Like all scientific and medical procedures, assisted human reproduction has the potential for both benefit and harm. It is in the interests of individual Canadians and Canadian society in general that these practices be regulated so as to maximize their benefits and minimize their harms. To help achieve this goal, the Canadian Medical Association (CMA) has developed this policy on regulating these practices. It replaces previous CMA policy on assisted reproduction.
The objectives of any Canadian regulatory regime for assisted reproduction should include the following:
(a) to protect the health and safety of Canadians in the use of human reproductive materials for assisted reproduction, other medical procedures and medical research;
(b) to ensure the appropriate treatment of human reproductive materials outside the body in recognition of their potential to form human life; and
(c) to protect the dignity of all persons, in particular children and women, in relation to uses of human reproductive materials.
When a Canadian regulatory regime for assisted reproduction is developed, it should incorporate the following principles:
For the regulation of assisted reproduction, existing organizations such as medical licensing authorities, accreditation bodies and specialist societies should be involved to the greatest extent possible.
If the legislation establishing the regulatory regime is to include prohibitions as well as regulation, the prohibition of specific medical and scientific acts must be justified on explicit scientific and/or ethical grounds.
If criminal sanctions are to be invoked, they should apply only in cases of deliberate contravention of the directives of the regulatory agency and not to specific medical and scientific acts.
Whatever regulatory agency is created should include significant membership of scientists and clinicians working in the area of assisted reproduction.
Elements of a Regulatory Regime
The regulation of assisted reproduction in Canada should include the following elements:
Legislation to create a national regulatory body with appropriate responsibilities and accountability for coordinating the activities of organizations that are working in the area of assisted reproduction and for carrying out functions that other organizations cannot perform.
The development and monitoring of national standards for research related to human subjects including genetics and reproduction. The regulatory body would work closely with the Canadian Institutes of Health Research, other federal and provincial research granting councils, the National Council on Ethics in Human Research and other such organizations.
The development and monitoring of national standards for training and certifying physicians in those reproductive technologies deemed acceptable. As is the case for all post-graduate medical training in Canada, this is appropriately done through bodies such as the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada.
The licensing and monitoring of individual physicians. This task is the responsibility of the provincial and territorial medical licensing authorities which could regulate physician behaviour in respect to the reproductive technologies, just as they do for other areas of medical practice.
The development of guidelines for medical procedures. This should be done by medical specialty societies such as the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Canadian Fertility and Andrology Society (CFAS).
The accreditation of facilities where assisted reproduction is practised. There is already in Canada a well functioning accreditation system, run by the Canadian Council on Health Services Accreditation, which may be suitable for assisted reproduction facitilies.
Whatever regulatory body is established to deal with assisted reproduction should utilize, not duplicate, the work of these organizations. In order to maximize the effectiveness of these organizations, the regulatory body could provide them with additional resources and delegated powers.
The CMA is opposed to the criminalization of scientific and medical procedures. Criminalization represents an unjustified intrusion of government into the patient-physician relationship. Previous attempts to criminalize medical procedures (for example, abortion) were ultimately self-defeating. If the federal government wishes to use its criminal law power to regulate assisted reproduction, criminal sanctions should apply only in cases of deliberate contravention of the directives of the regulatory agency and not to specific medical and scientific acts.
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.
The Canadian Medical Association (CMA) has always recognized the unique requirements of those individuals suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief.
However, there are a number of concerns, primarily related to the limited evidence to support many of the therapeutic claims made regarding cannabis for medical purposes, and the need to support health practitioners in their practice.1,2,3,4
While the indications for using cannabis to treat some conditions have been well studied, less
information is available about many potential medical uses.
Physicians who wish to authorize the use of cannabis for patients in their practices should consult relevant CMPA policy5 and guidelines developed by the provincial and territorial medical regulatory authorities to ensure appropriate medico-legal protection. The CMA’s policy Authorizing Marijuana for Medical Purposes6, as well as the CMA’s Guidelines For Physicians In Interactions With Industry7 should also be consulted.
The CMA makes the following recommendations:
1. Increase support for the advancement of scientific knowledge about the medical use of cannabis. The CMA encourages the government to support rigorous scientific research into the efficacy for therapeutic claims, safety, dose-response relationships, potential interactions and the most effective routes of delivery, and in various populations.
2. Apply the same regulatory oversight and evidence standards to cannabis as to pharmaceutical products under the Food and Drug Act, designed to protect the public by the assessment for safety and efficacy.
3. Increase support for physicians on the use of cannabis for medical purposes in their practice settings. As such, CMA calls on the government to work with the CMA, The College of Family Physicians of Canada, the Royal College of Physicians and Surgeons,
and other relevant stakeholders, to develop unbiased, accredited education options and licensing programs for physicians who authorize the use of cannabis for their patients based on the best available evidence.
In 2001, Health Canada enacted the Marihuana Medical Access Regulations (MMAR). These were in response to an Ontario Court of Appeal finding that banning cannabis for medicinal purposes violated the Charter of Rights and Freedoms.8 The MMAR, as enacted, was designed to establish a framework to allow legal access to cannabis, then an illegal drug, for the relief of pain, nausea and other symptoms by people suffering from serious illness where conventional treatments had failed.
While recognizing the needs of those suffering from terminal illness or chronic disease, CMA raised strong objections to the proposed regulations. There were concerns about the lack of evidence on the risks and benefits associated with the use of cannabis. This made it difficult for physicians to advise their patients appropriately and manage doses or potential side effects. The CMA believes that physicians should not be put in the untenable position of gatekeepers for a proposed medical intervention that has not undergone established regulatory review processes as required for all prescription medicines.
Additionally, there were concerns about medico-legal liability, and the Canadian Medical Protective Association (CMPA), encouraged those physicians that were uncomfortable with the regulations to refrain from authorizing cannabis to patients.
Various revisions were made to the MMAR, and then these were substituted by the Marihuana for Medical Purposes Regulations (MMPR) in 2013/ 2014 and subsequently by the Access to Cannabis for Medical Purposes Regulations (ACMPR) in 2016 and now as part of the Cannabis Act (Section 14)9. Healthcare practitioners that wish to authorize cannabis for their patients are required to sign a medical document, indicating the daily quantity of dried cannabis, expressed in grams.
For the most part, these revisions have been in response to decisions from various court decisions across the country.10,11,12 Courts have consistently sided with patients’ rights to relieve symptoms of terminal disease or certain chronic conditions, despite the limited data on the effectiveness of cannabis. Courts have not addressed the ethical position in which physicians are placed as a result of becoming the gate keeper for access to a medication without adequate evidence.
The CMA participated in many Health Canada consultations with stakeholders as well as scientific advisory committees and continued to express the concerns of the physician community. As previously noted, the Federal government has been constrained by the decisions of Canadian courts.
The current state of evidence regarding harms of cannabis use is also limited but points to some serious concerns. Ongoing research has shown that regular cannabis use during brain development (up to approximately 25 years old) is linked to an increased risk of mental health disorders including depression, anxiety, and schizophrenia, especially if there is a personal or family history of mental illness. Long term use has also been associated with issues of attention, impulse control and emotional regulation. Smoking of cannabis also has pulmonary consequences such as chronic bronchitis. It is also linked to poorer pregnancy outcomes. Physicians are also concerned with dependence, which occurs in up to 10% of regular users. From a public and personal safety standpoint, cannabis can impact judgement and increases the risk of accidents (e.g. motor vehicle incidents). For many individuals, cannabis use is not without adverse consequences.3,13,14
Pharmaceutically prepared alternative options, often administered orally, are also available and regulated in Canada.15 These drugs mimic the action of delta-9-tetra-hydrocannabional (THC) and other cannabinoids and have undergone clinical trials to demonstrate safety and effectiveness and have been approved for use through the Food and Drug Act. Of note is that in this format, the toxic by-products of smoked marijuana are avoided.16 However, the need for more research is evident.
Approved by the CMA Board in December 2010.
Last reviewed and approved by the CMA Board in March 2019.
1 Allan GM, Ramji J, Perry D, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician, 2018;64(2):111-120. Available: http://www.cfp.ca/content/cfp/64/2/111.full.pdf (accessed 2019 Jan 8).
2 College of Family Physicians of Canada (CFPC). Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance. Mississauga: CFPC; 2014. Available: https://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf (accessed 2019 Jan 8).
3 The 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: National Academies Press; 2017. 4 Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313(24):2456-73.
5 Canadian Medical Protective Association (CMPA). Medical marijuana: considerations for Canadian doctors. Ottawa: CMPA; 2018. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/medical-marijuana-new-regulations-new-college-guidance-for-canadian-doctors (accessed 2019 Jan 8).
6 Canadian Medical Association (CMA). Authorizing marijuana for medical purposes. Ottawa: CMA; 2014. Available: https://policybase.cma.ca/en/permalink/policy11514 http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-04.pdf (accessed 2019 Jan 8).
7 Canadian Medical Association. (CMA) Guidelines for Physicians In Interactions With Industry. Ottawa: CMA; 2007. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf. (accessed 2019 Jan22).
8 R. v. Parker, 2000 CanLII 5762 (ON CA). Available: http://canlii.ca/t/1fb95 (accessed 2019 Jan 8).
9 Cannabis Act. Access to Cannabis for Medical Purposes. Section 14. 2018. Available: https://laws-lois.justice.gc.ca/eng/regulations/SOR-2018-144/page-28.html#h-81 (accessed 2019 Jan 8).
10 Hitzig v. Canada, 2003 CanLII 3451 (ON SC). Available: http://canlii.ca/t/1c9jd (accessed 2019 Jan 8).
11 Allard v. Canada,  3 FCR 303, 2016 FC 236 (CanLII), Available: http://canlii.ca/t/gngc5 (accessed 2019 Jan 8).
12 R. v. Smith, 2014 ONCJ 133 (CanLII). Available: http://canlii.ca/t/g68gk (accessed 2019 Jan 8). 13 Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219–2227.
14 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: https://www.who.int/substance_abuse/publications/msbcannabis.pdf (accessed 2019 Jan 8).
15 Ware MA. Is there a role for marijuana in medical practice? Can Fam Physician 2006;52(12):1531-1533. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952544/pdf/0530022a.pdf (accessed 2019 Jan 8).
16 Engels FK, de Jong FA, Mathijssen RHJ, et.al. Medicinal cannabis in oncology. Eur J Cancer. 2007;43(18):2638-2644. Available: https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0959804907007368.pdf?locale=en_US (accessed 2019 Jan 8).
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.
Climate Change and Human Health
Climate change is increasingly recognized as a significant threat facing society and has the potential to be one of the greatest threats to human health in the 21st Century1. While the damage is being done now, many of the health effects may arise only decades in the future2.
Possible impacts could include some or all of the following:
* Increased mortality, disease and injuries from heat waves and other extreme weather events;
* Continued change in the range of some infectious disease vectors (i.e. 260-320 million more cases of malaria predicted by 2080, with six billion more at risk for dengue fever);
* Effects on food yields- increased malnutrition;
* Increased flooding in some areas and increased droughts in others, along with other impacts on freshwater supply;
* Increases in foodborne and waterborne illnesses;
* Warming and rising sea levels adding to displacement and also impacting water supply through salination;
* Impaired functioning of ecosystems;
* Negative effects on air quality associated with ground level ozone, including increases in cardio-respiratory morbidity and mortality, asthma, and allergens;
* Displacement of vulnerable populations (especially in coastal areas)1; and
* Loss of livelihoods3.
Most of the impacts of climate change will result from amplifying the existing health hazards found in populations4. How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities (i.e. disease burden, resources etc.) as well as their adaptive capacity5. The World Health Organization has projected that countries that have, and will likely continue to suffer the greatest effects, are those who have contributed the smallest amount to the causes of climate change.6
While the vast majority of climate change deaths will occur in developing countries with systemic vulnerabilities, a recent Health Canada report has noted that Canada is likely to experience higher rates of warming in this century than most other countries in the world. Climate change scenarios predict an increased risk of extreme weather and other climate events for all regions of Canada, with the exception of extreme cold7. Canadians most vulnerable to climate change include seniors, children and infants, socially disadvantaged individuals, and those with pre-existing medical conditions such as cardiovascular disease8. Those living in cities could be especially vulnerable due to the impact of the heat island effect. However, given their greater access to emergency, health, social, and financial resources, they might also have the greatest adaptive capacity9.
The health consequences of climate change have the potential to be more severe in far northern regions. Populations in Canada's north including aboriginals have already begun to see differences in their hunting practices as a result of changing ice patterns10, and the melting of permanent snowpacks11. Changes in ice patterns have also led to increased injuries12. In some places in the North, climate changes have led to greater risks from avalanches, landslides and other hazards13. Further problems are related to the infrastructure in Northern Canada, with some communities already noticing degradation of structures due to the thawing of the permafrost14. Given that much of the Northern infrastructure is already in disrepair, this represents a considerable problem. Geographic isolation, and a lack of resources may further exacerbate the situation15.
What CMA has done?
Physicians have a critical role to play in advancing public understanding of the potential impact of climate change on health and promoting health protecting responses.
The CMA has been working on the issue of climate change and human health for a number of years. CMA was supportive of Canada's ratification of the Kyoto Protocol, and urged the Government of Canada to commit to choosing a climate change strategy that satisfied Canada's international commitments while also maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives.
In 2007, a number of resolutions were passed at General Council calling on government to properly plan for the health impacts of climate change and put in place measures to mitigate the impact of climate change on vulnerable populations in Canada's north. In that same year, CMA and the Canadian Nurses Association updated a joint position statement first entered into in 1994 calling for environmentally responsible activity in the health-care sector.
Most recently, the CMA has been an integral part of the drafting of the World Medical Association (WMA) policies on health and climate change. The WMA Declaration of Delhi on Health and Climate Change was adopted at its annual General Assembly in New Delhi, India in October 2009, The declaration calls for action in five main areas; advocacy to combat global warming; leadership-help people be healthy enough to adapt to climate change; education and capacity building; surveillance and research; and collaboration to prepare for climate emergencies. This policy is written to complement the WMA declaration.
What needs to be done?
Climate change may lead to significant impacts on human health. While it is unlikely that these outcomes can be avoided, there are some strategies that can be employed to help limit the negative consequences.
Education and Capacity Building
There is a need for greater public and health professional awareness and education about climate change in order to gain understanding of the health consequences and support for strategies to reduce green house gases and mitigate climate change effects.
1. A national public awareness program on the importance of the environment and global climate change to personal health;
2. Encouraging health sciences schools to enhance their provision of educational programs on environmental health; and fostering the development of continuing education modules on environmental health and environmental health practices.
Surveillance and Research
There are important gaps in our knowledge on the health impacts of climate change as well as the effectiveness of various mitigation and adaptation strategies. Surveillance and reporting functions need to be strengthened to allow for greater accuracy in modeling of future impacts.
3. That the federal government must address the gaps in research regarding climate change and health by undertaking studies to
- quantify and model the burden of disease that will be caused by global climate change
- identify the most vulnerable populations, the particular health impacts of climate change on vulnerable populations, and possible new protections for such populations;
- increase the collection and accuracy of health data, particularly for vulnerable and underserved populations;
- report diseases that emerge in conjunction with global climate change, and participate in field investigations, as with outbreaks of infectious diseases; and
- develop and expand surveillance systems to include diseases caused by global climate change.
Reducing the Burden of Disease to Mitigate Climate Change Impacts
How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities. Therefore, work needs to be done to reduce the burden of diseases and improve upon the social determinants of health for vulnerable populations in Canada and globally.
4. That the federal and provincial/territorial governments work together to improve the ability of the public to adapt to climate change and catastrophic weather events by
- Encouraging behaviours that improve overall health,
- Creating targeted programs designed to address specific exposures,
- Providing health promotion information and education on self-management of the symptoms of climate-associated illness,
- Ensuring physical infrastructure that allows for adaptation;
5. That the federal government develop concrete actions to reduce the health impact of climate-related emissions, in particular those initiatives which will also improve the general health of the population;
6. That the federal government support the Millennium Development Goals and support the principles outlined in the WHO Commission on the Social Determinants of Health report; and
Preparing for Climate Emergencies
To deal with the future burden of climate change related health issues there is a need to ensure adequate health capacity and infrastructure. Rebuilding of public health capacity globally is seen as the most important, cost-effective, and urgently needed response to climate change16. Domestically, there is a need to ensure adequate surge capacity within the health care system to be prepared for an increase in illness related to climate change effects. There is also a need to strengthen not only the health systems, but the infrastructure (i.e. housing) for vulnerable populations including Aboriginals and those in the North.
CMA recommends that the federal and provincial /territorial governments work together to:
7. Strengthen the public health system both domestically and internationally in order to improve the capacity of communities to adapt to climate change;
8. Ensure adequate surge capacity within Canada's health system to handle the increase in climate change related illness;
9. Ensure the health of vulnerable populations is adequate to handle climate change related situations;
10. Develop knowledge about the best ways to adapt to and mitigate the health effects of climate change;
11. Integrate health professionals into the emergency preparedness plans of government and public health authorities so that front-line providers are adequately informed and prepared to properly manage any health emergencies.
Advocacy to Combat Climate Change
Finally, there is a need to take action to reduce the damaging effects of climate change. The global community needs to come together to reduce the levels of green house gases being released in the atmosphere, and focus on safer more environmentally friendly energy sources. Investments in cuts to greenhouse gas emissions would greatly outweigh their costs, and could help to reduce the future burden of climate change related illness17.
12. That the government of Canada become a global leader in promoting equitable, carbon neutral economic, industrial, and social policies, and practices that fight global warming and adopt specific green house gas reduction targets as determined by the evolving science of climate change.
13. That health care professionals act within their professional settings to reduce the environmental impact of medical activities and to develop environmentally sustainable professional settings;
14. That all Canadians act to minimize individual impacts on the environment, and encourage others to do so, as well.
The CMA believes that Canada must prepare now for the potential health threat that climate change poses to its population. While many of these effects will take decades to materialize, certain populations, such as those in Canada's north, or those in low lying coastal areas, are already starting to experience the impact of climate change.
A focus on education and health promotion, as well as advocacy for improved public policy and primary health care resources will be a good start in dealing with this issue. Additionally, further research and data collection is necessary to improve our understanding of climate change and the effectiveness of adaptation and mitigation strategies.
Finally, the global community needs to act together to address the health and environmental impacts of climate change. By working together, in an international response, strategies can be implemented to mitigate any negative health effects of climate change.
Canada's physicians believe that: What is good for the environment is also good for human health. It is past time for those of us in the health sector in Canada to engage fully in the debate and discussions within our own house, as well as in the broader body politic to ensure that protecting human health is the bottom line of environmental and climate change strategies.
1 Currently a third of the world's population lives within 60 miles of the shoreline and 13 of 20 biggest world cities located on the coast- more than a billion people could be displaced (Costello et.al., 2009)
1 Costello, Anthony et.al. "Managing the health effects of climate change.' The Lancet Volume 373 May 16, 2009. pp.1693-1733.
2 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf
3 Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf ; Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005.; Friel, Sharon; Marmot, Michael; McMichael, Anthony J.; Kjellstrom, Tord & Denny Vagero. "Global health equity and climate stabilization: a common agenda." The Lancet Volume 372 November 8, 2008. pp.1677-1683.
4Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf; World Health Organization (2009) Protecting Health From Climate Change: Global research priorities. Available at: http://whqlibdoc.who.int/publications/2009/9789241598187_eng.pdf
5 Health Canada (2001) Climate Change and Health & Well-being: A Policy Primer Available at: http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/policy_primer-abecedaire_en_matiere/index-eng.php
6 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237
7 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf
8 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf
9 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf
11 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf
12 Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005.
13 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf
14 Field, Christopher B. et.al. (2007) North America. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter14.pdf
15 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf
16 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf
17 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237
CMA PATIENT SAFETY POLICY FRAMEWORK (Update 2010)
The CMA’s mission is to promote the highest standard of health and health care for Canadians. This means, among other things, ensuring that the health care system is safe for patients and providers and effective in achieving good health outcomes for individuals and society. Unfortunately, studies published in recent years have raised concern that health care is not as safe as it could be; data collected by researchers in various countries has shown that there are unacceptably high levels of preventable adverse events, as high as 16% in one study of adverse events associated with hospital admissions. A study conducted by G. R. Baker, P.G. Norton et al, “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada” showed an adverse event rate of 7.5 per 100 hospital admissions. (1) This suggests that of the nearly 2.5 million hospital admissions yearly in Canada, approximately 185,000 are associated with an adverse event and 70,000 of those possibly preventable.
These studies have focused attention on health care error and adverse events, but patient safety requires that participants in the health care system are constantly aware of the risks present in the system, and that risks are addressed proactively - preferably before an adverse event occurs. If a preventable adverse event does occur, it provides an opportunity to learn about and correct sources of error.
The CMA considers that a national patient safety strategy, aimed at building a culture of safety, is a priority. This Policy Framework has been developed to provide a clear statement of the CMA’s views on the principles that should underpin a patient safety strategy and to ensure clear support and direction for CMA members and staff involved in patient safety initiatives.
The Health Care System
Errors and adverse events are inevitable in any complex system and more complex systems are more prone to errors. Nevertheless, studies have demonstrated an unacceptably high level of preventable adverse events associated with management of health care.
1. Patient safety initiatives should aim to improve health outcomes for patients by minimizing the rate of preventable adverse events and improving the management of events when they occur.
2. Patient safety is one aspect of quality health care; activities relating to patient safety should result in a net increase in the quality of health care.
3. Patient safety initiatives should recognize that error and adverse events occur because of qualities of the system within which individuals operate. A primary concern of initiatives should be to prevent future errors by addressing the system rather than blaming and punishing individuals.
The Canadian public has a reasonable expectation that health care will not result in avoidable injury.
4. Patient safety initiatives should support the accountability of the health sector, including providers, funders and regulators, to patients and the wider public for the safety of health care.
Participants in Health Care
Patients as partners
5. Patient safety initiatives should promote the role of patients as partners in the provision of safe care, including the prevention and management of adverse events.
6. Patient safety initiatives should encourage and anticipate the full and appropriate disclosure to patients of relevant information that is material to their health and healthcare, including information about adverse events or effects.
Professional responsibility and support
With a very few exceptions, health care is delivered by competent, caring professionals who are striving to achieve a good outcome for patients.
7. Patient safety initiatives should recognize the responsibility of professionals for achieving and maintaining the standard of their own practice.
8. Patient safety initiatives, while responding appropriately to adverse events, should be sensitive to the professional role and personal well being of individual physicians and other health care providers.
Learning and Collaboration
9. Patient safety initiatives should promote and reflect teamwork, communication and collaboration at all levels.
10. Patient safety initiatives should support learning from one’s own experience and the sharing of knowledge so that it is possible to learn from the experience of others.
Legal and Regulatory Environment
11. Patient Safety initiatives should promote a legal and regulatory environment that supports open communication and effective management of adverse events.
12. The protection afforded to the opinions expressed within quality assurance committees must be upheld
Evidence Base and Evaluation
Patient safety initiatives should be based on sound evidence.
Patient safety initiatives should contain provision for appropriate evaluation.
Patient safety initiatives should contain provision for broad dissemination of findings.
PATIENT SAFETY INITIATIVE AREAS
Building a culture of safety in Canadian health care will require the collaboration of many different groups and organizations. The CMA can play a leadership role within this larger group and within its own constituency of over 70,000 physicians. In some instances, it will be the CMA’s role to advocate for initiatives that can be delivered only by another provider or through a consortium; in other instances, CMA can assume sole responsibility for taking action. The CMA has identified that, as priorities, it will support:
Advocacy for changes to legislation and regulation that would remove disincentives for health care providers to share information about adverse events.
Raising awareness of patient safety and changing attitudes towards risk, error and adverse events within the health care community.
Developing and providing resources such as clinical practice guidelines and information technology systems that have been shown to standardize practice and reduce adverse events.
Reporting systems that collect and aggregate data on risks so that good practices can be developed and shared.
Education and training for health care professionals and managers to provide them with the conceptual and practical tools to introduce change into their practice and organizations.
Advocacy for, and development of, an agenda for patient safety research in Canada.
The involvement of government at all levels in supporting and committing resources to initiatives for improved patient safety.
Adverse event – any unintended injury or complication that is caused by health care management rather than the patient’s disease and that leads to prolonged hospital stay, morbidity or mortality. Adverse events do not necessarily result from error, for example a toxic reaction to a drug in a patient without apparent risk factors for the reaction.
Error – the failure of a planned action to be completed as intended (“error of execution”) or the use of a wrong plan to achieve an aim (“error of planning”). An error may not result in an adverse event if the error does not result in harm or is intercepted.
Risk – the chance of injury or loss as defined as a measure of the probability and severity of an adverse effect to health, property, the environment or other things of value.
(1) G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher, Robert J. Reid, Sam Sheps, and Robyn Tamblyn. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada Can. Med. Assoc. J., May 2004; 170: 1678 - 1686.
CMA Statement on Emerging Therapies
The CMA is keenly aware of the heart-rending suffering experienced by MS patients and the devastating impact it has on families and we recognize how desperately they are seeking treatments to alleviate their symptoms. Physicians and researchers dedicate their lives to finding new treatments to prevent and ease the suffering of patients while supporting those battling disease. Along with the physician's care and compassion, clinical research is a key weapon in the battle to manage and treat disease. The CMA believes that all medical decisions must be based upon scientific evidence. That is at the heart of our commitment to patient-centred care.
The CMA is committed to the principle that, before any new treatment is adopted and applied by the medical profession, it must first be rigorously tested and recognized as evidence-based. This principle is highly relevant in the case of the Canadian Institutes of Health Research (CIHR) recent recommendations. The CMA concurs with the CIHR's position on the need for an evidence-based approach to the development of clinical trials of the recently proposed condition called "chronic cerebrospinal venous insufficiency" (CCSVI). We would hope that the findings of the seven diagnostic studies that are underway will be shared and analyzed as soon as they become available, and that clinical intervention trials would be supported as indicated by the evidence and if researchers come forward with scientifically sound ethical protocols. If additional Canadian funding bodies initiate clinical research in the area, we would encourage CIHR to provide advice if requested.
CORE AND COMPREHENSIVE HEALTH CARE SERVICES
CMA believes that physicians must be actively involved in the decision-making process on core and comprehensive services. It developed a framework for this purpose after review and analysis of national and international decision-making frameworks, and after consideration of the political, policy and legal context of Canadian health care decision making. In addition to the framework, key terms associated with core and comprehensive health care services are operationally defined. Quality of care and ethical and economic factors are considered in a balanced and flexible manner, recognizing that the relative importance of any one factor may vary depending on the health care service being considered.
CMA first prepared this policy in 1994 to help physicians participate in making choices concerning core and comprehensive health care services. Over a decade later, the issue of defining these services remains a central issue for patients, providers and funders of Canada's health care system. Looking ahead, this will become even more pertinent as regional authorities assume greater authority in planning and allocating health funding across a broad range of programs.
Constructive leadership from the medical profession is essential to ensure a high quality Canadian health care system. Specifically, physicians must be actively involved in the decision-making process on core and comprehensive health care services.
CMA reviewed and analyzed several national and international decision-making frameworks and subsequently developed a framework for making decisions about core and comprehensive health care services (Core and Comprehensive Health Care Services: a Framework for Decision Making, CMA, 1994). It also considered the current political, policy and legal context in which decisions on health care are made in Canada. Key terms associated with core and comprehensive health care services were operationally defined.
CMA encourages the use of its framework for making decisions about these services. Quality of care and ethical and economic factors are considered in a balanced and flexible manner, recognizing that the relative importance of any one factor may vary depending on the health care service being considered. Each factor affects decision making at the patient-physician (micro) level, the hospital and regional (meso) level and the provincial, territorial and national (macro) level.
This policy summary addresses the requirement for governments to fund core medical services but not the availability or desirability of private or alternative funding for these services.
Uniform use and interpretation of the terms used in this area are particularly important in policy development, negotiations and communications. The 1984 Canada Health Act stipulates that all "medically necessary" services be insured; however, the act does not define "medically necessary." This lack of a clear operational definition gives the provinces/territories some flexibility in the breadth of coverage provided by their insurance plans. However, it may also cause ambiguity and difficulty in selecting core health care services.
CMA defines medically necessary services as those "that a qualified physician determines are required to assess, prevent, treat, rehabilitate or palliate a given health concern or problem as supported by available scientific evidence and/or professional experience." (Adapted from Core and Comprehensive Health Care Services, page 96.)
Health care services are "not only services provided by or under the supervision of a physician, but also a wide range of services performed by many other health care professionals." (Adapted from Core and Comprehensive Health Care Services, page 92.) Medical services is "a category of health care services provided by or under the supervision of a physician." (Core and Comprehensive Health Care Services, page 96.)
Comprehensive health care and medical services are distinguished from core health care and medical services. Comprehensive health care and medical services are "a broad range of services that covers most, if not all, health care needs. These services may or may not be funded/insured by a government plan." (Core and Comprehensive Health Care Services, page 86.) Core health care and medical services are those that "are available to everyone as funded/insured by a government plan. [Alternative] funding sources for these services are not necessarily excluded." (Core and Comprehensive Health Care Services, page 86.)
Framework for decision making
CMA advocates a systematic and transparent decision-making framework for determining which services are considered core and comprehensive health care services. The framework was originally intended for medical services; however, it can also be applied to health care services. It is flexible so that users may adapt it to their own specific circumstances and needs. It is not a formula or set process that yields a quantifiable result for any given service, nor does it prescribe which services to insure or not insure. CMA has put forth the following principle concerning the framework.
When decisions about core and comprehensive health care services are made, the various levels at which decisions can be made must be considered. These include the patient- physician (micro) level, the hospital and regional (meso) level and the provincial, territorial and national (macro) level.
CMA recognizes that decisions are made at several levels: (1) the micro level, which involves individual decisions about service delivery made by patients, physicians and other providers, (2) the meso level, which involves regional health authorities and health care institutions such as hospitals, community groups and professional staff, and (3) the macro level, which involves system wide decisions made by governments, the electorate and professions as a whole.
It is important to take into account the likely effect of any decision on each level: a decision that is acceptable at the macro level may be impossible to deliver at the meso level and inappropriate for patients or practitioners at the micro level. Coordination is essential to make consistent decisions among levels and incorporate the concerns of patients, providers and payers.
CMA upholds a second principle concerning the decision making framework.
Quality of care and ethical and economic factors must be considered when decisions about core and comprehensive health care services are made.
Quality of care
Effectiveness, efficiency, appropriateness and patient acceptance are elements of quality of care. To be considered a core medical service, a medical service must be of high quality (i.e., it addresses effectively a health concern or condition through improved health outcomes and is delivered efficiently, appropriately and in a manner acceptable to patients) as well as fulfilling ethical and economic criteria. A medical service that is shown to be of little effectiveness cannot be delivered efficiently or poses many problems for patient safety or acceptance is less "medically necessary" than services that meet the quality of care criteria. Such a service is therefore unlikely to become or remain a core medical service.
The adoption of evidence-based medicine such as through the use of clinical practice guidelines (CPGs) is a key component of quality improvement. CPGs are based on a systematic review of experience and research, and they help physicians to make decisions about necessary care. CPGs that are well developed and appropriately evaluated may also help to define core health care services. CPGs are also tools for the pursuit of quality, to maximize effective care and to reduce waste and ineffective activity in a given service, resulting in savings.
Clinical research is a key aspect of improvement in quality of care. Such research focuses on the effectiveness and impact of health care services on health outcomes. Procedures that demonstrate better outcomes than others should be included in a core health care package, whereas those that demonstrate inferior outcomes may be limited or excluded in some instances. When applying the concept of core health care services, provision must be made for ongoing evaluation of the quality of current services and appropriate assessment of new ones.
While it is important that the decision-making framework be evidence-based to the greatest extent possible, it should not be evidence-bound - that is, decisions may still need to be made from limited evidence.
Balancing finite fiscal resources and high quality medical and other health care services requires explicit societal choices about which services will be publicly funded (and for whom), which can be purchased and which will not be available at all in the Canadian system. These issues are ethical ones because they involve rights, responsibilities and societal values.
Whether decisions about resource allocation are made at the macro, meso or micro level, they must be fair. This means that those likely to be affected by a decision, whether they are patients, providers or payers, must have adequate opportunity for input into the decision-making process and must be informed about the reasons for the decisions.
When the availability of a health care service is inadequate to meet the demand, the criteria for allocating it should be fair and explicit. One such criterion is medical need: even if not all needed services can be publicly funded, services that are clearly unnecessary should not be funded in this way. Funding decisions should be nondiscriminatory; decisions about which health care services should or should not be publicly funded should not be based on age, sex, race, lifestyle and other personal and social characteristics of the potential recipients of a service.
Economic factors (Cost-effectiveness)
The level of public funding for health care services is ultimately a societal decision, as discussed in the section on ethical factors. Once such a societal decision has been made, economic factors are useful in determining the allocation of resources among health care services, especially in times of fiscal restraint.
There are various economic methods for evaluating funding decisions, the most common of which is cost effectiveness analysis. This approach suggests that decisions to insure a particular service should take into account cost in relation to outcome, e.g., cost per quality-adjusted life-year. Services that have a low cost for a significant gain in effectiveness may be more acceptable for public funding than others. This approach cannot be used in isolation; quality of care and ethical considerations must be taken into account before a final determination of the source of funding for core or comprehensive health care services is made.
Determination of which health care services are to be included in or excluded from a publicly financed health insurance plan should also incorporate an economic analysis of the primary and secondary effects on both the patient and provider populations. Some of the factors that should be included in such an analysis are: availability of substitutes, discretionary income, availability of private insurance, direct and indirect costs of service provision, barriers to entry and the existence of fixed global budgets. Economic analyses also include measurement of the opportunity costs, in terms of foregone services, associated with public financing of health care services. When possible, the public's needs should be distinguished from its wants for the purposes of public policy and funding.
From a clinical perspective, providers have always addressed patient needs on a case-by-case basis. However, fiscal restraint and the rationalization of health care services often result in the onus being placed on the provider to make micro resource allocation decisions. Local decisions (i.e., at the hospital and community level) about the rationalization of health care resources can restrict providers' ability to deliver services and patients' ability to receive them. Therefore, it is critical that the patient and provider perspectives be included in any economic analysis undertaken to define core health care services.
As enunciated in its policy statement, Federal Health Financing, the CMA will urge the federal government to ensure that full funding be available to support provincial and territorial provision of core medical services.
Nevertheless, there remain concerns regarding how the comprehensiveness principle is being interpreted. First, the array of core services varies considerably among the provinces/territories (e.g., prescription drug coverage). Second, the basket of core health services needs to be modernized to reflect Canadians' emerging health needs and how health care is now being delivered (e.g,. more out-patient care).
While a degree of latitude is required to accommodate differing regional needs, core services should be available to all Canadians on uniform terms and conditions and should not be limited to physician and hospital services. There should be ongoing periodic monitoring and reporting of the comparability of Canadians' access to a full range of medically necessary health services across the country.
Furthermore, there is a need for a federal/provincial/territorial process that is transparent, accountable, evidence-based and inclusive to regularly update the basket of core services. CMA will work with provincial/territorial medical associations and other stakeholders to develop a process for defining a national list of core medical services.
Greater transparency is required when de-insuring services, including the need for consultation and providing an adequate notice period for patients, providers and funders.
A new framework is also required to govern the funding of a basket of core health services that allows at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories.
Health and safety in the workplace continue to be areas of concern to the CMA. The CMA recommends that educational programs on the risks of drug-related impairment to health and safety in the workplace be directed toward labour, management and the public in general. Occupations for which impairment resulting from drug use may constitute a serious hazard should be identified and designated as such. The association recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds to suspect impairment of the worker. Workers holding safety-sensitive jobs should be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) being taken to the occupational health physician or, in the absence of such, to the physician of the worker's choice. The CMA is opposed to routine pre-employment drug testing. It recommends that random drug testing among employees be restricted to safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Drug testing should always be conducted in such a way as to protect confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law).
The idea of drug testing among workers has developed from society's concern over the relation between drug use and impairment, with resultant risks to the worker, fellow workers and the public.
Education: Since prevention is the principal and ultimate objective the association recommends that educational programs on the risks of impairment to health and safety in the workplace be directed toward labour, management and the public in general.
Illicit drugs are not the only ones that may cause impairment. Certain prescription drugs and even some over-the-counter medications may affect a person's ability to carry out professional functions safely; such effects may vary considerably from one person to another.
Alcohol is by far the most common impairing drug implicated in accidents; in addition, the scientific literature contains a growing body of information on impairment and dangers resulting from the use and misuse of various therapeutic medications. Far less is documented or known about the role of illicit drugs in work-related accidents.
Safety-sensitive occupations: In most workplaces there are occupations for which impairment may constitute a serious hazard. Such occupations should be identified and designated as such. Workers who hold such safety-sensitive jobs must accept the fact that other workers and the public need to be protected from the hazards of impairment, whether from physical or psychologic ill health or from the use of drugs (over-the-counter, prescription or illicit).
Performance assessment of safety-sensitive occupations: The CMA recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds (e.g., unsatisfactory performance or observed unusual behaviour) to suspect impairment of the worker. The examining physician may recommend that some tests (including tests for the presence of certain drugs) be carried out under pre-agreed protocols. Workers holding safety-sensitive jobs must be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) they may be taking to the occupational health physician or, in the absence of such, to the physician of the worker's choice.
Testing: Any discussion of drug testing must take the following into account:
If a quantitative test is to be used to determine impairment a limit must be established beyond which a person is deemed to be impaired. However, since the threshold of impairment varies from one person to another this variation should be taken into account when a worker is being assessed.
The tests must be valid and reliable. They must be performed only in laboratories accredited for drug testing.
The tests must provide results rapidly enough to be useful in deciding whether the person should continue to work.
If different testing procedures are available and the differences between the validity and reliability are not significant the least intrusive alternative should be chosen.
The test should be conducted in such a way as to ensure confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law).
Pre-employment testing: The CMA opposes routine pre-employment drug testing for the following reasons:
Routine pre-employment drug screening may not objectively identify those people who constitute a risk to society.
The mass, low-cost screening tests may not be reliable or valid.
The circumstances may not justify possible human rights violations.
Random testing: The CMA believes that random drug testing among employees has a limited role, if any, in the workplace. Such testing should be restricted to employees in safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable.
Role of occupational health services: Occupational health physicians must not be involved in a policing or disciplinary role with respect to employee testing.
CMA recommends that employers provide a safe environment for all workers. With the help of experts such as those from national and provincial agencies dedicated to dealing with substance abuse occupational health departments should develop lists of drugs known to cause short-term or long-term impairment, including alcohol. These lists should be posted prominently in the workplace, and workers should be advised that in the event of obvious impairment those involved in safety-sensitive occupations will be asked to undergo medical assessment. If testing for drugs is indicated refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job.
Alcohol impairment should not be tolerated, and legislation should be considered that would set a legal blood alcohol level for safety-sensitive occupations. Breathalyzers or other detection methods could be used if alcohol impairment is suspected in a person holding safety-sensitive occupation. As stated previously, refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job.
These measures should be discussed with labour and management. Labour should be expected to recognize drug-related impairment as a serious health and safety issue, and management should demonstrate its concern by ensuring access to treatment, prevention and educational programs such as employee assistance programs.
Federal Health Financing (Update 2008)
The Canadian Medical Association believes that financial support from the federal government for health care should provide the following:
* The maintenance and improvement of standards of health care service across Canada.
* The financial stability necessary to effectively plan health care delivery and flexibility in spending across Canada to respond to local circumstances, emerging health needs, and new patient-care modalities.
* The indexing of federal health cash payments to provinces and territories to reflect changes in population growth, ageing, epidemiology, current knowledge, new technology and economic growth.
* Greater accountability, visibility and improved linkages of services to users.
* Greater equity across the provinces and territories in the ability to finance necessary health care programs.
* The joint policy discussions necessary to address health issues of national importance.
The CMA is committed to preserving the right of reasonable access to high-quality health care regardless of ability to pay. It is also committed to achieving national health care standards (accessibility, universality, portability, comprehensiveness and public administration) and to developing health goals to ensure that all Canadians receive the best possible care when required. The CMA supports the goal of maintaining the national integrity of the health care system. It encourages the federal government to be sensitive to the concerns of equity, and to ensure that provinces and territories that have not attained a level of health care services and facilities equivalent to those of other provinces and territories, because of fiscal incapacities, have access to additional funding requirements to reduce the gap. The CMA recognizes that flexibility in spending across Canada is important to respond to changing health care needs and changes in the delivery of health care, as is the necessity of joint policy discussions to address health issues of national importance. Stability in funding is viewed as the mechanism to achieving effective health care planning.
Over 50 years of federal financing
In 1957 and 1966, the federal government introduced the Hospital Insurance and Diagnostic Services Act and Medicare Act. These programs reflected the federal government's desire to implement 50-50 basis with the provinces for the funding of hospital and physician services. The federal support was program specific, with contributions determined to be about half the national average of per-capita expenditures on health care. This provided greater assistance to provinces with lower per-capita costs.
In 1977, the funding arrangement was replaced by the negotiated Established Programs Financing (EPF) arrangements. The new "block-funding" agreement established a predetermined level of financial contributions by the federal government that was linked to the rate of change of gross national product (GNP) and changes in the provincial/territorial populations. It is important to note that federal transfers are comprised of cash and tax points.
The objectives of the EPF arrangements as set out by the Prime Minister in June 1976, were (a) to maintain across Canada the standards of service to the public under these major programs, and to facilitate their improvement; (b) to put the programs on a more stable footing, so that both levels of government are better able to plan their expenditures; (c) to give the provinces the flexibility of in the use of their own funds which they have been spending in these fields; (d) to bring about greater equity among the provinces with regard to the amount of federal funds that they receive under the program; and (e) to provide for continuing joint policy discussions relating to the health and post-secondary education fields.
The need for funding predictability
Over the course of their existence, the EPF arrangements were amended four times - 1982 (Bill C-97), 1984 (Bill C-96), 1989 (Bill C-33) and 1991(Bill C-69). These changes resulted in freezes in the growth of federal health transfers and created a period of funding uncertainty for provinces and territories.
On April 1, 1996, the federal government introduced the Canada Health and Social Transfer (CHST) which combined two transfer programs, EPF and the Canada Assistance Plan into one transfer program for insured health services, post secondary education and social assistance programs. Cash payments under the CHST were subject to the five program criteria of the Canada Health Act (1984) - accessibility, portability, comprehensiveness, and public administration as well as the single condition that the province/territory must provide social assistance to applicants without a minimum residency requirement.
In combining these programs the federal government used the opportunity to cut cash entitlements to the provinces/territories from $18.5 billion per year 1995-1996 to a low of $11.1 billion per year in 1999-2000. However, due to improving economic conditions and a rapidly impending balanced budget, the federal government announced in its September 1997 Throne Speech that it would be increasing the cash floor to $12.5 billion per year in 1998-1999 to 2002-2003. This measure was announced in the 1998-1999 budget; however, rather than an increase in funding, it was merely a partial reversal in cash reductions to the provinces/territories.
Targeted federal financing
Since 2000, the federal government has increased the use of targeted investments and in the health arena.
On Sept. 11, 2000, First Ministers issued a Communiqué on Health announcing a series of investments, over five years, which focused on health and other social programs. The CHST cash floor was "increased" by $2.5 billion effective April 1, 2001.
The February 2003 Budget in support of that year's First Ministers' Accord on Health Care Renewal confirmed: (1) a two-year extension to 2007-2008 of the five-year legislative framework put in place in September 2000, with an additional $1.8 billion; (2) a $2.5 billion CHST supplement, giving provinces the flexibility to draw down funds as they require up to the end of 2005-2006; and (3) the restructuring of the CHST to create a separate Canada Health Transfer and a Canada Social Transfer effective April 1, 2004, in order to increase transparency and accountability.
In September 2004, First Ministers signed an agreement on health care that included commitments to reduce wait times, address gaps in health human resources, expand home care, continue efforts in primary care reform, implement a national pharmaceutical strategy, and develop national public health goals.
To support the new agreement, the federal government committed to increase health funding by a total of $18 billion over 6 years or $41 billion over 10 years. This includes:
* $3 billion to close the "short-term Romanow gap;"
* $500 million for home care and catastrophic coverage;
* $4.5 billion for a Wait Time Reduction Fund;
* $1 billion for health human resources (to be transferred in last four years of agreement);
* $500 million for medical equipment; and
* a 6% escalator for the Canada Health Transfer.
The 2007 budget provided over one billion additional dollars for the health care system mainly through a $612 million investment to accelerate the implementation of patient wait-time guarantees, $400 million for Canada Health Infoway to support the further development of health information systems and electronic records, and $300 million for a vaccine program to protect women and girls against cancer of the cervix.
Clarifying responsibilities and accountability
The 2007 budget made reference to the federal government's constitutional responsibilities for health care and stressed an increased concern of accounting for federal health transfers to the provinces/territories.
The Oct. 16, 2007 Speech from the Throne, to open the second session of the 39th Parliament of the Government of Canada, included a commitment to introduce legislation that would place formal limits on the use of the federal spending power for new cost-shared programs in areas of provincial/territorial jurisdiction, and would also provide an opt-out option with compensation for provinces and territories if they offer compatible programs.
The main foundation for this proposal is set out in the Feb. 4, 1999 Social Union Framework Agreement (SUFA), in which the federal government gave several undertakings with regard to new "Canada-wide initiatives" in areas of provincial jurisdiction:
* collaboration with provincial/territorial governments to identify priorities and objectives;
* not to introduce new initiatives without agreement of a majority of provincial governments;
* provincial/territorial governments to determine detailed program design and mix;
* provincial/territorial governments can reinvest any funds not needed to deliver objectives;
* federal/provincial/territorial governments to agree on accountability framework; and
* funding to be contingent on meeting or committing to objectives specified in accountability framework.
The most notable application of SUFA principles in respect of new programs to date has been the Sept. 15, 2004 Asymmetrical Federalism that Respects Quebec's Jurisdiction Agreement in which Quebec agreed to develop and implement its own plan to attain the objectives of the First Ministers' 10-Year Plan to Strengthen Health Care, and to report progress to Quebecers using comparable indicators, mutually agreed to with other governments.
The accountability framework set out in SUFA would appear to be the linchpin of assuring the national character of any future health programs. Its implementation has thus far been a failure. While governments did agree to common indicators in 2000 and 2003, and did produce them in 2002 and 2004, they have been resistant to any attempts at comparability/benchmarking between jurisdictions and they failed to produce them at all in 2006. The Health Council of Canada lamented this lack of cooperation in its 2007 annual report.
Ensuring federal health financing is responsive to Canadians' health needs
The CMA believes that the federal government has a special responsibility for financing health care. The development of the health care financing system on a cooperative federal/provincial/territorial basis has many merits. It has resulted in the clear perception that the federal government has an obligation to ensure that reasonably comparable, high quality health care services are available, on a reasonably comparable basis, to all Canadians.
Through its financial contributions in support of the 2000, 2003 and 2004 health accords, the federal government has effectively restored the cuts made to federal health transfers during the early 1990s. However, health care which is now at 40 per cent of total provincial/territorial program spending continues to grow. The CMA must remain vigilant to ensure that the federal government continues to provide stable, predictable and adequate funding necessary to maintain and improve the standards of health care service across Canada. This federal funding should provide for a system that is effective, efficient and responsible.
With respect to the broader continuum of care, the future of Medicare is uncertain. While the federal government's role in funding health care remains tied to the Canada Health Act, Medicare must be modernized to reflect the current and future reality of the delivery of care. In 1975, just after Medicare was fully adopted, hospital and physician expenditures represented 60% of total health expenditures; as of 2006, this share has dropped by almost one-third to 43%. Over the past two decades, prescription drugs, as a proportion of total health spending, have doubled from 7% in 1986 to an estimated 14.2% in 2006. While a majority of Canadians have prescription drug coverage from either private or public plans, it is estimated that some 3.5 million are either uninsured or underinsured for prescription drug costs.
However, there is a clear consensus on the need for catastrophic prescription drug coverage and a growing concern about how to address the issue of very costly "orphan" drugs for rare diseases, and expensive treatments for common diseases such as breast cancer. In 2003, First Ministers committed to having catastrophic drug coverage in place by the end of 2005-2006, and while this is one of the elements of the National Pharmaceuticals Strategy, little collective action has taken place beyond further study. Similarly a 2003 commitment by First Ministers to first-dollar coverage for a basket of short-term acute home care, community mental health and end-of-life care services remains unmet.
The issue of long-term care of the elderly also looms on the horizon as the first cohort of the baby boom generation turns 65 in 2011. Indeed hospitals are already feeling the pinch of a lack of alternative level of care beds. International experience suggests that long-term care cannot nor should not be financed on the same pay-as-you-go basis as medical/hospital insurance.
Innovative approaches will be required to provide funding for the broader continuum of care (see CMA Policy Statement, It's Still About Access: Medicare Plus). We can expect to continue to see a mix of public and private plans and out-of-pocket payments (e.g., co-payments) and greater use of tax policy. This is the experience of most European and other industrialized countries. In Canada and internationally, the prospects for additional health programs funded on a first-dollar basis out of general taxation revenues are slim. In its 2007 budget, the federal government introduced a Registered Disability Savings Plan to help parents of children with a severe disability to ensure their children's future financial security by investing after-tax income on which the investment income will accumulate tax-free. Consideration should be given to implementing a similar contributions-based program for long-term care as is found in some other countries.
Another possibility would see the creation of a Canada Extended Health Services Financing Act that would provide a mechanism for sustainable federal funding to support provinces and territories providing necessary health services in the home and community setting. Such legislation would be based on a series of principles supported by Canadians to meet their health care needs.