The COVID-19 pandemic created circumstances that tested several aspects of the medical regulatory framework. Public health measures including vaccination programs, masking, and screening were the subject of significant public attention and, in some quarters, organized opposition. Physicians retained their professional obligations during this period: to follow established medical guidelines, to base clinical recommendations on recognized medical evidence, to document patient encounters appropriately, and to act consistently with the public protective function of the regulatory regime. Where physicians acted inconsistently with those obligations, the regulatory framework operated as it does in any other context, evaluating the conduct against the applicable professional standards.
College of Physicians and Surgeons of Ontario v Thirlwell, 2026 ONPSDT 5, released by the Ontario Physicians and Surgeons Discipline Tribunal on February 11, 2026, is one of the more notable pandemic-era discipline decisions on the Ontario record. The respondent was a psychiatrist who issued approximately 1,425 COVID-19 medical exemption letters during a three-month period in 2021, charging patients between $50 and $300 per letter. The Tribunal found that the exemptions were not based on recognized medical contraindications but on patients’ fears, misinformation, and emotional distress. The Tribunal made dual findings of professional misconduct (including under the disgraceful, dishonourable, or unprofessional standard) and incompetence within the meaning of the Health Professions Procedural Code. The certificate of registration was revoked.
The case is doctrinally important for several reasons. It is one of three pandemic-era revocation decisions in Ontario applying the regulatory framework to physicians who acted inconsistently with public health measures and professional guidelines. It articulates the framework for evaluating medical exemption letters issued at scale, including the relationship between recognized medical contraindications and the framework for exemption documentation. It addresses the framework for findings of incompetence (distinct from but operating alongside professional misconduct findings). It illustrates the role of financial motivation as an aggravating factor in the framework. It applies the framework for considering prior cautions and remedial agreements where these have failed to produce meaningful behavior change. And it confirms the application of the revocation framework as the appropriate sanction where the protective function of the regulatory regime requires removal from practice.
The legal framework — professional misconduct, incompetence, and revocation
A brief overview of the legal framework is useful for the analysis.
The Regulated Health Professions Act framework. Physicians in Ontario practise under the framework of the Regulated Health Professions Act, 1991, SO 1991, c 18 (the RHPA) and the Medicine Act, 1991, SO 1991, c 30. The framework establishes the regulatory authority of the College of Physicians and Surgeons of Ontario, the discipline framework, and the appellate framework.
The Health Professions Procedural Code. Schedule 2 to the RHPA establishes the Health Professions Procedural Code, which governs discipline and licensing procedures. The Code includes the framework for findings of professional misconduct, the framework for findings of incompetence, the framework for sanctions including revocation, and the framework for appeals.
The professional misconduct framework. Section 51 of the Code provides for findings of professional misconduct. The specific categories of misconduct are set out in the Professional Misconduct Regulation, O Reg 856/93, under the Medicine Act. The regulation lists more than 35 categories of conduct that constitute professional misconduct, ranging from specific clinical failings (failing to maintain the standard of practice; failing to keep records) to a well-known catch-all in section 1(1) paragraph 33: conduct that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable, or unprofessional.
The disgraceful, dishonourable, or unprofessional standard (often abbreviated as the DDU standard) operates as a broad framework capturing conduct that is inconsistent with professional standards even where it does not fit a more specific category. The framework asks how members of the profession would reasonably view the conduct, applying a reasonable specialist standard rather than a layperson standard.
The incompetence framework. Distinct from professional misconduct, the framework for findings of incompetence addresses the physician’s professional capacity rather than specific conduct. Section 52 of the Code provides for findings of incompetence where the physician’s professional care of a patient has displayed a lack of knowledge, skill, or judgment or disregard for the welfare of the patient of a nature or to an extent that demonstrates that the physician is unfit to continue to practise or that the physician’s practice should be restricted. The framework operates as a separate basis for sanction and can apply alongside or in place of professional misconduct findings.
The dual misconduct + incompetence finding is doctrinally important because it engages both the conduct-based and capacity-based frameworks for discipline. Where the underlying clinical practice falls below the standard in a way that reflects both improper conduct (under the misconduct framework) and inadequate capacity (under the incompetence framework), the framework supports findings under both.
The sanctions framework. Section 51(5) of the Code authorizes the Tribunal to impose a range of sanctions including revocation of the certificate of registration, suspension, conditions on practice, mandatory remedial education, reprimands, costs, and fines. The framework is calibrated to the seriousness of the misconduct and the protective considerations going forward.
Revocation as the appropriate sanction. Revocation is the most serious sanction available to the Tribunal. The framework treats revocation as appropriate where:
- The conduct is incompatible with continued practice
- Lesser sanctions cannot adequately protect the public
- The pattern of conduct or capacity issues cannot be remediated within the conditions framework
- The aggravating factors (including financial motivation, prior remedial failures, and aggressive response to investigation) collectively support revocation rather than suspension
The framework does not require absolute certainty about the impossibility of remediation. It requires the Tribunal to conclude that revocation is the appropriate response to the conduct and the protective considerations.
The clinical and regulatory context — COVID-19 medical exemptions
A brief context overview is useful for the analysis. The framework addresses the regulatory and professional context for medical exemptions during the COVID-19 pandemic period.
The exemption framework. During the COVID-19 pandemic period, various public health measures applied to most people in Ontario including vaccination requirements (for specific settings and contexts), masking requirements, and testing requirements. The frameworks included provisions for medical exemptions in circumstances where the underlying medical condition contraindicated the public health measure. The exemption framework was administered by employers, schools, and other institutions implementing the public health measures.
The medical contraindication framework. The medical contraindications for COVID-19 vaccines, masking, and testing were narrow and specific. They included documented anaphylactic allergy to a previous dose or a component of the vaccine; certain rare conditions affecting the immune or cardiovascular system that contraindicated specific measures; and other narrow clinical categories. The framework was articulated in CPSO guidance, Ministry of Health guidance, and the published clinical literature.
The framework did not include patient preference, philosophical objection, fear of side effects, exposure to misinformation, or general unease about the public health measures as medical contraindications. The framework for medical exemptions was specifically clinical, requiring documented contraindication on recognized medical grounds.
The professional standards framework for exemption documentation. Where a physician issued a medical exemption letter, the professional standards framework required:
- A clinical assessment of the patient sufficient to support the exemption
- Documentation of the assessment in the patient’s medical record
- Identification of the specific medical contraindication supporting the exemption
- Counseling of the patient regarding the risks of remaining unvaccinated, unmasked, or untested in light of their specific clinical circumstances
- Compliance with privacy and record-keeping standards in the documentation and storage of the exemption letter
The framework was articulated in CPSO guidance issued during the pandemic period and in subsequent regulatory communications. The framework operated as the practical application of broader professional standards (clinical assessment, documentation, consent, privacy) to the specific context of medical exemptions during a public health emergency.
The CPSO guidance during the pandemic. The College issued guidance during the pandemic period addressing the framework for medical exemptions and related matters. The guidance reinforced the requirement for clinical assessment, documentation, and counseling, and warned against issuing exemptions outside the recognized medical framework. The guidance was widely communicated to the profession.
The Ministry of Health framework. The Ministry of Health also issued guidance addressing the framework for medical exemptions in connection with various public health measures. The guidance reinforced the framework of recognized medical contraindications and the inappropriateness of exemptions on non-medical grounds.
The facts
The respondent. The respondent was a psychiatrist in active practice in Ontario.
The exemption letter practice. Between August and October 2021 (three months), the respondent issued approximately 1,425 COVID-19 medical exemption letters. The framework for the practice included:
- Charging patients between $50 and $300 per exemption letter
- Family discounts on the per-letter charge
- Estimated total earnings from the practice up to approximately $427,500 over the three-month period
The Tribunal’s findings on the clinical framework. The Tribunal found that the exemption letters were not based on recognized medical contraindications. The exemptions were issued in response to patients’ fears about vaccination, exposure to misinformation, and emotional distress, none of which constitute medical contraindications under the recognized framework.
Documentation and counseling failures. The Tribunal found that the respondent:
- Failed to adhere to CPSO and Ministry of Health guidelines for valid exemptions
- Did not properly document the clinical encounters supporting the exemptions
- Failed to counsel patients regarding the risks of remaining unvaccinated, unmasked, or untested
Privacy and administrative failures. The Tribunal found additional failures in the framework of professional practice:
- Improper storage of patient information on personal systems (rather than in the professional record-keeping framework required by the College)
- Conducting loud patient phone calls in public spaces (compromising patient privacy)
Response to the investigation. The Tribunal found that the respondent’s response to the College’s investigation was aggressive and unreasonable. The framework treats the response to investigation as a separate consideration from the underlying conduct, and an aggressive or obstructive response can operate as an aggravating factor in sanction.
Prior cautions and remedial agreements. The Tribunal noted that the respondent had previously been the subject of cautions and remedial agreements with the College. The framework for remedial intervention generally operates as a less restrictive alternative to formal discipline, addressing concerns about practice through education, supervision, and other supportive measures. The framework relies on the physician’s willingness to engage with the remedial intervention and to produce meaningful behavior change. The Tribunal found that previous corrective efforts had not produced meaningful change.
The Tribunal’s analysis
The professional misconduct findings. The Tribunal made findings of professional misconduct under several categories, including the DDU standard. The framework for the DDU analysis considers the conduct as a whole and asks whether members of the profession would reasonably regard it as falling outside what is acceptable in the practice of medicine.
The framework was satisfied on multiple grounds. Issuing exemption letters at scale without clinical basis, failing to document the encounters, failing to counsel patients about the risks, mishandling patient privacy, and the framework of financial motivation collectively supported the DDU finding.
The incompetence findings. The Tribunal made separate findings of incompetence under section 52 of the Code. The framework for incompetence considers the physician’s professional capacity and asks whether the care has displayed inadequate knowledge, skill, or judgment, or disregard for patient welfare, to an extent that demonstrates unfitness to continue practising.
The framework was satisfied by the demonstrated lack of clinical reasoning in the exemption letter practice, the systematic failure to apply recognized medical standards, the inadequate documentation framework, and the framework of disregard for patient welfare (including the failure to counsel patients about the public health risks of remaining unvaccinated, unmasked, or untested).
The dual finding framework. The dual finding of professional misconduct and incompetence is doctrinally important. The framework recognizes that the conduct engaged both the conduct-based discipline framework (professional misconduct) and the capacity-based discipline framework (incompetence). The dual finding supports a more comprehensive sanction analysis than either finding alone would support.
The financial motivation framework. The Tribunal addressed the financial motivation framework. The estimated earnings of up to $427,500 over the three-month exemption letter practice were treated as a significant aggravating factor in the misconduct analysis. The framework treats financial motivation as particularly serious where it operates as the apparent driver of conduct that is inconsistent with the recognized professional standards.
The prior remedial failure framework. The Tribunal addressed the framework for considering prior cautions and remedial agreements. The framework recognizes that where the College has previously engaged the physician through less restrictive interventions (cautions; remedial agreements; education) and these have not produced meaningful behavior change, the framework supports more formal discipline. The pattern of prior intervention without sustained improvement was treated as supporting the conclusion that less restrictive sanctions would not adequately protect the public.
The aggressive response framework. The Tribunal addressed the framework for considering the respondent’s aggressive and unreasonable response to the investigation. The framework treats the response to investigation as a separate consideration from the underlying conduct. An aggressive, obstructive, or unreasonable response can operate as an aggravating factor by demonstrating lack of insight into the regulatory framework and limited capacity for productive engagement with the regulatory regime.
The sanction
The Tribunal imposed:
- Revocation of the certificate of registration effective February 12, 2026
- Formal written reprimand to appear on the College’s public register
- $10,370 in costs
The revocation analysis. The framework for revocation considered the conduct as a whole, the dual misconduct + incompetence findings, the financial motivation, the prior remedial failures, the aggressive response to investigation, and the protective considerations going forward. The Tribunal concluded that lesser sanctions could not adequately address the framework of concerns and that revocation was the appropriate response.
The framework recognizes that revocation is the most serious sanction available. The Tribunal applies the framework where it concludes that the protective function of the regulatory regime requires removal from practice. Thirlwell is a recent application of the framework in the pandemic-era context.
The doctrinal anchors
Several doctrinal anchors emerge from the case.
The DDU standard framework. Section 1(1) paragraph 33 of the Professional Misconduct Regulation establishes the disgraceful, dishonourable, or unprofessional standard. The framework operates as a broad capture for conduct that is inconsistent with professional standards. Thirlwell applies the framework to mass exemption letter generation and the related framework of professional failures.
The dual professional misconduct + incompetence framework. Findings of professional misconduct and incompetence can apply alongside one another. The framework engages both the conduct-based and the capacity-based dimensions of the discipline regime. Thirlwell is the principal recent cluster authority on the dual finding framework.
The revocation framework. Section 51(5) of the Health Professions Procedural Code authorizes revocation as the most serious sanction. The framework supports revocation where the conduct is incompatible with continued practice and lesser sanctions cannot adequately protect the public. Thirlwell applies the framework in the pandemic-era context with multiple aggravating factors.
The pandemic-era misconduct framework. Professional standards continued to apply during the COVID-19 pandemic. Where physicians acted inconsistently with the recognized framework of medical exemptions, public health guidelines, and professional standards, the regulatory framework operated as it does in any other context. Thirlwell joins the broader pandemic-era discipline framework alongside other COVID-related cases.
The medical contraindication framework. Medical exemptions from public health measures required recognized medical contraindications. Patient preference, philosophical objection, fear of side effects, exposure to misinformation, or general unease did not constitute medical contraindications under the framework. The framework was articulated in CPSO and Ministry of Health guidance during the pandemic period.
The exemption documentation framework. Where a physician issued a medical exemption letter, the professional standards framework required clinical assessment, documentation, specific identification of the contraindication, counseling of the patient regarding risks, and compliance with privacy and record-keeping standards. Thirlwell applies the framework to a case where each of these elements was inadequate or absent.
The financial motivation framework. Financial motivation operates as an aggravating factor where it appears to drive conduct that is inconsistent with recognized professional standards. The framework treats financial motivation as particularly serious where it operates as the apparent organizing principle of the misconduct. Thirlwell applies the framework to a case with estimated earnings up to $427,500 over a three-month exemption letter practice.
The “patient fears not medical contraindications” framework. The framework distinguishes between recognized medical contraindications and patient fears, misinformation, or emotional distress. Issuing exemptions on the latter basis does not satisfy the recognized framework for medical exemptions and constitutes a basis for misconduct findings.
The privacy and record-keeping framework. Storage of patient information in compliance with the recognized framework (rather than on personal systems) and protection of patient privacy in clinical communications are part of the broader framework of professional standards. Thirlwell applies the framework to additional administrative failures alongside the substantive exemption letter misconduct.
The aggressive response to investigation framework. The framework treats the response to investigation as a separate consideration from the underlying conduct. An aggressive, obstructive, or unreasonable response can operate as an aggravating factor in the sanction analysis. Thirlwell applies the framework to a case where the response to investigation was a meaningful aggravating consideration.
The prior remedial failure framework. Where the College has previously engaged the physician through less restrictive interventions (cautions; remedial agreements; education) and these have not produced meaningful behavior change, the framework supports more formal discipline. The pattern of prior intervention without sustained improvement operates as a significant consideration in support of more restrictive sanctions including revocation.
The “incompatible with continued practice” framework. The framework for revocation asks whether the conduct is incompatible with continued practice and whether lesser sanctions can adequately protect the public. Thirlwell applies the framework where multiple aggravating factors (financial motivation, prior remedial failures, aggressive response to investigation) collectively supported the conclusion that revocation was the appropriate response.
The public protection rationale. The framework for revocation operates on the principle that the regulatory regime exists primarily to protect patients and the public. Revocation is imposed where the protective function requires removal from practice. Thirlwell applies the framework with explicit reference to public protection considerations.
Why this case matters
For patients. The case is a useful illustration of how the regulatory framework operates to address conduct inconsistent with professional standards in the pandemic-era context.
Some practical observations:
Professional standards continued through the pandemic. The framework of clinical assessment, documentation, counseling, and compliance with public health frameworks continued to apply during the pandemic period. Where physicians acted inconsistently with the framework, the regulatory regime operated as it does in any other context.
Medical exemptions require recognized contraindications. The framework for medical exemptions from public health measures required documented contraindication on recognized medical grounds. Patient preference, philosophical objection, or exposure to misinformation did not constitute medical contraindications under the framework.
Patients who paid for improperly issued exemptions may be affected. The framework recognizes that patients who paid for medical exemptions that were not based on recognized clinical grounds were affected by the misconduct. The framework does not provide a direct civil remedy through the discipline process, but the discipline findings can be relevant to potential civil claims or refund considerations.
The CPSO public register is a useful resource. Where a physician has been the subject of discipline including revocation, the framework reflects the discipline on the CPSO public register. Patients considering care from a particular physician can consult the register for relevant regulatory history.
For more on the framework for regulatory complaints and the broader landscape of healthcare accountability in Ontario, see A Patient’s Guide to Making Complaints About Health Care in Ontario.
For physicians. A few practical observations:
Professional standards apply uniformly. The framework operates the same way during public health emergencies as in ordinary circumstances. Clinical assessment, documentation, counseling, and compliance with privacy and record-keeping standards are foundational obligations.
The DDU and incompetence frameworks can apply alongside one another. Conduct that falls below the standard in ways that engage both the misconduct framework and the capacity framework can attract dual findings. The dual finding framework supports a more comprehensive sanction analysis.
Financial motivation is a significant aggravating factor. Where financial considerations appear to drive conduct that is inconsistent with the recognized framework, the financial motivation operates as a significant aggravating factor in the discipline analysis.
Engagement with remedial intervention matters. Where the College has engaged the physician through less restrictive interventions (cautions; remedial agreements), meaningful engagement with the framework supports the framework’s protective function. Where prior interventions have not produced sustained change, the framework can support more restrictive sanctions including revocation.
Response to investigation matters. The framework treats the response to investigation as a separate consideration. An aggressive, obstructive, or unreasonable response can operate as an aggravating factor by demonstrating lack of insight into the regulatory framework.
Decision Date: February 11, 2026 (revocation effective February 12, 2026)
Jurisdiction: Ontario Physicians and Surgeons Discipline Tribunal
Citation: College of Physicians and Surgeons of Ontario v Thirlwell, 2026 ONPSDT 5 (CanLII)
Outcome: Revocation of certificate of registration effective February 12, 2026; formal written reprimand on the public register; $10,370 in costs. The Tribunal made dual findings of professional misconduct (including under the disgraceful, dishonourable, or unprofessional standard) and incompetence within the meaning of the Health Professions Procedural Code. The Tribunal found that the respondent had issued approximately 1,425 COVID-19 medical exemption letters during a three-month period in 2021, charging patients between $50 and $300 per letter with estimated total earnings up to approximately $427,500. The exemptions were not based on recognized medical contraindications but on patients’ fears, misinformation, and emotional distress. The Tribunal found additional failures including inadequate documentation of clinical encounters, failure to counsel patients regarding risks, improper storage of patient information on personal systems, conducting loud patient phone calls in public spaces, and an aggressive and unreasonable response to the College’s investigation. The Tribunal also considered prior cautions and remedial agreements that had not produced meaningful behavior change. The framework supported revocation as the appropriate sanction where the conduct was incompatible with continued practice and lesser sanctions could not adequately protect the public.
Key authorities: Regulated Health Professions Act, 1991, SO 1991, c 18 (foundational regulatory framework); Health Professions Procedural Code (Schedule 2 to the RHPA), particularly s 51 (discipline framework) and s 52 (incompetence framework); Medicine Act, 1991, SO 1991, c 30 (physician-specific provisions); Professional Misconduct Regulation (O Reg 856/93) under the Medicine Act, particularly section 1(1) paragraph 33 (disgraceful, dishonourable, or unprofessional standard).
