1.  A Colleague in Trouble You are a physician who works in both urban and rural settings. Over the past six months, the behaviour of a colleague you have known for 10 years has changed. The physician has: o become somewhat unreliable, showing up late for meetings and/or procedures undergone personality changes o lacked attention to detail o occasionally smelled of alcohol o lacked judgment in some situations o responded negatively to colleagues who have attempted to intervene

What would you do in this situation?

Responses, as published in the Messenger, to this issue: I would first discuss with another colleague my observations and conclusions. Hopefully we would then go together to address her/him in a friendly, candid manner if we judged we had a reasonable chance of her/his seeking appropriate help. (Dr. Cliff Nelson) This situation should be handled in the same way as any person employed in a position which would be considered a critical safety position...Since this is a physician governed by the rules of a governing board, the College should be notified. It would not be your role to treat or diagnose this situation. (Dr. Tim Lepard) The first step when encountering a case like the one described, is the recognition that there exists a great likelihood of problematic substance use, which may not be limited only to alcohol. Untreated substance use disorders in healthcare professionals may have the potential of placing the public at risk, and where a reasonable index of suspicion exists, notification of the local regulatory body is indicated. This activates a protocol for full assessment, and if indicated, the appropriate treatment....Exciting new treatment options are emerging for the treatment of addiction and comorbid mental health concerns, and the occupational, health, and social outcomes for impaired physicians are indeed optimistic....The biggest dilemma physicians face is realizing that reporting of an impaired colleague is in the best interest of the involved physician and his patients, and in dispelling the perceived notion that staying silent “protects” our colleague. Silence only maintains the disease. (Dr. Charl Els)

2.  Accepting Patient's Gifts You are a family physician with hospital privileges working in a large urban clinic. Following hospitalization for pneumonia, one of your long­term patients gives you a gift as a thank you for the care you provided. The gift is a $250.00 certificate to a well­ known local tailor who you know does excellent work.

What would you do in this situation?

Responses, as published in the Messenger, to this issue: “The physician­patient relationship is complex and matures with time. It is the responsibility of the physician in this situation, therefore, to gauge the maturing and appropriateness of the physician­ patient relationship, and to determine the appropriateness of accepting the gift. This is one aspect of our professionalism that will not be able to be subjected to any “blanket rule.” (Dr. J. Fernandes) “It is never appropriate to accept monetary gifts or gifts of significant monetary value from patients...I believe that personal gifts or tokens of appreciation, such as “Thank you” cards or handmade gifts having more sentimental than monetary value, are entirely appropriate, and in fact are a healthy form of interaction between care providers and patients...Fundamentally, the issue devolves to this. It is a reasonable expectation that treating physicians accept and recognize the sentiment of gifts from patients. In order to retain an appropriate and healthy relationship with one’s patients, gifts which benefit the physician financially must always be redirected or refused. Like any other interaction with a patient, documentation is necessary.” (Dr. M. Rose) “I recommend not accepting the gift because this could have problems down the road.” (Dr. H. Hoffman) “I feel that it would be wrong to categorically forbid gifts from patients. It is a way in this society to express appreciation and affection. Gifts have to be differentiated from “bribes” and that is not always easy. Gifts should also be appropriate in size and a physician has to weigh whether there are expectations attached to this before acceptance, as this may haunt the physician later.” (Dr. E. Schuster) “I don’t know if ethical principles would make distinctions based on the size of the gift but it strikes me that there is a difference between an “appropriate” gift relative to service performed vs. something completely outrageous...Of course, there is another side to accepting gifts that should be considered. In accepting a gift does this imply that a favour may need to be returned? Does this mean that a physician will be expected to be more readily available, more easily convinced, more likely to provide a requested letter, more apt to squeeze in an appointment, etc, etc....The more I ponder on this gifting issue, the more complex it becomes.” (Dr. M. Joffe) “In general, a physician will feel uncomfortable if a gift from a patient has a substantial value, as opposed to a modest one. However, this cannot be defined by an exact dollar value...a $250 gift is not a modest one for most patients, but it may be modest for an affluent patient, and perhaps this long­term patient is trying to express his gratitude for years of service – not necessarily just his recent care.” (Dr. S. Shafran)

3. Confidentiality and High Risk Patients The parents of an adult child (age 23 years) come to you in your role as the patient’s family physician with concerns that they are unable to obtain information regarding their daughter. She had received much attention from the health care community as a result of diabetes mellitus and chronic pain, stemming from injuries sustained in a motor vehicle accident four years previously. She had recently become increasingly withdrawn.

What could you, as the usual treating physician, tell the parents? Is there an ethical way of having them understand what transpired in your treatment plans? Four months after their initial visit, the parents arrive at your office with a death certificate, the will of their recently deceased daughter, and a toxicology report indicating the presence of benzodiazpines and narcotics. They are actively grieving and questioning why they were not included in the treatment interventions. Does it make a difference to your obligations, if the patient herself indicated she does not want her parents to know about her health treatments? If the patient did not expressly state a desire to keep her information confidential, is there an obligation on your part to engage concerned parents in a treatment plan that will assure this high­risk individual’s safety?

Responses, as published in the Messenger, to this issue: This is an unfortunate situation that needs lots of communication.... Maybe a gentle suggestion (to the patient) that her parents are very worried and would like a bit of information may give the doctor a bit of room to discuss it with them... If the patient is competent and not a threat to herself or others then her confidentiality is paramount. (Dr. J. Huang) Trust is the foundation that grounds the physician­patient relationship. Respecting the privacy of patients, and giving them a place where they know their confidences will be protected, is key to the ongoing maintenance of that trust. When family members approach physicians for information about the past or current health status of patients, physicians are wise, not to mention obligated, to respect confidentiality. This should not mean a physician cannot speak to the parents of a 23­year­old woman with concerns about their daughter’s health. On the contrary, the presumption should be her parents are part of the support structure we hope exists for all of our patients. (Mr. G. Goldsand, Clinical Ethicist)

4. Disparaging Comments You are the training director for a residency program. Recently, several residents have come to you reporting that a physician frequently makes disparaging comments to residents and to patients about the work of other physicians. The physician’s latest comment was to a patient in which he said he would not allow a particular physician to treat his pets. Other comments attributed to this physician involved telling the residents that a surgeon is a butcher and a psychiatrist a mindless twit. The residents have attempted to speak to him about this practice to which the physician responded by saying he only speaks the truth, adding that patients and residents have a right to know. The residents report the comments appear to be unwarranted and they seem to be scaring the patients.

Is this physician behaving unethically? Should physicians question the work of their colleagues? How should this be done?

Responses, as published in the Messenger, to this issue: Unfortunately, this is something we see or hear too often. It is my opinion that this doctor is wrong and his behaviour is against the code of ethics. If a doctor has something to say against someone else’s practice, it should be done through regular channels and this may go up to health authorities, governing bodies or even a complaint to the CPSA. This resident is right and should report this doctor. (Dr. M. Trudeau) This doctor is ethically immoral and legally at risk of action for slander. He is destroying the trust in the medical establishment of both patients and colleagues. If he really believes what he says, then he should discuss his concerns with the other doctors themselves, face to face, or Chief of Staff, or the Ethical committee. (Dr. G. Stewart­Hunter) Should physicians question the work of their colleagues? Absolutely ­ within the realms of appropriateness, professionalism and courteousness, without malice or ill intent, for the purpose of improving patient care and in the right setting. Keep little things little, simple and straightforward, critique actions not people, don’t make it personal, do it for the right reasons, ensure that the correct person does it in a private place with adequate warning.When done in this manner it often has the best potential to be a building and growing experience. (Dr. L. Clarke)

5.  Elderly Patient's Autonomy You are nearing the end of your practice career and many of your patients are older. Several of them have developed mild dementia and you’ve been discussing their wishes should they continue to lose mental capacity. The other day, an elderly gentleman arrived for his appointment with his middle­aged son who reported that his father is becoming increasingly forgetful. The son would like to have his father moved to a facility rather than continue to live on his own. While examining your patient, you note he has multiple bruises on his upper arms that suggest he has been grabbed by someone’s hand. When you discuss with him the idea of moving to an assisted living facility, he becomes very upset and says his son wants to get his hands on his money and that is why he wants him to move from his own home. The patient’s Mini Mental Status examination is within the normal limits and he reports that his multiple bruises are the result of a friend grabbing his arm while they were out walking. You would like to respect your patient’s autonomy to make his own decisions but have some concerns that he may be at risk. You are not sure what the ethical principles are and approach your colleague for advice. What advice would you give to this colleague if you were approached? Responses, as published in the Messenger, to this issue: As physicians, we are often trying to balance the autonomous rights of our patients with the need to protect those who are vulnerable. Older patients, whose capacity to make decisions is diminishing, can be vulnerable to abuses. However, they can also display suspicious tendencies as a symptom of cognitive decline. In this case, it would be important to fully explore all aspects of the patient’s history, assess his capacity, determine if he has a personal directive and who would act for him if he lost capacity, and fully explore the potential for financial or physically abusive situations. (Dr. J. Wright, CPSA Assistant Registrar) Respecting the autonomy of patients has rightly become the central ethical principle in the delivery of healthcare, and this case is no exception. The physician is showing great respect for his/her patients with early dementia by discussing the expected trajectory of the illness, and then charting any opinions they convey about where they may eventually want to live, how they would like decisions made, acceptable levels of risk, general attitudes about quality vs. mere quantity of life, etc. When we encounter patients whose own hopes and preferences appear to differ from what their families may think, we should chart these observations and then strongly recommend that they make a personal directive while they retain the capacity to do so. We should offer to assist with this if need be, especially under these circumstances. (G. Goldsand, Clinical Ethicist)

6.  Managing your reputation Dr. Smith is a family physician working in a small town with a population of about 5,000 and frequently refers her patients to a larger urban centre. She has developed good working relationships with many of the specialists. This week, she received a copy of a consultation letter from one specialist to another that was very critical of the care she had provided to the patient. Although she was upset by the criticism, she felt that the physician did not have the full history, so she chose to disregard it. Later that day, the patient in question came for an appointment. The patient was very angry and reported that the specialist said that her incompetence had delayed the diagnosis and worsened her prognosis significantly. Dr. Smith was taken aback and had to spend a significant amount of time with the patient to discuss the issue. In the end, she felt that they could continue to work together; however, she was very upset with the specialist’s comments and wondered what to do? She notes that the Code of Ethics says, Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues. She comes to you to ask what she should do?

Responses, as published in the Messenger, to this issue: Poor Dr. Smith. She worked hard in a solitary practice in a small town with no colleague to consult with. Then she sees an interprofessional consultation that is critical of her care. One assumes her name specifically was used in the criticism. First, review the charts. Was there any possibility of malpractice? Have a friend­physician who works away from her practice review the situation by phone. (Don’t mention the name of the patient concerned or the staffman’s name in your conversation.) Next comes communication, and this can be tricky. First, talk to the staffman who received the complaint about you. He/she will obviously be aware of the criticism. He/she may identify what error may have been made, which would be helpful. On the other hand he/she may be baffled by the complaint as well. Now comes the difficult part. You have to confront the complainant, and the phone would be a good way. Call his/her secretary and ask if you could book a telephone appointment with his/her boss. Ask the secretary to kindly dig out the chart at the appropriate time. Do not discuss any matters pertaining with the secretary. Two things may happen, either you don’t hear back, or else he/she does call you. (...) see full text (Dr. Mike Hancock, Edmonton) The physician’s primary responsibility is the patient’s well being. Any concern about the maligning of the physician’s reputation by the specialist is secondary. In this case, the specialist caused direct and willful harm to the relationship between the physician and her patient. This is a complex longitudinal relationship that is built on mutual trust and respect and is central to the patient’s care over the long term. The criticism of one physician by another is often, as in this case, fueled by lack of information and understanding and is often unprofessional. There are venues to report truly incompetent care. If the specialist presumed the right to criticize the physician, then the specialist also had an obligation to ensure that his/her information was both correct and complete before rendering an opinion to the patient. In this case, the specialist did not attend to his/her responsibility to ensure that he/she had complete and correct information prior to rendering an opinion to the patient about the incompetence of the physician. (...) see full text( Dr. John Fernandes, Calgary) I read the Ethics 101 article in the latest issue of the "Messenger". I realize that you are expecting opinions from within the profession but I think that as a lay person I might have something to contribute. The danger of a well known physician having undue pressure on his/her colleagues would indicate that perhaps inviting these doctors to present at seminars supported by a pharmaceutical company would be contraindicated in a self governing profession that prides itself on it high standard of ethics and morality. These ethics must not only be practised but they should be seen to be practised. A physician who had been heavily involved in clinical studies and who was going to give an objective report on those studies, carefully avoiding any temptation to encourage the use of the treatment by others is probably an acceptable case. I have done some research and I would like to submit some numbers which might represent the cost to the company and benefit to the physician. I assume that the company wants to make a good impression on the physician, the amount of the honorarium is a guess as are allowances for meals and incidental expenses. Item First class airfare Edmonton, New York return Small suite in Fairmont hotel Meals Miscellaneous expenses taxis, limo's, laundry, phone calls, etc, Honorarium How Calculated airline website 4 nights @ $935 4 days @ $200 estimate estimate Grand Total Total $7,176 $3,740 $800 $500 $5,000 $17,216 I have been the patient of an incredible physician for almost 27 years and from what I understand if I were to give her a cheque for this amount she would have to answer to the college for receiving a large gift from a patient, I have read of such cases in the "Messenger". What is the difference from an ethical point of view if the gift comes from a patient or a pharmaceutical company? If I have overestimated the amounts of money I would appreciate a correction. (Paul S. Hinman, Edmonton)

7. Working with industry representatives While working in your office at a tertiary care hospital you agreed to meet with a representative from a pharmaceutical company. During that meeting, the pharmaceutical representative mentioned a meeting in New York City where she will be discussing the release of a new product. The company wants you to attend and participate in a educational session in New York and offers to pay for your flight, hotel and an honorarium. You tell her that you will think about it and get back to her. On reflection you are not sure that this is appropriate and decide to consult one of your colleagues. If you were the colleague, what advice would you provide?

Reponses, as published in The Messenger, to this issue: In general, I would tell my colleague that decisions to participate in this sort of event are personal decisions and each physician must make a decision with which he or she is comfortable. That said, it is important for my colleague to realize that there is frequently much more going on with such events than initially appreciated. Combining education with marketing is a very common strategy employed by industry. While there may be a real educational benefit to the event, the reason for including us is not altruistic. As physicians, we are very attractive to pharmaceutical companies. We prescribe medications for a third party. Convincing one physician to prescribe a medication, may lead to dozens (or even hundreds) of prescriptions for long term use. Moreover, convincing one high profile/opinion leader physician of the benefit of a medication may lead to many physicians adopting a new treatment, thus multiplying exponentially the potential number of prescriptions. So spending $5,000­$10,000 on a physician can be money very well spent. Of course, most of us will argue that just because we accept a dinner, or golf game or trip to New York, does not mean we are going to adopt the company’s product. In fact, we argue that it is insulting to think we can be bought off by such gimmicks. This argument is based on an important misconception. It is not about being bought off or bribed. Even the most morally dubious physician would have second thoughts about prescribing a medication just for a financial kick­back. What is actually going on in these scenarios is more subtle. Industry is exploiting societal conventions regarding obligation and reciprocity. (...)* See full text . (Dr. Wayne Rosen, Calgary) The physician thinking about industry supported travel to New York might consider several professional issues. In a tertiary care environment, the physician should be careful about role­modelling acceptance of largesse from industry. Medical trainees may come to believe that thinly veiled marketing influence on prescribing choices is an entitlement. The physician in a tertiary care academic environment should read the book “The Truth About Drug Companies” written by Dr. Marcia Angell, a former editor of the New England Journal of Medicine. Also the physician should become informed about the environment in New York and other parts of the United States where drug industry largesse has become a societal concern. United States Senate discussions stimulated by the 2009 Grassley­Kohl Physician Payments Sunshine Act have caused embarrassment for some academic physicians. The physician should read and consider the 2008 task force report of the Association of American Medical Colleges (AAMC) on industry sponsorship of medical education, and note the policies and guidelines on competing interests and disclosure. The Association of Faculties of Medicine of Canada has been less directive than its American counterpart, so far. The finances of medical schools are currently under great stress, but there needs to be a properly balanced approach to acceptance of industry support for institutions vis­a­vis individuals. If the physician has helped the drug company with legitimate clinical trials, he or she is not a company employee and should be aware of potential competing interests. And if the physician does accept support to attend the conference he or she will need to consider what to tell patients when prescribing the new drug, especially if there are reasonable alternative products. (...)* See full text . (Dr. Ray Lewkonia, Calgary)

8.  Obligation to the Community? You have enjoyed practising family medicine for 10 years but have recently received an offer to join a cosmetic practice. The hours and remuneration would be much better than you currently enjoy, but you are acutely aware of the shortage of family physicians that exists in your community. Furthermore, you know your patients will have difficulty finding a new physician. Do you have an obligation to the community to continue providing care? Or should you accept the offer, which will allow you to work less for significantly more income?

Responses, as published in the Messenger, to this issue: This society needs to decide what it values the most. If we allow cosmetic surgery to be better remunerated than dedicated family practice, we take a collective responsibility for this. Compared to other medical disciplines, the comprehensive family doctor has not been valued as much in the past (financially nor in societal status) and we are seeing the consequences in recruitment and retention. (Dr. E. Schuster) In this particular case, I think the physician has the right to change practices and I would fight hard to defend that right. Whether the doctor should choose to do so is another issue. Truth is that lots of doctors make this decision.... If the province wants doctors to stay in practice, they’d better make sure it is reasonably attractive. (Dr. G. Barr) The ethical dilemma is between exercising one’s autonomous rights as a private practitioner versus the violation of social obligations by creating hardship upon one’s own community of dependent patients. (Dr. N. Yee) Family practice is possibly the most undervalued area of medicine with physicians continually dealing with higher workloads, increasing overhead, and inadequate remuneration. Continuing the status quo out of "obligation" is endorsing a system that results in unhappiness, burnout and possibly poorer patient care. I believe the only way to have physicians (and perhaps specifically family physicians) valued appropriately is for actions to occur which force a realization of that value. (Dr. S. Kyle) I believe that the hypothetical case, as presented, is a real­time dilemma presenting to most of the newer family physicians, and, unfortunately, the lures of "cosmetic medicine" and the "easier hours" and "better lifestyle" are going to win in a substantial number of situations. ...Why should a family physician feel "guilty" about crossing the line into cosmetic medicine and "feel­good medicine" when a substantial number of plastic surgeons and dermatologists and ophthalmologists have already made the journey into such lucrative pursuits? (Dr. B. Fernandes) This is an example of the Messiah syndrome thinking, that is, one person can save the world. The reality of it is, that if this MD drops dead today, the patients will be seeing another tomorrow. Life is short and you only get to go through once. As long as the MD is employed in or billing for providing care to those patients in their care, they are ethically charged with the responsibility of caring for them to the best of their ability. What physicians have to realize is there is a difference between being self­serving and doing what is best for themselves. If this MD's life would be better by them changing their practice then so be it. (Dr. G. Bolduc) Why should I have any sense of community, if already five of my colleagues in my city provide cosmetic services? Why should I care about community when all community wants is timely service, e.g. Pharmacists prescribing, if I can’t respond yesterday? (Dr. P. Mah) My taking the position in the cosmetic practice would not be a loss to the community and therefore I would not be under the usual and customary obligation to that community. I would be willing to accept the less work for significantly more money. (Dr. M. Prowse) Under ideal circumstances, ethically speaking, a physician does have an obligation to the community to continue providing care if there is no one else available. Unfortunately, this is an unrealistic expectation because ethical physicians who start practices in many rural, underserviced areas could then potentially be stuck there forever without relief. (Dr. M. Bozdech)

9. Maintaining confidentiality in a small community You moved to a town of 5000 to join a family practice with two other physicians. You are enjoying the town very much and find everyone friendly and welcoming. The clinic staff seem to know everyone in town and often provide you with background information about patients and their families. Your wife teaches at the local school and one of her colleagues is married to one of your office staff. Last week your wife overheard her colleague talking about a patient who has been diagnosed with breast cancer and he said he learned about it from his wife who works at the medical clinic. You are wondering how to maintain confidentiality in a small close knit community and what you should say to your office assistant about this possible breach of confidentiality.

Response, as published in the Messenger, to this issue: In dealing with this problem, several principles need to be respected. It is not necessary to be specific about the third party information you have received from your wife. The best way to approach this issue is to announce to your staff that you will have “regular” (you set the frequency) meetings to discuss matters of interest shared by staff and doctor(s). Plan the first meeting soon, such as having a meal­brought­in “lunch” event. Tell your staff that the issues to be discussed at each meeting relate to patient and staff issues with patient concerns being of primary importance. The topics can be generated by the doctors or staff, but should generally be provided in advance so that everyone attending will know what to prepare for, and likely what participation is expected from them, at each session. Advise them that at this first session the agenda will be “patient privacy” and if you wish, other basic administrative issues, such as dealing with requests for charts or chart information as these items fall within the confidentiality issues of patient information. The long­term aim of these meetings is to develop standard policies on all important interpersonal and professional issues that doctors and staff must respect within their medical practice. Interpersonal staff and medical doctor issues can also be brought to this meeting, but the doctor’s intent is to develop an agenda that emphasizes the needs of patient service and office efficiency. Be sure that everyone in the office will be there – no one gets to avoid the planned meeting – so that everyone participates in these events. At the end of the first meeting, seek comments if none are offered, and then advise on the time and topic of the next meeting. At that meeting simply review approved policy relating to confidentiality of patient clinical data, covering receiving and sharing (gossiping) patient information as well as the need to protect contents of charts and other relevant communication devices involved in your medical practice. It will be necessary at this meeting to detail what penalties apply to those who are revealed to be discussing patient issues outside of the medical practice. This obviously will include the possibility of dismissal and the possibility of a civil suit by an aggrieved individual who identifies gossip and locates its source within the medical office. Further, health care policies on information handling should be formally presented, including the guidelines of the Medical Associations, Colleges and regulations established by government. The meeting can be kept short by preparing an information report which details the issue at hand and lists the reasons for the policy. This way, the added penalties for breaking the policies also just become part of the general education theme on this important issue. It would be convenient and useful to prepare a similar document each time a meeting is held. These documents will become the Office Procedures and Standards Manual, with guidelines to managing interpersonal and health­related matters in the doctor’s office. Should anyone miss the meeting, have the meeting secretary identify that individual in the records and provide the meeting summary and related important documents to that individual shortly after the meeting. In that communication, have the recipient sign and send back the meeting documents, indicating that they understand and respect the policies contained in the statement. Once this routine is developed, it will be very uncommon for anyone to avoid these meetings. In this way no personal issues are ever presented. But, the importance and problems that may develop should confidentiality not be respected will be clear to all. This same “impersonal” technique should apply to all other office health­related issues dealt with at each of the subsequent meetings. Should it become necessary to speak to an individual who continues to break the principled rules, it should be done privately, quickly after the issue is identified, and may involve severe reprimand, as the doctor can be held responsible for being involved in this type of thing, should it not be totally controlled. (Rod Morgan, MD)

10. Sub­Optimal Care The May 2011 issue of The Messenger contained an article written by Dr. Dennis Kendel, Registrar of the College of Physicians and Surgeons of Saskatchewan. In the article, Dr. Kendel asserts physicians have a collective responsibility to protect patients from receiving sub­optimal care and hold a position of great public trust akin to the sentries on the great wall. His article calls on our profession not to abrogate our sentry duty as protectors of patients from harm associated with sub­optimal physician performance. In this new scenario, you have completed a locum in a physician’s office and noted many significant concerns in the care of a large group of patients, ranging from missed follow­up of investigations to misdiagnosis and poor management of chronic diseases. You already decided not to do another locum in this practice but are wondering now if you should do something more. For example, do you have an ethical obligation to report your concerns to someone and, if so, who this should be? You approach a colleague to ask for advice. If you were this colleague, what advice would you provide and why?

Responses, as published in the Messenger, to this issue: Medical care is an ever­evolving, ever­changing entity requiring all of us as clinicians to attempt to remain up­to­date on many varied conditions. In addition, we are responsible for ever­increasing technology in record­keeping, lab and imaging reporting and other diagnostics. We must rely on our staff to assist us with appropriate follow­ups, alert us to patients requiring attention, and correctly file records and reports. It is the rare clinician who can say that he/she have never missed a diagnosis or a follow­up report. I also think it’s a rare clinician who would not appreciate the direct approach by a colleague to give some constructive criticism about any of these matters. The majority of us are interested in giving good medical care, keeping up with the rapidly changing standards of care in medicine and learning better ways of delivering care both clinically and from a practice perspective. My advice would be to assist that physician or group of physicians with some direct advice on betterment of the practice. To have already decided not to do another locum in the practice is not helpful unless clearly the physician in question is not interested in making a change (which I think is unlikely). To decide not to return makes no positive changes for the practice; education is the answer. We should all feel responsible for helping our fellow physicians where we can. Our roles as physicians include education for patients, students and colleagues. I think the College should be available to assist in a scenario that we cannot resolve physician­to­physician, but self­governance can begin at a basic one­to­one information exchange level. ­ Sharisse Kyle MD CFPC(EM) Dip Sport Med I would arrange to meet this colleague socially as soon as possible for a debriefing session following the locum. The colleague in my opinion suffers from burn­out and/or depression. There may be substance abuse, marital problems, etc. I would guide the discussion and take it from there. Naturally, I would aim for agreement to undertake steps for further assessment and treatment (for instance through the AMA’s Physician & Family Support program), which I expect would involve a period of sick leave away from work. (I wouldn’t be surprised if I was approached to do another locum for this colleague! ) In any case, I would ask for his/her permission to meet again for follow­up/support just to make sure the colleague and practice will be safe. If the colleague disagrees with my assessment/suggestions, I would have to explain the consequences, be more confrontational, touch on reporting, etc. The follow­up would still stand. ­ Hans Berkhout (retired but in the process of re­activating his practice permit) Talk to the colleague for which you are doing the locum. Offer helpful suggestions re: the transformation of the clinic to one that you think will be better. DO NOT BE JUDGEMENTAL. If your ego is not up to a personal confrontation, write a letter offering suggestions for change. Offer to help with the suggested changes and definitely offer to do another locum for him. (Perhaps he is ready to retire and will offer you his practice ­ now that's a challenge.) ­ Dr. Selby Frank

11. Personal health information Your practice has a large number of older adolescents and young adults, and your patients frequently say they do not want any information released to their parents. Yesterday, you saw a 19­year old woman who is suffering from depression, has a history of binge­drinking and has had increasing thoughts of suicide. She reports she would not act on these thoughts because it would hurt her family, but you are worried about her. Her mother frequently brings the patient to her appointments. You thought of speaking to the mother but decided against this when your patient asked you not to. This morning, you received notification that your patient was brought into emergency last night following an overdose and was admitted to the ICU. You are now wondering if you should have spoken with her mother about your concerns. A colleague reports you could not talk to the mother because of privacy legislation, but you wonder if this is correct, and even if so, should you have tried to ensure your patient’s safety?

Response, as published in the June 2011 Messenger: Under the Health Information Act ( HIA) , Alberta’s access and privacy law for the health sector, custodians of health information such as physicians have a duty to protect the confidentiality of patient information. At the same time, the HIA affords custodians the discretion to disclose health information if, in the professional judgment of the custodian, the disclosure is essential in the circumstances. Custodians have a duty under section 58(2) of the HIA to consider the expressed wishes of patients as an important factor in deciding how much health information they disclose about them. In this scenario, the patient asked you not speak to her mother. While this expressed wish is an important factor in deciding to disclose health information about the patient, clearly it is not the only factor. Patient safety is of primary concern. Under section 35(1)(b) of the HIA , custodians may disclose health information to a person who is responsible for providing continuing treatment and care to the patient. In this case, the patient is an adult, but because her mother has attended appointments with her there is some evidence to suggest the mother is involved in your patient’s care. Based on your understanding of the care relationship between mother and daughter, you may decide to disclose the daughter’s health information to her mother. There is another section of the HIA that would allow you to disclose health information to the patient’s mother if the situation is more urgent. Under section 35(1)(m) of the HIA , you have the discretion to disclose health information to anyone if you believe, on reasonable grounds, the disclosure will avert or minimize an imminent danger to the health and safety of any person. Custodians are not held to a standard of perfection under the HIA , rather a standard of reasonableness. Therefore, if you reasonably believe that disclosing your patient’s thoughts about suicide to her mother will avert the imminent danger of her harming herself, you could disclose this information. The HIA gives physicians the ability to exercise their professional judgment when a patient is at risk. In making a decision to disclose your patient’s health information to her mother, keep a record of your reasons for making the disclosure and, of course, you should only disclose the amount of health information essential to meet the intended purpose. (Brian Hamilton, Director, Health Information Act, Office of the Information and Privacy Commissioner)

12. Let's Make a Deal? A Pharmacy's Offer At your last office staff meeting, the rising cost of rent and overhead was discussed. One of your partners mentioned that he had been approached by a large pharmacy chain with an offer of space adjacent to their new pharmacy that is only one block from your current offices. The cost per square foot is half of what you are currently paying and there was a suggestion that the rent could be lowered if the volume of prescriptions from your office were substantial. Although this offer is very tempting, you have reservations about the potential conflict of interest. One of your partners is pushing to explore this option. You are wondering if you could manage the conflict by refusing to engage in any reduction in rent based on prescription volume but still take the space at the reduced lease costs. Another partner feels that this arrangement will compromise her autonomy and feels that it will look as if the office is associated with the pharmacy even if it is not. Everyone agrees that the overhead costs need to be reduced. What is the right thing to do?

Responses, as published in the Messenger, to this issue: 1. Accept the offer to rent the space at a lower cost as there is no conflict of interest in renting an office space. 2. Decline the offer of lowering the rent for a larger volume of prescriptions as this arrangement would most likely bias the physicians to over prescribe. (Dr. J. Tse) Many physicians have come to experience "suggestions" from colleagues in the pharmaceutical industry as a regular part of practicing medicine in this part of the world. Physicians and drug makers are entwined in a necessary relationship, each with vital roles in getting effective medicines to the right people in an efficient manner. But the fact that these two distinct parties – physician and pharmaceutical salesperson – owe primary allegiance to two different realms – physician to patient, and drug representative to company and shareholder – creates the constant possibility of conflict of interest. (G. Goldsand, Clinical Ethicist)

13. Questioning your colleague's ability to practise safely For ten years you have worked in a clinic with five family physicians. Everyone gets along very well. The most senior member of the clinic, who founded it 40 years ago, has been a mentor and teacher to most of the other physicians. He was planning to retire but changed his mind when he lost a significant percentage of his retirement income in a stock market crash. Over the past year, you have noticed he often forgets to do things, and his charting has declined significantly. Any attempts to discuss this with him were met with denial. The group decided to keep a close watch on him, hoping there would be no further decline to his practice prior to his retirement. When he announced that he was going to continue practising, the group attempted to discourage him but he reported that he could not afford to retire for another five years. His colleagues hold him in very high esteem and do not want to hurt him, but they are concerned about his ability to care for patients. The group met and a decision was made to approach him and insist that he sees his physician about his memory problems. No one was sure what to do if he refused, or if they continued to notice a decline in his functioning. The group wondered at what point they would need to act to protect patients. What would you do in this circumstance?

Responses, as published in the Messenger, to this issue: Physicians who maintain open and communicative relationships with colleagues and patients set the stage for being able to deal with the ethical dilemmas they will inevitably face together. And while duties to patients are generally clear, it is not so easy to know the extent of one’s duties to colleagues. The group is correct in having decided that someone needs to discuss the issue with their mentor directly, however difficult that might be. And while the extent of his cognitive decline is something he ought to discuss with his physician, this scenario also raises the question of how physicians ought to offer peer support and professional supervision to each other. While professional autonomy and independence are positive features of a medical career, if these are excessive, a practitioner can feel alone and abandoned. This team of five physicians could consider a more formalized structure where honest assessment of one’s performance and development can be discussed. Talking routinely with a trusted mentor or peer is beneficial for ongoing professional development, and should be standard. Wanting to spare the hurt feelings of their mentor is natural, but the member of the group closest to this physician should sit down and engage in an open and honest discussion. They should determine what insight he might have into his own decline, consider whether he is still able to see patients safely, and explore any face­saving alternatives that will enable him to complete his career with his dignity intact, and his patients safe. When close and trusting relationships already exist with colleagues, facing such dilemmas together will be far easier than in situations where insufficient communication and “excessive professional politeness” have rendered them unable to talk honestly with each other. (Gary Goldsand, Clinical Ethicist, Edmonton) As the original guy, now 26 years later with four colleagues, I must say that it has occurred to me that I may be the individual in question. The answer is of course: 1) Have a group intervention, 2) Advise the College if it does not go well! (Dr. Rick Zabrodski, Prof. Corp.)

14. Treating a Family Member You are a physician with a busy family practice in a mid­sized city. Recently, three of your colleagues left the region to practice elsewhere, adding to the pressure to take on more patients. On top of this, your elderly father recently moved into the community and is demanding of your time ­ particularly in looking after his medical needs. You have refilled his prescriptions and examined him when he developed a cough but have encouraged him to seek another family physician. He cannot find one accepting new patients. You ask a colleague for assistance but she feels she cannot accept another patient with complex medical needs. You continue to fill your father’s prescriptions but feel uncomfortable and wonder about the ethical issues of treating a family member. You decide to approach a senior colleague for advice. What is the right thing to do?

Responses, as published in the Messenger, to this issue: Ethics, in plain words, is simply a set of rules of conduct and, even though this is a rather simplistic approach, it is my opinion that there should be room for manoeuvre....The case in point illustrates quite well the dilemma facing the practising physician. I have no doubt that the physician, in that particular instance, must prescribe for his relative. (Dr. H. Jacobs) The remedy is simple. Ensure that each Canadian has one GP (with allowance made for locums and cover by associates) and one only. Pay the GP for having the patient on their list (even if they don’t need to see them). In return require the GP to see them promptly when the need is there. What if more people come into town than the doctors care to take on? In the long run, the law of supply and demand will put this right. In the short run, medicare physicians should be required to take on extra patients as a condition of the provincial contract. (J. Blakiston, MD) I can’t tell from the case scenario how many physicians are left in the city. I feel strongly that treating family members is a dangerous scenario. Certainly in a complex case, there will be pressures on the “child” aka physician to do what his parent wants. There needs to be a mutual/reciprocal agreement among members in smaller communities of treating each others’ families to maintain professional objectivity. (Dr. C. Hilbert) The physician should report his unwilling colleagues to the College. It is simply unacceptable to refuse to care for the family members of a colleague, no matter how busy our practice.It is an honour to be asked to care for someone like that. I absolutely will not even discuss health issues with my own family. They have a wonderful family doctor who will attend to their needs. (Dr. J. Currie) 1.) In the present circumstances if you don’t help out your elderly family members no one else is likely to. Do what you can to help. 2.) At the same time, do your utmost to help them "acquire" a physician (difficult) and minimize their dependence on you. (G. Hunter, MD)

15. Remaining Silent You have been reading a lot about the patient safety movement and the disclosure of errors to patients and their families. You cannot stop thinking about the following incident that occurred while you were a resident. While on call you were asked to see a woman whose labour was being induced with oxytocin or syntocinin. The fetal pH was becoming unacceptable and after consultation with your attending physician you elected to proceed with a C­Section. Once the oxytocin or syntocinin was discontinued, the fetal pH returned to normal so there was no urgency. You suggested an epidural be used but the young anesthetist wanted to do an immediate general anesthetic. This suggestion, as well as the anesthetist’s experience level concerned you, but you said nothing. The young anesthetist did not recognize nor know how to manage the woman’s extremely small mandible and you watched both the mother and baby die. At the inquiry you were called to testify but were not asked, nor did you volunteer, information about this aspect of the tragedy. You did not speak to the anesthetist despite having seen similar problems without consequences in the past. If you were faced with the same situation today, you are wondering what you could have done differently and why you felt compelled to remain quiet then. What could you have done then and what would you do today if faced with the same situation?

Responses, as published in the Messenger, to this issue: I am a FM resident, PGY1. I wouldn’t be quiet as a resident or if I was a student. I wouldn’t talk to the family or the anesthesiologist ­ I’d first explain the situation to my preceptor. I trust his judgment to make sure my perception of what happened is correct. I’ll follow up with what my preceptor advises me or call CCFP for further advice. (Dr. N. Khosrodad) I think that the main fear is to appear judgmental towards colleagues’ standard of practice. Young doctors need to still "practise" different techniques as they find what approaches they are comfortable with. I can sympathize with "remaining quiet" and hoping things work out. However, after seeing this pattern multiple times, I think there is no more understanding for silence. (Dr. C. Hilbert) In today’s complex environment, we would expect the disclosure would have occurred on perhaps multiple occasions. As always, comments about the performance of an individual team member would be avoided. It strikes me as quite difficult to address the decision made without questioning competence, although if this were to become a finger­pointing exercise no one would be well­served. The second question I would have, in this case, is what support was given to the anesthetist? This situation might (and more than likely) would be a career altering event. Support from his/her colleagues and institution would be crucial. (Dr. R. Johnston) The easy answer would be to tell the physician that he should have spoken up but speaking up can be very difficult. Many physicians are reluctant to speak up and say to themselves "there but for the grace of God, go I." Admitting our own errors is difficult and pointing out someone else's can be just as hard. However, it can be easier if we recognize that we are human and we all make errors. The patient safety movement calls for a shift in how we interact with each other and with our patients to minimize errors. Medicine is experiencing a cultural shift where it is not only acceptable but also expected that we will help our colleagues when we see the possibility of an error occurring. Evaluation of a critical incident looks at all the factors involved: fatigue, culture, hierarchy, equipment, etc. When an error occurs we are encouraged to disclose in a compassionate and honest fashion with our patients. (Dr. J. L. Wright)

16. Reporting Patients to the Police You have been treating a 24­ year­ old man for many years in your family practice. He has an anxiety disorder and had some trouble with substance abuse in his teens but has been doing well and attending university. After his last visit for a minor injury you noted that a prescription pad was missing. A few weeks later you received a call from a pharmacy asking you to verify a prescription for Lorazepam 1mg bid, 300 tablets and acetaminophen with codeine 300 tabs written for this patient. You report that this is a forgery and ask the pharmacy not to fill it. Your colleague urges you to report this to the police and states this is allowed under the Health Information Act. You are very angry with the betrayal of trust with your patient but you have never reported a patient to the police and wonder what you should do. The CMA code of ethics advises you to keep patients’ personal health information private and only consent to release to a third party with consent or as provided for by the law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm. You are wondering if your patient has a substance abuse problem and whether he could be selling this medication. You have called the patient to come in for an appointment but he has refused. Should you notify the police?

Responses: The following are excerpts from some of the responses we received. The full text of all letters is posted on the CPSA website at ­ look for Ethics 101 under publications/resources. Theft and forgery are criminal activities. If there is ambiguity with respect to the motive, let the judge decide. I suppose I should add, at the risk of stating the obvious, that yes, I would call the police. To amplify my comment, the patient has violated a boundary, crossing from merely self­ harming behaviour into criminality; enabling this benefits no one, least of all the patient. The behaviour typically represents the "tip of an iceberg." Anyone behaving in such a fashion is plagued by serious issues and needs serious intervention, heavy­handed as it may initially appear. The behavior is unlikely to self­ correct. (Dr. D. Fermor) The doctor­ patient professional relationship is complex, and must include consideration of the patient’s welfare and secondarily that of society in general. What constitutes "a significant risk of substantial harm?" Surely, except in extreme cases such as the risk of murder or suicide, this is a matter of opinion. In this young man’s case, his continuing suspected actions may result in the ruin of his life and that of others, but those possibilities do not yield an overwhelming argument for breaching the confidentiality code, all things considered. (Dr. E. Gingrich) Patient privacy ethics are designed neither to foster abuse of medications nor enable crimes against physicians. Clemency was offered but refused by the patient; therefore, reporting the patient to police is acceptable. (I. Gebhardt, MD) How can I know this person’s motivations for his behaviour, particularly if he won’t return to discuss the issue? Do I understand addiction, dependence or the patient’s underlying situation well enough to make a decision that may result in consequences that permanently affect his life, such as acquiring a criminal record? How can I come to an understanding that will allow me to make a more informed, appropriate decision? Given the nature of this situation, I’d be very sure to contact the patient myself. The importance of a face­to­face visit "to understand why this happened, and what should be done about it" cannot be understated. A personal call from a physician carries more weight than a call from the office staff, and also allows the physician, in the case where the patient categorically refuses to discuss this in person, to document, consider and act appropriately. (Dr. M. Rose)

17.  Peformance enhancing drugs A colleague has approached you for advice about a request he received from an athletic club to provide human growth hormone to athletes. He is wondering if there is any ethical reason not to proceed. He is aware of the prohibition by Sport Canada to performance enhancing drugs but feels that as long as the athlete freely chooses this option and is aware of all risks, medical and otherwise, then it should be allowed. What advice would you give your colleague and why? No reponses were received for this scenario.

18.  Prescribing for unnecessary treatments A 40­ year­ old woman came in and requested a prescription for a medication that was, in your opinion, contraindicated because of her co­morbid medical conditions. She said she was aware of the risks and insisted that if she wanted to proceed with the treatment, she should be allowed to do so. Furthermore, she stated that you had no right to refuse to prescribe it for her. You have always tried to act in accordance with the tenet “do no harm” and have felt that you must make an independent decision as to the acceptability of a treatment. One of your colleagues feels that if the patient is aware of the risks then you should provide her with the treatment if she requests it. You are unsure about this and wonder how best to sort this out. What should you do?

Responses, as published in the Messenger, to this issue: This scenario is timely and realistic, especially for family doctors. We must remember that the pharmaceutical industry is driven, like all big business, by profit. They advertise to the public and physicians to advance this goal. And it works, or they wouldn’t be spending millions on it. Most importantly, we must remember that this advertising (to both the public and doctors) is neither objective nor necessarily accurate. To that end, my answer to this patient would be a firm no. The analogy I’d offer is this: A Toyota salesman will never recommend an Accord, even if it’s better than a Camry. I will not base my medical judgement on the advertising efforts of the pharmaceutical industry. If this patient still has an issue with this, she should find a new doctor. (Dale Cole, CCFP ­ Calgary) While the patient has a right to the medication, the physician has an equal right to refuse to prescribe treatment he or she believes to be on balance harmful. The patient, however, deserves to be given a second opinion. So I would refuse to prescribe the medication but would provide a referral to a colleague for a second opinion regarding the risks vs. the benefits. I wonder what disease is supposed to be treated by the medication the 40 year old patient is requesting? Is it an urgent or even fatal condition? That would not change my position, but would change the urgency of the referral. (Dennis Fong, CCFP ­ California) When a patient is prescribed an antibiotic (clearly indicated for the patient at that point) both the doctor and the patient are aware of any side effects and/or adverse effects. The patient is given the prescription because the doctor clearly outlines the benefits vs. adverse effects so that the patient feels the treatment is justified. In this scenario, the patient should be given a type of presentation that will convince the patient to pick up the right prescription. This process may need a physician’s time, verbal expertise and a bit of patience. (Mira Parai, FRCPC, Pathologist ­ Red Deer)

19. End­ of­ life care Dr. Jones is an internist working in a tertiary care hospital. She covers the general medical units on weekends and supervises residents. Last weekend, a resident came to her with concerns about a patient who was receiving end of life care. The patient’s family had been reading about the Quebec discussion on euthanasia and expressed fears that the pain relief being offered to their mothr was designed to hasten her death. They were very opposed to this and wanted the resident to reduce the amount of medication given. The patient is unable to participate in these discussions and the resident is concerned that the patient will suffer extreme pain if the dose is lowered. Dr. Jones offers to speak to the family with the resident, but the conversation with the family does not go well. She approaches you to discuss any suggestions you might have to assist in discussions of end­of­life pain management and the ethical considerations associated with end­of­life care. How would you advise Dr. Jones?

Responses, as published in The Messenger, to this issue: The patient hopefully has had a family physician ­ who probably is not involved in the hospital care. I would recommend to Dr. Jones that she open the door for the patient’s personal physician to review the situation and advise the family accordingly. The communication block will hopefully be sidestepped to the satisfaction of all. (Warren Hindle MD ) The New York Times ran a terrific article on this called: When Morphine Fails to Kill by Gina Kolata (July 23rd, 1997)1. While it is somewhat older than I’d prefer ­ it is still incredibly accurate. The article quotes Portenoy, Kathleen Foley, Lynn, Mount, and others and is by far the best article I’ve seen on this particular myth about opioids. The article is rather North American centric in that it doesn’t quote Twycross, Bond, or others across the pond. (­morphine­fails­to­kill.html?emc=eta1 ). (Daniel Harries ) Find out if the patient has previously made her wishes known. An Advance Directive or nomination of a decision­making agent would be best, but even documented discussion with her family physician, or with hospital physicians when making a decision about ‘Goals of Care’, would clarify what the patient herself wished. If this can be established, the patient’s wishes are paramount, and should be carried out, though this should be done as tactfully as possible. If the patient’s wishes are not clear, I would suggest negotiating a written agreement with the relatives. This might require insisting that one person speaks for all. The agreement should acknowledge the relatives’ concern, then start from the premise that on no account should the patient be allowed to suffer pain, because this would be inhumane and unethical, and that the physician, with her special knowledge in this area, should be the judge of when her unconscious patient is in pain. She could explain about increased pulse­rate, blood­pressure, sweating, restlessness. Then she could agree to reduce the analgesic dose incrementally until the patient shows signs of pain, then increasing to the lowest dose at which pain is no longer evident, a task that could be delegated to the resident. (Dr Robert Burn, Family Physician )

20.  Responding to the College ­ your regulatory body While at the hospital doing rounds a colleague approaches you in an agitated state. She reports that she has been served a Notice to Practitioner from the College and has been charged with unbecoming conduct. She goes on to explain that she received a letter from the College six months ago and was so busy she never got around to responding to it. She claims it was a trivial matter relating to the failure to respond to a letter from a patient’s insurance company and can’t believe that the College would charge her. You are surprised too and ask if this came out of the blue. She admits that she was sent four reminder letters but that she had more important matters to attend to ­ like caring for patients. When she asks you what you think about this matter you are not sure what to say. What would you say to your colleague? Is it important to respond to the College ­ your regulatory body?

Responses, as published in the Messenger, to this issue: I would have told her that, “me and my scared ass would’ve responded immediately. My shaking fingers and sweaty palms would’ve made the phone call reluctantly but asap”. I have no empathy for this situation. Does she not stop her car when a police officer approaches either? What is her sense of entitlement that she is above the rules? (Dr. Nancy Blaney, Banff ) It is probably just as important to look after one’s “good health” in respect of the Registering Authority (College) as it is to look after one’s personal good health. Deterioration in either is going to negatively impact on our ability to service our patients, if that is our “raison d’etre”. (Dr. Selby Frank, Vegreville) I would be obliged to tell her this was a most serious mistake and I doubt if there can be a satisfactory excuse! I would also have to advise her that she had a responsibility to reply to the insurance company in a reasonable time frame. Not to respond to a patent’s request for information to be provided to a potential insurer could cause harm for the patient and also create a liability for the physician. I showed my son, who is a senior marketing consultant for a major Canadian Insurance agency the “ethics 101 case”. He told me that getting replies from physicians in a timely fashion is a major problem for the industry. (...)* See full text (Dr. Keith Todd, Calgary) ‚óŹ Responsibilities during a Pandemic You are a family physician working in a multi­physician practice. You and all of your partners also provide in­patient care and emergency room coverage at a local hospital. The outbreak of H1N1 influenza was raised at the last staff meeting and everyone is struggling to determine how the clinic and the hospital will manage during a pandemic situation. One of the physicians worked in Toronto during the SARS crisis and spoke about how difficult this was for health care workers. You do not have any children and one of your partners suggested that physicians with young children should not be required to put themselves at undue risk. What principles should your clinic consider as they make plans to prepare for a pandemic? Response, as published in The Messenger, to this issue: In the scenario outlined, there are two components to the problem: First is the risk of contracting and dying from infection, leaving possibly orphaned children. Second is the risk of acting as a carrier and infecting children who may have no immunity. I would draw your attention to another ethical dilemma. I am an older anesthesiologist on the verge of retirement and not sure whether I will continue practice for another year or not. I am in the age group which appears to have some immunity to the current threatening pandemic. Do I therefore have an ethical duty to renew my licence so that I may make myself available in an emergency? Obviously I cannot be forced to do so. My spouse is currently on home oxygen therapy for incipient respiratory failure. If I continue in practice can I ethically opt out of providing specialized airway care during a pandemic due to the obvious extreme risk I would expose her to? (Name withheld to maintain the confidentiality of personal health information)

21. Your Responsibilities During a Pandemic The year is 2007; Toronto has declared an emergency pandemic situation and all signs are that the cases in Alberta (and your community) are increasing rapidly. You have two school age children and are responsible for aging parents. You work in a multi­ doctor family clinic and take some shifts as a hospitalist every month. Your daughter has been sent home from school because she has been exposed to influenza and you are scheduled to do a shift in the hospital. You are aware the hospital is very busy, has many staff off sick and everyone is working to their maximum. What are your responsibilities to your family, the public, and your colleagues?

Responses, as published in the Messenger, to this issue: Since there is no/or pathetic protection protocols for medical staff working during a pandemic, ensuring basically that if you work during these time that you would get infected as well as transmitting the virus to your own home, all medical staff should stay home and tend their own families. Our first responsibility is to ourselves and our families. (Dr. W.T. de Vos) First and foremost, as a parent I am responsible for my children, both legally and morally. All other considerations are secondary. If I do not care for my children then no one else will... Don’t think that the powers in the Alberta Public Health Act scare me either. I’d rather get a $5,000 fine and have the judge throw me in jail for contempt of court than to have two children at home dying alone. (Dr. Padraic McCombe) The main issue in whether physicians will respond to a pandemic is one of personal safety. We do not ask others (i.e. paramedics) to enter an unsafe burning building since they will turn from rescuers to casualties (remember 9/11 and the firefighters lost in the building collapse). Physicians should not be asked to work in unsafe pandemic situations. Our ability to help others will be lost once we are infected ourselves. The healthcare workers infected with SARS were effectively removed from the response to SARS­­­and some died. (Dr. Warren Thirsk) I feel that in families where both parents work in the health care field, one parent should be allowed to stay and take care of children. (Dr. Alexandra Noga)

Source : Messenger - provided by student in pdf format (please email me the link if you know it so that the original source can be correctly acknowledged)  Editor: I feel that the issues these ethical questions raise are important too not for every day medical practice and not just interviews