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Introduction

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In 1988, Québec’s four faculties of medicine and the Collège des médecins du Québec decided to produce a document for residents in family medicine, with a view to preparing them for the new examination they would have to successfully pass to obtain a permit to practice. This document addressed aspects of medical practice specific to Québec. These were mainly legal, ethical and organizational in nature, hence the name ALDO-Québec, after the French acronym. The ALDO document has undergone several revisions and still aims to provide the information considered necessary to good medical practice in Québec: the organization of the health care system, and the legal and ethical framework of medical practice in Québec. Furthermore, mandatory ALDO educational activities are organized by the Collège des médecins within the faculties of medicine.

The document is divided into two main parts: the first is theoretical, and the second presents clinical situation scenarios.

Part l 

SECTION 1 deals with organizational aspects and includes three broad sub-sections. The first sketches the broad outlines of the road travelled in the area of health in Québec. In the 1970s, the government established a system of social solidarity to deal with disease. By ensuring first the provision of hospital care, then of medical care, the Québec system resembled those in other Canadian provinces and in many industrialized countries of the world. However, it subsequently distinguished itself from the others when public funding and government administration were extended to all social services.

The entire organization of the health care system reflects this policy. Its most striking example is the constantly reaffirmed determination to see the CLSCs as the point of entry to health care services, while acknowledging that physicians in private practice provide most of the primary services. The regional health and social services agencies (ASSS) and the health and social services centres (CSSS) are another revealing example. Since 2005, these are the solutions being applied to better link the local delivery of services to the central bodies. This sub-section presents the  actual organization of the Québec health care system and the anticipated organization of medical services, for it is vital that physicians know how their professional practice fits into this system.

The second sub-section touches on the present organization of medical practice. It describes the two main types of professional practice in Québec. Practice in institutions is an independent type of professional practice, but it is linked in many ways to the structure and operation of public institutions. Although practice outside an institution has a connection to the public health care system, the links are less direct and are not necessarily maintained via institutions. While increasingly prevalent, medical practice without any link to the public system remains a marginal phenomenon in Québec. The relatively new phenomenon of diversified practice  will also be presented. Running parallel to the common types of practice are the many other forms of medical practice, among them, clinical research, medico-legal assessment, public health, occupational medicine, as well as administrative and commercial practice. Each in its own way presents problems with respect to professional independence.

SECTION TWO is of more direct concern to physicians since it deals with ethical aspects of medical practice in Québec. Here, medicine is broached from the perspective of professional practice. The medical profession fulfilled a social function and had its own rules long before it was incorporated into health care systems. This was particularly true in Québec, where physicians were obliged as early as 1847 to become members of a professional order. An order whose disciplinary power imposed itself quickly, thanks to a code of ethics that was also quite distinctive. In the 1970s, following the example of other countries and other Canadian provinces, Québec recognized the existence of professional orders and invested them with substantial peer-review powers.

While the present structure and function of the Collège des médecins du Québec dates back to a time when professions were  little known, their intention essentially remains the same—that physicians themselves ensure the competence and proper practice of the members of their profession. Over time, the Code of Ethics of Physicians has become more complex, because this regulation, like many others that complement it, attempts to lay out as precisely as possible the obligations that every physician must fulfil. This is not easy in a context of our new and complex realities. The situation of a public system experiencing a period of restriction of resources is unprecedented. This applies to clinical  research, medical entrepreneurship and medicolegal assessment. Therefore, we must be innovative and ask our own questions with respect to the independence  of professional practice vis-à-vis the pressing economic and political constraints in the field of health care.

In this context, it must be recognized that the Collège is not the only organization that brings physicians together. The medical federations, for example, play a decisive role in negotiating the practice conditions of physicians. Medical ethics is still very much alive in Québec, and the Collège remains a vital organization for both the medical profession and the public.

SECTION THREE deals with the legal aspects of medical practice. In Québec, as elsewhere, many laws have a bearing on the practice of medicine. This section presents an overview, emphasizing those that impose special obligations on physicians and those that frame “medical civil liability.” When one analyzes the question of medical civil liability and the  risk of lawsuit—a subject of concern to physicians—, one realizes that it goes beyond the strict legal framework. Indeed, transparency, as well as ethical and organizational considerations, often improves the quality of medical practice and, as a result, reduces the risks of lawsuit.

Part II

How should the physician act, given the organizational constraints, the general points of reference established by the legislation, and the guideposts defined by the codes? For every physician, the moral challenge is to answer the question in the heat of the action.

PART  II of this document is perhaps the most important in this regard, for it demonstrates that one can and must integrate the various aspects mentioned earlier in order to make enlightened decisions. The best way to understand the legal and moral aspects of one’s professional practice is to look at practical problems and, even better, clinical situations. Many questions are examined:  consent, confidentiality, end-of-life issues and personal convictions. While the list is not exhaustive, it does provide practical examples to illustrate the new difficulties confronting physicians and society on a regular basis.

The collaborators in the production of the ALDO document have always been concerned with making it more than just a collection of laws and regulations to be followed to the letter so as to avoid problems. Hyperlinks have been added, allowing rapid access to legal texts and more exhaustive information on certain topics.

The primary goal of this document is to provide accurate information to Québec physicians on aspects deemed to be decisive for their professional practice. One hopes that the document will also induce them to participate in a critical reflection process, thereby making the information interesting and useful.

2012-12-19