The Canadian Medical Association (CMA) has drafted revisions to its Code of Ethics and Professionalism to promote health and reconciliation in Canada’s Indigenous communities.

The code establishes physicians’ ethical obligations and reaffirms the medical profession’s core values. The revisions are intended to provide clearer guidance for physicians and expectations for the public regarding professional conduct and healthcare decision-making. Many regulatory colleges across Canada stipulate that doctors must follow the code to fulfill their licensing requirements.

Indigenous leaders and community members have raised concerns about racism in the healthcare system. This problem manifests itself in patients who believe that they are not being listened to, lack of access to healthcare and hospital emergency room facilities, discrimination against healthcare workers and patients, and healthcare environments that are not always culturally, physically, and psychologically safe.

In 2024, the CMA issued an apology for its role — and the role of the medical profession — in previous and ongoing harm to First Nations, Inuit, and Métis patients. The proposed revisions to the code were prompted by concerns raised by the wording and scope of the apology, which Indigenous communities across Canada deemed inadequate.

“In the Indigenous context, just because someone offers you an apology doesn’t mean you have to accept it. An apology may be considered a starting point, but so much more systemic, sustained action at so many levels needs to be considered to remedy the situation. Institutions may not have culturally safe access, and the staff may not undergo training to promote cultural humility,” Patricia Farrugia, MD, associate clinical professor and associate dean of Indigenous health at McMaster University in Hamilton, Ontario, told Medscape News Canada.

The revisions to CMA’s code of ethics were informed by a review of the historical abuses that Canada’s First Nations patients have endured. “When the federal government made the decision to outlaw tradition and ceremony and the use of traditional medicine, which wasn’t reversed until the 1970s, that had an enormous impact on the sustainability of traditional medicine within Indigenous communities. In addition, medical experimentation with sterilization as a widespread practice across Canada occurred with the hospital system,” said Alika Lafontaine, MD, former CMA president and anesthesiologist at Grande Prairie Regional Hospital in Grande Prairie, Alberta.

Many Indigenous patients have experienced outright prejudice, where a derogatory comment has been made or stereotypes have been expressed, said Farrugia. When Indigenous people drink alcohol, it’s automatically assumed that they’re substance abusers, and they may receive dismissive treatment as a result, she noted.

“Gender-diverse individuals or marginalized populations are really under fire now, so if the code doesn’t reflect the current political and societal context of experiences for these people, it could miss an opportunity to uplift those who need the most help,” she added.

Bridging Cultural Gaps

“Because people don’t take the time to listen and allow patients to be heard, healthcare professionals may not arrive at the best plan to present to their patients,” Margot Burnell, MD, president of the CMA, told Medscape News Canada. “It’s important that we listen deeply and then jointly build a trusting relationship where we can present options and work together. A patient’s entire care team needs to conduct a thorough medical investigation and arrive at a differential diagnosis without cultural bias or assumptions. A lack of cultural sensitivity, along with previous trauma related to medical care, has led to avoidance of treatment because people don’t trust the system,” added Burnell. “Indigenous patients have less-than-optimal outcomes and delayed treatment as results of systemic racism in the Canadian healthcare system,” she said.

One of the purposes of the code revisions is to strengthen the interactions between physicians, medical students, and other healthcare workers because they also experience racism and discrimination in the workplace, according to Burnell. “They deserve and are entitled to a safe workplace. It’s important that the entire culture be improved.”

Creating Systemic Change

In 2025, the CMA consulted with physicians, Indigenous community leaders, and patients when it was revising its code. They also consulted more than 50 groups, including national Indigenous organizations, national medication organizations, regulatory colleges, provincial and territorial medical associations, and physicians.

But the consultation process was not transparent, said Farrugia. “The draft revisions to the code are a start. But as a member of the medical community in Canada, I’m not aware of the identities of the individuals involved. If there isn’t a balance between community members, those with lived experience, and the government, I’d be concerned that there may be some important voices left out,” she said.

The revisions to the code are responses to “cultural elements that have been ingrained within medicine and the ways that power structures have developed in Canada,” said Lafontaine. “There are also structural inequities, regarding the government’s decision not to build healthcare facilities and allow access in certain places, that have had profound effects on certain communities, including indigenous peoples.”

What happens at the patient’s bedside does not always follow the code, said Lafontaine. Behavioral change is one of the hardest steps in the process because of the number of stakeholders that must be engaged. “A lot of thought must be put into the predicted behavior that you think the changes are going to cause. The change at the bedside comes with the implementation of the code and ensuring that provincial and territorial health systems are aware that it has been updated. These systems must work with regulatory partners and other important stakeholders like the Canadian Medical Protective Association to ensure that people understand that there is a new standard of behavior,” added Lafontaine.

The CMA will be seeking feedback on the draft changes to the code. Once the feedback has been reviewed, the draft will be revised, and a new version will be published in June.

Farrugia, Lafontaine, and Burnell reported having no relevant financial relationships.