A jurisdictional review of the legislation governing informed consent by chiropractors across Canada

Abstract

The objective of this jurisdictional review is to provide summary information pertaining to the regulation of chiropractors in Canadian provinces and territories on the topic of informed consent. Our review shows that two provinces have legislated for all healthcare professions: Ontario and Prince Edward Island. Two chiropractic regulatory bodies (New Brunswick and, Newfoundland and Labrador) have adopted the Canadian Chiropractic Association Code of Conduct. All chiropractic regulatory bodies of the other provinces and Yukon have adopted their own specific dispositions regarding informed consent. Chiropractors in Prince Edward Island, Saskatchewan and Québec must obtain informed consent in writing.

Introduction

In a large telephone survey, Caspi¹ found that only 57% of U.S.-based complementary and alternative medicine (CAM) organizations have any informed consent (IC) policy and that only 16% mandate their members to obtain IC from their patients. They also found “no consistent standards with respect to the IC process across a broad range of CAM practices.” In a more recent study, the same authors² reported “CAM practitioners seem to represent their own opinions or preferences and not profession-based standards, perhaps because there are none.”

It is a truism that levels of training and regulation of CAM practices vary greatly but contrary to the opinion of the above mentioned authors, established CAM practices such as chiropractic are well regulated and implement profession-based standards. The objective of this jurisdictional review is to provide summary information relative to the regulation of chiropractors in Canadian provinces and territories on the topic of informed consent.

Methods

A review of current legislations and regulations pertaining to chiropractors in all Canadian provinces and territories was conducted. Research was conducted through the CANLII database and websites for each jurisdiction’s regulatory body and professional association. Missing information was completed by telephone interviews with representatives of regulatory bodies and associations.

Results

Chiropractors are regulated in all Canadian provinces and in the Territory of Yukon. There is no regulation of chiropractic in the North West Territories and in the Territory of Nunavut.

We present here the key findings of our review:

• British-Columbia: Authority comes from the Health Professions Act³ which authorizes a board to make bylaws that may include standards of professional practice.⁴ Provision and information on informed consent is provided in The Professional Conduct Handbook adopted by the College of Chiropractors of British-Columbia.⁵

• Alberta: Authority comes from the Health Professions Act⁶ which lays down that a regulated profession must establish, maintain and enforce a Code of Ethics. Provision and information on informed consent is provided in The Standards of Practice⁸ and in The Code of Ethics adopted by the Alberta College and Association of Chiropractors.⁹

• Saskatchewan: Authority comes from the Chiropractic Act¹⁰, which authorizes the Chiropractors’ Association of Saskatchewan (CAS) to make standards of practice and professional ethics. The CAS requires its members to use the Canadian Chiropractic Protective Association patient informed consent form.¹¹

• Manitoba: Authority comes from The Chiropractic Act¹², which authorizes the Manitoba Chiropractors Association “to make regulations to develop, establish and maintain standards for the practice of chiropractic”. Provision and information on informed consent are provided in the Code of Ethics adopted by the Manitoba Chiropractors Association.¹³

• Ontario: Authority comes from the Regulated Health Professions Act¹⁴ where the College has to “develop, establish and maintain” standards of practice and professional ethics and where members must follow a uniform set of rules for consent to treatment created by the Health Care Consent Act.¹⁵ Provision and information on informed consent are provided in the Standards of Practice S-002 (Record Keeping), S-005 (Manipulation/Adjustment), S-008 (Diagnosis/Clinical Impression) and S-013 (Consent) adopted by the College of Chiropractors of Ontario.¹⁷ Also, the Ontario Chiropractic Association, the largest advocacy group in the province, recommends its members to practice in accordance with the laws and regulations of the Province of Ontario.¹⁸

• Québec: Authority comes from the Professional Code ²⁰ where the Québec Board of Chiropractors must make, by regulation, a code of ethics. Provision and information on informed consent is provided in the Code of ethics of chiropractors.²² In Québec, the Québec Chiropractors Association published the Chiropractor’s Manual²³, adopted by the Québec Board of Chiropractors. This Manual is a summary of accepted standards of practice, and procedures and services performed in the daily practice of clinical chiropractic. Authority also comes from the Civil Code of Québec¹⁹ in harmony with the Charter of Human Rights and Freedoms and the general principles of law.

• New-Brunswick: Authority comes from An Act to Incorporate the New- Brunswick Chiropractors Association²⁴ which authorizes the Association “to establish, maintain, develop and enforce standards of professional ethics.” Provision and information on informed consent are provided in the Code of Ethics adopted by the New-Brunswick Chiropractors Association.²⁶ The Association has also adopted through its bylaws the Code of Ethics and the Clinical Guidelines for Chiropractic Practice In Canada by the Canadian Chiropractic Association.²⁵

• Nova Scotia: Authority comes from the Chiropractic Act.²⁷ The Act authorizes the College to “establish, maintain and develop” standards of professional ethics and practice. Provision and information on informed consent are provided in The Standards of Practice on Informed Consent ²⁹ and in The Code of Ethics adopted by the Nova Scotia College of Chiropractors²⁸.

• Prince-Edward-Island: Authority comes from to the Consent to Treatment and Health Care Directives Act³⁰ which creates a uniform set of rules for consent to treatment for all health care providers. Besides, the Prince Edward Island Chiropractic Association, which is the regulatory body in Prince Edward Island, requires Canadian Chiropractic Protective Association (CCPA) membership for liability coverage.³² CCPA strongly recommends use of their informed consent form.

• Newfoundland and Labrador: Authority comes from the Chiropractors Act 2009.³³ By regulation³⁴, improper professional conduct includes conduct contrary to the Code of Ethics set by the Canadian Chiropractic Association (CCA).³⁵ This Code of Ethics recommends that CCA members “share the responsibility of the health care decision making process with a patient.” Furthermore, the CCA has a specific position statement on informed consent.³⁶

• Yukon: Authority comes from the Chiropractors Act.³⁷ Provision and information on informed consent are those published by the Canadian Chiropractic Association.

Two provinces have enacted omnibus legislation with respect to informed consent: Ontario (Health Care Consent Act¹⁵) and Prince Edward Island (Consent to Treatment and Health Care Directives Act³⁰). Two provinces (New Brunswick and Newfoundland and Labrador) have adopted the Canadian Chiropractic Association Code of Conduct.^25,34 All other provinces and Yukon have adopted their own specific dispositions regarding informed consent (see Table).

Table 1.

Laws and regulations

Province : Acts and regulations	College or Association: Regulations / Bylaws / Codes
British-Columbia: Health Profession Act 3 http://www.bclaws.ca/EPLibraries/bclaws_new/document/ID/freeside/00_96183_01 a.15.1 (1) The British Columbia College of Chiropractors continued under the Chiropractors Act is continued as a college under this Act under the name College of Chiropractors of British Columbia. 16 Duty and objects of a college (1) It is the duty of a college at all times: […] (i) to inform individuals of their rights under this Act and the Freedom of Information and Protection of Privacy Act; Bylaws for college 19 (1) A board may make bylaws, consistent with the duties and objects of a college under section 16, that it considers necessary or advisable, including bylaws to do the following: (…) (k) establish standards, limits or conditions for the practice of the designated health profession by registrants; (l) establish standards of professional ethics for registrants, including standards for the avoidance of conflicts of interest;	College of Chiropractors of British-Columbia: Bylaws 4 http://www.chirobc.com/standards-and-legislation/bylaws/ Standards of professional ethics and practice a.82. The board must publish, on the college website or in another manner accessible to registrants and the public, all standards, limits and conditions established by the board in accordance with the authority set out in section 19 (1)(k), (l) and (z) and (1.1) of the Act. Registrants must at all times conduct their practice in a manner that is in keeping with the standards, limits or conditions published by the board under subsection (1). Under section 82 of the Bylaws, the College published The Professional Conduct Handbook for the guidance of registrants. 5 http://www.chirobc.com/standards-and-legislation/professional-conduct-handbook/
Alberta 1- Health Profession Act (subjects all health care practitioners). 6 http://www.qp.alberta.ca/documents/acts/h07.pdf a. 3 (1) A College (…) (c) must establish, maintain and enforce standards for registration and of continuing competence and standards of practice of the regulated profession (d) must establish, maintain and enforce a code of ethics 2- Chiropractic Profession Act 7 https://www.canlii.org/en/ab/laws/stat/rsa-2000-c-c-13/latest/rsa-2000-c-c-13.html a. 7 (1) The Alberta Chiropractic Association is continued as a corporation under the name “The College of Chiropractors of Alberta”	Alberta College and Association of Chiropractors 1- Standards of Practice 8 http://www.albertachiro.com/ieadmin/files/ACAC_Standards_of_Practice.pdf a.3.1 Informed Consent (Adopted 06/2004, Revised and Effective 01/2014) 2- Code of Ethics 9 http://www.albertachiro.com/ieadmin/files/Code_of_Ethics.pdf a. A5 and A6
Saskatchewan: The Chiropractic Act 10 http://www.qp.gov.sk.ca/documents/English/Statutes/Statutes/C10-1.pdf a.3 The Chiropractors’ Association of Saskatchewan, continued pursuant to The Chiropractic Act, is continued as a corporation. a.14 (2) The board may (a) make bylaws for any purpose set out in section 15 a.15 (h) setting standards regarding the manner and method of practice of members; (i) providing for a code of professional ethics;	Chiropractors’ Association of Saskatchewan11 Policy on informed consent: The CAS adopts the CCPA patient informed consent form as a mandatory part of the patient records (Unit V- K.1). http://www.saskchiropractic.ca/doc/BLK%20book/PolicyA_II_Jan_2014%281%29.pdf
Manitoba: The Chiropractic Act 12http://web2.gov.mb.ca/laws/statutes/ccsm/c100e.php a.3 The Manitoba Chiropractors Association is continued as a body corporate a.25 (2) The board may make by-laws respecting: (e) a code of ethics for the practise of chiropractic a.26 (b) the board may make regulations to develop, establish and maintain standards for the practice of chiropractic; Under legislation enacted in 2009 (RHPA) the College of Chiropractors of Manitoba will be the regulatory body established for the health profession of chiropractic. Every doctor of chiropractic practicing in Manitoba will be required to become a registered member of the College. According to the Manitoba Chiropractors Association, transition to the new legislation in under way. http://www.mbchiro.org/	Manitoba Chiropractors Association: Code of Ethics 13 http://www.mbchiro.org/docs/Approved-Code-of-Ethics.pdf II Principles Patient autonomy and informed consent (…) A chiropractor shall respect the patient’s right to participate in treatment decisions, to be informed of the potential risks and benefits of treatment options and venue, and to accept or refuse such treatment. III. Responsibilities and Accountability A. RESPONSIBILITY TO PATIENTS Article 4 Informed Consent to Treatment (a) Chiropractors must discuss with patients treatment recommendations including benefits, prognosis and significant risks, as well as reasonable alternatives and associated costs to enable patients to make an informed decision with regard to any proposed chiropractic care.
Québec 1- Civil Code 19 (subjects all citizens) a. 3, 10, 11 (establish the right to the inviolability, integrity and privacy of his person). https://www.canlii.org/en/qc/laws/stat/cqlr-c-c-1991/latest/cqlr-c-c-1991.html?autocompleteStr=civil%20code&autocompletePos=1 2- Professional Code 20 (subjects members of all orders) a. 87: The board of directors (of the professional order) must make, by regulation, a code of ethics governing the general and special duties of the professional towards the public, his clients and his profession. https://www.canlii.org/en/qc/laws/stat/cqlr-c-c-26/latest/cqlr-c-c-26.html?autocompleteStr=professional%20code&autocompletePos=1 3- Chiropractic Act 21 http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=2&file=/C_16/C16_A.html 2. All persons qualified to practise chiropractic in Québec constitute a professional order called the “Ordre professionnel des chiropraticiens du Québec” or the “Ordre des chiropraticiens du Québec”. 1973, c. 56, s. 2; 1977, c. 5, s. 229; 1994, c. 40, s. 284. Subject to the provisions of this Act, the Order and its members shall be governed by the Professional Code (chapter C-26). 1973, c. 56, s. 3	Quebec Board of Chiropractors: Code of Ethics of Chiropractors 22 http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=3&file=/C_16/C16R5_1_A.HTM a. 43 Prior to the examination or treatment proposed, chiropractors must obtain from the patient a written, free and enlightened consent after having informed the patient of the nature of the problem to be treated, the treatment procedure and the potential benefits and risks. Chiropractors must also inform their patient that their consent may be revoked at any time and that any material change in the treatment plan agreed to requires a separate consent. Association des chiropraticiens du Québec : Chiropractors’ Manual (adopted by the Québec Board of Chiropractors) 23 Since the Manual is a summary of accepted standards of practice, and procedures and services performed in the daily practice of clinical chiropractic, it must be used in accordance with the laws and regulations which govern chiropractic in their resident province or state.
Nova Scotia: Chiropractic Act 27 http://nslegislature.ca/legc/statutes/chiropractic.pdf 4 (1) The Nova Scotia College of Chiropractors is hereby created and established as a body corporate and is composed of the members on the register created under the former Act. (3) In order that the public interest may be served and protected, the objects of the College are to (b) establish, maintain and develop standards of knowledge and skill among its members; (c) establish, maintain and develop standards of qualification and practice for the practice of chiropractic; (d) establish, maintain and develop standards of professional ethics among its members;	Nova Scotia College of Chiropractors 1- Code of Ethics 28 (approved by the Board of the NSCC; effective June 2002) http://www.chiropractors.ns.ca/images/stories/NSCC_Members/NSCC_Code_of_Ethics.pdf a. 4: The ethical chiropractor will show concern and care for his/her patients, and will share information, whenever possible, so that his/her patients can make appropriate decisions regarding his or her care. 2- Standards of practice on informed consent 29 (approved by the Board of the NSCC April 20 2002) http://www.chiropractors.ns.ca/images/stories/NSCC_Members/Standards_of_Practice/05__Standards_of_Practice__Informed_Consent.pdf
Prince Edward Island 1- Consent to Treatment and Health Care Directives Act 30 (subjects all health care providers) http://www.gov.pe.ca/law/statutes/pdf/c-17_2.pdf This act creates a uniform set of rules for consent to treatment. 2- Chiropractic Act31 https://www.canlii.org/en/pe/laws/stat/rspei-1988-c-c-7.1/latest/rspei-1988-c-c-7.1.html?searchUrlHash=AAAAAQAlcHJpbmNlLWVkd2FyZC1pc2xhbmQgY2hpcm9wcmFjdGljIGFjdAAAAAAB 3. (1) The Prince Edward Island Chiropractic Association is continued as a body corporate 5. (1) There is established a council to be known as the Council of the Prince Edward Island Chiropractic Association (2) The functions of the Council are to Council (…) (d) establish, or adopt from another regulating body in another jurisdiction, professional ethical guidelines and standards of practice respecting the practice of chiropractic;	Prince Edward Island Chiropractic Association By-law: 2004-1: Memberships 32 By-law passed membership vote at Annual General Meeting on January 14, 2004 By-law in effect as of date vote: January 30, 2004: All registered chiropractors of the PEICA must be members of CFCRB (the Canadian Federation of Chiropractic Regulatory Board), the CCA (the Canadian Chiropractic Association) and retain mal-practice insurance with CCPA (the Canadian Chiropractic Protective Association).
Newfoundland and Labrador 1- Chiropractors Act 2009 33 https://www.canlii.org/en/nl/laws/stat/snl-2009-c-c-14.01/latest/snl-2009-c-c-14.01.html 2- Chiropractors regulation 34 Under the authority of section 15 of the Chiropractors Act and the Subordinate Legislation Revision and Consolidation Act : Improper conduct shall include a. 10 (t) : conduct contrary to the Code of Ethics set by the Canadian Chiropractic Association (CCA) http://www.assembly.nl.ca/legislation/sr/regulations/rc961101.htm	Newfoundland and Labrador Chiropractic Association All chiropractors’ obligations are set by the Chiropractors Act and the Chiropractors Regulations.
Territory: Act	Board or Association: Regulations / Bylaws / Codes
Yukon: Chiropractors Act 37 http://www.gov.yk.ca/legislation/acts/chiropractors.pdf a. 5 : The Code of Ethics and guidelines of the Canadian Chiropractic Association shall be the code of ethics and guidelines to be followed by chiropractors. S.Y. 1999, c.11, s.12.	All chiropractors’ obligations are set by the Chiropractors Act.
North West Territories Nil	Nil
Nunavut Nil	Nil

Two provinces have made it mandatory to obtain consent in writing and chiropractors in Saskatchewan must use the Canadian Chiropractic Protective Association form.¹¹ In Québec, chiropractors must obtain consent in writing but do not have the obligation to follow any specific format although the regulatory board recommends to its members to use either the Canadian Chiropractic Protective Association form or a provincial form (which itself has information, based on the CCPA form), that is made available to the members of the Québec Board of Chiropractors.

Details are provided in the Table below.^a

Discussion

First, in this review, we have highlighted the fact that several Canadian provinces have enacted informed consent legislations that apply to all health care professionals. Second, all chiropractic licensing bodies have adopted regulations and codes of ethics that specifically address the issue of informed consent in the health care context. Generally speaking, all of these statutes have an objective to organize the common law rules regarding informed consent as enunciated in Reibl v. Hughes.³⁸ This decision of the Supreme Court of Canada is of considerable importance because it recognizes that informed consent requires health care practitioners to inform their patients of risks that the “reasonable person in the position of the patient” would want to know and to ensure that their patients have understood the information that has been disclosed. This represents a significant change from a paternalistic perspective to informed consent toward a more patient-centered approach.

Chiropractic licensing bodies ensure the patients’ right to be informed and the need for the health practitioner to know how to fully comply with his or her duty of disclosure. In sum, the basic principles of Canadian chiropractic informed consent procedures and policies do not differ from allopathy and cover the essentials of the Supreme Court of Canada decision.³⁸

However, with 13 different jurisdictions (10 provinces and 3 territories), the format of those statutes may vary greatly from one region to another since health regulation is a provincial/territorial responsibility. This heterogeneity in statutes may lead to large variations in the day-to-day implementation of sound informed consent procedures. In Canada, approximately 87%^b of chiropractors have professional liability protection from the Canadian Chiropractic Protective Association, a mutual defence association which is governed by a council of chiropractors. For the benefit of its members, this association has published in October 2015 a revised version of its informed consent form.

This form reflects actual knowledge regarding chiropractic informed consent and represents what patients should know regarding their chiropractic care. The most significant change from the last version is a statement that patients should not sign the consent form before they have had an opportunity to speak to their chiropractor first. In other words, the consent form should never be signed during patient intake since obtaining informed consent requires that the patient understands the diagnosis, proposed treatment, alternatives and plan management. It is important to remember that informed consent is a process and not just a one-time event.

We suggest that chiropractic regulatory bodies and associations encourage chiropractors to use the documentation created by the Canadian Chiropractic Protective Association (CCPA) whether or not they get their professional liability coverage from this provider. However, Canadian chiropractors must ensure that the documentation complies with the nuances of their province/territory regulations. Also, they must ensure the understanding of these documents by their patients and cannot be content to provide information without explanation.

Chiropractic care remains unregulated in the Northwest Territories and Nunavut. According to our respondents, only a handful of chiropractors are practicing in those areas but patients receiving chiropractic care in those two regions are entitled to the same protection as those in the rest of Canada. We suggest that the Canadian chiropractic profession makes an in-depth analysis of this issue in order to ensure that patients in those regions are covered by the same standards of care than in the rest of Canada.

Conclusion

Chiropractic is a well-organized profession in Canada. In terms of informed consent, provincial and territorial regulations and profession-based standards ensure that chiropractic patients receive and understand all pertinent information related to their care. However little data exists on how chiropractors implement those procedures. Studies should be conducted to measure the compliance of chiropractors to informed consent standards.