For the record at CMA General Council

Ann Silversides; Roger Collier

doi:10.1503/cmaj.081317

Federal Health Minister assails ethics of InSite

Doctors and other health professionals who support the Vancouver-based InSite safe injection site are unethical, says federal Health Minister Tony Clement.

Federal Health Minister Tony Clement says the Vancouver-based supervised injection site “undercuts the ethic of medical practice and sets a debilitating example for all physicians and nurses, both present and future in Canada.” Image by: Roger Collier

There are no ethical grounds for health care professionals to support sites where drug addicts can shoot up under medical supervision, Clement stated during a 30-minute address to the Canadian Medical Association General Council in Montréal, Quebec on Aug. 18, 2008. He reiterated the federal government's belief that treatment programming is preferable to harm reduction strategies. The government is appealing a May 27, 2008, British Columbia Supreme Court ruling that the federal Controlled Drugs and Substances Act should allow for medical exemptions so that InSite can continue operations (CMAJ 2008;179[1]:25).

Clement also questioned whether doctors should be involved in any aspect of the administration of illegal drugs. “Is it ethical for health care professionals to support the administration of drugs that are of unknown substance or purity or potency?”

Clement expressed his concern that supervised injection is more of a form of palliative care than a means to promote full recovery from drug addiction. “Injections are not medicine,” he said. “They do not heal.”

Citing a recent government study (CMAJ 2008;178[11]:1412-3), Clement said that scientific evidence about InSite's efficacy was fraught with “uncertainty.”

Every dollar spent on InSite and other harm reduction facilities is better spent elsewhere, he said. “I believe that greater benefits could be achieved from its $3 million annual cost. … We have to do more to reach out to our own sons and daughters who are overdosing in [Vancouver's] Downtown Eastside. They need our compassion and they need our intervention, not help simply to shoot up.”

Noting that Insite claims to save one life per year, Clement said monies spent on treatment yield better results.

CMA President Dr. Robert Ouellet dubbed Clement's stance as “wrong” and said the minister took advantage of his appearance at general council to push a political agenda. “We are not politicians. We are doctors and we are concerned with taking care of patients.”

Vancouver Coastal Health Communications Officer Anne Marie D'Angelo defended harm reduction approaches. “We think it is beneficial, and independent research supports this.”

Inaugural address

Patient-based funding, a universal prescription drug program and better pay for doctors were among remedies to the ailments of Canada's health care system recommended by radiologist Dr. Robert Ouellet in his inaugural address as the CMA's new president.

The 2 biggest challenges facing the health care system, said Ouellet, are ensuring viability and improving access.

Integrating private care into the health system is part of the solution to funding problems within the system, Ouellet said. He offered few details but said additional resources could be found in the form of a designated health count or Medicare fund.

To attract and keep doctors, Canada must also offer competitive salaries and adequate working conditions, he added. “We need a system that treats health professionals, hospitals and, most importantly, patients, as value centres, not cost centres.”

Calling it “scandalous” that 3.5 million Canadians don't have access to prescription drugs, Ouellet also proposed the creation of a universal prescription drug access program. It could be modelled on Quebec's current program, he said. “Why reinvent the wheel when we can look within our own borders for a program that works?”

Gender discrimination

Gender discrimination against Canadian doctors and trainees stemming from patient pressure to apply practices “dictated by their religion on culture” should be prohibited, according to a CMA General Council resolution.

“A worrisome phenomenon seems to be emerging in several health care settings,” which affects several medical specialties and is “due to explicitly expressed values or beliefs that are solidly entrenched in the cultures and religions of certain communities,” said Quebec Medical Association President Dr. Jean-Bernard Trudeau.

“Men with deep religious commitments demand that their wives be examined by a female obstetrician-gynecologist and refuse any professional intervention by a male physician, even when safe childbirth is compromised,” Trudeau said. “These demands go against our society's fundamental values and should not be accepted.”

The issue is of particular concern to medical residents who may not get the clinical experience they need because of patient demands that exclude them from providing care, said Dr. Jimmy Bejjani, who seconded the motion.

Among the other approved motions was one callin on CMA to oppose “adoption of Bill C-484 and of any legislation would result in compromising access for women the medical services required to terminate a pregnancy.” The bill would “implicitly confer legal status on the fetus” and its adoption could open the door to all kinds of claims or court actions calling for the re-criminalization of abortion, said motion sponsor Dr. Paul Robinson.

Another motion will oblige CMA to lobby for “appropriate ‚Apology' legislation in all Canadian jurisdictions,” which would allow doctors to express regret about adverse events without incurring medico-legal risk.

President-elect puts patients first

Canadian doctors must be the “authoritative voice” that speaks for patients, says Saskatchewan family physician and CMA President-elect Dr. Anne Doig.

CMA President-elect Dr. Anne Doig. Photo by: Roger Collier

“Moreover, our voices must be loudest for those who cannot speak for themselves: our poor, our children and our elderly,” said Doig, who will assume the helm at the 2009 general council in Saskatoon, Saskatchewan.

Patient advocacy and sustainable funding for health care will be among her priorities. “Physicians must lead the changes necessary to sustain our publicly funded health care system,” she said.

Doig has chaired the CMA's Committee on Bylaws. She also teaches in the Department of Obstetrics and Gynecology at the University of Saskatchewan.

Mental health prejudices

Doctors are at least as guilty of discriminating against people with mental illnesses as the general population, according to the chair of the Mental Health Commission of Canada.

“One of the first targets for our anti-stigma campaign is health care professionals,” former Senator Michael Kirby told the CMA General Council on Aug. 18, 2008. “You'd think that health care workers would be less prejudiced about mental illness than the general population. You would be wrong.”

Delegates later passed motions calling on the CMA to work with the Mental Health Commission of Canada to: develop a national strategy for mental health; develop a 5-year plan to improve access to psychiatric care and reduce stigma; and establish benchmarks for access to psychiatric care and treatment in rural and remote areas. They also called on governments to improve coordination of mental health services for children.

Doctors must also “accept and have the courage to take care of ourselves as physicians,” said Dr. Jean-Bernard Trudeau, president of the Quebec Medical Association, who noted that 37% of doctors go through a depressive episode while in training. To that end, the CMA was urged to develop a strategy to support the mental health of Canada's doctors.