Medical Ethics

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Medical ethics:

State Institute of Health & Family Welfare, Jaipur Medical ethics 1 SIHFW: an ISO 9001:2008 certified Institution

Slide 2:

Doctors world over are- Regarded Trusted Trust may wither away, unless conscious attempt is made to preserve it 2 SIHFW: an ISO 9001:2008 certified Institution

Slide 3:

Trust, in fact, is shrinking, for Decline and Deviation from Ethics 3 SIHFW: an ISO 9001:2008 certified Institution

Pure medical Professionalism To Medical Industrialization Lead to deviation from ethics & loss of trust:

Pure medical Professionalism To Medical Industrialization Lead to deviation from ethics & loss of trust 4 SIHFW: an ISO 9001:2008 certified Institution

Profession:

Profession It is a vocation or calling and implies service to Others; It has a distinctive knowledge base which is kept up to date; It determines its own standards and sets its own Examinations; It has a special relationship with those whom it serves – patients; and It has particular ethical principles SIHFW: an ISO 9001:2008 certified Institution 5

Professionalism:

Professionalism “Constituting those attitudes and behaviors that serve to maintain patient interest above physician Self-interest” Altruism (interest of patients, not self-interest, is the rule.), Accountability, Excellence, Duty, Honor and Integrity, and Respect for others. 6 SIHFW: an ISO 9001:2008 certified Institution

Human social behavior is governed by::

Human social behavior is governed by : Custom etiquette Ethics Law Morality Mores Professional Prof. values States, Statutes, legislations Spirituality Tradition Courtesy Competence Enforcement Religious Fairness Compulsion Good v/s bad Truth Justice Right v/s wrong Integrity Judiciary Goodwill Punishment 7 SIHFW: an ISO 9001:2008 certified Institution

Medical Ethics:

Medical Ethics Ethics: Ethics or moral philosophy is the systematic endeavour to understand moral concepts and justify moral principles and theories . Medical etiquette Refers to the courtesy with which a doctor should treat his colleagues 8 SIHFW: an ISO 9001:2008 certified Institution

Morality and Ethics:

Morality and E thics Moral - Latin , mores Ethics - Greek, ethos Both deriving their meaning from the idea of “custom”. There is also another Greek word ēthos which denotes a character feature. Aristotle called his ethics a study of character traits, in sense of virtues and vices. 9 SIHFW: an ISO 9001:2008 certified Institution

Medical Ethics:

Medical Ethics Ethics: Ethics or moral philosophy is the systematic endeavour to understand moral concepts and justify moral principles and theories . Medical etiquette Refers to the courtesy with which a doctor should treat his colleagues 10 SIHFW: an ISO 9001:2008 certified Institution

Slide 11:

Medical Ethics: “Deals with the moral principle that doctors should adhere to in their transaction with patient, colleagues and the state”. C oncern not only doctors but also patients and society . The core of ME is doctor patient relationship. SIHFW: an ISO 9001:2008 certified Institution 11

Evolution of concept of ME:

Evolution of concept of ME Greek : 4 th century BC; “ Ethikos ”- means theory of living Hippocratic Oath Chinese code of conduct- 2 nd Century BC India: 2000 yrs. ago 12 SIHFW: an ISO 9001:2008 certified Institution

Slide 13:

Islamic code of ethics as follows : Personal Character of the physician His obligation towards patients His obligations towards the community His obligation towards his colleagues His Obligations towards his assistants. 13 SIHFW: an ISO 9001:2008 certified Institution

Slide 14:

Code of Medical Ethics Adopted by World Medical Association – the 3 rd General Assembly, London Oct 1949. Amended by the 22 nd World Medical Assembly Sydney , Australia , August 1968 35 th World Medical Assembly, Italy Oct. 1983 WMA General Assemb;ly , South Africa , Oct 2006 American Medical Association- Standard of conduct United Kingdom , General Medical council “ Good Medical Practice “ statement. 14 SIHFW: an ISO 9001:2008 certified Institution

Contemporary legal medical practices:

Contemporary legal medical practices Contract ( basis of patient doctor relationship ) Voluntary, Quasi Law at tort( please protect yourself, ) when liability of harm is on Doctor Negligence tort Intentional tort 15 SIHFW: an ISO 9001:2008 certified Institution

Negligence tort:

Negligence tort Duty Breach Causation Damage 16 SIHFW: an ISO 9001:2008 certified Institution

Intentional Tort :

Intentional Tort Assault- Immediate apprehension of harm ( words with supporting gestures) Battery- Unauthorized touching False imprisonment Defamation- Harming the repute – verbally/ written Invasion of privacy ( giving information to unauthorized ) Infliction of mental distress 17 SIHFW: an ISO 9001:2008 certified Institution

Scope of Medical Ethics:

Scope of Medical Ethics Development of ethical codes and guidelines Promotion of ethical practice Prevention of ethical breaches Recognition of ethical dilemmas Resolution of ethical conflicts 18 SIHFW: an ISO 9001:2008 certified Institution

Components of Medical Ethics:

Components of Medical Ethics Physician patients relationship Physician: physician relationship Physician : health system relationship Physician: Society relationship 19 SIHFW: an ISO 9001:2008 certified Institution

Importance of Medical Ethics :

Importance of Medical Ethics Increasing profile\Recent press headlines Increase in technology- use vs abuse Better informed society-awareness Doctors in Management Public scrutiny-Audit, CPA 20 SIHFW: an ISO 9001:2008 certified Institution

Why we need it:

Why we need it “Patients are entitled to, good standards of practice and care from their doctors. Essential elements of this are professional competence, good relationships with patients and colleagues and observance of professional ethical obligations.” From Good Medical Practice, GMC. SIHFW: an ISO 9001:2008 certified Institution 21

The moral duties of the doctor:

The moral duties of the doctor Help, cure Promote and protect the patient’s health Confidentiality Protect the patient’s life Respect the patient’s autonomy Protect privacy Respect the patient’s dignity 22 SIHFW: an ISO 9001:2008 certified Institution

The moral rights of the patient:

The moral rights of the patient High quality medical service Autonomous choice Decide Be informed Privacy Health education Dignity 23 SIHFW: an ISO 9001:2008 certified Institution

Role of the doctor within the health service :

Role of the doctor within the health service Understanding of the: Health care system Clinical responsibilities As researcher, mentor or teacher, manager Quality control Team work 24 SIHFW: an ISO 9001:2008 certified Institution

Six principles of Medical Ethics:

Six principles of Medical Ethics Beneficence To act in the best interest of the patient Non - Malfeasance Do no harm Autonomy The patient right to refuse or choose{ consent) Justice Who gets what treatment on the merit of illness Dignity Patient and doctor both have the right to dignity Truthfulness/ Honesty The patient deserve to know the whole truth about the illness and treatment 25 SIHFW: an ISO 9001:2008 certified Institution

Beneficence and Non – Malfeasance :

Beneficence and Non – Malfeasance Think good You may not say any thing- others can still read you Face Accent Body language/ Gestures silence may still be saying something Talk / Say good- the words The art of communication is the foundation of the patient doctor relationship Do good – the acts Write good 26 SIHFW: an ISO 9001:2008 certified Institution

Beneficence and Non-Malfeasance:

Beneficence and Non-Malfeasance Questions: Is the patient your only concern? (possible conflict with utility) Do we always know what is good for the patient? (patient’s view may differ from ours) 27 SIHFW: an ISO 9001:2008 certified Institution

Constraints on Beneficence:

Constraints on Beneficence Need to respect autonomy-patient and doctor may differ re. Management Need to ensure health is not bought at too high a price Need to consider rights of others 28 SIHFW: an ISO 9001:2008 certified Institution

Autonomy:

Autonomy Capacity to think, decide, take action Mental incompetence= no autonomy Autonomy –v-Paternalism When patient not autonomous –no clash. When patient autonomous-questionable procedure SIHFW: an ISO 9001:2008 certified Institution 29

Truth Telling:

Truth Telling Increase the Knowledge Increase the Sorrows” If you override it you endanger doctor/patient relationship(based on trust) At times there are good reasons for overriding the truth telling principle The case for deception is founded on 3 fallacies Hippocratic obligations Not in a position to know the truth Patients do not want the truth if the news is bad 30 SIHFW: an ISO 9001:2008 certified Institution

Duties of a doctor:

Duties of a doctor Compulsory duties: Notification of births, deaths, infectious disease and notifiable diseases and in some states industrial diseases too. Responsibilities to state Responding to emergency military services Attending accidents Reporting cases of poisoning Reporting unnatural death Reporting cases under privileged communication 31 SIHFW: an ISO 9001:2008 certified Institution

Duties of a doctor:

Duties of a doctor Voluntary duties Answerability and responsibility to patients Medical examination Surgical operation Medico-legal examination (including post- mortum examination) Issuing various certificates and carrying out tasks outlined under Geneva convention 32 SIHFW: an ISO 9001:2008 certified Institution

Doctor patient relationship:

Doctor patient relationship Formal agreement with a serious commitment and carries the possibility of legal action if breached. Implied by action of parties ,rarely expressed in formal contract terms . The fact that patient does not pay far services do not affect the existence of the contract or lessen the physicians’ duties, obligations , responsibilities and liabilities. Doctor is not an employee of patient Physical contact but even the telephonic instruction can infer relationship in courts. 33 SIHFW: an ISO 9001:2008 certified Institution

Doctor patient relationship:

Doctor patient relationship Doctor Patient relationship is not established : In emergency situation where the doctor has given some first aid. Court of law has asked doctor to examine the person. Once the relationship is established doctor can not stop treating the patient except in some circumstances like patient does not comply, wants to change doctor etc. 34 SIHFW: an ISO 9001:2008 certified Institution

Consent:

Consent Consent -a free and voluntary agreement/ approval or permission or compliance of some ac t Statutory legal obligation in accordance with section 13 of Indian contract act. In medical, consent is most important in followings: Examination of patient Examination of person for medico legal and statutory purpose Postmortem examination and removal of tissues and organs for transplantation. 35 SIHFW: an ISO 9001:2008 certified Institution

Consent:

Consent Implied consent: This is provided by behavior of patient and far the most common variety of consent, this does not apply to more complex procedure like rectal or vaginal examination. Expressed consent : Expressed either verbally or in writing For all major diagnostics or therapeutics procedure and general anesthesia written consent should be obtained Should be for specific procedure and not to be a blanket consent to cover all subsequent procedure. SIHFW: an ISO 9001:2008 certified Institution 36

Doctrine of informed consent:

Doctrine of informed consent Should explain to patient: Nature of procedure, treatment or disease. Expectation of proposed procedure and likelihood of success Availability , advantages, disadvantages , of reasonable alternatives and probable outcome in the absence of proposed treatment or procedure About the particular known inherent risks that are material to the formation of decision about whether to accept or reject the proposed procedure or treatment. 37 SIHFW: an ISO 9001:2008 certified Institution

Prerequisite for a valid consent:

Prerequisite for a valid consent Free and unconditional Voluntary without any fear or pressure Obtained in a mentally sound and conscious state Expressed Informed Consent of parent should be obtained for child below 12 years 38 SIHFW: an ISO 9001:2008 certified Institution

Medical confidentiality:

Medical confidentiality It forms a part of Hippocratic oath : “whatever in connection with my professional practice or not in connection with it I see or hear in my life which ought not to be spoken of abroad, I will not divulge as reckoning that all should be kept secret” 39 SIHFW: an ISO 9001:2008 certified Institution

Access to Records:

Access to Records Data Protection Act (1998) What records are covered? Does it matter when the record was made? Who can apply? Are their exemptions? Must copies be given if requested? Access to records of deceased patients? 40 SIHFW: an ISO 9001:2008 certified Institution

Professional secrecy:

Professional secrecy Professional secrets : Usually any information received by doctor from a patient is confidential and should not be disclosed to any other person except by his own (patient’s) consent This is morally and legally obligatory Privileged communication (P.C.) “ A communication made bonafide upon any subject matter by a doctor to the concerned authority by virtue of his duty to protect the interest of the community in general or of the state is known as privileged communication” 41 SIHFW: an ISO 9001:2008 certified Institution

Circumstances of P.C.:

Circumstances of P.C. Absolute privilege : doctor is asked by judge to disclose secrets in court of law or parliament . Qualified privilege : Doctor makes a statement in course of his moral or social duty to safeguard the community, must not be malicious and made only to those having interest or duty to receive it When the doctor has to safeguard his own duties which are mandatory to be reported to state. When the doctor learns, Patient has committed a crime or a criminal act is responsible for his patient’s condition 42 SIHFW: an ISO 9001:2008 certified Institution

Justice:

Justice How to allocate scarce healthcare resources? Medical need Medical Benefits Social worth-discriminates against underprivileged Merits/contribution to society-very contentious Desert Market Forces A lottery 43 SIHFW: an ISO 9001:2008 certified Institution

Slide 44:

X aged 15 yrs requests the OCP Her mum phones you the next day Several weeks later she tells you her boyfriend slapped her across the face Her boyfriend is her teacher 44 SIHFW: an ISO 9001:2008 certified Institution

Lord Fraser’s recommendations:

Lord Fraser’s recommendations The doctor should assess whether the patient understands his\her advice The doctor should encourage parental involvement The doctor should assess whether the patient is likely to have sexual intercourse without contraceptive The doctor should assess whether the patient’s physical\mental health are likely to suffer if she does not receive advice\treatment The doctor must consider whether the patient’s best interests require him\her to provide contraceptive advice\treatment without parental consent 45 SIHFW: an ISO 9001:2008 certified Institution

Statutory body to enforce regulation: MCI:

Statutory body to enforce regulation: MCI Created in year 1933 by virtue of Indian Medical Council Act 1933 Replaced by IMC act 1956 and further amended in 1964 Maintains and prescribes the standards of undergraduate and post graduate medical education Recognize the various medical qualification Maintains register of medical practitioners Advice state councils on disciplinary matters. 46 SIHFW: an ISO 9001:2008 certified Institution

Statutory body to enforce regulation:

Statutory body to enforce regulation State medical council Maintain register of medical practitioner in their states Obtaining a qualification alone does not mean a doctor can start his/her practice After registration a distinctive number is allotted which must appear on all his professional activities. 47 SIHFW: an ISO 9001:2008 certified Institution

Medical negligence:

Medical negligence “Defined as lack of exercising reasonable care and skill by physicians for treatment of a patient leading to endangering his health and life” Legal wrong : when the standard of medical care given to patient is considered to be of inadequate. The negligence could be civil and criminal depending upon severity. Ethical wrong : when the professional behavior falls below which is expected from a doctor i.e. professional misconduct of infamous conduct. 48 SIHFW: an ISO 9001:2008 certified Institution

Criteria to prove negligence:

Criteria to prove negligence Duty of care Dereliction of duty Causation of damage Direct causation 49 SIHFW: an ISO 9001:2008 certified Institution

Common criminal negligence :

Common criminal negligence In case of death doctor can be booked under section 304 A (rash and negligent act) Common example of criminal negligence. Amputation or removal of wrong limb or organ Ligation of ducts/ vessels Retaining of objects in surgical site Tight plaster cast leading to gangrene Transfusion or anesthetic mistakes. 50 SIHFW: an ISO 9001:2008 certified Institution

Euthanasia:

Euthanasia Active : an active intervention to end life Passive : deliberately withholding treatment that might help a patient live longer Voluntary : euthanasia is performed following a request from a patient Doctor assisted suicide : a doctor prescribes a lethal drug which is self administered by the patient Non-voluntary : ending the life of a patient who is not capable of giving permission I nvoluntary : ending life against a patients will 51 SIHFW: an ISO 9001:2008 certified Institution

Medical Ethics: Code :

Medical Ethics: Code Declaration General Duties and responsibilities Character Maintenance of Good Medical Practice Maintenance of Medical Records Display of Registration Numbers 52 SIHFW: an ISO 9001:2008 certified Institution

Duties of Physician in Consultation:

Duties of Physician in Consultation Avoid unnecessary consultation Consultation for Patient’s Benefit Punctuality in Consultation Statement to Patient after consultation Fee and other charges- Display Name and designation on prescription 53 SIHFW: an ISO 9001:2008 certified Institution

Duties of Physician towards patients:

Duties of Physician towards patients Do not practice if incapacitated Patience, Delicacy and Secrecy No physician shall arbitrarily refuse treatment to a patient 54 SIHFW: an ISO 9001:2008 certified Institution

Responsibility to fellow physician:

Responsibility to fellow physician Conduct in consultation: No rivalry Consultant not to take charge of the case Not criticize the referring physician Appointment of Substitute: Requests another physician to attend his patients during his temporary absence from his practice. Consideration to the interests and reputation of the absent physician SIHFW: an ISO 9001:2008 certified Institution 55

Slide 56:

Visiting another Physician’s case :When it becomes the duty of a physician occupying an official position to see and report upon an illness or injury, he should communicate to the physician in attendance so as to give him an option of being present. The medical officer / physician occupying an official position should avoid remarks upon the diagnosis or the treatment that has been adopted. Dependence of Physicians on each other : A physician should consider it as a pleasure and privilege to render gratuitous service to all physicians and their immediate family dependants. 56 SIHFW: an ISO 9001:2008 certified Institution

 Duties of physician to the public and to the paramedical profession:

Duties of physician to the public and to the paramedical profession Physicians as Citizens As good citizen should disseminate advice on public health issues Co-operate with the authorities in the administration of sanitary/public health Pharmacists / Nurses: recognize and promote the practice of different paramedical services 57 SIHFW: an ISO 9001:2008 certified Institution

Slide 58:

Public and Community Health Enlighten the public concerning quarantine regulations Measures for the prevention of epidemic and communicable diseases When an epidemic occurs a physician should not abandon his duty for fear of contracting the disease himself. 58 SIHFW: an ISO 9001:2008 certified Institution

Unethical acts:

Unethical acts Advertising, except Change in address Start of Practice & change in nature of practice Declaration of charges Proceeding on leave/ resuming Patents and copy rights Running own shop Rebates and commissions Secret Remedies Violation of Human Rights Euthanasia SIHFW: an ISO 9001:2008 certified Institution 59

Misconduct :

Misconduct Violation of the Regulations Adultery or Improper Conduct Conviction by Court of Law Sex Determination Tests 60 SIHFW: an ISO 9001:2008 certified Institution

Punishment and disciplinary action:

Punishment and disciplinary action A complete list of the infamous acts which calls for disciplinary action, and that by issuing this notice the Medical Council of India and or State Medical Councils are in no way precluded from considering and dealing with any other form of professional misconduct on the part of a registered practitioner. SIHFW: an ISO 9001:2008 certified Institution 61

Slide 62:

Any complaint with regard to professional misconduct can be brought before the appropriate Medical Council for Disciplinary action. Upon receipt of any complaint of professional misconduct, the appropriate Medical Council would hold an enquiry and give opportunity to the registered medical practitioner to be heard in person or by pleader. If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner. SIHFW: an ISO 9001:2008 certified Institution 62

Slide 63:

In case the punishment of removal from the register is for a limited period, the appropriate Council may also direct that the name so removed shall be restored in the register after the expiry of the period for which the name was ordered to be removed. Decision on complaint against delinquent physician shall be taken within a time limit of 6 months. SIHFW: an ISO 9001:2008 certified Institution 63

Slide 64:

Professional incompetence shall be judged by peer group as per guidelines prescribed by Medical Council of India During the pendency of the complaint the appropriate Council may restrain the physician from performing the procedure or practice which is under scrutiny. SIHFW: an ISO 9001:2008 certified Institution 64

An innate desire :

An innate desire P eople world over still wish to see the doctors as trustworthy and honorable SIHFW: an ISO 9001:2008 certified Institution 65

We can keep trust :

We can keep trust Wish for others what you wish for yourself How would you like to see a doctor if we were patients ourselves ? SIHFW: an ISO 9001:2008 certified Institution 66

Thank You :

Thank You For more details log on to www. Sihfwrajasthan.com or contact : Director-SIHFW on sihfwraj@yahoo.co.in SIHFW: an ISO 9001:2008 certified Institution 67