Ethics Violations: Canadian Medical Association exits World Medical Association

The Canadian Medical Association (CMA) has left the World Medical Association (WMA) because of ethics failings of its new President, Dr Leonid Eidelman. Apparently Eidelman's inaugural speech was in parts plagiarised from content produced, among others, by Dr Christopher Simpson, a former President of the Canadian Medical Association. As far as Eidelman is concerned, he says his speech was written by speech writers, and he was unaware of the plagiarism.

Let me just say that Eidelman ought to resign, whether or not his speech was written by others. He delivered plagiarized content as if it was his own, so the fact that he used speech writers is irrelevant, he remains responsible for what he says. The WMA did not force Eidelman to resign, it did not fire him.

The thing with the WMA is this: ethics failings are kind of power for the cause. That's what it does. It is a morally bankrupt organization, and it has been a morally bankrupt organization for a long time.  Its plagiarizing current President, by comparison, nearly falls into the category of 'good guy'.

In 1992 it wisely chose to elect a Nazi war criminal as its President, Dr Hans Sewering. Sewering was reportedly a member of the SS and the Nazi party. He signed death warrants for some 900 children with disabilities who were then murdered in a Nazi extermination centre.

In 2010 the WMA elected Ketan Desai to is President. He was found guilty by the High Court of Delhi of corruption and abuse of power in 2001.  The High Court ordered his removal from his job as President of the Medical Council of India. Investigators had charged him with seeking a massive bribe from a private medical college in return for approving admissions of students for the 2010-2011 academic year.

So, the WMA has a knack for picking the wrong people. The only thing that is odd about the CMA's timing is that they chose to resign their membership from the WMA over a comparably trifling matter, namely a vanity speech giving by its incoming President. Desai's failings were apparently of no concern at the time to the CMA.

The CMA's President, Dr Gigi Osler is quoted in the Toronto Star newspaper, '“We must continue to hold ourselves to a high standard of professionalism and ethical behaviour,” said Osler. “We are going to strive to uphold honesty, humility, integrity and prudence.”

This, of course, is the same medical association whose views on professionalism are akin to that of a trade union rather than that of a proud professional association. Dr Jeff Blackmer, the Director of the Canadian Medical Association’s Ethics Office wrote on behalf of the association that medical doctors are neither obliged to provide abortion services, nor are they obliged to transfer patients on to doctors they know will provide abortions to women seeking one. He holds the same view on medical aid in dying, and - one wonders - on what other medical services. Of course, doctors are monopoly providers of this service, abortion is legal in Canada, and pregnant women are entitled to receive that service free of charge (ie publicly funded) from said monopoly providers. The CMA's take is that the refusal to provide or transfer is perfectly compatible with professional conduct, when, by definition, that isn't the case.

Apparently Eidelman and Blackmer got into a bit of a bunfight over Eidelman lecturing the CMA over its support for medical aid in dying. Blackmer rightly criticises Eidelman for claiming that the CMA thought assisted dying is comparable in terms of its seriousness to prescribing antibiotics.

It appears to be the case that the WMA has again managed to appoint a reactionary doctor with questionable ethics as its President. One does wonder why anyone would take too seriously any longer its pronouncements on matters medical ethics. In its conduct it really is not dissimilar to the Roman Catholic Church. There is a lot of hand waving and posturing, but when it comes to actual conduct, it disqualifies itself as an arbiter of matters ethics.

So, kudos to the CMA for leaving the WMA; even though the point in time is ill-chosen, it was a long overdue decision.

Health Care - Not an Issue for Major Political Parties in Canada's Federal Election Campaigns

It's a somewhat surreal election campaign that is currently in full swing in Canada. It stays clear of issues of vital importance to Canada and Canadians. There we have a rapidly ageing population and really we need a national seniors strategy that accounts for that. One can nearly feel sorry for the Canadian Medical Association here. The association tried hard during the last few months to make this issue an issue in the current election campaign. It was rightly supported by sympathetic journalists such as the Globe and Mail's Andre Picard. Yet, for all those efforts, the issue gained no traction with any of the major parties. Our federal leaders' heads remain firmly planted deep in sand, with no effort made to look ahead and address major, dramatic challenges to our health care system. Instead we were treated to a good two weeks' worth of Mike Duffy and the usual corrupt shenanigans that are a hallmark of Prime Minister Harper's political operation.

I spoke yesterday to a journalist interviewing me on the state of federal and provincial planning with regard to the implementation of our Supreme Court's decision  on assisted dying. He asked why the political parties, in my estimation, haven't taken up this issue in their respective campaigns? He was puzzled that an issue that enjoys broad support among Canadians is ignored by the major political parties. What was I to say other than 'I don't get it either'. A new poll, released today, confirms what I told the journalist yesterday, it is not only the case that the vast majority of Canadians want to see the decriminalization of assisted dying, it is also the case that the vast majority of conservative party voters supports the decriminalization. 77% of Canadians generally support decriminalization and a whopping 67% of conservative party voters and 84% of NDP voters. This does beg the question why none of the mainstream parties have leveled with their supporters and the general voting public on how they would implement the Supreme Court judgment. I do still wonder why Prime Minister Harper appointed an advisory panel stacked with discredited anti-choice activists, given that the majority of his party's supporters is in favor of decriminalization. Why on earth would he stack his panel with folks known to be opposed to decriminalization? I sometimes wonder about the credit that is given to Mr Harper who is hailed as a master political tactician. His whole election campaign seems a shambles to me.

Surveys and surveys - The Canadian Medical Association should know better

The Canadian Medical Association currently debates the issue of assisted dying. That's a reassuring thing as everything points in the direction of doctors becoming the gatekeepers once assisted dying is regulated and will be made available to eligible Canadians who request it.

Strangely, the Association seems to put a lot of store in an on-line poll it inflicted on its members, where only 29% of those who responded said that they were willing to provide assisted dying to eligible patients while 63% objected. I'm surprised the Association's staff would have even mentioned this survey. It's troubled by obvious ( and quite deadly, pardon the pun) methodological problems that renders it useless.

The Associations Vice President Professional Affairs, Dr Jeff Blackmer produced a 34 slide presentation titled (no doubt to the horror of most living medical ethicists) 'End-of-Life Care in Canada: A Principles Based Approach to Assisted Dying'. There will be only few people left in bioethics who have not come to realize that the much celebrated principles approach to medical ethics guarantees arbitrary recommendations and outcomes. The principles approach is neither action guiding nor action justifying, it's useless as a tool of ethical or policy analysis and justification. Blackmer decided to add random other principles to the Georgetown Mantra, including vacuous nice sounding stuff like the 'dignity of life' (yes, really, he did!). We spent a fair amount of time in our Royal Society of Canada Report on the subject matter dissecting this particular issue.

After delivering to his audience this hotchpotch of principles, there's an unconnected slide with recommendations, followed by 8 or 9 slides reporting the results of the CMA's on-line poll. Blackmer reports that of about 80 000 doctors in Canada about 1400 clicked their way thru the on-line poll. At a minimum the negligible turnout suggests that most doctors in Canada didn't care to complete a survey that they probably realized ultimately tells us nothing about Canadian doctors' views on assisted dying. The reason for this is methodological. These kinds of surveys may or may not be representative, we just cannot know, because the survey participants may or may not be representative. If anything we should be suspicious of these results, because no professional survey organisations ensured that the sample was actually representative. Those who feel strongly about the subject matter - physicians opposed to it - will fire up their supporters to reject assisted dying and proclaim no collaboration.

Other surveys, including one reported in our above mentioned report, suggest significantly higher levels of support. It is all the more disheartening that a seasoned journalist like the Globe and Mail's Andre Picard takes the 29% figure at face value in his twitter reporting of the Blackmer presentation. (See the image above.) Doing that permits the anti-choice activists to feel good about their campaign strategy, their encouraging their like-minded doctor supporters to click thru the survey would pay off if people fell for this nonsense. I left a slightly more polite comment to this account under Blackmer's public slide presentation, but it was quickly deleted. Go figure.

The CMA recognizes that we will be getting assisted dying in some form or shape (determined by the criteria set out in the Supreme Court of Canada judgment on this subject) and that a small number of its members will be called upon to provide assisted dying services to their patients. The Association is rightly concerned about ensuring patient access while protecting its objecting members' conscience choices. There is a precedent for this. Abortion. Objecting doctors will be obliged to transfer their patients to a colleague they know will oblige them, without unreasonable delay. The CMA is apparently supportive of this compromise.

The train toward assisted dying in Canada has departed but hasn't reached its destination yet.

time to decriminalise assisted dying in canada

Here's this weekend's OpEd on Assisted Dying in the Kingston Whig-Standard.

This last week doctors organized under the Canadian Medical Association met for their policy convention in Calgary. A whole bunch of sensible policy recommendations came out of this meeting, including the suggestion that our kids should no longer be able to purchase energy drinks.

But commentators writing for national news organizations concluded, in typical handwringing style, that the CMA failed us terribly by not issuing a recommendation on the issue of the decriminalization of assisted dying.

I don’t think that was much of a failing. In fact, I don’t quite understand why it should matter more what doctors think than what you or I think about our own death. Why should they have a bigger say or stake in the manner of our own dying? I guess it could matter if they were to be forced to participate in assisted dying if it were to be decriminalized. The thing is, that would not be the case, anyway, so why get overly excited about our doctors’ views on the matter?

Where are we in the assisted dying stakes, anyway? Quebec has decided that assisted dying is no more than part of continuing medical care, and so, by its lights, it is its decision alone how it regulates this matter since health care is one of those powers entrusted to the provinces through the Constitution. The provincial government is intent on making assisted dying a possibility.

Quebecers overwhelmingly support this. There is even cross-party support in the province for the proposed legislation. The National Assembly is currently debating it. You can be sure that the federal government – currently controlled by conservative Christians – will try to have this provincial law set aside by the courts, and to be fair, there is a serious constitutional issue at stake here! The constitutional issue isn’t – as you might expect – about assisted dying, but about the question of whether our provinces should be able to set aside the parts of the federal Criminal Code that prohibit assisted dying by redefining it as a provincial health matter. If they were able to do so, what parts of the Criminal Code might be next?

Independent of the goings-on in Quebec, the Supreme Court of British Columbia declared in a 2012 ruling those parts of the Criminal Code that criminalize assisted dying unconstitutional. The federal government has appealed this decision and we should hear within the next few months how that went. However the Court of Appeals decides, the losing party will undoubtedly try to get this matter heard by the Supreme Court of Canada.

It is always tricky to predict how court judgements, especially Supreme Court of Canada judgements, will pan out. The latter, protests from legal eagles notwithstanding, has plenty of leeway to determine the course of assisted dying in this country.

I’m optimistic that decriminalization in some form or shape will eventually occur. The reason for this is essentially that our Charter of Rights and Freedoms places a very high value on respect for the autonomous choices we make for ourselves. That explains why suicide is legal in Canada. That also explains why we have the legal right to stop life-extending medical care at any time. Short of having us declared incompetent, doctors cannot treat us against our wishes.

Given this context, it doesn’t seem to be a great stretch for a court to determine that we also have the right to assistance in dying. Respect for our individual freedom will win out. It has on the abortion fronts, it has on the marriage equality front, and it will win on the assisted dying issue, too. As a species we seem bent on placing individual rights and freedoms, as far as self-regarding actions are concerned, above conservative values that have others determine what’s best for us.

The countervailing arguments against decriminalization are pretty thin - and that is putting it mildly. In the old days the same anti-euthanasia campaigners who busily contribute to public debate today were pretty clear that assisted dying would violate their religious rules, and so none of us should have access to it, regardless of our own worldviews. They have since realized that this kind of arguments doesn’t exactly help their cause among the wider Canadian public. Accordingly, they switched their campaigning to concerns about possible abuses of never-clearly defined “vulnerable” people.

Given that pro-choice campaigners are concerned about individual free choice and also our quality of life, the strategic shift in the anti-choice rhetoric to testable claims about worrying slippery slopes is actually to be welcomed. It is a fair enough question to ask whether disabled people, the poor and others you could reasonably describe as more vulnerable than some other classes of patients would be put at risk if we decriminalized assisted dying. No doubt the courts will look at this issue in great depth and detail.

The reason for my optimism on this front is that we know from jurisdictions that have decriminalized that there is no evidence that vulnerable people are disproportionately represented among those who receive assistance in dying. From some jurisdictions we even have firm data demonstrating that abuse has actually decreased since decriminalization. Even if there were a limited number of clear, uncontroversial cases of abuse in societies that have decriminalized, we would still need to establish that that abuse was a result of decriminalization.

The anti-choice campaigners have a habit of carefully fudging the issues here. Their claim that decriminalization has led to reductions in the quality and availability of palliative care also turns out to be without any basis in fact. None of the actual evidence we have fits the anti-choice campaigners’ scaremongering tactics, hence their ever-more-hysterical-sounding claims on that front.

With the exception of Quebec, I think it is fair to say that this country has been let down disgracefully by its elected representatives. Opinion poll after opinion poll - and this includes polling undertaken by anti-choice campaigners, too - concludes that an overwhelming majority of Canadians support the decriminalization of assisted dying. That, combined with the lack of evidence of a slippery slope to unwanted killings as a result of decriminalization in societies that have legalized assisted dying in some form or shape, makes a pretty powerful case for the decriminalization agenda.

Not so in the eyes of our elected representatives. They have caved in to the religious right’s lobbying and scaremongering on this issue, instead of showing the leadership we can rightfully expect of them. For what it’s worth, this failing cuts across party lines. Even the so-called Liberal Party of Canada, whose very name suggests that it should proudly support decriminalization, is to be found on the wrong side of history on this issue. The good news for us is that the courts will not be susceptible to pressure from religious and other campaigners.

Udo Schuklenk holds the Ontario Research Chair in Bioethics and Public Policy at Queen's University. He has chaired a panel of international experts drafting a landmark report on end-of-life issues on behalf of the Royal Society of Canada. He tweets @schuklenk

Common Sense and the CMAs Campaign for the Partial Privatization of Health Delivery

Here's a true story from Canada. It looks like 'market-friendly' forces in the Canadian Medical Association (CMA)are campaigning to allow the part-privatization of health delivery services. To be fair, a lot of health delivery services in Canada are actually private. For instance, much like in the UK, for some bizarre reason dental care isn't part of 'free at the point of delivery' care that public health care systems usually take pride in. Pride one should take in such public systems because they permit equitable access based on health needs as opposed to individuals' capacity to pay.

Well, the current CMA leadership aims to permit doctors to take on private patients. The argument is that this could reduce public sector waiting lists. Surely, this is either disingenious or mischievous. Public sector waiting lists in this country are seriously out of sync with delivery needs. This suggests that Canada likely invests insufficient resources into the training of future health care professionals.

Whatever the cause of the suboptimal supply of health care professionals (certainly GPs) in Canada, one thing is clear, the proposed piecemeal privatization of the public service will not change that status quo. If you have X numbers of physicians working today in a given country's public health service (and X is a fixed number), permitting those professionals who make up X (the group) to work in private practice is not going to change the number of professionals making up X.

What it does, however, is to create a market for health services. Those who are able and/or happy to pay will be able to jump the queue that exists in the public sector. They indeed will see their waiting times slashed. Of course, privatization is fundamentally about (not to say against) equal access. Equal access is undermined because if X remains stable (ie the number of GPs per 100 population), a smaller number of clinicians would have to serve the larger number of folks who couldn't afford private services. A large numbers of people will predictably be worse off, a smaller number will equally predictably be better off.

Which shows that the CMA is a doctors' trade union. It's more concerned about increasing doctors' income then patient welfare.