MEDICAL ETHICS

Dr.Nirmal k meenaDept. of psm

RNT medical college,udaipur

1

Doctors world overall-Respected,Regardedand Trusted

Trust may wither away, y yunless conscious attempt

is made to preserve itp

2

Trust, in fact, is shrinking,for decline & deviation from

ethics

.

Pure medical Professionalism

ToTo

Medical Industrialization

Lead to

deviation from ethicsdeviation from ethics

&

loss of trust

3

ProfessionProfessionIt is a vocation or calling and implies service toOthers;It has a distinctive knowledge base which iskept up to date;It determines its own standards and sets its ownExaminations;It has a special relationship with those whom itp pserves – patients; andIt has particular ethical principlesp p p

4

ProfessionalismProfessionalism“Constituting those attitudes and behaviors that

t i t i ti t i t t b h i iserve to maintain patient interest above physicianSelf-interest”

Altruism(interest of patients not self interest is theAltruism(interest of patients, not self-interest, is therule.),AccountabilityAccountability,Excellence,Duty,Duty,Honor and Integrity, andRespect for others.Respect for others.

5

Human social behavior is governed by:g yCustom etiquette Ethics Law Morality

Mores Professional Prof values States SpiritualityMores Professional Prof. values States, Statutes, legislations

Spirituality

Tradition Courtesy Competence Enforcement

Religious

Fairness Compulsion Good v/s bad

Truth Justice Right v/sTruth Justice Right v/s wrong

Integrity JudiciaryIntegrity Judiciary

Goodwill Punishment6

Medical EthicsMedical EthicsEthics:Ethics:

Ethics or moral philosophy is the systematic endeavour to understand moral conceptsendeavour to understand moral concepts and justify moral principles and theories.

Medical etiquetteqRefers to the courtesy with which a doctor should treat his colleaguesg

7

Greek word from "ETHIKOS"means Theory of living.

Medical Ethics:“Deals with the moral principle that doctorsDeals with the moral principle that doctorsshould adhere to in their transaction withpatient, colleagues and the state”.Concern not only doctors but also patientsand society.The core of ME is doctor patient relationship.

Contemporary legal medical practices

C t t ( b i f ti t d t l ti hi )Contract ( basis of patient doctor relationship ) Voluntary, Q iQuasi

Law at tort( please protect yourself, ) whenli bili f h i Dliability of harm is on Doctor

Negligence tort Intentional tort

9

Negligence tort

Duty BreachCausationDamageg

10

Intentional TortIntentional Tort

Assault Immediate apprehension of harm (Assault- Immediate apprehension of harm (words with supporting gestures)Battery Unauthorized touchingBattery- Unauthorized touchingFalse imprisonment D f ti H i th t b ll /Defamation- Harming the repute – verbally/ writtenInvasion of privacy ( giving information toInvasion of privacy ( giving information to unauthorized ) Infliction of mental distressInfliction of mental distress

11

Scope of Medical EthicsScope of Medical Ethics

Development of ethical codes and guidelines Promotion of ethical practicePrevention of ethical breachesRecognition of ethical dilemmas Resolution of ethical conflicts

12

Components of Medical EthicsComponents of Medical Ethics

Physician patients relationshipPhysician: physician relationship Physician : health system relationshipPhysician: Society relationship

13

Importance of Medical EthicsImportance of Medical Ethics

Increasing profile\Recent press headlinesIncrease in technology use vs abuseIncrease in technology- use vs abuseBetter informed society-awarenessDoctors in ManagementDoctors in ManagementPublic scrutiny-Audit, CPA

14

Why we need ity

“Patients are entitled to good standards ofPatients are entitled to, good standards ofpractice and care from their doctors. Essentialelements of this are professional competence,p p ,good relationships with patients andcolleagues and observance of professional

hi l bli i ”ethical obligations.”

From Good Medical Practice, GMC.

15

The moral duties of the doctorThe moral duties of the doctorHelp, curePromote and protect the patient’s healthConfidentialityP t t th ti t’ lifProtect the patient’s lifeRespect the patient’s autonomyProtect privacyProtect privacyRespect the patient’s dignity

16

The moral rights of the patientThe moral rights of the patientHigh quality medical serviceAutonomous choiceDecideBe informedPrivacyHealth educationDignityg y

17

Role of the doctor within the health iserviceUnderstanding of the:Understanding of the:

Health care systemClinical responsibilitiesAs researcher, mentor or teacher, managerQ li lQuality controlTeam work

18

Six principles of Medical EthicsSix principles of Medical EthicsBeneficence 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 meritJustice Who gets what treatment on the merit of illness

Dignity Patient and doctor both have the rightDignity Patient and doctor both have the right to dignity

Truthfulness/ The patient deserve to know the whole Honesty

ptruth about the illness and treatment

19

Beneficence and Non – Malfeasance Think goodYou may not say any thing- others can still read you

FaceAccentBody language/ GesturesBody language/ Gesturessilence may still be saying something

Talk / Say good- the wordsTalk / Say good the wordsThe art of communication is the foundation of the patient doctor relationship p p

Do good – the acts

Write good20

Beneficence and Non MalfeasanceBeneficence and Non-MalfeasanceQuestions:

Is the patient your only concern?(possible conflict with utility)

Do we always know what is good for theti t?patient?

(patient’s view may differ from ours)

21

Constraints on BeneficenceConstraints on BeneficenceNeed to respect autonomy-patient anddoctor may differ re. Management

Need to ensure health is not bought at toohigh a priceg p

Need to consider rights of othersg

22

AutonomyAutonomyCapacity to think, decide, take actionCapacity to think, decide, take action

Mental incompetence= no autonomy

Autonomy –v-Paternalism

Wh ti t t t l hWhen patient not autonomous –no clash.

When patient autonomous-questionable

procedure

23

Truth TellinggIncrease the Knowledge Increase the Sorrows”If you override it you endanger doctor/patientIf you override it you endanger doctor/patientrelationship(based on trust)At times there are good reasons for overridingg gthe truth telling principleThe case for deception is founded on 3 fallacies

Hippocratic obligationsNot in a position to know the truthPatients do not want the truth if the news isbad

24

Duties of a doctor

Compulsory duties:Notification of births, deaths, infectious diseaseand notifiable diseases and in some statesindustrial diseases too.Responsibilities to state

R di t ilit iResponding to emergency military servicesAttending accidentsReporting cases of poisoningReporting cases of poisoningReporting unnatural deathReporting cases under privileged communication

25

Duties of a doctorDuties of a doctorVoluntary duties1. Answerability and responsibility to patients2. Medical examination3. Surgical operation4. Medico-legal examination (including post-g ( g p

mortum examination)5. Issuing various certificates and carrying out

tasks outlined under Geneva convention

26

Doctor patient relationshipp pFormal agreement with a serious commitmentand carries the possibility of legal action ifand carries the possibility of legal action ifbreached.Implied by action of parties ,rarely expressedy yin formal contract terms.

The fact that patient does not pay far servicesdo not affect the existence of the contract orlessen the physicians’ duties, obligations ,responsibilities and liabilitiesresponsibilities and liabilities.Doctor is not an employee of patientPhysical contact but even the telephonicPhysical contact but even the telephonicinstruction can infer relationship in courts.

27

Doctor patient relationshipDoctor patient relationshipDoctor Patient relationship is not established :

In emergency situation where the doctor hasgiven some first aid.Court of law has asked doctor to examinethe person.

Once the relationship is established doctor cannot stop treating the patient except in somecircumstances like patient does not complycircumstances like patient does not comply,wants to change doctor etc.

28

Consent

Consent -a free and voluntary agreement/ approval or permission or compliance of someapproval or permission or compliance of some act

Statutory legal obligation in accordance withStatutory legal obligation in accordance with section 13 of Indian contract act.

In medical, consent is most important in ed ca , co se s os po afollowings:Examination of patientExamination of person for medico legal and statutory purposePostmortem examination and removal of tissues andPostmortem examination and removal of tissues and organs for transplantation.

29

ConsentImplied consent:This is provided by behavior of patient and farth t i t f t thi dthe most common variety of consent, this doesnot apply to more complex procedure like rectalor vaginal examinationor vaginal examination.Expressed consent :

Expressed either verbally or in writingExpressed either verbally or in writingFor all major diagnostics or therapeuticsprocedure and general anesthesia writtenprocedure and general anesthesia writtenconsent should be obtainedShould be for specific procedure and not to bep pa blanket consent to cover all subsequentprocedure. 30

Statutory body to enforce regulation: MCIregulation: MCI

Created in year 1933 by virtue of Indian MedicalCouncil Act 1933Replaced by IMC act 1956 and further amendedi 1964in 1964Maintains and prescribes the standards ofundergraduate and post graduate medicalundergraduate and post graduate medicaleducationRecognize the various medical qualificationRecognize the various medical qualificationMaintains register of medical practitionersAdvice state councils on disciplinary mattersAdvice state councils on disciplinary matters.

31

Statutory body to enforce regulationy y g

State medical councilMaintain register of medical practitioner in their

statesObtaining a qualification alone does not mean a

doctor can start his/her practiceAfter registration a distinctive number is allotted

which must appear on all his professionalactivitiesactivities.

32

Medical negligenceg g“Defined as lack of exercising reasonable careand skill by physicians for treatment of a patientand skill by physicians for treatment of a patientleading to endangering his health and life”Legal wrong: when the standard of medicalLegal wrong: when the standard of medicalcare given to patient is considered to be ofinadequate. The negligence could be civil andq g gcriminal depending upon severity.Ethical wrong: when the professional behaviorfalls below which is expected from a doctor i.e.professional misconduct of infamous conduct.

33

Criteria to prove negligenceCriteria to prove negligence

Duty of care

Dereliction of dutyDereliction of duty

Causation of damage

Direct causation

34

Common criminal negligenceg g

In case of death doctor can be booked undersection 304 A (rash and negligent act)

Common example of criminal negligence.Amputation or removal of wrong limb ororganLi ti f d t / lLigation of ducts/ vesselsRetaining of objects in surgical siteTi ht l t t l di tTight plaster cast leading to gangreneTransfusion or anesthetic mistakes.

35

EuthanasiaActive: an active intervention to end lifePassive : deliberately withholding treatmentPassive : deliberately withholding treatmentthat might help a patient live longerVoluntary : euthanasia is performed following aVoluntary : euthanasia is performed following arequest from a patientDoctor assisted suicide : a doctor prescribespa lethal drug which is self administered by thepatientNon-voluntary : ending the life of a patient whois not capable of giving permissionInvoluntary : ending life against a patients will

36

Duties of Physician in ConsultationDuties of Physician in ConsultationAvoid unnecessary consultationAvoid unnecessary consultation

Consultation for Patient’s Benefit

Punctuality in Consultation

Statement to Patient after consultationStatement to Patient after consultation

Fee and other charges- Display

Name and designation on prescription

37

Responsibility to fellow physicianConduct in consultation:

No rivalry yConsultant not to take charge of the case

Not criticize the referring physicianAppointment of Substitute:

Requests another physician to attend his patients d i hi t b f hi tiduring his temporary absence from his practice.Consideration to the interests and reputation of the absent physicianthe absent physician

38

CPublic and Community Health

Enlighten the public concerning quarantine

regulations

Measures for the prevention of epidemic andp p

communicable diseases

When an epidemic occurs a physician should notWhen an epidemic occurs a physician should not

abandon his duty for fear of contracting the disease

himself.

39

Unethical actsAdvertising, except

Change in addressChange in addressStart of Practice & change in nature of practiceDeclaration of chargesProceeding on leave/ resuming

Patents and copy rightsRunning own shopRebates and commissionsSecret RemediesViolation of Human RightsEuthanasia

40

MisconductMisconduct Violation of the Regulationso a o o e egu a o s

Adultery or Improper Conduct

Conviction by Court of Law

Se Determination TestsSex Determination Tests

41

Punishment and disciplinary action

A complete list of the infamous acts which callsfor disciplinary action, and that by issuing thisnotice the Medical Council of India and orState Medical Councils are in no wayState Medical Councils are in no wayprecluded from considering and dealing withany other form of professional misconduct onany other form of professional misconduct onthe part of a registered practitioner.

42

Any complaint with regard to professional misconductmisconduct cancan bebe broughtbrought beforebefore thethe appropriateappropriate Medical Council for Disciplinary action. Upon receippt of a yyn compplaint of pprofessional misconduct, the appropriate Medical Council would hold an enquiry and give opportunity to the registered medidcal practitioner to be heard in person. 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.

62

In case the punishment of removal from theregister is for a limited period the appropriateregister is for a limited period, the appropriateCouncil may also direct that the name soremoved shall be restored in the register aftergthe expiry of the period for which the namewas ordered to be removed.

Decision on complaint against delinquentphysician shall be taken within a time limit of 6months.

44

An innate desireAn innate desire

People world over still wish to see thePeople world over still wish to see the

doctors as trustworthy and honorable

45

Thank you