Tuesday, March 13, 2012

Canadian Psychiatric Code of Ethics

The Canadian Psychiatric Association has a code of ethics:  It's well written and well considered. It's is the Canadian Medical Associations Code of Ethics Annotated for Psychiatrists.  The CMA Code of Ethics was 1996 while the Annotated code of ethics for Psychiatrists was completed in 2002.
It's a bit lengthy and unweildy so that like a lot of 'beurocratic documents' I can honestly say that the majority of my colleagues would be hard pressed to recite a significant number of it's provisions.  The Canadian Medical Associations Code of Ethics is similiarly beurocratic, lengthy and unweildy such that a majority of physicians is unlikely to be able to cite a significant number of it's provisions.
That said, these same physicians and psychiatrist could tell you in detail and at length the diseases that affect the nervous system or list extensively what one must do procedurally in the proper work up of a desperately ill patient.  Further, the vast majority of physicians and especially psychiatrists act in a most ethical fashion as generally understood by their profession and the community at large. Indeed, relative to most sectors of the community at large physicians and especially psychiatrists are highly ethical individuals with years of experience and training and in depth consideration of relationships with other humans, those humans commonly being vulnerable, sick, sometimes psychotic, often in pain and clearly not on their best behaviour.
In reviewing though all these 'ethics' that are recommended I see that they are quite impossible to follow in some instances. This is something I will consider in due course.

My first consideration with regard to Codes of Ethics was the 'conflict' that ethics of physicians might have with  'ethics of administrators'. When I sought to find a Canadian Hospital Administrators Code of Ethics, I couldn't find one.  My personal experience has been that the ethical decisions that I have had to make often routinely have put me in direct conflict with hospital administrators who do not for instance share direct responsibility and accountability for an individual patient.  Indeed I have heard hospital administrators refer to me, not as a psychiatrist or as a physician but merely as a 'health care worker'.  The history of referring to someone as a 'worker' was common in the early years of communism and early union movements.  I'm not sure what 'code of ethics' the 'workers' of that era had and don't know of any 'code of ethics' for 'heath care workers'.

There further is as yet no agreed code for 'health care professionals', another term administrators have liked to call me, which obfuscates my own identity as a physician and a psychiatrist and the ethical obligations I have as a physician and a psychiatrist.

There was a conflict noted in England a decade or more ago which lead to considerable reorganization of hospital and community decision making to 'limit liability' of physicians. In Canada when 'health care professionals' gather the 'accountability' of the physician is directly associated with 'liability' and the liability of the physician historically was greatest.  Recently in the US law suits commonly cite the hospital and physician and increasingly the nurses but do not specify the CEO.

Increase in the accountability of administration relative to patient care is clearly an admirable dimension of ethical care.

To the best of my knowledge such reform of "individual and collective 'liability" and hence 'accountability' has not occured in Canada though it's been several years since I've actively involved myself in Canadian hospital and community care systems. I completed 2 years of the public health community medicine fellowship a couple of decades back. That training along with my community psychiatry training indeed sensitized me to the increasing chaos, ethical dilemnas and loss of autonomy of the physician relative to institutional perogatives. I personally experienced considerable bullying and abuse in the system so like large number of physicians retreated into my practice.  Increasing numbers of others are avoiding clinical care altogether, it being vogue indeed for people to get and md followed by an mba or llb (law degree) than actually specialized in clinical medicine or psychiatry.

In general a 'code of ethics' is limitted by the prevailing authorities.  A professional is only as professional as his or her autonomy.

The prime directive of the Canadian Medical Association Code of Ethics is
1) Consider first the well being of the patient

What happens if this comes  secondary to the 'profit' motive of the organization or 'the availability of  resources' .

It's a bit of a platitude like saying "the customer is always right'.

Today's newspaper and radio health care 'crisis' is that of a pharmaceutical company not making sufficient 'supply' of a life saving medicine and not warning Canadian pharmacies or governments that they were running short.  I was amused by this in a 'black humor' sense only because it reminded me of my work in northern Canada when the stock of 'penicillin' was depleted. I rasied hell and got the necessary penicillin flown into the community to save the life of a child with pneumonia or meningitis at the time.
I would today be called a 'disruptive physician' and severely reprimanded. The message to all physicians to day is not to rock the boat.

I have been in two hospitals now where the 'oxygen' tanks were not filled with 'oxygen'.  I know of two deaths directly related to this.  I recently learned that health care employees, including physicians were going to be required to sign 'non disclosure' agreements to have jobs. I wondered at the time if a physician could 'ethically' sign such an agreement.

On dozens of occasions I have followed the prime directive to 'consider first the well being of the patient at extreme personal cost to myself in terms of health and loss of wealth.  I know many physicians who have shared this experience in the present health care systems.  It is very hard indeed to 'consider first the well being of the patient' when there are those around who have entirely different agendas.

Recently a patient was found dead 24 hours in a Canadian hospital waiting room and to date I've not heard even who was ultimately held accountable.  I loathe the CBC going on and on about robocalls in the elections or about a defence minister chartering a plane to go home for a weekend when who is accountable for a person dying in a waiting room in a Canadian hospital goes without a Royal enquiry.

It's one of the greatest national scandals of the Canadian Health Care system and yet it's a subject that was covered in the popular media mostly as an isolated tragedy. I saw it as evidence of the epidemic proportion of administrative breakdown in the health care system. To the best of my knowledge it never warranted a letter to all physicians, hospitals, or hospital personnel about how we shant have that sort of thing happening again. My impression is that that sort of thing gets 'covered up' and shunted aside as an 'embarrassment'.  When things like this happen I want a "pathologists report' on the cause of death and the organs infected and decaying.  I really would like a department of 'systemic pathology' that gave 'weekly rounds' on the institution in question or the health care system as a whole.

There was  no mention that the hospital administrator was sacked either but they are forever going on about accountability. Accountability for physicians means loss of license and loss of position and loss of income and a whole dirge of liabilities.  I don't seen any evidence of a 'level playing' field in comparison when a patient lies dead in a hospital waiting room for 24 hours.

I don't know if the patient was 'admitted' and whether they were under a doctors name and if that doctor even knew they had a patient in the emergency. Mty emergency doctor colleagues have reported that increasingly they are last to know that sick patients have been assigned to their care and that more significantly they rarely today have the resources or staff to adequately 'consider first the well being of the patient'.  How can a physician 'consider first the well being of the patient' if he doesn't even know that patients have been assigned to him until there is a crisis.

What is a physician to do when the very system they work in is 'unethical'?

Bonhoffer, the remarkable priest who served during the Nazi reign and was martyred for his ethical and moral stance is one of the greatest tales of the 20th century. Bonhoffer's central dilemna was that he was ethical, his church wasn't , and the nazi's weren't.  He was Lutheran.   Ethics can't be considered in a vacuum.  The Catholc Pope and indeed most of the major church members of the day failed to function in an ethical or moral manner in face of the overwhelming systemic flaws.

Physicians who 'protest' are today called 'disruptive physicians'.   Ethically  'considering first the well being of the patient' in a hospital system or a community health care system they may well be  martyred.  Rocking the boat is professional suicide.  There are 'cultures' which surround institutions. This was the topic for psychiatrists of the book "Asylums, a study of totalitarian institutions".  The "company doctor's has historical been a term of derision to refer to a doctor whose 'ethics' are subsumed by his allegiance to the paycheque or paymaster.

Doctors of 'conscience' have increasingly taken to writing their names on lists.  The Bahrain Doctors are presently being tortured and imprisoned for being ethical doctors and following the general code of ethics most doctors subscribe too around the world. The partisan government of that state however decided that doctors could only treat police and not civilian protestors.  Doctors who treated protestors were subsequently raped, abused and faced all manner of persecution.

The most famous and historic medical code of ethics was found in the Hippocratic Oath.



Original, translated into English:[4]
I swear by Apollo, the healer, AsclepiusHygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:
To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art; and that by my teaching, I will impart a knowledge of this art to my own sons, and to my teacher's sons, and to disciples bound by an indenture and oath according to the medical laws, and no others.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause anabortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists inthis art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I willkeep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.

The modern version is a weak sister that doesn't even emphasize the is to 'do no harm'.  It strikes me too that the original Hippocratic oath contained greater wisdom and came from more extensive clinical experience and knowledge of humankind. The modern version is still pretty impressive and very clear as it uses the word 'covenant' indicating a 'covenanted relationship' between doctor and patient.

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not", nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, be respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.


Later I'd become a dues paying member of the Hippocratic Society in Canada because this group felt that the hippocratic oath was being violated by the demands of the Canadian government. As such I become politically incorrect and open to persecution for my ethical stance at variance with the position in Canada at the time in physicians increasingly being expected to 'do harm' in such areas as 'abortion" and 'euthanasia' or 'assisted suicide'. Having been a member of Canadian Civil Liberties Association and the Human Rights Association and Physicians for Social Responsibility I was concerned that physicians were being denied 'choice' in the procedures they personally agreed to do where there were alternative resources.

As a member of the Christian Medical and Dental Society I was discussing ethics and morality in a way which had simply never been a part of the discussion of the provincial bodies or federal bodies of the medical societies whose conferences I'd previously attended. The discussion of ethics was further a central topic of the small group discussions that were apart of the International Doctors in AA, especially the psychiatrist groups and the cyberdocs on line discussion. Here often doctors would share the dilemnas they faced and find support rather than judgement and exclusion as I'd noted in other areas of medicine.  Punishment was common in medicine whereas support was limitted. Judgementalness and hypocricy were common whereas 'collegiality' was declining annually in the 'new world order' of the health care worker paradigm.  I wrote national articles relating to this but these served more often to define me as a humorist and maverick than one deeply concerned for the future of health care in Canada.

It creates a major ethical dilemna for physicians working on health care teams when the doctor sees the relationship with patient as covenanted and the other players see the relationship differently.  As an example a former doctor, at the time functioning as an administrator, made the crude statement to me about medical practice, "it's just a job, Dr. Hay".  Ever since I heard that I've been waiting for millions of dollars back pay and all the benefits I didn't receive for the 'health care job' I never signed up for.  All that while I was being a physician and psychiatrist I apparently according to this administrator was just a worker doing a job. 

As a doctor I took a Hippocratic Oath in medical school.  I've had jobs and never been required to take an "oath" to do them.  I stood with a hundred classmates, as well as the dean and teachers at the University of Manitoba Medical School. Together we recited the code of ethics that I would practice medicine by thereafter. This was not to my knowlege the CMA code of ethics but the simplified  modern version of Hippocratic Oath. I have had to struggle repeatedly with the conflict that occurs with 'loyalty to the group' versus 'loyalty to the patient'.  I have further had a great deal of difficulty as a Christian and my Christian priority is to tell the truth, the whole truth, and nothing but the truth, so help me God, something I swear on the Bible.  In contrast I 've worked in a darwinian relativistic social setting where people routinely talk about 'my truth' and 'your truth' "whatever truth covers your ass' in beurocratic terms.

I did not study the CMA Code of Ethics as part of my medical school training or as a psychiatric resident. I was given a pamphlet and advised to read it.  I did that and only later did I take an interest in the code as an object of serious study.  The first time was when a superior demanded I do something that was unethical and I refused to do so.
A colleague replaced me who was more compliant and less ethically 'squeamish'.
I made a long lasting enemy of the superior who became wealthy and powerful through what by the Canadian Medical Code of Ethics was unethical behaviour.  People can witness that life is 'unjust' and often 'bad people' do succeed.  Whole religions and philosophical and cultural systems have been developed to address such problems.

By the time I became really interested in the code of ethics I had extensive clinical experience and knowledge and saw that the code was likely outdated at the time it was written. This was a result of the rapid change in the medical care delivery systems and changing relationships federally, provincially and most significantly, the means by which care in Canada was funded, the change in the 'health care team' and the change in status of the 'team player's and indeed the change in the "name of the game: and the game itself". The  different levels of care allocated by 'status' or 'weath' in Canada especially in British Columbia where I practiced psychiatry in a different light reflect the same ethical error the Bahrain doctors failed at.  If we are only 'health care workers" then clearly he who pays the piper calls the tune.

There is now and  increasing disparity of available care, even at the simple level of rural and urban but most importantly culturally.

In fact I reflected on the Hippocratic Oath which I had sworn too and how difficult it was for me to fulfill that oath dealing with beaurocrats and other contenders in the present system.

When I worked in a country hospital I left after a year when the monies for a baby incubator appeared to have been diverted for the remodelling of the administrator's office.  Administrators in general have had an inordinate interest in 'perks' .
As a result of my formal complaint to the board and meetings with the mayor and councill this administrator was eventually removed.  I would estimate that my time voluntarily spent in this endeavour was hundreds of hours. I wrote several lengthy papers and met with many individuals. I actually wasn't particularly interested in the individual but couldn't forget delivering a premie in the back of an ambulance at high speed in the middle of a blizzard.  We were travelling at high speed to the nearest hospital with an incubator and the volunteer assistant ambulance driver, a grizzly old farmer, held the baby close to his bare chest while I dealt with the mother's post partum hemorrhage.  Mother and baby did well as a result of the heroics.  Standard care would have certainly met death of the baby.

Indeed 2 years later when I was working with the university I was asked by mayor and town councill to return and address the issue so they could relieve the administrators whose behaviour had cost more life and suffering in the community and staff losess.  The consequence was that the hospital administrator was removed.

As in any of the disputes there were many angles, sides and politics and players.  In his mind he doing a 'good job'.

What most interested me though was learning that the same person had been removed from their previous appointment for simliar questionable behaviour.  Indeed a leading hospital administrator in the system was kind enough to take me aside and share that this person had once worked in her department and his behaviour could best be described as sociopathic.  Misallocation of funds was the least of his noxious behaviours.

She had had him removed and found that he was only transfered then and now she had become aware of his recent position because of the news and scandal  that surrounded his final removal.   He was indeed as tricky dicky as Nixon in his dealings and the board was mis informed of all manner of things going on in the hospital.  They were enlightened eventually and made what I personally considered the right ethical decision. Health care in the community and  hospital according to the doctors and nurses who remained improved dramatically.
I had effectively to my own way of thinking nipped "hitler' in the bud.  This devious and dubious person was caught with their hand in the cookie jar and matters rectified.  I could not practice medicine as I'd been trained and cover my back at this time. My colleagues were afraid of this person and felt bullied and terrorized.
I sacrificed my career though being an ethical physician.  I had hoped to stay at that hospital many years at least. I enjoyed the community and the staff and colleagues but I didn't abide by the administrators direct interference in medical care.  His behaviour was dangerous and unruly. The existing systems for addressing out of control administrators were wholly inadequate and cumbersome.
I admired most my colleague who was as concerned as I about the baby incubator but had given up hope on the ethics of hospital administrators or the ability to work with them. His solution which I so admired was to approach Kiwanis and ask them for help.  They raised the money for a baby incubator.  To this day my colleague is working within the system on behalf of his patients.  I know that he goes above and beyond the call of duty to be an ethical physician and that he is mostly an 'unsung hero'.

I personally was considered a 'loose cannon' in beaurocratic circles,  The peter principle prevails in peace time beurocratic systems and  anyone who rocks the boat is considered a threat.

The dilemna that faces the physician to day who attempts to 'consider first the well being of the patient' or try to live by the Hippocratic Oath is much the same problem an individual considering marriage might face if they thought marriage meant a monogamous institution and their partner felt marriage was a polygammous institution.

When these codes were written the doctor was the dominant person in the heath care field.  The health care system of Canada is considered by many to be a dirty product of the deplorable days of Canadian paternalism.  Indeed hospital administrators when I began were commonly former doctors or despite the sexist and erroneous descriptions of that era, nurse administrators.   Most of the administrators had medical family if they themselves hadn't started out in medicine or allied health care fields like nursing.  (The Minister of Health of Canada was even at one time a Psychiatrist and commonly had medical affiliation before the new administrative model which said a Minister of Health didn't need diddly squat health care training and the Minister of Agriculture anything need to know about farming either.  The fallacy of this argument is that to date the Attorney General remains a lawyer. Politically, administratively I don't believe in feudal lordship but agree with the antequated and much aggrieved notion that ships captains shouldn't be literary critics alone)

That has all changed.  The doctor is mostly an employee in the hospital today.  The Canadian Code of Ethics for physicians is commonly interpreted within the provincial framework of the medical association. Health care is primarily a provincial responsibility in Canada and increasingly division in Canada has resulted in diversity across the country.  Doctors working in one part of the country have different political expectations from doctors working in another part of the country. Privatization has thrown a whole other hoop into the game.

While collectively doctors have been demanding a 'national license' and 'national standard' for medicine and psychiatric licensing the existing beaurocracies have resisted all reform and impeded any effort to expedite standardization at these highest levels. Administrations have grown like a cancer with layers and layers of redundancy.

 The consequence is that a Canadian doctor today may well be at variance with provincial pay masters relative to ethics. In addtion provinces have developed a whole other level of beurocracis in 'authorities' and these confuse the matter more. Additionally the 'professional bodies' legislations have attempted to group disparate care givers from physicians to hospital janitors into an all encompassing "health care" "professional" bodies.

This destruction of relationships between individual professionals and their traditions is likened to the failed attempt to put the army,navy and airforce under one Canadian uniform and command without respect for inherrent differences. There are individuals and groups and ethically there is a need to respect these differences.
As a result of war the 'administrated' destruction of Army, Navy and Air Force in Canada was chucked despite milllions of lost dollars in administrative costs and Canada again has three separate divisions of military working together as they always have under a supreme commander.  (One almost wonders if the idiot administrators who created that costly fiasco didn't refuse to admit their stupidity and shuffle their bad ideas over to health care in a vain attemp to save face!_

When a physician with a code of ethics looks beside him at fellow team players, having already noted that the hospital administrators themselves may not have a code of ethcis,
the Canadian Nurses "code of ethics' present as a very different kettle of fish from  the Canadian Physicians Code of Ethics.
First It does not have the 'prime directive' of "Consider first the well being of the patient." that is the hall mark of the CMA Code of EThics. There is further no 'covenanted' relationship in modern nursing as their was in the long history of nursing, especially represented in the ideals of Florence Nightingale and all the other bed side clinician nurses.  The nursing code of ethics reads more like an academic beaurocratic document than something as glorious as the nursing tradition.
It drily begins instead: by listing 7 values:
1. Providing safe, compassionate, competent and ethical care 2. Promoting health and well-being 3. Promoting and respecting informed decision-making 4. Preserving dignity
5. Maintaining privacy and confidentiality 6. Promoting justice 7. Being accountable

Ethical nursing practice involves endeavouring to address broad aspects of social justice that are associated with health and well-being. Part II, “Ethical Endeavours,” describes endeavours that nurses can under- take to address social inequities.

It's noted first that there is no 'prime directive" to 'Consider first the well being of the patient" in the nursing code of ethics.  Also there is no simple statement such as 'do no harm' but instead a considerable emphasis on 'social inequitieys and 'justice' . Historically these latter have been 'legalisms' . (Imitation is the sincerest form of flattery).

The word 'ethical' is inherrent in the 'code of ethics' which is at least redundant and concerning given what I've written elsewhere about the circularity of definitions surounding terms such as ethics and morality in an 'age of narcissims' and a 'multi-cultural' aculturalism.  When one respects differences one doesn't deny them.
When I did a search for Canadian Pharmacists Code of Ethics I didn't find such a body but did find a Newfoundland and Labrador 2001 Pharmacists code of ethics.  It did not either have as a prime directive "Consider first the well being of the patient" and it didn't state clearly state as the original hippocratic oath did, 'do no harm'.

Given that the buzz word in medicine these days is 'team" approach and to hear the politiicans health care is about the patient there seems to be variance on first sight with the positions of the Codes of Ethics of the various 'team players. I haven't considered the "professional" body of hospital janitors or looked at their code of ethics but I would hazard the guess that the prime directive is not 'First consider the well being of the patient".

What I noticed in my practice was that different 'players' on the team called the 'patient' different things too. Most recently 'client' and 'consumer' have been popular words among the beuorcrats as recently parallelling these new motifs, patients have come forward in increasing numbers  calling themselves 'victims' and 'survivors'.

I personally believe that Hospital Administrators need a Code of Ethics if they don't already have one.  I would further suggest that all groups share the 'naming' of the thing they are discussing in their various 'codes of ethics' .  I have been treating patients as patients , a covenanted relationship, whereas I commonly am discussing a patient with an administrator who has been referring to them as consumers and sometimes even suggesting they are commodities.  Worst of all I have seen patients described as "units'.
That said I do think that if there is to be a 'professional body' that includes such disparate organizations as the navy, army and air force with all their various traditions and beliefs and responsibilties there needs to be a common 'code of ethic' for the 'team'
My vote, aging as I am, would be that we all agree:

1. Consider First the well being of the patient.
2. Do no harm

I personally find the nursing ethereal  code of ethics academic gobbly gook like the the ramblings of the pharmacists code of ethics made for lawyers,  sociologists and beaurocrats in general but not really relevant at the bed side where the rubber hits the road.
I have always considered first the prime directive 'Consider First the Well Being of the Patient" at the bedside and secondly I have known well that I must do my best to 'do no harm'.  It's a bit like the ABC's of life saving.  It's coloured my practice through every aspect of care and been a horrible  rock about my neck. Without adherence to these 2 ethical rules I could have been a millionaire many times over and long ago retired from the practice of medicine.

Ironically when the administrators are not meedling like enfant terribles the heath care teams function amazingly well because of the inherrent goodness of the people who enter care giving professions.  Given the disparity and differences in the end it's almost miraculous the good that gets done.  I don't think most of the grass roots folk consider the 'ethics' codes but rather "do the next right thing' and if they have clinical experience tend to be on the same page as those around them.

The same was found true in the military and the restoration of the separate traditions and respect for the independent and individual nature of the different warriors was again found necessary when Canada was at war.

I personally hope that this disgusting era of the Canadian 'health care worker' comes to an end and I can get back to what I was trained to be, a physician, and psychiatrist, ruled by the ethics (and traditions) of my profession.  I see that the Bahrain doctors are facing a kind of administration mindset that governs commodities, consumers and clients.  I don't see physicians being tortured for treating NDP patients in Canada this year but the detour that has taken place in these crazy years of increasing 'physican' and 'psychiatrist' as 'government health care worker' and 'unit' or commodity is likely to give rise to increasing ethical dilemnas the further along the road we go.

Professionalism requires that a body be independent and autonomous.  That is to say that I enter a relationship with the employer as a 'contractor' but may have all the benefits that were defined in the salaried relationship.  There is no longer a respect for the physician and psychiatrist as a professional and autonomous. Further there is coopting at all levels which create increasing ethical dilemnas especially if a physician holds to the prime directive 'Consider First the Well Being of the Patient.

I would argue that economists and ecologists even, and especially ethicists entering in to the health care field, be required to take an oath, indeed all working with patients, take the oath to 'do no harm' and to Consider First the Well being of the Patient.

My belief is that the Minister of Health as an elected representative indeed has already made such a committment to get into office in a democratic society.  But are those who are 'appointed' on the same ethical level.

How indeed can any team work if some are playing hockey whiles others are on the ice playing with golf clubs in silly golf suits. That's a touch of a  beginning for the discussion of the chaos in todays hospitals and community health care centres.

- late night ramblings after being woken again by a nightmare about trying to save a life