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.
Clinical photography is a valuable tool for physicians. Smartphones, as well as other devices supporting network connectivity, offer a convenient, efficient method to take and share images. However, due to the private nature of the information contained in clinical photographs there are concerns as to the appropriate storage, dissemination, and documentation of clinical images. Confidentiality of image data must be considered and the dissemination of these images onto servers must respect the privacy and rights of the patient. Importantly, patient information should be considered as any information deriving from a patient, and the concepts outlined therefore apply to any media that can be collected on, or transmitted with, a smart-device.
Clinical photography can aid in documenting form and function, in tracking conditions and wound healing, in planning surgical operations, and in clinical decision-making. Additionally, clinical photographs can provide physicians with a valuable tool for patient communication and education. Due to the convenience of this type of technology it is not appropriate to expect physicians to forego their use in providing their patients with the best care available.
The technology and software required for secure transfer, communication, and storage of clinical media is presently available, but many devices have non-secure storage/dissemination options enabled and lack user-control for permanently deleting digital files. In addition, data uploaded onto server systems commonly cross legal jurisdictions. Many physicians are not comfortable with the practice, citing security, privacy, and confidentiality concerns as well as uncertainty in regards to regional regulations governing this practice.1 Due to concern for patient privacy and confidentiality it is therefore incredibly important to limit the unsecure or undocumented acquisition or dissemination of clinical photographs.
To assess the current state of this topic, Heyns et al. have reviewed the accessibility and completeness of provincial and territorial medical regulatory college guidelines.2 Categories identified as vital and explored in this review included: Consent; Storage; Retention; Audit; Transmission; and Breach. While each regulatory body has addressed limited aspects of the overall issue, the authors found a general lack of available information and call for a unified document outlining pertinent instructions for conducting clinical photography using a smartphone and the electronic transmission of patient information.2
The discussion of this topic will need to be ongoing and it is important that physicians are aware of applicable regulations, both at the federal and provincial levels, and how these regulations may impact the use of personal devices. The best practices supported here aim to provide physicians and healthcare providers with an understanding of the scope and gravity of the current environment, as well as the information needed to ensure patient privacy and confidentiality is assessed and protected while physicians utilize accessible clinical photography to advance patient care. Importantly, this document only focusses on medical use (clinical, academic, and educational) of clinical photography and, while discussing many core concepts of patient privacy and confidentiality of information, should not be perceived as a complete or binding framework. Additionally, it is recommended that physicians understand the core competencies of clinical photography, which are not described here.
The Canadian Medical Association (CMA) suggests that the following recommendations be implemented, as thoroughly as possible, to best align with the CMA policy on the Principles for the Protection of Patient Privacy (CMA Policy PD2018-02). These key recommendations represent a non-exhaustive set of best practices - physicians should seek additional information as needed to gain a thorough understanding and to stay current in this rapidly changing field.
* Informed consent must be obtained, preferably prior, to photography with a mobile device. This applies for each and any such encounter and the purpose made clear (i.e. clinical, research, education, publication, etc.). Patients should also be made aware that they may request a copy of a picture or for a picture to be deleted.
* A patient's consent to use electronic transmission does not relieve a physician of their duty to protect the confidentiality of patient information. Also, a patient's consent cannot override other jurisdictionally mandated security requirements.
* All patient consents (including verbal) should be documented. The acquisition and recording of patient consent for medical photography/dissemination may be held to a high standard of accountability due to the patient privacy and confidentiality issues inherent in the use of this technology. Written and signed consent is encouraged.
* Consent should be considered as necessary for any and all photography involving a patient, whether or not that patient can be directly recognized, due to the possibility of linked information and the potential for breach of privacy. The definition of non-identifiable photos must be carefully considered. Current technologies such as face recognition and pattern matching (e.g. skin markers, physical structure, etc.), especially in combination with identifying information, have the potential to create a privacy breach.
* Unsecure text and email messaging requires explicit patient consent and should not be used unless the current gold standards of security are not accessible. For a patient-initiated unsecure transmission, consent should be clarified and not assumed.
* Transmission of photos and patient information should be encrypted as per current-day gold standards (presently, end-to-end encryption (E2EE)) and use only secure servers that are subject to Canadian laws. Explicit, informed consent is required otherwise due to privacy concerns or standards for servers in other jurisdictions. Generally, free internet-based communication services and public internet access are unsecure technologies and often operate on servers outside of Canadian jurisdiction.
* Efforts should be made to use the most secure transmission method possible. For data security purposes, identifying information should never be included in the image, any frame of a video, the file name, or linked messages.
* The sender should always ensure that each recipient is intended and appropriate and, if possible, receipt of transmission should be confirmed by the recipient.
* Storing images and data on a smart-device should be limited as much as possible for data protection purposes.
* Clinical photos, as well as messages or other patient-related information, should be completely segregated from the device's personal storage. This can be accomplished by using an app that creates a secure, password-protected folder on the device.
* All information stored (on internal memory or cloud) must be strongly encrypted and password protected. The security measures must be more substantial than the general password unlock feature on mobile devices.
* Efforts should be made to dissociate identifying information from images when images are exported from a secure server. Media should not be uploaded to platforms without an option for securely deleting information without consent from the patient, and only if there are no better options. Automatic back-up of photos to unsecure cloud servers should be deactivated. Further, other back-up or syncing options that could lead to unsecure server involvement should be ascertained and the risks mitigated.
4. Cloud storage should be on a Canadian and SOCII certified server. Explicit, informed consent is required otherwise due to privacy concerns for servers in other jurisdictions.
5. AUDIT & RETENTION
* It is important to create an audit trail for the purposes of transparency and medical best practice. Key information includes patient and health information, consent type and details, pertinent information regarding the photography (date, circumstance, photographer), and any other important facts such as access granted/deletion requests.
* Access to the stored information must be by the authorized physician or health care provider and for the intended purpose, as per the consent given. Records should be stored such that it is possible to print/transfer as necessary.
* Original photos should be retained and not overwritten.
* All photos and associated messages may be considered part of the patient's clinical records and should be maintained for at least 10 years or 10 years after the age of majority, whichever is longer. When possible, patient information (including photos and message histories between health professionals) should be retained and amalgamated with a patient's medical record. Provincial regulations regarding retention of clinical records may vary and other regulations may apply to other entities - e.g. 90 years from date of birth applies to records at the federal level.
* It may not be allowable to erase a picture if it is integral to a clinical decision or provincial, federal, or other applicable regulations require their retention.
* Any breach should be taken seriously and should be reviewed. All reasonable efforts must be made to prevent a breach before one occurs. A breach occurs when personal information, communication, or photos of patients are stolen, lost, or mistakenly disclosed. This includes loss or theft of one's mobile device, texting to the wrong number or emailing/messaging to the wrong person(s), or accidentally showing a clinical photo that exists in the phone's personal photo album.
* It should be noted that non-identifying information, when combined with other available information (e.g. a text message with identifiers or another image with identifiers), can lead to highly accurate re-identification.
* At present, apps downloaded to a smart-device for personal use may be capable of collecting and sharing information - the rapidly changing nature of this technology and the inherent privacy concerns requires regular attention. Use of specialized apps designed for health-information sharing that help safeguard patient information in this context is worth careful consideration.
* Having remote wipe (i.e. device reformatting) capabilities is an asset and can help contain a breach. However, inappropriate access may take place before reformatting occurs.
* If a smartphone is strongly encrypted and has no clinical photos stored locally then its loss may not be considered a breach.
* In the event of a breach any patient potentially involved must be notified as soon as possible. The CMPA, the organization/hospital, and the Provincial licensing College should also be contacted immediately. Provincial regulations regarding notification of breach may vary.
Approved by the CMA Board of Directors March 2018
i Heyns M†, Steve A‡, Dumestre DO‡, Fraulin FO‡, Yeung JK‡
† University of Calgary, Canada
‡ Section of Plastic Surgery, Department of Surgery, University of Calgary, Canada
1 Chan N, Charette J, Dumestre DO, Fraulin FO. Should 'smart phones' be used for patient photography? Plast Surg (Oakv). 2016;24(1):32-4.
2 Unpublished - Heyns M, Steve A, Dumestre DO, Fraulin FO, Yeung J. Canadian Guidelines on Smartphone Clinical Photography.
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.
CMA CODE OF ETHICS AND PROFESSIONALISM
A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances
of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient.
An honest physician is forthright, respects the truth, and does their best to seek, preserve, and communicate
that truth sensitively and respectfully.
A humble physician acknowledges and is cautious not to overstep the limits of their knowledge and skills or the
limits of medicine, seeks advice and support from colleagues in challenging circumstances, and recognizes the
patient’s knowledge of their own circumstances.
A physician who acts with integrity demonstrates consistency in their intentions and actions and acts in a
truthful manner in accordance with professional expectations, even in the face of adversity.
A prudent physician uses clinical and moral reasoning and judgement, considers all relevant knowledge
and circumstances, and makes decisions carefully, in good conscience, and with due regard for principles of
exemplary medical care.
The CMA Code of Ethics and Professionalism articulates the ethical and professional commitments and responsibilities of the
medical profession. The Code provides standards of ethical practice to guide physicians in fulfilling their obligation to provide
the highest standard of care and to foster patient and public trust in physicians and the profession. The Code is founded on
and affirms the core values and commitments of the profession and outlines responsibilities related to contemporary medical
In this Code, ethical practice is understood as a process of active inquiry, reflection, and decision-making concerning what
a physician’s actions should be and the reasons for these actions. The Code informs ethical decision-making, especially in
situations where existing guidelines are insufficient or where values and principles are in tension. The Code is not exhaustive;
it is intended to provide standards of ethical practice that can be interpreted and applied in particular situations. The Code and
other CMA policies constitute guidelines that provide a common ethical framework for physicians in Canada.
In this Code, medical ethics concerns the virtues, values, and principles that should guide the medical profession, while
professionalism is the embodiment or enactment of responsibilities arising from those norms through standards,
competencies, and behaviours. Together, the virtues and commitments outlined in the Code are fundamental to the ethical
practice of medicine.
Physicians should aspire to uphold the virtues and commitments in the Code, and they are expected to enact the professional
responsibilities outlined in it.
Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions.
Trust is the cornerstone of the patient–physician relationship and of medical professionalism. Trust is therefore
central to providing the highest standard of care and to the ethical practice of medicine. Physicians enhance
trustworthiness in the profession by striving to uphold the following interdependent virtues:
A. VIRTUES EXEMPLIFIED BY THE ETHICAL PHYSICIAN
B. FUNDAMENTAL COMMITMENTS OF THE MEDICAL PROFESSION
Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient.
Provide appropriate care and management across the care continuum.
Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a
risk of harm or if harm has occurred.
Recognize the balance of potential benefits and harms associated with any medical act; act to bring about
a positive balance of benefits over harms.
Commitment to the well-being of the patient
Promote the well-being of communities and populations by striving to improve health outcomes and
access to care, reduce health inequities and disparities in care, and promote social accountability.
Commitment to justice
Practise medicine competently, safely, and with integrity; avoid any influence that could undermine
your professional integrity.
Develop and advance your professional knowledge, skills, and competencies through lifelong learning.
Commitment to professional integrity and competence
Always treat the patient with dignity and respect the equal and intrinsic worth of all persons.
Always respect the autonomy of the patient.
Never exploit the patient for personal advantage.
Never participate in or support practices that violate basic human rights.
Commitment to respect for persons
Contribute to the development and innovation in medicine through clinical practice, research, teaching,
mentorship, leadership, quality improvement, administration, or advocacy on behalf of the profession or
Participate in establishing and maintaining professional standards and engage in processes that support
the institutions involved in the regulation of the profession.
Cultivate collaborative and respectful relationships with physicians and learners in all areas of medicine
and with other colleagues and partners in health care.
Commitment to professional excellence
Value personal health and wellness and strive to model self-care; take steps to optimize meaningful
co-existence of professional and personal life.
Value and promote a training and practice culture that supports and responds effectively to colleagues in
need and empowers them to seek help to improve their physical, mental, and social well-being.
Recognize and act on the understanding that physician health and wellness needs to be addressed at
individual and systemic levels, in a model of shared responsibility.
Commitment to self-care and peer support
Value and foster individual and collective inquiry and reflection to further medical science and to
facilitate ethical decision-making.
Foster curiosity and exploration to further your personal and professional development and insight; be
open to new knowledge, technologies, ways of practising, and learning from others.
Commitment to inquiry and reflection
C. PROFESSIONAL RESPONSIBILITIES
The patient–physician relationship is at the heart of the practice of medicine. It is a relationship of trust that recognizes the
inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of
loyalty to protect and further the patient’s best interests and goals of care by using the physician’s expertise, knowledge, and
prudent clinical judgment.
In the context of the patient–physician relationship:
1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic
characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race,
religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the physician to refuse to
accept a patient for legitimate reasons.
2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer
required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the
patient has been given reasonable notice that you intend to terminate the relationship.
3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your
duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and
requests whatever your moral commitments may be.
4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or
practice of any medical procedure or intervention as it pertains to the patient’s needs or requests.
5. Communicate information accurately and honestly with the patient in a manner that the patient understands and can
apply, and confirm the patient’s understanding.
6. Recommend evidence-informed treatment options; recognize that inappropriate use or overuse of treatments or
resources can lead to ineffective, and at times harmful, patient care and seek to avoid or mitigate this.
7. Limit treatment of yourself, your immediate family, or anyone with whom you have a similarly close relationship to
minor or emergency interventions and only when another physician is not readily available; there should be no fee for
8. Provide whatever appropriate assistance you can to any person who needs emergency medical care.
9. Ensure that any research to which you contribute is evaluated both scientifically and ethically and is approved by a
research ethics board that adheres to current standards of practice. When involved in research, obtain the informed
consent of the research participant and advise prospective participants that they have the right to decline to participate
or withdraw from the study at any time, without negatively affecting their ongoing care.
10. Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure.
Physicians and patients
11. Empower the patient to make informed decisions regarding their health by communicating with and helping the patient
(or, where appropriate, their substitute decision-maker) navigate reasonable therapeutic options to determine the best
course of action consistent with their goals of care; communicate with and help the patient assess material risks and
benefits before consenting to any treatment or intervention.
12. Respect the decisions of the competent patient to accept or reject any recommended assessment, treatment, or plan of
13. Recognize the need to balance the developing competency of minors and the role of families and caregivers in medical
decision-making for minors, while respecting a mature minor’s right to consent to treatment and manage their personal
14. Accommodate a patient with cognitive impairments to participate, as much as possible, in decisions that affect them;
in such cases, acknowledge and support the positive roles of families and caregivers in medical decision-making and
collaborate with them, where authorized by the patient’s substitute decision-maker, in discerning and making decisions
about the patient’s goals of care and best interests.
15. Respect the values and intentions of a patient deemed incompetent as they were expressed previously through advance
care planning discussions when competent, or via a substitute decision-maker.
16. When the specific intentions of an incompetent patient are unknown and in the absence of a formal mechanism for
making treatment decisions, act consistently with the patient’s discernable values and goals of care or, if these are
unknown, act in the patient’s best interests.
17. Respect the patient’s reasonable request for a second opinion from a recognized medical expert.
Physicians and the practice of medicine
Patient privacy and the duty of confidentiality
18. Fulfill your duty of confidentiality to the patient by keeping identifiable patient information confidential; collecting,
using, and disclosing only as much health information as necessary to benefit the patient; and sharing information only
to benefit the patient and within the patient’s circle of care. Exceptions include situations where the informed consent of
the patient has been obtained for disclosure or as provided for by law.
19. Provide the patient or a third party with a copy of their medical record upon the patient’s request, unless there is a
compelling reason to believe that information contained in the record will result in substantial harm to the patient or
20. Recognize and manage privacy requirements within training and practice environments and quality improvement
initiatives, in the context of secondary uses of data for health system management, and when using new technologies in
21. Avoid health care discussions, including in personal, public, or virtual conversations, that could reasonably be seen as
revealing confidential or identifying information or as being disrespectful to patients, their families, or caregivers.
Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making and is informed
by the patient’s experience and values and the physician’s clinical judgment. This deliberation involves discussion with the
patient and, with consent, others central to the patient’s care (families, caregivers, other health professionals) to support
In the process of shared decision-making:
22. Recognize that conflicts of interest may arise as a result of competing roles (such as financial, clinical, research,
organizational, administrative, or leadership).
23. Enter into associations, contracts, and agreements that maintain your professional integrity, consistent with evidenceinformed
decision-making, and safeguard the interests of the patient or public.
24. Avoid, minimize, or manage and always disclose conflicts of interest that arise, or are perceived to arise, as a result of
any professional relationships or transactions in practice, education, and research; avoid using your role as a physician to
promote services (except your own) or products to the patient or public for commercial gain outside of your treatment role.
25. Take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to a third party
when acting on behalf of a third party.
26. Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees.
27. When conducting research, inform potential research participants about anything that may give rise to a conflict of
interest, especially the source of funding and any compensation or benefits.
28. Be aware of and promote health and wellness services, and other resources, available to you and colleagues in need.
29. Seek help from colleagues and appropriate medical care from qualified professionals for personal and professional
problems that might adversely affect your health and your services to patients.
30. Cultivate training and practice environments that provide physical and psychological safety and encourage help-seeking
31. Treat your colleagues with dignity and as persons worthy of respect. Colleagues include all learners, health care partners,
and members of the health care team.
32. Engage in respectful communications in all media.
33. Take responsibility for promoting civility, and confronting incivility, within and beyond the profession. Avoid impugning
the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional
conduct by colleagues.
34. Assume responsibility for your personal actions and behaviours and espouse behaviours that contribute to a positive
training and practice culture.
35. Promote and enable formal and informal mentorship and leadership opportunities across all levels of training, practice,
and health system delivery.
36. Support interdisciplinary team-based practices; foster team collaboration and a shared accountability for patient care.
Physicians and self
Physicians and colleagues
Managing and minimizing conflicts of interest
38. Recognize that social determinants of health, the environment, and other fundamental considerations that extend
beyond medical practice and health systems are important factors that affect the health of the patient and of
39. Support the profession’s responsibility to act in matters relating to public and population health, health education,
environmental determinants of health, legislation affecting public and population health, and judicial testimony.
40. Support the profession’s responsibility to promote equitable access to health care resources and to promote resource
41. Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific
knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the
42. Contribute, where appropriate, to the development of a more cohesive and integrated health system through interprofessional
collaboration and, when possible, collaborative models of care.
43. Commit to collaborative and respectful relationships with Indigenous patients and communities through efforts
to understand and implement the recommendations relevant to health care made in the report of the Truth and
Reconciliation Commission of Canada.
44. Contribute, individually and in collaboration with others, to improving health care services and delivery to address
systemic issues that affect the health of the patient and of populations, with particular attention to disadvantaged,
vulnerable, or underserved communities.
Approved by the CMA Board of Directors Dec 2018
37. Commit to ensuring the quality of medical services offered to patients and society through the establishment and
maintenance of professional standards.
Physicians and society
These Guidelines constitute an implementation tool of seven recommendations and are informed by Guidelines for CMA’s Activities and Relationships with Other Parties (aka CMA’s Corporate Relationships Policy) and CMA’s Advertising and Sponsorship Policy.
These Guidelines apply to the Canadian Medical Association (and not to its subsidiaries). As these are Guidelines, exceptions may be necessary from time to time wherein staff may use their discretion and judgment.
Endorsement is an umbrella term encompassing “policy endorsement”, “sponsorship1” and “branding”.
Policy endorsement includes:
(a) CMA considering upon request, non-pecuniary public approval, which may include the use of
CMA’s name and/or logo, of an organization’s written policy, on an issue that aligns with CMA policy, where there is no immediate expectation of return; or,
(b) CMA adopting the policy of another organization as our policy; or
(c) CMA asking another organization to publicly support our policy.
(a) Criteria: For policy endorsement requests from another organization to endorse their policy2 the following criteria shall be applied:
i) we have a policy on the subject-matter and
ii) we are actively working on advancing that policy position and
iii) the organization has a follow-up action plan associated with its request.
(b) Approval: Where policy exists, approval requires a policy staff member (with portfolio responsibility) and the VP of Medical Professionalism, or the policy staff member (with portfolio responsibility) and the Chief Policy Advisor. Where no policy exists, approval of the Board of Directors is required.
(c) Annual confirmation: Where CMA adopts the policy of another organization3, CMA staff shall confirm annually, or more frequently if circumstances dictate, that the policy has not been altered by the other organization.
(d) Requests: Pursuit of personal endorsement requests are not appropriate. Wherever possible, requests should come from an organization and not an individual.
(a) Where CMA adopts the policy of another organization, the adopted policy shall become CMA policy, and will include a notation on the document as being an adopted policy of [organization].
(b) All adopted policies will be housed in an accessible searchable database.
(c) All requests by organizations for CMA to endorse their policy will be tracked in a central location, along with any response.
1 Sponsorship means, to consider upon request, pecuniary public approval, which may include the use of CMA’s name and/or logo, of an organization’s event (eg., conference), on an issue that is supported by CMA policy or that promotes CMA brand awareness, where there is an immediate expectation of return.
2 That is, part (a) of the definition in Section 2.
3 That is, part (b) of the definition in Section 2.
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.
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.
Guidelines for CMA’s Activities and Relationships with Other Parties
As the national voice of medicine in Canada, the CMA provides leadership for physicians, promotes the highest standards of health and health care for Canadians and acts as advocate for all Canadian physicians. In the furtherance of its purpose, the CMA conducts a variety of activities and has a variety of relationships with other parties. The CMA’s activities range from policy development to the delivery of products and services to physicians and the public. Its relationships with other parties range from the purchase of goods and services that support operations to partnerships that further or are consistent with its advocacy strategies.
The CMA actively seeks out relationships with others in recognition of the benefits these bring in the attainment of the CMA’s purposes. Such benefits may include:
- unifying the profession through relations with physician groups, including the divisions and affiliates
- enabling a stronger advocacy voice in association with others
- enhancing the CMA’s credibility with other parties
- providing financial and human resources to support CMA activities
- providing skills and capabilities that CMA may not possess
- providing additional membership services.
Activities or relationships with other parties and products and services produced through the activity or relationship (“activities or relationships”) that undermine the CMA’s reputation of professionalism, independence and quality are to be avoided, not only for their own sake but also because a diminishment of the CMA’s reputation impedes its ability to achieve its purposes.
The following principles have been developed to help guide decisions about the kinds of activities CMA undertakes and about its relations with other parties, with the objective of ensuring the integrity and good reputation of the CMA. A process or processes will be developed to implement the principles, which will include the preparation of subdocuments on applying the principles to specific areas; for example, sponsorship, endorsement and coalitions.
The CMA should rigorously and actively pursue its laudable ends and seek out relationships with others to attain them with the caveat that activities or relationships that would tarnish the integrity or reputation of CMA or the medical profession or that would diminish the trust placed in them should be avoided.
Conformity with CMA’s purpose
The activity or relationship should further or support the CMA’s purposes as elaborated in its objects, vision and mission.
The CMA’s purposes have been explicitly and widely agreed upon.
The CMA holds itself to be, and encourages reliance that it is, an organization that pursues its specified purposes.
Activities and relationships that do not further or support the CMA’s purposes have the potential to thwart these purposes in a number of ways, including inadequate accountability, inappropriate use of resources, unconstrained exercise of merely private judgement or inappropriate self-interest.
2. Medical professionalism and ethics
The activity or relationship should be consistent with medical professionalism and with CMA’s Code of Ethics.
The CMA is an association of physicians.
When the CMA acts, it represents the medical profession.
The CMA’s actions reflect upon the medical profession.
The CMA’s stature and reputation are inextricably linked to the medical profession’s work, the professional stature of its member physicians and the trust Canadians place in their physicians.
Engaging in activities or relationships that are inconsistent with medical professionalism and CMA’s Code of Ethics would erode trust in the CMA.
The activity or relationship should not undermine the CMA’s independence.
To be a credible voice and influence and to be worthy of the trust and confidence of physicians and of the public, the CMA should be, and be seen to be, free of undue influence and in control of the decisions it makes.
Undue influence occurs when one is induced to do or not do something that is contrary to what one would otherwise do if left to act freely. Undue influence deprives one of free agency and destroys free will such that it is rendered more the will of another than of one’s own.
Activities and relationships that may undermine independence include:
activities or relationships that provide revenue or benefit to the CMA such that ongoing dependency on the revenue or benefit impedes independence
activities and relationships that create a product or service that is seen to be associated with the CMA but over which the CMA does not have final control or veto or the capacity to extricate itself
Consistency with policy
The activity or relationship should be consistent with CMA policy.
The CMA develops policy in pursuance of its purposes; these should be referred to when making decisions in connection with activities or relationships.
Conflicting goals and activities
Relationships with parties whose goals or activities directly conflict with the CMA’s objects, mission or vision should be avoided.
This does not preclude discussion with others or participation in events for the purposes of obtaining information, monitoring or lobbying.
The terms and conditions of the activity or relationship should be transparent.
Transparency promotes an openness to scrutiny and serves to enhance accountability and to discourage relationships or activities that could be considered problematic.
The principle is generally applicable except in connection to matters related to competitive advantage, trade secret or a reasonable agreement of confidentiality.
Compliance and accountability
Processes must be in place to ensure that proposed and ongoing activities or relationships are appropriately reviewed for compliance with and clear accountability for these principles.
These include the activities of the secretariat and the corporate subsidiaries.
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.