Figure 1: Elements of Consent

Figure 1: Elements of Consent

Figure 2: Balancing beneficence and autonomy with incapable patients

Caption: Incapable patients can be located on a continuum, at one end of which beneficence is uppermost on a clinician’s mind, and at the other end of which autonomy has primacy. Clinically, whether one principle or the other is primary affects the sources of substitute decisions and the standard of decision-making that is appropriate on the patient’s behalf. SDM = substitute decision maker.

(Note 1): Patients with nascent/developing capacity should be involved in decision making as much as possible. There may be decisions for which they are capable – see below.

Table 1: Capacity and patient age

Note 1: i.e.: presumed capable unless a specific capacity assessment suggests otherwise.

Note 2: This is the doctrine of the mature minor.

Figure 3: Consent algorithm for incapable patient, previously capable.

Caption:

Note 1: unequivocal evidence of a patient preference, even in the event of a life-threatening emergency, must nonetheless guide decision-making.

Figure 4: Consent algorithm for incapable patient, never previously capable

Caption

Note 1: e.g.: immature minor, minor whose age < statutory age of consent, patient with mental retardation or developmental delay.

Table 2: Disclosures of health information in Alberta

Caption: Though the particular acts and instances cited above are specific to Alberta, similar arrangements may exist in other provinces. This table is not exhaustive. Specific instances covered by the Health Information Act, the Mental Health Act, and the Health Professions Act, among others, are omitted. Source: College of Physicans and Surgeons of Alberta, Release of Medical Information: A Guide for Alberta Physicians.

Note 1: Disclosures required by federal statute apply uniformly throughout Canada.

Note 2: Though noted as a permissive disclosure, US case law suggests that failure to disclose in such a situation may expose healthcare providers to legal liability in common law.

Note 3: In jurisdictions where no statutory age of consent exists, a minor of any age capable of providing consent has a right to confidentiality.

Table 3: The many functions of the medical record

Figure 5.: The medical record and health information – rights and obligations – custodians and patients

Figure 6: Levels of healthcare resource allocation

Figure 7: Possible ethical dilemmas – conflicting physician duties – patient VS community needs

Table 4: Dealing with patient requests of questionable or uncertain medical value

Figure 8: The Canadian research ethics landscape, simplified

Caption: The Canadian research ethics framework involves national standards and local review. REB = Research Ethics Board; NCEHR = National Council on Ethics in Human Research

Figure 9: When asked to enrol a patient …

Figure 10: Professionalism

Caption: Professionalism: The practice of medicine according to a common set of norms and standards, characterized by ethical conduct, self-regulation, and clinical independence.

Table 5: Professional expectations of physician-pharmaceutical interactions

Caption: Selected and abridged from the CMA Policy, Physicians and the Pharmaceutical Industry, 2001

Table 6: Additional federal powers related to health

Caption: NOTE 1: The federal spending power has been interpreted broadly, allowing the federal government to use financial incentives to achieve specific aims among and within the provinces. This power is particularly important for the Canada Health Act.

Figure 11: The public sector and health – organizational overview

(Taken and adapted from

Marchildon, Gregory P. Health Systems in Transition: Canada, Sara Allin and Elias Mossialos (Eds.). University of Toronto Press Inc, Toronto: 2006. P. 26.)

(See hand drawing)

Table 7: Conditions of the Canada Health Act

NOTE 1: The rates of pay for out-of-province and out-of-country services are defined according to rates for similar services in the province of service delivery and the home province, respectively. Quebec violates this condition – it refuses to compensate costs incurred in other provinces. The federal government has not pursued this breech.

NOTE 2: This condition is an addition to principles outlined in previous healthcare legislation. It targets such practices as user charges, which impede access on the basis of ability to pay.

Table 8: Rough sketch of funding sources by healthcare sector

NOTE 1: With quality services provided by the public system at little or no cost, there is no incentive for patients to seek private insurance. As well, provinces have erected barriers to private insurance in the CHA-privileged sectors (see Box 12).

Table 9: Overview of physician organizations

Figure 12: Four elements of negligence

NOTE 1: This relationship does not typically extend to non-patients, even those that need care. So, physicians have not been found to owe a general duty of rescue, unless they hold out to the public that such care will be provided (e.g.: an emergency physician while at work). Recent cases suggest that this may change – physicians may be liable for failing to provide emergency care when requested to do so in non-professional settings.

NOTE 2: The standard of care is inferred in court from expert testimony and approved practices (e.g.: hospital policies, specialty organization policies, etc.).

NOTE 3: In practice, there is local variation – e.g.: a physician cannot be held liable for failing to provide an MRI scan where none exists. However, the same physician may be liable for failing to refer the patient, or for an unreasonable delay in referral.

NOTE 4: However, a failure to revaluate a faulty diagnosis in light of continued deterioration may be actionable …