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Multiple Choice Questions LMCC 2008

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									LMCC Review 2008

 Communication, Legal,
    Ethical Issues
 Lilian Thorpe MD PhD FRCP
      MCC Considerations for Cultural-
     Communication, Legal, Ethical and
     Organizational Aspects of Medicine
• CLEO developed in 1999
• Incorporated into the qualifying examinations Part I
  and Part II in 2000 to 2001
• C2LEO integrated into the CanMeds medical
  practitioner proficiency competencies, now include
  cultural and communication issues and are being
  incorporated into the Medical Council of Canada
  examination starting in 2008
 Cultural-communication issues
Candidates participating in the MCC examinations
  from 2008 and later must demonstrate the ability
• Work in diverse cultures and circumstances.
• Integrate the family’s role in home-
  care/continuity of care, mindful of cultural issues.
• See the patient as the focus of culturally
  sensitive communication in the care of chronic
  illness and health care in general.
• Interact with those of a differing spiritual belief in
  end-of life situations.
 Cultural-communication issues
• Manage cross-cultural issues around mental health
• Acknowledge and resolve issues dealing with gender
  (e.g. male/female urogenital and rectal examination) and
  societal values.
• Tactfully deal with specific issues unique to adolescents
  and the elderly.
• Manage legal issues surrounding patient/human rights in
  social contexts such as abortion, sexual
  orientation/function, and life-threatening illnesses.
• Emergency/intensive care (pediatric and adult), low-risk
  obstetrics/pre-natal care.
          Legal Issues

•   Definitions
•   Consent
•   Confidentiality
•   Negligence and liability
•   Physician professional behavior
• Autonomy
  – The moral right to choose and follow one’s own plan of life
    and action.
• Beneficence
  – The moral duty to help persons in need
• Capacity
  – The patient’s ability to understand information relevant to
    making a decision. Capacity determinations are made by
    physicians in general, sometimes using the help of
    specialists physicians such as psychiatrists and other
    members of the health care team.
• Competence
  – This term is frequently used interchangeably with capacity.
    Strictly speaking it is a legal term denoting the right to
    make a decision. The legal presumption is that all adults
    are competent, and only a judge can rule a person
• Conflict of interest
  – A set of conditions in which professional judgment
   concerning a primary interest (such as a patient’s
   welfare or the validity of research) tends to be
   unduly influenced by a secondary interest (such as
   financial gain).
• Consent
  – The autonomous authorization of a medical
    intervention by individual patients. Consent has
    three components: disclosure, capacity, and
• Disclosure
  – The provision of relevant and material information
    regarding a decision by a doctor to a patient (and its
    comprehension by the patient).
• Discrimination
  – An act, practice or policy that differentiates
    between, or otherwise treats persons in a different
    way, on the basis of such status as gender, age,
    nationality, religion, race, financial means, sexual
    orientation, etc.
• Ethics
  – The discipline dealing with principles and values
    defining what is good and bad, and with duties and
    obligations for various groups.
• Euthanasia
  – A deliberate act undertaken to end the life of
    another person in order to end suffering; the act is
    the cause of death.
• Fiduciary
  – Person to whom property or power is entrusted for
    the benefit of another.
• Fiduciary obligation
  – The obligation to promote the best interests of
    persons who have entrusted themselves to the
    fiduciary (e.g., the physician); an obligation of the
    highest loyalty, fidelity and trust.
• Justice
  – The fair distribution of benefits and burdens within a
• Material risks
  – Those that are common, and those that are serious,
    even if uncommon.
• Morals
  – The practice of ethics in everyday life.
• Non-maleficence
  – The duty to refrain from doing harm.
• Physician-assisted suicide
  – The act of intentionally killing oneself with the
    assistance of a physician
• Resource allocation (and rationing)
  – The distribution of goods and services to programs
    and people; rationing is the systematic distribution
    of goods to specific individuals in conditions of
• Security of the person/inviolability
  – The fundamental right of all persons to
    respect for and non-violation of their body and
    person, be it through physical, psychological
    or other means
• Voluntariness
  – The patient’s right to come to a decision
    freely, without undue pressure including force,
    coercion, or manipulation
   Canadian Law (varies by province)
             Based On:
• Common law (in Quebec, the Civil Code of
  – tort law allows for patients to recover damages;
    negligence, battery
  – doctors are expected to act in the best interest of the
    patient (fiduciary duty).
• Specific Statutes (federal and provincial)
  – Canadian Charter of Rights and Freedoms
  – The Personal Information Protection and Electronic
    Documents Act (PIPEDA:
• The constitution (supreme law of Canada: all other
  laws must be consistent)
 Saskatchewan Health Legislation
The Ambulance Act Regulates the provision of emergency
                  medical services.
The Emergency      Provides protection from liability for
Medical Aid Act    physicians, nurses and others when they
                   are providing, in good faith, emergency
                   care outside a hospital or place with
                   adequate facilities or equipment.
The Health         Protects personal health information in the
Information        health system in Saskatchewan and
Protection Act     establishes a common set of rules that
                   emphasize the protection of privacy, while
                   ensuring that information is available to
                   provide efficient health services.
 Saskatchewan Health Legislation
Hospital         Provides the standards to be met for services delivered
Standards Act    in hospitals.

Medical          Regulates physicians and surgeons.
Profession Act
Mental Health    Regulates the provision of mental health services in the
Services Act     province and the protection of persons with mental
Public Health    Provides authority for the establishment of public health
Act 1994         standards, such as public health inspection of food
Regional         Addresses the governance and accountability of the
Health           regional health authorities, establishes standards for the
                 operation of various programs.
Services Act
Saskatchewan Health Legislation

The Vital        Administers the registration of births, deaths,
Statistics Act   marriages, adoptions and divorces in the
1995             province.
The Youth        Provides authority for the detention of youth
Drug             who are suffering from severe drug addiction
Detoxification   and abuse.
     Consent for Health Care
• May be formal, expressed verbally or
• Written is best
• Consent must be informed, specific to the
  particular situation, made by a capable
  individual, and be voluntary (free of
  coercion or pressure).
• Consent may be withdrawn or changed at
  any point before or during an intervention
• It is mandatory that the patient’s consent be
  obtained for any medical investigation, treatment,
  or research
• Full information must be given, in language that
  the patient or involved person(s) can understand.
  This must include information regarding the
  nature of the proposed treatment or investigation,
  anticipated effects, material or significant risks,
  alternatives available, and any information
  regarding delegation of care, and will be given
  according to the circumstances of each particular
• The obligation of disclosure rests with the
  physician who is to carry out the treatment. It may
  be delegated in appropriate circumstances to
  another qualified physician, but responsibility lies
  with the delegating physician.
• If the patient is not competent or lacks capacity to
  consent, then consent may be obtained
  (according to the law applicable in each province
  and the specific circumstances) from a court,
  parent or substitute decision-maker. The law
  regarding delegation of care is specific to each
  province and the physician should be fully aware
  of local requirements in this regard.

• Treatment is limited to the scope of
  consent given, including to the identity of
  the treating physician.
          Exceptions to Consent
• Emergency treatment can be provided if the patient is
  experiencing severe suffering, where a delay in
  treatment could lead to serious harm and when
  consent cannot be obtained (cannot violate previously
  expressed wishes, such as advance care directives).
• Patients with mental illnesses can be treated
  involuntarily in certain circumstances.
• Public health legislation may allow for treatment
  without consent when there are issues of public
• Legal situations (warrants) may provide for the
  release of patient information.
• Definition of capacity varies over time and from
  jurisdiction to jurisdiction
• Definition of capacity is influenced by societal
  values and by assessors
• Elements:
   – The ability to communicate a choice
   – The ability to understand the specific choice
   – The ability to appreciate fully the broad
     ramifications (to him/her-self and others) of a
     specific choice
  Factors influencing capacity
• Communication
• Cognitive skills (MR, dementia, mild
  cognitive impairment)
• Education
• Mental illness
  – Delirium
  – Medications
  – Depression
  – Psychosis
    Health Decisions: Main Sources
       Of Substituted Consent
•   Parent/guardian for incompetent minors
•   Advance directive
•   Appointed proxy for health-care decisions
•   Power of Attorney (health-care)
•   Guardianship/co-decision maker order
•   Nearest relative
•   Two health care providers
•   Emergency treatment
Makes own treatment decision
                                                  No     Two treatment
                               Other substitute           exceptions
                               decision maker
                                  available?           yes
                                          No                  Follow
             Competent?            Legal guardian      Yes
                                   with power to
                                   make decision?

                                     No        Yes        Follow
      Advance directive, POA                             directions
      or proxy available?
• Physicians are legally required to maintain
  the confidentiality of a patient's medical
  information (Personal Information
  Protection and Electronic Documents Act,
  Canadian Charter of Rights and Freedoms)
• Confidentiality is necessary to preserve
  trust in the doctor-patient relationship and
  to provide optimal care
• Physicians must only access information of
  patients under their care
• Physicians are also required to store,
  handle and dispose of health information
  appropriately, informing patients of their
  mechanisms of doing so.
• Patients have the right to access their own
  health information, with a few limitations,
  such as when there is a potential for harm
  to either the patient or another person.
• It is considered appropriate to share information
  with other members of the health care team (circle
  of care), as it is necessary to care for the patient
• Disclosure of patient information may also occur:
   – with the consent of the patient (or legally
      designated decision maker)
   – in various circumstances dictated by law (child
      abuse or neglect, fitness to drive or fly, certain
      communicable diseases, improper conduct of
      physicians or other health professionals, vital
      statistics and reporting to coroners).
   – In situations posing material risks to others or
      themselves (Duty to warn)
• Breach of a legal duty of care which results
  in damage to a patient.
• Courts normally expect physicians to
  adhere to a standard of care which would
  reasonably be expected under similar
  circumstances of a physician with a roughly
  equivalent training and experience.
• Physicians may also be held liable for the
  actions of staff acting under their direction,
  such as nurses or junior physicians.
Physician professional behavior
• This is mostly under the auspices of the
  provincial College of Physicians and
  Surgeons in each province, which is the
  designated licensing authority.
• Physicians are required to maintain a legal
  license to practice.
• Appropriate clinical coverage must be
• Sexual relationships with patients are
  generally considered to be inappropriate.
Physician professional behavior
• Appropriate records must be maintained
  for the appropriate length of time, as
  designated by provincial legislation.
• In Saskatchewan, physicians should keep
  their records for 15 years after the last
  clinical contact with adults (mostly CMPA
  related), and longer in the case of minors.
Ethics: Key Principles

•   Autonomy
•   Beneficence
•   Non-maleficence
•   Justice
          Ethics: Particular Issues
•   Confidentiality
•   Consent
•   Truth-telling
•   Resource allocation
    –   Fair access to health care resources
    –   Obligations to seek best interest of patient
    –   Prudent use of health care resources
    –   Rank known patients above future or future patients
    –   Consult hospital ethics committees or other bodies in
        cases of conflict
       Ethics: Particular Issues
• Research Ethics
  – Scientific and ethical merits of research
  – Conflict of interest
  – Full disclosure to informed consent
  – Right of non-participation or withdrawal
    without prejudice
  – Appropriate ethics committee approvals
  – Acknowledgement and disclosure of any
    possible conflict of interest on the part of
 Ethics: Physicians and Industry
• The primary obligation of the physician is to their
  patient. Relationships with industry are
  appropriate only if they do not impinge upon that
• Any conflicts of interest arising from a relationship
  with industry must be resolved in favour of the
• Physicians in their practice must preserve their
  professional autonomy. Any potential conflict of
  interest must be disclosed to the patient.

            CMA Code of Ethics and CMA Guidelines
         for physicians in interactions with industry, 2007
Ethics: Doctor Patient Relationship

    • Obligations and restrictions
    • Conflict of interest, disclosure of
      personal or moral limitations
    • Professional boundaries
    • Physician’s and patient’s rights
    • Care of friends and family
    Ethics: Controversial and Evolving
         Ethical Issues in Practice
•   Euthanasia
•   Physician assisted suicide
•   Maternal-fetal conflict of rights
•   Advanced reproductive technology
•   Fetal tissue
•   Abortion
•   Genetic testing
     Which of the following are in the
         CMA Code of Ethics?
1. Consider first the well-being of the patient.
2. Practise the profession of medicine in a manner that
   treats the patient with dignity and as a person worthy
   of respect.
3. Provide for appropriate care for your patient, even
   when cure is no longer possible, including physical
   comfort and spiritual and psychosocial support.
4. Consider the well-being of society in matters
   affecting health.

                       All True
   Which of the following is not in the
        CMA Code of Ethics?
1. Recognize and disclose conflicts of interest that
   arise in the course of your professional duties and
   activities, and resolve them in the best interest of
2. Decline to provide service to patients when this
   might be seen as a conflict of interest
3. Limit treatment of yourself or members of your
   immediate family to minor or emergency services
   and only when another physician is not readily

                    2 is incorrect.
    In providing medical service, you
     may not discriminate against a
          patient the grounds of:
• Age                  •   Political affiliation
• Gender               •   Race
• Marital status       •   Religion
• Medical condition    •   Sexual orientation
• National or ethnic   •   Socioeconomic status
• Physical or mental
                             All true
  Which of the following is true:
1. Because of the previous principle, a physician
   may not refuse to accept any patient as long as
   there is still available time in the practice.
2. The “meet and greet” session for new patients is
3. Physicians may decline to accept patients
   whose needs they are not able to meet

                    3. is true
  Ethical principles for Previous Questions
            (CMA Code of Ethics)
• Inform your patient when your personal values
  would influence the recommendation or practice
  of any medical procedure that the patient needs
  or wants.
• Recognize your limitations and, when indicated,
  recommend or seek additional opinions and
• Promote and maintain your own health and
    Which is True: Having accepted
professional responsibility for a patient:
 1. Services must continue to be provided until the
    patient no longer requires or wants them
 2. Services cannot be discontinued until another
    suitable physician has assumed responsibility
    for the patient.
 3. Services may be discontinued if the patient has
    been given reasonable notice that you intend to
    terminate the relationship

                     3. is true
Ethical principles for the preceding question
            (CMA Code of Ethics)

       • “This does not abrogate
         your physician’s right to
         refuse to accept a patient
         for legitimate reasons.”
 You have had a few drinks at a party when
   a person collapses. What do you do?
• You clear space around the person and immediately
  proceed to follow your best resuscitation practices
• You quickly leave the room as you are mildly impaired
  and may not make the best decisions
• You announce that you have had a few drinks, and
  ask if anyone else has appropriate expertise to take
  over. If not, proceed if medically necessary while
  asking someone else to call emergency services.

                 3 is the best choice
    Ethical principles relating to Previous
      Question. (CMA Code of Ethics)

• Practise the art and science of medicine
  competently, with integrity and without impairment
• Take all reasonable steps to prevent harm to
  patients; should harm occur, disclose it to the
• Recognize your limitations and, when indicated,
  recommend or seek additional opinions and services
• Provide whatever appropriate assistance you can to
  any person with an urgent need for medical care.
• Provide your patience with the information they need
  to make informed decisions about their medical care,
  and answer their questions to the best of your ability.
  A patient demands a treatment that does
   not usually help in his situation and has
 significant potential for serious side effects
1. You explain the potentially serious side effects and poor
   treatment efficacy, but give him the treatment anyway since
   autonomy is one of the most important ethical principles
2. You explain the potentially serious side effects and poor
   treatment efficacy and deny his request
3. You explain the potentially serious side effects and poor
   treatment efficacy and decline to provide this treatment
   yourself. You provide him with the name of a physician in
   town who does administer this treatment, and express your
   support in him pursuing a second opinion from the physician

                   3 is the best choice
Ethical principles for the preceding question
            (CMA Code of Ethics)
• Consider first the well-being of the patient
• Recommend only those diagnostic and therapeutic
  services that you consider to be beneficial to your
  patient or to others.
• Practise the art and science of medicine competently,
  with integrity and without impairment.
• Take all reasonable steps to prevent harm to patients;
  should harm occur, disclose it to the patient.
• Respect the right of a competent patient to accept or
  reject any medical care recommended
  Your patient has had a catastrophic stroke, and can
     no longer swallow. Her advance care directives
    clearly state that she does not want any feeding
   tubes in this situation. Her daughter says that you
                    can’t let her starve.
1. You call the surgeon to put the feeding tube in and
   have the daughter sign the consent
2. You tell the daughter that she has no say in the
3. You tell the daughter you are legally bound to
   respect the directive, but spend time with the
   daughter explaining feeding tubes, legal status of
   directives, and control of discomfort.

                 3 is the best choice
Ethical principles for the preceding question
            (CMA Code of Ethics)
•   Ascertain wherever possible and recognize your
    patient's wishes about the initiation, continuation or
    cessation of life-sustaining treatment.
•   Respect the intentions of an incompetent patient as
    they were expressed (for example through valid
    advance directive or proxy designation) before the
    patient became incompetent.
•   Be considered of the patient's family and significant
    others and cooperate with them in the patient's
    Your patient has had a catastrophic stroke,
     and can no longer swallow. She has no
      advance care directives and no family.
1. You call the surgeon to put in a feeding tube
2. You decide she won’t benefit from a feeding tube,
   so you call palliative care to keep her comfortable
3. You or the social worker find a friend and get some
   information about her previous wishes. You make
   your best decision about her likely wishes, and ask
   a second treatment provider to write a progress
   not stating he/she is in agreement with the

                  3 is the best choice
Ethical principles for the preceding question
            (CMA Code of Ethics)

 • When the intentions of an incompetent
   patient are unknown and when no formal
   mechanism for making treatment
   decisions is in place, render such
   treatment as you believe to be in
   accordance with the patient's values or, if
   these are unknown, the patient's best
  Legal principle: Saskatchewan
• Health care Directives and Substitute
  Decision Makers Act
• Where there is no relative or when a
  reasonable attempt to find a relative has
  been made but the nearest relative cannot
  be found, …. A treatment provider may
  provide treatment (to an incompetent
  patient) if another treatment provider
  agrees in writing that the treatment is
 You get a fax from an unknown doctor’s
 office telling you to fax them your notes
   on a patient you saw two years ago.
1. You fax them all you can find dating back to
   that time
2. You throw the fax in the garbage
3. You ask them to have the patient send a
   release of information form

               3 is the best choice
 Ethical principles for the preceding
       (CMA Code of Ethics)
• Consider first the well-being of the patient
• Protect the personal health information of
  your patients
• Disclose your patient's personal health
  information to third parties only with their
  consent, or as provided for by law
 Your patient discloses plans to shoot his
wife as he believes she has been unfaithful
1. You encourage him not to do so, but respect
   his right to confidentiality and don’t tell anyone
2. You notify the police and hope he doesn’t find
3. You tell him that you are required to breach
   confidentiality, and then notify the police

                 3 is the best choice
Ethical principles for the preceding
 question (CMA Code of Ethics)
 • Disclose your patient's personal health
   information to third parties only with their
   consent, or as provided for by law:
   – such as when the maintenance of
    confidentiality would result in a significant risk
    of substantial harm to others or, in the case of
    incompetent patients, to the patients
    themselves. In such cases take all reasonable
    steps to inform the patients that the usual
    requirements for confidentiality will be
The daughter of your elderly patient wants to go
on holidays and insists you admit her to hospital
   for the duration, as she cannot stay alone.
1. You admit her to hospital: other patients having
   surgeries cancelled because of bed shortages is not
   your problem
2. You tell her absolutely not….. And move on to your
   next patient!
3. You explain the bed shortages and connect her with
   respite resources

                  3 is the best choice
    Ethical principles for the
      preceding question
     (CMA Code of Ethics)
• Recognize the responsibility of
  physicians to promote equitable access
  to health care resources.
• Use health-care resources prudently
  You are part of a prestigious and very well
reimbursed drug trial, which was approved by
ethics. You have discovered new information
that this treatment helps the condition you are
   studying, but increases overall mortality
1. You keep quiet, as you can’t afford to antagonize
   the sponsor who is giving you a large,
   “unrestricted” grant for your other research.
2. You notify the sponsor, but keep entering patients
3. You put your concerns in writing, make sure the
   other investigators and your patients are aware of
   your information and withdraw your patients from
   the study if they wish.

               3 is the best choice
Ethical principles for the preceding
       (CMA Code of Ethics)
• The practising physician’s primary responsibility
  is to the patient (CMA Guidelines for physicians
  in interactions with industry, 2007)
• Do not exploit patients for personal advantage
• Take all reasonable steps to prevent harm to
  patients; should harm occur, disclose it to the
Pharmaceutical company X gives you samples of
their latest, very expensive product, and tells you
they are conducting post-marketing research, so
will pay you for every patient you put on the drug
     while filling out a brief outcome sheet.

1. This is just research, so you participate
2. You ask how the study was designed, how they will
   analyze it, and then decide you will decline

               2 is the best choice
 Ethical principles for the preceding question
(CMA Code of Ethics and CMA Guidelines for
physicians in interactions with industry, 2007)
• The distribution of samples should not involve any
  form of material gain for the physician
• Ensure that any research in which you participate is
  evaluated both scientifically and ethically and is
  approved by a research ethics board that meets
  current standards of practice
• Inform the potential research subject, or proxy, about
  the purpose of the study, its source of funding, the
  nature and relative probability of harms and benefits,
  and the nature of your participation including any
A company invites you and 12 of your colleagues
 to a fancy spa to give them feedback about their
new drug (after extensive presentations about the
   benefit of their drug by the company research
  physician). The company tells you that you are
considered faculty (as you are helping them fine-
tune use of the drug), so they will pay everything,
               including the massages.
1. You ask if you can bring your spouse and kids
2. You decline politely, referring to the CMA
   Guidelines for physicians in interactions with
   industry (well…. Duhhhhhhhh)
 Ethical principles for the preceding
  (CMA Code of Ethics and CMA Guidelines for
  physicians in interactions with industry, 2007)

• Faculty indicates a presenter who prepares
  and presents a substantive educational
  session in an area in which they are a
  recognized expert or authority.
• All attendees at an event cannot be
  designated faculty.

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