in anonymous or identifiable form the Report requires that notice be given about the use of the information in either form. In the case of the use of identifiable information, the Report states that the research should be subject to independent ethics review with the onus on the person seeking to use the information without consent to demonstrate that: (a) a tangible public good of significant benefit will result; (b) consent is impossible to secure at a reasonable cost; (c) less identifiable data will not serve the same purpose; and (d) no harm can occur to any person directly or indirectly [note the above discussion on group privacy] as a result of this use of his or her personal information. E. Disclosure Without Knowledge Or Consent Bill C-54 The comments found under C. and D. above apply equally here. Section 7(3) adds further instances when collected information can be disclosed to others without knowledge or consent. CMA Code In the case of health information CMA takes a far more restrictive approach. In the case of use, disclosure or access the CMA Code states: The potential that health information, in whole or in part, may be subsequently collected, used, disclosed or accessed for other purposes without their consent, and what those purposes might be, must be made know to the patient by reasonable means before it is confided or collected for primary purposes. Moreover, the CMA Code recognizes that information disclosed by one organization is collected by another. The Code defines collection to mean: the act of accessing, receiving, compiling, gathering, acquiring or obtaining health information from any source, including third parties, and by any means. It includes information collected from the patient, as well as secondary collection of this information in whole or in part by another provider or user. The collecting organization should be bound by the provisions of the CMA Code, which generally requires consent for use for any purpose and always requires knowledge of the potential purposes that information will or must be put to prior to the information being disclosed. CMA’s Code states: Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Finally, the CMA Code explicitly recognizes that information can be retrieved from a variety of sources to formulate records. Any and all such practices and the composite form developed are given the same degree of protection as that accorded the original data collected by or through the patient. F. Information Flow Within Organizations Bill C-54 Bill C-54 defines use to include, “the transfer of personal information within an organization.” Therefore, to the extent that Bill C-54 restricts the free flow of information it restricts in within an organization. In the health care context this is not a reasonable or desirable outcome. CMA Code The CMA Code recognizes that the free flow of health information is desirable to the extent that it furthers the provision of the health care benefit sought and that it occurs with patient consent. The CMA Code defines the primary purpose to mean: (i) Primary therapeutic purpose is the initial reason for a patient seeking or receiving care in the therapeutic context, and pertains to the delivery of health care to a particular patient with respect to the presenting health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. (ii) Primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to the presenting health need or problem, in order to enhance ongoing care to that person. The Code goes on to state that: Health information collection, use, disclosure or access for the primary therapeutic and longitudinal purposes may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context. And further states that: Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. Finally, in addressing consent the Code states: Consent to health information collection, use, disclosure and access for the primary therapeutic purpose may be inferred. Consent to subsequent collection, use, disclosure and access on a need-to-know basis by or to other physicians or health providers for this purpose, and for this purpose alone, may be inferred, as long as there is no evidence that the patient would not give express consent to share the information. G. Individual Access Bill C-54 Bill C-54 restricts the right of individual access to personal information. The grounds for denying access to information are inappropriate in the health care context. CMA Code The CMA Code follows the prevailing case law as it relates to medical records. Primarily this gives the patients a right of access to their record in all but very limited circumstances. These circumstances are, if there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus lies on the provider to justify denial of access. H. Accuracy and Amendment Bill C-54 Bill C-54 requires that information be as accurate, complete and up-to-date as possible and that it shall not be routinely updated unless this is necessary to fulfil the purpose for its collection. In so far as amendment is concerned, Bill C-54 permits amendment to the record in specified circumstances. CMA Code The CMA Code takes a different approach in light of the nature and purpose of health information. The Code recognizes that the “recording of statements of fact, clinical judgements and determinations or assessments should reflect as nearly as possible what has been confided by the patient and what has been ascertained, hypothesized or determined to be true using professional judgement.” In terms of amending the record in light of a patient’s request, the CMA Code seeks to preserve the original record but also note the patient’s concerns. To accommodate both requirements the CMA Code states: Patients who have reviewed their information and believe it to be inaccurately recorded or false have the right to suggest amendments and to have their amendments appended to the health information. I. Sensitivity Bill C-54 In a number of instances Bill C-54 and in particular schedule 1 recognize that medical records have a high level of sensitivity attached. Which in turns warrants special attention concerning consent, reasonable expectations, individual access and implicity, the degree of security that is appropriate. CMA Code The CMA Code seeks to recognize that while all health information is sensitive (when considered against other forms of information about individuals) there are also variations in the level of sensitivity in various aspects of the health record. The CMA Code defines the “sensitivity of health information” to refer to: the patient’s interest in keeping the information secret. It varies according to the nature of the information, its form, and the potential negative repercussions of its collection, use or disclosure on the patient’s interests. Under the Code’s consent provisions it is stated that: Although all health information is sensitive and should be treated as such, the more sensitive the health information is likely to be, given what is known about the circumstances or preferences of the patient, the more important it is to ensure that consent is voluntary and informed. With respect to security the Code states: The development of security safeguards with respect to levels of access for various users shall recognize the differences in the sensitivity of health information and permit access accordingly. V. Conclusions The increased capacity to collect, store, transfer, merge and access information coupled with trends that support increased use of and access to information have the potential to erode our traditional understanding and protection of privacy and confidentiality. The issues are complex and the choices we must make are difficult. Nevertheless, these issues should be squarely on the table and the choices that we make must be clear, transparent and defensible. Of paramount importance is that the public is not mislead into believing that their information is being protected or kept confidential when in fact it is not. Therefore, even to refer to Bill C-54 as the “Personal Information Protection and Electronic Documents Act” should be the subject of debate. Is the Bill truly about information protection or is it actually about permitting access to information? Bill C-54 presents one approach, an approach that values commerce and access. In CMA’s view the approach is totally inadequate when applied to health information. CMA also believes that the public would also find Bill C-54 inadequate. CMA presents a different approach, an approach that values privacy and the preservation of the trust and integrity of the patient-physician relationship. CMA believes that its approach would receive broad public support. Moreover, CMA believes that to the extent the CMA Code presents tests rather than conclusions, these tests should be administered in good faith prior to legislative initiatives related to health information or in the case of secondary usage of health information in general. CMA believes that its approach draws support from the Federal Advisory Council Report, which also recognizes the importance of preserving patient privacy and the confidentiality of the health record in an era of increased use of technology. Implicitly, the Report recognizes that the benefits of such technology cannot be realized if public support, based on assurance of privacy protection, cannot be secured. CMA urges this committee to implement CMA’s recommendations and in doing so provide the type of protection that health information deserves and that Canadians desire. VI. Summary of Recommendations That Bill C-54 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Code provide the basis of such provisions; and That the proposed rules for health legislation be subject to the legislative test found in CMA’s Code and formulated in light of this process; and That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite form produced when information is linked to any information about a person from any other source; and That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors.
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Review of the Personal Information Protection and Electronic Documents Act (PIPEDA) : CMA's Presentation to the House of Commons Standing Committee on Access to Information, Privacy and Ethics - December 13, 2006

https://policybase.cma.ca/en/permalink/policy8668
Last Reviewed
2019-03-03
Date
2006-12-13
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2006-12-13
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
Text
The Canadian Medical Association (CMA) is pleased to be here today to participate in your review of the Personal Information Protection and Electronic Documents Act, or PIPEDA. The CMA has had a long-standing interest in privacy-related matters, including enhancing measures to protect and promote the privacy of health information. We welcome the opportunity to share our policies and thoughts on these vital matters. As a pediatric oncologist from Winnipeg and Chair of the CMA's Committee on Ethics, I come here today with one bottom line: Physicians have always- and continue to - take their patients' privacy very seriously. This is the cornerstone of the special bond between patients and their doctor and has been thus since the time of Hippocrates. In recognition of the importance of privacy, the CMA has produced such documents as the CMA Code of Ethics and the CMA Health Information Privacy Code to guide our more than 64,000 members across the country. These documents existed before the federal government introduced PIPEDA. It is out of our concern for protecting and ensuring the privacy of medical information that we speak to you today. There are three specific areas which we would like to raise: 1) Recognition in law of the unique nature of health care; 2) Physician information as "work product"; and 3) Emerging Privacy and Health information issues. 1. Recognition in law of the unique nature of health care I would like to highlight the importance of recognizing in law the special circumstances of protecting health information. In fact, when PIPEDA was first being debated, CMA posed questions about the scope of the Act and was told that the legislation, originally designed for commerce and the private sector, would not capture health information. We were also told that even if it did, PIPEDA wouldn't change how we practiced medicine. The passing of PIPEDA generated enough concern and uncertainty that government agreed to delay its application to health for 3 years. For example, PIPEDA failed to clarify the issue of implied consent for the sharing of patient information between health professionals providing care. For example, when the family physicians says to a patient "I'm going to send you to see an oncologist to run some tests" and the patient agrees and follows that course of action, then clearly there is "consent" to the sharing of their health information with others. As an oncologist I assume there is consent to send the test results to other specialists that I may need to consult in order to advance the patient's care in a timely fashion. This, however, needed to be addressed before PIPEDA was applied to health care. The delayed application allowed the federal government and health care community to work together and develop a set of guidelines for how PIPEDA would be applied. The resulting PIPEDA Awareness Raising Tools, known as PARTs, contain a series of questions and answers that make up guidelines for health care providers. They answered many of our concerns, provided necessary definitions and allowed for the implied consent model to continue to be used within the circle of care. The CMA applauds the government for this collaborative effort and the resulting guidelines have been used by health care providers ever since. However, we remain concerned that the PARTs guidelines have no legal status. This limitation creates a degree of uncertainty that the CMA would like this legislative review to see addressed by ensuring the PARTs series of questions and answers are referenced in PIPEDA. In addition to participating in the PARTS initiative, since PIPEDA's implementation, the CMA has designed practical tools for physicians and patients: * adopted the CMA policy Principles Concerning Physician Information to address the importance of protecting the privacy of physician information; * produced Privacy in Practice: a handbook for Canadian physicians to help physicians maintain best practices in the protection of patient health information; and * created the PRIVACYWIZARD(tm) designed to help physicians record their current privacy practices, communicate these to patients and identify possible areas for enhancement. 2. Physician Practice Information as "Work Product" I referred earlier to CMA's Policy document on physician information. The CMA strongly believes that physicians have legitimate privacy concerns about the use by third parties of information - such as prescribing and other practice data for commercial purposes. Currently deemed "work product" this information can be collected, used and disclosed without consent. We feel PIPEDA inadequately protects this information. We recognize that it is information generated out of the patient-physician relationship. We disagreed with findings of the previous Privacy Commissioner that physician prescribing information is not subject to PIPEDA's privacy protection provisions for "personal information". The CMA has consistently advocated that physician prescribing data and other practice information is personal information and appeared as an intervener in a Federal Court review of this issue that was ultimately settled by the main parties. Also, insufficient regard for the privacy of prescribing and other physician data could have a negative impact on the sanctity of the physician-patient relationship. Patients confide highly sensitive information to physicians with the expectation this information will be kept in the strictest confidence. This expectation exists because they know that physicians are under ethical and regulatory dictates to safeguard their information and that physicians take this responsibilities very seriously. The perceived and indeed actual loss of control by physicians over information created in the patient encounter, such as prescribing data, could undermine the confidence and faith of our patients that we are able to safeguard their health information. This concern is not hypothetical. For physicians, so called "work product" information also encompasses practice patterns such as discharge rates, referral rates, billing patterns, hospital length of stays, complaints, peer review results, mortality and re-admittance rates. With the advent of electronic medical records and growth in pay-for-performance and outcome-based incentive programs for physicians, there is an enormous potential for the resulting physician "performance" data or "work product" to be "mined" by other parties and used to influence performance review (traditionally the purview of the medical licensing authorities) as well as decisions around treatment funding and system planning. The lack of transparency in the sale and compilation of physicians' prescribing and other performance data means that physicians might find themselves to be the unwitting subject and targets of marketing research. We believe practice decisions must be made in the best interest of patients and not the bottom-line interests of businesses and marketers. CMA therefore recommends a legislative change to include physician information as personal information under PIPEDA. Legislation in Quebec provides an example that is consistent with CMA's approach since it requires regulatory oversight and gives individuals the right to opt out of the collection, use and disclosure of "professional" information. 3. Emerging Privacy and Health information issues With budgetary and demographic pressures, our health care system is under strain and physicians are striving to deliver timely, quality care to patients, often with competing and multiple demands. Physicians are therefore seeking assurances from law makers that any amendments to PIPEDA will take into account the potential impact on them and their patients. Therefore, we seek assurances that: * health care is recognized as unique when it comes to the disclosure of personal information before the transfer of a business (one physician transferring his/her practice to another) because it is regulated at the provincial level through the appropriate licensing body. As a general rule, physicians must give notice to the public, whether via a newspaper ad or a notice in the office about the change in practice. * the federal government will consider the impact of the trans-border flow of personal information on telehealth and Electronic Health Record activities. Communications between patients and physicians via electronic means are likely to increase and to move across geographic boundaries with increasing frequency; and * the federal government will study the issue of international cross border data flows, particularly among Canadian researchers who receive funding from US drug companies. These arrangements should be governed by Canadian law (PIPEDA) not American (HIPAA or the US Patriot Act). In closing, the privacy protection of personal health information is a responsibility that my colleagues and I do not take lightly. It is a key pillar of our relationship with Canadians, they not only expect it-they deserve it. I look forward to taking questions from Committee members. Canadian Medical Association Ottawa, December 13, 2006
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Submission to House of Commons Standing Committee on Health Regarding the Common Drug Review

https://policybase.cma.ca/en/permalink/policy8719
Last Reviewed
2019-03-03
Date
2007-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association represents more than 65,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. In pursuit of this mission we are developing a growing body of policy on pharmaceutical issues. In November 2003, we presented to the House of Commons Standing Committee on Health during its study of prescription drug issues. In July 2006 CMA, along with four other national organizations representing patients, health professionals, health system managers and trustees, formed the Coalition for a Canadian Pharmaceutical Strategy and released a framework and principles that we believed should govern the development of pharmaceutical strategy in this country. We understand that the current study of the Common Drug Review (CDR) is part of a larger, more comprehensive study of prescription drugs being contemplated by the House of Commons Standing Committee on Health. We look forward to assisting you with this study. In the meantime, we will note that the CDR is intimately linked to related issues such as catastrophic coverage and a national formulary, and will also briefly discuss these in our presentation. Pharmaceuticals are important to the health of Canadians. For many patients prescription drugs have prevented serious disease, reduced hospital stays, replaced surgical treatment and improved their capacity to function productively in the community. Pharmaceuticals also offer health-care system benefits by reducing other costs such as hospital expenses and disability payments. While prescription drugs offer significant benefits, expenditures on them are also growing faster than any other component of health care. It is realistic to expect that the role of prescription drugs in health care will continue to increase and that as a result government expenditures on them will rise accordingly. As patients become increasingly knowledgeable and politically aware, they will continue to expect and demand access to an expanded range of prescription drugs. CMA believes that any pharmaceutical strategy should be predicated on two pre-eminent principles, which are in keeping with longstanding Canadian values: * All Canadians should have access to safe and effective prescription drugs; and * No Canadian should be deprived of medically necessary drugs because of inability to pay. Whether the CDR serves to further these goals has been a matter of vigorous debate. Federal and provincial representatives have told the House of Commons Committee that the CDR is meeting their needs and has in some cases provided them with a higher-quality review than they could have achieved on their own. On the other hand, patient groups have charged that the CDR is an unnecessary layer of bureaucracy and a barrier between them and potentially life-saving new therapies. It is possible, if not probable, that reforms to the CDR may never completely eliminate the tension between these two viewpoints. We understand the frustration of patients and their advocates when the CDR recommends against public reimbursement or even more, when the CDR approves a drug but individual provinces refuse to include that drug on their formularies. In both these cases, sustainability of the health care system is an important and valid consideration. It would be unfortunate if our limited health care dollars, which might otherwise have been spent on disease treatment or prevention strategies of proven effectiveness, went instead to funding expensive drugs which ultimately proved no more beneficial to patients than others which cost much less. 2) General principles regarding drug review The process of reviewing drugs for inclusion in public formularies did not begin with the CDR. Before it was created, each federal and provincial formulary conducted its own review. Without the CDR, separate reviews would still be taking place. To dismantle the review process entirely would be unacceptable, both economically and politically. Within the context of an overarching goal to enhance access to medically required pharmaceuticals to the extent that they are needed, the primary purpose of a drug review process should be to help ensure access to prescription drugs for which evidence indicates safety and effectiveness in the treatment, management and prevention of disease, and/or significant benefits in quality of life. To help ensure that it achieves this purpose, we believe the following principles should apply to drug review in Canada: * The review process should be impartial and founded on the best available scientific evidence. * The primary criteria for inclusion in a formulary should be whether the drug improves health outcomes, and offers an improvement over products currently on the market. * The review process should also incorporate evaluation of the drug's cost-effectiveness. * Drugs should be evaluated not in isolation but as an integral part of the health care continuum. The review should consider: * A drug's impact on overall health care utilization. If a drug reduces a patient's hospital stay, helps an otherwise disabled patient return to work, or replaces other costlier or more invasive therapies, this should be considered in evaluating its overall cost-effectiveness. * Alternatives to the drug under review. The review should compare a drug's performance to other drugs in the same class, and to available non-drug therapies. * The review process should be flexible, taking into account the unique needs and therapeutic outcomes of individual patients, and the expertise of physicians in determining which drugs are best for their patients. * The review process should be open and transparent. We support the CDR's intent to publish the rationales for its decisions, including lay-language versions. * CDR findings are a valuable source of information on the safety and effectiveness of the drugs physicians prescribe. As such, they should be communicated to caregivers and patients as part of an ongoing strategy to encourage best practices in prescribing. * Meaningful participation by patients and health professionals should be part of the review process; we note with approval the expansion of the Canadian Expert Drug Advisory Committee to include members of the public. We also suggest that the CDR experiment with open fora and other means of obtaining public input. * A process for appealing the review's decisions should be established. * Ongoing evaluation of the review process should be required. We note that the CDR has already undergone an evaluation, and is planning to implement some of the key recommendations. Impartial evaluations should continue to take place, to assess whether the CDR is having a positive impact on the health of Canadians and of their health care system. 3) The Larger Picture The Common Drug Review does not exist in isolation. As the Coalition for a Canadian Pharmaceutical Strategy - of which CMA is a member - stressed in its 2006 statement, the elements of a comprehensive Canadian pharmaceutical strategy are interdependent and should be developed concurrently to ensure that the strategy is coherent and holistic. The CDR is interlinked with other issues concerning access to health care generally and to prescription drugs more specifically, and we suggest that the Committee also consider the following issues: a) Drugs for Rare Disorders. One controversy surrounding the CDR is that its approval rates are low for drugs for very rare disorders, many of which are first-in-class. One reason may be the cost of these drugs, which is often extremely high. It is also alleged that the Canadian Expert Drug Advisory Committee's (CEDAC) current review standards, which place a high value on large-sample clinical trials, are unable to adequately capture the value of these drugs. It has been recommended that more drugs for rare disorders be approved based on interim targets or surrogate endpoints. The ultimate measure of a drug's effectiveness is its clinical endpoint; this should not be forgotten in any process of drug approval. This issue merits closer consideration, as do all issues related to drugs for rare disorders. CMA recommends that Canada develop a policy on drugs for rare disorders, which: * Encourages their development; * Evaluates their effectiveness; and * Ensures that all patients who might benefit have reasonable access to them. b) Common Formulary. CMA recommends that Canada's governments consider the possibility of establishing a pan-Canadian formulary. Canadian patients need a national standard; 18 different levels of coverage is not acceptable. Should the CDR form the basis of this formulary? That would depend on whether evaluation proves that the CDR is the most effective vehicle. We do believe that cost control, though not the primary function of a pan-Canadian formulary, is a valid system concern. If two drugs in the same class are equally effective, it is reasonable to expect that the less expensive drug should be preferentially covered and/or prescribed. On the other hand, a pan-Canadian formulary should be flexible. It should include a process to allow patients access to off-formulary drugs if in the opinion of the attending physician the recommended product is not the right choice for them. This process should be designed so as to minimize the administrative burden on health professionals. c) Catastrophic Drug Coverage. It is now generally accepted that a pan-Canadian catastrophic drug program is needed. The point of discussion now is what type of program should be put in place. To ensure that Canadians can access the drugs they need, regardless of where they live or how much they earn, CMA recommends that federal, provincial and territorial governments, in collaboration with private insurers, assess the drug needs of Canadians, particularly those who are uninsured or under-insured, and agree on an option for providing equitable and comprehensive prescription drug coverage. As a starting point, CMA has recommended that governments give priority to a national pharmacare program to provide necessary drugs for all Canadian children and youth. Conclusion In principle, CMA believes that a process for reviewing prescription drugs for their clinical effectiveness and cost-effectiveness can contribute to improving the health of Canada's patients and our health care system. The value of the CDR will be determined by how well it performs this function. Canadian Medical Association May 14, 2007
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CMA letter to the House of Commons Standing Committee on Justice and Human Rights. Bill C-32 (An Act to amend the Criminal Code (Impaired driving) and to make consequential amendments to other Acts)

https://policybase.cma.ca/en/permalink/policy8789
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Standing Committee on Justice and Human Rights of the House of Commons concerning the study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts). The CMA supports measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code (attached). While our 1999 brief focuses primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. Recently, the CMA has published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles (attached). It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs (attached), the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues. With regard to Clause 4 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and health information privacy. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 9 of Bill-32 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 9(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 9(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could be of individuals who are not actually convicted of an offence. One should query whether the Clause 9(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 9(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 5, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 5) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.1 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.2 In our 1999 response to this Committee's issue paper on impaired driving3 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 4 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-32, must be accompanied by public awareness and education strategy. This constitutes the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is cause by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Colin J. McMillan, MD, CM, FRCPC, FACP President Attachments (3) 1 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 2 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 3 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 4 Mann et al
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Joint Submission to the Subcommittee on Sport-Related Concussions in Canada House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy14080
Date
2019-01-29
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2019-01-29
Topics
Health care and patient safety
Text
Based on a well-established collaboration addressing concussion, the Canadian Academy of Sport and Exercise Medicine (CASEM) the College of Family Physicians of Canada (CFPC), and the Canadian Medical Association (CMA) are pleased to submit this brief to the Subcommittee on Sport-Related Concussions (SCSC) of the House of Commons Standing Committee on Health. About the Canadian Academy of Sport and Exercise Medicine (CASEM) CASEM is a physician member-based organization comprised of 850 medical doctors from many specialties who have specialized training and skills in sport and exercise related injuries/illnesses for active patients of all ages and abilities, including concussion care. CASEM physicians hold national and international leadership roles in concussion care. Namely, at the national level, CASEM chairs the Canadian Concussion Collaborative (CCC) and at the international level, several CASEM members played leadership roles in the development of the International Consensus Statements on Concussion in Sport which is the key document that establishes concussion management recommendation every 4 years. About the College of Family Physicians of Canada (CFPC) The CFPC is the professional organization that represents more than 38,000 family physician members across the country. The College establishes the standards for, and accredits, postgraduate family medicine training for Canada’s 17 medical schools. It reviews and certifies continuing professional development programs, and materials, that enable family physicians to meet certification and licensing requirements. The CFPC provides high-quality services, supports family medicine teaching and research, and advocates on behalf of family physicians and the specialty of family medicine. About the Canadian Medical Association (CMA) The Canadian Medical Association unites 85,000 physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. Along with CASEM, the CMA is a co-founding member of the CCC. 3 KEY KEY THEMESTHEMES AND RECOMMENDATIONSAND RECOMMENDATIONS: In this brief, CASEM, CFPC, and the CMA submit a series of recommendations under two key themes. Taken as a whole, we believe these will help inform the Subcommittee’s study on how to improve concussion awareness, prevention and treatment for all Canadians. Background information regarding the groups and initiatives mentioned in the key themes and recommendations, is provided in the subsequent part of this document. KEY THEME #1: The impacts of concussion and the benefits of awareness efforts are slowly becoming better known at the higher levels of sport participation that received support for the implementation of proper concussion management strategies (namely through the Canadian Concussion Protocol Harmonization Project). Further efforts and government funding should address the issue at all levels of sport participation. This must include school-based sport programs, and concussion occurring in other contexts (e.g. leisure, occupation, etc.). RECOMMENDATIONS related to key theme #1: #1.1 The federal government should commission and fund the development and evaluation of additional efforts to improve awareness and proper management of concussion at all levels of sport participation and contexts where concussions occur in Canada. #1.2 Since “key aspects of concussion prevention, detection and management occur prior to, as well as after, the initial medical intervention”1, “public health strategies should be developed and implemented to address the issue of concussions.”1 #1.3 Given their competencies and expertise in this area, “family physicians2 and sport and exercise medicine (SEM) physicians should play a central role in the design and implementation of strategies that work in conjunction with families, schools, sports organizations, employers and governments to educate, support and empower the implementation of proper concussion prevention, detection and management protocols.”1 #1.4 Any future effort to improve concussion awareness and management should, whenever possible, be evidenced-informed, and aim for synergy with ongoing Canadian initiatives. #1.5 Innovative dissemination strategies that have the potential to reach all levels of sport participation and contexts where concussions occur should be considered and evaluated (e.g. massive open online course or MOOC 3). 1 The Role of Family Physicians and physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. A joint position statement of CASEM, CFPC, and the CMA. 2017 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105 2 This is not meant to exclude the possible role of other health care disciplines, such as nurse practitioners, that can be involved in the diagnosis and medical management of concussions in some Canadian jurisdictions. 3 https://www.ulaval.ca/les-etudes/mooc-formation-en-ligne-ouverte-a-tous/commotion-cerebrale-prevention-detection-et-gestion-dans-mon-milieu.html 4 KEY THEME #2: For the majority of Canadians affected by a concussion, family physicians play a central role in concussion identification and management through the recovery process. However, where persistent concussion symptoms arise, family physicians and their patients require timely access to SEM physicians, and multidisciplinary care for the development and implementation of individualized treatment plans. As it presently stands, access to such expert medical and multidisciplinary resources for concussion is very limited (especially in rural and remote regions). To complicate matters, Canadians affected by a concussion are all too often uncertain how best to navigate a health care system that isn’t well organized to address their unique needs. RECOMMENDATIONS related to key theme #2: #2.1 Medical schools and organizations should maintain continuous efforts aiming for the rapid integration of the most current clinical practice recommendations about concussion. #2.2 Initial care for Canadians affected by a concussion should be coordinated by the patient’s family physician. #2.3 To work in collaboration with their family physicians, patients affected by persistent symptoms following a concussion should have timely access to medical experts on concussion and allied professionals with expertise in concussion management. #2.4 The potential of telemedicine strategies or other virtual network to improve access to concussion experts for support in the management of concussion should be considered and evaluated. BACKGROUNDBACKGROUND:: The challenging dynamics of concussion: Sport-related concussion seriously impacts the health and well-being of Canadians across the country; to say nothing of the costs to the health care system and concussed individuals. Canadian statistics show that among children and youth (10-18 years) who visit an emergency department for a sports-related head injury, 39% were diagnosed with concussions, while a further 24% were possible concussions.4 Between 2003 and 2013 in Ontario, a 4.4-fold increase of pediatric concussion-related consultations has been observed, with a sharp increase between 2010 and 2013 and nearly 35000 visits in 2013.5 Although, the precise reasons for this increased incidence of concussion are unknown, the study suggests that “…concussion education and awareness, improved diagnosis of 4 https://www.canada.ca/en/canadian-heritage/services/concussions.html 5 Zemek et al. J Pediatr 2017; 181: 222-8 (https://doi.org/10.1016/j.jpeds.2016.10.067) 5 concussion, and revised concussion guidelines advocating stricter follow-up…” played an important role. The body of knowledge regarding concussion is rapidly and constantly changing; a dynamic that is unlikely to change for the foreseeable future. One important limitation of our knowledge about concussion is the lack of information on the true burden of concussion in Canada. A significant proportion of all concussions are not captured by traditional health-related databases, or clinical research, because individuals often do not consult a physician. One positive and recent development that will help better understand the true burden of sport related concussion in youth occurred in November 2018 when a group of more than 30 Canadian researchers including CASEM and CFPC leaders on concussion received $12 million from the National Football League “Play Smart, Play Safe” initiative.6 This 3-year longitudinal cohort study will evaluate diagnostic tools, prognostic indicators, prevention strategies, and treatment strategies. This study will characterize the true incidence rate and recovery characteristics of concussion in high school-based sport settings. Psychological and social factors must also be considered. Attitudes and awareness towards injury are complicating factors that highlight the need for improved concussion prevention and awareness. These include injury minimization, the lack of a visible injury, and a general lack of both pre and post-injury awareness. Those closely associated with a concussed individual (coaches, co-workers, employers, or an injured individual themselves) may have an incentive, or experience pressure, to hide/downplay injury or avoid medical assessment due to stigma.7 The natural human predilection towards downplaying the nature of injury is another important factor to consider, especially where, post-injury, the effects aren’t clearly visible. A concussed individual may lack the mental acuity to be able to understand that their symptoms require medical attention. Another area to consider is the availability of qualified health care resources. Family physicians, whether in primary care settings or emergency departments, and SEM physicians, are generally the first medical professionals seen by a person who has sustained a concussion during a sport, leisure or occupational activity. They are the first point of contact for proper management, advice, and education regarding that person’s gradual return to cognitive (e.g. school and work) and physical activities (e.g. sport, exercise or work).8 Gaps in medical training, and the fast-paced evolution of concussion best practices, means that clinicians sometimes struggle to maintain up-to-date knowledge regarding the detection and treatment of concussions. These factors are further complicated by ambiguous scopes of practice across the multidisciplinary professions involved 6 https://www.ucalgary.ca/utoday/issue/2018-11-16/nfl-gives-significant-funding-help-youth-shred-burden-concussion 7 Delaney J, Caron J, Correa J, et al. Why Professional Football Players Choose not to Reveal their Concussion Symptoms During a Practice or Game. Clin J Sport Med, 2018, 28(1): 1-12. 8 College of Family Physicians of Canada & Canadian Academy of Sport and Exercise. Joint Position Statement - The Role of Family Physicians and Physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. 2017. 6 with concussion management. Finally, there is general lack of available medical experts on concussion to whom family physicians can refer patients that present persistent symptoms. Our recommendations also take into consideration the following factors:
The simple principles of initial concussion management6-8 are within the scope of practice of family physicians.
In the vast majority (80-90%) of cases, once simple principles of initial management have been implemented, concussion is a condition that will evolve favorably within 7-10 days.8
Even with proper initial management, some concussion patients will present with persistent symptoms that require a multidisciplinary team approach.
“Persistent symptoms” has been defined as more than 4 weeks in youth and more than 2 weeks in adults.9
Access to physicians with added competencies in concussion care (e.g. SEM Physicians, Physiatrists, Neurologists), and allied health professionals with experience in treating specific presentations of concussions is limited, especially in Canada’s rural and remote areas. CASEM & CFPC’s concussion efforts to date: Since 2012, CASEM has played a key role in the evolution of concussion care in Canada by leading the work of the CCC10. The CCC is composed of 18 health organizations concerned with concussions that aim “to improve education about concussions, and the implementation of best practices for the prevention and management of concussions”. The CFPC has been involved with the CCC from the start. In 2015, the CCC published 2 key recommendations in a document entitled “Recommendations for policy development regarding sport-related concussion prevention and management in Canada”11 that state:
Organizations responsible for operating, regulating or planning sport and sporting events with a risk of concussion should be required to develop/adapt and implement a concussion management protocol, based on current best practices, that is customized for their context and available resources.
In situations where timely and sufficient availability of medical resources qualified for concussion management is lacking, multidisciplinary collaborative approaches should be used to improve concussion management outcomes while facilitating access to medical resources where appropriate. Since 2015, the CCC has contributed a multidisciplinary health care perspective to key concussion-related initiatives in Canada. The first of these initiatives was initiated in January 2015 by Sport Canada and led to the creation of a Federal-Provincial-Territorial working group (FTP-WG) on 9 McCrory et al. Consensus statement on concussion in sport. (2017) https://bjsm.bmj.com/content/51/11/838 10 https://casem-acmse.org/resources/canadian-concussion-collaborative/ 11 https://bjsm.bmj.com/content/49/2/88 7 concussion that brings together sport, education, government and health stakeholders. Later in 2015, the mandate letters from Prime Minister Trudeau asked the Minister of Health and the Minister of Sport and Persons with Disabilities to collaborate on a national strategy on concussion. The Federal government budgeted $1.4 million to allow the Public Health Agency of Canada to work with provinces and territories to develop harmonized concussion management guidelines across Canada.12 Most of that work has been accomplished by funding to Parachute for the development of the Canadian guideline on concussion in sport.13 Members of the CCC and concussion leaders from the CFPC and CASEM were closely involved. Since 2016, one of the CASEM and CFPC leaders on concussion developed a Massive Open Online Course (MOOC) to develop general awareness on concussion and facilitate the implementation of proper concussion management protocols in specific settings. After 4 iterations of that French language MOOC, over 8000 participants have accessed it. Presently an English version is being developed in collaboration between Laval University and the University of Calgary. In August 2017, CASEM and CFPC, published a joint position statement entitled “The role of family physicians and physicians with added competencies in sport and exercise medicine in a public health approach to concussions”14 that is directly related to the recommendations presented in this brief. Finally, since mid-2018, CASEM and CFPC have partnered with the Canadian Medical Association (CMA) to completely revamp the CMA’s policy on Head Injury in Sport. To foster high-level advocacy, cultural sensitivity, and awareness messaging on concussion, it has been redeveloped for a host of target audiences from all relevant perspectives. It is set for release in early 2019. CONCLUSIONCONCLUSION: Concussion is a pressing public health issue in Canada. The members of the SCSC should keep in mind that concussions are not limited to higher level organized sport. It’s a sudden, and unwanted challenge that hundreds of unsuspecting and unprepared Canadians face each day. These concussions occur in a range of situations, inside and outside of sports settings, and often go untreated; with a potential for tragic consequences. To truly address the issue and make progress towards the objectives expressed by Prime Minister Trudeau in the mandate letters, the Government of Canada must provide significant investments. To make progress across the spectrum of sports, leisure and other context where concussions 12 https://www.budget.gc.ca/2016/docs/plan/ch5-en.html 13 The Canadian guideline on concussion in sport was part of the Parachute-led Concussion Protocol Harmonization Project. 14 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105 8 occur, the Government funding should minimally represent a 10-fold increase from the initial $1.4M budgeted in 2016. With their respective membership, tools and resources, CASEM and the CFPC can play an important role in addressing the burden that concussions place on Canadians. With this brief, we are expressing the willingness of our organizations to collaborate with the government in the design and implementation of strategies to systemically address concussion from all causes as a public health issue. To be successful this must occur across all levels of sport participation and include: leisure, school-based sports, occupational activities and address the rural and remote areas of the country. On behalf of CASEM, and the CFPC, we would welcome the opportunity, and privilege, to present and discuss these recommendations with your Committee. Respectfully submitted, Dr. Paul Watson CASEM President Dr. Pierre Fremont Chair of the CFPC’s SEM Committee and Past President of CASEM Dr.Tatiana Jevremovic Past President of CASEM Dr. Gigi Osler CMA President Contacts: Dawn Haworth, Executive Director, CASEM dhaworth@casem-acmse.org 613 748 5851 – ext 1 Artem Safarov, Director of Health Policy and Government Relations, CFPC asafarov@cfpc.ca 905-629-0900 x 249
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Bill C-45: The Cannabis Act

https://policybase.cma.ca/en/permalink/policy13861
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The CMA is pleased to provide this submission to the Senate Standing Committee, Social Affairs, Science &Technology on Bill C-45, the Cannabis Act. The CMA has long-standing concerns about the health risks associated with consuming cannabis,i particularly in its smoked form.1,2 Children and youth are especially at risk for cannabis-related harms, given their brains are undergoing rapid and extensive development. The CMA's approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4 Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research. There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like "deep inhalation" to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6 Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation ("the Task Force").7 Overview According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%-30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis' increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation and method of use make it difficult to study the full health impacts and produce replicable, reliable scientific results. The CMA submits, therefore, that any legalization of cannabis for non-medical use must be guided by a comprehensive cannabis public health strategy and include a strong legal-regulatory framework emphasizing harm reduction principles. Given that the Task Force employed a minimizing of harms approach11 and given how the proposed legislation aligns with the Task Force's recommendations,12 the bill addresses several aspects of a legal-regulatory framework "to provide legal access to cannabis and to control and regulate its production, distribution and sale."13 This work provides the starting point for creating a national cannabis public health strategy. The CMA has long called for a comprehensive drug strategy that addresses addiction, prevention, treatment, enforcement and harm reduction.3 There are, however, key public health initiatives that the Canadian government has not adequately addressed and should be implemented before, or no later than, the implementation of legislation. One such initiative is education. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. Supporting a Legal-Regulatory Framework that Advances Public Health and Protection of Children and Youth From a health perspective, allowing any use of cannabis by people under 25 years of age, and certainly those under 21 years of age, is challenging for physicians given the effects on the developing brain.1,3,14 The neurotoxic effect of cannabis, especially with persistent use, on the adolescent brain is more severe than on the adult brain.15,16 Further, neurological studies have shown that adolescent-onset cannabis use produces greater deficits in executive functioning and verbal IQ and greater impairment of learning and memory than adult-onset use.17,18 This underscores the importance of protecting the brain during development. Since current scientific evidence indicates that brain development is not completed until about 25 years of age,19 this would be the ideal minimum age for legal cannabis use. Youth and young adults are among the highest users of cannabis in Canada. Despite non-medical use of cannabis being illegal in Canada since 1923, usage has increased over the past few decades. The CMA recognizes that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach.3 Harm reduction is not one of polarities rather it is about ensuring the quality and integrity of human life and acknowledging where the individual is at within his/her community and society at large.5 The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug's physiological harm. The Canadian government has recognized this disproportionality for over 15 years. Since 2001, there have been two parliamentary committee reportsiii and two billsiv introduced to decriminalize possession of small amounts of cannabis (30 g). It was recommended that small amounts of cannabis possession be a "ticketable" offence rather than a criminal one. Given all of the above, the CMA recommends that the age of legalization should be 21 years of age and that the quantities and the potency of cannabis be more restricted to those under age 25. Supporting a Comprehensive Cannabis Public Health Strategy with a Strong, Effective Education Component The CMA recognizes that Bill C-45 repeals the prohibition against simple possession while increasing penalties against the distribution and sale of cannabis to young people, but this is not enough to support a harm reduction approach. We note that the Federal Tobacco Control Strategy, with its $38 million budget, is intended to help reduce smoking rates and change Canadians' perceptions toward tobacco.20 Similarly, there are extensive education programs concerning the dangers of alcohol, particularly for young people.v The government of Canada has proposed a modest commitment of $9.6 million to a public awareness campaign to inform Canadians, especially youth, of the risks of cannabis consumption, and to surveillance activities.21 A harm reduction strategy should include a hierarchy of goals with an immediate focus on groups with pressing needs. The CMA submits that young people should be targeted first with education. The lifetime risk of dependence to cannabis is estimated at 9%, increasing to almost 17% in those who initiate use in adolescence.22 In 2012, about 1.3% of people aged 15 years and over met the criteria for cannabis abuse or dependence - double the rate for any other drug - because of the high prevalence of cannabis use.23 The strategy should include the development of educational interventions, including skills-based training programs, social marketing interventions and mass media campaigns. Education should focus not only on cannabis' general risks but also on its special risks for the young and its harmful effects on them. This is critical given that for many, the perception is that (i) legalization of possession for both adults and young people translates into normalization of use and (ii) government control over the source of cannabis for sale translates into safety of use. Complicating this has been the fear-mongering messaging associated with illegal drugs. The evidence shows that fewer adolescents today believe that cannabis use has any serious health risks24 and that enforcement policies have not been a deterrent.25 Having an appropriate education strategy rolled out before legalization of possession would reduce the numbers of uninformed young recreational users. It would also provide time to engage in meaningful research on the impact of the drug on youth. Such strategies have been successful in the past; for example, the long-termvi Federal Tobacco Control Strategy has been credited with helping reduce smoking rates to an all-time low in Canada.26 The Lower-Risk Cannabis Use Guidelines were developed as a "science-based information tool for cannabis users to modify their use toward reducing at least some of the health risks."6 The CMA urges the government to support the widespread dissemination of this tool and incorporation of its messages into educational efforts. Other strategies must include plain packaging and labelling with health information and health warnings. Supporting a One-System Approach. Alternatively, a Review of Legislation in Five Years The CMA believes that once the act is in force, there will be little need for two systems (i.e., one for medical and one for non-medical cannabis use). Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization (some people may self-medicate with cannabis to alleviate symptoms but may be reluctant to raise the issue with their family physician for fear of being stigmatized), and for those who wish to use it for other purposes. The medical profession does not need to continue to be involved as a gatekeeper once cannabis is legal for all, especially given that cannabis has not undergone Health Canada's usual pharmaceutical regulatory approval process. The Task Force's discussion reflects the tension it heard between those who advocated for one system and those who did not. One concern raised by patients was about the stigma attached to entering retail outlets selling non-medical cannabis. The CMA submits that this concern would be alleviated if the federal government continued the online purchase and mail order system that is currently in place. Given that there is a lack of consensus and insufficient data to calculate how much of the demand for cannabis will be associated with medical authorization, the Task Force recommended that two systems be established, with an obligation to review - specifically, a program evaluation of the medical access framework in five years.11 If there are two systems, then in the alternative, the CMA recommends a review of the legislation within five years. This would allow time to ensure that the provisions of the act are meeting their intended purposes, as determined by research on the efficacy of educational efforts and other research. Five-year legislative reviews have been previously employed, especially where legislation must balance individual choice with protecting public health and public safety.vii For example, like Bill C-45, the purpose of the Controlled Drugs and Substances Act is to protect public health and public safety.27 Its review within five years is viewed as allowing for a thorough, evidence-based analysis to ensure that the provisions and operations of the act are meeting their intended purpose(s).viii Furthermore, a harm reduction approach lends itself to systematic evaluation of the approach's short- and long-term impact on the reduction of harms.5 The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process. Conclusion Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis' production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction. Recommendations 1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use. 2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis. 3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age). 3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years. i The term cannabis is used as in Bill C-45: that is, referring to the cannabis plant or any substance or mixture that contains any part of the plant. ii The plant contains at least 750 chemicals, of which there are over 100 different cannabinoids. Madras BK. Update of cannabis and its medical use. Agenda item 6.2. 37th Meeting of the Expert Committee on Drug Dependence, Department of Essential Medicines and Health Products, World Health Organization; 2015. Available: www.who.int/medicines/access/controlled-substances/6_2_cannabis_update.pdf (accessed 2017 Jul 27). iii House of Commons Special Committee on the Non-Medical Use of Drugs (2001) and the Senate Special Committee on Illegal Drugs (2002). iv An Act to amend the Contraventions Act and the Controlled Drugs and Substances Act (Bill C-38), which later was reintroduced as Bill C-10 in 2003. v For example, the Substance Use and Addictions Program (SUAP), a federal contributions program, is delivered by Health Canada to strengthen responses to drug and substance use issues in Canada. See Government of Canada. Substance Use and Addictions Program. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/services/health/campaigns/canadian-drugs-substances-strategy/funding/substance-abuse-addictions-program.html (accessed 2017 Jul 27). vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years. vii Several federal acts contain review provisions. Some examples include the Controlled Drugs and Substances Act, SC b1996, c 19, s 9 (five-year review); the Preclearance Act, SC 1999, c 20, s 39 (five-year review); the National Defence Act, RSC 1985, c N-5, s 273.601(1) (seven-year review); the Public Servants Disclosure Protection Act, SC 2005, c 46, s 54 (five-year review); and the Red Tape Reduction Act, SC 2015, c 12 (five-year review). viii The 2012 amendments to the Controlled Drugs and Substances Act were adopted from Bill S-10, which died on order papers in March 2011. The Senate Standing Committee on Legal and Constitutional Affairs reviewed Bill S-10 and recommended that the review period should be extended from two to five years as two years is not sufficient to allow for a comprehensive review. See Debates of the Senate, 40th Parliament, 3rd Session, No 147:66 (2010 Nov 17) at 1550; see also Senate Standing Committee on Legal and Constitutional Affairs, Eleventh Report: Bill S-10, An Act to Amend the Controlled Drugs and Substances Act and to Make Related and Consequential Amendments to Other Acts, with Amendments (2010 Nov 4). 1 Canadian Medical Association. Health risks and harms associated with the use of marijuana. CMA submission to the House of Commons Standing Committee on Health. Ottawa: The Association; 27 May 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/Brief-Marijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2017 Jul 27). 2 Canadian Medical Association. A public health perspective on cannabis and other illegal drugs. CMA submission to the Special Senate Committee on Illegal Drugs. Ottawa: The Association; 11 Mar 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed 2017 Jul 27). 3 Canadian Medical Association. Bill C-2 An Act to Amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the House of Commons Standing Committee on Public Safety and National Security. Ottawa: The Association; 28 Oct 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf (accessed 2017 Jul 27). 4 Harm Reduction International. What is harm reduction? A position statement from Harm Reduction International. London, UK: Harm Reduction International; 2017. Available: www.hri.global/what-is-harm-reduction (accessed 2017 Jul 27). 5 Riley D, O'Hare P. Harm reduction: history, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: national and international perspectives. Thousand Oaks, CA: Sage Publications; 2000. 6 Fischer B, Russel C, Sabioni P, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017;107(8):e1-e12. 7 Canadian Medical Association. Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada - Task Force on Cannabis Legalization and Regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27). 8 Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa: Government of Canada; 2017. Available: www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html (accessed 2017 Jul 27). 9 Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): summary of results for 2012. Ottawa: Health Canada; 2014. Available: www.canada.ca/en/health-canada/services/health-concerns/drug-prevention-treatment/drug-alcohol-use-statistics/canadian-alcohol-drug-use-monitoring-survey-summary-results-2012.html (accessed 2017 Jul 27). 10 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1 (accessed 2017 Jul 27). 11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. 12 Government of Canada. Legislative background: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (Bill C-45). Ottawa: Government of Canada; 2017. 13 An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, Bill C-45, First Reading 2017 Apr 13. 14 Crean RD, Crane NA, Mason BJ. An evidence based review of acute and long-term effects of cannabis use on executive cognitive functions. J Addict Med 2011;5(1):1-8. 15 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109(40):E2657-64 16 Crépault JF, Rehm J, Fischer B. The cannabis policy framework by the Centre for Addiction and Mental Health: a proposal for a public health approach to cannabis policy in Canada. Int J Drug Policy 2016;34:1-4. 17 Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug Alcohol Depend 2003;69(3):303-310. 18 Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav 2011;26(3):496-506. 19 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington (DC): The National Academies Press; 2017. 20 Canadian Cancer Society. 2017 federal pre-budget submission. Canadian Cancer Society submission to the Standing Committee on Finance. 2014 Aug. Available: www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398102/br-external/CanadianCancerSociety-e.pdf (accessed 2017 Jul 27). 21 Health Canada. Backgrounder: legalizing and strictly regulating cannabis: the facts. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/health-canada/news/2017/04/backgrounder_legalizingandstrictlyregulatingcannabisthefacts.html (accessed 2017 Jul 27) 22 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374(9698):1383-91. 23 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. The Daily. 2013 Sep 18. Statistics Canada cat. No. 11-001-X. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2017 Jul 27). 24 Miech RA, Johnston LD, O'Malley PM, Bachman JG, Schulenberg, JE. Monitoring the future national survey results on drug use, 1975-2010. Vol 1: Secondary students. Ann Arbor: Institute for Social Research, University of Michigan; 2011. 25 Spithoff S, Kahan M. Cannabis and Canadian youth: evidence, not ideology. Can Fam Physician 2014;60(9):785-7. 26 Health Canada. Strong foundation, renewed focus: an overview of Canada's Federal Tobacco Control Strategy 2012-2017. Ottawa: Health Canada; 2012. Available: www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/tobacco-strategy-2012-2017-strategie-tabagisme/alt/tobacco-strategy-2012-2017-strategie-tabagisme-eng.pdf (accessed 2017 Jul 27). 27 Controlled Drugs and Substances Act, SC 1996, c 19, s 9.
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Response to Health Canada’s Discussion Papers on “Proposed New Labelling Requirements for Tobacco Products” and “Options for Tobacco Promotion Regulations”

https://policybase.cma.ca/en/permalink/policy1982
Last Reviewed
2018-03-03
Date
1999-03-12
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2018-03-03
Date
1999-03-12
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
I. Introduction This document presents the position of the Canadian Medical Association (CMA)on the discussion papers “Proposed New Labelling Requirements for Tobacco Products” and “Options for Tobacco Promotion Regulations”, which were released by Health Canada on January 18, 1999. The document assesses the proposals outlined in the two papers and places them in the context of CMA’s comprehensive policy on tobacco control. The CMA is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including advocating health promotion and disease and injury prevention policies and strategies. It is in this capacity that we present this brief, the most recent of many statements on tobacco which CMA has made since it issued its first public warning on tobacco’s hazards in 1954. We have spoken out strongly and consistently for more than forty years because physicians have first-hand experience of the havoc that tobacco plays with the lives of Canadians. Tobacco kills 45,000 people a year in this country1 - more than traffic accidents, murders, suicides, drug abuse and AIDS combined. Because many people with tobacco-related diseases do not die of them, this number greatly underestimates the actual burden of suffering caused by tobacco in Canada. This burden of disease comes with a high price tag. Health Canada estimates that tobacco costs the Canadian health care system $3.5 billion a year in direct health care expenses. This does not include the cost of the disability, lost productivity and human pain and suffering caused by tobacco, which has been estimated at between $8 and 11 billion annually.2 It is for these reasons that the CMA has consistently recommended tough legislative and regulatory measures to control tobacco use. Since the Supreme Court of Canada struck down portions of the Tobacco Products Control Act in 1995, we have advocated strong replacement legislation. We supported Bill C-71, the Tobacco Act, and welcomed its enactment in 1997; since then we have repeatedly expressed our opposition to suggested amendments that would weaken the Act. CMA now commends Health Canada on its proposal to augment the Tobacco Act with regulations to mandate strong health warnings on packages of tobacco products, and on initiating discussion on regulations to control tobacco advertising and promotion. The following discusses in detail Health Canada’s specific suggestions. II. “Option for Tobacco Promotion Regulations” Before discussing specific options it should be said that the CMA advocates the prohibition of all forms of tobacco promotion in Canada. This includes advertisements in broadcast and print media, the sale of accessories and tobacco products displaying brand names, logos or colours, and advertising at point of sale. Accordingly we view the options described in the paper as compromises rather than ideal solutions, and our recommendations should be considered from this viewpoint. a) Tobacco Products, (Sections 3.1 (a) to 3.1 (f)) The CMA recommends a total ban on advertising and promotion of tobacco products at point of sale. The eye-catching “power walls” of cigarettes that one sees in corner stores could be considered a form of advertising. CMA therefore recommends the most restrictive option proposed in the paper, i.e. that tobacco products not be displayed above counter-tops. There should be no exemption from this restriction for any store. b) Accessories and Nontobacco Products (Section 3.1 (g) to 3.1 (k)) CMA’s recommended ban on tobacco advertising extends to a ban on the sale of accessories and nontobacco products carrying tobacco brand elements. We are aware that the Tobacco Act permits the use of tobacco brand elements on nontobacco products; however, we recommend that regulations restrict their use to the greatest extent possible. c) Service (Section 3.1 (l)) We assume that this provision is intended to control in-store advertising for events sponsored by tobacco companies. CMA has publicly opposed all advertising related to such events. We note that this advertising will be removed from stores altogether by 2003, under the provisions of Bill C-42. d) Availability Signs (Sections 3.1(m) - 3.1(p)) The CMA questions the need for availability signs; however, if they are permitted, Health Canada’s regulations must ensure that they not be used as advertising. For example, the number of signs that a location can display should be limited; the text on signs should be in plain black and white font; and the content should be restricted as described in Section 3.1(p). e) Advertising (Section 3.2) Again, CMA reminds Health Canada that it opposes tobacco advertising in all forms and would prefer a total ban to the options proposed in this section. However, since the Tobacco Act permits a limited amount of advertising, we recommend that Health Canada act on its stated intent to restrict this advertising’s attractiveness to young people and its potential to reach them. Accordingly we recommend the following: * that all advertisements for tobacco products, accessories or nontobacco products displaying tobacco product brand elements carry prominent health warning messages as proposed; * that advertisements be “text-only” without illustrations or decorative fonts; * that if it is impossible to keep brand elements off advertisements, they occupy as small a space as possible; * that advertisements be print-only and restricted to adult-circulation publications, as mandated in the Tobacco Act; * that the size of advertising signs be restricted; and * that the above recommendations also apply to advertising signs in places where young persons are not permitted. The Tobacco Act allows advertising in such places with the proviso that it not be “lifestyle” related. However, the concept of "lifestyle" advertising is vague and open to broad interpretation; as such, it is difficult to police and could be easily ignored or circumvented. Therefore CMA believes that a comprehensive ban on advertising is preferable to a partial one. f) Tobacco Product Packaging (Section 3.3) Packaging is an important part of the marketing of any product, and tobacco is no exception. Cigarette packages should not serve as an advertising tool and inducement to purchase. Plain packaging would reduce the attractiveness of cigarette boxes to consumers; accordingly CMA recommends that tobacco products be sold in plain packages. We are pleased to see standardized plain packaging presented as an option in this section, and we recommend that this option be adopted. III. “Proposed New Labelling Requirements for Tobacco Products” As Health Canada’s own research indicates, package labelling is a health education tool that can reach a large number of people for minimal cost; we believe that health warning labels have contributed to raising public awareness of the dangers of smoking and the toxic content of tobacco. Accordingly, CMA supports in principle the proposals in this paper. In addition to our support for plain packaging, CMA recommends that packages of tobacco products: * Contain health warnings prominently displayed; * Display messages that are as simple and direct as possible; this applies not only to health warnings but to all proposed messages, e.g. those reminding of the ban on sales to minors; * Use messages that are supported by scientific data and focus on the health effects of tobacco rather than social norms or emotional appeals. In particular, CMA recommends eliminating the message, “Smoking is a weakness, not a strength.” We believe that this message unfairly blames the victim for an activity that is in fact an addiction, not a weakness; * Display a list of toxic ingredients and additives; and * Provide information on treatment for tobacco addiction, for example, information on nicotine replacement, advice to smokers to consult their physicians if they are ready to stop smoking, and information about available cessation programs. Packages might also include inserts containing additional information on product content and health risks. This information should also be based on scientific evidence focusing on the medical consequences of tobacco use. However, the use of inserts should be carefully evaluated in light of its possible impact on the environment. The labelling requirements proposed in this paper are consistent with the spirit of CMA’s policy. We commend Health Canada for taking these steps, and for mandating health warnings not only on cigarettes but on all tobacco products. IV. The Larger Context It is important to emphasize that CMA does not consider the proposed regulations, or any other single initiative, a “miracle cure” for Canada’s tobacco problem. Just as there are a variety of reasons why children take up the smoking habit, so it will take a variety of initiatives, working in combination, to effectively fight tobacco. We urge the government of Canada to augment its proposed regulations on labelling and promotion by: * Providing support for smoking cessation services for those who are addicted to tobacco. CMA has been involved with three of its provincial divisions in the “Mobilizing Physicians for Clinical Tobacco Intervention (MP-CTI)” project, whose purpose is to help physicians counsel their patients on how to stop smoking. Evidence shows that even brief counseling by a health professional increases the quit rate, particularly when combined with the “patch” or other nicotine replacement therapies.3 MP-CTI has provided physicians and other health professionals with motivation to make smoking cessation counseling a part of their routine and with tools to enhance their counseling practices. The CMA believes that the government should support MP-CTI and other programs that encourage evidence-based practices in health care. * Continuing to increase consumer and manufacturer tobacco taxes, raising them as high as is compatible with discouraging smuggling. In our 1998 pre-budget brief to the Standing Committee on Finance we recommended that the government gradually increase tobacco taxes, and we supported the tobacco tax increase implemented in February 1998.4 * Providing funding to ensure that Canada maintains strong, sustained and effective programs to discourage children from smoking. In 1997 the Liberal Party promised to commit $100 million over five years for tobacco control programs, including $50 million for public education5. We would like to see this amount committed as a minimum, and preferably increased. The CMA also continues to support the concept of a levy on tobacco products to fund programs to discourage tobacco use, and we urge the government to take action soon in this regard. Tobacco is the number one cause of preventable disease and death in Canada. The CMA urges the Government of Canada to deal with it as strongly as the burden it imposes on this country warrants. V. References 1. Ellison LF, Mao Y, Gibbons L Projected smoking-attributable mortality in Canada, 1991 2000. Chron Dis Can 1995; 16: 84 - 89. 2. Health Canada. Economic Costs due to Smoking (Information Sheet). Health Canada, November 1996. 3. Agency for Health Care Policy and Research. Smoking Cessation (Clinical Practice Guideline Number 18). U.S. Department of Health and Human Services, 1996. 4. Canadian Medical Association. Canadians’ Access to Quality Health Care: a System in Crisis. Brief submitted to the House of Commons Standing Committee on Finance, August 1998. 5. Liberal party. Securing our Future. Liberal Party of Canada, 1997.
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Proposed Amendments to the Criminal Code of Canada (Impaired Driving) : Response to Issue Paper of the Standing Committee on Justice and Human Rights

https://policybase.cma.ca/en/permalink/policy1983
Last Reviewed
2018-03-03
Date
1999-03-05
Topics
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2018-03-03
Date
1999-03-05
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a multidimensional approach to the issue. The CMA therefore recommends the following: * developing awareness campaigns and education programs, particularly at the high school level where the pattern of alcohol misuse is often established; * retaining the curative treatment provision found in Section 255(5) of the Criminal Code; * providing comprehensive treatment suited to the needs of the individual person. Those repeatedly convicted of impaired driving should be considered for mandatory assessment; * seizing or impounding the driver’s vehicle for the length of the license suspension if an individual is charged with impaired driving while his or her licence is suspended because of a previous impaired driving conviction; * lowering the legal BAC limit to 50 mg%; and * creating probationary licence systems for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. I. Introduction The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including advocating health promotion and disease and accident prevention policies and strategies. It is in this capacity that we present our position on proposed amendments to the Criminal Code sections on impaired driving. The CMA welcomes this opportunity to comment on the issue of drinking and driving and the safety of our public roadways. The injuries and deaths resulting from impaired driving present a major public health concern. Physicians see the consequences of impaired driving in their practices. In 1996, 3,420 persons were killed in motor vehicle crashes. Alcohol was involved in 39.7% of those fatalitiesi. In CMA policy documents and publications like the Physicians’ Guide to Driver Examination, the CMA has advocated for measures to reduce injury and death resulting from drinking and driving. The CMA has previously endorsed legislation aimed at reducing the incidence of drinking and driving, including the use of the breathalyser test, more severe penalties for those convicted and the taking of a mandatory blood sample if the individual is unable to provide a breath sampleii. Several of CMA’s provincial and territorial divisions have also issued policy statements on impaired driving (Appendix 1). II. Multidimensional Approach From 1987 to 96, there was a general decline in the percentage of fatally injured drivers who had been drinkingiii. In 1996, of tested drivers fatally injured in motor vehicle crashes, 41.6% had been drinking (with a Blood Alcohol Content (BAC) over 1 mg%>) while 34.9% were legally impaired (BAC >80 mg%)iv. CMA believes that to reduce the number of fatalities and injuries even further, a comprehensive, multidimensional approach encompassing the expertise, resources and experience of health professionals and all levels of government is required. This approach encompasses: (1) public education, (2) medical assessment and treatment interventions and (3) legislation. 1. Public Education Drinking and driving must be viewed as socially unacceptable behaviour and until this change in attitude occurs, the judicial system cannot be completely effective in controlling the drinking and driving patterns of individuals. Education and information programs which increase society’s awareness of the consequences of using alcohol in combination with driving are integral parts of any attempt to reduce injuries and fatalities. The CMA supports and recommends the development of awareness campaigns and education programs, particularly at the high school level where the pattern of alcohol misuse is often established. 2. Medical Assessment and Treatment Interventions CMA shares the belief of specialists in the field of addiction medicine that punishment in the form of incarceration will not solve the problem of impaired drivingv. Rather, in addition to public education campaigns and criminal law sanctions, government must create and fund appropriate assessment and treatment interventions. Impaired drivers may be occasional users of alcohol. They may also suffer from the disease of Substance Dependence. In the case of alcohol, this disease is commonly known as alcoholism. There are several assessment tools and screening tests to diagnose chronic alcoholismvi. The term “Hard Core” drinking driver has also been coined to describe impaired drivers who repeatedly drive after drinking, often with a high BAC of 150 mg% or more. They are also resistant to change despite previous actions, treatment or education effortsvii. Although roadside surveys have revealed a general decrease in the overall level of drinking-driving in Canada, drivers with very high levels of BAC (over 150 mg%) seemed immune to this trendviii. “Hard Core” drinking drivers are most likely suffering from substance dependence or alcoholism, a condition requiring significant treatment interventionix. Physicians, in their educational capacity, can assist in establishing programs in the community aimed at the recognition of the early signs of alcohol abuse or dependency. These programs should recognize the chronic, relapsing nature of alcohol addiction as a disease. There is also good evidence that physician interactions like the Alcohol Risk Assessment and Intervention program developed by the College of Family Physicians of Canada can have a positive impact on the behaviours of moderate drinkersx. Another tool to aid physicians in the assessment of patients who drive impaired is the CMA publication, The Physicians’ Guide to Driver Examination. The Physicians’ Guide to Driver Examination is a collection of guidelines and expert opinions designed to help physicians assess their patients’ medical fitness to drive. The Physicians’ Guide discusses the impact of a variety of medical conditions on driving, including alcohol use, abuse and dependency. The Physicians’ Guide underlines the fact that alcohol-induced impairment is the single greatest contributor to fatal motor vehicle accidents in Canadaxi. The Physicians Guide to Driver Examination takes a strong stance on the status of drivers with chronic alcohol problems. It recommends that a chronic alcohol abuser should not be allowed to drive any type of motor vehicle until the patient has been assessed and received treatment. The Physicians' Guide to Driver Examination is currently under revision with an anticipated distribution date in the fall of 1999 for the sixth edition. (a) Discharge for Curative Treatment The Standing Committee on Justice and Human Rights has asked whether it is appropriate under Section 255(5) of the Criminal Code to allow the courts to discharge an impaired driver who is in need of “curative treatment” by placing that person on probation with a condition that he or she attends such treatment. Section 255(5) of the Criminal Code reads: Notwithstanding subsection 736(1), a court may, instead of convicting a person of an offence committed under section 253, after hearing medical or other evidence, if it considers that the person is in need of curative treatment in relation to his consumption of alcohol or drugs and that it would not be contrary to the public interest, by order direct that the person be discharged under section 730 on the conditions prescribed in a probation order, including a condition respecting the person’s attendance for curative treatment in relation to his consumption of alcohol or drugs. The CMA believes that Section 255(5) should remain within the Criminal Code. Section 255(5) is an important recognition within the punitive framework of the Criminal Code of the necessary medical and rehabilitative elements at stake in the issue of impaired driving. CMA believes that there are sufficient safeguards within the wording of Section 255(5) to conclude that it does not invite misuse. There are several hurdles to meet in Section 255(5) before the court may award curative treatment. First, the court hears “medical or other evidence”. In essence, the granting of the curative treatment order is not merely dependent on the pleas of the impaired driver. Second, the court must be satisfied that the discharge is not contrary to the public interest. In determining what is in the public interest, the courts look to the accused’s motivation and good faith, whether he or she was already subject to a driving prohibition, the risk of recidivism, previous convictions for impaired driving, prior curative discharges and the circumstances of the offence, including consideration of whether the accused was involved in an accident which caused death, bodily harm or significant property damagexii. Finally, it is highly unlikely that the “curative treatment” at issue in Section 255(5) would be involuntary or enforced against the wishes of the accused because his or her motivation or good will in pursuing treatment as an alternative to conviction is a key factor in the court’s decisionxiii. The CMA recommends retaining the curative treatment provision found in Section 255(5) of the Criminal Code. (b) Assessment and Rehabilitation Rehabilitation can occur through education and treatment programs designed for impaired drivers. The CMA believes it is important to provide comprehensive treatment suited to the needs of the individual person. The CMA recognizes that as an exception to the general rule that medical interventions should be voluntary, individuals repeatedly convicted of the offence of impaired driving should be considered for mandatory assessment. This mandatory assessment, followed by medical recommendations for appropriate treatment, would not only benefit those with a chronic alcohol problem but could also help to reduce the incidence of drunk driving incidents attributable to repeat offenders. Physicians have the training, knowledge and expertise to assist in developing alcohol assessment, treatment and rehabilitation programs. Currently, nine jurisdictions have some form of mandatory assessment and rehabilitation programsxiv. The CMA recommends providing comprehensive treatment suited to the needs of the individual person. Those repeatedly convicted of impaired driving should be considered for mandatory assessment. 3. Legislation (a) Impoundment On the issue of whether the current penalties provide sufficient deterrence, the CMA is in general agreement with the impoundment measures currently found in eight provincial and territorial jurisdictionsxv. CMA would encourage jurisdictions that do not have these impoundment programs to consider enacting them. Since 1989, the CMA has recommended that if an individual is charged with impaired driving while his or her licence is suspended because of a previous impaired driving conviction, the suspended driver’s vehicle should be seized or impounded for the length of the license suspension. (b) Blood Alcohol Content (BAC) In response to the question of whether the legal BAC limit should be lowered from 80 mg%, since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canadaxvi. A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BACxvii. Finally, the CMA notes that many jurisdictions have 50 mg% as the limit for impairmentxviii. The CMA recommends lowering the legal BAC limit to 50 mg%. The CMA has also supported the 1987 recommendation of the former Standing Committee of National Health and Welfare on Alcohol and Drug Abuse in Canada that the provinces establish a probationary or graduated licence system for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. Several studies have remarked on the significant reduction in casualty collisions when there is a 0 BAC limit for novice drivers xix. The CMA notes that several provinces have instituted such a graduated licensing systemxx. The CMA supports probationary licence systems for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. (c) Police Powers On the issue of police powers to demand breath, blood or saliva samples for alcohol and/or blood testing, the CMA reiterates its earlier support for mandatory blood alcohol testing as outlined in the Criminal Code. At the request of CMA, physicians and other health care workers who take blood samples under this law are specifically protected from criminal and/or civil litigation, but it is not an offense for these health care workers to refuse to take a blood samplexxi. III. Conclusion The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education campaigns constitute the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. It is prefererable to use countermeasures that prevent the occurrence of motor vehicle crashes involving impaired drivers rather than those that deal with the offender after the fact. The multifaceted nature of the issue of impaired driving requires multidimensional countermeasures as part of a comprehensive policy involving all levels of government, private organizations, communities and individuals. The CMA urges all Canadians to support such efforts to reduce the prevalence of drinking and driving. IV. Appendix 1 A List of Some Policy Statements and Resolutions on Impaired Driving from CMA Provincial and Territorial Divisions: * Alberta Medical Association, 1983: That the AMA recommend to the Government of Alberta that it take whatever steps are necessary to ensure that there are adequate penalties for impaired driving and that such penalties are well enforced. * New Brunswick Medical Society: February, 1988.“Statement on Driving Impairment” October, 1992. “NBMS Position Statement on Alcohol” * Northwest Territories Medical Association: Endorsed June, 1998. “Strategy to Reduce Impaired Driving in the Northwest Territories: Interagency Working Group on Impaired Driving. June, 1996.” * Ontario Medical Association: November, 1994. “An OMA Position Paper on Drinking and Driving”. V. Endnotes i.Traffic Injury Research Foundation (TIRF) (1998).Strategy to Reduce Impaired Driving 2001: STRID 2001 Monitoring Report: Progress in 1996 and 1997. Ottawa: Traffic Injury Research Foundation at 25, 28. ii.Canadian Medical Association (1989). Substance Abuse and Driving: A CMA Review. Ottawa: Canadian Medical Association at 3. 3. Mayhew, D.R., S.W. Brown and H.M. Simpson. (1998) Alcohol Use Among Drivers and Pedestrians Fatally Injured in Motor Vehicle Accidents: Canada, 1996. Ottawa: Traffic Injury Research Foundation at 19. iv.Ibid at 13-14. v. Hajela, Raju CD, MD, MPH, CCFP, CASAM, FASAM, President of the Canadian Society of Addiction Medicine. Letter to CMA dated January 13, 1999. vi.American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Washington, D.C.: American Psychiatric Press. vii. Beirness, D.J., H.M. Simpson, and D.R. Mayhew (1998). Programs and policies for reducing alcohol-related motor vehicle deaths and injuries. Contemporary Drug Problems 25/Fall 1998. See also the Century Council (1998) National Hardcore Drunk Driver Project. http://www.dwidata.org. viii. Beirness, D.J., Mayhew, D.R., Simpson, H.M. and Stewart, D.E. (1995) Roadside surveys in Canada: 1974-1993. In Kloeden, C.N. and McLean, A.J. (eds). Alcohol, Drugs and Traffic Safety-T’95.Adelaide, Australia:NHMRC Road Accident Research Unit, University of Adelaide, pp. 179-184 as cited in Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E at 14-15. ix. Hajela, note 5 at 2. x. Brison, Robert J., MD (1997). The Accidental Patient. Canadian Medical Association Journal, 157 (12) 1661-1662. xi. Canadian Medical Association (1991).Physicians' Guide to Driver Examination. Ottawa: Canadian Medical Association at 51. xii. R v. Storr (1995), 14 M.V.R. (3d) 34 (Alta. C.A.). xiii. Ibid. xiv.Traffic Injury Research Foundation (TIRF), note 1 at 12. xv.Ibid. xvi. Mann et al., note 8 at 54. xvii. Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13. xviii.Mann et al., note 8 at 24. xix.Hingson, R., Heeren, T. and Winter, M. (1994) Lower legal blood alcohol limits for young drivers. Public Health Reports, 109, 738-744 as cited in Mann et al., note 8 at 36. xx.Mann et al., note 8 at 29. xxi.Canadian Medical Association, note 2 at 3.
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CMA’s Recommendations for Bill S-5 An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy13918
Date
2018-02-15
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2018-02-15
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Standing Committee on Health for its study of Bill S-5, An Act to amend the Tobacco Act and the Non-Smokers Health Act and to make consequential amendments to other Acts. We support the government’s effort to implement a new legislative and regulatory framework to address vaping products and related matters. Vaping products, such as electronic cigarettes (or e-cigarettes) replicate the act and taste of smoking but do not contain tobacco. We also recognize that the federal government is attempting to find a balance between regulating vaping devices and making them available to adults. Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. Our most recent efforts centred on our participation in the 2016 Endgame Summit, held late last year in Kingston, Ontario. This brief will focus on three areas: supporting population health; the importance of protecting youth; and, the promotion of vaping products. Overview Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Smoking has been on the decline in Canada the most recent Canadian Community Health Survey reports that 17.7% of the population aged 12 and older were current daily or occasional smokers in 2015 (5.3 million smokers); that is down from 18.1% in 2014.1 Many strong laws and regulations have already been enacted but some areas remain to be addressed and strengthened especially as the 1 Statistics Canada. Smoking, 2015. Health Fact Sheets. Statistics Canada Cat. 82-625-X. Ottawa: Statistics Canada; 2016. Available: http://www.statcan.gc.ca/pub/82-625-x/2017001/article/14770-eng.htm (accessed 2018 Feb 1). 2 Czoli CD, Hammond D, White CM. Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Can J Public Health. 2014;105(2):e97-e102. 3 Filippos FT, Laverty AA, Gerovasili V, et al. Two-year trends and predictors of e-cigarette use in 27 European Union member states. Tob Control. 2017;26:98-104. 4 Malas M, van der Tempel J, Schwartz R, Minichiello A, Lightfoot C, Noormohamed A, et al. Electronic cigarettes for smoking cessation: A systematic review. Nicotine Tob Res. 2016;18(10):1926–36. 5 O’Leary R, MacDonald M, Stockwell T, Reist D. Clearing the air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. Victoria, BC: Centre for Addictions Research of BC; 2017. Available: http://ectaofcanada.com/clearing-the-air-a-systematic-review-on-the-harms-and-benefits-of-e-cigarettes-and-vapour-devices/ (accessed 2018 Feb 1). 6 El Dib R, Suzumura EA, Akl EA, Gomaa H, Agarwal A, Chang Y, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis. BMJ Open. 2017 23;7:e012680. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337697/pdf/bmjopen-2016-012680.pdf (accessed 2018 Feb 1). 7 Shahab L, Goniewicz M, Blount B, et al. Nicotine, carcinogen, and toxin exposure in long-term e- cigarette and nicotine replacement therapy users: A cross sectional study. Annals of Internal Medicine. 2017;166(6):390-400. 8 Collier R. E-cigs have lower levels of harmful toxins. CMAJ. 2017 Feb 27;189:E331. 9 Sleiman M, Logue J, Montesinos VN, et al. Emissions from electronic cigarettes: Key parameters affecting the release of harmful chemicals. Environmental Science and Technology. 2016 Jul 27;50(17):9644-9651. 10 England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: A neglected element in the electronic cigarette debate. Am J Prev Med. 2015 Aug;49(2):286-93. 11 Foulds J. Use of Electronic Cigarettes by Adolescents. J Adolesc Health. 2015 Dec;57(6):569-70. 12 Khoury M, Manlhiot C, Fan CP, Gibson D, Stearne K, Chahal N, et al. Reported electronic cigarette use among adolescents in the Niagara region of Ontario. CMAJ. 2016 Aug 9;188(11):794-800. 13 U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA- 8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. 14 Miech R, Patrick ME, O’Malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tob Control. 2017 Dec;26(e2):e106–11. 15 Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatr. 2015 Nov;169(11):1018–23. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800740/pdf/nihms768746.pdf (accessed 2018 Feb 1). 16 Hoe J, Thrul J, Ling P. Qualitative analysis of young adult ENDS users’ expectations and experiences. BMJ Open. 2017;7:e014990. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353280/pdf/bmjopen-2016-014990.pdf (accessed 2018 Feb 1). 17 Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco “endgame.” N Engl J Med. 2014 Jan 23;370:4 Available: http://www.nejm.org/doi/pdf/10.1056/NEJMp1313940 (accessed 2018 Feb 1). 18 Choi K, Grana R, Bernat D. Electronic nicotine delivery systems and acceptability of adult cigarette smoking among Florida youth: Renormalization of smoking? J Adolesc Health. 2017 May;60(5):592–8. tobacco industry continues to evolve. Electronic cigarettes and vaping represents the next step in that evolution. While Canada is to be congratulated on its success to date, it needs to maintain an environment that encourages Canadians to remain tobacco-free if smoking prevalence is to be reduced further in Canada. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Supporting Population Health The arrival of vaping products in Canada placed them in a “grey zone” with respect to legislation and regulation. Clarification of their status is crucial from a public health perspective because of their growing popularity, particularly among youth.2 E-cigarettes have both defenders and opponents. Proponents say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease. Indeed, some believe they serve a useful purpose as a harm reduction tool or cessation aid (though it is forbidden to market them as such since that claim has never been approved by Health Canada). Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the cigarettes may contain other toxic ingredients such as nitrosamines. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to the use of tobacco by people who might otherwise have remained smoke-free. This issue will be addressed later in this brief. This difference of opinion certainly highlights the need for more research into the harms and benefits of vaping products and the factors that cause people to use them.3 Encouraging smokers to move from combustible tobacco products to a less harmful form of nicotine may be a positive step. However the current available evidence is not yet sufficient to establish them as a reliable cessation method. A systematic review published by M. Malas et al. (2016) concluded that while “a majority of studies demonstrate a positive relationship between e-cigarette use and smoking cessation, the evidence remains inconclusive due to the low quality of the research published to date.”4 Indeed, some are helped by these devices to quit smoking but “more carefully designed and scientifically sound studies are urgently needed to establish unequivocally the long-term cessation effects of e-cigarettes and to better understand how and when e-cigarettes may be helpful.”4 The authors found that the evidence examining e-cigarettes as an aid to quitting smoking was determined to be “very low to low.”4 A similar result was found for their use in reducing smoking; the quality of the evidence was revealed as being “very low to moderate.”4 This conclusion is supported by another review conducted by the University of Victoria (2017). It too indicates that there are not enough studies available to fully determine the efficacy of vaping devices as a tobacco cessation device.5 This review also noted that there is “encouraging evidence that vapour devices can be at least as effective as other nicotine replacements.”5 Another review by R. El Dib et al. (2017) reinforces these findings. Limited evidence was also found with respect to the impact of electronic devices to aide cessation. They also noted that the data available from randomized control trials are of “low certainty” and the “observational studies are of very low certainty.”6 The wide range of devices available makes it very difficult to test which are the most effective in helping cessation efforts. Many of the studies are on older devices so it is possible that as second-generation technology becomes available they will prove to be more successful. In view of this uncertainty, the CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. Physicians need to be confident that if they recommend such therapy to their patients it will have the desired outcome. To that end, we are pleased that Health Canada will continue to require manufacturers to apply for authorization under the Food and Drugs Act to sell products containing nicotine and make therapeutic claims. Risk and Safety In addition to the discussion concerning the usefulness of vaping devices as cessation devices, concerns from a public health standpoint involve the aerosol or vapour produced by heating the liquids used in these devices, and the nicotine some may contain. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine and/or flavourings that are intended to boost their appeal to young people. The CMA is concerned that not enough is known about the safety of the ingredients in the liquids being used in vaping devices. While it is the case that because e-cigarettes heat rather than burn the key constituent, they produce less harmful toxins and are much safer than conventional cigarettes. Research in the UK suggested that “long-term Nicotine Replacement Therapy (NRT)-only and e-cigarette-only use, but not dual-use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.”7 However, this study has been criticized because “it only looked at a few toxins and didn’t test for any toxins that could be produced by e- cigarettes.”8 The variety of flavourings and delivery systems available make it imperative that the risks associated with these products be fully understood. As one study noted “analysis of e-liquids and vapours emitted by e-cigarettes led to the identification of several compounds of concern due to their potentially harmful effects on users and passively exposed non-users.”9 The study found that the emissions were associated with both cancer and non-cancer health impacts and required further study.9 There is another aspect of the public health question surrounding vaping devices. There is data to support the idea that “nicotine exposure during periods of developmental vulnerability (e.g., fetal through adolescent stages) has multiple adverse health consequences, including impaired fetal brain and lung development.”10 Therefore it is imperative that pregnant women and youth be protected. There is not enough known about the effects of long-term exposure to the nicotine inhaled through vaping devices at this time.11 Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. Protecting Youth The CMA is encouraged by the government’s desire to protect youth from developing nicotine addiction and inducements to use tobacco products. Young people are particularly vulnerable to peer pressure, and to tobacco industry marketing tactics. The CMA supports continued health promotion and social marketing programs aimed at addressing the reasons why young people use tobacco and have been drawn to vaping devices, discouraging them from starting to use them and persuading them to quit, and raising their awareness of tobacco industry marketing tactics so that they can recognize and counteract them. These programs should be available continuously in schools and should begin in the earliest grades. The “cool/fun/new” factor that seems to have developed around vaping devices among youth make such programs all the more imperative.12 The CMA recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. We are pleased to see that Bill S-5 aims to restrict access to youth, including prohibiting the sale of both tobacco and vaping products in vending machines as well as prohibiting sales of quantities that do not comply with the regulations. In fact, the CMA recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. The more restricted is availability, the easier it is to regulate. The CMA considers prohibiting the promotion of flavours in vaping products that may appeal to youth, such as soft drinks and cannabis, to be a positive step. A recent report published by the World Health Organization and the US National Cancer Institute indicated that websites dedicated to retailing e-cigarettes “contain themes that may appeal to young people, including images or claims of modernity, enhanced social status or social activity, romance, and the use of e-cigarettes by celebrities.”13 We are therefore pleased that sales of vaping products via the internet will be restricted through prohibiting the sending and delivering of such products to someone under the age of 18. This will be critical to limiting the tobacco industry’s reach with respect to youth. There have also been arguments around whether vaping products will serve as gateways to the use of combusted tobacco products. The University of Victoria (2017) paper suggests this isn’t the case; it notes that “there is no evidence of any gateway effect whereby youth who experiment with vapour devices are, as a result, more likely to take up tobacco use.”5) They base this on the decline in youth smoking while rates of the use of vaping devices rise.Error! Bookmark not defined. Others contend that vaping is indeed a gateway, saying it acts as a “one-way bridge to cigarette smoking among youth. Vaping as a risk factor for future smoking is a strong, scientifically-based rationale for restricting access to e-cigarettes.”14 Further, in a “national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e- cigarettes to adolescents and young adults.”15 However, there may be a role for vaping products in relation to young users. A New Zealand study conducted among young adults that examined how electronic nicotine delivery systems (ENDS) were used to recreate or replace smoking habits. It found that study participants “used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance.”16 Further, it was suggested that ascertaining how “ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.”16 The CMA believes that further research is needed on the question of the use of vaping products as a gateway for youth into combustible tobacco products. Recommendations: 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. Promotion of Vaping Products The CMA has been a leader in advocating for plain and standardized packaging for tobacco products for many years. We established our position in 1986 when we passed a resolution at our General Council in Vancouver recommending to the federal government “that all tobacco products be sold in plain packages of standard size with the words “this product is injurious to your health” printed in the same size lettering as the brand name, and that no extraneous information be printed on the package.” The CMA would like to see the proposed plain packing provisions for tobacco be extended to vaping products as well. The inclusion of the health warning messages on vaping products is a good first step but efforts should be made to ensure that they are of similar size and type as those on tobacco as soon as possible. The restrictions being applied to the promotion of vaping products is a positive step, especially those that could be aimed at youth, but they do not go far enough. The CMA believes the restrictions on promotion should be the same as those for tobacco products. As the WHO/U.S. National Cancer Institute has already demonstrated, e- cigarette retailers are very good at using social media to promote their products, relying on appeals to lifestyle changes to encourage the use of their products. The CMA is also concerned that e-cigarette advertising could appear in locations and on mediums popular with children and youth if they are not prohibited explicitly in the regulations. This would include television and radio advertisements during times and programs popular with children and youth, billboards near schools, hockey arenas, and on promotional products such as t-shirts and ball caps. As efforts continue to reduce the use of combustible tobacco products there is growing concern that the rising popularity of vaping products will lead to a “renormalization” of smoking. In fact, worry has been expressed that the manner they have been promoted “threaten(s) to reverse the successful, decades-long public health campaign to de- normalize smoking.”17 A recent US study indicated that students that use vaping products themselves, exposure to advertising of these devices, and living with other users of vaping products is “associated with acceptability of cigarette smoking, particularly among never smokers.”18 Further research is needed to explore these findings. Recommendations: 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. Conclusion Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Our members see the devastating effects of tobacco use every day in their practices and to that end the CMA has been working for decades toward the goal of a smoke-free Canada. The tobacco industry continues to evolve and vaping represents the next step in that evolution. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Bill S-5 is another step in that journey. Researchers have identified potential benefits as well as harms associated with these products that require much more scrutiny. The association of the tobacco industry with these products means that strong regulations, enforcement, and oversight are needed. Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids.. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products.
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