Contributed by Mark Faassen
Following the killing of George Floyd in the United States in 2020, many health organizations in Canada issued statements denouncing racism and discrimination in health care. These organizations were varied and included national (for example, see here, here, and here), provincial/territorial (for example, see here, here, here, and here), and practitioner/learner organizations (for example, see here, here and here), and educational institutions.
In addition to citing systemic racism and discrimination, some statements acknowledged the existence of anti-Black and anti-Indigenous racism in Canada. Some expressed solidarity with these communities and with other people of colour. The Toronto Board of Health and the Canadian Nurses Association declared anti-Black racism as a public health crisisand a public health emergency respectively. Fewer statements acknowledged the role of police in the death of Mr. Floyd and/or the deaths of Black and Indigenous individuals in Canada.
Some organizations issued supplementary statements to their initial statements. One issued a further statement after many of its members “asked what active steps we are taking to address systemic racism.” Another explained it was a mistake to reference only the death of George Floyd initially and went onto recognize “the racialized Canadians who have died in encounters with police during wellness checks, including Ontarians Regis Korchinski-Paquet, D’Andre Campbell, Caleb Tubila Njoko and Ejaz Choudry.”
Research by Brown et al evaluating the initial statements by medical schools and organizations in Canada and the United States found that they tended to minimize the pervasiveness of anti-Black racism and externalize its existence “as outside the institution, and deflected institutional accountability by emphasizing individual action instead of institutional change.” Research by Kalifa et al considering the efforts of Canadian medical schools to address anti-Black racism in 2020 found that “since most medical schools did not have any Black faculty, particularly in leadership positions, and had historically neglected issues of anti-Black racism within their institution, schools relied heavily on Black medical students for guidance and direction.” The authors note that while students viewed this reliance on them as burdensome and inappropriate, “they felt compelled to remain involved to keep their medical school accountable beyond the statement.”
Several health organizations in Canada issued similar statements condemning anti-Indigenous racism following reports in June 2020 of health workers in British Columbia Emergency Rooms playing a game to guess the blood alcohol level of Indigenous patients (for example, see here), the death of Joyce Echaquan at a hospital in Joliette, Québec in September 2020 (for example, see here, here, here, here, here, and here), and following the discovery of the remains of 215 children at a former residential school site in Kamloops, British Columbia in May 2021 (for example, see here and here). Incidentally, the Truth and Reconciliation Commission of Canada’s Calls to Action were released in 2015 (with action numbers 18 to 24 related to health).
Since mid-2020, several health professional regulators across Canada have also issued statements committing to learning and examining how to better address systemic racism and discrimination in their role as regulators. British Columbia Health Regulators (a collaboration of all health regulatory colleges in the province) and the Nova Scotia College of Nursing, for example, emphasized the regulator’s role in ensuring that health care providers deliver qualified, safe, and ethical care to all patients, including by establishing codes of ethics, standards of practice, and other guidelines to promote justice and prohibit discrimination. The College of Physicians and Surgeons of Ontario committed to addressing all forms of discrimination through “bringing equity, diversity, and inclusion (EDI)” to its processes and policies. As noted by the external Task Force that reviewed systemic anti-Black racism within the College of Physicians and Surgeons of Nova Scotia in 2021, “vocal allyship, as necessary and appreciated as it might be, will have minimal impact, if any, without a genuine commitment and actions to dismantle systemic anti-Black racism.”
With the passage of time since mid-2020, there is an opportunity to survey how some health professional regulators in Canada are beginning to contend with systemic racism, diversity, equity, and inclusion as legal-regulatory concepts. While there appears to be a willingness to embrace these concepts, initiatives are relatively nascent. It remains to be seen what meaningful structural changes to health professional regulation, if any, are being explored, proposed and implemented.
It is useful to recall that the health professions in Canada are regulated at the provincial/territorial level by statute establishing professional self-regulation. Regulators are meant to serve the public interest through their core regulatory functions: licensing members; ensuring quality care is provided by members; investigating and adjudicating complaints from the public about members (including potential discipline); and developing professional standards/guidelines. The regulated health professions go beyond the traditional disciplines of medicine, nursing, dentistry, and pharmacy, and include a variety such as midwifery, physiotherapy, message therapy, and acupuncture. In Ontario alone, there are 29 distinct health professions regulated by 26 colleges.
As this extended introduction has tried to show, the discussion of the role of health professional regulation in addressing racism is occurring within a larger discussion of racism in health care and health education, including in medicine and nursing (for example, see here, here, here, here, and here),which is ongoing. No health professional regulator has devised a master framework, including in the United States where regulators are having similar discussions. To get a sense of where Canadian health professional regulators are in their processes, this post will focus on one profession – medicine – with examples from two provinces; Manitoba and Ontario.
Manitoba
The College of Physicians and Surgeons of Manitoba (CPSM) recently issued two apologies on Indigenous-specific racism in medical practice to the Anishinaabeg, Anishlnlnewuk, Dakota Gyate, Denesuiine, and Nehethowuk peoples (on January 31, 2023) and to the Inuit (on February 27, 2023). These apologies are not only for racism experienced in their medical care but also for the CPSM’s “failure to regulate the medical profession in the public interest by failing to adequately address Indigenous-specific racism by medical practitioners, whether in their clinical practice or administrative roles.”
Notably, the CPSM states that its responsibility as regulator extends to the “racist actions and inactions of physicians, residents, medical students, clinical assistants, and physician assistants against Indigenous persons” (emphasis added).
Examples of historical failures of the medical profession to address racist and substandard medical care for Indigenous patients specified in the apologies are for racially segregated and substandard hospitals; residential schools in which physicians provided care and knew or ought to have known of Indigenous children’s physical, mental, and sexual abuses; providing substandard care during tuberculosis outbreaks and in racially segregated TB sanatoriums; failing to obtain consent for treatment, including forced or uninformed sterilization of Indigenous women; and conducting unethical nutrition experiments depriving Indigenous children of food.
Examples of current Indigenous-specific racism named in the apologies include failing to recognize traditional Indigenous healthcare practices alongside Western medicine; accepting or advancing stereotypical perceptions of alcohol and illicit drug consumption or socioeconomic status; inadequate treatment of pain; failing to demonstrate interest, respect, and humility to understand the context of patients’ Indigenous teachings, communications, lived experiences, and circumstances; and committing outright acts of racism, including derogatory comments.
According to the CPSM, the apologies are a first step and result of an organizational priority that began in June 2021 to address Indigenous racism in physician practice. The College engaged Dr. Lisa Monkman to form a Truth and Reconciliation Advisory Circle, which ultimately presented seven initial recommendations for action in September 2022. In addition to creating an apology and an appropriate land acknowledgement, other recommendations include:
- developing a new standard of practice to recognize racism as professional misconduct (potentially modelled after the College of Physicians and Surgeons of British Columbia’s Indigenous Cultural Safety, Cultural Humility and Anti-Racism practice standard);
- developing ways for Indigenous patients to better participate in the complaints and investigation process, including an emphasis on restorative justice;
- broadening Indigenous representation on College committees, Council and staff;
- requiring College councillors, committee members, staff and physician registrants to undergo anti-Indigenous racism training; and
- creating a culture to support Indigenous physicians, including by recognizing the duality of Western medicine and Indigenous medicine, recognizing the duality of Indigenous physicians living in their culture and mainstream culture, and creating an environment where physicians are not fearful of voicing concerns about racism against a colleague or when discussing racism in health care.
The apologies further contain a commitment to act on most of these recommendations.
Responses to the apologies and commitments from Indigenous groups have been prudent. While the Manitoba Inuit Association views it as “an amazing step in the right direction, it is meaningless without action.” The Grand Chief of the Assembly of Manitoba Chiefs offers: “I walk away with cautious optimism until I hear and feel from our people the changes you promise here today.” According to the CPSM, the work of the Advisory Circle continues and it will make further recommendations with respect to implementing the College’s new commitments.
Ontario
The College of Physicians and Surgeons of Ontario (CPSO) appointed its first Equity, Diversity, and Inclusion (EDI) Lead, Dr. Saroo Sharda, in January 2021. It acknowledged that systemic racism and discrimination exist in the field of medicine on both the provider and patient side. It began to consider “what steps would meaningfully identify and address systemic discrimination, racism, inequity, and bias in our regulatory processes,” with the goal of ensuring a more equitable system for all. Information about the College’s activities can be found in its 2021 and 2022 EDI Reports, which included a focus on implicit/unconscious bias and anti-Indigenous racism in 2021 and 2SLGBTQIA+ health and anti-Black racism in 2022.
With respect to its internal functioning, initiatives to date have included broader EDI education and training for all committees and Council members (including new members), staff, and newly hired peer assessors. With respect to investigating complaints, staff are considering new approaches for addressing complaints of discrimination and have received training on the College of Physicians and Surgeons of Alberta’s approach to managing complaints from Indigenous patients. It is unclear, at present, if changes have been made to the way in which the College investigates and/or processes complaints as a result of these activities.
An initiative of the College in 2021-2022 was a consultation process with respect to its Professional Obligations and Human Rights policy, which was up for review. After seeking feedback from a range of stakeholders, a draft (and newly named) Human Rights in the Provision of Health Services policy was created and available for public comment until November 2022. Proposed additions to the revised policy include:
- an expectation that physicians will take reasonable steps to incorporate cultural humility, cultural safety, anti-racism, and anti-oppression into their practices (paragraph 1);
- an implicit acknowledgement that racism and discrimination may not only flow from physician to patient but from patient to physician (and between physicians), with guidance on how to navigate patient requests to receive care from a physician with a particular social identity when the reason for the request is perceived to be discriminatory (paragraph 4); and
- an expectation that physicians will take reasonable steps to stop acts of violence, harassment, and discrimination seen occurring against a patient or another health provider and/or staff (paragraph 13, which seems to contemplate and also apply to medical students and/or postgraduate trainees).
This last provision is similar yet different to one included in the College of Physicians and Surgeons of British Columbia’s Indigenous Cultural Safety, Cultural Humility and Anti-Racism practice standard, which requires physicians to report acts of racism, but does not expect them to intervene and take reasonable steps to stop them (paragraph 3.1). While the BC policy requires physicians to report acts of racism to the relevant professional regulator, it is unclear if the draft CPSO policy includes a similar reporting obligation to a regulator. The CPSO has also created a draft Advice to the Professiondocument providing further guidance on the policy’s proposed changes, including with respect to how physicians might implement the new expectations. It is unclear what further amendments, if any, will be made to the policy, which the College expects to be finalized by the end of 2023.
Going Forward
Professional health regulators across Canada are exploring and developing approaches to reflect the role of professional regulation in addressing racism and supporting diversity, equity, and inclusion efforts in health care. This process is ongoing but we can make out the types of things regulators are starting to do, as seen in the initial efforts from Manitoba and Ontario. The CPSM’s public acknowledgement of its failure to regulate racist treatment of Indigenous peoples in the medical profession is significant, and appears to demonstrate institutional critical reflection. It appears to acknowledge that racism is not limited to individual beliefs or actions (perhaps seen in valuable moves to recognize racism as professional misconduct) but can also permeate institutions including regulators. Additional work will be required to evaluate any future institutional or structural changes to health professional regulation, including changes to the complaints and investigation, and adjudication processes undertaken by provincial and territorial regulators and to their internal governance and decision making.
Finally, the role of the Federation of Medical Regulatory Colleges of Canada (FMRAC) should be noted. FMRAC is a national association comprised of provincial and territorial medical regulatory authorities (including the CPSM and CPSO), whose purposes include developing policies, standards, statements and perspectives on aspects of medical regulation in Canada. In December 2022, its Board approved a Framework on Wise Practices and Medical Regulation prepared by its Working Group on Anti-Racism. The framework proposes recommendations and minimum regulatory standards to its medical regulatory members, and is intended to promote pan-Canadian consistency. After acknowledging the existence of systemic-anti-Indigenous racism in medicine and medical regulation, its recommendations made to regulators include to recognize and address Indigenous-specific racism, and all other forms of racism, as professional misconduct; to recognize the importance of cultural humility as an essential component of professionalism in medicine and cultural safety as an essential component of competence; and to regulate physicians who fail to demonstrate cultural humility and commit to cultural safety. FMRAC further states it is incumbent on each medical regulatory authority to develop its own policies and approaches to ensure effective regulation.
About the Author
Mark Faassen is a lawyer and Junior Online Editor of the McGill Journal of Law and Health. He is currently an LLM candidate at McGill University’s Faculty of Law. His legal practice focuses on professional liabilityand health law.
McGill Journal of Law and Health 