Controversies
Abortion info leak
The Calgary Regional health authority won a court judgement preserving the private, confidential nature of documents concerning genetic terminations of pregnancy that were leaked to Alberta Report by one or more angry pro-life nurses. The self-described right-wing, Christian-based magazine lambasted Calgary's Foothills General Hospital and some of its doctors in a series of articles published in April and May 1999. [CMAJ 1999;161(4):424-5]
Antiabortion pamphlet
An American antiabortion publication that was mailed to Canadian physicians and residents angered many Ontario doctors and caused Queen's University to contact police. The 32-page pamphlet, Quack the Ripper, was mailed by Life Dynamics Inc. of Denton, Texas, in March 1999. The publication's goal was to persuade young physicians not to perform abortions. [CMAJ 1999;160(7):977]
Antivaccine advocates
A member of the Canadian air force who refused to take anthrax vaccine finds himself stuck squarely in the middle of two strongly opposing factions. On one side is the military, which launched court-martial proceedings against Sgt. Michael Kipling, and on the other is a small but vocal antivaccine lobby that praises him for taking his stand. The case sparked a national debate over the military's use of vaccines. [CMAJ 1999;160(6):883]
A growing number of parents are questioning the wisdom of immunizing their children. In Montreal, approximately one-third of 2-year-olds have incomplete immunization. Nationally, the coverage drops for vaccines that have to be administered after a child is 12 months old. [CMAJ 1999;161(6):737-8]
The new dean of medicine at Dalhousie University says physicians should put immunizations back on the frontline of Canadian prevention strategies. Dr. Noni Macdonald said immunizations have been so successful that "the public doesn't see the risk because they don't see the disease any more." Experience elsewhere in the world indicates this is a mistake. [CMAJ 1999;161(7):791]
Conflicts of interest may be relative
Some ethicists consider any conflict of interest, no matter how small, a factor that automatically disqualifies a physician or researcher from participation in a project. Others think disqualification should depend on whether the conflict is likely to have an impact, consciously or subconsciously, on the person's ability to deliver an impartial appraisal. [CMAJ 1999;160(13):1866]
DNR requests in the field
Ontario paramedics are bound by a duty to initiate aggressive life-support measures when responding to 911 cardiac-arrest calls, even though this duty may conflict with the expressed wishes of patients with terminal illnesses. A new study reviewed the ambulance call reports of 144 terminally ill patients who were experiencing cardiac arrest and found that in 90 of these cases there was a request - in many cases written - not to resuscitate. Legally, paramedics must initiate aggressive life-support measures, so paramedics ignored these requests in more than 75% of the cases. Cardiopulmonary resuscitation was attempted and the patients were transported to emergency rooms against the wishes of the patient and relatives. None of the 144 patients survived. [CMAJ 1999;161(10):1251-4]
A related commentary states that it is up to physicians to educate patients and their families about these issues and to discuss the policy of the local ambulance service. The authors also recommend that other jurisdictions follow the example of the British Columbia Ambulance Service, which has created a standard DNR form that is signed by both the patient (or advocate) and the physician to ensure that the patient's final wishes are followed. [CMAJ 1999;161(10):1262-3]
Joint statement to head off ethical conflicts
The CMA and national organizations representing nurses and hospitals endorsed a joint policy to help avoid conflicts surrounding patient treatment. The CMA, Canadian Healthcare Association, Canadian Nurses Association and Catholic Health Association teamed up to release the joint statement, which deals with conflicts, or potential conflicts, between care providers and patients receiving care, or their proxies. These ethical issues involve value preferences that arise when people of good will are uncertain of, or disagree about, the right thing to do when someone's life, health or well-being is threatened by a disease or illness. The statement offers guidance for developing policies on initiating, continuing, withholding or withdrawing care or treatment. [CMA News 1999;9(8):3]
JAMA editor fired
The American Medical Association fired the editor-in-chief of its flagship journal Jan. 15, 1999. Dr. George Lundberg, at the helm of the Journal of the American Medical Association since 1982, was dismissed for making an editorial decision that, in the opinion of AMA's executive vice-president, "threatened the historic tradition and integrity of [the journal] by inappropriately and inexcusably interjecting JAMA into a major political debate that has nothing to do with science or medicine."
Lundberg had published a brief report in JAMA's Jan. 20 issue on a 1991 survey of some 600 college students that sought to find out what they thought "having sex" actually meant. Roughly 60% of respondents did not consider that engaging in oral sex amounted to "having sex." The article appeared around the time that President Bill Clinton maintained that his sexual activities with Monica Lewinsky did not constitute "having sex." [CMAJ 1999;160(4):507-8]
Dr. Jozef Krop
Physicians who practise alternative medicine are paying close attention to the case of Ontario physician Jozef Krop, who was found guilty of professional misconduct in December 1998. The College of Physicians and Surgeons of Ontario sent its first letter to Krop expressing concerns about some of his "highly unusual" treatments in 1989. Krop insists he has been unfairly targeted by the licensing body. [CMAJ 1999;160(6):877-9]
In June, Krop received a reprimand from the College of Physicians and Surgeons of Ontario on the grounds that he had "failed to meet the standard of practice" required of doctors in the province. The college imposed 11 conditions on Krop's practice. Krop had assumed the college would revoke his licence; now he is determined to clear his name and restore his reputation. He has served notice to appeal to the civil court and is trying to raise money. [CMAJ 1999;161(11):1431-2]
Marijuana available at "Compassion Club"
Vancouver's Compassion Club Society has been supplying medicinal marijuana since May 1997. The club now has 700 members, ranging in age from 18 to 92, who have been referred by about 100 doctors. Three-quarters of the members have AIDS, around 15% have multiple sclerosis or experience chronic pain, and the remainder are cancer patients. [CMAJ 1999;161(8):1024]
Million dollar loss after audit
A 45-year-old Ontario GP is out more than $1 million in billings following an investigation by Ontario's Medical Review Committee. The GP, who wasn't identified but practises in an urban area, saw between 150 and 300 patients per day, and an average of 16 per hour. He also billed for services he didn't provide, his patient records were scanty and many visits were not medically necessary. [CMAJ 1999;160(11):1617]; the GP later lost his licence to practise in Ontario. [CMAJ 1999;161(2):123]
Dr. Nancy Olivieri
The dispute between internist Nancy Olivieri of Toronto's Hospital for Sick Children and Apotex Inc. was finally resolved in January. Under the agreement, Olivieri transferred to the Toronto Hospital and the HSC paid $150,000 of her legal expenses and withdrew all written complaints against her. The dispute developed between Olivieri and Apotex when the company objected to her claims that a drug it had in development to treat thalassemia was ineffective and possibly dangerous. The company threatened to sue if she made the findings public; she published anyway. A flurry of editorials in the lay and medical press about the ethics of research partnerships followed. CMAJ 1999:160(3):386-8
One-tier medicine on trial
Dr. Jacques Chaoulli of Montreal, who opted out of Quebec's medicare system and thus was prohibited from providing private medical services in hospital, challenged the system in court this year. Chaoulli is angry at what he considers a provincial monopoly over health care. In a fall trial spanning four weeks and involving 20 witnesses, Chaoulli and a patient whose surgery was delayed three times, demanded that two sections of the provincial health care and hospital insurance acts be struck down. Final pleas were heard in December 1999. [CMAJ 1999;161(10):1305-6]
Patient privacy
Bill C-54 - The Personal Information Protection and Electronic Documents Act - was drafted to promote electronic commerce and to govern the use of personal information collected, used or disclosed in the course of commercial activities. It also allows electronic versions of documents and signatures to be recognized by law. Although there have been claims that the bill has nothing to do with health information, the CMA is worried that it could affect the privacy of health data by not giving the information specific protection. The CMA told the House of Commons Standing Committee on Industry that the bill could pose serious problems for the protection of private health information. Recent CMA research shows that an overwhelming majority of Canadians want their health information to be kept private and that most do not want the information used for research purposes without their consent. The CMA wants Bill C-54 to include specific provisions for health information based on guidelines spelled out in the CMA Health Information Code. The association stressed that proposed rules for health legislation should be subject to the legislative test contained in the CMA code. CMA News 1999;9(4):3
Technology privacy code
The CMA's technology privacy code was back in the limelight as the federal government passed legislation governing the personal health information of Canadians. Several individuals and groups have spoken out forcefully both for and against Bill C-6 - formerly Bill C-54 - the Personal Information Protection and Electronic Documents Act. The CMA's position is that, as guardians of the patient record, physicians take the privacy of their patient's health information very seriously and many feel the bill could pose serious problems for the protection of private health information.
Bill C-6 was drafted to promote electronic commerce and to govern the use of personal information collected, used or disclosed in the course of commercial activities. It also allows electronic versions of documents and signatures to be recognized by law. The CMA believe that the bill leaves too much room for interpretation and does not spell out how health information will be protected on a day-to-day basis. CMA News 1999;9(12):4
Withdrawing advanced life support
The ability of many ICU technologies to prolong life has led to an outcomes-oriented approach to technology assessment, focusing on morbidity and mortality as clinically important end points. However, with advanced life support, the therapeutic goals sometimes shift from extending life to allowing it to end. In order to better understand why advanced life support is withheld, provided, continued or withdrawn in the ICU, researchers observed 25 rounds and 11 family meetings in a 15-bed ICU where the issue of withdrawal or withholding of advanced life support was addressed. The authors report that while life-support technologies are traditionally used to treat morbidity and delay mortality in ICU patients, they are also used to orchestrate dying. The authors question whether advance directives can accurately reflect the complexity of the issue. [CMAJ 1999;161(9):1109-13]
