Health care professionals, including physicians, play an essential role in promoting health and preventing disease among all Canadians. A significant proportion of death, illness and injury in Canada is preventable. These preventable health problems place a substantial burden of suffering on individuals, families and communities as well as a heavy burden on society because they draw on scarce health care resources.
The World Health Organization defines health promotion as "the process of enabling people to increase control over and improve their health." Health promotion activities generally seek to influence either a person’s individual behaviours such as smoking and sedentary lifestyle. Effective health promotion also addresses the broader social determinants of health, for example, income, access to services and physical environment.
The CMA views prevention and health promotion as a responsibility to be shared among all health care providers, rather than the sole responsibility of any one group or specialty.
At a collective level, medical and other health organizations can be involved in prevention and health-promotion activities such as organizing public education campaigns, advocating for legislation that promotes health, such as laws to control pollution and tobacco products, and disseminating clinical practice guidelines to enhance standards of preventive care.
At an individual level, the role of physicians in the continuum of patient care is an important one, with the potential for further enhancement, and can include:
Health enhancement: As part of daily practice, physicians routinely offer information to support the prevention of disease. These activities include appropriate discussions with patients about nutrition, physical activity and access to social supports. In providing these services, physicians consider the social, economic and environmental conditions in which their patients live.
Risk avoidance: Physicians ensure that people take measures that will prevent specific risks of disease. Examples include providing immunizations, promoting breast-feeding, physical activity and the use of bicycle helmets.
Risk reduction: Physicians screen, counsel and work with individuals or segments of the population at higher risk of disease or injury to reduce their risk. Examples include screening for risk factors for the development of heart disease or diabetes, such as nutrition, smoking and alcohol use.
Early identification: Physicians screen people to detect diseases at an asymptomatic stage, when intervention can improve the outcome. Papanicolaou smears to detect cancer of the cervix and breast exams to detect breast cancer are two types of tests being used in early detection. With the increase in public awareness and interest in prevention, physicians often spend time with their patients discussing the pros and cons of tests such as mammographic screening of women and the prostate-specific antigen screening test for men.
Complication reduction: Physicians can prescribe therapy to prevent complications in patients with diagnosed conditions or diseases. For example, the use of medication to reduce the incidence of stroke or myocardial infarction in high risk patients.
1) Physicians should continue to incorporate all levels of health promotion and disease prevention into their practices, emphasizing activities for which there is sufficient scientific evidence.
2) Education in prevention and health promotion both at an individual and at a collective level, should be given high priority in undergraduate medical programs, in residency training and in continuing medical education.
3) Physicians should be encouraged to work with other health care professionals in the office setting and the community to enhance delivery of care that incorporates prevention and health promotion.
4) Remuneration systems should support a multidisciplinary approach to the delivery of these services; they should also support the provision of these services by individual physicians.
5) Patients should have access to a family physician who can provide care that includes prevention and health promotion. Family physicians should continue to develop professional relationships with their patients that encourage the long-term promotion and maintenance of good health.
6) Clear, simple and current guidelines for prevention and health promotion services should be widely distributed to physicians. The Canadian Task Force on Preventive Health Care regularly develops and updates guidelines in this area.
7) Simple, easy-to-understand patient guidelines for prevention and health promotion should be developed and made available to the public. Physicians should continue to develop, improve and promote patient-counselling programs and office-management systems that encourage effective delivery of preventive care and health promotion.
8) Governments should give high priority to public policies that take account of the broad range of determinants of health, and proposed legislation should be routinely reviewed for any impact on the health of individuals and the community. CMA, in collaboration with other health professions and governments, will continue to explore means to ensure that public policies are developed with due attention paid to their potential health consequences.
Approved by the CMA Board in 2001.
Last reviewed and approved by the CMA Board in March 2019.
Inherent in all health care professional Codes of Ethics is the duty to provide care to patients and to relieve suffering whenever possible. However, this duty does not exist in a vacuum, and depends on the provision of goods and services referred to as reciprocal obligations, which must be provided by governments, health care institutions and other relevant bodies and agencies. The obligation of government and society to physicians can be seen as comparable to the obligations of physicians to their patients.
The recent experience of Canadian physicians during the SARS epidemic in Toronto has heightened the sensitivities of the medical profession to several issues that arose during the course of dealing with that illness. Many of the lessons learned (and the unanswered questions that arose) also apply to the looming threat of an avian flu (or other) pandemic. Canadian physicians may be in a relatively unique position to consider these issues given their experience and insight.
The intent of this working paper is to highlight the ethical issues of greatest concern to practicing Canadian physicians which must be considered during a pandemic. In order to address these issues before they arise, the CMA presents this paper for consideration by individual physicians, physician organizations, governments, policy makers and interested bodies and stakeholders. Although many of the principles and concepts could readily be applied to other health care workers, the focus of this paper will be on physicians.
Policies regarding physicians in training, including medical students and residents, should be clarified in advance by the relevant bodies involved in their oversight and training. Issues of concern would include the responsibilities of trainees to provide care during a pandemic and the potential effect of such an outbreak on their education and training.
A. Physician obligations during a pandemic
The professional obligations of physicians are well spelled out in the CMA Code of Ethics and other documents and publications and are not the main focus of this paper. However, they will be reviewed and discussed as follows.
Several important principles of medical ethics will be of particular relevance in considering this issue. Physicians have an obligation to be beneficent to their patients and to consider what is in the patient's best interest. According to the first paragraph of the CMA Code of Ethics (2004), "Consider first the well-being of the patient".
Traditionally, physicians have also respected the principle of altruism, whereby they set aside concern for their own health and well-being in order to serve their patients. While this has often manifested itself primarily as long hours away from home and family, and a benign neglect of personal health issues, at times more drastic sacrifices have been required. During previous pandemics, many physicians have served selflessly in the public interest, often at great risk to their own well-being.
The principle of justice requires physicians to consider what is owed to whom and why, including what resources are needed, and how these resources would best be employed during a pandemic. These resources might include physician services but could also include access to vaccines and medications, as well as access to equipment such as ventilators or to a bed in the intensive care unit. According to paragraph 43 of the CMA Code of Ethics, physicians have an obligation to "Recognize the responsibility of physicians to promote equitable access to health care resources".
In addition, physicians can reasonably be expected to participate in the process of planning for a pandemic or other medical disaster. According to paragraph 42 of the CMA Code of Ethics, physicians should "Recognize the profession's responsibility to society in matters relating to public health, health education, environmental protection, legislation affecting the health and well-being of the community and the need for testimony at judicial proceedings". This responsibility could reasonably be seen to apply both to individual physicians as well as the various bodies and organizations that represent them.
Physicians also have an ethical obligation to recognize their limitations and the extent of the services they are able to provide. During a pandemic, physicians may be asked to assume roles or responsibilities with which they are not comfortable, nor prepared. Paragraph 15 of the CMA Code of Ethics reminds physicians to "Recognize your limitations and, when indicated, recommend or seek additional opinions or services".
However, physicians have moral rights as well as obligations. The concept of personal autonomy allows physicians some discretion in determining where, how and when they will practice medicine. They also have an obligation to safeguard their own health. As stated in paragraph 10 of the CMA Code of Ethics, physicians should "Promote and maintain your own health and well-being".
The SARS epidemic has served to reopen the ethical debate. Health care practitioners have been forced to reconsider their obligations during a pandemic, including whether they must provide care to all those in need regardless of the level of personal risk. As well, they have been re-examining the obligation of governments and others to provide reciprocal services to physicians, and the relationship between these obligations.
B. Reciprocal obligations towards physicians
While there has been much debate historically (and especially more recently) about the ethical obligations of physicians towards their patients and society in general, the consideration of reciprocal obligations towards physicians is a relatively recent phenomenon.
During the SARS epidemic, a large number of Canadian physicians unselfishly volunteered to assist their colleagues in trying to bring the epidemic under control. They did so, in many cases, in spite of significant personal risk, and with very little information about the nature of the illness, particularly early in the course of the outbreak. Retrospective analysis has cast significant doubt and concern on the amount of support and assistance provided to physicians during the crisis. Communication and infrastructure support was poor at best. Equipment was often lacking and not always up to standard when it was available. Psychological support and counselling was not readily available at the point of care, nor was financial compensation for those who missed work due to illness or quarantine. Although the Ontario government did provide retrospective compensation for many physicians whose practices were affected by the outbreak, the issue was addressed late, and not at all in some cases.
It is clear that Canadian physicians have learned greatly from this experience. The likelihood of individuals again volunteering "blindly" has been reduced to the point where it may never happen again. There are expectations that certain conditions and obligations will be met in order to optimize patient care and outcomes and to protect health care workers and their families.
Because physicians and other health care providers will be expected to put themselves directly in harm's way, and to bear a disproportionate burden of the personal hardships associated with a pandemic, the argument has been made that society has a reciprocal obligation to support and compensate these individuals.
According to the University of Toronto Joint Centre for Bioethics report We stand on guard for thee, "(The substantive value of) reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families."
Therefore, in order to provide adequate care for patients, the reciprocal obligation to physicians requires providing some or all of the following:
Prior to a pandemic
- Physicians and the organizations that represent them should be more involved in planning and decision making at the local, national and international levels. In turn, physicians and the organizations that represent them have an obligation to participate as well.
- Physicians should be made aware of a clear plan for resource utilization, including:
- how physicians will be relieved of duties after a certain time;
- clearly defined roles and expectations, especially for those practicing outside of their area of expertise;
- vaccination/treatment plans - will physicians (and their families) have preferential access based on the need to keep caregivers healthy and on the job;
- triage plans, including how the triage model might be altered and plans to inform the public of such.
- Physicians should have access to the best equipment needed and should be able to undergo extra training in its use if required.
- Politicians and leaders should provide reassurances that satisfy physicians that they will not be "conscripted" by legislation.
During a pandemic
- Physicians should have access to up-to-date, real time information.
- Physicians should be kept informed about developments in Canada and globally.
- Communication channels should be opened with other countries (e.g. Canada should participate in WHO initiatives to identify the threats before they arrive on our doorstep).
- Resources should be provided for backup and relief of physicians and health care workers.
- Arrangements should be made for timely provision of necessary equipment in an ongoing fashion.
- Physicians should be compensated for lost clinical earnings and to cover expenses such as lost wages, lost group earnings, overhead, medical care, medications, rehabilitative therapy and other relevant expenses in case of quarantine, clinic cancellations or illness (recognizing that determining exactly when or where an infection was acquired may be difficult).
- Families should receive financial compensation in the case of a physician family member who dies as a result of providing care during a pandemic.
- In the event that physicians may be called upon in a pandemic to practice outside of their area of expertise or outside their jurisdiction, they should to contact their professional liability protection provider for information on their eligibility for protection in these circumstances.
- Interprovincial or national licensing programs should be developed to provide physicians with back-up and relief and ensure experts can move from place to place in a timely fashion without undue burden.
- Psychological and emotional counselling and support should be provided in a timely fashion for physicians, their staff and family members.
- Accommodation (i.e. a place to stay) should be provided for physicians who have to travel to another locale to provide care; or who don't want to go home and put their family at risk, when this is applicable, i.e. the epidemiology of the infectious disease causing the pandemic indicates substantially greater risk of acquiring infection in the health care setting than in the community.
- Billing and compensation arrangements should ensure physicians are properly compensated for the services they are providing, including those who may not have an active billing number in the province where the services are being provided.
After a pandemic
- Physicians should receive assistance in restarting their practice (replacing staff, restocking overhead, communicating with patients, and any other costs related to restarting the practice).
- Physicians should receive ongoing psychological support and counselling as required.
C. How are physician obligations and reciprocal obligations related?
Beyond a simple statement of the various obligations, it is clear that there must be some link between these different obligations. This is particularly important since there is now some time to plan for the next pandemic and to ensure that reciprocal obligations can be met prior to its onset. Physicians have always provided care in emergency situations without questioning what they are owed. According to paragraph 18 of the CMA Code of Ethics, physicians should "Provide whatever appropriate assistance you can to any person with an urgent need for medical care".
However, in situations where obligations can be anticipated and met in advance, it is reasonable to expect that they will be addressed. Whereas a physician who encounters an emergency situation at the site of a car crash will act without concern for personal gain or motivation, a physician caring for the same patient in an emergency department will rightly expect the availability of proper equipment and personnel.
In order to ensure proper patient care and physician safety, and to ensure physicians are able to meet their professional obligations and standards, the reciprocal obligations outlined above should be addressed by the appropriate body or organization.
If patient and physician well-being is not optimized by clarifying the obligations of physicians and society prior to the next pandemic, in spite of available time and resources necessary to do so, there are many who would call into question the ethical duty of physicians to provide care. However, the CMA believes that, in the very best and most honourable traditions of the medical profession, its members will provide care and compassion to those in need. We call on governments and society to assist us in optimizing this care for all Canadians.
Tobacco Control (Update 2008)
Tobacco is an addictive and hazardous product, and the number one cause of preventable disease and death in Canada. 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 ever since to advocate for the strongest possible measures to control its use.
It is estimated that over 37,000 deaths each year are attributable to tobacco use. Tobacco imposes a heavy burden on society in the form of hospital care, disability, absenteeism and loss of productivity. Health Canada estimates that tobacco costs this country $17 billion annually of which $4.4 billion constitutes direct health care costs.
Since 2001, Canada's smoking rate has fallen from 25% to below 20%; the decline has been particularly dramatic among young people. The drop is attributed mainly to a comprehensive tobacco control strategy that employs a variety of different interventions, including high prices and taxes, bans on smoking in public places, restrictions on advertising and sponsorship of tobacco products, and social marketing programs to de-normalize tobacco use and the tobacco industry. 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 it is to sustain and improve upon these rates.
To ensure such an environment, the CMA believes that all governments in Canada should continue to implement a comprehensive, coordinated and effective tobacco control strategy which should include the following elements:
Legislation and regulation
The CMA supports strong comprehensive tobacco control legislation, enacted and enforced by all levels of government. Many strong laws and regulations have already been enacted; but some areas remain to be addressed. The CMA recommends that Canadian governments enact the following measures to strengthen tobacco control:
Advertising and promotion: The CMA supports a total comprehensive ban on all advertising and promotion of tobacco. In 2007, the Supreme Court of Canada declared that such a ban is constitutional. Canada currently permits a limited amount of tobacco promotion, and must enact a comprehensive ban if it wishes to comply with the terms of the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC), to which it is a signatory. In order to make the current promotion restrictions complete, Canada should enact:
- a ban on the sale of non-tobacco products displaying tobacco brand names, logos or colours;
- a nationwide ban on the display of tobacco products at point of sale, as has been implemented in some provinces;
- a ban on all tobacco-brand marketing associated with the sponsorship of sports, cultural and other events. In addition, the CMA recommends that the tobacco industry be prohibited from using contests or similar events as promotional activities; and
- restrictions on cross-border advertising of tobacco products.
Tobacco manufacturers make frequent use of subtle marketing messages to render smoking attractive and glamorous to young people. The CMA supports educational and public relations initiatives aimed at countering these messages. For example, movie classification systems should restrict access by children and youth to films that portray tobacco use and tobacco product placement.
Descriptors and packaging: The CMA supports a ban on the use of misleading terms such as "light" and "mild" to describe tobacco products with low tar content. There is no evidence that low-tar cigarettes reduce the health risk to smokers. The CMA also calls for an end to brand extensions, such as colours, numbers and code words, which are being used to replace descriptors such as "light".
One way to negate the risk of misleading labelling is to require that tobacco products be sold in plain packages - a measure that Canada was among the first countries to consider in the 1980s. These packages should display prominent, simple and powerful health warnings, such as the graphic pictorial warnings pioneered by Canada, as well as quit tips and information on product content and health risks.
There should also be a minimum package size for all tobacco products, to guard against the use of small-size "kiddie packs" for single sales of cigars or cigarillos.
Access: The CMA recommends that existing regulations involving the sale of tobacco to minors be strictly enforced, with substantial fines for violators.
Restrictions on buying tobacco products should be enacted for Canadians of all ages. In addition to supporting existing bans on cigarette vending machines and self-service displays, the CMA recommends tightening the licensing system to limit the number of outlets where tobacco products can be purchased. The more restricted is tobacco availability, the easier it is to regulate.
Product regulation: The CMA congratulates the Government of Canada on requiring that tobacco products be modified to reduce their risk of starting fires. In addition, the CMA recommends that the federal government set ceilings on the content of toxic ingredients such as tar, nicotine and carbon monoxide in tobacco products, and lower these ceilings progressively. The federal government should exercise its legislative power to regulate the content of tobacco products, for example, by banning flavourings such as menthol and clove.
The CMA recommends that any new products or product changes made by the tobacco industry be studied and evaluated by an independent research body, prior to being approved for marketing.
Financial disincentives: Price controls are one of the most effective means of discouraging smoking, particularly among young people; a 10% rise in cigarette prices has been associated with a 4% decrease in tobacco use by teenagers. The CMA supports high prices and taxes on tobacco products, and recommends that governments progressively raise taxes as a disincentive to use. All taxes collected from tobacco products should be allocated to providing health care for Canadians, including programs to discourage smoking.
Sale of contraband tobacco has become a major problem in recent years. To discourage the smuggling of lower-cost cigarettes, the CMA recommends that the federal government work with other countries to ensure that tobacco prices are harmonized across national borders. In addition, all levels of government should take the strongest possible measures to control the sale and distribution of contraband tobacco, on their own and in cooperation with other affected jurisdictions.
Sustainable programs: Effective implementation of a comprehensive tobacco control program requires an ongoing commitment by all levels of government. The CMA calls on governments to commit to sustained, well-funded and comprehensive programs to reduce tobacco use, combining policy interventions with educational and social-marketing interventions including mass media campaigns. These programs should reflect current best practices, and be evaluated regularly for effectiveness and impact.
Support for global tobacco control: Effective tobacco control measures such as those described above are required not only in Canada; but worldwide, particularly in developing countries, where multinational tobacco companies are promoting their products aggressively to make up for loss of revenue in their Western markets. Canada was one of the first countries to ratify the WHO's FCTC; the CMA commends the Government of Canada for showing this leadership and hopes it will continue to do so by implementing all elements of the FCTC in Canada, and providing financial support for implementation globally.
Reduction of tobacco use in high-risk populations
The tobacco strategy recommended above involves population-based tools, which have demonstrated their effectiveness in addressing an epidemic that touches every Canadian to some extent. These should be augmented with tools to reach "high-risk" or "hard-to-reach" populations, such as:
Young people: Most current smokers in Canada started smoking before the age of 17, many before the age of 12. Chewing tobacco is becoming increasingly popular among young people, adding to the already considerable risk that they will become predisposed to cigarette use. 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, preventing them from starting to use tobacco and encouraging them to quit, and raising their awareness of tobacco industry marketing tactics so that they can recognize and counteract them. These programs should be continuously available in schools and should begin in the earliest primary grades.
The CMA also recommends to provincial/territorial and municipal governments that tobacco use be banned, both outdoors and indoors, on all school properties and post-secondary campuses.
Aboriginal peoples: Tobacco has ceremonial significance among First Nations peoples; the harm associated with tobacco arises not from its ceremonial use but from its daily, repeated abuse. It is estimated that almost 60% of Aboriginal people smoke. Tobacco control policies such as bans on smoking in public places and on sales to minors, may be poorly implemented on reserves.
The CMA recommends that governments work with Aboriginal leaders in developing meaningful, well-funded programs to discourage tobacco use on reserves, and in implementing policies that raise the level of tobacco control on First Nations' communities to FCTC standards.
Other populations at risk. Some populations, such as pregnant women, may be at particularly high health risk from tobacco use. Other populations, for example people on low incomes, have higher smoking rates than the overall Canadian population and may not have received the full benefit of existing tobacco control programs. Interventions should be created specifically for these target groups, to augment rather than replace programs designed for the overall population. They should address the concerns of target groups in a culturally relevant manner and should be designed with their input.
Control of environmental tobacco smoke
Second-hand or environmental tobacco smoke is an established health hazard, particularly for children, pregnant women and people with respiratory problems. Nearly all provinces and territories, and the federal government, have enacted legislation banning smoking in public places and workplaces. The CMA has always supported this move; in 2003, we committed to holding annual meetings only in jurisdictions where legislation ensured a 100% ban on smoking in indoor public places.
The CMA encourages all smokers to restrict their smoking to areas where it will not jeopardize the health of others, and particularly encourages Canadians to keep their homes and cars smoke-free. All jurisdictions should work toward banning smoking in cars when children are present, and in other locations, such as day care centres, in which second-hand smoke may constitute a hazard to non-smokers.
Accountability of the tobacco industry
Internal industry documents have revealed that tobacco manufacturers knew for many years about the dangerous and addictive nature of their products but consistently suppressed this knowledge, and misinformed the public, when promoting them. The CMA recommends that the federal government initiate a transparent review of the practices of the tobacco industry and closely monitor its activities. The CMA also encourages initiatives aimed at bringing the industry's duplicitous activities to the attention of the public.
The tobacco industry has taken a number of steps to promote itself as a good corporate citizen, and the CMA urges Canadians to be aware of such self-serving moves. Since 2004, the CMA has urged the Canada Pension Plan Investment Board to divest itself of its tobacco holdings. Recently, the tobacco industry has made a bid for legitimacy in the research field by establishing partnerships with academic centres or sponsoring research activities. The CMA opposes the involvement and/or sponsorship of the tobacco industry in education and research at universities, colleges and medical research institutions and recommends that all Canadian medical schools adopt policies banning donations and/or grants from the tobacco industry.
The CMA advocates eliminating the Canadian tobacco-growing and tobacco-manufacturing industries and deplores the domestic manufacture of tobacco products for export.
The CMA supports stringent reporting requirements on the tobacco industry concerning all aspects of manufacturing, distribution and sale; this information should be made available to the public regularly. The CMA also supports in principle efforts to hold the tobacco industry legally accountable for the health care costs attributable to tobacco use. Any settlements from such lawsuits should be used specifically for health care (including tobacco-control programs) and not diverted to any other purposes.
Helping patients become smoke-free
The CMA believes that the health care sector should act decisively to prevent and reduce tobacco use. Smoking should not be permitted in health care facilities. Pharmacies should refrain from selling tobacco products, and those provinces and territories which have not banned sales of tobacco products in pharmacies and other health care facilities are urged to do so.
Smoking is prohibited at the CMA and at all its official and social functions. The association has a long-standing policy of refusing to accept advertising from tobacco companies for any of its publications and refusing to purchase or hold tobacco-product stocks in investment portfolios for its members.
The CMA recommends that those few physicians who still smoke become non-smokers. Physicians should refrain from stocking magazines that carry tobacco advertising and refuse to invest in tobacco-industry stocks.
Helping patients become tobacco-free is one of the most important services a health professional can offer; even a brief counselling session with a health care provider on the dangers of smoking and the importance of quitting is a cost-effective method of tobacco control. Physicians and other health professionals can discourage tobacco use by practising systematic clinical tobacco interventions, which may include:
- routinely counselling children and youth against starting to smoke or chew tobacco;
- taking advantage of "teachable moments," such as pregnancy or respiratory illness, to empathetically motivate smokers to quit;
- asking each patient about current smoking status and readiness to change; and
- offering personalized care, which may include setting a target quit date and offering behavioural counselling and pharmacotherapy.
The CMA recommends that clinical tobacco intervention be recognized as an essential part of medical care and a core medical service. Pharmacotherapy has been established as an effective therapy for smoking cessation and should be made affordable for patients who require it.
The CMA has taken an active role in developing and disseminating tobacco-control resources for physicians, their office staff and their patients. In 2001, the CMA and eight other health professional associations released a joint statement affirming the vital role of health professionals in counselling patients against tobacco use.
The CMA will continue to build on these recommendations and its previous activity, working with other stakeholders toward the goal of a tobacco-free Canada.
FIREARMS CONTROL (UPDATE 2001)
Firearms are a major cause of death and injury in Canada and account for nearly 1,400 deaths annually. The CMA has made several recommendations to governments and other bodies undertaking legislative review and public policy change. These recommendations relate to the regulation of firearms, education for the safe handling of firearms, broad-based violence prevention programs, and research and information provision. In addition, the CMA has produced guidelines to assist physicians in identifying and counselling patients at risk of violent behaviour and in reporting patients at risk.
Firearms are a major cause of death and injury in Canada.. The cost to society of firearm-related injury, particularly spinal cord and head injuries, is considerable.
Over the short term, policy should focus on firearms and the user. Applying stringent controls on firearms, however, may have little effect on the rates of death and injury if the underlying problems of violence in society are not addressed.
In an effort to accommodate both short-term and long-term solutions the CMA recommends the following to governments and bodies undertaking legislative review and public policy change.
The object of regulation should be to deter people at risk for violent or self-destructive behaviour from having easy access to firearms. A regulatory policy should address (a) the acquisition of firearms (e.g., licensing of firearms and/or users, processes to screen would-be purchasers who are at risk), b) secure firearm and ammunition storage methods and modifications to firearms that would render them less accessible to children or those acting on violent impulses and (c) severe penalties for offenses such as the use of a firearm in the commission of a crime or an act of violence, including family violence.
Training in safe handling of firearms is strongly recommended, particularly for all first-time firearm users. Broader-based education programs aimed at the prevention of violence (e.g., in schools) may also be efficacious and should be evaluated for their impact in reducing violence.
Research and information provision
CMA encourages research in a number of areas, including the following.
Firearm surveillance: the types of firearms or classes of ammunition disproportionately involved in intentional deaths and injuries, the circumstances surrounding a firearm incident (e.g., argument between friends, alcohol involvement) and data on injuries and deaths.
Determination of behavioural or environmental risk factors for violent behaviour: the relative risk or benefit of keeping a firearm at home for protection i.e.. the scientific assessment of the deterrence effect):
The effects of factors such as alcohol, drug use and family history of violence on the risk of violent death; and how accurately experts can identify people at risk.
Case-control and cohort studies on gun control, crime and the antecedents of violent behaviour.
Evaluation of education programs that discourage firearm-related violence or promote safe handling of firearms.
Role of physicians
The CMA recommends that physicians consider the following guidelines.
Management of patients at risk
It is not always possible to identify people at risk of violent or self-destructive behaviour; however, the CMA recommends that physicians be alert to warning signs that a patient may be at risk and manage that patient accordingly. For example, always ask depressed patients about suicidal and homicidal thoughts and plans (asking will not plant ideas); admit suicidal patients to hospital, even against their will, particularly if they do not have supportive families who can monitor them at home; have the family remove all firearms from the home of a patient at risk; and monitor the patient frequently, writing small prescriptions if medication is required.
Good clinical judgement and close follow-up are perhaps the most effective ways of managing a self-destructive or violent patient.
Reporting of patients at risk
No specific guidelines exist for the reporting of patients at risk of violent behaviour. The physician should consider whether the risk of harm to society (or a third party) posed by a patient outweighs that patient's right to confidentiality.
Counselling and public advocacy
A physician may be asked for a reference for an applicant of a firearms acquisition certificate. Before providing the reference the physician should consider the applicant carefully for risk factors, recommend appropriate firearms training and caution against the concomitant use of firearms, alcohol and other drugs.
A physician should become an advocate for nonviolent conflict resolution. As research accumulates about the most effective interventions for nonviolent conflict resolution the health sector may be able to draw on this research to work to reduce violence in society.
Like motor vehicle and bicycle safety, firearm safety is a public health issue. The CMA holds that physicians, as advocates for the health of Canadians, can help reduce firearm-related damage and address the concomitant underlying problem of violence in society.
The CMA recommends to the appropriate government authorities that all boxing be banned in Canada. Until such time, strategies to prevent injury should be pursued.
The CMA considers boxing a dangerous sport. While most sports involve risk of injury, boxing is distinct in that the basic intent of the boxer is to harm and incapacitate his or her opponent.
Boxers are at significant risk of injuries resulting in brain damage. Boxers are susceptible not only to acute life-threatening brain trauma, but also to the chronic and debilitating effects of gradual cerebral atrophy. Studies demonstrate a correlation between the number of bouts fought and the presence of cerebral abnormalities in boxers. There is also a risk of eye injury including long-term damage such as retinal tears and detachments.
- CMA supports a ban on professional and amateur boxing in Canada.
- Until boxing is banned in this country, the following preventive strategies should be pursued to reduce brain and eye injuries in boxers:
- Head blows should be prohibited. CMA encourages universal use of protective garb such as headgear and thumbless, impact-absorbing gloves
- The World Boxing Council, World Boxing Association and other regulatory bodies should develop and enforce objective brain injury risk assessment tools to exclude individual boxers from sparring or fighting.
- The World Boxing Council, World Boxing Association and other regulatory bodies should develop and enforce standard criteria for referees, ringside officials and ringside physicians to halt sparring or boxing bouts when a boxer has experienced blows that place him or her at imminent risk of serious injury.
- The World Boxing Council, World Boxing Association and other regulatory bodies should encourage implementation of measures advocated by the World Medical Boxing Congress to reduce the incidence of brain and eye injuries.
- CMA believes that the professional responsibility of the physician who serves in a medical capacity in a boxing contest is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even injured athletes that they not be removed from the contest should not influence the physician’s medical judgment.
- Further long term outcome data should be obtained from boxers in order to more accurately establish successful preventive interventions. CMA encourages ongoing research into the causes and treatments of boxing-related injuries, and into the effects of preventive strategies.