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An ophthalmology code of ethics in Canada: enhancing our practice patterns
EDITORIAL
An ophthalmology code of ethics in Canada: Enhancing our practice patterns Medical codes of ethics are social contracts between physicians and the public that describe ethical values and standards of care to which we hold all members of our profession. These codes of conduct reflect the virtuous and trustworthy character that society expects from physicians. Codes of ethics also help guide physicians facing challenging situations through a framework of fundamental principles and values of medical ethics. The Canadian Medical Association code of ethics (CMA code),1 first published in 1868, is a robust and well-established ethical guide to help all practicing Canadian physicians. However, Canadian eye physicians and surgeons may face several unique ethical challenges not addressed in the CMA code due to evolving research, abundant innovative technology, and changing practice patterns in ophthalmology. In 2014, the Eye Physicians and Surgeons of Ontario (EPSO) recognized an opportunity to develop an ophthalmology code of ethics (EPSO code)2 to help our membership better address challenging eye care scenarios, such as the combining of insured and noninsured services, mandatory reporting of visual acuity and field defects, and supporting patients with current or potential visual impairment and blindness. The concept of a specialty-specific code of ethics is not novel in medicine or in ophthalmology. Codes have been established in orthopaedics, surgery, psychiatry, emergency medicine, and others. The International Academy of Ophthalmology published a “Code of Ophthalmology Ethics” in 1978.3 In 1977, the American Academy of Ophthalmology (AAO) began developing a code of ethics (AAO code).4 At the time, reports of unethical practice in the United States prompted the inclusion of sanctions to those who did not follow the “rules” of the code,5 which remain enforceable by the AAO ethics committee today. Similarly, recent anecdotes of practice patterns of some Canadian ophthalmologists echo concerns voiced in the past, with talk of fee splitting, unethical charges to patients, and deficient informed consent. From a public perspective, these allegations may bring into question the integrity of our profession and threaten physician self-regulation. Self-regulation is a privilege not held in all medical jurisdictions. Physicians in the United Kingdom lost selfregulation in 2009 due to the General Medical Council’s inability to address scandals involving “bad apple” doctors.6 Self-regulation in Canada is left to the provincial medical colleges and requires a clear understanding of accepted ethical standards of practice in each specialty.
These standards should be driven by our fiduciary duty to our patients, with trust as the essence of this duty and central to the physician-patient relationship. The development of a Canadian ophthalmology code of ethics helps clarify to all stakeholders that eye physicians and surgeons uphold the promise we make as doctors to “consider first the well-being of the patient.”1 At the same time, a code of ethics is practically useful to help guide members on ethical decision making. The EPSO code is heavily based on the CMA code, familiar to all Canadian ophthalmologists, and considers content found in the AAO code. One significant difference between the EPSO code and the AAO code is the absence of sanctions from the former. The AAO code is divided up into aspirational principles of “exemplary” professional conduct and mandatory rules of “minimally-acceptable” professional conduct.4 Bettman highlights legal struggles the American ophthalmology group overcame to be able to include sanctions in the AAO code. Without sanctions, Bettman suggests, the AAO code would be “written and ignored.”7 However, the resulting artificial division of values may also inadvertently send the message that some ethics are optional and takes away from the larger meaning of a code of ethics: to guide “right” action. We felt it best to leave disciplinary action to the provincial colleges. The EPSO code was circulated to the general membership in draft form before publication, providing an opportunity for membership input and feedback considered in draft revisions. This consensus process not only ensured all relevant specialty-specific issues were addressed, but also ensured the EPSO code reflects the current standards of ethical practice accepted in Ontario. Codes of ethics are living documents that change as practice standards evolve. The final version of the EPSO Code (www.epso.ca)2 was ratified at the 2014 Annual General Membership and will be revised as needed in future with consensus and approval from our membership. The EPSO code provides legitimacy to formal and informal discussions surrounding ethical dilemmas in our profession. The 2015 Canadian ophthalmological meeting invited guest lecturer, Alex V. Levin, MD, discussed the ethics of surgical innovation. We need to continue the conversation on ethically challenging situations at regional and national ophthalmology meetings and conferences, and we need to incorporate formal mandatory ethics curricula into Canadian postgraduate ophthalmology training programs. Training in the fundamentals of bioethics will empower new ophthalmologists to develop the skills needed to resolve conflicts in the best interest of their patients. The development of a code of ethics is a step towards regaining and maintaining the trust of our patients and Canadian society. The EPSO code reinforces to the public
CAN J OPHTHALMOL — VOL. 50, NO. 4, AUGUST 2015
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Editorial the importance ophthalmologists place on virtuous patient-oriented practice patterns. Chryssa McAlister, MHSc, MD, FRCSC,* Rosa Braga-Mele, MEd, MD, FRCSC,* Sherif El-Defrawy, PhD, MD, FRCSC,* Tim Hillson, MA, MD, FRCSC†
*
Department of Ophthalmology and Vision Sciences, University of Toronto, Ontoria † Department of Surgery, McMaster University, Ontoria Correspondence to: Chryssa McAlister, MHSc, MD, FRCSC: chryssa.mcalister@ utoronto.ca REFERENCES 1. Canadian Medical Association. Code of Ethics, 2004 Update. http://policy base.cma.ca/dbtwwpd/PolicyPDF/PD04-06.pdf. Accessed April 2, 2015.
Un code de déontologie pour les ophtalmologistes canadiens : pour renforcer nos modèles d’exercice Les codes de déontologie médicaux sont des contrats sociaux entre des médecins et le public qui énoncent les valeurs éthiques et les normes de soins que nous voulons voir tous les membres de notre profession respecter. Ces codes de conduite reflètent ce que la société attend des médecins : qu’ils soient intègres et dignes de confiance. Ils guident aussi les médecins dans des situations difficiles, en définissant des valeurs et des principes fondamentaux de déontologie médicale. Le code de déontologie de l’Association médicale canadienne (le code de l’AMC)1, publié pour la première fois en 1868, constitue un cadre robuste et bien reconnu qui guide tous les médecins praticiens au Canada. Les médecins et les chirurgiens ophtalmologistes canadiens peuvent cependant être confrontés à plusieurs défis particuliers d’ordre éthique que ne couvre pas le code de l’AMC, en raison de l’évolution de la recherche, de la technologie et des modèles d’exercice en ophtalmologie. En 2014, l’organisme Eye Physicians and Surgeons of Ontario (EPSO) a jugé nécessaire d’élaborer un code de déontologie des ophtalmologistes (le code de l’EPSO)2 pour aider ses membres à gérer des situations difficiles en matière de soins oculaires, telles que la combinaison de services assurés et non assurés, la déclaration obligatoire d’une perte d’acuité visuelle ou de champ visuel, ou encore le soutien de patients souffrant de déficience visuelle ou de cécité, ou à risque d’en souffrir.
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2. Eye Physicians and Surgeons of Ontario. Code of Ethics. 2014. http://www.epso.ca/what_s-new_/code-of-ethics/ Accessed April 2, 2015. 3. International Academy of Ophthalmology. Code of ophthalmological ethics. Trans Ophthalmol Soc UK. 1978;98:514-20. 4. American Academy of Ophthalmology. Code of Ethics. http:// www.aao.org/about/ethics/code_ethics.cfmpreamble. Accessed April 2, 2015. 5. Bettman JW. Ethics and the American Academy of Ophthalmology in historical perspective. Ophthalmology. 1996;103:S29-39. 6. Dixon-Woods M, Yeung K, Bosk CL. Why is U.K. medicine no longer a self-regulating profession? The role of scandals involving “bad apple” doctors. Soc Sci Med. 2011;73:1452-9. 7. Bettman JW. The Development of the Code of Ethics for the American Academy of Ophthalmology. Surv Ophthalmol. 2000;44:357-9.
Can J Ophthalmol 2015;50:253–255 0008-4182/15/$-see front matter & 2015 Published by Elsevier Inc on behalf of the Canadian Ophthalmological Society. http://dx.doi.org/10.1016/j.jcjo.2015.04.013
L’idée d’un code de déontologie propre à une spécialité n’est pas nouvelle en médecine ni en ophtalmologie. Il existe des codes en orthopédie, en chirurgie, en psychiatrie, en médecine d’urgence et dans d’autres disciplines. L’International Academy of Ophthalmology a publié en 1978 un document intitulé Code of Ophthalmological Ethics3. En 1977, l’American Academy of Ophthalmology (AAO) entreprenait la rédaction d’un code de déontologie (le code de l’AAO)4. À l’époque, des signalements de pratiques contraires à l’éthique aux États-Unis avaient mené ce groupe à prévoir des sanctions contre ceux qui ne respectaient pas les « règles » du code5; ces sanctions restent applicables aujourd’hui par le comité de déontologie de l’AAO. Plus près de nous, la mise au jour récente de pratiques douteuses d’ophtalmologistes canadiens fait écho aux préoccupations soulevées dans le passé – il est question de partage d’honoraires, de facturation contraire à l’éthique, de lacunes dans l’obtention du consentement éclairé. De telles situations peuvent miner l’intégrité de notre profession aux yeux du public et menacer l’autoréglementation de la médecine. L’autoréglementation est un privilège dont la profession médicale ne jouit pas partout dans le monde. Les médecins du Royaume-Uni, par exemple, ont perdu ce privilège en 2009 après que le General Medical Council a été incapable de répondre à des scandales impliquant des « pommes pourries » (“bad apple” doctors, en anglais)6. Au Canada, l’autoréglementation est l’affaire des collèges des médecins des provinces et territoires et elle nécessite une compréhension claire des normes de pratique éthiques acceptées dans chaque spécialité. Ces normes doivent être dictées par notre obligation fiduciaire envers nos patients – obligation qui repose sur la confiance, pierre angulaire de la relation médecin-patient.
An ophthalmology code of ethics in Canada: Enhancing our practice patterns Medical codes of ethics are social contracts between physicians and the public that describe ethical values and standards of care to which we hold all members of our profession. These codes of conduct reflect the virtuous and trustworthy character that society expects from physicians. Codes of ethics also help guide physicians facing challenging situations through a framework of fundamental principles and values of medical ethics. The Canadian Medical Association code of ethics (CMA code),1 first published in 1868, is a robust and well-established ethical guide to help all practicing Canadian physicians. However, Canadian eye physicians and surgeons may face several unique ethical challenges not addressed in the CMA code due to evolving research, abundant innovative technology, and changing practice patterns in ophthalmology. In 2014, the Eye Physicians and Surgeons of Ontario (EPSO) recognized an opportunity to develop an ophthalmology code of ethics (EPSO code)2 to help our membership better address challenging eye care scenarios, such as the combining of insured and noninsured services, mandatory reporting of visual acuity and field defects, and supporting patients with current or potential visual impairment and blindness. The concept of a specialty-specific code of ethics is not novel in medicine or in ophthalmology. Codes have been established in orthopaedics, surgery, psychiatry, emergency medicine, and others. The International Academy of Ophthalmology published a “Code of Ophthalmology Ethics” in 1978.3 In 1977, the American Academy of Ophthalmology (AAO) began developing a code of ethics (AAO code).4 At the time, reports of unethical practice in the United States prompted the inclusion of sanctions to those who did not follow the “rules” of the code,5 which remain enforceable by the AAO ethics committee today. Similarly, recent anecdotes of practice patterns of some Canadian ophthalmologists echo concerns voiced in the past, with talk of fee splitting, unethical charges to patients, and deficient informed consent. From a public perspective, these allegations may bring into question the integrity of our profession and threaten physician self-regulation. Self-regulation is a privilege not held in all medical jurisdictions. Physicians in the United Kingdom lost selfregulation in 2009 due to the General Medical Council’s inability to address scandals involving “bad apple” doctors.6 Self-regulation in Canada is left to the provincial medical colleges and requires a clear understanding of accepted ethical standards of practice in each specialty.
These standards should be driven by our fiduciary duty to our patients, with trust as the essence of this duty and central to the physician-patient relationship. The development of a Canadian ophthalmology code of ethics helps clarify to all stakeholders that eye physicians and surgeons uphold the promise we make as doctors to “consider first the well-being of the patient.”1 At the same time, a code of ethics is practically useful to help guide members on ethical decision making. The EPSO code is heavily based on the CMA code, familiar to all Canadian ophthalmologists, and considers content found in the AAO code. One significant difference between the EPSO code and the AAO code is the absence of sanctions from the former. The AAO code is divided up into aspirational principles of “exemplary” professional conduct and mandatory rules of “minimally-acceptable” professional conduct.4 Bettman highlights legal struggles the American ophthalmology group overcame to be able to include sanctions in the AAO code. Without sanctions, Bettman suggests, the AAO code would be “written and ignored.”7 However, the resulting artificial division of values may also inadvertently send the message that some ethics are optional and takes away from the larger meaning of a code of ethics: to guide “right” action. We felt it best to leave disciplinary action to the provincial colleges. The EPSO code was circulated to the general membership in draft form before publication, providing an opportunity for membership input and feedback considered in draft revisions. This consensus process not only ensured all relevant specialty-specific issues were addressed, but also ensured the EPSO code reflects the current standards of ethical practice accepted in Ontario. Codes of ethics are living documents that change as practice standards evolve. The final version of the EPSO Code (www.epso.ca)2 was ratified at the 2014 Annual General Membership and will be revised as needed in future with consensus and approval from our membership. The EPSO code provides legitimacy to formal and informal discussions surrounding ethical dilemmas in our profession. The 2015 Canadian ophthalmological meeting invited guest lecturer, Alex V. Levin, MD, discussed the ethics of surgical innovation. We need to continue the conversation on ethically challenging situations at regional and national ophthalmology meetings and conferences, and we need to incorporate formal mandatory ethics curricula into Canadian postgraduate ophthalmology training programs. Training in the fundamentals of bioethics will empower new ophthalmologists to develop the skills needed to resolve conflicts in the best interest of their patients. The development of a code of ethics is a step towards regaining and maintaining the trust of our patients and Canadian society. The EPSO code reinforces to the public
CAN J OPHTHALMOL — VOL. 50, NO. 4, AUGUST 2015
253
Editorial the importance ophthalmologists place on virtuous patient-oriented practice patterns. Chryssa McAlister, MHSc, MD, FRCSC,* Rosa Braga-Mele, MEd, MD, FRCSC,* Sherif El-Defrawy, PhD, MD, FRCSC,* Tim Hillson, MA, MD, FRCSC†
*
Department of Ophthalmology and Vision Sciences, University of Toronto, Ontoria † Department of Surgery, McMaster University, Ontoria Correspondence to: Chryssa McAlister, MHSc, MD, FRCSC: chryssa.mcalister@ utoronto.ca REFERENCES 1. Canadian Medical Association. Code of Ethics, 2004 Update. http://policy base.cma.ca/dbtwwpd/PolicyPDF/PD04-06.pdf. Accessed April 2, 2015.
Un code de déontologie pour les ophtalmologistes canadiens : pour renforcer nos modèles d’exercice Les codes de déontologie médicaux sont des contrats sociaux entre des médecins et le public qui énoncent les valeurs éthiques et les normes de soins que nous voulons voir tous les membres de notre profession respecter. Ces codes de conduite reflètent ce que la société attend des médecins : qu’ils soient intègres et dignes de confiance. Ils guident aussi les médecins dans des situations difficiles, en définissant des valeurs et des principes fondamentaux de déontologie médicale. Le code de déontologie de l’Association médicale canadienne (le code de l’AMC)1, publié pour la première fois en 1868, constitue un cadre robuste et bien reconnu qui guide tous les médecins praticiens au Canada. Les médecins et les chirurgiens ophtalmologistes canadiens peuvent cependant être confrontés à plusieurs défis particuliers d’ordre éthique que ne couvre pas le code de l’AMC, en raison de l’évolution de la recherche, de la technologie et des modèles d’exercice en ophtalmologie. En 2014, l’organisme Eye Physicians and Surgeons of Ontario (EPSO) a jugé nécessaire d’élaborer un code de déontologie des ophtalmologistes (le code de l’EPSO)2 pour aider ses membres à gérer des situations difficiles en matière de soins oculaires, telles que la combinaison de services assurés et non assurés, la déclaration obligatoire d’une perte d’acuité visuelle ou de champ visuel, ou encore le soutien de patients souffrant de déficience visuelle ou de cécité, ou à risque d’en souffrir.
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2. Eye Physicians and Surgeons of Ontario. Code of Ethics. 2014. http://www.epso.ca/what_s-new_/code-of-ethics/ Accessed April 2, 2015. 3. International Academy of Ophthalmology. Code of ophthalmological ethics. Trans Ophthalmol Soc UK. 1978;98:514-20. 4. American Academy of Ophthalmology. Code of Ethics. http:// www.aao.org/about/ethics/code_ethics.cfmpreamble. Accessed April 2, 2015. 5. Bettman JW. Ethics and the American Academy of Ophthalmology in historical perspective. Ophthalmology. 1996;103:S29-39. 6. Dixon-Woods M, Yeung K, Bosk CL. Why is U.K. medicine no longer a self-regulating profession? The role of scandals involving “bad apple” doctors. Soc Sci Med. 2011;73:1452-9. 7. Bettman JW. The Development of the Code of Ethics for the American Academy of Ophthalmology. Surv Ophthalmol. 2000;44:357-9.
Can J Ophthalmol 2015;50:253–255 0008-4182/15/$-see front matter & 2015 Published by Elsevier Inc on behalf of the Canadian Ophthalmological Society. http://dx.doi.org/10.1016/j.jcjo.2015.04.013
L’idée d’un code de déontologie propre à une spécialité n’est pas nouvelle en médecine ni en ophtalmologie. Il existe des codes en orthopédie, en chirurgie, en psychiatrie, en médecine d’urgence et dans d’autres disciplines. L’International Academy of Ophthalmology a publié en 1978 un document intitulé Code of Ophthalmological Ethics3. En 1977, l’American Academy of Ophthalmology (AAO) entreprenait la rédaction d’un code de déontologie (le code de l’AAO)4. À l’époque, des signalements de pratiques contraires à l’éthique aux États-Unis avaient mené ce groupe à prévoir des sanctions contre ceux qui ne respectaient pas les « règles » du code5; ces sanctions restent applicables aujourd’hui par le comité de déontologie de l’AAO. Plus près de nous, la mise au jour récente de pratiques douteuses d’ophtalmologistes canadiens fait écho aux préoccupations soulevées dans le passé – il est question de partage d’honoraires, de facturation contraire à l’éthique, de lacunes dans l’obtention du consentement éclairé. De telles situations peuvent miner l’intégrité de notre profession aux yeux du public et menacer l’autoréglementation de la médecine. L’autoréglementation est un privilège dont la profession médicale ne jouit pas partout dans le monde. Les médecins du Royaume-Uni, par exemple, ont perdu ce privilège en 2009 après que le General Medical Council a été incapable de répondre à des scandales impliquant des « pommes pourries » (“bad apple” doctors, en anglais)6. Au Canada, l’autoréglementation est l’affaire des collèges des médecins des provinces et territoires et elle nécessite une compréhension claire des normes de pratique éthiques acceptées dans chaque spécialité. Ces normes doivent être dictées par notre obligation fiduciaire envers nos patients – obligation qui repose sur la confiance, pierre angulaire de la relation médecin-patient.