New Changes to Bill 20: Small Victory for Reproductive Rights and Family Doctors

Posted By Lana McCrea

Bill 20 – or An Act to enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation – is a healthcare reform bill proposed by Mr. Gaétan Barrette, the Quebec Minister of Health and Social Services.

The bill is divided into two parts. Part I – an Act to promote access to family medicine and specialized medicine services – imposes certain obligations on physicians who participate in the Quebec Health Insurance Plan. Part II affects the practice and availability of assisted procreation activities.

Part I: Family Physician Obligations

One of the big controversies regarding Part I was the imposition of annual patient quotas on family physicians: either take on a caseload of 1,000 patients per year, or face penalties.

On March 30, 2015, approximately 1,000 Quebec medical students from McGill University, Université de Montréal, Université Laval, and Université de Sherbrooke gathered in Quebec City to speak out against Bill 20. The protests followed a mémoire signed by the deans of all four Faculties of Medicine expressing their concerns regarding the new bill.

Quebec physician groups such as the Fédération des médecins spécialistes du Québec and the Fédération des médecins omnipraticiens du Québec also criticized Bill 20, saying that it would aggravate the problem it was designed to address.

Why the imposition of quotas?

While Quebec has more family physicians per capita than most provinces, access to healthcare doesn’t measure up. One study analyzed this discrepancy. The study largely blamed the fact that Quebec physicians have a shorter work week, at 34.9 hours, compared to 43 hours in Ontario. It also noted that Quebec has fewer enrolled patients per physician at an average rate of 1,081 compared to 1,539 in Ontario.

Is Bill 20 the answer?

Critics expressed fear that the bill would encourage ‘assembly-line’ practices in medicine, favouring quantity over quality of care.

The mémoire prepared for the Commission de la santé et des services sociaux by the deans of four faculties of medicine also expressed concern that the bill would have a negative impact on the education and training of physicians. They claimed that the bill did not recognize the additional teaching and research responsibilities that some physicians will have to undertake, such as those practicing in hospitals and other health care institutions with educational missions (e.g. Family Medicine Units).

Further, there were concerns that the bill would affect the number of family physicians in the province. Increasing obligations on family physicians could eventually reduce the amount of family physicians in Quebec as it becomes a less attractive career choice. It could even push doctors out of the province. The average doctor in Canada earned $307,482 in 2010-2011, compared to $253,539 in Quebec and $340,020 in Ontario.

Part II: Assisted Procreation

Part II of the bill, which amended assisted procreation practices, imposed new penal provisions and increased the amount of fines already prescribed in the Act.

Some of the provisions were highly controversial as they seem unnecessary, patronizing, and not justified by medical evidence. There was concern that these elements constituted an attack on women’s rights.

While Quebec was the first province to fully fund in vitro fertilization (IVF) treatments, Bill 20 amended the Health Insurance Act to no longer cover any assisted procreation activities, except for artificial insemination. It also made it an offense to provide IVF treatments to women outside the age range of 18 to 42 (article 10.1).

An additional requirement was that physicians make sure that a woman seeking in vitro fertilization engaged in a suitable period of sexual relations or a number of artificial inseminations “determined by government regulation” (10.3).

Under article 10.2, it also stated that if the ‘parental project’ involves a third party’s genetic material, then fertility treatments could no longer be provided unless the parties seeking treatment have gotten a ‘positive psychosocial assessment’, at their own expense. The bill even imposed these restrictions on parties who are willing to pay out-of-pocket, and prohibited physicians from referring them out of province.

Thus, the concern was that these elements amounted to discrimination on the basis of age, social condition, and sexual orientation, prohibited under section 10 of the Quebec Charter of Human Rights and Freedoms. In particular, the provisions targeted women who choose to wait to procreate and parents who use third party genetic material – often same-sex couples.

The Changes

On May 25, 2015, the Minister of Health and Social Services announced a new agreement with family physicians that would delay the effects of the bill for two years. Family doctors would be spared the quotas and penalties for non-compliance in exchange for a guarantee that by 2017, 85% of Quebec’s population would have a family doctor.

Just one day later, the Minister also backtracked on some of the provisions affecting assisted procreation. The new amendments would give the responsibility of determining guidelines for assisted fertilization to the Collège des médecins du Québec. They would take away the requirement that couples engage in a period of sexual activity before they are eligible for fertility aid and reduce the ‘positive psychosocial assessment’ requirement to cases when the doctor has reason to believe there is a risk to the security or development of the child.

Although the changes still incorporate certain controversial elements, albeit in a less draconian manifestation, the new changes can definitely be counted as a victory for reproductive rights – Pyrrhic as it may be.

The Sleepwalking Defence and Implications of the Not Criminally Responsible Reform Act

Posted By Lana McCrea

The National Post reported on February 17, 2015 that a man on trial for sexually assaulting his seven-year-old daughter in December 2010 was found not criminally responsible. The judge ruled that he was sleepwalking and therefore in a state of automatism. The man was accused of entering his daughter’s bed after his wife kicked him out of their bed for having spent the night drinking. He allegedly tried to remove his daughter’s underwear and held her down as he touched her. Dr. Colin Shapiro testified that the man suffered from parasomnia, a type of sleep disorder that can include ‘sleep sex’.

R v Parks (1992) established that sleepwalking can be classified as automatism resulting in the verdict of not guilty. In that case, the defendant drove 25 kilometers to the home of his in-laws and stabbed his father-in-law to death, seriously injuring his mother-in-law.

In Canada v Campbell (2000), George Campbell was found not criminally responsible by reason of mental disorder after he attacked a woman in her bed where she had been sleeping with him. He was charged with attempted murder, assault with a weapon, aggravated assault, choking, and uttering a death threat. The judge ruled that he had been sleepwalking and therefore the defence of automatism applied. On October 14, 2014, CBC News reported that Phyllis John was attacked by the same George Campbell. She claimed that she “didn’t realize her new boyfriend was the ‘sleepwalker’” at first.

One important aspect of the Not Criminally Responsible Reform Act is that it creates a high-risk designation. Upon being designated as such by a court, the accused would be held in custody at a hospital and could not be released by a review board until the designation was revoked by a court. The designation has other important consequences that may help safeguard victims from future acts by those held not criminally responsible. Sleepwalking is just one of many manifestations of the automatism defence which may be affected by the new legislation.

The McGill Journal of Law and Health will discuss some of these important developments and what their implications may be at its Colloquium on February 21st, 2015.

For more information on the MJLH Colloquium, and to read up on our other distinguished speakers, click here.

Interested in sleepwalking and neuroscience? See MJLH Online Editor Jey Kumarasamy’s recent blog post, here.

Mind the Gap: Bridging Evidence and Policy in Health

Posted By Lana McCrea

One of the big issues confronting the health system is how to translate evidence into sound policy. It sounds deceptively easy, but in reality, there is often a yawning gap between what the science says and the strategies actually implemented. The Institute for Health and Social Policy is taking on this question with its new Evidence to Policy Speaker Series in 2014-2015. What are the best ways to tame the widening gyre?

The Problem

In an ideal world, health policy would be driven by a linear model of knowledge transfer, and compelling new scientific evidence would garner swift, effective policy responses. But the actual action cycle rarely resembles the ideal paradigm. Research is often misapplied or simply ignored. Public perception skews the focus of policymakers: issues like Ebola garner attention that is wildly disproportionate to the actual risk it presents to Canadians. Practical considerations underlie these problems as well: underfunding, decentralization, and the effort required for transforming raw research into real-world applicability.

The Dangers of Knowledge Transfer

It is easy to think that more knowledge and evidence leads to better policy. But are there any hidden dangers to consider? Once published, preliminary scientific evidence can be widely and quickly disseminated through the Internet and social media. Policy decisions may be made prematurely in response, and even if the evidence is retracted from peer-reviewed sources, the ramifications can remain. For example, there was an article in Science postulating that xenotropic murine leukemia virus-related virus (XMRV) was a causative agent for chronic fatigue syndrome (CFS), which in turn triggered blood donor deferral policies targeting individuals with any history of CFS. These policies may still apply, despite the fact that the science no longer supports the association. The MMR vaccine-autism link has long been debunked, but the impact of that information is felt to this day; people are still protesting the vaccine and many parents refuse to vaccinate their children. The distribution and application of evidence is not always optimal. Cultivating a healthy dialogue and regulating knowledge transfer are essential to avoiding premature or misguided responses.

The Appetite for Progress

One of the first hurdles to confront when moving evidence to policy is the appetite for progress. As Maureen O’Neil pointed out at the IHSP launch, research will not be implemented if there is no capacity to address the issue from a political standpoint. Even the most perfect knowledge transfer mechanisms cannot ensure that sound policy will result. The federal government’s response to Insite, North America’s first safer injecting facility (SIF), could be seen as an example of this problem. The health minister would not grant Insite anything more than a 6-month extension for the legal exemption from Canada’s drug laws, despite clear scientific evidence showing the efficacy of the service. Policy remained unaffected by research. So the preliminary questions are: Where is the appetite? Are there conflicting policy considerations? How can we approach the question of why certain approaches are taken in the first place? What happens when there is no appetite for progress?

Concerns about the diminishing role of science in policymaking have provoked some political action. Proposed in December 2013, Bill C-558 would create a Parliamentary Science Officer who answers directly to members of parliament and provide them with sound information and expert advice on scientific issues. The goal is to encourage more transparent and evidence-based policymaking. The bill has not seen much success yet, but hopefully it will not be the last initiative of its kind.

Bridging the Knowledge-to-Policy Gap

The good news is that technology can be used to bridge the gap between policy and evidence by facilitating knowledge transfer. For example, Scientific Director of the Institute of Health Services and Policy Research (IHSPR), Dr. Robyn Tamblyn, spoke about their Policy Rounds. Created by the Canadian Institute of Health Research, the IHSPR hosts webinars to create a dialogue between researchers, healthcare policymakers, and other stakeholders on pressing topics. Ms. Tamblyn also spoke about the Evidence-Informed Healthcare Renewal (EIHR) Portal, which is a comprehensive repository of documents on healthcare renewal. The portal offers a single point of access to the burgeoning body of evidence that can feed policy in this domain. Lastly, the Evidence to Policy Initiative (E2Pi) created by the Global Health Group aims to facilitate the synthesis of evidence and policy by providing the tools and information necessary for policymakers to make informed decisions. Where there is a clear demand for recommendations, E2Pi steps in to translate evidence into sound strategy options.

Alternatives to Policy

Policy isn’t necessarily the best or only route for applying evidence on the ground. Influencing patterns of work by engaging motivated teams and encouraging education may be just as effective. At the IHSP talk, Maureen O’Neil spoke about the CFHI’s flagship EXTRA program, which targets health service professionals in senior management positions. The program engages nurses, physical executives, and other health administrative executives, and develops their capacity to optimize the use of research in managing healthcare organizations with the goal of increasing evidence-informed decision-making in the health system.

Going Forward

There will always be challenges when transferring evidence into policy. The key solutions seem to be facilitating dialogue, optimizing resources, and working to create a stable structure for implementing research that is both vertically and horizontally integrated.