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Conflicts of Interest in Canadian Health Care

Published online by Cambridge University Press:  24 February 2021

Bernard M. Dickens
Bernard M. Dickens*
Affiliation:
University of Toronto
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Extract

A study of conflicts of interest in Canadian health care law supposes that Canadian law contains features that distinguish it from law in any other jurisdiction. There was a time when law applied in the Canadian Common Law jurisdictions lacked these features. The law and legal process of the Common Law jurisdictions derived directly from England, whereas the Civil Law of Quebec was fashioned on the French Code Napoléon. Indeed, as recently as 1959, a distinguished Canadian academic commentator observed that “a perusal of Canadian law reports … conveys the impression that most of the opinions reported there are those of English judges applying English law in Canada, rather than those of Canadian judges developing Canadian law to meet Canadian needs with guidance of English precedent.” However, modern developments in Canadian society in general, and in its health care system in particular, now justify the claim that Canadian law is sufficiently distinctive to warrant its inclusion in comparative studies of legal regulation of health care professionals’ conflicts of interest.

Type
Articles
Information
American Journal of Law & Medicine , Volume 21 , Issue 2-3: Conflicts of Interest in Health Care , 1995 , pp. 259 - 280
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 1995

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References

1 The Common Law jurisdictions include all of Canada outside Quebec.

2 Horace E. Read, The Judicial Process in Common Law Canada, 37 CANADIAN BAR REV. 265, 959).

3 S.O. ch. 18 (1991), amended by S.O. ch. 37 (1993) (Can.).

4 For a full list of included professions, see infra note 36.

5 S.O. ch. 18, sched. 2 (1991), amended by S.O. ch. 37 (1993) (Can.). Health Professions Procedural Code, cl. 95(21); subcl. 95(22) similarly provides for a conflict of interest affecting a member of a health profession's Council or any of its committees.

6 See Norberg v. Wynrib, 92 D.L.R.4th 449 (Can. 1992).

7 See Malette v. Shulman, 67 D.L.R.4th 321 (Ont. Ct. App. 1990).

8 See Ernest J. Weinrib, The Fiduciary Obligation, 25 U. TORONTO L.J. 1, 9-15 (1975).

9 Taylor v. McGillivray, 110 D.L.R.4th 64 (N.B. Ct. Q.B. 1993).

10 Malette, 67 D.L.R.4th 321.

11 For texts on equity principles, see generally EQUITY, FIDUCIARIES AND TRUSTS (T.G. Youdan ed., 1989); EDMUND H.T. SNELL, SNELL's EQUITY (Paul V. Baker & Peter Langan eds., 29th ed. 1990); Weinrib, supra note 8.

12 92 D.L.R.4th 449 (Can. 1992).

13 Hodgkinson v. Simms, 117 D.L.R.4th 161, 178-79 (Can. 1994).

14 Norberg, 92 D.L.R.4th at 480.

15 Id. at 480-81. It is speculated that, rather than “neighbourhood,” Justice Sopinka intended “neighbour,” based on Lord Atkins’ test in Donahue v. Stevenson, 1932 App. Cas. 562 (H.L. 1932).

16 93 D.L.R.4th 415 (Can. 1992).

17 Norberg, 92 D.L.R.4th at 486.

18 Mclnerney, 93 D.L.R.4th at 424-25.

19 See generally supra note 11.

20 Hodgkinson v. Simms, 117 D.L.R.4th 161 (Can. 1994).

21 Id. at 178.

22 Henderson v. Johnston, 5 D.L.R.2d 524 (Ont. High Ct. 1956).

23 11 D.L.R.2d 19 (Ont. Ct. App. 1957); 19 D.L.R.2d 201 (Can. 1959).

24 Henderson, 5 D.L.R.2d at 533.

25 Id. at 534.

26 See generally supra note 11.

27 See, e.g., Hodgkinson v. Simms, 117 D.L.R.4th 161 (Can. 1994).

28 Id. at 181.

29 Id.

30 Taylor v. McGillivray, 110 D.L.R.4th 64 (N.B. Ct. Q.B. 1993). For legal comparisons, see Matthew Certosimo, A Conflict is A Conflict is A Conflict: Fiduciary Duty and Lawyer-Client Sexual Relations, 16 DALHOUSIE L.J. 448 (1993), and Szarfer v. Chodos, 27 D.L.R.4th 388 (Ont. High Ct. 1986), where a lawyer was found liable to a client for using confidential information of marital disharmony to have an affair with the client's wife.

31 Reibl v. Hughes, 114 D.L.R.3d 1 (Can. 1980).

32 See Annas, George J., Reframing the Debate on Health Care Reform by Replacing Our Metaphors, 332 NEW ENG. J. MED. 744 (1995)Google Scholar.

33 20 ENCYCLOPEDIA AMERICANA 740, 741 (20th ed. 1991) (noting that 9.5 million of Canada's 29 million citizens live in Ontario).

34 S.O. ch. 18 (1991), amended by S.O. ch. 37 (1993) (Can.).

35 Id. § 4.

36 The twenty-one professions covered are audiology and speech-language pathology, chiropody, chiropractic, dental hygiene, dental technology, dentistry, denturism, dietetics, massage therapy, medical laboratory technology, medical radiation technology, medicine, midwifery, nursing, occupational therapy, opticianry, optometry, pharmacy, physiotherapy, psychology, and respiratory therapy. Id.

37 S.O. ch. 18, cl. 51(l)(c) (1991). For specific regulations, see, e.g., Dental Hygiene Act regulations, R.O. 797/93, cl. 1(11) (1993); Nursing Act regulations, R.O. 799/93, cl. 1(26) (1993).

38 See, e.g., Medical Radiation Technology Act regulations, R.O. 855/93, cl. 1(16) (1993); Dietetics Act regulations, R.O. 680/93, cl. 1(33) (1993).

39 See, e.g., Medicine Act regulations, R.O. 856/93, cl. 1(21) (1993); Dentistry Act regulations, R.O. 853/93, cl. 2(31) (1993).

40 See, e.g., Chiropody Act regulations, R.O. 750/93, cl. 1(14) (1993); Chiropractic Act regulations, R.O. 852/93, cl. 1(14) (1993).

41 See, e.g., Nursing Act regulations, R.O. 799/93, cl. 1(12) (1993); Chiropractic Act regulations, R.O. 852/93, cl. 1(13) (1993).

42 See, e.g.. Medicine Act regulations, R.O. 856/93, cl. 1(1)(11) (1993); Pharmacy Act regulations, R.O. 681/93, cl. 1(19) (1993).

43 See, e.g., Audiology and Speech-Language Pathology Act regulations, R.O. 749/93, cl. 1(5) (1993); Massage Therapy Act regulations, R.O. 751/93, cl. 1(8) (1993).

44 S.O. ch. 18, cl. 95(21) (1991).

45 R.O. 797/93, cl. 1(19) (1993).

46 Id.

47 R.O. 798/93,-cl. 1(4) (1993).

48 R.O. 853/93, Cl. 2(35) (1993).

49 Id. cl. 5(3).

50 Id. cl. 5(4).

51 R.O. 853/93, cl. 5(4)(f) (1993).

52 Id. cl. 5(4)(g).

53 Id. cl. 5(5).

54 For the American Medical Association approach to physician ownership of laboratories to which patients’ samples may be given for analysis, see Council on Ethical and Judicial Affairs, Am. Medical Ass'n, Council Report, Conflicts of Interest: Physician Ownership of Medical Facilities, 267 JAMA 2366 (1992).

55 See Hodgkinson v. Simms, 117 D.L.R.4th 161 (Can. 1994).

56 R.O. 856/93, cl. 1(1)(5) (1993).

57 R.O. 853/93, cl. 5(5) (1993).

58 R.O. 800/93, cl. 1(27) (1993).

59 See generally supra note 11.

60 Id.

61 R.O. 681/93, cl. 1(20) (1993).

62 See infra notes 67-88 and accompanying text.

63 R.O. 856/93, cl. 1(1) (33) (1993).

64 Id. cl. 1(1) (34).

65 The tribunal's mandate is to protect the public against unqualified practice and unethical practice by qualified, licensed practitioners.

66 For example, fee-splitting or finder's fees.

67 6 5 O.R.2d 461, 463 (Ont. Div. Ct. 1988).

68 Id. at 463-64.

69 R.S.O., ch. 196 (1980) (Can.).

70 R.S.O., reg. 450 (1980) (Can.).

71 Id. cl. 25.

72 Cox, 65 O.R.2d at 463-64.

73 Id. at 466-67.

74 Id.

75 Id. at 466.

76 Id. at 467.

77 R.S.O., ch. 196 (1980) (Can.).

78 Cox, 65 O.R.2d at 466.

79 Id. (citing In re Feingold and Discipline Comm. of College of Optometrists of Ont., 33 O.R.2d 169, 173-74 (Ont. Div. Ct. 1981)).

80 Id. at 468.

81 Id. at 466.

82 Id. at 472.

83 Id. at 468-69.

84 Id. at 470.

85 Id. at 469.

86 Id. at 469-70.

87 Id. at 474.

88 Id.

89 COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS, AM. MEDICAL ASS'N, CODE OF MEDICAL ETHICS: CURRENT OPINIONS WITH ANNOTATIONS (1995).

90 See, e.g., Brigham and Women's Hosp., Policies on Hospital-Industry Relationships: Conflict of Interest Policy, Patent Policy, and Other Related Materials III-1 (Jan. 1989).

91 Id.

92 Id. III-2 to III-4.

93 793 P.2d 479 (Cal. 1990), cert. denied, 499 U.S. 936 (1991).

94 ROYAL COMM'N ON NEW REPRODUCTIVE TECHNOLOGIES, FINAL REPORT: PROCEED WITH CARE 967- 1015 (1993).

95 See Dickens, Bernard M., The Ethics of Fetal-Tissue Donation: Consensus and Contradiction, 151 CANADIAN MED. ASS'N J. 279 (1994).Google Scholar

96 Moore, 793 P.2d at 483.

97 Leading U.S. case law on informed consent was applied by the Supreme Court of Canada in Reibl v. Hughes, 114 D.L.R.3d 1 (Can. 1980).

98 Mclnerney v. McDonald, 93 D.L.R.4th 415 (Can. 1992).

99 Sanctions range from suspension, limitations on the access to funds, and limitations on the use of university affiliation in publication submissions or grant applications, to dismissal, including from a tenured position.

100 45 C.F.R. § 46 (1994).

101 Halushka v. University of Sask., 53 D.L.R.2d 444 (Sask. Ct. App. 1965).

102 See Reibl v. Hughes, 114 D.L.R.3d 1 (Can. 1980).

103 See, e.g., MEDICAL RESEARCH COUNCIL OF CANADA, GUIDELINES FOR RESEARCH ON SOMATIC CELL GENE THERAPY IN HUMANS (1990).

104 MEDICAL RESEARCH COUNCIL OF CANADA, GUIDELINES ON RESEARCH INVOLVING HUMAN SUBJECTS (1987) [hereinafter HUMAN SUBJECTS RESEARCH GUIDELINES].

105 MEDICAL RESEARCH COUNCIL OF CANADA ET AL., MEMORANDUM OF NOVEMBER 16, 1994 FROM FREDERICK H. LOWY, CHAIR, TRI-COUNCIL WORKING GROUP REGARDING THE ETHICS OF RESEARCH INVOLVING HUMANS (1994).

106 See CLAIRE BERNARD ET AL., NAT'L COUNCIL ON BIOETHICS IN HUMAN RESEARCH, LEGAL ASPECTS OF RESEARCH AND CLINICAL PRACTICE WITH HUMAN BEINGS (2d ed. 1995).

107 HUMAN SUBJECTS RESEARCH GUIDELINES, supra note 104, at 10-11.

108 LAW REFORM COMM’ N OF CANADA, TOWARD A CANADIAN ADVISORY COUNCIL ON BIOMEDICAL ETHICS 2-3, 14 (1990).

109 45 C.F.R. § 46 (1994).

110 HUMAN SUBJECTS RESEARCH GUIDELINES, supra note 104, at 12.

111 Weiss v. Solomon, 1989 R.J.Q. 731 (Que. Sup. Ct. 1989).

112 See Emanuel, Ezekiel J. & Steiner, Daniel, Sounding Board: Institutional Conflict of Interest, 332 NEW ENG: J. MED. 262 (1995)Google Scholar.

113 R.S.C., ch. C-6 (1985).

114 Tuohy, Carolyn Hughes, Principles and Power in the Health Care Arena: Reflections on the Canadian Experience, 4 HEALTH MATRIX 205 (1994)Google Scholar.

115 R.S.C., ch. C-6 (1985).

116 Id. § 12(l)(a).

117 Id. § 2.

118 Tuohy, supra note 114, at 212.

119 Id. at 227.

120 Id.

121 Id. at 210.

122 See Evans, Robert G. et al., Controlling Health Expenditures: The Canadian Reality, 320 NEW ENG. J. MED. 571 (1989)Google Scholar.

123 Tuohy, supra note 114, at 227.

124 Id. at 228-41.

125 Id. at 228-32.

126 Id. at 215-20.

127 See NATIONAL HEALTH AND WELFARE, CANADA, PRESERVING UNIVERSAL MEDICARE (1983).

128 Tuohy, supra note 114, at 215-20.

129 Evans et al., supra note 122.

130 In Ontario, for instance, medical misconduct was redefined by R.O. 857/93 to include “[c]harging a block or annual fee, which is a fee charged for services that are not insured services … and is a set fee regardless of how many services are rendered to a patient,” “[c]harging a fee for an undertaking not to charge for a service or class of services,” and “[c]harging a fee for an undertaking to be available to provide services to a patient.“

131 CONSEIL D’EVALUATION DES TECHNOLOGIES DE LA SANTÉ DU QUÉBEC, EVALUATION OF LOW VS HLGH OSMOLAR MEDIA, PRINCIPAL REPORT (1989-1990).

132 Tuohy, supra note 114, at 228.

133 CONSEIL D’EVALUATION DES TECHNOLOGIES DE LA SANTÉ DU QUÉBEC, SUpra note 131.

134 Id.

135 Roy, David J. et al., Editorial, The Choice of Contrast Media: Medical, Ethical and Legal Considerations, 147 CANADIAN MED. ASS'N J. 1321, 1322 (1992)Google Scholar.

136 Id.

137 Id. at 1323.

138 Id. at 1322.

139 See, e.g., L.W. SUMNER, ABORTION AND MORAL THEORY 18-19 (1981).

140 See Weinstein, Bruce D., Do Pharmacists Have a Right to Refuse to Fill Prescriptions for Abortifacient Drugs?, 20 LAW MED. & HEALTH CARE 220 (1992)Google Scholar.

141 R. v. Morgentaler, 44 D.L.R.4th 385 (Can. 1988).

142 See Weinrib, Lorraine E., The Morgentaler Judgment: Constitutional Rights, Legislative Intention and Institutional Design, 42 U. TORONTO L.J. 22, 69 (1992)Google Scholar.

143 See generally Bonbrest v. Kotz, 65 F. Supp. 138 (D.C. Cir. 1946) (illustrating the right of fetuses in the United States to maintain causes of action).

144 Tremblay v. Daigle, 62 D.L.R.4th 634 (Can. 1989).

145 Dickens, Bernard M., Abortion and Distortion of Justice in the Law, 17 LAW MED. & HEALTH CARE 395, 402-03 (1989)Google Scholar.

146 See Superintendent of Belchertown State Sch. v. Saikewicz, 370 N.E.2d 417 (Mass. 1977).

147 See Dickens, supra note 145.

148 A fee-for-service relationship is contractual even though the contract price is set by the provincial health plan fee schedule and payment is made directly by the provincial health insurance plan.

149 Evans et al., supra note 122.

150 Hodgkinson v. Simms, 117 D.L.R.4th 161, 173 (Can. 1994).

151 Tuohy, supra note 114, at 221.

152 Mathews, Julie E., Note, The Physician Self-Referral Dilemma: Enforcing Antitrust Law as a Solution, 19 AM. J.L. & MED. 523 (1993)Google Scholar.

153 See supra notes 67-88 and accompanying text regarding Cox v. College of Optometrists of Ontario.

154 Mathews, supra note 152, at 523 n.2.

155 Tuohy, supra note 114, at 227-28.