10.3 CMA Code of Ethics, Professionalism, & Physician Health/Boundary Issues

The 2018 CMA Code of Ethics and Professionalism

The Canadian Medical Association (CMA) Code of Ethics and Professionalism outlines the ethical obligations and professional standards expected of all physicians in Canada. The code is structured around five core ethical virtues: Compassion, Honesty, Humility, Integrity, and Prudence.

Fundamental Commitments of Canadian Physicians

1. Commitment to the Well-being of the Patient: Place the health and well-being of the patient as the primary consideration.
2. Commitment to Respect for Persons: Respect the autonomy, dignity, privacy, and rights of patients.
3. Commitment to Professional Integrity: Maintain high personal and professional standards; practice with honesty and transparency.
4. Commitment to Health System Stewardship: Exercise responsible stewardship of healthcare resources while advocating for equitable access to care.
5. Commitment to Self-Care and Peer Support: Maintain personal health, resilience, and fitness to practice while supporting colleagues.

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Professional Boundaries & Prevention of Sexual Misconduct

The physician-patient relationship involves an inherent power imbalance due to the physician's clinical authority, specialized knowledge, and access to the patient's intimate physical and emotional details. Physicians must establish and enforce strict professional boundaries.

Boundaries vs. Boundary Violations

• Boundary Crossings: Minor, non-exploitative deviations from standard interaction that may be benign or clinically therapeutic (e.g., accepting a small handmade token of appreciation at the end of treatment, offering a brief comforting touch on the hand to a grieving patient).
• Boundary Violations: Harmful, exploitative actions where the physician satisfies their own personal, romantic, sexual, or financial needs at the expense of the patient.

Zero Tolerance for Sexual Abuse of Patients

Under provincial medical acts across Canada (such as Ontario's Regulated Health Professions Act), sexual contact or romantic relationships between a physician and a current patient constitute sexual abuse and professional misconduct. The legal penalty is mandatory revocation of the physician's license for a minimum statutory period (e.g., 5 years in Ontario).

Exam Trap: Consent is NOT a legal defense against professional misconduct in physician-patient sexual relationships! Even if a capable adult patient initiates or consents to romantic or sexual involvement, the physician is legally held responsible for violating boundaries.

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Treating Self, Family Members, or Close Friends

Both the CMPA and provincial regulatory colleges (e.g., CPSO, CPSA, CPBC) strictly advise physicians against providing medical care to themselves or immediate family members (spouse, children, parents, siblings).

Why Medical Care of Family is Problematic

• Loss of clinical objectivity and diagnostic impartiality;
• Reluctance of family members to disclose sensitive history (e.g., sexual history, substance use);
• Tendency to perform incomplete physical examinations or skip necessary investigations;
• Inappropriate prescribing practices.

Permissible Exceptions

Physicians may treat themselves or immediate family members only under two exceptional circumstances:

1. Minor, Self-Limiting Conditions: Treating minor ailments (e.g., mild upper respiratory tract infection, minor skin abrasions) when another physician is unavailable.
2. Emergency Situations: Immediate life-saving stabilization when no other qualified physician is accessible.

Absolute Prohibition: A physician must NEVER prescribe controlled substances, narcotics, benzodiazepines, or habit-forming medications to themselves or immediate family members under any circumstances, even in an emergency!

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Conscientious Objection & Effective Referral Guidelines

Physicians in Canada have the freedom of conscience to decline providing specific medical procedures (such as Medical Assistance in Dying [MAID], abortion, gender-affirming care, or prescription of emergency contraception) if doing so conflicts with their personal moral or religious beliefs.

Mandatory Regulatory Obligations for Objecting Physicians

While physicians have the right to conscientious objection, they cannot abandon the patient or impede access to legally permissible healthcare services. Regulatory colleges mandate that an objecting physician must:

1. Promptly Inform the Patient: Communicate the objection clearly, respectfully, and without expressing moral judgment, lecturing, or demeaning the patient.
2. Provide an Effective Referral: Ensure the patient is provided a timely, direct referral to a non-objecting, accessible physician, healthcare provider, or centralized referral agency capable of delivering the requested service.
3. Provide Emergency Care: If the requested intervention is urgently required to prevent imminent death or serious harm, the physician must provide care regardless of conscientious objection.

               [Patient Requests Controversial Procedure (e.g., MAID / Abortion)]
                                               |
                       +-----------------------+-----------------------+
                       |                                               |
           [Physician Has No Objection]                     [Physician Has Conscientious Objection]
                       |                                               |
          [Provide Care & Assessment]                 +----------------+----------------+
                                                      |                                 |
                                         [Express Moral Objection?]        [Provide Effective Referral?]
                                                      |                                 |
                                           (PROHIBITED BY COLLEGE)            (MANDATORY OBLIGATION)
                                                      |                                 |
                                        Do not judge or lecture patient    Direct transfer/referral to
                                                                           willing, accessible provider

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Physician Health, Impairment, & Peer Reporting

Physicians are ethically obligated to maintain their health and wellness to ensure their fitness to practice medicine safely. Burnout, major depression, substance use disorders, and age-related cognitive decline can compromise clinical judgment and endanger patient safety.

Mandatory Peer Reporting of Impaired Colleagues

If a physician has reasonable grounds to believe that a colleague is practicing medicine while impaired by chemical dependence, mental illness, or cognitive impairment, or is engaging in professional incompetence or sexual abuse:

• The physician has a legal and ethical duty to report the colleague to the provincial licensing authority (College of Physicians and Surgeons).
• Reporting ensures patient safety while enabling the impaired colleague to receive confidential support and rehabilitation through provincial Physician Health Programs (PHPs).

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Professional Social Media & Public Communication Guidelines

Physicians using social media must uphold professional boundaries, protect patient confidentiality, and preserve public trust in the medical profession:

• Never post identifiable patient information or images without explicit written consent.
• Maintain professional decorum and avoid offering individual medical advice on public forums.
• Declare any commercial conflicts of interest when communicating health information publicly.