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Cultural safety


Respect for patients and families

Boundaries for practice


Man sitting with psychiatrist

Attitudes toward healthcare and illness play a significant role in the doctor-patient relationship. Physicians with a monocultural mindset may think their own culture is most important, while those with an intercultural mindset try to understand the other culture and address issues that may interfere with the provision of good and safe care. This approach helps patients feel safe to express their preferences.

For example, the conventional western medical treatment of depression generally involves a psychotherapeutic approach which assumes patients will calmly disclose their difficulties. A physician might experience significant therapeutic challenges with, for example, a First Nations patient until the physician learns that some First Nations people need to participate in a sweat lodge ritual before being ready to express feelings.

While different people will have varying levels of comfort with difference and diversity, practising with a monocultural mindset increases medical-legal risk.

While individual physicians have a right to their personal beliefs, there are nevertheless strict expectations about what is and is not acceptable in practice and which boundaries physicians must respect.

Each Canadian jurisdiction has human rights legislation that prohibits discrimination.

Click on any word in the image below to understand the various attributes on which discrimination is prohibited.

Sex: While "sex" pertains to biological or physiological characteristics that define men and women, "gender" pertains to the attitudes, social roles, and behaviours a society attributes to a particular sex. Discrimination on the basis of sex in some human rights legislation includes the fact that a woman is or may become pregnant.Gender identity: Describes a person's self-identification as male, female, or transgender. Gender expression: Describes how someone communicates gender (i.e. through clothing or communication style). It need not be consistent with a person's gender identity or with societally-prescribed gender roles. Sexual orientation: Refers to the sex of partners to which a person is sexually or romantically attracted. Creed: Religion and creed are often used interchangeably and refer to a professed system and confession of faith which includes beliefs and observances or worship. Religion and creed are defined subjectively. A belief in a single supreme being or deity is not a prerequisite and human rights codes generally recognize non-traditional, non-deistic bodies of faith as creeds. Ethnicity, race, ancestry, and place of origin: Race and ethnicity are overlapping sociologic concepts. Race, once closely linked with ancestry, classifies individuals based on superficial physical traits such as skin colour and hair type. Ethnicity is defined by shared sociocultural characteristics such as ancestry, language, religion, and traditions. Ethnicity is however not fixed but rather self-ascribed; for example, individuals may more closely identify with the culture of their adopted homeland than that of their ancestry or place of origin. Disability: Refers to any degree of physical, mental, developmental or learning disability, impairment or dysfunction, including a person's use of remedial appliances, devices, or guide animals. Age: The length of time a person has lived to date. Marital status: Being married, single, widowed, divorced, separated, or living with someone in a conjugal relationship outside marriage. Family status: Being in a parent and child relationship. Citizenship : Refers to the country in which a person was born or given citizenship through naturalization. A person may have more than one citizenship.
Sexual orientation Marital status Creed Disability Sex Family status Citizenship Gender identity Gender expression Age Ethnicity Ethnicity Ethnicity

Doctor in reflection

Physicians generally do not intend to discriminate against either individuals or groups and may not realize that their actions might be perceived as, or sometimes constitute, discrimination.

  • Consider the following cases and reflect on how the physicians' actions could be seen as discriminatory. While these cases were not necessarily intentional abuses of the patients' rights, in all cases the patients alleged the physician had discriminated against them.

Case: Cancelling an appointment for surgery
Male surgeon with arms crossed

Background

A surgeon cancels an appointment for a patient who is HIV positive. After another surgeon performs the planned procedure in the same clinic, the patient complains to the medical regulatory authority (College)
Regulatory authority, professional:  Licensing body for a profession.
Provincial/territorial medical regulatory authority (College)
Body that regulates the practice of medicine in each province or territory to ensure the public receives quality medical care from physicians. The responsibilities include:
- Issuance of certificates of registration to allow the practice of medicine,
- Maintenance of standards of practice,
- Investigation of complaints against physicians, and
- Remedial education or discipline for those guilty of professional misconduct or incompetence.
The medical profession is self-regulating in Canada. Each authority has an investigative process and committee structure to make decisions on different issues and complaints.
 that the cancellation constitutes discrimination on the basis of a medical condition.

The first surgeon explains to the College that given the risk of post-operative infection, he believes surgery on HIV patients should be done only in hospital, not in an outpatient setting.

Outcome

The College ruled the physician had indeed discriminated against the patient on the basis of his medical condition.

The surgeon was reminded that universal precautions are the appropriate way to minimize risks when dealing with possible infection. The College stated that, in any event, the patient could not be denied access to treatment.

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Case: The meet and greet
Close up of female physician's hand reaching out for handshake

Background

A family physician always has "meet and greet" interviews before accepting new patients.

After being rejected, one interviewee complains to the College.

The physician's response to the College is that the patient had multiple problems that she felt should be handled by specialists.

Outcome

The College ruled the physician had indeed discriminated against the patient on the basis of the medical condition.

The College pointed out that the family physician could follow the patient's general condition and progress, while conditions outside the physician's expertise could be referred to specialists.

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Case: Sexual orientation
Two female gender symbols

Background

A fertility specialist refuses to perform artificial insemination for a same sex couple.

The couple complains to the human rights tribunal in their jurisdiction.

The specialist's reason for refusing is that a previous same sex couple for whom the service had been provided had involved the specialist in a legal action after the couple separated.

Outcome

The human rights tribunal ruled that this was indeed discrimination on the basis of sexual orientation. They noted the specialist readily provided the service to heterosexual couples, despite the fact such relationships can also break down and engender litigation.
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When considering refusing a person's request to become a patient or to receive a specific treatment, think about whether the refusal might be perceived as discriminatory.

  • To help establish diligence, document your rationale for the decision and any discussions with the patient. Complaints to a regulatory authority (College) will generally be reviewed in the context of Article 17 of the Canadian Medical Association's Code of Ethics which states:

    "In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status. This does not abrogate the physician's right to refuse to accept a patient for legitimate reasons."