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CMA PolicyBase

Policies that advocate for the medical profession and Canadians


22 records – page 1 of 3.

Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC09-92
The Canadian Medical Association recognizes addiction as a chronic, treatable disease and urges that it be included in national and provincial/territorial efforts to improve chronic disease management.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC09-92
The Canadian Medical Association recognizes addiction as a chronic, treatable disease and urges that it be included in national and provincial/territorial efforts to improve chronic disease management.
Text
The Canadian Medical Association recognizes addiction as a chronic, treatable disease and urges that it be included in national and provincial/territorial efforts to improve chronic disease management.
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Adverse events

https://policybase.cma.ca/en/permalink/policy9574
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health care and patient safety
Resolution
GC09-88
The Canadian Medical Association, while recognizing the importance of disclosing adverse events to affected patients in a timely manner, recommends that regional health authorities, institutions and professional associations develop policies to ensure the confidentiality of medical quality assurance deliberation, unless public notification is required to mitigate any possibility of ongoing harm.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health care and patient safety
Resolution
GC09-88
The Canadian Medical Association, while recognizing the importance of disclosing adverse events to affected patients in a timely manner, recommends that regional health authorities, institutions and professional associations develop policies to ensure the confidentiality of medical quality assurance deliberation, unless public notification is required to mitigate any possibility of ongoing harm.
Text
The Canadian Medical Association, while recognizing the importance of disclosing adverse events to affected patients in a timely manner, recommends that regional health authorities, institutions and professional associations develop policies to ensure the confidentiality of medical quality assurance deliberation, unless public notification is required to mitigate any possibility of ongoing harm.
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CMA Pre-budget Submission

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

https://policybase.cma.ca/en/permalink/policy14245
Date
2020-06-02
Topics
Ethics and medical professionalism
Health care and patient safety
  1 document  
Policy Type
Policy document
Date
2020-06-02
Topics
Ethics and medical professionalism
Health care and patient safety
Text
Racism is a structural determinant of health and drives health and social inequities. The recent incidents of anti-Black violence, racism and discrimination in the US and Canada also shed light on the structural inequities and racism that exist within the medical profession and the health system. The profession of medicine is grounded in respect for all people. This commitment recognizes that everyone has equal and inherent worth, the right to be valued and respected, and the right to be treated with dignity. It’s critical that our medical culture – and society more broadly – upholds these values. But today, we’re reminded that there’s much more to do as a profession, and as a global community, to get us there. Earlier this year, we launched our first-ever policy on equity and diversity in medicine Opens in a new window to help break down the many broad and systemic barriers that remain, to reduce discrimination and bias within our profession, and to create physically and psychologically safe environments for ourselves, our colleagues and our patients. Alongside this policy comes a commitment to holding ourselves accountable to recognizing and challenging behaviours, practices and conditions that hinder equity and diversity, including racism. Instances of racism, intolerance, exclusion, violence and discrimination have no place in medicine, and no place in our society. The Canadian Medical Association condemns racism in all its forms. Today, we stand alongside all those who have been affected by these appalling and inexcusable actions and beliefs. Dr. Sandy Buchman President, Canadian Medical Association
Documents
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Electronic health records

https://policybase.cma.ca/en/permalink/policy9543
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health information and e-health
Health care and patient safety
Resolution
GC09-47
The Canadian Medical Association will work with provincial/territorial medical associations to demand that governments recognize that the flow of information from the patient record to the electronic health records is the professional responsibility of physicians.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health information and e-health
Health care and patient safety
Resolution
GC09-47
The Canadian Medical Association will work with provincial/territorial medical associations to demand that governments recognize that the flow of information from the patient record to the electronic health records is the professional responsibility of physicians.
Text
The Canadian Medical Association will work with provincial/territorial medical associations to demand that governments recognize that the flow of information from the patient record to the electronic health records is the professional responsibility of physicians.
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Emergency federal measures to care for and protect Canadians during the COVID-19 pandemic

https://policybase.cma.ca/en/permalink/policy14132
Date
2020-03-16
Topics
Health care and patient safety
  2 documents  
Policy Type
Parliamentary submission
Date
2020-03-16
Topics
Health care and patient safety
Text
It is with a sense of urgency that the Canadian Medical Association (CMA) submits the recommendations herein for emergency federal measures that, taken together, will ensure Canadians receive appropriate care and that supportive measures are implemented for public health protection during the COVID-19 pandemic. While Canada has made significant strides since SARS to establish and implement effective public health infrastructure, resources and mechanisms, the significant resource constraints across our health systems present a major challenge in our current response. Federal emergency measures must be developed in the context of the current state of health resources: hospitals across the country are already at overcapacity, millions of Canadians lack access to a regular family doctor, countless communities are grappling with health care shortages, virtual care is in its infancy, and so on. Another core concern is the chronic underfunding and ongoing budget cuts of public health resources and programming. Public health capacity and leadership at all levels is fundamental to preparedness to respond to an infectious disease threat, particularly one of this magnitude. It is in this context that the Canadian Medical Association recommends that the following emergency measures be implemented by the federal government to support the domestic response to the COVID-19 pandemic: 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 1) FEDERAL RECOMMENDATION AND SUPPORT FOR SOCIAL DISTANCING In this time of crisis, Canadians look to the federal government for leadership and guidance. The single most important measure that can be implemented at this time is a consistent national policy calling for social distancing. This recommendation by the federal government must be paired with the resources necessary to ensure that no Canadian will be forced to choose between financial hardship — whether by losing employment or not being able to pay rent — and protecting their health. The CMA strongly recommends that the federal government immediately communicate guidance to Canadians to implement social distancing measures. The CMA further recommends that the federal government deliver new financial support measures as well as employment protection measures to ensure that all Canadians may engage in social distancing. 2) NEW FEDERAL EMERGENCY FUNDING TO BOOST PROVINCIAL/ TERRITORIAL CAPACITY AND ENSURE CONSISTENCY It is the federal government’s role to ensure a coordinated and consistent national response across jurisdictions and regions. This is by far the most important role for the federal government in supporting an effective domestic response, that is, protecting the health and well-being of Canadians. The CMA strongly recommends that the federal government deliver substantial emergency funding to the provinces and territories to ensure health systems have the capacity to respond to the pandemic. Across the OECD, countries are rapidly stepping up investment in measures to respond to COVID-19, including significant investment targeting boosting health care capacity. In considering the appropriate level of federal emergency funding to boost capacity in our provincial/territorial systems, the CMA urges the federal government to recognize that our baseline is a position of deficit. New emergency federal funding to boost capacity in provincial/territorial health systems should be targeted to:
rapidly enabling the expansion and equitable delivery of virtual care;
establishing a centralized 24-hour national information hotline for health care workers to obtain clear, timely and practical information on clinical guidelines, etc.;
expanding the capacity of and resources for emergency departments and intensive care units;
coordinating and disseminating information, monitoring and guidance within and across jurisdictions; and
rapidly delivering income stabilization for individuals and families under quarantine. Finally, the inconsistencies in the provision and implementation of guidance and adoption of public health measures across and within and jurisdictions is highly concerning. The CMA strongly encourages the federal government enable consistent adoption of pan-Canadian guidance and measures to ensure the health and safety of all Canadians. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 3) ENSURING AN ADEQUATE SUPPLY OF PERSONAL PROTECTIVE EQUIPMENT FOR CANADIAN HEALTH CARE WORKERS AND ENSURING APPROPRIATE USAGE The CMA is hearing significant concerns from front-line health care workers, including physicians, about the supply and appropriate usage of personal protective equipment. It is the CMA’s understanding that pan-Canadian efforts are underway to coordinate supply; however, additional measures by the federal government to ensure adequate supply and appropriate usage are required. Canada is at the outset of this public health crisis — supply issues at this stage may be exacerbated as the situation progresses. As such, the CMA strongly recommends that the federal government take additional measures to support the acquisition and distribution throughout health systems of personal protective equipment, including taking a leadership role in ensuring our domestic supply via international supply chains. 4) ESTABLISH EMERGENCY PAN-CANADIAN LICENSURE FOR HEALTH CARE WORKERS In this time of public health crisis, the federal government must ensure that regulatory barriers do not prevent health care providers from delivering care to patients when and where they need it. Many jurisdictions and regions in Canada are experiencing significant shortages in health care workers. The CMA urges the federal government to support piloting a national licensure program so that health care providers can opt to practice in regions experiencing higher infection rates or where there is a shortage of providers. This can be accomplished by amending the Canadian Free Trade Agreement (CFTA) to facilitate mobility of health care workers. Specifically, that the following language be added to Article 705(3) of the CFTA: (j) A regulatory authority of a Party* shall waive for a period of up to 100 days any condition of certification found in 705(3)(a) - (f) for any regulated health care worker to work directly or indirectly to address the Covid-19 pandemic or any health care emergency. Any disciplinary matter emanating from work in any province shall be the responsibility of the regulatory authority of the jurisdiction where the work is performed. Each Party shall instruct its regulatory authorities to set-up a rapid check-in/check-out process for the worker. *Party refers to a signatory of the CFTA To further enable this measure, the CMA recommends that the federal government deliver targeted funding to the regulatory colleges to implement this emergency measure as well as targeted funding to support the provinces/territories in delivering expanded patient care. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 5) ESTABLISH AN EMERGENCY NATIONAL MENTAL HEALTH SUPPORT SERVICE FOR HEALTH PROVIDERS Health care providers may experience trauma and hardship in meeting the increasing health needs and concerns of Canadians in this time of crisis. The CMA strongly recommends that the federal government establish an emergency National Mental Health Support Services hotline for all health care providers who are at the front lines of patient care during the pandemic. This critical resource will ensure our health care providers have the help they may need as they care for patients, including helping them to deal with an increasing patient load. 6) IMPLEMENT A TARGETED TAX CREDIT FOR HEALTH PROVIDERS EXPERIENCING FINANCIAL LOSS DUE TO QUARANTINE In addition to supporting income stabilization measures for all Canadians who may benefit from support, the CMA recommends that the federal government establish a time-limited and targeted tax credit for health providers who may experience financial loss due to quarantine. Many health care providers operate independently and may face significant fixed expenses as part of their care model. As health care providers may have an increased risk of contracting COVID-19, this may result in significant financial loss. A time-limited tax credit to ease this loss may help ensure the continued viability of their care model. Further, the CMA supports extending the federal tax filing timeline in recognition of the fact that health care workers and all Canadians are focused on emergency matters. CLOSING The CMA’s recommendations align with the OECD’s call to action: “Governments need to ensure effective and well-resourced public health measures to prevent infection and contagion, and implement well-targeted policies to support health care systems and workers, and protect the incomes of vulnerable social groups and businesses during the virus outbreak.” Now is the time to ensure that appropriate leadership continues and that targeted investments are made to protect the health of Canadians.
Documents
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Fetal Alcohol Spectrum Disorder (Update 2009)

https://policybase.cma.ca/en/permalink/policy9489
Last Reviewed
2017-03-04
Date
2009-05-31
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2017-03-04
Date
2009-05-31
Replaces
Fetal alcohol syndrome (Update 2000)
Topics
Health care and patient safety
Text
FETAL ALCOHOL SPECTRUM DISORDER (UPDATE 2009) Fetal Alcohol Spectrum Disorder (FASD) is a leading cause of environment-related birth defects and developmental disabilities in North America. The Canadian Medical Association (CMA) believes that the prudent choice for women who are or may become pregnant is to abstain from alcohol, and encourages their partners to support them in this endeavour. The CMA urges Canadian governments to enact legislation that requires alcoholic beverages sold in Canada to be labelled with warnings of the hazards of consuming alcohol during pregnancy. The CMA also calls upon the federal government to examine the role that advertising plays in promoting the consumption of alcoholic beverages and to review existing policies and regulations in this area. Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe the range of disabilities and diagnoses that result from drinking alcohol during pregnancy. It is estimated that more than 3,000 babies in Canada are born with FASD every year. Those who live with FASD may have mild to very severe problems with their health. They may have delays in their development, intellectual problems and problems in their social lives. Examples of these include: * skeletal abnormalities such as facial deformities * physical disabilities such as kidney and internal organ problems * depression or obsessive-compulsive disorder * difficulty understanding the consequences of their actions These disabilities are lifelong and those affected may need lifelong support. The drinking patterns of teenagers and the potential for women of reproductive age to consume alcohol mean that the health care system must actively address the prevention of FASD. Also, alcohol use may play a considerable role in unplanned pregnancy and inadequate prenatal and postnatal care. The CMA strongly supports all activities that encourage Canadians to moderate their alcohol consumption. The association encourages the public to be aware of the issues related to alcohol consumption, particularly the adverse effects on the fetus. In a continued effort to support the reduction of alcohol consumption, the CMA urges Canadian governments to enact legislation that requires alcoholic beverages sold in Canada to be labelled with warnings of the hazards of alcohol consumption during pregnancy.1 Appropriate agencies should also adopt regulations and/or policies to ensure that warnings about the adverse interaction between alcohol and both prescription and non-prescription products are prominently displayed or distributed wherever alcohol and drugs are sold or dispensed.2 The CMA also calls upon the federal government to examine the role that advertising plays in promoting the consumption of alcoholic beverages and to review existing policies and regulations in this area. The adverse effects of alcohol consumption by pregnant women are preventable. The CMA believes that the prudent choice for women who are or may become pregnant is to abstain from alcohol and encourages their partners to support them in this endeavour. Physicians should use appropriate screening methods to identify alcohol use in their patients. Physicians can play a leading role in educating and counselling women, spouses and family members about the dangers of alcohol to the fetus. The CMA also recommends that alcohol and drug addiction treatment services give high priority to the needs of pregnant women seeking help. 1 General Council resolution 89-67: That the Canadian Medical Association urge Governments in Canada to enact legislation requiring that all alcoholic beverages sold in Canada be labelled with warnings on the hazard from the consumption of alcohol during pregnancy. Note: this motion was rescinded because it was superseded by the Policy on Fetal Alcohol Syndrome (2000). 2 General Council resolution 87-31
Documents
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Framework for Ethical Decision Making During the Coronavirus Pandemic

https://policybase.cma.ca/en/permalink/policy14133
Date
2020-04-01
Topics
Ethics and medical professionalism
Health care and patient safety
  1 document  
Policy Type
Policy document
Date
2020-04-01
Topics
Ethics and medical professionalism
Health care and patient safety
Text
The current global pandemic caused by the novel coronavirus has presented the international medical community with unprecedented ethical challenges. The most difficult of these has involved making decisions about access to scarce resources when demand outweighs capacity. In Canada, it is well accepted that everyone should have an equal opportunity to access and receive medical treatment. This is possible when there are sufficient resources. But in contexts of resource scarcity, when there are insufficient resources, difficult decisions have to be made about who receives critical care (e.g., ICU beds, ventilators) by triaging patients. Triage is a process for determining which patients receive treatment and/or which level of care under what circumstances in contexts of resource scarcity. Priority-setting for resource allocation becomes more ethically complex during catastrophic times or in public health emergencies, such as today’s COVID-19 pandemic, when there is a need to manage a potential surge of patients. Physicians from China to Italy to Spain to the United States have found themselves in the unfathomable position of having to triage their most seriously ill patients and decide which ones should have access to ventilators and which should not, and which allocation criteria should be used to make these decisions. While the Canadian Medical Association hopes that Canadian physicians will not be faced with these agonizing choices, it is our intent, through this framework, to provide them with guidance in case they do and enable them to make ethically justifiable informed decisions in the face of difficult ethical dilemmas. Invoking this framework to ground decisions about who has access to critical care and who does not should only be made as a last resort. As always, physicians should carefully document their clinical and ethical decisions and the reasoning behind them. Generally, the CMA would spend many months in deliberations and consultations with numerous stakeholders, including patients and the public, before producing a document such as this one. The current situation, unfortunately, did not allow for such a process. We have turned instead to documents, reports and policies produced by our Italian colleagues and ethicists and physicians from Canada and around the world, as well as provincial level documents and frameworks. The CMA is endorsing and recommending that Canadian physicians use the guidance provided by Emmanuel and colleagues in the New England Journal of Medicine article dated from March 23rd, as outlined below. We believe these recommendations represent the best current approach to this situation, produced using the highest current standard of evidence by a panel of internationally recognized experts. We also recognize that the situation is changing constantly, and these guidelines may need to be updated as required. The CMA will continue to advocate for access to personal protective equipment, ventilators and ICU equipment and resources. We also encourage physicians to make themselves aware of any relevant provincial or local documents, and to seek advice from their regulatory body or liability protection provider. It should be noted that some provinces and indeed individual health care facilities will have their own protocols or frameworks in place. At the time of its publication, this document was broadly consistent with those protocols that we were given an opportunity to review. The CMA recognizes that physicians may experience moral distress when making these decisions. We encourage physicians to seek peer support and practice self-care. In addition, the CMA recommends that triage teams or committees be convened where feasible in order to help separate clinical decision making from resource allocation, thereby lessening the moral burden being placed on the individual physician. The CMA recommends that physicians receive legal protection to ensure that they can continue providing needed care to patients with confidence and support and without fear of civil or criminal liability or professional discipline. In this time of uncertainty, physicians should be reassured that their good faith efforts to provide care during such a crisis will not put them at increased medical-legal risk. Providing such reassurance is needed so that physicians have the confidence to continue to provide care to their patients. Recommendations: Recommendation 1: In the context of a pandemic, the value of maximizing benefits is most important. This value reflects the importance of responsible stewardship of resources: it is difficult to justify asking health care workers and the public to take risks and make sacrifices if the promise that their efforts will save and lengthen lives is illusory. Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. It is consistent both with utilitarian ethical perspectives that emphasize population outcomes and with nonutilitarian views that emphasize the paramount value of each human life. There are many reasonable ways of balancing saving more lives against saving more years of life; whatever balance between lives and life-years is chosen must be applied consistently. Limited time and information in a Covid-19 pandemic make it justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim. The latter becomes relevant only in comparing patients whose likelihood of survival is similar. Limited time and information during an emergency also counsel against incorporating patients’ future quality of life, and quality-adjusted life-years, into benefit maximization. Doing so would require time-consuming collection of information and would present ethical and legal problems. However, encouraging all patients, especially those facing the prospect of intensive care, to document in an advance care directive what future quality of life they would regard as acceptable and when they would refuse ventilators or other life-sustaining interventions can be appropriate. Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life. Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent. We agree with these guidelines that it is the ethical thing to do. Initially allocating beds and ventilators according to the value of maximizing benefits could help reduce the need for withdrawal. Recommendation 2: Irrespective of Recommendation 1, Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses and RTs are incapacitated, all patients — not just those with Covid-19 — will suffer greater mortality and years of life lost. Whether health workers who need ventilators will be able to return to work is uncertain but giving them priority for ventilators recognizes their assumption of the high-risk work of saving others. Priority for critical workers must not be abused by prioritizing wealthy or famous persons or the politically powerful above first responders and medical staff — as has already happened for testing. Such abuses will undermine trust in the allocation framework. Recommendation 3: For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. First-come, first-served is used for such resources as transplantable kidneys, where scarcity is long-standing, and patients can survive without the scarce resource. Conversely, treatments for coronavirus address urgent need, meaning that a first-come, first-served approach would unfairly benefit patients living nearer to health facilities. And first-come, first-served medication or vaccine distribution would encourage crowding and even violence during a period when social distancing is paramount. Finally, first-come, first-served approaches mean that people who happen to get sick later on, perhaps because of their strict adherence to recommended public health measures, are excluded from treatment, worsening outcomes without improving fairness. In the face of time pressure and limited information, random selection is also preferable to trying to make finer-grained prognostic judgments within a group of roughly similar patients. Recommendation 4: Prioritization guidelines should differ by intervention and should respond to changing scientific evidence. For instance, younger patients should not be prioritized for Covid-19 vaccines, which prevent disease rather than cure it, or for experimental post- or pre-exposure prophylaxis. Covid-19 outcomes have been significantly worse in older persons and those with chronic conditions. Invoking the value of maximizing saving lives justifies giving older persons priority for vaccines immediately after health care workers and first responders. If the vaccine supply is insufficient for patients in the highest risk categories — those over 60 years of age or with coexisting conditions — then equality supports using random selection, such as a lottery, for vaccine allocation. Invoking instrumental value justifies prioritizing younger patients for vaccines only if epidemiologic modeling shows that this would be the best way to reduce viral spread and the risk to others. Epidemiologic modeling is even more relevant in setting priorities for coronavirus testing. Federal guidance currently gives priority to health care workers and older patients but reserving some tests for public health surveillance could improve knowledge about Covid-19 transmission and help researchers target other treatments to maximize benefits. Conversely, ICU beds and ventilators are curative rather than preventive. Patients who need them face life-threatening conditions. Maximizing benefits requires consideration of prognosis — how long the patient is likely to live if treated — which may mean giving priority to younger patients and those with fewer coexisting conditions. This is consistent with the Italian guidelines that potentially assign a higher priority for intensive care access to younger patients with severe illness than to elderly patients. Determining the benefit-maximizing allocation of antivirals and other experimental treatments, which are likely to be most effective in patients who are seriously but not critically ill, will depend on scientific evidence. These treatments may produce the most benefit if preferentially allocated to patients who would fare badly on ventilation. Recommendation 5: People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 interventions. Their assumption of risk during their participation in research helps future patients, and they should be rewarded for that contribution. These rewards will also encourage other patients to participate in clinical trials. Research participation, however, should serve only as a tiebreaker among patients with similar prognoses. Recommendation 6: There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions. If the Covid-19 pandemic leads to absolute scarcity, that scarcity will affect all patients, including those with heart failure, cancer, and other serious and life-threatening conditions requiring prompt medical attention. Fair allocation of resources that prioritizes the value of maximizing benefits applies across all patients who need resources. For example, a doctor with an allergy who goes into anaphylactic shock and needs life-saving intubation and ventilator support should receive priority over Covid-19 patients who are not frontline health care workers. Approved by the CMA Board of Directors April 2020
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Front-line care providers in epidemics

https://policybase.cma.ca/en/permalink/policy9571
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health care and patient safety
Physician practice/ compensation/ forms
Ethics and medical professionalism
Resolution
GC09-85
The Canadian Medical Association, provincial/territorial medical associations, affiliates and associates urge governments to ensure that front-line care providers in practice and training are provided with adequate information, resources (including ventilators, masks, gloves, medications and vaccines) and personal and family disability and life insurance if performing clinical duties in the context of an epidemic or other public health emergency.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health care and patient safety
Physician practice/ compensation/ forms
Ethics and medical professionalism
Resolution
GC09-85
The Canadian Medical Association, provincial/territorial medical associations, affiliates and associates urge governments to ensure that front-line care providers in practice and training are provided with adequate information, resources (including ventilators, masks, gloves, medications and vaccines) and personal and family disability and life insurance if performing clinical duties in the context of an epidemic or other public health emergency.
Text
The Canadian Medical Association, provincial/territorial medical associations, affiliates and associates urge governments to ensure that front-line care providers in practice and training are provided with adequate information, resources (including ventilators, masks, gloves, medications and vaccines) and personal and family disability and life insurance if performing clinical duties in the context of an epidemic or other public health emergency.
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Health Canada consultation on proposed vaping products promotion regulations

https://policybase.cma.ca/en/permalink/policy14128
Date
2020-01-20
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2020-01-20
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Since 1867, the Canadian Medical Association has been the national voice of Canada’s medical profession. We work with physicians, residents and medical students on issues that matter to the profession and the health of Canadians. We advocate for policy and programs that drive meaningful change for physicians and their patients The Canadian Medical Association (CMA) appreciates this opportunity to respond to the notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada’s proposed Vaping Products Promotion Regulations “that would (1) prohibit the promotion of vaping products and vaping product-related brand elements by means of advertising that is done in a manner that can be seen or heard by young persons, including the display of vaping products at points of sale where they can be seen by young persons; and (2) require that all vaping advertising convey a health warning about the health hazards of vaping product use.” Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always, and will continue to support, strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on governments in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence. Introduction It is imperative that the regulations concerning the promotion of vaping products be tightened sooner rather than later. While the CMA views Health Canada’s proposed regulations as a step in the right direction, they should only be considered as the start of extensive regulatory, policy and public health work required to effectively address the harms associated with vaping. Vaping is not without risks. Evidence continues to grow about the hazards associated with the use of e-cigarettes, especially for youth and young adults. The emergence of e-cigarette, or vaping, product use-associated lung injury (EVALI) in the United States and to a lesser extent in Canada, illustrates the danger these products can pose. The Centers for Disease Control and Prevention (CDC) reported that as of January 7, 2020 that there were 2,602 cases of hospitalized EVALI or deaths (57 so far) reported by all 50 states, the District of Columbia, and 2 U.S. territories (Puerto Rico, and the U.S. Virgin Islands). In an update published in the CDC’s Morbidity and Mortality Weekly Report, “younger age was significantly associated with acquiring THC-containing and nicotine-containing products through informal sources.” The report concludes with this warning: “Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.”3 In Canada, as of January 7, 2020, 15 cases of severe pulmonary illness associated with vaping have been reported to the Public Health Agency of Canada. A recent public opinion survey conducted by the Angus Reid Institute (ARI) indicates that Canadians are growing more concerned about the safety of vaping as more information on the potential harms becomes available. The survey found that the number of people saying that vaping does more harm than good rose from 35% in 2018 to 62% in 2019.5 Further, 17% of parents with children under 19 said their child either vaped or had tried it; 92% of those parents considered vaping harmful.5 Significant to this discussion is the fact that 90% of respondents support “banning advertisements of vaping products in areas frequented by young people. This includes areas such as bus shelters or parks, and digital spaces like social media.”5 As public unease continues to rise, the need for further tightening of regulations becomes vital. Unfortunately, the federal government is still behind the curve when it comes to the proliferation of vaping and the vaping industry. Health Canada will have to step up surveillance and enforcement if tightening of the regulations is to be effective. This brief will address the planned regulations as well as discuss important issues not covered such as nicotine levels and flavours. We have expressed concerns about these topics in previous consultations and will be reiterating them here. Promotion of Vaping Products The CMA appreciates Health Canada’s intent to tighten the regulations but this proposal is not sufficient, and we must reiterate our long-held position that the restrictions on the promotion of all vaping products and devices be the same as those for tobacco products. , The proposed regulations provides the vaping industry with too much latitude in their promotion activities to ensure youth are protected. As we noted in our response to Health Canada’s consultation on The Impact of Vaping Products Advertising on Youth and Nonusers of Tobacco Products, the advertisements that have been permitted to this point seem to have managed to find their way to youth, even if they are not directed at them, as has been asserted.7, We recommended vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. The CMA stands by that recommendation.7 The methods used by the vaping industry in the past succeeded in attracting more and more youth and young adults and it will no doubt continue efforts to find novel approaches for promoting their products, including the use of popular social media channels. , , , Indeed, “JUUL’s™ advertising imagery in its first 6 months on the market was patently youth oriented. For the next 2 ½ years it was more muted, but the company’s advertising was widely distributed on social media channels frequented by youth, was amplified by hashtag extensions, and catalyzed by compensated influencers and affiliates.”10 The vaping industry’s efforts to circumvent marketing restrictions in other jurisdictions are evident in view of some recent developments. A US study outlines an e-cigarette marketing technique that involves the promotion of scholarships for students. The study found 21 entities (manufacturers, e-cigarette review websites, distributors) offering 40 scholarships, ranging in value from $300 to $5000 (US).13 Most of the scholarships required “an essay submission, with most listing prompts related to e-cigarettes or eliciting information about the benefits of vaping.”13 The authors suggest “that prohibitions on e-cigarette scholarships to youth are also needed, as many of these scholarships require youth under the age of 18 years (for whom use of e-cigarettes are illegal) to write positive essays about vaping.”13 Health Warnings The CMA reiterates, yet again, its position that all health warnings for vaping products and devices should be similar to those presently required for tobacco packages in Canada.6, The need for such cautions is important in that we still do not understand fully the effects vaping can have on the human body. Harms More research is needed into the potential harms of using electronic cigarettes to understand the long-term effects users may face. , , The proposed health warnings are not strong enough in light of the research and knowledge that has emerged to date about the harms caused by e-cigarettes. For example, a recent US study highlighted the potential link between e-cigarette use and depression. It found “a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use.”18 As the authors note, “the potential mental health consequences may have regulatory implications for novel tobacco products.”18 Further, with respect to respiratory issues, a US study found that “use of e-cigarettes appears to be an independent risk factor for respiratory disease in addition to all combustible tobacco smoking.” The authors also don’t recommend the use of e-cigarettes as a smoking cessation tool because “for most smokers, using an e-cigarette is associated with lower odds of successfully quitting smoking.”19 Nicotine Levels Nicotine levels and flavours are not addressed in this consultation. However, the CMA considers these issues to be vital in the effort to protect youth and young adults from the harms associated with e-cigarettes and will therefore provide comment in effort to speed movement toward resolving these problems. The CMA remains very concerned about the rising levels of nicotine available through the vaping process. They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.” Hammond et al noted in their 2019 study that “JUUL® uses benzoic acid and nicotine salt technology to deliver higher concentrations of nicotine than conventional e-cigarettes; indeed, the nicotine concentration in the standard version of JUUL® is more than 50 mg/mL, compared with typical levels of 3-24 mg/mL for other e-cigarettes.”9 The salts and flavours available to be used with these devices reduce the harshness and bitterness of the taste of the e-liquids with some of the competition delivering even higher levels of nicotine. The CMA called on Health Canada to restrict the level of nicotine in vaping products to avoid youth (and adults) from developing a dependence.20 Health Canada set the maximum level at 66 mg/ml while a European Union (EU) directive of 2014 indicates the level should not exceed 20 mg/ml. , Nicotine, among other issues, “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment. , Utilizing the EU level as an interim measure until more scientific research is available to determine an optimal level is acceptable. Flavours On December 5, 2019, the Government of Nova Scotia became the first province or territory to announce it would institute a ban on sale of flavoured e-cigarettes and juices, as of April 1, 2020. The CMA recommends that flavours banned to reduce the attractiveness of vaping to youth as much as possible; others share this sentiment.6,7, Flavours are strong factors in attracting youth, especially when coupled with assertions of lower harm. Their success in doing so is evidenced by the rise in the rates of vaping among youth.9, A recent US study found that “perceiving flavored e-cigarettes as easier to use than unflavored e-cigarettes may lead to e-cigarette use progression among youth never tobacco users. Determining the factors (including e-cigarette marketing and specific e-cigarette flavors) that lead to perceived ease of using flavored e-cigarettes would inform efforts to prevent and curb youth e-cigarette use.” The CMA recommends that flavours be banned to reduce the attractiveness of vaping to youth as much as possible. Recommendations 1. The CMA recommends that vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. 2. The CMA reiterates its position that all health warnings for vaping products and devices should be similar to those for tobacco packages. 3. The CMA believes that the European Union 2014 directive indicating the nicotine concentration not exceed 20 mg/ml should be adopted as an interim measure until more scientific research is available to determine an optimum level. 4. CMA recommends flavours be banned to reduce the attractiveness of vaping to youth as much as possible.
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22 records – page 1 of 3.