QUEBEC PROFESSIONAL LAW AS AN OBSTACLE TO INTERPROFESSIONAL CARE PATRICK GARON-SAYEGH Faculty of Law and Biomedical Ethics Unit McGill University, Montreal December 2016 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Master’s of Law, Specialization in Bioethics © Patrick Garon-Sayegh 2016 TABLE OF CONTENTS ABSTRACT ii RÉSUMÉ iii ACKNOWLEDGEMENTS–REMERCIEMENTS iv INTRODUCTION 1 CHAPTER 1. THE OBJECT OF STUDY 4 §A. OCCUPATIONS AND PROFESSIONS DEFINED 4 §B. QUEBEC'S PROFESSIONAL SYSTEM 5 i. Two Types of Professions 5 ii. Institutional Structure 14 §C. CONCLUSION TO CHAPTER 1 18 CHAPTER 2. HISTORY OF THE PROFESSIONAL SYSTEM 21 §A. WHY HISTORY MATTERS 23 §B. THE GENERAL HISTORICAL CONTEXT 28 §C. THE CASTONGUAY-NEPVEU COMMISSION 35 i. Formation and mandate 36 ii. Overview of the Commission’s Report 36 a. Volumes I–III 37 b. Volumes IV–VII 43 iii. Protection of the public 50 a. A Central Objective 51 b. Palliating Mistrust 54 c. Institutional Solutions 57 iv. Systemic Vision: Bringing Order to Disorder 61 a. Conceptual Disorder 61 b. A New Definition 65 c. Factual Disorder 69 d. Systematization 74 v. Aftermath of the Commission’s Report 79 §D. CONCLUSION TO CHAPTER 2 84 CHAPTER 3. STRUCTURED CONFLICTS 86 §A. BOUNDARY IDENTIFICATION 88 i. Boundaries and the Commission’s Discourse 90 ii. Examples 91 iii. Separating Legal Authority from Clinical Ability 100 §B. COMPETITION AND CONTROL 104 i. How dominance is created 107 a. Exclusive Professions 110 b. Professions with Reserved Titles 113 ii. Professional Rivalries 116 iii. Functionalism and Failed Policy 119 §C. CONCLUSION TO CHAPTER 3 123 CONCLUSION 126 BIBLIOGRAPHY 129 i ABSTRACT I argue that Quebec professional law poses an obstacle to the implementation of interprofessional care in the healthcare system. Interprofessional care is distinct from multi- professional care. The former requires different types of professionals to work in a thoroughly integrated fashion, constantly communicating and collaborating, sharing knowledge and decision-making responsibility. The latter only requires patients to be seen by different types of professionals; it allows for minimal communication and little or no sharing of tasks, knowledge and responsibilities. In Chapter 1, I describe Quebec’s professional system—the legal regime that regulates all professions in the province. One of the central characteristics of this system is the fact that it organizes professions into reserved scopes of practice, which determine the types of activities that professionals are legally entitled to perform. In Chapter 2, I describe the history of the professional system, in order to expose the reasons for which professional law acts as an obstacle to the implementation of interprofessional care. I argue that these reasons are rooted in history. I give an overview of the general historical context, and show how the professional system and the healthcare system are historically intertwined. I then focus on a key actor in the emergence of these two systems: the Castonguay-Nepveu Commission. I argue that this parliamentary commission’s report laid the conceptual foundation for today’s professional and healthcare systems. I focus on the ways in which the Commission rationalized its proposals using a discourse whose essential features persist to this day in professional law and the professional system. In Chapter 3, I describe how the Commission’s discourse contributes to perpetuating dynamics that obstruct the implementation of interprofessional care. Professions are separated from each other in rigid and unproductive ways. Professions’ incentives towards collaboration are decreased. The team ethos that is necessary for true interprofessional care is undermined by professional rivalry. I conclude that in order to truly implement interprofessional care in the healthcare system, our understanding of professions and professional regulation must change. Otherwise, future reforms of professional law will fail to remove the obstacles to interprofessional care that I describe. ii RÉSUMÉ Mon argument est le suivant : le droit professionnel québécois constitue un obstacle à la mise en œuvre de soins interprofessionnels dans le système de santé. Les soins « interprofessionnels » sont distincts de ceux dits « multi-professionnels ». Dans le premier cas, les divers professionnels soignant le patient travaillent ensemble de manière profondément intégrée : communiquant et collaborant constamment, et partageant savoir et responsabilité décisionnelle. Dans le second cas, les patients ne font que consulter et être soignés par divers professionnels, sans que ces derniers ne communiquent ensemble de manière poussée et sans partage réel de tâches, savoir, et responsabilités. Dans le Chapitre 1, je décris le système professionnel québécois—le régime juridique encadrant toutes les professions de la province. Une des caractéristiques clef de ce système est qu’il organise les professions selon des sphères d’activités réservées qui déterminent les types d’activités que les professionnels peuvent légalement entreprendre. Dans le Chapitre 2, je décris l’histoire du système professionnel afin d’exposer pourquoi le droit professionnel agit comme obstacle à la mise en œuvre des soins interprofessionnels. Je soutiens que les causes ont des racines historiques. Je donne un aperçu du contexte historique général dans lequel sont nés le système professionnel et le système de santé, et je démontre comment ces deux systèmes sont historiquement entremêlés. Je me concentre plus particulièrement sur un acteur central de l’émergence de ceux deux systèmes : la Commission Castonguay-Nepveu. Je soutiens que cette commission parlementaire est à l’origine du cadre conceptuel sur lequel s’appuient ces deux systèmes. Je détaille la manière dont la Commission rationnalise ses recommandations à travers un discours dont les caractéristiques essentielles persistent à ce jour dans le droit professionnel et le système professionnel. Dans le Chapitre 3, je décris comment le discours de la Commission contribue à perpétuer des dynamiques qui obstruent la mise en œuvre des soins interprofessionnels. Les professions se trouvent séparées les unes des autres de manière rigide et non-productive. Les professions voient leurs incitatifs à la collaboration diminués. L’esprit d’équipe nécessaire à la mise en œuvre de réels soins interprofessionnels est miné par les rivalités professionnelles. Je viens à la conclusion suivante : afin de réellement mettre en œuvre les soins interprofessionnels dans le système de santé, la manière dont nous comprenons les professions et la réglementation professionnelle doit changer. À défaut, de futures réformes du droit professionnel n’enlèveront pas l’obstacle que le droit professionnel pose aux soins interprofessionnels. iii ACKNOWLEDGEMENTS–REMERCIEMENTS This thesis was made possible thanks to the support and encouragement of many people, to whom I extend my warmest thanks. I thank my supervisor, Professor Vincent Forray, for his insightful comments and genuine interest and enthusiasm for my chosen thesis topic. His practical advice with respect to drafting was key to helping me shape this thesis into its final form. He helped make my thesis-writing experience an inspired one, and for that I am privileged. I also thank Professor Daniel Weinstock for agreeing to act as the second evaluator of my thesis, and for his observant and kind comments. J’aimerais également remercier les Professeures Lara Khoury et Alana Klein, co- responsables du Groupe de Recherche en Santé et Droit de McGill, pour m’avoir impliqué dans les activités du Groupe. J’ai également pu bénéficier du support financier du Groupe, ce pour lequel je suis très reconnaissant. I was lucky to have two great friends and lawyers who were willing to listen to my ideas, review my thesis and provide valuable feedback: Maîtres Anik Pierre-Louis and Marc Bishai. I extend my heartfelt gratitude to them for their time, insights and friendship. J’ai eu le privilège d’avoir d’excellents mentors, sans lesquels je n’aurai jamais développé les habiletés qui m’ont permises d’entamer mon projet de recherche et rédiger ce mémoire. En premier lieu, je désire remercier Maîtres Luc Gratton et Normand D’Amour, autant excellents juristes et avocats que collègues de travail. Je suis l’avocat que je suis grâce à eux, ce pour quoi je leur serai toujours reconnaissant. Je dois aussi énormément à mon ancien Professeur et Doyen à la Faculté de Droit de McGill, Nicholas Kasirer, maintenant juge à la Cour d’appel du Québec. J’ai appris de lui que la beauté du droit réside en son non- dit et ses « entre deux » (ou même trois !) : l’outre-loi entre les lignes et les langues. Of course I could not have pursued this project without my family. My parents’ encouragements and support were key in my decision to pursue graduate studies. Considering the excellent experience I have had, I cannot thank them enough. My sister Catherine and her husband Walid must be commended for patiently listening to me ramble on about my academic interests. Finally, my wife Marie has been astonishingly patient, understanding and loving throughout the course of my master’s studies, despite my ceaseless retreats into thick bubbles of thought. Her sensible advice has kept me on track in more ways than I can count, and her sustained interest for my topics of study have been immensely helpful to me as I refined my ideas. I am privileged to share my life with her. Merci infiniment. iv INTRODUCTION Professionals are a central feature of Quebec’s healthcare system. Physicians, nurses, and members of over a dozen other professions provide the services that are at the core of the healthcare system’s mission. All professionals in Quebec are regulated under a comprehensive legal regime, one that is commonly referred to as the “professional system.” The professional system shapes the organization of work in the healthcare system, most notably via the rigid boundaries it establishes around each profession’s activities. These boundaries are “rigid” because they can only be crossed under strict conditions, and failure to respect these conditions exposes one to penal sanctions.