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\"\"<\/a><\/p>\n

vol. 64
\nMedical
\nWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 3, September 2018
\nContents
\n\u201cSo, do you like being a treasurer? Yes. What, really??\u201d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t1
\nRegulating the Regulators? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t3
\nPatient-reported Indicator Survey (PaRIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t8
\nPhysician Complicity in Capital Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t14
\nEuthanasia in Canada: a Cautionary Tale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t17
\nTelemedicine and its Ethical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t24
\nGlobal Migration and the Health Workforce: the Experiences of Internationally
\nEducated Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t27
\nSome Ethical Aspects of Aesthetic
\nMedicine in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t31
\nPseudosciences\/Pseudotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t36
\nNew IFPMA Code of Practice 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t37
\nInterview with Dr. Otmar Kloiber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t39
\nWorld Federation for Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \tiii
\nEditor in Chief
\nDr. P\u0113teris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nMaira Sudraba, Velta Poz\u0146aka; lma@arstubiedriba.lv
\nJournal design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher, \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nThe Latvian Medical Association, \u201cLatvijas \u0100rstu biedr\u012bba\u201d,
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr. Yoshitake YOKOKURA
\nWMA President
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,
\nTokyo, Japan
\nDr. Ren\u00e9 H\u00c9MAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nP.O. Box 20051
\n3502 LB, Utrecht
\nNetherlands
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nWMA Vice-Chairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Ketan DESAI
\nWMA Immediate Past-President
\nIndian Medical Association
\nIndraprastha Marg
\n110 002 New Delhi
\nIndia
\nDr. Joseph HEYMAN
\nWMA Chairperson
\nof the Associate Members
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nDr. Andrew DEARDEN
\nWMA Treasurer
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Leonid EIDELMAN
\nWMA President-Elect
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.,
\nP.O. Box 3566
\n52136 Ramat-Gan
\nIsrael
\nDr. Heidi STENSMYREN
\nWMA Chairperson of the Medical
\nEthics Committee
\nSwedish Medical Association
\n(Villagatan 5) P.O. Box 5610
\nSE\u00a0\u2013 114 86 Stockholm
\nSweden
\nDr. Miguel Roberto JORGE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr. Ardis D. HOVEN
\nWMA Chairperson of Council
\nAmerican Medical Association
\nAMA Plaza, 330 N. Wabash,
\nSuite 39300
\n60611-5885 Chicago, Illinois
\nUnited States
\nDr. Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of The World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nBACK TO CONTENTS
\nEditorial
\n\u201cSo, do you like being a treasurer? Yes. What, really??\u201d
\nAt a recent medical dinner, I was asked why
\nI enjoyed being a treasurer so much. It was
\nan interesting question as I currently serve as
\nthe treasurer of the British Medical Associa-
\ntion and the World Medical Association and
\nas the internal auditor for the CPME, the
\nStanding committee for doctors in Europe.
\nMy answer (I was told) was so energetic and
\nenthusiastic that I was asked to write an ar-
\nticle on the question. Nothing I am about to
\nsay is new or, I suspect, original but seeks to
\nexplain why I find money fascinating. I am
\nnot a scholar or an academic,(so don\u2019t expect
\ntoo much!) I\u2019m a family practitioner with an
\ninterest in finance.
\nI\u2019ve always been fascinated by money, not so
\nmuch in the obtaining or keeping it but in
\nthe way it acts, the way it reacts, the way it
\nresponds to our activities and how it tells us so much about our-
\nselves.
\nIn just the same way as a microbiologist is fascinated by the be-
\nhaviour of bacteria \u2013 the way they live, the way they adapt, the
\nway they coexist with us and sometimes the profound effects they
\ncould have on us as humans, so I am fascinated by the entity we
\ncall money. I\u2019m fascinated by the effect our creation can have on
\nus.
\nFor example, in a recent article in the Independent (a UK broad-
\nsheet paper) commenting on a survey done by the law firm Slat-
\ner and Gordon, it was reported that \u201cA poll of over 2,000 British
\nadults by legal firm Slater and Gordon found that money worries
\ntop the list of reasons why married couples split up, with one in five
\nsaying it was the biggest cause of marital strife\u201d. Further it was
\nreported that \u201cOver a third of those questioned said that financial
\npressures were the biggest challenge to their marriage, while a fifth
\nsaid that most of their arguments were about money. One in five of
\nthose polled blamed their partner for their money worries, \u00ad
\naccusing
\nthem of overspending or failing to budget
\nproperly\u201d.
\nThe effect money can have on our happiness,
\nour families, our children and often on our
\nhealth makes me believe it is equally impor-
\ntant as a subject of study as any infectious
\nagent.
\nIn very early human interactions, bartering
\nseemed to be the way that we exchanged
\ntime, goods and skills. It wasn\u2019t long be-
\nfore we began to use intermediary methods
\nto value those things and to then use this
\nas a method of exchange. This intermedi-
\nary method has included not just notes and
\ncoins but a whole host of objects, for exam-
\nple, animals, beads, salt, shells and cigarettes,
\na widely used and recognised \u201ccurrency\u201d in
\nmany prison populations.
\nThe importance is not the \u201cthing\u201d but the value we attach to it. For
\nexample, in Christopher Columbus\u2019s time the value of gold to the
\nSpanish was as a form of currency, the more gold you had the richer
\nyou were, whereas it appears that the Aztecs used gold primarily
\nin jewellery and ornaments. They seemed to put greater \u201cmonetary\u201d
\nvalue on feathers, jewels, cotton and they used cacao beans as a cur-
\nrency. (ThoughtCo. The Treasure of the Aztecs. Christopher Minster.
\nSept. 2017).
\nThough we may smile at this,we do similar things today.For example,
\nwe invest in paintings, wine, comics, antiquities, cars and an assort-
\nment of other things.In one retirement seminar at which I\u00a0spoke,one
\nperson who attended told me proudly of how he had travelled Eu-
\nrope buying fine wines which would help fund his retirement. When
\nI\u00a0asked him about his last purchase he told me he had bought a case
\nof 12 excellent bottles of wine. When I asked him how many he had
\nleft,he smiled a bit shyly and said \u201ceight\u201d.I\u00a0informed him this was not
\nso much retirement planning as much as enjoying life.
\nAndrew Dearden
\n2
\nEditorial
\nI find it fascinating that either we learn to control our money or it
\ncontrols us. In some Christian scriptures, for example, debt is de-
\nscribed as a form of bondage. It has been said that we either work
\nfor money or we can get money to work for us and so I\u2019m amazed
\nat the number of methods we have created to increase our money,
\nto make it grow. We have devised a multitude of ways with various
\ndegrees of risk and, in some cases, legality, in an attempt to increase
\nthe money that we have. Whole industries have been created with
\nthis single purpose in mind and it has developed its own language
\nand culture. This whole culture around money can be a lifetime\u2019s
\nstudy and pursuit. It can also become an obsession.
\nI believe it is possible to determine what is important to each of
\nus, what we value and what we feel is important by reviewing how
\nand where we spend our money. If you were to examine your own
\nbudget you would see how much money you spend on your home,
\nyour garden, your family, travelling, your hobby, etc. You would also
\nsee how much of your money (and therefore your time) you give to
\ncharitable causes important to you.
\nAgain, when speaking about retirement planning, I often suggest
\nthat we review our spending and saving patterns as if we were an
\noutside external person with no knowledge of us personally. I sug-
\ngest we look to where our money goes, what it is used for and spent
\non and then form an opinion on what is important to that person,
\nus, and see if it matches our view of ourselves.
\nI find the way money responds to external factors, for example eco-
\nnomic ones, is really a reflection of how we are responding to those
\nthings.When the news reports that the markets are nervous they re-
\nally mean we are nervous, when we are told the markets are panick-
\ning they really mean we are. So sometimes we see money as some-
\nthing different to us, something separate as if it had a mind and will
\nof its own, yet in a very basic way, it reflects how we think and how
\nwe feel. Many people \u201cstockpile money\u201d feeling this is important,
\nuntil an impending hurricane, for example, makes them shift priori-
\nties and they exchange that stockpile for food, water, batteries, etc.
\nSo, when I look at the accounts of an organisation like the BMA
\nor the WMA, I hope to see what is important to the organisation,
\nby seeing where, and on what they spend their money. Or at least
\nI\u00a0would hope to be able to do so. But like the person who claims to
\nlove to spend time with the family, but who in reality, rarely does,
\nsometimes it is hard to match our aims, aspirations, our core values
\nand functions with what we spend our money on.
\nBy listening to members of any organisation when they discuss fi-
\nnances you can often judge how members value the organisation by
\nthe amount of the willing to pay into it, in terms of not just money
\nbut time (personal and corporate), the value they feel they get from
\nmembership and over the past few years the changing attitudes of
\nyounger people towards organisations. Membership loyalty cannot
\nbe assumed from the younger generation in the same way that it
\ncould be expected from my generation,for example.One only has to
\nlook at how often my children generation change banks compared
\nto mine. (I\u2019ve had the same bank since I was 17 in case you were
\nwondering!)
\nAccounts can tell us what we think about risk, member services,
\nteaching, planning or interactions with external agencies. Accounts
\ncan tell us how strongly we feel about the statement of the Charles
\nDickens\u2019character Mr Micawber who stated \u201cannual income twenty
\npounds,annual expenditure nineteen pounds,nineteen shillings and
\nsix pence, result happiness. Annual income twenty pounds, annual
\nexpenditure twenty pounds ought (nothing) and six (pence), result
\nmisery\u201d. For the record, I think the statement to be 100% accurate
\nand financially astute.
\nWe often see money as some sort of external thing,something sepa-
\nrate to ourselves, yet it is, in a very real way, a method in which we
\n\u201cexpress\u201d ourselves. In the same way painters have different styles
\nand different ways to express what they see, I think the same applies
\nto people and organisations and their money and what they value.
\nBut as a final thought,most studies show that money does not make
\nus personally happier in a consistent and constant way, but our re-
\nlationships do.
\nDr. Andrew Dearden
\nMBCCh FRCGP
\nTreasurer of the BMA and WMA
\nadearden@bma.org.uk
\n3
\nBACK TO CONTENTS
\nHealth Care
\nThe frequency and veracity questions relating to
\nwho regulates the regulators seems to have been
\nincreasing in recent years and is a topic of atten-
\ntion in many countries around the world. This
\npaper based on a presentation at the fifth World
\nHealth Professions Regulation Conference in
\nGeneva Switzerland addresses this question.
\nThrough the use of documentary analysis four
\nspecific themes Motivation, Challenges, Tools,
\nand Measurement Dimensions emerged from a
\ndiverse range of sources. It is clear that there is
\na wide range of approaches being taken to the
\nregulation of regulators but unfortunately there
\nis paucity of evidence on the relative effectiveness
\nand efficiency of these methods. After comparing
\nthe results from this study with already pub-
\nlished work it is appropriate to conclude that if
\nregulators are to live up to the changing require-
\nments of acting in the public interest, they must
\nshow leadership in this agenda. By designing
\nrobust reliable and valid metrics, transparency
\nand accountability can be enhanced and vulner-
\nability to political whims potentially reduced.
\nIntroduction
\nThis article is based on a paper presented at
\nthe fifth World Health Professions Regu-
\nlation Conference in Geneva Switzerland,
\n2018. Questions like the one posed in the
\ntitle of this article have been around for two
\nmillennia. Indeed, as noted by Uden [1],
\nthe first and second century Roman poet
\nand satirist Juvenal posed a similar ques-
\ntion \u201cWho guards the guards themselves?\u201d
\n(Quis custodiet ipsos custodes?). However,
\nfrom a regulatory perspective, the frequency
\nand veracity of such questions seems to have
\nbeen increasing in recent years and is a topic
\nof attention in many countries around the
\nworld [2-6]. The reason for this increased
\ninterest seems to be multifactorial. In some
\ncases, such as in the case of the United
\nKingdom, interest in scrutinizing the per-
\nformance of regulators has, at least in part,
\nbeen driven by high profile regulatory sys-
\ntems failures such as those identified in the
\nShipman Inquiry [7]. Such interest is often
\namplified by intense media coverage [8-10].
\nIn Australia, commitment to a reduction of
\nregulatory burdens and a focus on best prac-
\ntice has played a major role in their reform
\nagenda. Whereas in the United States [11]
\nthe need to address the tension that can arise
\nbetween pursuit of economic market mod-
\nels and public interest protections has acted
\nas a major stimulus.Irrespective of the cause
\nfor this increased interest a more detailed
\nunderstanding of the topic is warranted if
\nefficient and effective public protection is to
\nbe assured. After all, some authors such as
\nBaetjer [12] would have us believe that reg-
\nulators are not subject to scrutiny, lack ac-
\ncountability and view the existing political
\nprocesses, designed to hold regulators to ac-
\ncount, as ineffective. Accordingly, the time
\nwould seem right to more critically examine
\nthe issue of who regulates the regulators and
\nmore importantly to consider to what effect
\nand purpose they should be regulated.
\nAim
\nTo systematically examine using documen-
\ntary analysis the approaches taken to hold-
\ning regulators to account.
\nMethod
\nA structured review of the published and
\ngrey literature using a variety of search terms
\ncombined in a systematic way through the
\napplication of logical operators was con-
\nducted.To generate the search terms a small
\ngroup of nurse regulators from around the
\nworld were asked to suggest terms that could
\nbe used to identify relevant literature. The
\nterms generated were as follows,((Regulation
\nOR Regulator OR Licensure OR Licensing)
\nAND (Performance OR Accountability OR
\nReview OR Sunset OR Sunrise OR Inquiry
\nOR Evaluation OR Audit OR Governance)
\nAND (Nurse OR Nursing)). In addition, it
\nwas suggested that both published and grey
\nliterature be searched as it was noted that
\nmany of the reviews that have been under-
\ntaken by legislative and other bodies are not
\nindexed in the peer-reviewed bibliographic
\ndatabases. Accordingly, the search terms
\nwere used to interrogate Pubmed, Scopus and
\nGoogle search engines. The Initial yields of
\npapers identified were then reviewed for rel-
\nevance through scrutiny of the title and ab-
\nstract. Remaining papers were then retrieved
\nfor more detailed consideration.
\nRegulating the Regulators?
\nDavid C Benton Julie George
\nUNITED STATES OF AMERICA
\n4
\nAnalysis of papers
\nAll retrieved papers were initially read
\nand reviewed for specific relevance to the
\nstudy aim. Any papers whose substantive
\ncontent was written in any language other
\nthan English was rejected along with those
\nthat did not address the study aim. At this
\nstage all those remaining papers were then
\nuploaded to NVIVO 11plus for detailed
\nanalysis. All content relating to the over-
\nsight, scrutiny and review of the regulatory
\nbody, its powers and actions were coded us-
\ning the general inductive coding method as
\ndescribed by Thomas [13]. This approach is
\nsaid to offer efficient and defendable pro-
\ncedures for analyzing qualitative data. The
\nmethod according to Thomas [13] draws on
\nbest practices from a range of experts in the
\nfield of inductive qualitative analysis and
\naccommodates and condenses large quan-
\ntities of varied text into meaningful and
\nrelated themes and concepts. In this case
\nboth authors read all the material several
\ntimes and independently identified con-
\ntent that addressed the aim of the study.
\nBoth researchers then compared and con-
\ntrasted their coded work so as to identify
\nand agree content that formed the basis for
\nthe identification of specific interventions
\nand associated thematic categories. Wes-
\nley [14] insists that the trustworthiness of
\nthe analysis must apply the same degree of
\nrigor as those approaches dealing with the
\nreliability and validity of quantitative stud-
\nies. To enhance the trustworthiness and
\nprecision of the analysis the researchers
\ncompleted a series of cycles of independent
\ncoding, comparing and contrasting their
\nwork followed by consensus agreement.
\nHowever, Tashakkori and Teddie [15] pro-
\nposed that a triangulation of analysis by the
\nresearchers may not be sufficient to assure
\ntrustworthiness. Tashakkori and Teddie
\n[15] suggest that any analysis should be
\naugmented and objectified by reference to
\nexisting literature. To this end, the results
\nof the analysis was further compared and
\ncontrasted with existing literature as part of
\nthe discussion section.
\nEthical Approval
\nAs this study did not involve human sub-
\njects and was based upon an analysis of
\npublicly available documentary sources the
\nstudy did not require ethical or institutional
\napproval. Nevertheless, the design and ap-
\nproach used was reviewed by two indepen-
\ndent researchers experienced in regulatory
\nand policy analysis. This review confirmed
\nthe appropriateness of the planned meth-
\nodological approaches and procedures to be
\nused.
\nResults
\nA total of 3723 papers were identified and
\nafter review of the titles and associated ab-
\nstracts one hundred and fifty eight were
\nretained for retrieval and further analysis.
\nOn closer consideration of these papers a
\nfurther eighty seven papers were rejected.
\nOf those rejected, nine were published in
\na language other than English and the re-
\nmainder either did not focus specifically on
\nthe study aim or were opinion pieces. This
\nleft seventy one papers for detailed review
\nand analysis.
\nThe papers fell into four categories.The most
\nfrequently found (n=39) could be classified as
\nsunset or legislative reviews where the func-
\ntioning of the regulator was under scrutiny
\nby the establishing or accountable oversight
\nbody. However, there was no consistency to
\nthe topics addressed by these reviews. Nor
\ndid the reviews follow any standard struc-
\nture,analytical approach or reporting format.
\nThe next most frequent type of publication
\nwas independently funded reviews by policy
\nthink-tanks or philanthropic organizations
\n(n=16). Most of these papers were propo-
\nnents of a market based model of regulation
\nand frequently advocated for deregulation. A
\nfew research studies in peer reviewed journals
\nwere identified (n=10).These covered a range
\nof relatively narrow aspects of performance
\nsuch as the efficiency of notification of the
\nNational Practitioner Data Bank [16]. The
\nleast frequently found papers (n=6) were col-
\nlations of suggested best practices produced
\nby inter-departmental or intergovernmental
\nbodies such as the Organization for Eco-
\nnomic Co-operation and Development [17].
\nThematic Content
\nFour specific themes emerged from the
\nanalysis, Motivation, Challenges, Tools, and
\nMeasurement Dimensions. Each theme had
\nseveral sub-themes and accordingly these
\nare reported in detail. Figure 1 provides a
\nsynopsis of the composition of each of the
\nthemes.
\nMotivation
\nIrrespective of the type of publication, all
\npapers offered an explanation of why it was
\nnecessary to undertake the review of the
\nregulatory body or its functions thereby
\nspecifying the motivation behind the work.
\nCloser examination of this theme identi-
\nfied that the motivating factors could be
\nclassified under three main topics\u00a0\u2013 control,
\nalignment and operational improvements. In
\nthe case of control, the motivation related
\nto ensuring there was no abuse of power
\ngranted to the regulator and that they re-
\nmained within the bounds of the purpose
\nand responsibilities delegated to them by
\ntheir establishing legislation. Alignment was
\nmore specific in ensuring that the actions of
\nthe regulators were in step with their public
\nprotection mandate. Operational Improve-
\nments were far more narrowly defined and
\naddressed specific aspects of the perfor-
\nmance of various functions as well mecha-
\nnisms to improve efficiency, effectiveness
\nand quality of the services being delivered.
\nChallenges
\nMultiple references in the documents were
\nidentified, which highlighted the challenges
\nassociated with holding regulators to ac-
\ncount. These challenges are classified under
\nthe three sub-themes of complexity, temporal
\nHealth Care UNITED STATES OF AMERICA
\n5
\nBACK TO CONTENTS
\ncomponents and clarity & capacity. Measur-
\ning the performance of regulators can be
\ncomplex as it is only recently that robust
\nresearch into the topic has been conducted.
\nAlso the fact that there can be both inter-
\nnal and external overlapping responsibilities
\ncan make determining accountability more
\nchallenging. For example, in the case of an
\ninternal overlap where a board of nursing
\nis part of an umbrella structure and it does
\nnot have control of some of its key resources
\nsuch as their investigators. Consequently,
\nit is difficult to attribute accountability for
\nboth success and failure. Similarly, in the
\ncase of educational program approval where
\nthe Department of Education requires ac-
\ncreditation to be conducted and the board
\nof nursing has overlapping program re-
\nsponsibilities determining how these dif-
\nfering approaches interact can be complex
\nto unpack. The temporal component refers
\nto the time taken to identify and resolve
\nissues. Sometimes there can be criminal
\nprocedures taking place in parallel with the
\ninvestigation of conduct or performance
\ncomplaints. Ensuring a speedy resolution
\ncan be a challenge. Finally, the difficulties
\nof precisely specifying clear measures that
\nare robust, reliable and valid can, along with
\nthe relevant board and staff capacity to in-
\nterpret and respond to the findings, pres-
\nent leadership of the organizations as well
\nas any oversight entities both operational
\nand strategic challenges. For example, in-
\ncreasingly boards of nursing have enormous
\namounts of digital data that relate to their
\ncore purpose yet the analytical capacity to
\ninterrogate and interpret such material may
\nbe limited or in some cases entirely absent.
\nMeasurement Dimensions
\nFrom consideration of the various reviews
\nconducted it is possible to identify that the
\nmeasures used to hold the regulators to
\naccount are multidimensional. While the
\nstudies do not frame the measures used as
\na set of polar-opposites it is a useful way to
\nconsider the evidence identified. As can be
\nseen from Figure 1 there is a framework of
\nfour dimensions that can be used to classify
\nmeasures that can be used to hold the regu-
\nlator to account (Level, Frequency, Status,
\nand Methodological Approach).
\nA wide range of tools, techniques and pro-
\ncedures were identified as being used to
\nhold regulators to account. Some of these
\nare general in nature and amenable for use
\nacross a range of responsibilities. Other
\napproaches were far more specific and ad-
\ndressed a single aspect of the board\u2019s func-
\ntioning. Collectively these two aspects can
\nbe used to delineate the coverage of the spe-
\ncific tools, techniques and procedures used
\n(Figure 2). In addition, the potential impact
\nof these approaches could be further classi-
\nfied as being either weak or strong.
\nAlthough it is not illustrated as part of Fig-
\nure 2, it would also be possible to further
\nclassify these interventions as either rou-
\ntine or ad-hoc, as well as being internally
\nor externally focused. These classifications
\nare congruent with the dimensions already
\nnoted under the measurement theme.
\nDiscussions
\nIt has been reported by Baugas and Bose
\n[18] (2015) that 36 of the 50 US states have
\nsome form of sunset legislation providing
\nregular scrutiny to the laws that govern
\nregulation and other controls on services
\noffered to citizens. In some cases, the sun-
\nset review is mandated on a regular cycle
\nwhereas for other States it is an optional
\npower that the legislature can bring into
\nplay when necessary either due to specific
\nperformance problems or in some cases due
\nto political exigencies. It is clear from the
\nresults presented in this paper and the find-
\nings of Baugas and Bose [18] that this is a
\ncommon approach used to scrutinize the
\nperformance of regulatory bodies. However,
\nFigure 1.\u2002 Themes from the Inductive Qualitative Analysis of Documents
\nHealth Care
\nUNITED STATES OF AMERICA
\n6
\nthe non-standardized methods used, the ir-
\nregularity of frequency, and inconsistency of
\nreporting means that it is difficult to track
\nimprovements over time or provide oppor-
\ntunities for comparison between regulators.
\nThese comparisons could be across regula-
\ntors in the same jurisdiction or for specific
\nregulators that regulate the same discipline
\nacross jurisdictional boundaries. This vari-
\nability, while in some cases addressing de-
\nfined concerns, denies legislators and the
\nregulators themselves an opportunity to
\nbenchmark and learn from optimum prac-
\ntices.
\nOne approach to address this problem
\nwould be to attempt to generate a normative
\nmovement through conducting an integra-
\ntive review of the sunset reports and their
\nassociated guidance so as to identify best or
\nat least promising practices that could then
\nbe followed.
\nAn alternative way to address variability
\nwould be to use the finding of this study
\nto design a set of regulatory metrics that
\nare cognizant of the challenges identified
\nand utilize sound measurement design ap-
\nproaches. The resulting, clearly defined
\nmetrics can then be uniformly gathered so
\ncomparisons both within and across juris-
\ndictions would be possible. The addition of
\nsuch metrics to the plethora of tools and
\napproaches already in place would poten-
\ntially add value to the many existing efforts
\nof holding regulators to account. Again,
\nthe production of such measures, ideally
\nthrough a collaborative-based generative
\napproach would provide an opportunity to
\ntake advantage of the normative impact of
\ndeveloping standards of best practices. Ulti-
\nmately, based on the experience of the Na-
\ntional Council of State Boards of Nursing
\nCommitment to Regulatory Excellence[19]
\n(CORE) program, this approach should
\nprovide opportunities for increasing effi-
\nciency, effectiveness, transparency and ac-
\ncountability of the regulator. A more radical
\napproach,but one that may be viewed by the
\nlegislators as being more proactive, would
\nbe for regulators themselves to develop and
\nimplement an accreditation system where
\npeers provide expert commentary against a
\nset of well defined standards of best regula-
\ntory practices.
\nWork by others have identified that the di-
\nmensions of regulatory accountability have
\nbeen changing. Some authors [20-22] have
\nexplored and documented how professional
\nregulation has changed over the years. A
\ncloser look at their work enables a synopsis
\nof key features of how the concept of act-
\ning in the public interest, captured in the
\nthree boxes, has evolved both in terms of
\nincreased complexity and additional dimen-
\nsions (Figure 3). Identification of these di-
\nmensions potentially provides a useful basis
\nfor augmenting the findings of this study in
\ndeveloping evidence based approach to the
\nreview of regulators.
\nIn recent years, at least in the nurse regula-
\ntory space some attempts have been made
\nto identify and use more robust, reliable
\nand valid performance metrics. Benton et al
\n[23] in their global Delphi study identified
\na multi-dimensional framework for the per-
\nformance assessment of nurse regulators. In-
\ndeed, this framework was subsequently used
\nby Clarke et al [24] across five different disci-
\nplines (medicine, dentistry, midwifery, nurs-
\ning and pharmacy) in Cambodia to bench-
\nmark and contrast their relative performance
\nas a means of seeking opportunities for qual-
\nity improvement. More specific interest into
\naddressing the question of to what extent
\nare the administrative structures of regula-
\ntory boards having an impact of efficiency,
\neffectiveness and public safety is also being
\naddressed [25].The work of the Washington
\nState Care Quality Assurance Commission
\n[26], North Carolina General Assembly
\n[27], Benton et al [25], and Benton and Ra-
\njwany [16] are all congruent with the wider
\nrecommendations of the Organization for
\nEconomic Co-operation and Development
\n[17] highlighting the advantages in terms of
\neffectiveness of assuring the independence of
\nregulatory bodies who advocate for a proac-
\ntive approach to performance review.
\nConclusions
\nThis study demonstrates that Baetjer [12]
\nview of regulators being unregulated is far
\nfrom the truth.There is already a wide range
\nCoverage
\nSpecific
\n\u2022\u2002
\nComplaints
\n\u2022\u2002
\nRegulatory Impact
\nAssessment
\n\u2022\u2002
\nPeer Review
\n\u2022\u2002
\nFreedom of Information
\nRequest
\n\u2022\u2002
\nBenchmarks with Best
\nPractices
\n\u2022\u2002
\nJudicial Reviews
\n\u2022\u2002
\nMedia Reports
\n\u2022\u2002
\nBoard Appointments\/
\nRemovals
\n\u2022\u2002
\nAudit Reports
\n\u2022\u2002
\nCEO Appointments
\n\u2022\u2002
\nOrganizational Competence\/
\nScope
\nGeneral
\n\u2022\u2002
\nAnnual Reports
\n\u2022\u2002
\nParliamentary Committees
\n\u2022\u2002
\nLay Board Member
\nAppointments
\n\u2022\u2002
\nConsultation Requirements
\n\u2022\u2002
\nGiving Reasons for decisions
\n\u2022\u2002
\nPublishing Minutes
\n\u2022\u2002
\nWebcasting meetings
\n\u2022\u2002
\nMinisterial\/Governor
\nDirection
\n\u2022\u2002
\nFunding Control
\n\u2022\u2002
\nSunset Reviews
\n\u2022\u2002
\nSuper-Regulators
\nWeak Strong
\nImpact
\nFigure 2.\u2002 Current Approaches to Holding Regulators to Account
\nHealth Care UNITED STATES OF AMERICA
\n7
\nBACK TO CONTENTS
\nof tools being used. However, we agree with
\nBaetjer [12] in his contention that there is,
\nas yet, no robust and consistent approach to
\nregulatory performance review. Variabilities
\nin approach, frequency and measures re-
\nsult in a sub-optimum patchwork of find-
\nings. Despite there being a wide range of
\napproaches to the regulation of regulators
\nthere is currently a paucity of evidence on
\nthe relative effectiveness and efficiency of
\nthese methods. Regulators both within the
\nsame discipline, across jurisdictions, as well
\nas those from different disciplines, within
\nthe same jurisdiction, need to collaborate to
\nstandardize performance metrics. Such col-
\nlaborations could generate data collection
\nmethods that subsequently could offer the
\nbasis for the identification of best practices
\nto optimize and systemize the pursuit of
\nregulatory excellence. Accordingly, if regu-
\nlators are to live up to the changing require-
\nments of acting in the public interest, they
\nmust show leadership in this agenda. By
\ndesigning robust reliable and valid metrics,
\ntransparency and accountability can be en-
\nhanced and vulnerability to political whims
\npotentially reduced.
\nThe authors wish to thank Dr M\u00e1ximo
\nGonz\u00e1lez-Jurado and Dr. Juan Beniet-Mon-
\ntisinos for the helpful comments on the design
\nof this study.
\nReferences
\n1.\t Uden, J. (2015) The invisible satirist: Juvenal and
\nsecond century Rome. Oxford, Oxford Univer-
\nsity Press.
\n2.\t Australian National Audit Office, (2014) Ad-
\nministrating Regulation: Achieving the right
\nbalance. Barton, ACT, Australian National
\nAudit Office. https:\/\/www.anao.gov.au\/sites\/g\/
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\n4.\t Balthazard, C. (2017) Measuring the per-
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\nToronto, Human Resources Professional As-
\nsociations https:\/\/www.hrpa.ca\/Documents\/
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\n5.\t Department of Health, (2017) Promoting Pro-
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\n7.\t Smith,J.(2005) The Shipman Inquiry: Sixth and
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\n8.\t Soothill, K., Peelo, M., Francis, B., Pearson,
\nJ.\u00a0 Ackerley, E. (2002) Homicide and the me-
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\n9.\t Bouwman, R., Bomhoff, M., de Jong, J.D., Ron-
\nnen, P., Friele, R. (2015) The public\u2019s voice about
\nhealthcare quality regulation policies. A\u00a0 pop-
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\nResearch. 15:325, 1-9. https:\/\/bmchealthservres.
\nbiomedcentral.com\/track\/pdf\/10.1186\/s12913-
\n015-0992-z
\n10.\tHutcheson, J.S. (2016) Scandals in health-care:
\ntheir impact on health policy and nursing. Nurs-
\ning Inquiry. 23:1, 32-41.
\n11.\tDepartment of the Treasury Office of Economic
\nPolicy, the Council of Economic Advisors and
\nthe Department of Labour, (2015) Occupa-
\ntional Licensure: A framework for Policymakers.
\nWashington, DC. The White House. https:\/\/
\nobamawhitehouse.archives.gov\/sites\/default\/
\nfiles\/docs\/licensing_report_final_nonembargo.
\npdf
\n12.\tBaetjer, H. (2015) Regulating Regulators: Gov-
\nernment Vs Markets. Cato Journal 5:3, 627-656.
\n13.\tThomas, D.R., (2006) A general inductive ap-
\nproach to analyzing qualitative evaluation data.
\nAmerican Journal of Evaluation. 27:2, 237-246.
\n14.\tWesley J.J. (2009) Analyzing Qualitative Data.
\nIn Explorations: A Navigator\u2019s Guide to re-
\nsearch in Canadian political science. Ed. Archer,
\nK. and Youngman B., 2nd Ed. Toronto, Oxford
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\n15.\tTashakkori, A. and Teddie, C. (2003) Handbook
\nof Mixed Methods in Social and Behavioural Re-
\nsearch.Thousand Oaks, CA, Sage Publications.
\nFigure 3.\u2002 Changing Features of Acting in the Public Interest
\nHealth Care
\nUNITED STATES OF AMERICA
\n8
\nHealth Care
\n16.\tBenton, D. Rajwany, N. (2017) Protecting the
\npublic through NPDB and Nursys\u00ae compli-
\nance: an exploratory analysis. Journal of Nursing
\nRegulation. 7:4, 46-51.
\n17.\tOrganization for Economic Co-operation and
\nDevelopment (2017) The Governance of Regu-
\nlators: Creating a culture of Independence\u00a0 \u2013
\npractical guidance against undue influence.
\nParis, Organization for Economic Co-operation
\nand Development
\n18.\tBaugus, B, Bose, F. (2015) Sunset legislation in
\nStates: Balancing the legislature and the execu-
\ntive. Mercatus Research: George Mason Univer-
\nsity, VA. https:\/\/www.mercatus.org\/system\/files\/
\nBaugus-Sunset-Legislation.pdf
\n19.\tHudspeth, R (2009) Regulatory Issues: Boards
\nof Nursing: Commitment to Regulatory Excel-
\nlence. Nursing Administration Quarterly. 33(2),
\n188-9.
\n20.\tVeloso, L., Freire, J., Lopes, N., Oliveira, L.
\n(2015) Regulation, public interest and research
\nin the professional field: The case of the health
\nsector. Journal of Sociology. 51:4, 903-916.
\n21.\tAdams, T.L. (2016) Professional Self-Regu-
\nlation and the Public Interest in Canada. Pro-
\nfessions & Professionalism 6(3), 1-15. http:\/\/
\ndx.doi.org\/10.7577\/pp.1587
\n22.\tBenton, D.C. (2017) Bibliometric Review:
\nIdentifying Evolving and Emergent Regula-
\ntory Trends. Journal of Nursing Regulation. 8(2)
\nSupplement, S5-S14.
\n23.\tBenton, D.C., Gonz\u00e1lez-Jurado, M.A., Beniet-
\nMontisinos, J.V., (2013) Defining nurse regula-
\ntion and regulatory body performance: A policy
\nDelphi Study. International Nursing Review.
\n60:3, 303-312.
\n24.\tClarke, D., Duke, J., Wuliji, T., Smith, A.,
\nPhuong, K. San, U. (2015) Strengthening health
\nprofessions regulation in Cambodia: a rapid as-
\nsessment. Human Resources for Health 14:9,
\n1-9. https:\/\/human-resources-health.biomed-
\ncentral.com\/track\/pdf\/10.1186\/s12960-016-
\n0104-0
\n25.\tBenton, D., Brekken, S. Ridenour, J. & Thomas,
\nK. (2016) Comparing performance of umbrella
\nand independent nursing boards: An initial re-
\nview.Journal of Nursing Regulation.7(3),52-57.
\n26.\tWashington State Care Quality Assurance
\nCommission (2012) 1103 Report comparison of
\nperformance outcomes. Olympia, WA: Author.
\nRetrieved from www.doh.wa.gov\/Portals\/1\/
\nDocuments\/Pubs\/631041NCQAC.pdf
\n27.\tNorth Carolina General Assembly (2014) Oc-
\ncupational licensing agencies should not be cen-
\ntralized, but stronger oversight is needed. Final
\nreport to the Joint Legislative Program Evalu-
\nation Oversight Committee. Raleigh, NC: Pro-
\ngram Evaluation Division of the North Carolina
\nGeneral Assembly. Retrieved from www.ncleg.
\nnet\/PED\/Reports\/documents\/OccLic\/OccLic_
\nReport.pdf
\nDavid C Benton PhD RGN FRCN FAAN
\nChief Executive Officer
\nNational Council
\nof State Boards of Nursing
\nUSA
\nJulie George MSN RN FRE
\nExecutive Office
\nNorth Carolina Board
\nof Nursing &
\nPresident
\nNational Council
\nof State Boards of Nursing
\nUSA
\nE-mail: dbenton@ncsbn.org
\nMedical professionals and healthcare prac-
\ntitioners are fundamentally motivated to
\nhelp patients improve their health and limit
\nthe impact of their illness. Achieving this
\nin a way that respects the patient\u2019s dignity,
\nas well as their preferences and values, is
\nPatient-reported Indicator Survey (PaRIS):
\nAligning Practice and Policy for Better Health Outcomes
\nLuke Slawomirski Michael van den Berg Sunita Karmakar-Hore
\n9
\nBACK TO CONTENTS
\nHealth Care
\nthe underlying reason\u00a0 \u2013 and the intrinsic
\nreward\u00a0\u2013 for choosing a profession in the
\nchallenging and demanding field of health-
\ncare.
\nGiven the global trend of increased ex-
\npenditure on health care as a share of na-
\ntional income, it is therefore surprising
\nthat systematic, empirical measurement of
\nthe outcomes and experiences of care from
\nthe patient\u2019s perspective is still the excep-
\ntion in most healthcare systems across the
\nworld [1, 2]. This gap in knowledge limits
\nthe ability for evidence-based policy mak-
\ning and value-based health care, which
\naims to maximise benefits of health care at
\nan acceptable cost (including opportunity
\ncost of alternative investment of these re-
\nsources).
\nThis knowledge-gap impacts medical prac-
\ntice in two crucial and related ways. First,
\nhealthcare providers lack information on
\nthe effect of their work on factors valued by
\ntheir patients such as pain, function, inde-
\npendence, and being treated with compas-
\nsion and respect. Second, this lack of in-
\nformation is a missed opportunity to frame
\nclinical activity around the person in front
\nof you\u00a0\u2013 to ask \u2018what matters to you\u2019? rather
\nthan \u2018what\u2019s the matter with you?\u2019 [3] Bet-
\nter information on outcomes and experi-
\nences of care is also needed by policy mak-
\ners trying to reorient the healthcare system
\nto meet the needs and expectations of the
\ncommunities it serves.
\nIn this paper we seek to describe the cur-
\nrent shortcomings of measurement in
\nhealth care, what changing this means for
\nmedical practitioners, and how the Patient-
\nReported Indicator Survey (PaRIS)\u00a0\u2013 a new
\nOECD initiative\u00a0\u2013 can help health profes-
\nsionals measure what matters to their pa-
\ntients.
\nOutcome Measures
\nMiss a Very Important
\nPerspective: the patient\u2019s
\nMedicine is fundamentally a scientific en-
\ndeavour and, like all sciences, based on em-
\npirical measurement and observation.Many
\nmetrics are collected in health care but not
\nalways those that tell us about of the impact
\nof care on patients\u2019 lives.The problems with
\ntraditional measurement in health can be
\ndistilled to three concerns.
\nOne: we confuse outputs with
\noutcomes
\nThe number of procedures performed or
\ndrugs prescribed are commonly measured.
\nBut these describe outputs not outcomes.
\nWhile they have their use in some contexts,
\nthey are inconsequential to the outcomes of
\ninterventions.
\nFor example, the age-adjusted rate of total
\nknee replacements in OECD countries has
\nmore than doubled since the year 2000, ris-
\ning from 55 to 119 per 100,000 population
\n(Figure 1). Rates vary more than 4-fold
\nbetween countries, and similar variation is
\nalso observed within countries by hospital
\nor geographic region [4]. Such differences
\nprovoke questions about the value gener-
\nated for patients, and for communities that
\npay for these procedures, which are expen-
\nsive, involve a lengthy and painful recovery
\nperiod, and are not without risk. Which
\nrates are justified by commensurate patient
\noutcomes compared to other treatment
\nmodalities? What proportion of patients
\nexperience an acceptable improvement in
\ntheir pain and symptoms? How many ex-
\nperience improved mobility, and to what
\nextent? In the majority of countries we
\ndo not know. A recent US study of about
\n4,000 patients who underwent total knee
\nreplacement suggests that most experience
\nno improvement in their symptoms [5].
\nBut systematic data across entire healthcare
\nsystems are rare.
\nReadmission and revision rates following
\nknee replacement\u00a0\u2013 outcomes that most pa-
\ntients wish to avoid\u00a0\u2013 are often measured
\nbut shed little light on the other important
\noutcomes: less pain and better function.
\nThese data can\u2019t be harvested from admin-
\nistrative information systems but must be
\nFigure 1.\u2002 Total knee replacement rates per 100,000 population in selected OECD
\ncountries and the all-OECD age-adjusted average, 2000\u20132015
\nSource: https:\/\/stats.oecd.org
\nNote: National average of 29 OECD countries adjusted for increased life expectancy (reference year: 2000)
\n10
\ncollected from patients themselves, and
\nare needed to answer important questions
\nabout effectiveness and value.
\nTwo: \u2018hard\u2019 outcome metrics
\nhave their limits
\nCertain outcome measures, while useful
\nand informative in some instances, are too
\nblunt to capture the subtle effects of many
\nmedical interventions. For example, in ad-
\ndition to readmission and surgical revision
\nmetrics, mortality outcomes are commonly
\nused in some sectors and specialties. Pa-
\ntient suicide is an important sentinel met-
\nric, but only one of several indicators to
\nhelp us understand how well mental health
\nprograms are working. Patient-reported
\nanxiety and depression, sleep quality and
\nsocial health status are softer but equally
\nimportant metrics that should be collected
\nsystematically to inform practice and pol-
\nicy.
\nSurvival or mortality rates are tradition-
\nally deployed as the prevailing outcomes
\nfor many pathologies. But these lack the
\ngranularity and responsiveness to tell us
\nhow well treatments are working at the
\nindividual level. People diagnosed with
\ncancer highly value surviving the dis-
\nease\u00a0\u2013 but when these patients and their
\nfamilies are asked, it is clear that thera-
\npeutic \u2018success\u2019 entails more: pain control,
\nretaining independence, ability to sleep
\nand perform normal activities of daily liv-
\ning [6, 7]. Yet, measuring the effectiveness
\nand the value of cancer treatment rarely
\nextends beyond mortality [8], despite the
\nconvergence on these measures in recent
\nyears (Figure 2). In a growing number of
\npathologies survival lacks sufficient sensi-
\ntivity to differentiate between therapies,
\nregions, hospitals or other units of mea-
\nsurement\u00a0\u2013 little separates the best from
\nthe rest [9, 10, 11].
\nThis evolution is also a cause for celebra-
\ntion\u00a0 \u2013 modern medicine has become so
\ngood at treating this disease that it now
\nlimits how much we can learn from mortal-
\nity statistics. To explore the full impact of
\ntreatment on the patient, other outcomes
\nneed to be considered. Men with prostate
\ncancer, for example, place high value in
\npreserving erectile function and avoiding
\nincontinence\u00a0 \u2013 outcomes for which the
\nsurvival metric cannot capture and which
\nrequire direct input from the patient [12].
\nOther outcomes valued by patients re-
\nceiving treatment for a range of acute and
\nchronic conditions include self-rated health
\nstatus, fatigue, limitations on daily activities
\nand bodily functions.
\nThree: the patient experience
\nmatters more and more
\nThe experience of care is important for all
\npatients, especially the growing cohort with
\nmultiple chronic conditions who need to
\nmanage their health over time and with the
\nhelp of a range of healthcare providers. The
\ncare experience includes being treated with
\nrespect and compassion, being supported,
\nlistened to and involved in decision making;
\nit also means that care is integrated across
\nteams who communicate with each other
\nand with the patient. A good experience of
\ncare is an important end in itself especially
\nfor patients with complex health needs for
\nwhom navigating a fragmented health sys-
\ntem is challenging, frustrating, time con-
\nsuming and costly.
\nA positive care experience is also associ-
\nated with better clinical outcomes, and is a
\nstrong signal of a well-run healthcare prac-
\ntice or organisation [13, 14, 15]. While in
\nsome sectors of care, such as palliative and
\nend of life care, dimensions of the care ex-
\nperience\u00a0 \u2013 compassion, dignity, respect of
\npatient and family wishes\u00a0\u2013 arguably com-
\nprise the most important, alongside pain
\ncontrol, for patients and their loved ones.
\nWhile considerable progress has been made
\nin some places, the care experience is not
\ncaptured systematically or routinely com-
\npared to other healthcare metrics.
\nPatient-reported measures
\nare an opportunity to
\nimprove practice and
\noptimise results
\nPatient-reported outcomes and experience
\nmeasures\u00a0 \u2013 PROMs and PREMs\u00a0 \u2013 can
\nenable clinicians to improve their practice,
\ncommunication and outcomes in several
\nways [16]. Nevertheless, many practioners
\nare anxious about collecting these data from
\ntheir patients and about the way in which
\nthese data may be used. In our discussions
\nwith providers, practical and professional
\nFigure 2.\u2002 Age-standardised mortality from cancer, 2013
\nSource: https:\/\/stats.oecd.org\/
\nHealth Care
\n11
\nBACK TO CONTENTS
\nissues are often cited including additional
\nclinical and administrative burden, the va-
\nlidity and reliability of these metrics, their
\nuse in pay-for-performance (P4P) schemes,
\nand the jettisoning of useful existing met-
\nrics.
\nPatient-reporting can
\nimprove clinical practice
\nCollecting PREMs and PROMs may
\nseem like additional work for providers.
\nHowever, given the benefits, it should
\nnot be viewed that way. Rather, collecting
\nthese data should be seen as part of good
\npractice\u00a0 \u2013 as routine as taking a sound
\nhistory and vital signs. PROMs especially
\ncan add more structure and rigour to the
\noral history during initial and subsequent
\nconsultations, yielding valuable clinical
\ninformation that enables care tailored
\nto individual patient needs, especially in
\ncomplex cases. One randomised study
\nfound that during chemotherapy, regu-
\nlar patient-reporting of symptoms such
\nas pain and nausea was associated with
\nsignificant reductions in emergency de-
\npartment visits, better quality of life and
\nlonger survival [17, 18].
\nShared clinical decision making can be dif-
\nficult for providers and patients, even for
\npatients with higher socioeconomic sta-
\ntus [19]. PROMs and PREMs can enable
\nmore effective partnering between pro-
\nviders and their patients, particularly for
\npreference-sensitive care [20, 21]. Deci-
\nsions may also be based on aggregated out-
\ncomes and experiences of other patients.
\nAs a result, clinical conversations change,
\nand care cycles pivot to what patients
\nneed and prefer. Aggregated PREMs and
\nPROMs data are also an opportunity to
\nmonitor and improve practice and policy
\nat a system level over time, through mean-
\ningful benchmarking across organisations
\n[22]. The data can be used to develop and
\nupdate clinical guidelines and decision-
\nsupport tools.
\nRather than increasing clinical workload,
\njurisdictions implementing routine PREMs
\nand PROMs collection are reporting that
\nthis can actually streamline clinical pro-
\ncesses and the flow of information [23, 24,
\n25]. Data submitted by the patient prior
\nto a consultation identifies in a structured
\nand consistent way their clinical status and
\nneeds.This information is useful for triaging
\npatients, and better preparing the clinical
\nteam. Using digital tools like smartphone
\napps or web portals can further streamline
\nthis process, and enable the patient to pro-
\nvide their data at their convenience. Link-
\nage with electronic health records means
\nthat information is delivered directly to the
\npractitioner\u2019s desktop with minimal delay
\n[26].
\nNevertheless we do acknowledge that the
\nnumber of metrics collected by provid-
\ners are has grown over the years. Calls
\nare heard to modernise data collection
\nmethods, improve information feedback
\nto providers and patients in addition to
\nrationalising the amount of measurement
\nrequired and to focus on what truly mat-
\nters [27]. However, we would argue that
\nPREMs and PROMs are indispensable
\nmetrics that should be routinely collected.
\nUse of the right state-of-the-art technol-
\nogy could greatly reduce administrative
\nburden, and with enough interest and
\ninvestment data collection could become
\npartly automated in the future. For exam-
\nple, a patient\u2019s mobility can be uploaded
\nfrom a wearable device or smartphone,
\nrather than manually reported in paper or
\nelectronic form. This would not only re-
\nduce the burden but also boost the quality
\nof the data.
\nPatient-reported measures
\nare valid and robust
\nThe validity and the sensitivity of PREMs
\nand PROMs is often questioned as is their
\nability to discern the influence of a clini-
\ncal intervention from other factors that
\ninfluence outcomes. On the first point, the
\ndevelopment and validation of the various
\ntools to measure outcomes and experience
\nfrom patients is decades old. PROMs have
\nundergone rigorous psychometric test-
\ning and statistical validation, with results
\npublished in the peer-reviewed literature.
\nThe evidence for disease-specific and ge-
\nneric tools measuring what is intended in
\na valid and objective way is sound [28].
\nData are collected at various time points
\nthroughout a patient\u2019s care, or pre- and
\npost-intervention, reducing recall bias by
\neliciting responses for the various dimen-
\nsions and outcomes of interest at the time
\nof reporting. PROMs instruments for a
\nspecific condition or intervention seek
\nscaled responses in the relevant dimensions
\n(e.g. pain, anxiety, function and mobility)
\nin a standardised, unambiguous way. Many
\nhave been translated into various languages
\nand validated across a number of countries,
\nin order to take linguistic and culture nu-
\nances into consideration.
\nPREMs also are now sophisticated and
\nsensitive, beyond the patient \u2018satisfac-
\ntion\u2019 surveys that many providers may
\nhave encountered in the past. They elicit
\nscaled data across a range of dimensions
\nincluding accessibility, communication,
\ncontinuity and confidence. These data
\nare now used to inform assessment and
\ninternational comparisons of health sys-
\ntems [29].
\nSome factors that influence the outcomes of
\ncare\u00a0\u2013 patient behaviour, adherence to treat-
\nment as well as age and comorbidities\u00a0\u2013 are
\nbeyond the clinician\u2019s control. However,
\nthis problem can be attributed to any met-
\nric. Readmission, death and infections are
\nall subject to these confounding variables.
\nSingling out patient-reported measures
\nspecifically in this manner is arbitrary. And
\nlike any data that are reported and bench-
\nmarked, confounders for patient-reported
\nindicators can and should be adjusted for
\nin order to make meaningful comparisons
\n[30]. This is also a way to correct for differ-
\nHealth Care
\n12
\nent response-tendencies between groups of
\npatients.
\nThe goal is to facilitate
\nlearning and improvement
\nOn the question of P4P, collecting and re-
\nporting these data would help learning and
\nimprovement. P4P is being tested in many
\nhealthcare systems, but the evidence on
\nwhat financial incentives work best in im-
\nproving \u2018performance\u2019 is not clear-cut [31].
\nNumerous reasons exist for this. As previ-
\nously noted, a fundamental motivation for
\nmedical practitioners is the desire to im-
\nprove their patients\u2019 lives. Financial incen-
\ntives are difficult because they often focus
\non individual elements to be rewarded, and
\nmay lead to clinicians focusing on certain
\nelements of their care only, while good care
\nis a product of individual, systemic and or-
\nganisational factors.
\nWith P4P, it is also difficult to reflect the
\ninherent complexities of modern medi-
\ncine which, in highly functioning systems,
\nis the product of an integrated healthcare
\nteam involving numerous practitioners and
\nsupport staff working within and across
\n\u00ad
\norganisational boundaries and communities
\nover time. It has proved difficult to design a
\nscheme that effectively and equitably targets
\nfinancial rewards or penalties [32, 33]. Pro-
\nviding feedback and information on vari-
\nous dimensions of \u2018performance\u2019 stimulates
\ncontinuous improvement across health care
\nteams [34]. This, of course, should include
\ninformation reported by the patients receiv-
\ning care.
\nPatient-reported measures will
\ncomplement\u00a0\u2013 not replace\u00a0\u2013
\nexisting outcome indicators
\nWhile traditional outcome metrics such
\nas mortality or hospital readmission have
\ntheir limitations, they also have an impor-
\ntant place in informing policy and practice.
\nFor many diseases and interventions, these
\nmetrics remain valuable for making clini-
\ncal decisions and monitoring performance.
\nPREMs and PROMs are meant to comple-
\nment\u00a0\u2013 not replace\u00a0\u2013 these important indi-
\ncators.
\nWe also wish to point out that reporting
\nand benchmarking traditional outcome
\nmetrics\u00a0 \u2013 such as standardised mortality
\nrates\u00a0\u2013 were also resisted when first intro-
\nduced. However, with time they have be-
\ncome an accepted outcome measure. The
\nrichness and granularity of health care
\nevaluation would be greatly enhanced by
\nalso including information reported by pa-
\ntients.
\nHow can an international
\ninitiative like PaRIS
\nhelp practitioners?
\nIn January 2017 OECD Health Minis-
\nters met in Paris to discuss the next gen-
\neration of health reforms. These discussions
\nrevealed clear political momentum to pay
\ngreater attention to what matters to pa-
\ntients. The resulting Ministerial Statement
\n[35] calls on health systems to become more
\npeople-centred by developing international
\nbenchmarks of health system performance
\nas reported by patients themselves. The
\nstatement makes clear the nexus between
\nthe core objective of medical professionals
\nand policy makers\u00a0 \u2013 between policy and
\npractice.
\nTaking forward this mandate, the OECD
\nlaunched the Patient Reported Indictor
\nSurvey (PaRIS) initiative. PaRIS aims to
\nbuild international capacity to measure and
\ncompare care outcomes and experiences
\nas reported by patients, using indicators
\nthat enable comparisons across countries.
\nIt also aims to encourage patient-reported
\nmeasures to evolve in a common direction
\ninternationally, to enable shared learning,
\ndevelopment and research.
\nPaRIS hopes to advance
\nby accelerating routine
\nadoption
\nUp to now, routine collection of patient-
\nreported measures has been predominantly
\nled by forward-thinking clinicians and
\nhealth services. Collection of PROMs in
\nspecific conditions like cancer or osteo-
\narthritis is growing in a number of coun-
\ntries. An objective of PaRIS is to support
\ncountries where such initiatives already ex-
\nist to accelerate the routine adoption and
\nreporting of validated, standardised, inter-
\nnationally-comparable patient-reported
\nmeasures, and to disseminate useful learn-
\nings and insights to other countries wishing
\nimplement PROMs. It is also to encourage
\ndevelopment of common metrics and in-
\ndicators that can enable comparisons and
\nlearning at national and international levels.
\nOECD has established international work-
\ning groups comprising clinicians, patients,
\nacademics and policy makers to develop
\npatient-reported indicators suitable for in-
\nternational comparisons in elective arthro-
\nplasty (hip and knee), breast cancer and
\nmental health, with the ambition to report
\ncommence reporting in 2019.
\nAn information gap needs
\nto be addressed
\nThe proportion of people in OECD coun-
\ntries who suffer from one or more chronic
\ncondition is growing. This cohort does not
\nfit neatly into one disease category and most
\nreceive routine follow-up care in primary
\ncare or other ambulatory settings. Often,
\ndifferent providers are involved and people
\nmust navigate fragmented, un-coordinated
\ncare. The result is substandard care, and
\nsystematic data for this group of patients is
\nvirtually non-existent.
\nPaRIS is therefore developing a new in-
\nternational survey on outcomes and ex-
\nperiences of patients with one or more
\nchronic conditions. This new survey will
\nHealth Care
\n13
\nBACK TO CONTENTS
\nmeasure both PROMs and PREMs in-
\ncluding health status, pain, fatigue, func-
\ntion, anxiety and depression, access, com-
\nmunication and care continuity. Indicators
\nwill be selected on the basis of criteria such
\nas reliability, validity, relevance, feasibility
\nand fitness for use. The survey will make
\nvariation within countries visible.Together
\nwith other data, this will help shed light
\non variations in care and how successful
\nhealthcare systems and organisations are in
\nresponding to the needs of this important
\ngroup of patients.
\nA rising tide can lift all boats
\nHow can country-level reporting and
\nbenchmarking of patient-reported indica-
\ntors influence grass roots clinical practice?
\nOECD collects a range of indicators, many
\nof which concern the quality and outcomes
\nof care. Some of these\u00a0\u2013 cancer survival and
\nhospital readmissions\u00a0\u2013 have been discussed
\nabove. The aim of international reporting
\nof these, like any other indicator, is not to
\ncreate league-based tables but to flag areas
\nof care that may need greater examination
\nand drive quality improvement strategies.
\nEach country runs its health system in a
\nunique context, based on its own priori-
\nties, values and resourcing constraints. The
\nvalue of international reporting lies in the
\nprovision of accurate, timely and consistent
\ninformation on a range of structural,process
\nand outcome measures that is critical to the
\neffective governance and functioning of any
\nhealthcare system.
\nPractice and policy should be based on solid
\nevidence and continuous measurement.
\nOECD provides a forum for countries to
\nlearn and to improve the way these data are
\ncollected and indicators are generated. Nu-
\nmerous examples exist where improved data
\ncollection at the country level has generated
\ntangible benefits.
\nThe objective of PaRIS is no different. Its
\naim is to help participating countries build
\ntheir internal capacity to reliably measure
\nthis very important dimension of health
\ncare, and to deploy this information for
\ncontinuous learning and improvement in
\nclinical practice to policy. Countries are
\nat very different stages of implementing
\npatient-reported measures, and PaRIS pro-
\nvides a platform and a set of tools to achieve
\nthe necessary transformation\u00a0\u2013 a rising tide
\nthat can lift all boats.
\nMany outputs are measured and reported in
\nhealth care. However, metrics on improv-
\ning health, limiting the impact of disease
\nand experience of care are currently lack-
\ning. The systematic collection of this infor-
\nmation through PROMS and PREMS is
\nan important lever to meet the needs and
\nexpectations of patients in an increasingly
\ncomplex and challenging environment. The
\nOECD PaRIS initiative aims to help coun-
\ntries institute consistent and reliable col-
\nlection of patient-reported measures across
\ntheir health systems.
\nHealthcare practitioners and providers
\nhave much to gain from collecting and
\nusing patient-reported measures if imple-
\nmented in concert and with proper sup-
\nport from administrators, health system
\nmanagers and policy makers. PROMs and
\nPREMs can and should be part of routine
\npatient care, as a robust way to gather in-
\nformation from patients to better inform
\ntheir clinical care and improve the health
\nsystem for the benefit of patients, providers
\nand societies.
\nDisclaimer: The opinions expressed and ar-
\nguments employed herein are those of the
\nauthor and do not necessarily reflect the of-
\nficial views of the OECD, CIHI, or of the
\ngovernments of OECD\u2019s member coun-
\ntries.
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\ncentre of health care. HuffPost 2017 https:\/\/
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\ndoi:10.1001\/archinternmed.2012.2360
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\ndoi\/epdf\/10.1002\/hec.2999
\n31.\tFrakt AB, Jha AK. Face the Facts: We Need
\nto Change the Way We Do Pay for Perfor-
\nmance. Ann Intern Med. 2018;168:291\u2013292.\u00a0doi:
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\n33.\tOECD. Better ways to pay for health care.
\nOECD Health Policy Studies 2016. Paris
\n34.\tC Cashin, Y-L Chi, PC Smith, M Borowitz,
\nS Thomson: Paying for performance in health
\ncare: implications for health system perfor-
\nmance and accountability, European Observa-
\ntory on Health Systems and Policies Series 2014
\nhttp:\/\/www.euro.who.int\/__data\/assets\/pdf_
\nfile\/0020\/271073\/Paying-for-Performance-in-
\nHealth-Care.pdf
\n35.\tOECD Health Ministerial Meeting, January
\n2017.Minsters\u2019Statement http:\/\/www.oecd.org\/
\nhealth\/ministerial\/ministerial-statement-2017.
\npdf
\nLuke Slawomirski
\nOrganisation for Economic
\nCo-operation and Development
\n(OECD), Paris
\nMichael van den Berg
\nOrganisation for Economic Co-operation
\nand Development (OECD), Paris
\nSunita Karmakar-Hore
\nCanadian Institute for Health
\nInformation (CIHI), Toronto
\nE-mail: luke.slawomirski@oecd.org
\nFollowing the violations of medical ethics
\ncommitted by physicians during the Nazi
\nregime and immediately after the Nurem-
\nberg revelations, the World Medical As-
\nsociation adopted two documents that em-
\nbodied the Hippocratic Oath and asserted
\nthe prohibition of physician complicity in
\nantihumanitarian acts.
\nThe Declaration of Geneva affirms the
\nmedical professional\u2019s pledge \u201cto dedicate
\ntheir lives to the service of humanity\u201dand \u201cto
\nnot use medical knowledge to violate human
\nrights and civil liberties, even under threat\u201d.1
\nThe International Code of Medical Ethics
\nsustains the physician\u2019s duty to provide \u201ccom-
\npetent medical service in full professional
\n1\u2002
\nWMA Declaration of Geneva, 2017. Retrieved
\nfrom https:\/\/www.wma.net\/policies-post\/wma-
\ndeclaration-of-geneva\/ on August 17, 2018.
\nPhysician Complicity in Capital Punishment
\nViolating the ethical obligation to do no harm
\nEthical Aspects of Health Care UNITED STATES OF AMERICA
\n15
\nBACK TO CONTENTS
\nand moral independence, with compassion
\nand respect for human dignity\u201d.2
\nThese documents not only make it explicit
\nthat medicine is a therapeutic and com-
\npassionate field but also that the medical
\nprofessional has a duty to uphold medical
\nethics in the face of contravening laws or
\nregulations. This idea is portrayed clearly in
\nthe WMA Council Resolution in the Re-
\nlation of Law and Ethics.3
\nIt follows then
\nthat physician involvement in the admin-
\nistration of capital punishment is ethically
\nproscribed because it violates the ethical
\nprinciples of the profession.
\nIn the Islamic Republic of Iran, physicians
\nhave been implicated as complicit in the
\nsentencing of persons convicted of crimes
\ncommitted as juveniles (below the age of
\n18) to the death penalty. In June 2018, a
\n2\u2002
\nWMA International Code of Medical Eth-
\nics, 2006. Retrieved from https:\/\/www.wma.net\/
\npolicies-post\/wma-international-code-of-medical-
\nethics\/ on August 17, 2018.
\n3\u2002
\nWMA Council Resolution on the Relation of
\nLaw and Ethics, 2003. Retrieved from https:\/\/
\nwww.wma.net\/policies-post\/wma-council-resolu-
\ntion-on-the-relation-of-law-and-ethics\/ on August
\n17, 2018.
\n19\u2011year old Iranian teenager was executed.
\nHis sentence had been issued based on an
\nofficial medical opinion that he was \u201cmen-
\ntally mature\u201d at the age of 14 when the
\ncrime of which he was convicted had taken
\nplace.In its verdict,the court cited an expert
\nmedical opinion from the Legal Medicine
\nOrganization of Iran, which stated without
\nexplanation that he had gained \u201cfull matu-
\nrity\u201d at the age of 14.4
\nMost crucially, this teenager is the fourth
\nindividual since the beginning of 2018 to
\nbe executed after being convicted of crime
\ncommitted when under the age of 18.There
\nare at least 85 other juvenile offenders who
\ncurrently remain on death row based on
\nmedical maturity assessments.5
\nThe issue of concern is twofold. Firstly, such
\nphysicians are complicit in the administra-
\ntion of capital punishment, which as men-
\ntioned is a direct violation of their ethical
\nduties as medical professionals.
\nSecondly, it is a matter of violating the
\nrights of a child, by both physicians and the
\nIranian government.
\nUnder international law and in accordance
\nwith international principles of juvenile jus-
\ntice, including articles 17.1 and 17.2 of the
\nUnited Nations Minimum Rules for the
\nAdministration of Juvenile Justice (\u201cThe
\nBeijing Rules\u201d) [6] and the International
\nCovenant on Civil and Political Rights6
\nto
\nwhich Iran is a State Party, the use of the
\n4\u2002
\nIran: Teenager\u2019s execution exposes complicity
\nof courts, parliament and doctors in assault on
\nchildren\u2019s rights. Amnesty International Pub-
\nlic Statement, 29 June 2018. Retrieved from
\nhttps:\/\/www.amnesty.org\/download\/Documents\/
\nMDE1386962018ENGLISH.PDF on August
\n17, 2018.
\n5\u2002Ibid.
\n6\u2002
\nInternational Covenant on Civil and Political
\nRights, 1966. Office of the High Commissioner
\nof Human Rights, United Nations. Retrieved
\nfrom https:\/\/www.ohchr.org\/en\/professionalinter-
\nest\/pages\/ccpr.aspx August 17, 2018.
\ndeath penalty against people who were be-
\nlow the age of 18 at the time of the crime
\nthey are convicted of committing is abso-
\nlutely prohibited.
\nThe decision of countries such as Iran to
\ncontinue to administer the death penalty
\namong persons who committed crimes as
\njuveniles is also in direct opposition to the
\nConvention on the Rights of the Child,7
\nwhich Iran has ratified. This Convention
\nwrites: State parties shall ensure that: No
\nchild shall be subjected to torture or other
\ncruel, inhuman or degrading treatment or
\npunishment.
\nIt should be noted that this interpretation
\ndepends on what one considers capital
\npunishment to be. If we are to consider the
\ndeath penalty as torture or inhuman treat-
\nment, then it is not only in violation of the
\nRights of the Child, but it is also in viola-
\ntion of the Universal Declaration of Hu-
\nman Rights, which explicitly dictates under
\nArticle 5 that \u201cno person shall be subjected
\nto torture or to cruel, inhuman or degrading
\ntreatment or punishment\u201d.8
\nNevertheless, the Universal Declaration of
\nHuman Rights is non-binding. Countries
\nare not internationally mandated to abide
\nby the provisions of this declaration.
\nIn fact, the Iranian Penal Code in many
\nways is abiding by the tenets of human
\nrights. In relation to juvenile crimes for
\nexample, children who commit crimes are
\nnot immediately subject to execution or the
\ndeath penalty; rather, they are sentenced to
\n7\u2002
\nConvention on the Rights of the Child, 1990.
\nOffice of the High Commissioner for Human
\nRights, United Nations. Retrieved from https:\/\/
\nwww.ohchr.org\/en\/professionalinterest\/pages\/crc.
\naspx on August 17, 2018.
\n8\u2002
\nThe Universal Declaration of Human Rights,
\n1948. United Nations General Assembly. http:\/\/
\nwww.un.org\/en\/ga\/search\/view_doc.asp?symbol=A\/
\nRES\/217(III).
\nRania Mansour
\nEthical Aspects of Health Care
\nUNITED STATES OF AMERICA
\n16
\ncorrectional and rehabilitation measures.9
\nHowever, the age of criminal responsibility
\nfor a child is associated with age of men-
\ntal maturity or puberty under Shari\u2019a Law
\n(and consequently the Iranian Penal Code),
\nwhich is around 9 years of age for girls and
\n15 years for boys. A judge must therefore
\ndecide a juvenile\u2019s sentence based on wheth-
\ner the child was mentally mature at the time
\nthe crime was committed.This maturity as-
\nsessment is made by physicians of the Legal
\nMedicine Organization of Iran.
\nPhysician contribution to this decision by
\nproviding a medical opinion is effectively
\nfacilitating the execution of individuals and
\nconsequently violating international hu-
\nman rights law and their ethical duties as
\nphysicians. As stated in the WMA Resolu-
\ntion on Physician Participation in Capital
\nPunishment10
\n, it is unethical for physicians
\nto participate in capital punishment, in any
\nway, or during any step of the execution
\nprocess.
\nThe World Medical Association, as a rep-
\nresentative of physicians worldwide, has
\n\u00ad
\ncontinuously published Resolutions and
\nDeclarations pertaining to physician in-
\nvolvement in capital punishment.
\nIn 1975, the WMA Declaration of To-
\nkyo11
\ndefined torture as the deliberate,
\n9\u2002
\nIslamic Penal Code of the Islamic Republic of
\nIran\u00a0\u2013 Book Five,2013.Iran Human Rights Doc-
\numentation Center. Retrieved from http:\/\/www.
\niranhrdc.org\/english\/human-rights-documents\/
\niranian-codes\/1000000351-islamic-penal-code-
\nof-the-islamic-republic-of-iran-book-five.html on
\nAugust 17, 2018.
\n10\u2002
\nWMA Resolution on Physician Participation in
\nCapital Punishment, 2008. World Medical As-
\nsociation. Retrieved from https:\/\/www.wma.net\/
\npolicies-post\/wma-resolution-on-physician-partic-
\nipation-in-capital-punishment\/ August 17, 2018.
\n11\u2002
\nWMA Declaration of Tokyo\u00a0\u2013 Guidelines for
\nPhysicians Concerning Torture and other Cruel,
\nsystematic, or wanton infliction of suffer-
\ning by one or more persons acting alone or
\non the orders of any authority. It called on
\nNational Medical Associations to encour-
\nage physicians to continue their profes-
\nsional development training and education
\nin human rights.
\nIn 1997, the WMA Declaration of Ham-
\nburg12
\nencouraged its constituent members
\nto take action so that physicians are held
\naccountable before the law in case of com-
\nplicity in acts of torture, and to protest in-
\nternationally against any pressure to involve
\nphysicians in acts of torture.
\nFollowing global reports in 2009 regarding
\npractices by health professionals indicating
\ntheir direct involvement in the infliction
\nor ill-treatment and participation in inter-
\nrogation processes, the WMA published
\nthe Council Resolution on Prohibition of
\nPhysician Participation in Torture13
\n.
\nInhuman or Degrading Treatment or Punish-
\nment in Relation to Detention and Imprison-
\nment, 2016. World Medical Association. Re-
\ntrieved from https:\/\/www.wma.net\/policies-post\/
\nwma-declaration-of-tokyo-guidelines-for-physi-
\ncians-concerning-torture-and-other-cruel-inhu-
\nman-or-degrading-treatment-or-punishment-in-
\nrelation-to-detention-and-imprisonment\/ August
\n17, 2018.
\n12\u2002
\nWMA Declaration of Hamburg Concerning
\nSupport for Medical Doctors Refusing to Par-
\nticipate in, or to Condone, the use of Torture
\nand other Cruel, Inhuman or Degrading Treat-
\nment, 2017. World Medical Association. Re-
\ntrieved from https:\/\/www.wma.net\/policies-post\/
\nwma-declaration-of-hamburg-concerning-sup-
\nport-for-medical-doctors-refusing-to-participate-
\nin-or-to-condone-the-use-of-torture-or-other-
\nforms-of-cruel-inhuman-or-degrading-treatment\/
\nAugust 17, 2018.
\n13\u2002
\nWMA Council Resolution on Prohibition of
\nPhysician Participation in Torture, 2009. World
\nMedical Association. Retrieved from https:\/\/
\nwww.wma.net\/policies-post\/wma-council-resolu-
\ntion-on-prohibition-of-physician-participation-
\nin-torture\/ August 17, 2018.
\nAlthough the WMA cannot hold its na-
\ntional medical association members respon-
\nsible for the actions, policies, and laws of
\ntheir respective governments,the WMA re-
\nleased a Statement on the United Nations
\nResolution14
\nin 2013 recommending and
\nsupporting the UN GA Resolution 65\/206
\ncalling for a moratorium on the use of the
\ndeath penalty.
\nHowever, National Medical Associations
\nmust also work towards guaranteeing that
\nphysicians are complying with the fun-
\ndamental principles of medical ethics by
\nprohibiting physician involvement in the
\npreparation, facilitation, or participation in
\nexecutions of persons who commit crimes
\nas juveniles.
\nMoving forward, the international commu-
\nnity of physicians and medical professionals
\nmust continue to collectively call upon their
\nIranian colleagues and their organizations
\nto acknowledge a physician\u2019s duty to do no
\nharm. The medical maturity assessments as
\ndescribed in this article and as provided by
\nthe Legal Medicine Organization of Iran,
\nwhereby physicians are using their medical
\nknowledge to violate ethical duties, human
\nrights, and civil liberties, are both: unethical
\nand illegal.
\nRania Mansour BSc MPH Candidate,
\nUniversity of Pennsylvania
\n2018 Intern,
\nWorld Medical Association
\nPhiladelphia, USA
\nE-mail: mrania@pennmedicine.upenn.edu
\n14\u2002
\nWMA Statement on the United Nations Reso-
\nlution for a Moratorium on the Use of the Death
\nPenalty, 2013. World Medical Association. Re-
\ntrieved from https:\/\/www.wma.net\/policies-post\/
\nwma-statement-on-the-united-nations-resolu-
\ntion-for-a-moratorium-on-the-use-of-the-death-
\npenalty\/ August 17, 2018.
\nEthical Aspects of Health Care UNITED STATES OF AMERICA
\n17
\nBACK TO CONTENTS
\nWe are Canadian physicians who are dis-
\nmayed and concerned by the impact\u00a0\u2013 on
\npatients, on doctors, on medical practice\u00a0\u2013
\nof the universal implementation, in our
\ncountry, of euthanasia defined as medical
\n\u201ccare\u201dto which all citizens are entitled (sub-
\nject to the satisfaction of ambiguous and
\narbitrary qualifying criteria). Many of us
\nfeel so strongly about the difficulty of prac-
\nticing under newly prescribed constraints
\nthat we may be forced, for reasons of per-
\nsonal integrity and professional conscience,
\nto emigrate or to withdraw from practice
\naltogether. All of us are deeply worried
\nabout the future of medicine in Canada.
\nWe believe this transformation will not
\nonly be detrimental to patient safety, but
\nalso damaging to that all-important per-
\nception by the public\u00a0\u2013 and by physicians
\nthemselves\u00a0\u2013 that we are truly a profession
\ndedicated to healing alone. Thus, we are
\nalarmed by attempts to convince the World
\nMedical Association (WMA) to change its
\npolicies against physician participation in
\neuthanasia and assisted suicide.
\nNotwithstanding the disavowals of those
\npromoting change of the WMA policies,
\nsuch a change would encourage legalization
\nof the procedures in other countries, and it
\nis certain that this would have a major ad-
\nverse impact on our patients and colleagues
\naround the world. Hence, we believe it is
\nimportant for them to reflect upon our per-
\nspective: that of Canadian physicians who
\nrefuse to kill our patients or to help them
\ncommit suicide, who refuse to facilitate eu-
\nthanasia or assisted suicide by others, and
\nwho practise in a country where such refus-
\nals are widely thought to reflect unaccept-
\nably extreme and unprofessional views. Our
\nperspective has been missing in WMA dis-
\ncussions until now.
\nThe Law
\nIn Canada, the federal government is re-
\nsponsible for criminal law and the prov-
\ninces have jurisdiction over health care and
\nenforcement of criminal law. In 2014, the
\nProvince of Quebec exploited this consti-
\ntutional arrangement by legally redefining
\nend-of-life medical care to include eutha-
\nnasia [1]. The law came into force in De-
\ncember 2015.
\nIn February 2015, the Supreme Court of
\nCanada ruled in Carter v. Canada that phy-
\nsicians may provide euthanasia or assisted
\nsuicide for competent adults who clearly
\nconsent, who have a grievous and irreme-
\ndiable medical condition (including illness,
\ndisease, or disability) that causes enduring
\nand intolerable physical or psychological
\nsuffering, and that cannot be relieved by
\nmeans acceptable to the individual [2]. The
\ncriteria are broader than those specified in
\nthe Quebec statute.
\nThe Criminal Code was amended in June
\n2016 to give effect to the ruling throughout
\nthe country [3]. Quebec law allows only eu-
\nthanasia, and only for someone \u201cat the end
\nof life\u201d who is in an \u201cadvanced state of irre-
\nversible decline in capability\u201d [1]. Similarly,
\nthe Criminal Code states that the natural
\ndeath of the candidate must be \u201creasonably
\nforeseeable\u201d (an undefined term) and repli-
\ncates Quebec\u2019s requirement of an advanced
\nstate of decline. It also specifies that the
\ncandidate\u2019s illness, disease or disability be
\nincurable [3].
\nDetermined patients who do not meet
\nthese requirements because of natural dis-
\nease processes can opt to starve themselves
\nto the point of qualifying for the procedures
\n[4]. This has been denounced as \u201ccruel\u201d and
\nsuggested as a reason to abolish the require-
\nments [5]. Lawsuits underway in British
\nColumbia [6] and Quebec [7] assert the
\nrequirements are unconstitutional.
\nExpanding Access
\nto Euthanasia and
\nAssisted Suicide
\nIf current lawsuits are successful, euthana-
\nsia and assisted suicide will be available as
\na supposed \u201ctreatment\u201d for mental illness,
\nsince not all mental illnesses permanently
\nimpair decisional capacity. Moreover, the
\nSupreme Court did not rule out allowing
\neuthanasia and assisted suicide for reasons
\nbeyond those identified in Carter [2].
\nEuthanasia in Canada: a Cautionary Tale
\nRene Leiva Margaret
\nM Cottle
\nCatherine Ferrier Sheila Rutledge
\nHarding
\nTimothy Lau Terence
\nMcQuiston
\nJohn F Scott
\nEthical Aspects of Health Care
\nCANADA
\n18
\nWithin a year of the ruling, the pressure
\nfor \u201cCarter Plus\u201d had become so great that
\nthe federal government legally commit-
\nted itself to consider allowing euthanasia
\nand assisted suicide for adolescents and
\nchildren, for indications caused by mental
\nillness alone, and by advance directive (for
\nthose who lack capacity, like patients with
\ndementia) [8].
\nIn sum, while the WMA regional meetings
\ndemonstrate there is no appetite for eutha-
\nnasia outside some parts of Europe and the
\nEuropean diaspora, in Canada we have ob-
\nserved that even the prospect of legalization
\nwhets the appetite for it, and the appetite is
\nnot satisfied by legalization alone.
\nThe unreliability of
\nLegal \u201cSafeguards\u201d
\nThe Supreme Court of Canada believed that
\n\u201ca carefully designed and monitored system
\nof safeguards\u201d would limit risks associated
\nwith allowing physicians to kill patients or
\nhelp them commit suicide [2].However,the
\nVulnerable Persons Standard, developed to
\nassist in establishing such safeguards, finds
\ncurrent Canadian law seriously deficient
\n[9]. Even supplemented by provincial and
\nprofessional guidelines, current criteria are
\nso broad as to have permitted lethal injec-
\ntion of an elderly couple who preferred to
\ndie together by euthanasia rather than at
\ndifferent times by natural causes [10].
\nDespite this, only a year after legalization,
\nCanadian Euthanasia and Assisted Suicide
\n(EAS) practitioners were already complain-
\ning about having to meet with patients
\n(perhaps more than once), review their
\noften \u201clengthy and complicated\u201d medical
\nhistories, counsel and overcome resistance
\nfrom family members [11], refer patients
\nto psychiatrists or social workers [12], find
\ntwo independent witnesses to verify the
\nvoluntariness of a patient\u2019s request [13],
\nand manage the \u201cpaperwork and bureau-
\ncracy involved,\u201d[14] such as having to com-
\nplete forms and fax reports to the coroner
\n[13;15].What others see as safeguards, they
\ncharacterized as \u201cdisincentives\u201d to physician
\nparticipation that were creating \u201cbarriers\u201dto
\naccess.
\nDemand for Collaboration
\nEAS practitioners also claimed that there
\nwas \u201ca crisis\u201dbecause so few physicians were
\nwilling to provide euthanasia or assisted
\nsuicide [16]. Their alarm seems to have
\nbeen triggered by a 46.8% increase in EAS
\ndeaths in the second half of the first year of
\nlegalization.Canada\u2019s EAS death rate in the
\nfirst year\u00a0\u2013 about 0.9% of all deaths [17]\u00a0\u2013
\nwas not reached by Belgium for seven to
\neight years [18].
\nHowever, inter-jurisdictional comparisons
\nindicate that, even in the first year of legal-
\nization, more than enough Canadian EAS
\npractitioners were available to meet the
\ndemand [19]. This ought to make coercion
\nof unwilling physicians unnecessary, but
\nprominent, influential and powerful people
\nin Canada disagree.
\nIt is true that nothing in the Criminal
\nCode requires physicians to personally kill
\npatients or help them commit suicide [3].
\nHowever, nothing in the Criminal Code
\nprevents compulsion by other laws or poli-
\ncies. Thus, for example, Canada\u2019s largest
\nmedical regulator demands that physicians
\nwho are unwilling to personally provide eu-
\nthanasia or assisted suicide must collaborate
\nin homicide and suicide by referring pa-
\ntients to colleagues who are willing to do
\nso [20].
\nWe categorically refuse. Such collabora-
\ntion would make us morally responsible
\nfor killing our patients; if not for the Carter
\ndecision, it would make us criminally re-
\nsponsible and liable to conviction for mur-
\nder, just as it still does in most parts of the
\nworld. For refusing to collaborate in killing
\nour patients, many of us now risk discipline
\nand expulsion from the medical profession.
\nHow has this come about?
\nAccess to Euthanasia and
\nAssisted Suicide as Entitlements
\nPart of the explanation is that Canada\u2019s
\nstate-run health insurance system pays for
\n\u201cmedically necessary hospital and physician
\nservices\u201d from public funds. Most Canadian
\nphysicians are independent contractors paid
\nonly for services we provide, but many Ca-
\nnadians now believe we are state employees,
\nand we face an entrenched attitude of en-
\ntitlement. Since taxpayers pay for \u201cmedical-
\nly necessary\u201d health services, many people
\nthink it is unacceptable for physicians to
\nrefuse to provide those [21].
\nAnd what counts as a \u201cmedically necessary\u201d
\nservice? In brief, anything declared to be
\nso by the state. As we have seen, in 2014
\nthe Quebec government redefined medi-
\ncal practice to include euthanasia. Indeed,
\nQuebec deliberately restricted the practice
\nof euthanasia to physicians [1].
\nAccess to Euthanasia
\nand Assisted Suicide
\nas Human Rights
\nThe sponsor of Quebec\u2019s law claimed that
\neuthanasia would remain \u201cvery exceptional\u201d
\n[24]. However, the law also said qualified
\npatients had a right to euthanasia, and the
\nexercise of a right cannot be exceptional.
\nThus, all public health care institutions
\n(residences, long term care facilities, com-
\nmunity health centres and hospitals\u00a0 \u2013 in-
\ncluding palliative care units) are required to
\nprovide or arrange for euthanasia [1]. Even
\nthis, however, has not been enough.
\nMcGill University Health Centre complied
\nwith Quebec law by arranging to transfer
\npatients from the palliative care unit to be
\nlethally injected elsewhere in the facility.
\nEthical Aspects of Health Care CANADA
\n19
\nBACK TO CONTENTS
\nThe Quebec Minister of Health forced eu-
\nthanasia into the palliative care unit, citing
\n\u201cpatients\u2019 lawful right to receive end-of-life
\ncare\u201d [23; 24].
\nQuebec law allows hospices to opt out of
\nproviding euthanasia [1], but when Quebec
\nhospices opted out, the Minister of Health
\ndenounced them for \u201cadministrative funda-
\nmentalism,\u201d declaring their refusal \u201cincom-
\nprehensible.\u201d Notwithstanding the law, a
\nprominent Quebec lawyer urged that their
\npublic subsidies be withdrawn, accused
\nthem of compromising the right of access
\nto care, and warned that allowing refusal
\nwas a slippery slope [25]. A similar situa-
\ntion is also being faced by the hospices in
\nother provinces such as British Columbia
\n[26].
\nQuebec physicians and health care practi-
\ntioners now work in environments charac-
\nterized by an emphasis on a purported \u2018right\u2019
\nto euthanasia. The notion that access to eu-
\nthanasia and assisted suicide is a fundamen-
\ntal human right has spread across Canada
\nsince the Supreme Court of Canada ruling
\nin Carter. We are accused of violating hu-
\nman rights\u00a0\u2013 even called bigots\u00a0\u2013 because
\nwe refuse to kill or collaborate in killing our
\npatients [27].
\nProviding Euthanasia as an
\nEthical\/Professional Obligation
\nLeaders of the medical profession contrib-
\nuted substantially to the legal redefinition of
\neuthanasia as a medical act and to the le-
\ngalization of physician assisted suicide and
\neuthanasia.
\nThe Coll\u00e8ge des m\u00e9decins du Qu\u00e9bec
\n(CMQ) told Quebec legislators that ac-
\ntively causing the death of a patient is \u201ca
\nmedical procedure\u201d for which physicians
\nmust be completely responsible, insisting
\nthat physician assume \u201cthe moral burden\u201d
\nof killing patients [28]. The Federation of
\nGeneral Practitioners of Quebec was ada-
\nmant that only physicians should provide
\neuthanasia [29].
\nThe Canadian Medical Association (CMA)
\nsecured approval of an apparently neutral
\nresolution on euthanasia and assisted sui-
\ncide, supporting both physicians willing to
\nprovide the services and those unwilling
\nto do so [30]. The CMA later told the Su-
\npreme Court of Canada those positions for
\nand against physician participation in eu-
\nthanasia\/assisted suicide were both ethically
\ndefensible, and that its long-standing policy
\nagainst physician participation would be re-
\nvised to reflect support for both views [31].
\nHowever, in 2014, prior to the 2015 Su-
\npreme Court ruling its legalization, the
\nCMA formally approved physician assist-
\ned suicide and euthanasia (subject to legal
\nconstraints) as responses to \u201cthe suffering
\nof persons with incurable diseases.\u201d It clas-
\nsified both practices as \u201cend of life care,\u201d
\nand promised to ensure access to \u201cthe full
\nspectrum\u201d of end of life care (i.e., including
\neuthanasia and assisted suicide) [32]. The
\nSupreme Court cited the CMA\u2019s new policy
\nwhen it struck down the law two months
\nlater [2].
\nBy redefining euthanasia and assisted sui-
\ncide as therapeutic medical services [33],
\nthe CMA made physician participation
\nnormative for the medical profession; refus-
\ning to provide them in the circumstances set
\nout by law became an exception requiring
\njustification or excuse. That is why public
\ndiscourse in Canada has since centred large-
\nly on whether or under what circumstances
\nphysicians and institutions should be al-
\nlowed to refuse to provide or collaborate in
\nhomicide and suicide: hence the \u201clong de-
\nbate\u201d about conscientious objection at the
\nCMA\u2019s 2015 annual meeting to which the
\nCMA Vice-President, Medical Profession-
\nalism referred in his World Medical Journal
\narticle [34].
\nThe CMA Vice-President, Medical Profes-
\nsionalism elsewhere noted that, for years,
\nphysicians opposed to euthanasia and as-
\nsisted suicide have lobbied the CMA to
\nsupport their right to refuse to participate
\nin the procedures. \u201cThey have made tear-
\nful pleas at several CMA General Council
\nmeetings, asking their non-objecting col-
\nleagues to support them and to defend their
\nrights\u201d[35]. We have had to do this precise-
\nly because of the reversal of CMA policy
\nagainst physician participation in euthaniz-
\ning patients, the reclassification of euthana-
\nsia and assisted suicide as medical services,
\nand the insistence that there should be no
\n\u201cundue delay\u201d in providing them [36].
\nTo be fair,our pleading has not been in vain.
\nThe CMA does support physicians who re-
\nfuse to provide or refer for euthanasia and
\nassisted suicide, asserts that the state should
\ndevelop mechanisms to allow patients di-
\nrect access to the services without violating
\nphysicians\u2019 moral commitments, and rejects
\ndiscrimination against objecting practitio-
\nners [36]. But this advice can be ignored
\nand, when it is, Hippocratic practitioners
\nface the state in court and foot the bill for
\nexpensive constitutional challenges [37].
\nFurther, public calls from influential voices
\nhave been heard for those medical students
\nwho are personally opposed to the euthana-
\nsia imperative, to either abandon, or refrain
\nfrom applying for, medical training [38].
\nCanada\u2019s Euthanasia\/
\nAssisted Suicide Regime
\nThe CMA is sincerely convinced that it \u201cdid
\nthe right thing\u201d in shaping the debate and
\nlaw in Canada and that it is on the right
\nside of history.It is urging the WMA to fol-
\nlow its lead [34]. Our colleagues in other
\ncountries thus need to be aware that the
\nEAS regime in Canada is one of the most
\nradical in the world.
\nPatients do not have a \u2018right to euthanasia\u2019
\nin the Netherlands [39] or in Belgium [40],
\nthough long practice inclines the public to
\nthe contrary view [41]. Euthanasia is not
\nEthical Aspects of Health Care
\nCANADA
\n20
\npermitted in either country unless a phy-
\nsician is personally convinced there is no
\nreasonable alternative [42; 43]. Similarly,
\nDutch and Belgian physicians must be per-
\nsonally convinced that a patient\u2019s suffering
\nis intolerable and enduring [42, 43], and
\nBelgian physicians may insist upon criteria
\nbeyond those set by law [42].
\nIn Canada, however, access to euthanasia
\nand assisted suicide is seen as a tax-paid en-
\ntitlement, is described as a \u201cconstitutionally
\nprotected civil and human right\u201d [44], and
\nhomicide and suicide are legally and profes-
\nsionally defined to be therapeutic medical
\nservices. Moreover, a physician\u2019s conviction
\nthat there are other reasonable and effica-
\ncious alternatives is irrelevant; patients can
\ninsist upon lethal injection. Finally, the
\ncriterion of intolerable suffering is entirely
\nsubjective, established unilaterally by the
\npatient.
\nSmall wonder, then, that the onus seems
\nincreasingly to lie on physicians to show
\nwhy euthanasia should be refused, and that
\nhealth care administrators may be more
\nanxious about being accused of \u201cobstructing
\naccess\u201d [45] than about \u201ckilling people who
\nreally ought not to be killed\u201d [46].
\nOnly a year after legalization,Dr.Yves Rob-
\nert, Secretary of the CMQ was alarmed by
\n\u201cthe rapidity with which public opinion
\nseems to have judged [the new law] insuf-
\nficient.\u201d
\n\u201cIf anything has become apparent over the
\npast year, it is this paradoxical discourse
\nthat calls for safeguards to avoid abuse,\u201d he
\nwrote, \u201cwhile asking the doctor to act as if
\nthere were none. \u2026 [W]e sees the emer-
\ngence of pressure demanding a form of
\ndeath \u00e0 la carte,\u201d he warned [47].
\nPatients and Palliative Care
\nAs Hippocratic practitioners, our focus is
\non the good of our patients, avoiding thera-
\npeutic obstinacy and responding to their
\nsuffering with compassion,competence,and
\npalliative care. We are disturbed that the
\nnumber of Quebec practitioners entering
\npalliative care dropped after legalization of
\neuthanasia, and the CMQ and the Quebec
\nSociety for Palliative Care are concerned
\nthat patients are choosing euthanasia be-
\ncause adequate palliative care is unavailable
\n[48].
\nWe are disturbed and grieved by the story
\nof a 25-year-old disabled woman in acute
\ncrisis in an Emergency ward, pressured to
\nconsider assisted suicide by an attending
\nphysician, who called her mother \u201cselfish\u201d
\nfor protecting her [49].
\nWe are disturbed and angered to hear that
\nhospital authorities denied a chronically ill,
\nseverely disabled patient the care he needed,
\nsuggesting euthanasia or assisted suicide in-
\nstead [50].
\nAnd we were astonished to hear that some
\nemergency physicians in Quebec were, for a
\ntime,letting suicide victims die even though
\nthey could have saved their lives. The inci-
\ndents came to light at about the time the
\nQuebec euthanasia law came into force, and
\nthe president of the Association of Quebec
\nEmergency Physicians speculated that the
\nlaw and accompanying publicity may have
\n\u2018confused\u2019 the physicians about their role
\n[51].
\nThese incidents are entirely consistent with
\nthe acceptance of euthanasia and physician
\nassisted suicide and they illustrate grave vio-
\nlations of traditional medical ethics. This is
\nnot coincidental.
\nEuthanasia and the
\nTransformation of
\nMedical Culture
\nCanadian medical leaders learned that, in
\nother jurisdictions, legalizing assisted sui-
\ncide and euthanasia caused \u201cchanges in the
\nmedical culture\u201d leading to \u201cgeneral, overall
\ncomfort\u201d with the law [52].
\nHowever, when emergency physicians re-
\nfuse to resuscitate patients who attempt
\nsuicide and urge disabled patients in crisis
\nto request euthanasia, such \u201cchanges in the
\nmedical culture\u201dare not, in our view, consis-
\ntent with ensuring patient safety, nor with
\nmaintaining the trust essential to preserving
\nthe Hippocratic physician-patient relation-
\nship.
\nAnd when physicians are told to write \u2018natu-
\nral death\u2019instead of \u2018euthanasia\u2019on the death
\ncertificates [53,54]\u00a0\u2013 and, by extension, to
\nmisrepresent facts\u00a0\u2013 \u201cchanges in the medical
\nculture\u201d may make physicians comfortable,
\nbut we do not believe that they will sustain
\ntrust in the medical profession. Even newly
\nreleased federal guidelines for monitoring
\neuthanasia lack any emphasis on prevention
\nof EAS, in favour of merely regulating these
\npractices [55; 56; 57].
\nFinally, when a Jewish nursing home for-
\nbids euthanasia and assisted suicide on its
\npremises out of respect for Jewish beliefs
\nand concern for its residents (who include
\nHolocaust survivors),\u201cchanges in the medi-
\ncal culture\u201d may encourage applause for the
\nEAS practitioner who crept in at night to
\nlethally inject someone [58], but we do not
\napplaud; we are aghast.
\nOur observations and personal experiences
\nover the last two years confirm our belief
\nthat the practice of Hippocratic medicine is
\nfundamentally incompatible with euthana-
\nsia and assisted suicide. Mandating system-
\nwide provision and physician involvement
\nin the practices can be expected to trans-
\nform medical culture, ultimately making
\nHippocratic medical practice impossible.
\nThe WMA regional conferences demon-
\nstrate that the great majority of physicians
\nworldwide agree with us. Nonetheless, it is
\ntrue that some physicians and patients seek
\nEthical Aspects of Health Care CANADA
\n21
\nBACK TO CONTENTS
\neuthanasia or assisted suicide where the
\nprocedures are legal. Supposing that killing
\npeople or helping them to commit suicide
\nmight sometimes be an acceptable response
\nto human suffering (something we do not
\nconcede), how might these demands be ac-
\ncommodated?
\nThe answer is intuitively obvious: with the
\nleast possible disruption of existing long-
\nstanding medical practice. And from this
\nperspective a completely non-medical
\nsolution would be best. Where this is no
\nlonger practicable, law and policy should
\nallow medical practice to remain largely
\nunchanged. Patients have no entitlement;
\npractitioners and institutions have no duty;
\nmedical associations respectfully continue
\nunresolved ethical debates; the amplitude
\nof the phenomena remains proportional to
\nminority demands. The introduction of eu-
\nthanasia in Canada has caused doubt, con-
\nflict and crisis. In our view, new disciplines,
\nnew professions and new methods may
\narise to satisfy new social goals; but not
\nin the name of Medicine. We believe that
\ndoctors, and medical associations, should
\nvigorously defend the successful model
\ninherited from our past. Euthanasia is not
\nmedicine.
\nAs Canadians, we are saddened by this situ-
\nation, but we hope that our experience and
\nobservations will serve as a warning for our
\ncolleagues in other countries, and their pa-
\ntients. Most important: The World Medical
\nAssociation must recognize that accommo-
\ndating the kind of radical change in medical
\nculture underway in Canada is ill-advised.
\nMindful of the legacy of past WMA lead-
\ners, such as former Secretary General, Dr.
\nAndre Wynen, who, based on his personal
\nexperience, stood courageously against any
\nminimization of the dangers of euthanasia
\nto patients and physicians [59], we advise
\nagainst any compromising additions or
\nmodifications to existing WMA declara-
\ntions, and strongly support a full defence
\nof established policy against euthanasia and
\nassisted suicide.
\nReferences
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\nbe-paid-a-premium-for-assisted-deaths\/
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\nvide medically assisted dying? It\u2019s not the money
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\nnasia
\n15.\tLetter from Jesse A. Pewarchuk, MD, FRCPC.
\n\u201cDear referring physician\u201d [Internet]. Undated
\n[cited 2018 Sep 01]. Available from: https:\/\/as-
\nsets.documentcloud.org\/documents\/3884668\/
\nDrletter.pdf
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\nsisted dying over fees [Internet]. The Globe and
\nMail; 2017 Jul 3 [cited 2018 Sep 01]. Avail-
\nable from: https:\/\/www.theglobeandmail.com\/
\nnews\/national\/payment-complications-turning-
\ncanadian-doctors-away-from-assisted-dying\/
\narticle35538666\/
\n17.\tHealth Canada. 2nd Interim Report on Medical
\nAssistance in Dying in Canada [Internet]. Ot-
\ntawa: Health Canada, 2017 Oct [cited 2018 Sep
\n01]. Available from: https:\/\/www.canada.ca\/en\/
\nhealth-canada\/services\/publications\/health-sys-
\ntem-services\/medical-assistance-dying-interim-
\nreport-sep-2017.html
\n18.\tMurphy S. Euthanasia reported in Belgium: sta-
\ntistics compiled from the Commission F\u00e9d\u00e9rale
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\nscience Project. 2017 August [cited 2018 Sep
\n01]. Available from: http:\/\/www.consciencelaws.
\norg\/background\/procedures\/assist018.aspx
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\nEuthanasia practitioners warn of nationwide
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\n\u201ca real problem\u201d [Internet]. Protection of Con-
\nscience Project. 2017 Oct [cited 2018 Sep 01].
\nAvailable from: http:\/\/www.consciencelaws.org\/
\nbackground\/procedures\/assist026.aspx
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\nMedical Assistance in Dying [Internet]. 2017
\nJul [cited 2018 Sep 01]. Available from: https:\/\/
\nwww.cpso.on.ca\/Policies-Publications\/Policy\/
\nMedical-Assistance-in-Dying
\n21.\tLaidlaw S. Does faith have a place in medicine?
\n[Internet]. Toronto Star; 2008 Sep 18 [cited
\n2018 Sep 01]. Available from: https:\/\/www.
\nthestar.com\/life\/health_wellness\/2008\/09\/18\/
\ndoes_faith_have_a_place_in_medicine.html
\nEthical Aspects of Health Care
\nCANADA
\n22
\n22.\tConsultations & hearings on Quebec Bill 52:
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\nGeoffroy, Nathalie Adams) [Internet]. Thursday,
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\nT#075. Available from: http:\/\/www.consciencel-
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\naspx#075
\n23.\tPlante C. MUHC\u2019s assisted death policy re-
\npealed: Barrette [Internet]. Montreal Gazette;
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\nhttps:\/\/montrealgazette.com\/news\/quebec\/
\nmuhcs-assisted-death-policy-repealed-barrette
\n24.\tPlante C. Barrette chastises MUHC over policy
\nnot to provide medically assisted death [In-
\nternet]. Montreal Gazette; 2016 Jul 05 [cited
\n2018 Sep 01]. Available from: https:\/\/montre-
\nalgazette.com\/news\/quebec\/barrette-chastises-
\nmuhc-administration-over-policy-not-to-pro-
\nvide-medically-assisted-de
\n25.\tLacoursi\u00e8re A, Gagnon K. Maisons de Soins
\nPalliatifs: Le financement pourrait \u00eatre remis en
\nquestion, croit un expert [Internet]. La Presse;
\n2018 Sep 03 [cited 2018 Sep 01].Available from:
\nhttp:\/\/plus.lapresse.ca\/screens\/62045f35-5443-
\n4333-b9ba-6e5d3427c90b|yNd_68fPrlvF.html
\n26.\tA hospice must provide a medically-assisted
\ndeath if a patient asks: Fraser Health [Inter-
\nnet]. Global News; 2018 Feb 07 [cited 2018
\nSep 01]. Available from: https:\/\/globalnews.
\nca\/news\/4012677\/hospices-medically-assisted-
\ndeath-fraser-health\/
\n27.\tAttaran A. Doctors can\u2019t refuse to help a patient
\ndie\u00a0\u2013 no matter what they say [Internet]. iPoli-
\ntics; 2015 Nov 13 [cited 2018 Sep 01]. Available
\nfrom: http:\/\/ipolitics.ca\/2015\/11\/13\/doctors-
\ncant-refuse-to-help-a-patient-die-no-matter-
\nwhat-they-say\/
\n28.\tConsultations & hearings on Quebec Bill 52:
\nCollege of Physicians of Quebec (Dr. Charles
\nBernard, Dr. Yves Robert, Dr. Michelle March-
\nand) [Internet]. 2013 Sep 17 [cited 2018 Sep
\n01]\u00a0\u2013 Vol.43 no.34.Available from: http:\/\/www.
\nconsciencelaws.org\/background\/procedures\/as-
\nsist009-001.aspx#121
\n29.\tConsultations & hearings on Quebec Bill 52:
\nFederation of General Practitioners of Quebec
\n(Dr. Louis Godin, Dr. Marc-Andr\u00e9 Asselin)
\n[Internet]. 2013 Sep 17 [cited 2018 Sep 01]\u00a0\u2013
\nVol. 43 no. 34. Available from: http:\/\/www.
\nconsciencelaws.org\/background\/procedures\/as-
\nsist009-002.aspx – 084
\n30.\tCanadian Medical Association, 147th General
\nCouncil Delegates\u2019 Motions: End-of-Life Care:
\nMotion DM 5-6 [Internet]. 2014 Aug 15 [cited
\n2018 Sep 01]. Available from: https:\/\/www.
\ncma.ca\/Assets\/assets-library\/document\/en\/GC\/
\nDelegate-Motions-end-of-life.pdf
\n31.\tMurphy S. Re: Joint intervention in Carter v.
\nCanada\u00a0\u2013 Selections from oral submissions. Su-
\npreme Court of Canada, 15 October 2014. Harry
\nUnderwood (Counsel for the Canadian Medical
\nAssociation) [Internet]. Protection of Conscience
\nProject; Undated [cited 2018 Sep 01]. Available
\nfrom: http:\/\/consciencelaws.org\/law\/commen-
\ntary\/legal073-009.aspx#Harry_Underwood
\n32.\tCanadian Medical Association. Policy: Eutha-
\nnasia and Assisted Death (Update 2014) [Inter-
\nnet]. 2014 [cited 2018 Sep 01]. Available from:
\nhttps:\/\/www.cma.ca\/Assets\/assets-library\/docu-
\nment\/en\/advocacy\/EOL\/CMA_Policy_Eutha-
\nnasia_Assisted%20Death_PD15-02-e.pdf
\n33.\tDoctor-assisted suicide a therapeutic service,
\nsays Canadian Medical Association [Internet].
\nCBC News; 2016 Feb 06 [cited 2018 Sep 01].
\nAvailable from: http:\/\/www.cbc.ca\/news\/health\/
\ndoctor-assisted-suicide-a-therapeutic-service-
\nsays-canadian-medical-association-1.2947779
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\n01]; 63(3):6-9. Available from: https:\/\/lab.ar-
\nstubiedriba.lv\/WMJ\/vol63\/october-2017\/
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\ncians\u2019 Alliance against Euthanasia; 2018 Apr 30
\n[cited 2018 Sep 01]. Available from: https:\/\/
\ncollectifmedecins.org\/en\/dr-blackmer-blog-
\nresponse\/
\n36.\tThe Canadian Medical Association describes
\neuthanasia and physician assisted suicide as
\n\u201clegally permissible medical service[s]\u201d [Inter-
\nnet]. Canadian Medical Association. Medical
\nAssistance in Dying; 2017 May [cited 2018
\nSep 01]. Available from: https:\/\/www.cma.ca\/
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\ning_pd17-03-e.pdf
\n37.\tMcKeen A.Doctors challenge Ontario policy on
\nassisted-death referrals: Physicians go to court
\nover requirement to send patients to other doc-
\ntors if they don\u2019t want to provide medical assis-
\ntance in dying [Internet].Toronto Star; 2017 Jun
\n13 [cited 2018 Sep 01]. Available from: https:\/\/
\nwww.thestar.com\/news\/gta\/2017\/06\/13\/group-
\nof-doctors-challenge-policy-requiring-referral-
\nto-services-that-clash-with-morals.html
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\nCanadian doctors, urge ethicists in volatile com-
\nmentary [Internet]. National Post; 2016 Sep 22
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\nnationalpost.com\/health\/ban-conscientious-
\nobjection-by-canadian-doctors-urge-ethicists-
\nin-volatile-commentary
\n39.\tde Jong A, van Dijk G. Euthanasia in the Neth-
\nerlands: balancing autonomy and compassion.
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\nable from: https:\/\/lab.arstubiedriba.lv\/WMJ\/
\nvol63\/october-2017\/
\n40.\tDe Hert M, Van Bos L, Sweers K, Wampers
\nM, De Lepeleire J, Correll CU. Attitudes of
\nPsychiatric Nurses about the Request for Eu-
\nthanasia on the Basis of Unbearable Mental
\nSuffering (UMS) [Internet]. PLoS One. 2015
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\nable from: http:\/\/journals.plos.org\/plosone\/
\narticle?id=10.1371\/journal.pone.0144749
\n41.\tDescribed by the Royal Dutch Medical As-
\nsociation as a \u201ccommon misconception.\u201d
\nRoyal Dutch Medical Association [Konin-
\nklijke Nederlandsche Maatschappij tot be-
\nvordering der Geneeskunst (KNMG)].
\nThe Role of the Physician in the Voluntary
\nTermination of Life [Internet]. Utrecht,
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\nnl\/web\/file?uuid=b55c1fae-0ab6-47cb-a979-
\n1970e6f60ae6&owner=5c945405-d6ca-4deb-
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\nSuicide (Review Procedures) Act [Internet].
\n2002 Apr 01 [cited 2018 Sep 01]. Available
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\ndesa2002.pdf
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\n2002 [Internet]. Ethical Perspectives 9 (2002)
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\nable from: http:\/\/www.ethical-perspectives.be\/
\nviewpic.php?TABLE=EP&ID=59
\n44.\tA.B. v Canada (Attorney General) [Internet].
\n2017 ONSC 3759 (CanLII). 2017 Jun 19 [cited
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\ncanlii.org\/en\/on\/onsc\/doc\/2017\/2017onsc375
\n9\/2017onsc3759.html?autocompleteStr=A.B.
\nv.\u00a0Canada (Attorney Gene
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\nternet].Convivium; 2018 Jun 18 [cited 2018 Sep
\n01]. Available from: https:\/\/www.convivium.ca\/
\narticles\/maid-and-modern-medicine
\n46.\tJustice Moldaver, referring to the consequences
\nof failing to provide adequate safeguards. Su-
\npreme Court of Canada, 35591, Lee Carter, et
\nal. v. Attorney General of Canada, et al (British
\nColumbia) (Civil) (By Leave) [Webcast}. 2016
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\n171:56 | 205:09 Available from: http:\/\/www.
\nscc-csc.ca\/case-dossier\/info\/webcastview-web-
\ndiffusionvue-eng.aspx?cas=35591&urlen=http%
\n3a%2f%2fwww4.insinc.com%2fibc
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\n(Vers la mort \u00e0 la carte?) [Internet]. Coll\u00e8ge des
\nM\u00e9decins du Qu\u00e9bec; 2017 May 10 [cited 2018
\nSep 01]. English translation published by the
\nPhysicians\u2019 Alliance against Euthanasia. Avail-
\nable from: https:\/\/collectifmedecins.org\/en\/dr-
\nroberts-regrets\/
\n48.\thttp:\/\/www.cmq.org\/nouvelle\/fr\/vers-la-mort-
\na-la-carte.aspx
\nEthical Aspects of Health Care CANADA
\n23
\nBACK TO CONTENTS
\n49.\tCBC News. Lack of palliative care pushing
\nQuebecers toward medically assisted death,
\nCollege of Physicians says. 31 May 2018 [cited
\n2018 Sep 01]. Available from: https:\/\/www.
\ncbc.ca\/news\/canada\/montreal\/lack-of-palli-
\native-care-pushing-quebecers-toward-med-
\nically-assisted-death-college-of-physicians-
\nsays-1.4685470
\n50.\tFatal Flaws Film Clip : \u201cThey wanted me to do
\nan assisted suicide death on her\u201d [Video]. You-
\nTube; 2017 Oct 10 [cited 2018 Sep 01]. Avail-
\nable from: https:\/\/youtu.be\/hB6zt43iCs8
\n51.\tChronically ill man releases audio of hospital
\nstaff offering assisted death [Internet]. CTV
\nNews; 2018 Aug 02 [cited 2018 Sep 01]. Avail-
\nable from: https:\/\/www.ctvnews.ca\/health\/
\nchronically-ill-man-releases-audio-of-hospital-
\nstaff-offering-assisted-death-1.4038841
\n52.\tHamilton G. Some Quebec doctors let suicide
\nvictims die though treatment was available:
\ncollege [Internet]. National Post; 2016 Mar 17
\n[cited 2018 Sep 01]. Available from: https:\/\/
\nnationalpost.com\/news\/canada\/some-quebec-
\ndoctors-let-suicide-victims-die-though-treat-
\nment-was-available-college
\n53.\tGeddes J. Interview: The CMA\u2019s president on
\nassisted dying [Internet]. Macleans; 2015 Feb
\n06 [cited 2018 Sep 01]. Available from: http:\/\/
\nwww.macleans.ca\/politics\/ottawa\/interview-
\nthe-cmas-president-on-assisted-dying\/). This
\npart of the interview is not included in the edit-
\ned published transcript, but can be heard on the
\nlinked audio file (02:43-03:25) [cited 2018 Sep
\n01] Available from: https:\/\/soundcloud.com\/
\nmacleans-magazine\/john-geddes-in-conversa-
\ntion-with-cma-president-chris-simpson
\n54.\tMurphy S. A bureaucracy of medical decep-
\ntion: Quebec physicians told to falsify eutha-
\nnasia death certificates [Internet]. Protection of
\nConscience Project; 2015 [cited 2018 Sep 01].
\nAvailable from: http:\/\/www.consciencelaws.org\/
\nbackground\/procedures\/assist012.aspx
\n55.\tMichael Swan. Can a doctor-assisted death be
\n\u2018natural\u2019 and \u2018suicide\u2019? [Internet]. The Catho-
\nlic Register; 2018 Aug 08 [cited 2018 Sep 01].
\nAvailable from: https:\/\/www.catholicregister.
\norg\/item\/27790-can-a-doctor-assisted-death-
\nbe-natural-and-suicide
\n56.\tGlobe editorial: Ottawa should do more to ex-
\namine how medically-assisted death is working
\n[Internet]. The Globe and Mail; 2018 Aug 16
\n[cited 2018 Sep 01]. Available from: https:\/\/
\nwww.theglobeandmail.com\/opinion\/editorials\/
\narticle-globe-editorial-ottawa-should-do-more-
\nto-examine-how-medically\/
\n57.\tRegulations for the Monitoring of Medical As-
\nsistance in Dying: SOR\/2018-166 [Internet].
\nGovernment of Canada; 2018 Jul 27 [cited 2018
\nSep 01]. Available from: http:\/\/www.gazette.
\ngc.ca\/rp-pr\/p2\/2018\/2018-08-08\/html\/sor-
\ndors166-eng.html
\n58.\tFrazee C. Medically assisted dying needs
\nmore monitoring [Internet]. The Star; 2018
\nAug 29 [cited 2018 Sep 01]. Available from:
\nhttps:\/\/www.thestar.com\/opinion\/contribu-
\ntors\/2018\/08\/29\/medically-assisted-dying-
\nneeds-more-monitoring.html
\n59.\tLazaruk S. Jewish care home accuses doctor of
\n\u2018sneaking in and killing someone\u2019 [Internet].
\nVancouver Sun; 2018 Jan 05 [cited 2018 Sep
\n01]. Available from: https:\/\/vancouversun.com\/
\nnews\/local-news\/jewish-care-home-accuses-
\ndoctor-of-sneaking-in-and-killing-someone
\n60.\tWorld Medical Association issues Madrid Dec-
\nlaration against euthanasia [Internet]. 1987
\nNov 20 [cited 2018 Sep 01]. Available from:
\nhttps:\/\/larouchepub.com\/eiw\/public\/1987\/eir-
\nv14n46-19871120\/eirv14n46-19871120_014-
\ndr_andre_wynen.pdf
\n(Institutional affiliations are provided for
\nidentification purposes only and do not imply
\nendorsement by the institutions. See below
\nfor list of professional designation abbrevia-
\ntions.)
\nRene Leiva, MDCM, CCFP
\n(COE\/PC), FCFC
\nFamily Medicine, Palliative
\nCare, Care of the Elderly
\nBruyere Continuing Care
\nOttawa, Ontario, Canada
\nMargaret M Cottle, MD, CCFP (PC)
\nPalliative Care
\nAssistant Professor, University
\nof British Columbia
\nVancouver, British Columbia, Canada
\nCatherine Ferrier, MD,
\nCCFP (COE), FCFP
\nFamily Medicine, Care of the Elderly
\nMcGill University Health Centre
\nAssistant Professor of Family
\nMedicine, McGill University
\nMontreal, Quebec, Canada
\nSheila Rutledge Harding, MD, MA, FRCPC
\nHematology
\nSaskatchewan Health Authority
\nProfessor, University of Saskatchewan
\nSaskatoon, Saskatchewan, Canada
\nTimothy Lau, MD, MSc, FRCPC
\nGeriatric Psychiatry
\nRoyal Ottawa Hospital
\nAssociate Professor, University of Ottawa
\nOttawa, Ontario, Canada
\nTerence McQuiston, MD
\nFamily Medicine (special
\ninterest in Geriatrics)
\nDonway Place Retirement Residence
\nToronto, Ontario, Canada
\nJohn F Scott, MD, MDiv
\nPalliative Care
\nAssociate Professor, University of Ottawa
\nThe Ottawa Hospital
\nOttawa, Ontario, Canada
\nAcknowledgements and Endorsements
\nThe authors want to express our deepest thanks
\nfor insights, edits and support received from
\nmany of our colleagues. The final article has
\nbeen explicitly endorsed by the following Ca-
\nnadian physicians:
\nBalfour\u00a0M\u00a0Mount, Anita\u00a0Au,
\nSasha\u00a0Bernatsky, Thomas\u00a0Bouchard,
\nJulia\u00a0Bright, Myra\u00a0Butler, Luigi\u00a0Castagna,
\nJulia\u00a0Cataudella, Cyril\u00a0Chan, Luke\u00a0Chen,
\nJoyce\u00a0Choi, Andre\u00a0Constantin, Alana\u00a0Cormier,
\nMD, David\u00a0D\u2019Souza, Ed\u00a0Dubland,
\nAbraham\u00a0Fuks, Dominique\u00a0Garrel,
\nRichard\u00a0Haber, Ronald\u00a0E\u00a0Hiller,
\nNeil\u00a0Hilliard, Todd\u00a0C\u00a0Howlett,
\nEvelyne\u00a0Huglo, K.\u00a0Issigonis,
\nAndre\u00a0Jakubow, Will\u00a0Johnston, Lynn\u00a0Kealey,
\nNuala\u00a0P\u00a0Kenny, Anthony\u00a0T\u00a0Kerigan,
\nEdmond\u00a0Kyrillos, Joseph\u00a0M\u00a0Lam,
\nRenata\u00a0Leong, Constant\u00a0H.\u00a0Leung,
\nHenry\u00a0Lew, Andrea\u00a0H.\u00a0S.\u00a0Loewen,
\nJean-Noel\u00a0Mahy, Fran\u00e7ois\u00a0Mai,
\nKaren\u00a0MacDonald, Karen\u00a0Mason,
\nJohn\u00a0R\u00a0McLeod, J\u00a0Stephen\u00a0Mitchinson,
\nIbrahim\u00a0Mohamed, Jos\u00e9\u00a0A.\u00a0Morais,
\nLouis\u00a0Morissette, Laurence\u00a0Normand\u2011Rivest,
\nLiette\u00a0Pilon, Roger\u00a0Roberge,
\nCameron\u00a0Ross, Paul\u00a0Saba, Kevin\u00a0Sclater,
\nWilliam\u00a0F.\u00a0Sullivan, Vanessa\u00a0Sweet,
\nSephora\u00a0Tang, Mark\u00a0Tsai, Stephen\u00a0Tsai,
\nJames\u00a0Warkentin, Maria\u00a0Wolfs, Paul\u00a0Yong
\nEthical Aspects of Health Care
\nCANADA
\n24
\nTelemedicine entered the scene during the
\nearly 19th century and has been steadily
\ngrowing and further developing in the
\nbackground. Dr Hugo Gernsback featured
\nhis \u2018teledactyl\u2019 device in the 1925 edition
\nof the Science and Invention Magazine,
\nwith the hope that the device would be
\na medical breakthrough whereby physi-
\ncians would be able to examine patients
\nfrom a distance using radio technology.
\nThis \u2018failed\u2019 invention paved the way for
\ntelemedicine, and was shortly followed by
\nstudies at the University of Nebraska in
\n1959 where physicians were able to trans-
\nmit neurological examinations to medical
\nstudents across the campus via a two-way
\ninteractive television. Within ten years,
\nphysicians were able to use a telemedicine
\nlink to provide health services at a Norfolk
\nState Hospital over a distance of 180 kilo-
\nmetres [1].
\nIn general, telemedicine is defined as the
\nremote diagnosis and treatment of pa-
\ntients via telecommunications technology.
\nThe World Medical Association (WMA)
\ndescribes telemedicine as \u201cthe practice of
\nmedicine over a distance, in which inter-
\nventions, diagnostic and treatment deci-
\nsions and recommendations are based on
\ndata, documents and other information
\ntransmitted through telecommunication
\nsystems\u201d[2].Telemedicine can refer to con-
\nsultation between a physician and a patient
\nor between two physicians\/health profes-
\nsionals, with a primary physician\/health
\nprofessional being in the same location as
\nthe patient.Telehealth services may be pro-
\nvided through two types of communication
\nplatforms: (i) asynchronous communica-
\ntions, which is known more commonly as
\n\u201cstore and forward\u201d (e.g. X-rays, CT scan
\nreports, video-recorded symptoms) and (ii)
\nsynchronous communication, described as
\n\u201creal-time\u201d communication (e.g. video con-
\nsultation) [3].
\nThe definition of telemedicine can differ
\nacross different jurisdictions, and what is
\nlegal in one jurisdiction may be illegal in
\nthe other. Some jurisdictions recognise
\ntelemedicine as an interaction between
\nthe physicians and their patients and some
\njurisdictions limit telemedicine between
\nhealth professionals [4]. It is therefore
\nimportant for physicians to understand
\ndefinitions of telemedicine in their juris-
\ndictions\u201d [5].
\nTop fields in telemedicine include Tele-
\nradiology, Telepathology, Teledermatol-
\nogy, Telepsychiatry, Teleophthalmology,
\nTelenephrnology, Teleobstetrics, Teleon-
\ncology, and Telerehabilitation, Telesurgery
\nand telemonitoring (or remote surgery).
\nTelemedicine can also be used for patient
\neducation and follow-up [5-7].
\nBenefits of Telemedicine
\nTelemedicine can be used to improve ac-
\ncess to healthcare services in remote and
\nunderserved areas. [8] Telemedicine can be
\nused as a direct link to patients or to enable
\nremote facilities to obtain specialised sup-
\nport from major centres [8,9].Telemedicine
\ncan also be used for learning and develop-
\nment of junior physicians, resident officers,
\nnurses and general practitioners. Increas-
\ningly,telemedicine is being used for patients
\nwith barriers to access outside geographical
\nlimitations; these include physical disability,
\nemployment, family commitments (includ-
\ning caring for others), patients\u2019 cost and
\nphysician schedules.
\nTelemedicine can allow for frequent follow-
\nup of chronic patients, therefore, increasing
\ncontact time at low costs. Patient tele-edu-
\ncation also assists in providing patients with
\nindividualised health promotion messages
\nand may improve empowerment [9].
\nPotential Risks in
\nTelemedicine
\nQuality of care: The ultimate purpose of
\nany medical care is to maintain or im-
\nprove health and well-being. Like all clini-
\ncal interventions, telemedicine should be
\nsubjected to the evaluation of efficiency,
\neffectiveness and cost-effectiveness. Argu-
\nments in favour of the use and expansion
\nof telemedicine include, amongst others,
\nSalaelo Mametja
\nTelemedicine and its Ethical Aspects
\nJolene Hattingh
\nTelemedicine SOUTH AFRICA
\n25
\nBACK TO CONTENTS
\nincreased access and affordability. This
\nshould, however, not be done at the ex-
\npense of quality of care, and in fact should
\nnot replace access to essential clinical ser-
\nvices and face-to-face consultations, as not
\nall clinical conditions can be treated using
\ntelemedicine.
\nTelemedicine can result in three types of
\nquality problems: [10] (i) Overuse of medi-
\ncal care due to unnecessary consultations
\nand investigations, (ii) under-use of medical
\ncare through failure to conduct appropriate
\nclinical examination and referral appropri-
\nate\/referral delayed referral and (iii) poor
\ntechnical or interpersonal performance
\n(e.g. incorrect interpretation of pathology
\nspecimen or inattention to patient con-
\ncerns)\u00a0[11].Telemedicine should be used as
\nan adjunct to health services and not as a
\nstandalone intervention.
\nThe effectiveness of telemedicine: Studies
\nof effectiveness in telemedicine are incon-
\nsistent. Compared to usual care, telemedi-
\ncine did not result in the improvement in
\noutcomes in heart failure [12, 13]. In one
\nsystematic review, telemedicine was found
\nto be associated with decreased hospi-
\ntalisation and mortality, and resulted in
\nlower patient satisfaction12. In another
\nrandomised control trial, telemedicine was
\nreported to reduce HBA1C but had no ef-
\nfect on health outcomes such as mortal-
\nity [14]. The inconsistency in findings can
\nbe due to variable telemedicine platforms,
\nsettings and to the extent to which usual
\ncare is replaced or complemented by tele-
\nmedicine. It is therefore, important that
\nphysicians test effectiveness, efficiency,
\nsafety and feasibility of telemedicine plat-
\nforms in their setting before wide-scale
\nrollout.
\nEthics andTelemedicine
\nSome of the most prominent ethical con-
\ncerns include the effect on patient-physi-
\ncian relationships, and threats to patient
\nprivacy[14]. Properly informed written
\nconsent requires that all necessary infor-
\nmation regarding the telemedicine visit be
\nexplained fully to patients, including ex-
\nplaining how telemedicine works, how to
\nschedule appointments, privacy concerns,
\nthe possibility of technological failure, pro-
\ntocols for contact during virtual visits, pre-
\nscribing policies,and coordinating care with
\nother health professionals in a clear and un-
\nderstandable language, without influencing
\nthe patient\u2019s choices [15].
\nTelemedicine involves the use of an in-
\nformation technology platform, which
\ncan result in unintended confidentiality
\nbridges by hacking and unauthorised ac-
\ncess. IT staff responsible for telemedicine
\nplatforms may not have similar ethical
\nrules as the medical professionals.This risk
\nis even higher when secular telemedicine
\nplatforms such as Skype or WhatsApp are
\nused. Therefore, a physician needs to use
\nappropriate, accredited, secure and compli-
\nant IT platforms for telecommunication
\nwhere applicable.
\nGenerally, the patient needs to have an ex-
\nisting relationship with the medical profes-
\nsional performing the telemedicine con-
\nsultation. There is a therapeutic value of
\nface-to-face encounters with a physician
\nthat helps to build a relationship of mutual
\ntrust and rapport building[16].Face-to-face
\nconsultation allows the physician to obtain
\nan appropriate history as well as conduct
\ngeneral and symptomatic examinations. For
\nthese reasons, telemedicine should only be
\nimplemented for existing patients, where
\nthe physician has an intimate knowledge of
\nthe patient\u2019s history.
\nIn providing telemedicine, physicians must
\nbe aware of its benefits and harms. Tele-
\nmedicine should not replace face-to-face
\nconsultation.There are circumstances where
\ntelemedicine is inappropriate and physi-
\ncians must, therefore, retain their autonomy
\nin deciding on the appropriate use of tele-
\nmedicine.The standards of care provided in
\ntelemedicine should be similar to face-to-
\nface consultations.
\nTelemedicine can be harmful as the physi-
\ncians\u2019 ability to clinically examine the pa-
\ntients is limited. Physician-only relies on
\ntwo (visual and audio) senses instead of four
\n(visual, audio, smell and touch) to complete
\na clinical exam.
\nJustice: The healthcare system has a duty to
\ndistribute social benefits and burdens equal-
\nly.Telemedicine can widen the gap in health
\noutcomes if people are treated differently
\nbased on their ability to access telecommu-
\nnication or denial of necessary face-to-face
\nconsultation in lieu of telemedicine.
\nFurthermore, reimbursement for telemedi-
\ncine should be proportionate to the bur-
\ndens. Physicians should be careful of per-
\nverse incentives geared to promote uptake
\nof telemedicine as this can erode the ethics
\nin medicine [15, 17].
\nBarriers to Implementation
\nof Telemedicine
\nInfrastructure remains a huge barrier to ex-
\npansion and access to telemedicine. Ironi-
\ncally, this affects remote and rural societ-
\nies who are believed to be beneficiaries of
\ntelemedicine. Instead, telemedicine is ex-
\npanding rapidly in urban areas and metro-
\npolitans. Barriers that physicians, in general,
\nexperience with the implementation of tele-
\nmedicine in their practices include a lack
\nof access to infrastructure, requirements of
\ncomplex systems, absences of standards in
\ntelemedicine, and a lack of direction from
\nregulatory bodies and national departments
\nof health [8].
\nLegal Considerations
\nThe regulations for telemedicine vary from
\ncountry to country and within countries.
\nGenerally, there is also a lack of harmony
\nTelemedicine
\nSOUTH AFRICA
\n26
\nwithin and between countries legal frame-
\nworks. For, examples, in the US, physicians
\nare required to be licensed or registered with
\nthe relevant regulator to practise telemedi-
\ncine. However, regulators in other countries
\nare often silent on consultations across ju-
\nrisdictions [18].This can threaten a patient\u2019s
\nsafety and lead to abuse by unscrupulous
\nfraudsters. Physicians should be cognisant
\nthat in the absence of guidance on cross-
\njurisdictional regulations, long-arm laws
\nmay grant the court\u2019s jurisdiction over out-
\nof-state individuals.
\nWhilst there are telecommunication laws,
\ntelemedicine requires a special type of
\nregulation due to the sensitivity of medi-
\ncal information, and the requirements for
\nregulation of physicians and medical in-
\nterventions. This requires harmonisation of
\nboth medical and telecommunication legal
\nframeworks.
\nTelemedicine can increase the potential for
\nlitigation due to an inability to assess symp-
\ntoms and signs appropriately through elec-
\ntronic consultation media.
\nConclusion
\nTelemedicine can provide access to health-
\ncare in under-resourced areas. However,
\nphysicians must adhere to biomedical ethics
\nand be cognisant of the unintended adverse
\neffects both at individual and population
\nlevel. Face-to-face medicine remains the
\ngold standard of care. Telemedicine should
\nnot be used for any medical emergencies
\n(unless justified by lack of access) or condi-
\ntions where physical examination is required.
\nPhysicians should use their professional
\njudgment, along with available legislation
\nand guidelines,to decide when telemedicine
\nis appropriate. Prescribing medicine virtu-
\nally is generally acceptable; however, physi-
\ncians should only prescribe medicine when
\nthere is a pre-existing relationship with the
\npatient and guard against potential abuse
\nand fraudulent use of prescribed medicine.
\nPhysicians need to be aware of medicines
\nthat cannot be prescribed via telemedicine
\nconsultations. Physicians should only prac-
\ntise telemedicine in countries or jurisdic-
\ntions where they are licenced to practice.
\nCross-jurisdictional consultations should
\nonly be allowed between two physicians.
\nReferences
\n1.\t Bashur, R. and G. Shannon, History of Tele-
\nmedicine: Evolution. Context, and Transforma-
\ntion Mary Anne Liebert, New Rochelle, 2009.
\n2.\t Association, WM,Statement on the Ethics of
\nTelemedicine. adopted by the 58th WMA Gen-
\neral Assembly, Copenhagen, Denmark, 2007.
\n3.\t Marcoux,RM and FR Vogenberg,Telehealth: ap-
\nplications from a legal and regulatory perspective.
\nPharmacy and Therapeutics, 2016. 41(9): p. 567.
\n4.\t Health Professions Council for South Africa,
\nGeneral Ethical Guidelines for Good PRactice
\nin Telemedicine. 2010.
\n5.\t Smith Y, Types of telemedicine. News Medical
\nLife Science, 2015.
\n6.\t Wikipedia,Telemedicine. 2017.
\n7.\t Smith R, Research in Lag Time set to Deter-
\nmine the Future of Telesurgery. TechChurch,
\n2015.
\n8.\t Parajuli, R. and P. Doneys, Exploring the role
\nof telemedicine in improving access to health-
\ncare services by women and girls in rural Ne-
\npal. Telematics and Informatics, 2017. 34(7): p.
\n1166-1176.
\n9.\t Anderson, JG, Social, ethical and legal barriers
\nto e-health. International journal of medical in-
\nformatics, 2007. 76(5-6): p. 480-483.
\n10.\tInstitute of Medicine (US) Committee on Eval-
\nuating Clinical Applications of Telemedicine,
\nTelemedicine: A Guide to Assessing Telecom-
\nmunications in Health Care. 1996.
\n11.\tField, MJ and I.o.M.C.o.E.C.A.o. Telemedi-
\ncine, Evaluating the effects of telemedicine on
\nquality, access, and cost. 1996.
\n12.\tScherr, D, et al., Effect of home-based telem-
\nonitoring using mobile phone technology on the
\noutcome of heart failure patients after an epi-
\nsode of acute decompensation: randomized con-
\ntrolled trial.Journal of medical Internet research,
\n2009. 11(3).
\n13.\tLee, SWH, et al., Comparative effectiveness
\nof telemedicine strategies on type 2 diabetes
\nmanagement: A systematic review and network
\nmeta-analysis. Scientific Reports, 2017. 7(1): p.
\n12680.
\n14.\tJack,C,Telemedicine a need for ethical and legal
\nguidelines in South Africa. South African Fam-
\nily Practice, 2008. 50(2): p. 60-60.
\n15.\tBeauchamp, TL and JF Childress, Principles
\nof biomedical ethics. 2001: Oxford University
\nPress, USA.
\n16.\tHewitt, H, J Gafaranga, and B McKinstry,
\nComparison of face-to-face and telephone
\nconsultations in primary care: qualitative anal-
\nysis. Br J Gen Pract, 2010. 60(574): p. e201-
\ne212.
\n17.\tEL,Z,Electronic Health Records raise new eth-
\nical concerns.The National Psychologist, 2014.
\n18.\tEuropean Health Telematics Association,
\nETHICAL Principles for eHealth: Briefing Pa-
\nper. 2012: p. 7-10.
\nDr. Salaelo Mametja, MBBCh, MMed (PH),
\nFCPHM, PGD (Health Management)
\nJolene Hattingh, BA (Psychology), CCSA
\nRegistered (Counsellor), MPH student
\nKnowledge Management and Research, the
\nSouth African Medical Association (SAMA)
\nE-mail: SelaeloM@Samedical.org
\nTelemedicine SOUTH AFRICA
\n27
\nBACK TO CONTENTS
\nMigration has been a constant of human
\nlife for centuries [1]. In our own time, the
\nmovement of individuals between cities,
\ncountries, and cultures has accelerated due
\nto ease of transportation and communica-
\ntion, yet the fundamental issues faced by
\npeople uprooting themselves and their fam-
\nilies for new opportunities remain similar
\n[2]. Issues related to the alignment of ex-
\npectations with realities, integration in new
\ncommunities,cultural understanding within
\nnew societies, and a psychological sense of
\nloss are all common experiences that con-
\ntinue to occur [3]. More recently, especially
\nwithin many Western countries, increased
\nscrutiny on migrants and migration policies
\nhave created new challenges for individuals
\nwho may simply want a better life for their
\nfamilies [4].
\nInternationally educated health profession-
\nals (IEHPs) are generally defined as indi-
\nviduals who received their primary educa-
\ntion and training in a health care field in a
\ndifferent country than the one they current-
\nly reside within. In some cases (for example
\nthe movement of physicians between Aus-
\ntralia and New Zealand) [2] there may be
\nminimal regulatory, cultural, or social bar-
\nriers to professional practice. In other cases
\n(for example the movement of nurses be-
\ntween sub-Saharan Africa and the United
\nStates) there may be significant barriers and
\nobstacles to overcome [3].
\nWhile political debate around migration
\nand its benefits continues to swirl, the un-
\ndeniable reality in many Western countries
\nis that reliance upon IEHPs to comple-
\nment the domestic workforce continues
\nto increase [4, 5]. In some professions and
\nin some jurisdictions, this reliance can be
\nsignificant; for example, in the Canadian
\nprovince of Ontario, upwards of 50% of all
\npharmacists registered to practice each year
\ncome from outside Canada or the United
\nStates, and without their contributions to
\nthe workforce, the practice of the phar-
\nmacy profession in Ontario would be over-
\nwhelmed [6].
\nDespite increasing reliance on IEHPs for
\nan aging population and health care sys-
\ntems under stress, relatively little is known
\nabout their experiences in navigating
\nthe personal and professional transitions
\nrequired by all migrants [6]. In our cur-
\nrent time in which migration in general
\nhas become a political issue, and actions
\nto reduce all forms of migration currently
\nseize the public agenda, policy makers may
\nlack an understanding of the real, impor-
\ntant, and invaluable contributions made by
\nIEHPs in allowing health care systems to
\ncontinue to function safely and effectively
\n[7].
\nThese contributions, however important,
\nmust also be balanced against perceptions
\nrelated to integration of newcomers into
\nthe social and cultural fabric of their ad-
\nopted societies. Integration of IEHPs into
\nthe community and into the health care
\nsystem may be more complicated today
\ndue to the patterns of migration, particu-
\nlarly the movement of peoples across large
\ngeographic \u2013 and cultural \u2013 distances.
\nWell-publicized cases of (for example)
\nforeign-trained physicians refusing service
\nto gay and lesbian patients due to religious
\ndifferences can sometimes create the im-
\npression for the public \u2013 and for policy
\nmakers \u2013 that IEHPs are more bother-
\nsome than helpful. The reality, of course,
\nis that in many Western countries, reliance
\non IEHPs to complement the domestic
\nworkforce will only increase over time [1,
\n4, 6].
\nGiven this reality, it is important to under-
\nstand the experiences and diverse trajecto-
\nries of IEHPs as they become a more im-
\nportant part of our communities and health
\ncare systems for several reasons. First, it is
\nimperative that policy makers understand
\nboth the value IEHPs bring to domestic
\nhealth care systems as well as the barri-
\ners and facilitators to fuller integration in
\nthe workforce [5]. Second, regulators need
\ngreater clarity around how their policies
\nand practices may create inadvertent ac-
\ncess barriers that ultimately may result in
\nunfairness to potential registrants or inef-
\nficiencies that adversely impact patient care
\nby inappropriately reducing the number of
\nhealth care providers available. Third, pub-
\nlic awareness of the contributions of, and
\nstruggles faced by, IEHPs is essential: while
\nhealth care personnel shortages are an issue
\nacross the globe, few members of the public
\nunderstand the importance of global migra-
\ntion as a health human resources planning
\ntool to forestall staffing problems. Fourth,
\nZubin Austin
\nGlobal Migration and the Health
\nWorkforce: the Experiences of
\nInternationally Educated Health
\nProfessionals
\nMigration and Health Care
\nCANADA
\n28
\neducators and those involved in skills up-
\ngrading and immigration settlement require
\nfurther research to support their curricular
\nefforts to enhance professional and com-
\nmunity integration of IEHPs as efficiently
\nand \u00ad
\neffectively as possible. Finally, IEHPs
\nthemselves need access to better informa-
\ntion about the personal and professional
\nimplications of migration; in cases of eco-
\nnomic or voluntary migration, IEHPs may
\nhave unfounded or unrealistic expectations
\nregarding the ease and speed with which
\ntheir qualifications may be recognized and
\nrespected in their adopted country of choice
\n[6].
\nHealthforce Integration
\nResearch and Education
\nfor Internationally Educated
\nHealth Professionals
\n(HIRE IEHPs)
\nFrom 2012\u20132017, the Canadian govern-
\nment (like many national governments)
\nrecognized the importance of greater un-
\nderstanding of the experiences of IEHPs
\nin Canada, especially given the large and
\ngrowing reliance of the Canadian health
\ncare system for foreign-trained doctors,
\nnurses, pharmacists, and other health
\nprofessionals [6] As part of a menu of
\ninitiatives designed to address needs of
\nmultiple stakeholders across the country,
\nthe HIRE IEHPs initiative was funded to
\nsupport integration of IEHPs in the Ca-
\nnadian health workforce.The ultimate ob-
\njective was to use research to guide curric-
\nulum design for educators and to provide
\nsupports for employers and community
\nagencies to more effectively and efficiently
\nsupport full integration of IEHPs into
\nCanadian health care practices and set-
\ntings.
\nOver the course of this project, several key
\ninsights have emerged, which may be of
\nrelevance to jurisdictions similar to Canada
\nworking to support and enhance integration
\nof IEHPs to alleviate domestic health care
\nworkforce shortages:
\n1.\u2002 Personal and Professional
\nMigration Needs Differ
\nDuring the course of the project, we
\nworked with literally thousands of foreign
\ntrained health professionals from all over
\nthe world, representing over a dozen regu-
\nlated and recognized health professions
\nincluding medicine, dentistry, midwifery,
\nnursing, and pharmacy. Across these in-
\nteractions \u2013 and regardless of profession,
\ncountry of origin, gender, or age \u2013 a strik-
\ningly common theme emerged amongst
\nvoluntary\/economic migrants to Canada.
\nAlmost without exception, health profes-
\nsionals who decided to leave \u201chome\u201d and
\nmove to Canada did so with the express
\npurpose of enhancing prospects and im-
\nproving life for their children, rather than
\nfor themselves [6]. In some cases, this same
\nsentiment was expressed by IEHPs even if
\nthey were currently childless. IEHPs rec-
\nognized that \u201cback home\u201d they had social
\nstatus, good jobs, good incomes, and a rea-
\nsonable or good quality of life \u2013 but that
\nthey expected that migration to Canada
\nwould be of primary benefit for their chil-
\ndren rather than for themselves. Their pro-
\nfessional degree\/designation was merely of
\ninstrumental use to meet Canada\u2019s immi-
\ngration requirements; virtually no IEHPs
\nin our project said they had undertaken the
\nstressful migration process to Canada be-
\ncause of professional opportunities or the
\nchance to practice their profession. Indeed,
\nthe vast majority described how they would
\npersonally be less well-off, less profession-
\nally satisfied, and less personally happy be-
\ncause of the migration experience but in
\nthe longer term it would be a sacrifice that
\nwas rewarded by the happiness and future
\nprosperity of their children [8].
\nThis is a crucial insight for regulators,
\neducators, and employers: professional
\nsatisfaction and practice are secondary to
\nparental responsibilities for the vast major-
\nity of IEHPs, yet the existing literature on
\nIEHPs rarely discusses this issue. It is easy
\nto overlook the reality that health profes-
\nsionals are also people who must juggle
\nmultiple roles and multiple responsibili-
\nties; for the IEHPs in this project, their
\nprofessional integration was merely a tool
\nto support personal\/social integration to
\nsupport their children. This underlying
\nmotivation was frequently ignored or over-
\nlooked throughout their registration and
\nemployment experiences yet it is crucial
\nto understanding who they were as indi-
\nviduals. Perhaps most importantly when
\nviewed from this perspective, failure to be-
\ncome licensed as a professional or delays
\nin finding suitable employment are not
\nsimply \u201cpersonal\u201d issues \u2013 they have enor-
\nmous implications for a family network, a
\nsense of self-worth and self-identity, and
\ncan therefore provoke strong emotional
\nresponses.
\n2.\u2002 Domestic professional
\nand regulatory cultures can
\nappear cold and indifferent to
\noutsiders
\nA second common theme across all pro-
\nfessions was the interactions experienced
\nwith profession-specific regulators, edu-
\ncators, professional associations, and em-
\nployers. IEHPs in this project spoke of the
\ndifficulties they had simply understanding
\nwhat they needed to do in order to get reg-
\nistered and gain employment. Bureaucratic
\nindifference or complexity was frequently
\nexperienced as hostility or discrimination
\ndue to country of origin. While very few
\nIEHPs in this project reported blatant rac-
\nism or outright discrimination, a subtle
\nlevel of systemic barriers was omnipresent,
\nblocking progress through the licensing
\nsystem and frustrating attempts at gain-
\ning Canadian experience or employment.
\nThis was interpreted as the system being
\n\u201crigged\u201d to favour Canadian graduates
\nover non-Canadian graduates; while most
\nMigration and Health Care CANADA
\n29
\nBACK TO CONTENTS
\nIEHPs did not necessarily object to this
\ntype of favouritism per se, they did ob-
\nject to the lack of transparency and clarity
\nabout what they needed to do in order to
\ncontinue to progress in the system. While
\nofficial policy and practice amongst regula-
\ntors, educators, and employers in Canada
\nclearly emphasizes non-discrimination
\nand treating all applicants fairly regardless
\nof country of origin, the lived experiences
\nof many IEHPs suggest improvements are
\nneeded in systems to achieve this policy
\nobjective.
\n3.\u2002 Technical\/procedural skills
\nare less important than
\nsocial\/contextual ones
\nMany IEHPs \u2013 regardless of their profes-
\nsional background \u2013 expressed surprise at
\nthe extent to which the Canadian health
\ncare system prioritized social competencies
\nover technical competencies, particularly
\nin fields such as medicine. In most cases,
\nIEHPs were expecting greater challenges
\nin mastering the technical nuances of
\nCanadian health practice than they expe-
\nrienced; indeed many project participants
\nnoted that the actual practice of their
\nprofession from a technical perspective
\nwas not that dissimilar in Canada to their
\nexperience in another country. What was
\ncompletely different \u2013 and in many cases
\nvery overwhelming \u2013 were the multiple
\nsocial interactions and interpersonal nice-
\nties that characterize professional practice
\nin Canada. The conversational burden
\namongst health care professionals, and
\nthe \u201csmall talk\u201d demanded by patients was
\nfrequently challenging for IEHPs to mas-
\nter, which in turn may have led Canadian
\npatients and providers to label IEHPs as
\n\u201ccold\u201d, \u201caloof \u201d or \u201cnot personable enough
\nto work here\u201d. Most IEHPs reported man-
\naging to pass requirements related to the
\ntechnical aspects of their professional work
\n(e.g. licensing exams), but struggling to
\nmaster the application of this learning in
\na Canadian health care context.The impli-
\ncations for Canadian regulators, educators,
\nand employers are significant \u2013 greater sup-
\nport for \u201csoft skills\u201dupgrading and training
\nis needed to more fully engage IEHPs and
\nhelp them better integrate in the Canadian
\nsystem.
\n4.\u2002 Communication is more
\nthan just language skills
\nIn all regulated health professions in
\nCanada, there are mandatory English or
\nFrench language fluency requirements that
\nmust be demonstrated prior to registration
\nin the field. Standardized widely available
\ninternational tests such as the TOEFL or
\nIELTs are used by regulators, educators,
\nand employers to establish communication
\nreadiness for practice. IEHPs in this proj-
\nect were virtually unanimous in describing
\nhow passing standardized language tests
\nwas not the same as being able to com-
\nmunicate in a Canadian context. First,
\nstandardized language tests are frequent-
\nly general in nature, and do not focus on
\ncomplex medical terminology or nuances.
\nSecond, while the vast majority of IEHPs
\ncoming to Canada speak some English or
\nFrench, there are many different kinds of
\n\u201cenglishes\u201d and \u201cfrenches\u201d spoken in differ-
\nent parts of the world. Specific local idioms
\nor dialects are rarely tested in standardized
\ntests, yet are crucial for establishing social
\nbonds with patients or other health care
\nprofessionals.Third, standardized language
\ntests only test verbal, written, or aural com-
\nmunication and as noted by many IEHPs
\nin this project much of \u201ccommunication\u201din
\nhealth care is non-verbal in nature. Many
\nnon-verbal cues and gestures (for example,
\neye contact, handshakes, physical distance
\nwhile speaking) are just as (if not more)
\nimportant than the specific word choices
\nand verbal communication used, yet for
\nsome IEHPs their non-verbal commu-
\nnication patterns were misinterpreted or
\nmisunderstood by others in a negative way.
\nEducators, regulators and employers need
\nto be aware that communication is not
\nsimply about verbal skills, but instead cover
\na constellation of issues for which further
\neducation and support may be required to
\ntruly support integration of IEHPs in the
\nworkforce.
\n5.\u2002 Patient Centeredness
\nThe Canadian health care system \u2013 like the
\nsystem of many other countries \u2013 is based
\nupon the notion of patient autonomy, pa-
\ntient rights and patient centeredness. The
\ncentral role of patients in decision making
\nis instilled in health professional students
\nfrom the first day of their studies. Inter-
\nestingly, IEHPs in this project highlighted
\nhow their interpretations and understand-
\nings of patient centeredness were at times
\nmisaligned with Canadian expectations,
\nparticularly with respect to the patient\u2019s
\nrole in clinical decision making. While
\nmany IEHPs in this project recognized
\nand acknowledged that their views of pa-
\ntient centeredness may appear patriarchal
\nor professionally-focused by Canadian
\nstandards, they equally expressed discom-
\nfort regarding how a truly patient-centred
\nhealth care system could actually function.
\nMany of them noted that by definition
\nthere is knowledge and skills gap between
\nmost patients and most professionals and
\nthat one of the primary responsibilities
\nof professionals was sometimes to lever-
\nage their higher levels of knowledge in
\npositive ways to overcome patients\u2019 misap-
\nprehensions. While at times this may give
\nthe appearance of being overly directive or
\npaternalistic in care delivery, many IEHPs
\n\u2013 and in particular physicians \u2013 struggled
\nwith the overly idealistic notion of a pa-
\ntient-centred health care model that did
\nnot suitably value their privileged knowl-
\nedge base and skill set. Many framed it
\nin terms of responsibility to and for the
\npatient, even if the patient him\/herself
\nwas not behaving responsibly or choosing
\nwisely. Particularly for physicians there
\nwas significant discomfort in the notion of
\na patient-led care team or decision making
\nMigration and Health Care
\nCANADA
\n30
\nprocess that was at odds with a physician\u2019s
\nrecommendations, and a sense of helpless-
\nness in terms of how to better communi-
\ncate or better negotiate in such situations.
\nFor educators, regulators, and employers,
\nthis introduces challenges and opportu-
\nnities around integration. First, there is a
\nneed to provide IEHPs with both back-
\nground knowledge but also advanced in-
\nterpersonal and communication skills to
\nwork within the patient centred world-
\nview that is integral to Canadian health
\npractice. Second, there may be a need for
\nnot only greater education but more ro-
\nbust assessment of such competencies to
\nensure that those entering professional
\npractice are well equipped to deal with
\nthe realities of working with diverse Ca-
\nnadian populations. Third, finding ways of
\nhonouring the personal and professional
\ntraditions of IEHPs while still meeting
\nthe expectations of Canadian patients is
\nessential \u2013 pride in one\u2019s profession and
\nprofessional role is an important part of
\nbeing a professional, but of course cannot
\nbe used as an excuse for inappropriately
\npaternalistic behaviours. Finding ways of
\nreconciling these issues is essential to sup-
\nport greater integration of IEHPs in the
\nworkforce, and require collaboration from
\nall parts of a profession.
\n6.\u2002Interprofessionalism
\nThe delivery of health care in Canada (as
\nin many countries) is rapidly evolving to-
\nwards more highly integrated interprofes-
\nsional teams where professionals with dif-
\nferent designations can perform different
\nnon-traditional roles.For example,in many
\nparts of Canada,pharmacists may prescribe
\nmedications or physical therapists may di-
\nrectly order and interpret x-rays without a
\nphysician being involved. Canadian gradu-
\nates of these fields are trained for these
\nsorts of responsibilities, but those from
\nother countries where more traditional
\nprofessional silos exist may struggle with
\nadvanced practice responsibilities. Further,
\nin the Canadian system, it is both expected
\nand desired that health care professionals
\nfully discuss and debate patient care deci-
\nsions with one another as a way of ensur-
\ning best possible care. At times, this may
\nmean questioning physicians\u2019 orders in a
\ncollaborative, non-hierarchical way. Again,
\nin many parts of the world, medical team
\nhierarchy may be stronger than in Canada,
\nand non-physicians may have little expe-
\nrience and no comfort in questioning or
\ndisagreeing with a doctor. Models of inter-
\nprofessional practice require a diverse array
\nof skill sets related to conflict management,
\nnegotiation, interpersonal communication
\nand other soft skills, and these were identi-
\nfied by many IEHPs as a significant bar-
\nrier to their full integration in the health
\ncare workforce. Simply stating that health
\ncare professionals work together is very
\ndifferent than actually working together
\nin practice; those IEHPs (physician and
\nnon-physician alike) who come from more
\ntraditional hierarchical health care systems
\nfound themselves struggling with the real-
\nity of interprofessional practice in Canada.
\nFor educators, regulators, and employers, it
\nis clear that further education, in-service
\ntraining, and summative and formative as-
\nsessment are needed to ensure interprofes-
\nsional competencies are met or exceeded to
\nfacilitate greater integration in the work-
\nforce.
\nWhile the six primary themes noted above
\nwere consistent and expressed by IEHPs
\nregardless of their profession or demo-
\ngraphic background, they all point to the
\ncentral importance of non-technical or
\n\u201csoft skills\u201d in the daily practice of any
\nprofession. The real barrier to registration,
\nlicensure, employment, and meaningful
\nintegration in the Canadian health care
\nsystem does not appear to be technical or
\nprocedural skills\u00a0\u2013 as reported by IEHPs
\nin this project, the main issues are those
\nrelated to interpersonal, communication,
\ninterprofessional, and socio-cultural skills
\nthat are much more challenging to teach
\nand assess.
\nEnhancing Integration
\nof IEHPs in the
\nWorkforcev
\nOne of the outcomes of the HIRE IEHPs
\nproject was the development of a reposi-
\ntory of online resources aimed at both
\nIEHPs themselves and employers\/regula-
\ntors of IEHPs to support development of
\nthe \u201csoft skills\u201d that are so crucial to suc-
\ncess in the workforce. These resources are
\nfreely available on-line at www.hireiehps.
\ncom and are meant to be a set of tools that
\ncan be accessed before or after migration.
\nWhile the focus and context of this work
\nis the Canadian health care system, many
\nof the modules contained in this program
\nwill have applicability to other jurisdic-
\ntions. The repository was explicitly de-
\nsigned to be patient focused and interpro-
\nfessional in its orientation, to reinforce the
\nstructure of health care delivery and prac-
\ntice in Canada. Any professional \u2013 physi-
\ncian, nurse, midwife, physical therapist
\netc \u2013 who is internationally educated can
\naccess the repository and benefit from its
\ncontent.The repository is rich in video and
\npatient simulations, provides opportunities
\nfor self-assessment and formative evalua-
\ntion, provides links for onward readings,
\nand uses a variety of teaching and learning
\nstrategies to convey complex content in an
\nengaging manner that is aligned with their
\nlearning needs.
\nConclusions
\nGlobal migration continues to be an im-
\nportant public policy and personal issue
\nthat affects all individuals in society. In
\nmany Western countries, reliance upon in-
\nternationally educated health professionals
\nis growing and health care systems would
\nstruggle to cope with increasing demands
\nwithout the contributions and talents of
\nIEHPs. The experience in Canada suggests
\nthat key issues related to better workplace
\nintegration for IEHPs include \u201csoft skills\u201d
\nMigration and Health Care CANADA
\n31
\nBACK TO CONTENTS
\nrelated to interprofessionalism and patient-
\ncentred care, and those specific strategies to
\nsupport learning and assessment in these
\nsoft-skills areas is necessary and valuable,
\nand will ultimately lead to better quality
\ncare for patients.
\nReferences
\n1.\t Organization for Economic Cooperation and
\nDevelopment (OECD) Migration Outlook
\n2015. Changing patterns in the international
\nmigration of doctors and nurses to OECD
\ncountries. Accessed at: https:\/\/read.oecd-
\nilibrary.org\/social-issues-migration-health\/
\ninternational-migration-outlook-2015\/chang-
\ning-patterns-in-the-international-migration-
\nof-doctors-and-nurses-to-oecd-countries_
\nmigr_outlook-2015-6-en#page1
\n2.\t Zurn P and Dumont JC. Health workforce and
\ninternational migration: can New Zealand com-
\npete? Organization for Economic Cooperation
\nand Development (OECD) case study.Accessed
\nat: http:\/\/www.who.int\/workforcealliance\/
\nknowledge\/resources\/oecd_migration_newzea-
\nland\/en\/
\n3.\t International Organization for Migration,
\nUnited Nations. World Migration Report 2018.
\nAccessed at: http:\/\/www.iom.int\/wmr\/world-
\nmigration-report-2018
\n4.\t Aluttis C,BishawT and Frank M.The workforce
\nfor health in a globalized context \u2013 global short-
\nages and international migration. Glob Health
\nAction 2014;7:10. Accessed at: https:\/\/www.
\nncbi.nlm.nih.gov\/pmc\/articles\/PMC3926986\/
\n5.\t Walton-Roberts, M, Runnels V, Rajan S et al.
\nCauses, consequences, and policy responses
\nto the migration of health workers: key find-
\nings from India. Human Resources for Health
\n2017;15:28. Accessed at: https:\/\/human-
\nresources-health.biomedcentral.com\/arti-
\ncles\/10.1186\/s12960-017-0199-y
\n6.\t Paul R, Martimianakis M, Johnstone J, Mc-
\nNaughton N and Austin Z. Internationally edu-
\ncated health professionals in Canada: navigating
\nthree policy subsystems along the pathway to
\npractice. Acad Med 2017;92(5):635-640.
\n7.\t Chen L, Evans T, Anand S et al. Human re-
\nsources for health: overcoming the crisis. The
\nLancet 364(9449):1984-1990.
\n8.\t Arah O, Ogbu and Okeke C. Too poor to leave,
\ntoo rich to stay: developmental and global health
\ncorrelates of physician migration to the United
\nStates, Canada, Australia, and the United King-
\ndom. Am J Pub Health 2008;98(1):148-154.
\nZubin Austin, BScPhm, MBA,
\nMISc, PhD, FCAHS
\nProfessor and Koffler Chair in Management,
\nLeslie Dan Faculty of Pharmacy,
\nUniversity of Toronto Canada
\nE-mail: zubin.austin@utoronto.ca
\nPaul AM Gregory, BA, MLS
\nResearch Associate, Leslie Dan Faculty of
\nPharmacy, University of Toronto Canada
\nMedicine is the \u201cscience or practice of
\nthe diagnosis, treatment, and preven-
\ntion of disease\u201d [1]. Another widely ac-
\ncepted definition is \u201cscience and art that
\ndeals with the maintenance of health and
\nthe prevention, alleviation or cure of dis-
\neases\u201d\u00a0[2]. Considering these two defini-
\ntions of medicine, it is clear that aesthetic
\nmedicine, as a new developing branch, has
\nsome features distinguishing it from con-
\nventional medicine.
\nAesthetic medicine encompasses special-
\nties that are aimed at improving the ap-
\npearance by treating certain conditions.
\nTraditionally, aesthetic medicine includes
\naesthetic dermatology, reconstructive
\nplastic surgery and cosmetic (aesthetic)
\nplastic surgery [3, 4]. A wide range of
\nprofessionals are involved in the field of
\naesthetic medicine\u00a0\u2013 dermatologists, plas-
\ntic surgeons, medical cosmetologists. In
\nsome cases, the medical team includes
\npsychiatrists, psychologists and dietitians.
\nThe training of different professionals on
\nBioethics and communication skills also
\ndiffers.
\nAccording to the American Academy of
\nAesthetic Medicine (AAAM), the term
\n\u201caesthetic medicine\u201d includes only mini-
\nmally invasive procedures and is quite dif-
\nferent from plastic surgery, which includes
\nface lift, breast implants, liposuction,
\netc\u00a0[5].
\nSome Ethical Aspects of Aesthetic
\nMedicine in Adolescents
\nRadka Goranova-Spasova Andrey Kehayov
\nEthical Aspects of Health Care
\nBULGARIA
\n32
\nIn this paper, we discuss all procedures that
\nare designed to improve the appearance,
\nnot just the minimally invasive. Conven-
\ntional medicine has a thousand-year his-
\ntory and the conditions it treats justify its
\nmeans, \u00ad
\nincluding violating the integrity
\nof the human body in surgical operations
\n[5,\u00a06]. When a person is ill, the only pur-
\npose is to cure or at least improve the con-
\ndition of the patient. In aesthetic medicine,
\nthe goal is not to restore impaired health
\nbut to improve the aesthetic appearance.
\nHowever, if we refer to the broad defini-
\ntion of the World Health Organization
\n(WHO), \u201chealth is a state of complete
\nphysical, mental and social well-being and
\nnot merely the absence of disease or infir-
\nmity\u201d [7]. In this sense, cosmetic proce-
\ndures are justified because they create the
\npsycho-physical balance necessary for the
\nhealthy human being. In addition, they can
\nsignificantly improve the quality of life and
\nsocial well-being of the individual.
\nImportance of the topic
\nWestern cultures (also Eastern ones) idol-
\nize the perfection of the human body. This
\nis not new in human history because the
\nbeautiful appearance is associated with
\ngood health, well-being and prosperity [8].
\nNever before, however, improving appear-
\nance with the contibution of medical pro-
\nfession has been so significant. Following
\nliterature review we have formulated the
\nfollowing reasons, which make the topic
\nrelevant, important and requiring increased
\nattention by the medical community and in
\nparticularly by the physicians involved in
\ncosmetic procedures.
\n\u2022\t Aesthetic procedures (dermatological and
\nsurgical) are becoming more and more
\npopular as a result of media, social net-
\nworks and aggressive marketing, promot-
\ning a particular appearance as attractive,
\ndesirable and accessible [9].
\n\u2022\t The contemporary values of Western so-
\ncieties, focused on beauty and perfection,
\nare a source of profits for those involved
\nin aesthetic medicine. According to the
\neconomy laws demand and supply are
\ninterrelated. And the orientation of the
\nmedical professionals to a purely eco-
\nnomic benefit is in contradiction with
\nmedical ethics values.
\n\u2022\t Improving economic, social and cultural
\nstatus is a prerequisite for easier access to
\ncosmetic procedures [10, 11].
\nWorldwide statistics show an increase in
\ncosmetic procedures. According to the lat-
\nest published data of The International So-
\nciety of Aesthetic Plastic Surgery for the year
\n2016, 31,610 million plastic surgeries were
\nperformed worldwide, and the total in-
\ncrease in surgical and non-surgical cosmet-
\nic procedures in one year was 9%. The ten
\nleading countries in cosmetic procedures
\nare the United States, Brazil, Japan, Italy,
\nand Mexico, where approximately 41.4%
\nof all worldwide cosmetic procedures are
\nperformed. These are followed by Russia,
\nIndia, Turkey, Germany, and France [12].
\n\u2022\t Adolescents are a specific group that
\nneeds legal protection. The number of
\nminors willing to undergo aesthetic in-
\ntervention is also rising [9].
\nAim of the study
\nWe set our aim to study and analyze some
\nethical aspects of aesthetic procedures in
\nadolescents. To achieve the aim, we used
\ncommon and private scientific methods, in-
\ncluding a documentary method and a litera-
\nture review, analysis, synthesis, and a\u00a0com-
\nparative method.
\nResults and discussion
\nFirst we reviewed the classification of aes-
\nthetic procedures (dermatological and sur-
\ngical) to assess their relevance to adoles-
\ncents and the ethical acceptability of each.
\nAnti-aging and rejuvenating procedures are
\nTable 1.\u2002 Types of aesthetic procedures and degree of ethical acceptability
\nType of procedure Procedure Ethical acceptability
\nReparative plastic surgery
\nSurgical treatment Cleft
\nlips\/ palates and other
\ncongenital malformations
\nEthically acceptable at a
\nreasonable risk
\nReconstructive plastic
\nsurgery
\nIn case of major injuries,
\nburns, accidents and
\ndiseases of the face and
\nbody
\nEthically acceptable at a
\nreasonable risk
\nAesthetic plastic surgery
\nBreast augmentation\/
\nreduction
\nOtoplasty
\nRhinoplasty
\nLiposuction
\nBlefaroplasty
\nHymenorrhaphy
\nDifferent degrees of ethical
\nacceptability in individual
\ncases.
\nIncreased attention: general
\nanesthesia; allergic reactions;
\nfailed surgery; dissatisfying
\neffect; complications.
\nNon-surgical cosmetic
\nprocedures
\n(face and body)
\nBotulinum Toxin
\nFacial fillers
\nLip augmentation
\nLaser for acne treatment
\nLaser hair removal
\nDifferent degrees of ethical
\nacceptability in individual
\ncases.
\nIncreased attention: local
\nanesthesia; allergic reactions;
\nfailed procedure; dissatisfying
\neffect; complications.
\nEthical Aspects of Health Care BULGARIA
\n33
\nBACK TO CONTENTS
\nnot used by minors, thus they are not in-
\ncluded [13].
\nPlastic surgery is usually divided into two
\ncategories\u00a0 \u2013 reconstructive and cosmetic
\n(aesthetic) surgery. The most commonly
\nused procedures on minors are presented by
\ntype on the following table.
\nReparative and reconstructive surgery is
\nassociated with pathology or major disfig-
\nurements. As these surgeries are most com-
\nmonly considered ethically acceptable, we
\nwill not put emphasis on them later in this
\npaper.
\nBreast augmentation is the most common
\naesthetic surgical intervention that is par-
\nticularly discussable in adolescents. Other
\nfrequent interventions include otoplasty,
\nrhinoplasty, lip augmentation with fill-
\ners and laser treatments. The ethical ac-
\nceptability of each procedure depends on
\na number of factors\u00a0\u2013 the severity of the
\ncondition, patient age, the risks of inter-
\nvention, etc.
\nApplication of the
\nPrinciples of Biomedical
\nEthics in Aesthetic
\nMedicine
\nIn 1979, Beauchamp & Childress pub-
\nlished the Principles of Biomedical Ethics,
\nwhich are now widely accepted as the ethi-
\ncal basis of medical practice.The Principal-
\nism is an ethical theory, based on the four
\nfundamental principles (autonomy, benefi-
\ncience, non- maleficience, and justice), and
\nis suitable for practical purpuses. In many
\ncases, solving ethical dilemmas is based on
\nintuitive professional knowledge [6].The
\nemergence of a moral case in which there
\nis a collision of value systems imposes a
\nhigher level of rules and guidelines to be
\ninvoked by medical professionals. Ethical
\nprinciples provide the abstract frames of
\nethical norms and outline the morally ac-
\nceptable limits of moral relationships [15,
\n18].
\nThe principle of respect for autonomy is
\nexpressed in the right of each individual
\nto make their own choices for themselves,
\nfollowing their own plan of life [6, 16]. In
\ngeneral, competent adults have the right
\nto decide whether or not they want to
\nundergo invasive manipulation. For that
\npurpuse, they receive complete informa-
\ntion on the need for the procedure and the
\npotential risks and give informed consent.
\nInformation should include, in addition to
\nprocedure risks, the probability of failure
\nand possible alternatives. One of the pre-
\nrequisites for informed consent is patient\u2019s
\ncompetence, i.e. the patient is able to un-
\nderstand the implications of informed con-
\nsent and the ability to freely give their con-
\nsent [17, 18] Adolescents have a different
\ndegree of autonomy and decision-making
\nability. Informed consent is given by their
\nlegal guardians\u00a0\u2013 parents or other guardians.
\nHowever, it is considered that the physician
\nshould provide sufficient and accessible in-
\nformation on the procedure\u00a0\u2013 its type, com-
\nplications, price and risks, both to parents
\nand minor patients [17, 18].
\nThe principle of beneficience requires that
\nmedical professionals act in favor of and for
\nthe benefit of the patient or what will fur-
\ntherer the patient\u2019s interest. This principle
\nhas been fundamental to the medical pro-
\nfession since its beginning.
\nThe principle of non-maleficience requires
\nmedical professionals to limit the harm to
\nthe patient or what will be against his\/her
\nbest interest. Patient\u2019s unrealistic expecta-
\ntions can raise ethical issues and, in order
\nfor a healthcare professional to comply with
\nthe principle of non-maleficience, he must
\nexplain the expected results and the pos-
\nsibility of failure. The physician should as-
\nsess both the physical and the psychological
\nstate of the patient in order to minimize the
\npossible risk, especially when it is not a per-
\nson with a disease [10].The registration of a
\nform of psychosomatic disorder is essential
\nfor the success of the procedure and for pa-
\ntient\u2019s satisfaction.
\nIt should be borne in mind that the risks
\nof different aesthetic interventions vary de-
\npending on the type of procedure, health
\nstatus, age of the patient, etc. Some proce-
\ndures do not require anesthesia,while others
\nare under local or general anesthesia. If the
\npatient\u2019s expectations are unrealistic and the
\nrisks unjustified, the physician has a duty to
\nassume moral responsibility and to refuse to
\nperform an aesthetic procedure. Physician\u2019s
\nduty should be put in front of the financial
\ninterest in line with the maxim Primum non
\nnocere\u201d (First, to do no harm).
\nBoth principles (of beneficience and non-
\nmaleficience) rest on the fundamental im-
\nportance of the interest of and benefit to the
\npatient [19]. In the first the focus is on the
\npositive requirement to affirm the interest
\nof the patient and in the second\u00a0\u2013 on the
\nabstinence from actions that will disrupt the
\npatient\u2019s interest. It is sometimes difficult to
\njudge whether an action has benefit or harm
\nto the patient. Because the medical benefit
\nmay be accompanied by moral harm and
\nvice versa.
\nThe principle of justice in medicine is pri-
\nmarily seen in the context of distributed
\njustice and means honest, impartial and
\nappropriate action on the person [6].This
\nprinciple requires medical professionals to
\nprovide medical care to all those in need.
\nHealthcare systems, despite the variety of
\nfunding sources and payment methods,
\nwould rarely cover the cost of cosmetic pro-
\ncedures. So these procedures remain in the
\nprivate sector at the expense of consumers.
\nThose who can afford to pay undergo cos-
\nmetic procedure.Even in countries with low
\neconomic growth, the demand for aesthetic
\nmedicine is rising [20]. Aesthetic medicine
\ncan be referred to as a client\u00a0\u2013 user of health
\nservices\u00a0\u2013 rather than a patient.But the pro-
\nvider of these medical services should not
\nbe just a profit-driven dealer.
\nEthical Aspects of Health Care
\nBULGARIA Ethical Aspects of Health Care
\nBULGARIA
\n34
\nFactors for Increased
\nDemand for Aesthetic
\nMedicine in Adolescents
\nWe tried to summarize and systematize
\nthe main motives of adolescents to search
\nfor the services of aesthetic medicine. The
\ndemand for cosmetic surgery is usually mo-
\ntivated by psychosocial factors.
\n\u2022\t Psychological problems: The search for
\nplastic surgery is most often provoked
\nby psychological factors. In some cases,
\nit may be psychiatric disorders (for ex-
\nample, Body Dysmorphic Disorders\u00a0 \u2013
\nBDD). Typical of these patients is that
\nthe aesthetic problems they are looking
\nfor cosmetic services are not real. Often
\nafter a procedure, they are looking for
\nmore new interventions to improve their
\nappearance. Patients with such pathology
\nshould be consulted with a psychiatrist.
\nThe role of the aesthetic physician is to
\nrecord the likelihood of such disorder and
\nto redirect the patient,following the prin-
\nciple of harmlessness [21].
\n\u2022\t Low self-esteem, provoked by numerous
\nfactors\u00a0 \u2013 beauty standards promoted in
\nthe media and social networks; bullying at
\nschool; social exclusion. Each of these rea-
\nsons is real and in the specific cases the real
\nneed for the procedure must be assessed.
\n\u2022\t Real serious physical problem (severe
\nacne, congenital malformations, disabili-
\nties, etc.)
\n\u2022\t Aggressive advertising [22] and media
\ninduced perceptions [8].
\n\u2022\t Public acceptability and complicity of
\nparents (for example,in 2008,over 10,000
\nteenagers in Italy have corrected their
\nbreasts, most of whom have received the
\nsurgery as a gift from their parents).
\nAdolescent Patient\u00a0\u2013
\nFeatures And Rights
\nSome characteristics of adolescents that
\ndistinguish them from adults undergoing
\naesthetic procedures are as follows:
\n\u2022\t Adolescent patients may be considered as
\na specific vulnerable group. They do not
\nhave complete autonomy and their health
\ndecisions are often taken by their parents
\nand legal guardians [18]. Even more deli-
\ncate are cases in procedures that do not
\naim at restoring the health of the indi-
\nvidual and, as in aesthetic medicine, are
\napplied to healthy individuals [9].
\n\u2022\t Adolescents are still developing physi-
\ncally, mentally and emotionally. Unreal-
\nistic expectations and underestimation of
\nmedical risks are characteristic of them
\nbecause of their social immaturity.
\n\u2022\t In any case, besides the medical assess-
\nment, the physician should also assess
\nthe emotional maturity of the patient-
\ncustomer.
\nThe \u201cDoctor-Patient\u201d
\nRelationship and the Specific
\nRole of the Physician in
\nAesthetic Medicine
\nThe \u201cdoctor-patient\u201d relationship is funda-
\nmental to medical ethics. The health and
\ninterest of the patient are leading for the
\nphysician. The Declaration of Geneva of
\nthe World Medical Association states \u201cThe
\nhealth of my patient will be my first consid-
\neration\u201d [23]. In the present case, this rela-
\ntionship has two distinctions: 1\/ the patient
\nis more like a client, as discussed above; and
\n2\/ the patient is a minor and cannot declare
\ntheir own interest by themselves due to lack
\nof autonomy.
\nAesthetic medicine can be referred to as a
\nclient-user of health services rather than
\na patient. As we mentioned earlier, con-
\nsidering fairly distribution of resources in
\nhealthcare, aesthetic services are in the pri-
\nvate sector.
\nAdolescents cannot give informed consent
\non their own. Although they have no legal
\ncapacity, many are able to relate cause and
\neffect and to cover different tests that assess
\ntheir competence. In the case of cosmetic
\nprocedures, adolescents play an essential
\nrole in the decision-making process and the
\ndiscussion with them is just as important
\nas the one with the parent. Minor patients
\nmay have acquired autonomous capacity,
\nwhich is not always directly dependent on
\nthe age of the patient. The relationship be-
\ntween the parent\u2019s authority and the youth\u2019s
\nfreedom is dynamic. In the event of a dis-
\ncrepancy between the wishes and expecta-
\ntions of parents and children, the physician
\nmust always act in the best interests of the
\nchild; to reduce the potential adverse conse-
\nquences, including physical suffering, pain,
\nstress and death; to respect the spiritual and
\ncultural values \u200b\u200b
\nof the family and the child. 18
\nIn the case of a significant risk for small aes-
\nthetic benefits,procedures should be refused
\neven with the consent of the parents.
\nAdequate communication with the patient
\nis a mandatory professional characteristic
\nof the physician [6]. Communicative skills
\nare not simply granted, they are subject to
\nimprovement. Working with healthy indi-
\nviduals with certain expectations and wishes
\nposes new challenges for medical profes-
\nsionals. The patient-client is not dependent
\nand vulnerable, but demanding.
\nProfessionalism and
\nLegal Framework
\nAccording to the definition of Epstein and
\nHundert professional competence is the
\n\u201chabitual and judicious use of communi-
\ncation, knowledge, technical skills, clinical
\nreasoning, emotions, values, and reflection
\nin daily practice for the benefit of the indi-
\nvidual and community being served\u201d [24].
\nProfessionalism in medicine is guaranteed
\nby professional codes, ethical frameworks
\nand rules of good medical practice. This
\nhappens in the context of a more compre-
\nhensive legal framework [6].
\nMany European countries are introducing
\ntougher rules to protect adolescents under-
\nEthical Aspects of Health Care BULGARIA
\n35
\nBACK TO CONTENTS
\ngoing aesthetic medicine. In Austria and
\nGermany, adolescents under the age of 16
\ncannot undergo aesthetic surgery. Future
\npatients between 16 and 18 years of age
\nundergo a mandatory psychological assess-
\nment and need the consent of their par-
\nents\u00a0[9].Legislators in Italy have introduced
\na ban on breast plastic surgery in minors [8].
\nIn the field of aesthetic medicine there are
\nethical dilemmas which, given the increase in
\nthese procedures worldwide,require increased
\nattention. Therefore, the scientific commu-
\nnity develops relevant professional codes and
\nethical frameworks.The International Society
\nof Plastic Surgery, for example, introduces a
\ncode that guarantees the preservation of hu-
\nman dignity, academic and practical skills
\nof involved professionals. Adolescents are a
\nspecific vulnerable group with varying com-
\npetence degrees, but without the necessary
\nautonomy for self-informed consent. In each
\nparticular case, the physician should consult
\nthe adolescent, evaluate their expectations,
\nseek a balance between risks and benefits,and
\nact in the best interests of the patient.
\nProfessionals, beyond knowledge of the legal
\nframework of their country, must know the
\nbasic principles and rules of medical profes-
\nsion, the ethical codes and the rules of good
\nmedical practice in the specific field.The in-
\ntroduction of such rules in aesthetic medi-
\ncine is necessary and a guarantor of the qual-
\nity of medical services. Continuing training
\nin communication skills is a prerequisite for
\nbetter coping with ethical problems in the
\npractice of aesthetic medicine where patients
\nhave client characteristics.
\nReferences
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\n3.\t American Academy of Anti-Aging Medicine,
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\n4.\t Definition of aesthetic medicine, International
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Medical Professionals<\/a><\/p><\/blockquote>\n