Inherent in all health care professional Codes of Ethics is the duty to provide care to patients and to relieve suffering whenever possible. However, this duty does not exist in a vacuum, and depends on the provision of goods and services referred to as reciprocal obligations, which must be provided by governments, health care institutions and other relevant bodies and agencies. The obligation of government and society to physicians can be seen as comparable to the obligations of physicians to their patients.
The recent experience of Canadian physicians during the SARS epidemic in Toronto has heightened the sensitivities of the medical profession to several issues that arose during the course of dealing with that illness. Many of the lessons learned (and the unanswered questions that arose) also apply to the looming threat of an avian flu (or other) pandemic. Canadian physicians may be in a relatively unique position to consider these issues given their experience and insight.
The intent of this working paper is to highlight the ethical issues of greatest concern to practicing Canadian physicians which must be considered during a pandemic. In order to address these issues before they arise, the CMA presents this paper for consideration by individual physicians, physician organizations, governments, policy makers and interested bodies and stakeholders. Although many of the principles and concepts could readily be applied to other health care workers, the focus of this paper will be on physicians.
Policies regarding physicians in training, including medical students and residents, should be clarified in advance by the relevant bodies involved in their oversight and training. Issues of concern would include the responsibilities of trainees to provide care during a pandemic and the potential effect of such an outbreak on their education and training.
A. Physician obligations during a pandemic
The professional obligations of physicians are well spelled out in the CMA Code of Ethics and other documents and publications and are not the main focus of this paper. However, they will be reviewed and discussed as follows.
Several important principles of medical ethics will be of particular relevance in considering this issue. Physicians have an obligation to be beneficent to their patients and to consider what is in the patient's best interest. According to the first paragraph of the CMA Code of Ethics (2004), "Consider first the well-being of the patient".
Traditionally, physicians have also respected the principle of altruism, whereby they set aside concern for their own health and well-being in order to serve their patients. While this has often manifested itself primarily as long hours away from home and family, and a benign neglect of personal health issues, at times more drastic sacrifices have been required. During previous pandemics, many physicians have served selflessly in the public interest, often at great risk to their own well-being.
The principle of justice requires physicians to consider what is owed to whom and why, including what resources are needed, and how these resources would best be employed during a pandemic. These resources might include physician services but could also include access to vaccines and medications, as well as access to equipment such as ventilators or to a bed in the intensive care unit. According to paragraph 43 of the CMA Code of Ethics, physicians have an obligation to "Recognize the responsibility of physicians to promote equitable access to health care resources".
In addition, physicians can reasonably be expected to participate in the process of planning for a pandemic or other medical disaster. According to paragraph 42 of the CMA Code of Ethics, physicians should "Recognize the profession's responsibility to society in matters relating to public health, health education, environmental protection, legislation affecting the health and well-being of the community and the need for testimony at judicial proceedings". This responsibility could reasonably be seen to apply both to individual physicians as well as the various bodies and organizations that represent them.
Physicians also have an ethical obligation to recognize their limitations and the extent of the services they are able to provide. During a pandemic, physicians may be asked to assume roles or responsibilities with which they are not comfortable, nor prepared. Paragraph 15 of the CMA Code of Ethics reminds physicians to "Recognize your limitations and, when indicated, recommend or seek additional opinions or services".
However, physicians have moral rights as well as obligations. The concept of personal autonomy allows physicians some discretion in determining where, how and when they will practice medicine. They also have an obligation to safeguard their own health. As stated in paragraph 10 of the CMA Code of Ethics, physicians should "Promote and maintain your own health and well-being".
The SARS epidemic has served to reopen the ethical debate. Health care practitioners have been forced to reconsider their obligations during a pandemic, including whether they must provide care to all those in need regardless of the level of personal risk. As well, they have been re-examining the obligation of governments and others to provide reciprocal services to physicians, and the relationship between these obligations.
B. Reciprocal obligations towards physicians
While there has been much debate historically (and especially more recently) about the ethical obligations of physicians towards their patients and society in general, the consideration of reciprocal obligations towards physicians is a relatively recent phenomenon.
During the SARS epidemic, a large number of Canadian physicians unselfishly volunteered to assist their colleagues in trying to bring the epidemic under control. They did so, in many cases, in spite of significant personal risk, and with very little information about the nature of the illness, particularly early in the course of the outbreak. Retrospective analysis has cast significant doubt and concern on the amount of support and assistance provided to physicians during the crisis. Communication and infrastructure support was poor at best. Equipment was often lacking and not always up to standard when it was available. Psychological support and counselling was not readily available at the point of care, nor was financial compensation for those who missed work due to illness or quarantine. Although the Ontario government did provide retrospective compensation for many physicians whose practices were affected by the outbreak, the issue was addressed late, and not at all in some cases.
It is clear that Canadian physicians have learned greatly from this experience. The likelihood of individuals again volunteering "blindly" has been reduced to the point where it may never happen again. There are expectations that certain conditions and obligations will be met in order to optimize patient care and outcomes and to protect health care workers and their families.
Because physicians and other health care providers will be expected to put themselves directly in harm's way, and to bear a disproportionate burden of the personal hardships associated with a pandemic, the argument has been made that society has a reciprocal obligation to support and compensate these individuals.
According to the University of Toronto Joint Centre for Bioethics report We stand on guard for thee, "(The substantive value of) reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families."
Therefore, in order to provide adequate care for patients, the reciprocal obligation to physicians requires providing some or all of the following:
Prior to a pandemic
- Physicians and the organizations that represent them should be more involved in planning and decision making at the local, national and international levels. In turn, physicians and the organizations that represent them have an obligation to participate as well.
- Physicians should be made aware of a clear plan for resource utilization, including:
- how physicians will be relieved of duties after a certain time;
- clearly defined roles and expectations, especially for those practicing outside of their area of expertise;
- vaccination/treatment plans - will physicians (and their families) have preferential access based on the need to keep caregivers healthy and on the job;
- triage plans, including how the triage model might be altered and plans to inform the public of such.
- Physicians should have access to the best equipment needed and should be able to undergo extra training in its use if required.
- Politicians and leaders should provide reassurances that satisfy physicians that they will not be "conscripted" by legislation.
During a pandemic
- Physicians should have access to up-to-date, real time information.
- Physicians should be kept informed about developments in Canada and globally.
- Communication channels should be opened with other countries (e.g. Canada should participate in WHO initiatives to identify the threats before they arrive on our doorstep).
- Resources should be provided for backup and relief of physicians and health care workers.
- Arrangements should be made for timely provision of necessary equipment in an ongoing fashion.
- Physicians should be compensated for lost clinical earnings and to cover expenses such as lost wages, lost group earnings, overhead, medical care, medications, rehabilitative therapy and other relevant expenses in case of quarantine, clinic cancellations or illness (recognizing that determining exactly when or where an infection was acquired may be difficult).
- Families should receive financial compensation in the case of a physician family member who dies as a result of providing care during a pandemic.
- In the event that physicians may be called upon in a pandemic to practice outside of their area of expertise or outside their jurisdiction, they should to contact their professional liability protection provider for information on their eligibility for protection in these circumstances.
- Interprovincial or national licensing programs should be developed to provide physicians with back-up and relief and ensure experts can move from place to place in a timely fashion without undue burden.
- Psychological and emotional counselling and support should be provided in a timely fashion for physicians, their staff and family members.
- Accommodation (i.e. a place to stay) should be provided for physicians who have to travel to another locale to provide care; or who don't want to go home and put their family at risk, when this is applicable, i.e. the epidemiology of the infectious disease causing the pandemic indicates substantially greater risk of acquiring infection in the health care setting than in the community.
- Billing and compensation arrangements should ensure physicians are properly compensated for the services they are providing, including those who may not have an active billing number in the province where the services are being provided.
After a pandemic
- Physicians should receive assistance in restarting their practice (replacing staff, restocking overhead, communicating with patients, and any other costs related to restarting the practice).
- Physicians should receive ongoing psychological support and counselling as required.
C. How are physician obligations and reciprocal obligations related?
Beyond a simple statement of the various obligations, it is clear that there must be some link between these different obligations. This is particularly important since there is now some time to plan for the next pandemic and to ensure that reciprocal obligations can be met prior to its onset. Physicians have always provided care in emergency situations without questioning what they are owed. According to paragraph 18 of the CMA Code of Ethics, physicians should "Provide whatever appropriate assistance you can to any person with an urgent need for medical care".
However, in situations where obligations can be anticipated and met in advance, it is reasonable to expect that they will be addressed. Whereas a physician who encounters an emergency situation at the site of a car crash will act without concern for personal gain or motivation, a physician caring for the same patient in an emergency department will rightly expect the availability of proper equipment and personnel.
In order to ensure proper patient care and physician safety, and to ensure physicians are able to meet their professional obligations and standards, the reciprocal obligations outlined above should be addressed by the appropriate body or organization.
Conclusion
If patient and physician well-being is not optimized by clarifying the obligations of physicians and society prior to the next pandemic, in spite of available time and resources necessary to do so, there are many who would call into question the ethical duty of physicians to provide care. However, the CMA believes that, in the very best and most honourable traditions of the medical profession, its members will provide care and compassion to those in need. We call on governments and society to assist us in optimizing this care for all Canadians.
Dear Prime Minister Trudeau & Ministers Taylor and Hussen,
We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint.
Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination.
Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”.
Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to:
1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants.
2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status.
3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services.
For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo.
Sincerely,
Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON
Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON
Michaela Beder, MD, Psychiatrist, Toronto ON
Ritika Goel, MD, Family Physician, Toronto ON
This open letter is signed by the following organizations and individuals:
Bathurst United Church
TOPS
1. Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON
2. Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON
3. Michaela Beder, MD FRCPC, Psychiatrist, Toronto ON
4. Ritika Goel, MD, Family Physician, Toronto ON
5. Gordon Guyatt, MD FRCPC, Internal Medicine Specialist, McMaster University, Hamilton ON
6. Melanie Spence, RN, Nursing, South Riverdale Community Health Centre, Toronto ON
7. Yipeng Ge, BHSc, Medical Student, University of Ottawa, Ottawa ON
8. Stephen Hwang, MD, Professor of Medicine, University of Toronto, Toronto ON
9. Gigi Osler, BScMed, MD, FRCSC, Otolaryngology-Head and Neck Surgery, Canadian Medical Association, Ottawa ON
10. Anjum Sultana, MPH, Public Policy Professional, Toronto ON
11. Danyaal Raza, MD, MPH, CCFP, Family Medicine, Toronto ON
12. P.J. Devereaux, MD, PhD, Cardiologist, McMaster University, Brantford ON
13. Mathura Karunanithy, MA, Public Policy Researcher, Toronto ON
14. Philip Berger, MD, Family Physician, Toronto ON
15. Nanky Rai, MD MPH, Primary Care Physician, Toronto ON
16. Michaela Hynie, Prof, Researcher, York University, Toronto ON
17. Meb Rashid, MD CCFP FCFP, Family Physician, Toronto ON
18. Sally Lin, MPH, Public Health, Victoria BC
19. Jonathon Herriot, BSc, MD, CCFP, Family Physician, Toronto ON
20. Carolina Jimenez, RN, MPH, Nurse, Toronto ON
21. Rushil Chaudhary, BHSc, Medical Student, Toronto ON
22. Nisha Toomey, MA (Ed), PhD Student, University of Toronto, Toronto ON
23. Matei Stoian, BSc, BA, Medical Student, McMaster University, Hamilton ON
24. Ruth Chiu, MD, Family Medicine Resident, Kingston ON
25. Priya Gupta, Medical Student, Hamilton ON
26. The Neighbourhood Organization (TNO), Toronto, ON
27. Mohammad Asadi-Lari, MD/PhD Candidate, University of Toronto, Toronto ON
28. Kathleen Hughes, MD Candidate, McMaster University, Hamilton ON
29. Nancy Vu, MPA, Medical Student, McMaster University, Hamilton ON
30. Ananthavalli Kumarappah, MD, Family Medicine Resident, University of Calgary, Calgary AB
31. Renee Sharma, MSc, Medical Student, University of Toronto, Toronto ON
32. Daniel Voloshin, Medical Student , McMaster Medical School , Hamilton ON
33. Sureka Pavalagantharajah, Medical Student, McMaster University, Hamilton ON
34. Alice Cavanagh , MD/PhD Student, McMaster University, Hamilton ON
35. Krish Bilimoria, MD(c), Medical Student, University of Toronto, North York ON
36. Bilal Bagha, HBSc, Medical Student, St. Catharines ON
37. Rana Kamhawy, Medical Student, Hamilton ON
38. Annie Yu, Medical Student, Toronto ON
39. Samantha Rossi, MA, Medical Student, University of Toronto, Toronto ON
40. Carlos Chan, MD Candidate, Medical Student, McMaster University, St Catharines ON
41. Jacqueline Vincent, MA, Medical Student, McMaster, Kitchener ON
42. Eliza Pope, BHSc, Medical Student, University of Toronto, Toronto ON
43. Cara Elliott, MD, Medical Student, Toronto ON
44. Antu Hossain, MPH, Public Health Professional, East York ON
45. Lyubov Lytvyn, MSc, PhD Student in Health Research, McMaster University, Burlington ON
46. Michelle Cohen, MD, CCFP, Family Physician, Brighton ON
47. Serena Arora, Medical Student, Hamilton ON
48. Saadia Sediqzadah, MD, Psychiatrist, Toronto ON
49. Maxwell Tran, Medical Student, University of Toronto, Toronto ON
50. Asia van Buuren, BSc, Medical Student, Toronto ON
51. Darby Little, Medical Student, University of Toronto, Toronto ON
52. Ximena Avila Monroy, MD MSc, Psychiatry Resident, Sherbrooke QC
53. Abeer Majeed, MD, CCFP, Family Physician, Toronto ON
54. Oluwatobi Olaiya, RN, Medical Student, Hamilton ON
55. Ashley Warnock, MSc, HBSc, HBA, Medical Student, McMaster University, Hamilton ON
56. Nikhita Singhal, Medical Student, Hamilton ON
57. Nikki Shah, MD Candidate, Medical Student, Hamilton ON
58. Karishma Ramjee, MD Family Medicine Resident , Scarborough ON
59. Yan Zhang, MSc, Global Health Professional, Toronto ON
60. Megan Saunders, MD, Family Physician, Toronto ON
61. Pooja Gandhi, MSc, Speech Pathologist, Mississauga ON
62. Julianna Deutscher, MD, Resident, Toronto ON
63. Diana Da Silva, MSW, Social Worker, Toronto ON
Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government
Sign here - https://goo.gl/forms/wAXTJE6YiqUFSo8x1
The Right Honourable Justin Trudeau, Prime Minister of Canada
The Honourable Ginette P. Taylor, Minister of Health
The Honourable Ahmed D. Hussen, Minister of Immigration, Refugees and Citizenship
CC: Mr. Dainius Puras, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health
Dear Prime Minister Trudeau & Ministers Taylor and Hussen,
We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint.
Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination.
Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”.
Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to:
1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants.
2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status.
3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services.
For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo.
Sincerely,
Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON
Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON
Michaela Beder, MD, Psychiatrist, Toronto ON
Ritika Goel, MD, Family Physician, Toronto ON
