In codes of ethics, is less still more?

Britain's mammoth medical ethics tract has just
been unleashed on the world -- how does
Canada's code stack up?

BY GILLIAN WOODFORD

You've got two patients, a brother and sister, who don't speak to each other. The brother is diagnosed with a familial disease, colon cancer, but he won't let you tell his sister. And because he can't stand her he won't tell her either. What do you do?

For a start, you won't go looking for the answer in the Canadian Medical Association's (CMA) Code of Ethics. The three and a half page document simply doesn't go into that kind of detail--but should it?

The Code is currently being revised, but according to Dr Jeff Blackmer, CMA's Executive Director for ethics, there are no plans to expand it. By contrast, the recent revision of the British Medical Association's (BMA) code has just been released, and compared to the Canadian version, it's a whopper.

Weighing in at 848 pages, the BMA code dwarfs the Canadian one. The sheer size difference between the two can't just be down to British hot air and Canadian modesty. The size of the documents reveals almost as much about their philosophies as the content does.

Our approach
The Canadian version is resolutely generalist --"The Code is not, and cannot be, exhaustive," declares the preamble. Meanwhile, the BMA document --doorstop may be more apt --brings together all the decisions of the ethics committee and also cites examples from the legal code and case studies to illustrate each point. Their stated aims are to be as practical and hands-on as possible and to try to "look ahead to identify future ethical dilemmas and begin the process of review and critical analysis in order to produce guidance and direction that is ethically robust." The CMA Code is determined to avoid this kind of crystal ball gazing.

Because of its commitment to generality the CMA Code necessarily leaves out many important issues that plague today's doctors. Dr Nuala Kenny, a Dalhousie bioethicist, made the point in an editorial about the last revision in 1996, that it "fails to address issues such as peer review and conflict of interest. It is deafeningly silent on both abortion and euthanasia. In view of these limitations, the Code must be seen as an important but unfinished reflection on the essence of being a good physician."

Again, the BMA document has it all covered; it touches on all the issues cited by Dr Kenny, spending 10 pages on abortion and 19 pages on euthanasia.

Behind the times?
Is it possible that Canada simply hasn't caught up with the changing tide of medical ethics? Possibly. The trend away from paternalism and toward patient autonomy is gradually being incorporated into CMA doctrine, but it hasn't quite made it into the Code. This is reflected in its brevity and philosophy --not too "in your face", not trying to cover all the angles before the doctor gets a chance to exercise his or her moral muscle.

All the same, Dr Kenny's gripes still stand. The draft of the revised Code, available on the CMA website, removes the only mention of issues like abortion and euthanasia -- and that was only a line telling people they were covered in separate policy documents.

Dr Kenny has seen the proposed revision. "My main concern is that the revision looks more and more like a minimalist list of 'dos and don'ts' and would benefit from a richer elaboration of the key values and principles that a Canadian physician or surgeon should aspire to and which we believe the public expects," she says.

But can these sorts of complexities be dealt with in an ethics code? Dr Blackmer isn't sure it's necessary, or desirable. "Our Code is a general guideline," he says, "and I don't think most doctors would like it if we tried to dictate every aspect of their clinical practice."

Dr Steve Blitzer, an Ontario GP, agrees. "I think I'm naturally ethical and don't need to be told what to do," he says. "I'd worry that a guidebook that long would have too restrictive a purpose, trying to restrict or control my day-to-day activities."

So what about the feuding brother and sister case we started with? Dr Blitzer is their doctor and when he decided he didn't want to go it alone he sought the advice of the Ontario Medical Association. "Basically they told me I was stuck," says Dr Blitzer. "I can't tell the sister. But what I should do is try to find another reason to tell her to go get tested."

It's solid advice, but could it have been simpler if it had been built into a code that Dr Blitzer could pull off the shelf and run with?

The CMA says no--and so does Dr Blitzer. He doesn't have a problem with the current system. "When I have a problem, usually I just call them," he says.

And though he deals with ethical dilemmas all the time, he doesn't get too hot under the collar about the finer points of the code itself. And what would he say if a British-style code landed on his doorstep?

"If there was an 800-page code of ethics, I don't know whether I would laugh or cry first," he says. "It's a joke if someone thinks I have time to read 800 pages."

Come to think of it, maybe a three and a half page Code is just what the doctor ordered --but better keep that CMA number on the speed dial, just in case.