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Handbook of Medical Ethics
FOR UNDERGRADUATE MEDICAL STUDENTS OF
Southeast Asian Region
Contents
Part – 1 : Introduction: Principles of medical ethics
1. Ethics and medical ethics
2. Human civilization and Medical ethics
Part – 2 : Ethics in clinical practice
1. Doctor-patient relationship
A. General principles
B. Patient autonomy
C. Confidentiality
D. Truth telling/disclosure
E. Informed consent
F. End-of-life decisions
G. Patient rights
2. Equity and social justice
3. Codes of conduct and etiquette
4. Professionalism
5. Medical negligence
6. Professional misconduct
7. Ethical issues faced by medical students
8. Relationship with the pharmaceutical industry
9. Ethical issues related with healthcare in the private sector
10. Ethical issues related to reproductive health –
Issues of beginning of life.
11. Ethical aspects of treating patients with HIV/AIDS
Part – 3 : Specific Ethical issues
1. Ethical aspects of genetics
2. Ethics of transplantation/organ donation
3. Ethical aspects of treating the mentally ill
4. Ethical issues in treating children
5. Resource allocation in the health-care system
6. Ethics of public health and health promotion.
7. Ethical issues of dealing with other systems of medicine
8. Country-specific situations
Part – 4 : Research ethics
1. Principles of research ethics and research publication.
Part -1 : Introduction : Principles of Medical ethics
Chapter -1
In this chapter you would learn
1. What is morality, ethics and medial ethics and what are their interrelationship.
2. Why should a medical student know about medical ethics.
3. What are the hazards of not knowing ethics.
4. Ethics and law.
Questions and exercises
1. How would you define morality?
2. What are the parameters ‘ethics’ seek to lay down in performing ‘duty’?
3. How would you like to define what is medical ethics?
4. Enumerate the reasons why should a medical student know ethics.
5. What are the hazards of not knowing ethics properly?
Exercise:
Students should make small groups amongst themselves and discuss these questions trying to express the answers in their own language.
Morality, ethics and medical ethics
Human society has always placed great importance on two philosophical principles of Morality and ethics. The principles of medical ethics also developed from these twin concepts.
When we speak of morality and ethics in general we soon realise that it is a very wide field which basically deals with all aspects of human behaviour and decision making.
Morality and ethics are very closely related. Morality can be said to denote a system of human though that seeks to determine what is DUTY and one that tries to lay down what should be human CONDUCT in fulfilling the duty. The Oxford dictionary tells us that the word morality originates from the Latin word – Moralis which means Principles concerning the difference between right and wrong. We may surmise that morality denotes what are the right duties and what are the right conducts.
Ethics seeks to lay down the standards for such moral principles as Duty and conduct. Again us Oxford dictionary teaches us that Ethics is derived from the Greek word Ethos meaning moral custom. Thus ethics means a system of moral principles or standard governing culture. This standard not only sets a benchmark or aim but also lays down what should be the correct behaviour in achieving these aims. Ethics therefore lays down such things as rights and responsibilities, what is good or bad, just or unjust, right or wrong in accordance with human and social value systems. Though usually these arise in particular human societies the basic principles are always universal.
Medical Ethics is the applications of these ethical principals in the field of medical treatment, care and research. Medical Ethics is defined as ‘a system of principles governing medical conduct- It deals with the relationship of a physician to the patient, the patients family, fellow physicians and society at large’ (Taber’s Cyclopedia Medical Dictionary). Naturally apart from general connotations these principles now have specificities unique to medical situations. Ethics to a great extent is always profession specific. Medical Ethics denote a set of moral and social values that are inseparably associated with the practice of medicine. These may also change with the changing times. With development of medicine and treatment modalities newer ethics questions keep emerging and can gain great importance while some older issues may lose their previous preeminence.
An example
Let us look at an example. ‘Caring for the sick’ is a general moral principle, a human duty and conduct that is upheld by all societies and all religions at all times. This is morality. To take care of the sick would be moral and refusal to take care of the sick would be immoral and failing in human duty and conduct.
Ethics would demand that ‘caring for the sick’ should be the genuine behaviour of all persons and societies. To take care of the sick would be ethical behaviours for a person and not to take care or refusal to take care would be unethical for a person. Ethics would also want that the laws of the country should be such that all the citizens should actively participate in the process of ‘caring for the sick’. That is how ethics would like to make this behaviour legal.
Medical ethics demands that a professional physician should not only care for the sick but he or she should do it honestly, competently, apply his knowledge and training to care for his patients correctly and behave in such a way that the patient, the family members of the patient, the society and law approves the behaviour of the physician. Medical ethics thus lays standards for patient care and behaviour of a physician and ethically judges him/her against these standards. We must also understand that ethical values are greatly influenced by social and cultural beliefs of the society.
Contents of Medical Ethics
The moral and social values of medical ethics that we are talking about are of two types – personal and social.
The personal values are personal to the physician. They basically concern about the standard of behaviour of the physician and his decision making. The decision making is not about scientific or technical questions like modalities of treatment which the physician shall anyway have to take, but these questions essentially concern about his sense of duty, awareness of his responsibilities, approach to patients, respect for the rights of patients, maintenance of highest standards of personal and professional honesty and integrity in the entire process of patient management and medical research.
The social responsibilities involve the relationship of the physician with the society at large and to his own profession in particular. It includes following and conforming to the expectations and demands of the society regarding competence and behaviour of physicians as a person and a group. It involves also the following and upholding of traditions and value systems prevalent in the society. Respect for the laws promulgated in a country, both the general laws applicable to all citizens and also the laws specific to the medical profession is also another important consideration.
So you can make out that a physician not only will have to treat a patient competently but he has to do so with a sense of responsibility and in a correct, socially acceptable and legally valid way conforming to set standards. This basically is medical ethics.
Why do we need medical ethics?
A medical student may ask, ‘why should I know about medical ethics? How does it concern me?’ Let us now try to answer these questions.
1) Knowledge of medical ethics is required for a proper medical practice
Medical ethics is intimately related with medical practice and there can be no real medical practice without ethics. Knowledge of ethics teaches us as to what are our duties, responsibilities as a doctor, what should be our conduct during carrying out these duties and responsibilities in our professional life as a physician. Without this knowledge we will not be able to do these properly.
2) Society, law and people all expect a doctor to know about medical ethics and practice ethically.
The practice of medicine which covers the whole of medical diagnosis, investigations, choosing modality of treatment, maintaining correct relationship with patients, health administration and also at times medical research, is essentially a social practice conducted with living persons. Human civilization has adopted certain value systems, accepted certain forms of behaviour as good and just, evolved certain traditions and promulgated sets of laws which all go to define what is ethical practice and what is not. Unless we study and know about medical ethics we shall not know how we should act and behave as a doctor in the society, we shall not be able to meet the expectations of society, people and law in our practice.
3) Medical ethics teaches us about our duties as a physician.
To be a good doctor we must clearly know what are our duties as a physician. Since medicine and medical practice is essentially a social and an ethical professional practice it is not enough for a doctor to have only medical or scientific competence to treat a particular disease correctly. Certain more things are required of a physician. Most important of these is that a doctor has to follow certain principles. These ethical principles can be summarized as follows –
a. Respect for the dignity and rights of the patient.
b. Maintaining confidentiality of the patient.
c. Informing the patient and taking consent for diagnosis and treatment.
d. Care to see that no negligence occurs in treatment.
e. Maintaining proper conduct with patients, family members, fellow doctors, other health professionals and society.
f. Care to see that doctor does not commit a professional misconduct.
A doctor has basically three kinds of duties as a professional, these are 1) General duties (2) Duties to the patient (3) Duties to physician and colleagues. Study of Medical Ethics teaches us about the duties of a doctor that we have to do in our professional life.
The World Medical Association (WMA) has adopted an international code of Medical Ethics and in this code the duties of a doctor are beautifully laid out. This code is put in a box in the end of this chapter for your reference. This list lays down an international standard which doctors should know and follow in letter and spirit.
4) Sound knowledge of medical ethics enable a doctor to apply these in real life situations.
As medical ethics cover all the aspects of a doctors life and his work as a professional, a sound knowledge of ethical principles and rules are essential for the doctor so to be able to apply them in real life situations in everyday practice. For example what a doctor should ethically do when a patient refuses treatment, when patient asks for a second opinion, when a patient demands a particular form of investigation or a particular modality of treatment? Further what a doctor should ethically do at the death bed of a patient, in treating a child or a mentally challenged person, in dealing with an unconscious patient etc? A good doctor by training knows how to medically and scientifically deal these situations. But that is not enough, the doctor should also know how to deal with these situations ethically. Study of medical ethics equip us with this knowledge and enables us a doctor to recognize the ethical issues involved in different medical situations and to deal with them in a rational and principled manner.
5) Knowledge of medical ethics is essential to avoid allegations of misconduct, medical negligence and thus to avoid damaging malpractice litigations.
What constitutes medical misconduct? When a doctor can be held negligent? These are essential components of teaching of medical ethics. The doctor should recognize that these are professional pitfalls for a doctor in his professional life and can have serious consequences, such as fines, legal punishments and temporary or permanent cancellation of the license to practice. Knowledge of medical ethics teach a doctor what these misconducts and negligences are so that a doctor can consciously take steps to avoid them in professional life. Study of medical ethics equip us for this task.
Litigations against doctors has increased all over the world in recent times. Most of these litigations are started with allegations of misconduct and negligence on part of the treating doctor. The motive in most of these litigations is to get financial compensation from treating doctors (and also from hospitals). These litigations are called medical malpractice suits in a general way. A sound knowledge of medical ethics enable a doctor to avoid these malpractice suits and also to win them.
6) Knowledge of Medical ethics enable a doctor to practice legally and to avoid illegal acts.
Medical ethics is intimately related with law. Each country may have different laws that govern various aspects of medial practice and a doctor has to operate within these laws. Each of these laws may present and address different ethical questions for the doctor and knowledge of ethics in the sphere of laws help a doctor to practice legally. (The next section deals with ethics and law in a more detail).
7) Global migration of health professionals make knowledge of medical ethics important
In this age of globalization where medical migration across national boarders have increased. This has made knowing medical ethics very important for doctors.
Ethics and law
As already stated medical ethics have a close relationship with law. Each country has general laws that are applicable to all citizens including doctors. In addition to that these, may be laws which specifically address and regulate different spheres of medical practice. For example there may be following laws.
1. Laws regulating medical termination of pregnancy or abortion.
2. Laws regulating or prohibiting euthanasia.
3. Laws regarding prenatal genetic testing and sex determination
4. Laws regarding withdrawal of life support system.
5. Laws regarding treatment of mentally ill.
These are only illustrative examples. There may be many other laws regulating various spheres of medical practice. There may be variation from country to country in the type of laws. These laws directly affect the work of the doctors and they have to strictly work within the provisions of these laws. Breaking the provisions of the laws are not only illegal but is considered to be unethical too.
Many countries have laws that directly lay down ethical parameters of practice. In addition to the civil and criminal laws of a country many countries in the world have well developed medical regulatory authorities (medical councils) which may have their own codes of medical ethics along with related regulations which a doctor has to follow. They generally look after the ethical aspects of medical practice and usually have disciplinary powers. They may take a doctor to task for ethical violations and can punish them on ethical grounds. Such punishments can be upto suspension of license to practice medicine temporarily or even permanently.
Further international laws also may have direct bearing on medical practice. When national governments endorse and accept these laws they become applicable on the doctors of the country. Human rights, patient’s rights, rights of the child are examples of international declarations and laws that affect practice of the doctors. A Doctor must be aware of this close interrelationship between law, medical ethics and medical practice and must be well conversant about the laws.
World Medical Association: International code of medical Ethics
Duties of a doctor
Duties of Physicians in General
A physician shall always exercise his/her independent professional judgment and maintain the highest standards of professional conduct.
A physician shall respect competent patient’s right to accept or refuse treatment.
A physician shall not allow his/her judgment to be influenced by personal profit or unfair discrimination.
A physician shall be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.
A physician shall deal honestly with patients and colleagues, and report to the appropriate authorities those physicians who practice unethically or incompetently or who engage in fraud or deception.
A physician shall not receive any financial benefits or other incentives solely for referring patients or prescribing specific products.
A physician shall respect the rights and preferences of patients, colleagues, and other health professionals.
A physician shall recognize his/her important role in educating the public but should use due caution in divulging discoveries or new techniques or treatment through non-professional channels.
A physician shall certify only that which he/she has personally verified.
A physician shall strive to use health care resources in the best way to benefit patients and their community.
A physician shall seek appropriate care and attention if he/she suffers from mental or physical illness.
A physician shall respect the local and national codes of ethics.
Duties of Physicians to Patients
A physician shall always bear in mind the obligation to respect human life.
A physician shall act in the patient’s best interest when providing medical care.
A physician shall owe his/her patients complete loyalty and all the scientific resources available to him/her. Whenever an examination or treatment is beyond the physician’s capacity, he/she should consult with or refer to another physician who has the necessary ability.
A physician shall respect a patient’s right to confidentiality. It is ethical to disclose confidential information when the patient consents to it or when there is a real and imminent threat of harm to the patient or to others and this threat can be only removed by a breach of confidentiality.
A physician shall give emergency care as a humanitarian duty unless he/her is assured that others are willing and able to give such care.
A physician shall in situations when he/she is acting for a third party, ensure that the patient has full knowledge of that situation.
A physician shall not enter into a sexual relationship with his/her current patient or into any other abusive or exploitative relationship.
Duties of Physicians to Colleagues
A physician shall behave towards colleagues as he/she would have them behave towards him/her.
A physician shall NOT undermine the patient-physician relationship of colleagues in order to attract patients.
A physician shall when medically necessary, communicate with colleagues who are involved in the case of the same patient. This communication should respect patient confidentiality and be confined to necessary information.
World Medical Association International Code of Medical Ethics
Adopted by the 3rd General Assembly of the World Medical Association, London, England, October 1949 and amended by the 22nd World Medical Association Sydney, Australia, August 1968
And the 35th World Medical Assembly Venice, Italy, October 1983
And the WMA General Assembly, Pilanesberg, South Africa, October 2006
Part -1 : Introduction : Principles of Medical ethics
Chapter – 2
In this chapter you would learn that
1. The ideas of morality, ethics and medical ethics emerged independently in each human civilization and these ideas are universal.
2. Major ethical codes that have emerged in the world are applicable both to students as well as practicing doctors.
3. Medical ethics could emerge as a system of thought only from that time when medicine dislenced itself from ancient religion and witchcraft and assumed a rational and scientific approach.
Question and exercises
1. List the universal principles that have emerged in the medical ethical thoughts of different civilizations and religions.
Exercise
If there are small indigenous, tribal, migratory communities around you who may also practice traditional or ethnic medicines, try to find out the ethical principles – the dot and donots that may be there for the practioners of the local systems.
Human Civilization and Medical Ethics
Each major human civilization developed its own system of medicine, its own understanding of disease, its own method of treatment and along with its own system of medical ethics. Even in the most primitive human communities where medicine may essentially consist of herbal and natural remedies along with rituals of magic; even there we find such thoughts as not causing any harm to the patient by attempts at cure. So the idea of medical ethics has a history as old as medicine itself. When we compare the ethical principles that have developed with each civilization we will find that they are universal in nature with local variation. In the ancient and the medieval ages religion was closely associated with medicine and almost all other human thoughts and endeavour. Hence even in the medical ethical thoughts we would see that various Gods are invoked.
Modern system of medicine, where is also called allopathic medicine, dates its ethical traditions from the oath of Hippocrates who is acknowledged as the father of a rational system of medicine - the predecessors of modern.
The development of Medicine and ethical thoughts in the ancient civilization of Egypt, Greece and Rome and Codification of the Hippocratic oath.
The oath of Hippocrates has also developed from the preexisting system of medicine that had developed in Greece from the 5th century BC. It is also said that the ancient Egyptians contributed to the development of this system. In ancient Egypt several great medical discoveries were made and disease was first started to be treated in a physical manner rather then by magic alone. This laid the foundation of medicine as an professional art (or science). This was then taken up by the civilization of Greece which developed it further. Hippocrates and his followers were the first to record several scientific thoughts regarding health and disease and developed a system of medical reasoning based on his theory of four humors. Medicine began to distance itself increasingly from witchcraft, magic and ancient religious beliefs.
Along with this ancient system of medicine and medical practice such thoughts as to what should be done to cure the sick and what should not be done also developed. Along with it the ideas about role and responsibilities of the physician also crystallized. Hippocrates collected all these thinking and codified them into his famous oath which was supposed to be taken and adhered to by all practicing physicians. Thus the seeds of Medical ethics were sown in Europe.
The oath is not only very important but is also quite interesting. All medical students and doctors should read and reflect on it seriously. The full text is given in the Annexure for the interested amongst you. It starts with an invocation to Apollo, the physician God of Greek mythology and myriad other Gods who are asked to bear witness to the physician taking the oath.
The new or apprentice physician swears to accept the physician or physicians under whom he learns the art of healing as his teacher, guide and father and also to show respect as well as to uphold the interest and prestige of the tribe of physicians to which the novice seeks admittance. It laid down guidelines for a physician’s commitment to his teachers, colleagues, profession and patients. It also lays down the duties and ethics of the physician during his clinical practice. It also stipulates that society would be the final judges of the physician and the physician shall be accountable to the society. Another interesting thing that comes out is that - 'oath' essentially is a mechanism of ‘self regulation’ of the doctors.
The Hippocratic oath was lost for a long time. The complete text of Hippocrates was found in a papyrus scroll dating 300 AD, 700 years after it was written and since then it had been amended suit different purposes.
In Roman civilization the heritage of Egypt and Greece was further developed by Galen and his followers. Galen improved medicine through his system of empirical observation and recording. The establishment of the linkage between public health and public health facilities like pure drinking water, public baths etc. were Rome's contribution to Medicine.
However in Medieval Europe under the early Christian church, medicine and Medical ethics also suffered severe setbacks. From the realm of physical basis of disease, empirical observation, scientific and rational approach the church steered human thoughts to such belief that God sends illness, and prayers, repentance for sins and pilgrimage etc. cures them. Only later, with the enlightenment, did the Christian church came back to the universal humanistic principles that informed rational Medicine and Medical ethical thought. The Hippocratic oath then found favour again.
The scholars of medieval Europe then adopted the Hippocratic oath into Christian doctrine with certain changes, the prominent being replacement of the mention of Apollo by the Christian God. Under the leadership of the Christian church the basic humanistic principles of Hippocrates oath were then adopted and incorporated into Christian thoughts of morality and ethics in medicine.
Medical Ethics in Ancient Indian Civilization
In ancient Indian civilization, during the birth and development of the Indian system of medicine known as Ayurveda - the science of life, medical ethical thoughts also developed along with it.
Charaka who is held to be the father of Indian Medicine crystallized these thoughts into his famous Oath of Initiation in the medical anthology called 'Charaka Samhita' under a section called 'Atreya Anushasana'. It is interesting to note that this anthology and oath is dated by scholars as belonging to Seventh Century B.C. It therefore predates the Hippocratic oath by nearly 2 centuries. The oath is said to bear testimony to be development of very high level of professional medical ethics in ancient Indian civilization.
This oath was used to be administered at the starting of the seven years study of 'Ayurveda' by the student and is also reaffirmed at the point of entry to the profession.
The oath essentially asks the learners and the physicians to reaffirm themselves to the ideals, teachings and teachers of Ayurveda and enjoins them to lead a life of truthfulness, integrity, piety, morality with a very high level of professional competence. It further asks them to be caring and compassionate towards the patient and to consider the care and concern of the patient as their primary duty. It asks them to cause no harm to the patient knowingly and unknowingly. It is this oath that had laid the foundation of medical ethics in the Indian civilization.
For those of you who would like to know more about the oath the basic percepts are given in the annexure in simple translation.
Medical Ethical thoughts in Buddhism
Buddhism has a long association with caring for the sick which was enshrined in the 'Vinaya' propounded by the Buddha himself wherein he had stated that whosoever cares for the sick shall be like caring for the Buddha himself. The Buddhist aim of eliminating suffering and compassion for the sick conforms well with the principles of medical ethics and it has close relationship with Ayurveda and both developed quite parellely. The concept of a good doctor in Buddhist system of thoughts is one who is a moral person, one who is compassionate towards the sick, is totally caring, and always strives to preserve life in all forms - including that of the unborn child. Though a specific moral or ethical code for physicians is not known to exist in different Buddhist schools of thought but the universal principles of medical ethics is present in the teachings of this religion.
Medical Ethics in ancient China
Chinese medical system is one of the earliest medical treatment system that was developed systematically. Popularly known as traditional Chinese Medicine (TCM) this system has a recorded history of around three thousand years.
During the Zhou dynasty (1065-771 BC) an independent medical system and profession developed in China and gradually it distanced itself from magic and emerged as a system based on experience based knowledge and acquired skill during 770 - 221 BC.
Along with the concept of profession in medicine the concept of professional duties was born too. This was the birth of ethics in medicine in China. The development of medicine and ethical thoughts was greatly influenced first by the teachings of Buddhism which became the dominant religion in China at one time and then, during the Han dynasty of 206 BC - 220 CE, with the teachings of the great teacher Confucius. These thoughts were based on such general moral and ethical principles as 'benevolence', and 'love and kindness'. According to the percepts of Confucian thought 'Medicine is a benevolent art' and the practitioners of it should be kind to their patients in cureing and preventing disease gradually became established.
These ancient traditions of medical ethics were codified in the seventh century AD by the famous Chinese physician Sun Simiao (986-682) in two chapters of his book - Qlanjinfang (prescriptions worth of thousand Gold). These two chapters are titled as Proficiency and conduct of a great physician respectively. In this treatise the great Physician San Simiao hold that 'whoever comes to seek cure must be treated by the physicians as his own relatives regardless of their social status, family economic conditions, appearances, age, race and mental ability. These guiding principles laid the foundation of traditional Chinese medical ethics and expouse the same universal humanistic and moral values.
For those of you who are interested the codes and conducts for doctors laid down by Sun Simiao it is placed in annexure of this book.
Islam
The religion of Islam and the way of life that it brought about, led to the development of civilization in many parts of the world that is magnificent and marvelous. From early days Islam placed great importance on medicine and hospitals for treatment and care of the sick were established all over the Islamic world - in Bagdad (850-931 AD), Damascus and Cairo. Formal training and examination for physicians was introduced in Baghdad in that period. Islamic medical scholars like Rhazes perfected the art of observation of different diseases and their minute recordings while Avicenna wrote the canons of Medicine which became an important Medical treatise both in Arabia and the west. It was the Islamic scholars who adopted, preserved and further developed the teachings of Greece and Rome, of Hippocrates and Galen and preserved them for posterity during the dark ages. Europe rediscovered these treasures from them. Islam has developed a unique system of jurisprudence based on the holy Quoran, teachings of the prophet Mahmmad and traditions and accepted practices. The practice of Medicine, which developed into a honoured profession under Islam has also developed an unique system of medical ethics. One however does not know about any specific oath or a code of conduct for the physicians from the ancient days of Islam.
The Islamic Medical Association of North America had in 1977 adopted a formal oath for Muslim physicians based on these traditions which is reproduced in the annexure for interested students. It is a composite from the historical and contemporary writings of physicians in Islamic world.
From our discussion of the history of evolution of medical ethical thoughts in different civilizations around the world we can really appreciate that in all the civilizations the development of such thoughts are quite similar and thus these are essentially universal in nature. It goes to show that the world is really one and human race is essentially the same. Whatever the differences that we see between people and places these are due to differences in cultural and religious practices. But these differences are also important for physicians. Who must know about them, respect them from the heart and should mould his behaviors in such a way that his patients religious and cultural beliefs are not hurt.
Part - 2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
A) General principles
Introduction
A patient coming to a doctor always does so with certain expectation. A patient is really a person in distress, coming to the doctor for guidance and solutions to his problems. He or she likes to place him or herself on the competent hands of the doctor with trust. The patient expects that the doctor will guide him truthfully in his ailment, tell him truthfully whether he is capable of taking up his case and if not to guide and refer him to the correct specialist. Truthfulness is the first ethical principle a doctor has to follow and also it is the first expectation of the patient. The patient also expects that the doctor would be friendly, patient enough to hear what the patient has to tell and give him clear, precise and professional directions. Once the doctor takes up the case of the patient for management the patient expects the doctor to give it necessary attention and care. It is ethically necessary on the part of the doctor to set up his practice in such a way that the patients concerns can be addressed and expectations can be met. Doctors attitude towards the patient is of vital importance. When a person chooses the medical profession the dye is cast. He or she is then expected to behave in a certain way, uphold certain value systems, follow and exemplary and disciplined conduct both in public and private life, be transparent in all dealings including financial ones and be aware at all times that once the profession of medicine has been chosen it will be necessary to have a mentality of service towards the patient, towards the people. The society, ethics and law all expect a doctor to do so.
1) Core area of Medical Ethics
Clinical medicine essentially means a relationship and a partnership between the doctor who advices and treats and the patient who is advised and treated. Therefore this relationship also constitutes one of the core areas of Medical ethics too. You have observed in the previous chapter that all historical codes of medical ethics whether it is the Caraka’s code of ancient India or Hippocratic oath of ancient Greece, or the other religious and social guidelines, they mainly harp on this issue and lay down the principles of this unique relationship. These codes lay down a guideline as to how a doctor should behave with a patients and what are the things he should do or should not do. In other words all these code essentially try to define the parameters of the doctor patient relationship. Apart from these universal principles the laws of individual countries also put additional conditions that further seek to define this relationship.
This relationship is an unique relationship and it covers a wide range of subjects which we shall now explore.
2) An unique relationship
The professional relationship between a doctor and a patient starts whenever a patient comes to consult a doctor and the doctor agrees to the consultation. Once this relationship starts it cannot be easily terminated (We shall discuss the conditions when it can be terminated afterwards) and even the death of the patient does not end this relationship (see the section on confidentiality). Doctors should, when required, establish good relations and gain confidence of patient’s family and friends.
The doctor patient relationship is one of the most unique relationship in the world and is based mainly on mutual trust and respect. The doctor has to be careful all the time so as to be able to earn the trust and respect and to keep it. And to be able to do so the doctor has to follow certain things carefully which we shall enumerate in the following chapters.
4. The changing nature of the relationship
However this doctor patient relationship has undergone quite a change over the years. In past this relationship was Paternalistic and patronizing. It held that the ‘doctor knows best’ and the patient merely submitted to the doctor and believed that he would give the best advice. With increasing level of education and consciousness and the availability of a wealth of medical information in the web things are fast changing. Now the patient wants to be an equal and informed participant on all the decisions taken regarding his health and treatment – rather than being a mere recipient of doctor’s advice – unquestioningly following his decisions. Now the traditional doctor patient relationship has changed into one of doctor patient partnership and many authorities are now labeling it as such. This change has got a profound effect on the practice of medicine and Medical ethics which we shall realize as we go by.
5. Professional Conduct of the Doctor
For a good doctor-patient relationship to exist the doctor is the main person who has to follow and establish very high standards of professional conduct. Unless a doctor does so he/she shall not be able to gain the trust and confidence of his/her patients.
A doctor must always believe that he has chosen a profession out of his own free will – that is, nobody has forced him to take up this profession. Once he has taken up this profession it enjoins him to behave in a professional manner and to follow very high standards of professional conduct and follow some high principles.
The physician should always remember that the first principle he always has to follow is that ‘the health of the patient would be the first consideration of the physician. And the Physician shall owe his patient complete loyalty’. These principles are enshrined in the declaration of Geneva the text of the declaration is given below which would be of interest to students.
DECLARATION OF GENEVA
All the time of being admitted as a member of the medical profession:
I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
I WILL GIVE to my teachers the respect and gratitude that is their due;
I WILL PRACTISE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my honour.
- the World Medical Association
These are lofty ideals no doubt and you may be tempted to think – how important are these in the practical life? Do they really constitute an important part of medical ethics? It is really difficult to understand the importance of them till the moment when you yourself or one of your relatives personally suffer from rudeness, discourtesy, lack of compassion, dishonesty or discrimination on any grounds from any physician or a medical establishment. This possibly is an extreme situation, but is illustrative. Just think whether you would like to be treated with a physician who has all the above attributes or by one who does not have. And just remember you may be accused of being an unethical doctor by your patients, colleagues or the society at large if you do not follow these standards of professional conduct in your life. The doctor should always remember that he/she has to follow the codes of national regulatory authorities and professional bodies of each country.
6. Ending doctor patient relationship
You have already learnt that the doctor patient relationship once it is formed is an enduring one and the code of confidentiality that the doctor has to follow even does not end with the death of the patient.
A doctor should never desert or abandon a patient whom they have undertaken to care. To do so would not only be a very grave ethical misconduct but is likely to have legal implications too inviting penalty.
A doctor patient relationship may be terminated under the following broad conditions.
1. When the doctor feels the patient requires different skills and is referred
If the doctor does not have the necessary skill and competence to treat the patient, and the patient requires the skills of another physician, then the doctor should formally refer the patient to another physician or specialist formally in writing.
The patient may come to a family physician, GP and after examinations the doctor feels the patient requires an operation, more advanced investigation and specialist consultation. In that case it is incumbent upon him to refer the patient even if the patient insists that he/she be treated by the doctor. Similarly when a specialist of one discipline realizes that patient requires the service of another discipline the specialist should refer the patient formally.
With such formal referral the doctor patient relationship that came into being with the first consultation formally ceases ethically and even legally but still the confidentiality of the consultation needs to be maintained lifelong.
2. Physician moving or stopping practice
Under this condition the relationship entered into during the practice ceases. The doctor should however try to inform his patients of such a move. Traditionally it is done through newspaper advertisement which is a good practice. Even often such a step whenever a former patient requires any help the patient may be appropriately referred or directed
3. Patients refusal to comply with the advice given by the physician.
If the patient refuses to follow the advice given by the doctor willfully the doctor may formally end the doctor patient relationship by stating so and referring the patient. This fact needs to be recorded so that the doctor is not held at fault.
4. When the patient refuses or is unable to pay for the doctors service
The doctor has a legitimate right to expect his due fees for the services rendered which ideally should be displayed in the consulting chamber or informed beforehand. When the patient refuses to pay despite having capacity to do so the issue is clearcut. But in case of a genuinely poor and deserving patient it depends on the doctor whether he/she will offer his services free or not. The doctor should advise the patient regarding obtaining social support, government or insurance support in such genuine poor cases. When doctor patient relationship is ended due to refusal to pay despite capacity to do so the doctor should record this fact in writing.
5. When there is mutual dislike of the doctor or the patient for each other.
A proper and good doctor patient relationship cannot be sustained without the trust, respect and confidence. In the absence of which it is not possible to proceed with the relationship. It such a situation arises the doctor should be candid about it, and courteously terminate the relationship formally in writing informing and giving the patient a choice of referral.
A word of caution here: A doctor should never take the issue of termination of doctor patient relationship lightly. Except in the first instance where a patient has been referred to another doctor for his/her own benefit, in all other cases the doctor must be able to justify such a decision to himself, to the authorities, to his colleagues and all other concerned people.
6. Effective communication between Doctor and the patient
To build up a good doctor patient relationship based on mutual trust and respect an effective communication between the doctor and the patient cannot be overemphasized. In this too, the role of the doctor is of primary importance. Doctors must be good communicators and they must train themselves up to be so by following some guidelines and practices. These are given below,
1. The art of listening to the patients – the doctor must be a good listener and should listen to the patient with courtesy and interest. The doctor must remember the old saying that you learn half about the disease by merely listening to the patient. But more than that, the act of interested listening, gets the doctor the first confidence of the patient. Not only the doctor should encourage the patient to talk and help the patient in expressing their views regarding their state of health, respect their expressed views, talk about their concerns and priorities. The doctor should also respond adequately and encouragingly to the views expressed by the patient with an open mind even if the doctor knows that such views or concerns may not always be totally correct or scientific. This constitutes good history taking.
2. Encouraging free expression
The doctor should encourage the patient to tell freely about their condition and how the patient is coping with it, what measures the patient is taking for them including the use of drugs, remedies and other measures.
3. Informing the patient - The doctor should gently inform the patient about the nature of the ailment once a provisional diagnosis is made. For example when a patient comes with pain abdomen the doctor may say that it may be due to gastritis, ulcer, gale bladder or pancreatic inflammation. Then he should explain to the patient the investigations that are required to be done, explain the necessity of each. Then the patient should be told about the tentative treatment plan needed to relieve the patient. If any procedures are needed to be performed which can be invasive or non invasive, the same should be explained to the patient. When the final diagnoses is made the treatment plan should be explained encouragingly. During this whole process the patient should be encouraged to ask questions, discuss their doubts and even to refuse any investigation, intervention and treatment.
4. Not to keep the patient in the dark – The patient should be told about their condition with gentleness and the available management options should be discussed with them. The potential benefits, risks, harms etc. should be told gently. Care must taken to explain the material risks of each stop of management – whether it is a diagnostic procedure or a therapeutic step. If any specialized help or treatment is available at any other peace the same must be told to the patient and during all this the doctor should always take care that whatever he has spoken should be understood by the patient.
5. Responding to questions – The patients must be encouraged to ask questions about their ailment, diagnosis, investigation and treatment. Their fears, anxieties and concerns about the above must the addressed. The questions should be answered gently, truthfully and they should be kept informed about their clinical progress.
6. Showing genuine concern – A patient can come from diverse socio-economic, linguistic and cultural backgrounds and these can have specific attributes of their own. The doctor should try to understand these and should show genuine respect for them. Where there is difficulty, the help of knowledgeable persons, language interpreters should to be taken.
Ensuring that the patient understands – The doctor must take pains to ensure that the patient has understood what has been said and discussed. Good communication between the doctor and the patient reduces many misunderstanding and conflicts and make treatment easier. Medical students should learn the art of good communication from their student days.
Part -2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
B) Patient autonomy
Another important component of doctor patient relationship is patient autonomy. This also been described as patient’s rights or patient’s right to self determination. It means that a mentally sound and adult patient has the right to take all decisions regarding his health, disease and treatment. It is also implied that the patient must therefore have all the information enabling him to take an informed decision. The doctor must respect this autonomy or the right of the patient and must help the patient by providing the necessary information so that the patient can take an informed decision.
Let us have a look as to what does the WMA (World Medical Association)’s declaration on the rights of the patient say about this.
“The patient has the right to self-determination to make free decisions regarding himself/herself. The physician will inform the patient of the consequences of his/her decisions. A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions. The patient should understand clearly what is the purpose of any test or treatment, what the results would imply and what would be the implications of withholding consent.”
If we analyze the statement above we see that
1. The patient has the absolute right to take any decision regarding his/her health and disease.
2. The patient has the right not only to choose the modality of his treatment but also the doctor who would be treating.
3. The patient has a right to know all aspects of the investigations required, treatment modalities planned – including the availability of alternative modalities of treatment.
4. The patient has right to expect from the doctor all the information required to arrive at their decision and the doctor has the obligation to provide them.
5. The patient has the right to refuse the advice for any investigation, procedure, therapy or operation partially or fully. “The WMA – Medical Ethics manual” (2nd edition) says that ‘competent patients have the right to refuse treatment, even when the refusal will result in disability or death.’ The doctor has to respect and accept this right but it is necessary for him to tell the patient the consequence of such refusal. This should also be communicated to the attendants.
6. The patient has the right to seek a second opinion. The doctor has to respect this right of the patient to seek a second opinion and if requested the doctor has to guide the patient in this aspect.
Against patient autonomy
There are certain situations when a doctor has to go against the principles of patient’s autonomy in the best interest of the patient. Such situations arise during an emergency when a patient’s life is at stake and the patient is either unconscious or not in a position to take a decision by ownself. In such cases the doctor has to take a medical decision keeping the best interest of the patient in mind. What is expected of a doctor in such a situation is that he or she should know what has to be done and why. The doctor should also keep proper records. If more than one doctor is available a joint decision is always better and safe, but if no second doctor is available the treating doctor has to proceed alone. In such cases involving and discussing with nurse and paramedics is always better. You must remember that a doctor is always duty and honour bound to treat an emergency case.
Part -2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
C) Confidentiality
Another very important aspect of the doctor patient relationship is the question of maintaining confidentiality and respecting the right of privacy of the patient.
II. It is the duty of the doctors to safeguard the confidentiality and privacy of the patient
The patient reveals many types of information to the doctor during consultation. Such information may be about the disease, about family and background and some of them can be very personal in nature. It is always been said the informations given by the patient to a doctor are ‘privileged communications. The doctor has obtained these information only because of his profession –i.e.- being a physician.
A doctor should never give out these information to anyone but must guard them jealously. These informations not only include the information given by the patient verbally, but also all the data that have been obtained regarding the patient after conducting various investigations on him (test reports), subjecting him to various procedures, the diagnosis, the prognosis thereof, the treatment data etc. Such information regarding the patient should never the loosely discussed by the doctor even with his own professional colleagues, spouse or any other person.
The doctor should recognize and respect the fact that it is the patient and only the patient who have the exclusive right to these information and nobody else. The doctor should not divulge such information even to the wife, children and closest relatives of the patient without the express permission of the patient. Unguarded discussion in ward settings, even during teaching of medical students, should be avoided. The doctor must be careful not to breach the confidentiality of the patient as much as possible.
The WMA Declaration on the Rights on the Patient summarises the patient’s right to confidentiality as follows:
▪ All identifiable information about a patient’s health status, medical condition diagnosis, prognosis and treatment and all other information of a personal kind must be kept confidential even after death. Exceptionally the descendents may have a right of access to information that would inform them of their health risks.
▪ Confidential information can only be disclosed if the patient gives explicit consent or if expressly provided for in the law information can be disclosed to other healthcare providers only on a strictly “need to know” basis unless the patient has given explicit consent.
▪ All identifiable patient data must be protected. The protection of the data must be appropriate to the manner of its storage. Human substances from which identifiable data can be derived must be likewise protected.
In Asian countries a patient is usually brought to the doctor by his family members, relatives and friends and they are usually genuinely concerned about the welfare of the patient. Further they constitute the social and even economic support system of the patient for his treatment. It is only natural that they would want to know all the information about the patient. What should a doctor do? The doctor should then specifically ask the patient whether the patient wants the doctor to share the information about the patient’s health and disease with his family members and relatives. If the patient agrees then only the doctor should do it. If the patient does not agrees the doctor should politely inform the others about the decision of the patient and in view of this the inability of the doctor to discuss and share information.
The doctor should maintain such confidentiality always and should realize that keeping this confidentiality is the most important prerequisite of building a relationship of mutual trust and confidence between the doctor and the patient – or in other words of a good doctor patient relationship.
III. Commitment to confidentiality is permanent
The doctor should further realize that the nature of the doctor patient relationship and the ethical need of maintaining confidentiality is permanent in nature. Even when the doctor patient relationship is formally ended (we shall discuss it later) or even when the patient dies the doctor is still bound by the clause of confidentiality and by the ethical codes of honour and the doctor cannot divulge the patients information even then.
IV. Confidentiality of children also need to be maintained
In case of children too a doctor has to observe this code of confidentiality. See also chapter on ethical issues in treating children. The information given by the children, should be strictly maintained and they should be treated with respect.
V. Genetic information
Genetic information of the patient is a very sensitive and important issue. The doctor should never divulge the genetic information of the patient and shall take necessary precautions to safeguard any material, tissue etc which can reveal the genetic information of the patient (see also chapter ethical aspect of Genetics).
VI. When the doctor has to divulge information about the patient.
a) Routine breaches of confidentiality
Under all general conditions the information given by the patient to the doctor should not be divulged to anybody.
There are some routine situation where partial breach of confidentiality can be justified as part of the treatment process. In normal ward setting there is routine breaches of patients confidentiality due to the normal access of the bed headed ticket to all members of the treating team of doctor, nurses, paramedics, students etc. This is a necessity to provide patient care. Similarly information about an unconscious patient, incompetent patient have to be routinely given out. Doctors also talk to relatives and attendants of the patient informing them about how the patient is doing. These are justifiable breaches of confidentiality but the doctor should always try to keep even such justifiable breaches to the minimum.
b) Disclosing patient information to authorities
Normally a doctor need not disclose information regarding patients to administrative authorities, police or investigating agencies even if asked for. However if the laws of the country stipulate that such disclosers need to be made, the doctors should examine the whole issue from ethical, moral and legal viewpoint before doing so. Disclosure of information of certain communicable diseases which can affect the society by increasing disease transmission and causing disease outbreaks and even epidemics may be mandatory. In such cases the doctors should comply with these legal and health requirements and volunteer the information. Similarly when a doctor thinks that concealment of the disease of the patient can put other persons, including family members and friends at risk he may decide to disclose it. (Please see chapter 14 also)
Whenever the doctor feels that it is justifiable to make discloses due to legal requirement or otherwise, the ideal situation is to discuss such a step with the patient, convince the patient and obtain permission. More appropriate would be to convince the patient for self disclosure. This is also important while dealing with imprisoned patients.
C) Disclosure before a court of law
Only place where the doctor has to reveal their information is a judicial court of law. The doctor should then reveal before the judge or the court such information, as are asked for. This applies even to government doctors. Ideally such disclosure should be done in camera and not in a open court where such divulged information becomes public knowledge. Further only such information as is asked for needs to be divulged. The laws of individual countries and the nature of political setup also determines to a great extent the behaviours of doctors in such situations.
Part -2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
D) Truth telling/disclosure
‘Truth telling’ denotes revealing the truth about the medical condition to the patient. A doctor is duty and hour bound to tell the patient the complete truth about the diagnosis, treatment, progress and prognosis. Good medical practice, good doctor patient relationship all demand it. It is also the right of the patient to know about his condition fully. We have already discussed that it is the patient who alone has the right to know and not anybody else and the doctor cannot reveal about the condition of the patient to others, including the spouse, children and relations. It can be done only with the permission of the patient.
Truth telling may involve informing the patient about
1. Provisional diagnosis – if such a diagnosis can be made.
No speculation shall be made regarding
diagnosis.
2. Investigations - any why they are required.
3. Procedures and why they are requires – e.g. invasive diagnostic
such as angiography, biopsy etc.
4. Final diagnosis
5. Implication of the diagnosis, risks, likely complications
6. Suggested treatment modalities, medical or surgical including different modalities.
7. Risks involved in treatment and risks involved in non treating.
8. Cost and expenses (if the doctor is in a position to give)
It is quite easy to say all these but in practical it is not all that easy. If the condition the patient as suffering is curable the task of truth telling is easy, but if the patient is suffering from incurable illness like malignancy or from terminal illness truth telling is not easy at all. The doctor then has to keep in mind the following points.
1. THE DOCTOR SHOULD ALWAYS REMEMBER THAT IN CASES OF SERIOUS ILLNESS the news should be broken in such a way that it does not alarm, frighten or depress the patient. The doctor should be gentle, friendly, caring and compassionate and should be encouraging to the patient. The news should be given to the patients gently and if required part by part.
2. However the doctor should not crate any false hopes or say things which are not true or recommend remedies which are not proper, correct or proven.
3. The doctor should realize that bad news if given in a brash manner may cause incurable harm to the patient who may go into a downward spiral or severe depression. Therefore he should be always careful in breaking such news and exercise utmost discretion and fineness. He must remember that this is an acid text that determines whether he is a good and humane doctor or a bad one.
Part -2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
E) Informed Consent
A very important aspects of medical ethics is obtaining Informed Consent of the patient in all the major steps of patient management. You may say it is the culmination of the process started first with consultation when the doctor patient relationship is first established. From then onward it travels through the care taken to establish a good doctor patient relationship, effective communication, respect for confidentiality, maintaining patient autonomy, truth telling, disclosures etc. You will realize that these process usually run simultaneously in parallel courses and not always in a sequence of one after another.
1. What constitutes Informed Consent?
How is to be informed consent defined then? Informed consent is the authority given voluntary by the patient to the doctor for the proposed medical care. This authority is given after the patient gets all the information about his medical condition and understands the benefits and risks involved.
Informed consent as the name suggests therefore has two parts. First part involves informing the patient and making him understand the various aspects of his disease and the plan of management. The second part involves getting voluntary consent of the patient for different interventions planned for his management. There are many situations where informed consent has to be obtained by the doctor from the patient and that too ideally in writing. We shall discuss the typical situations later in this chapter.
2. Information the doctor has to give
The doctor has to give all the necessary information (also discussed under truth telling) to the patient regarding his diagnosis, proposed investigation and treatment modalities and this information has to be given in a way the patient understands it. This must to done before asking consent from the patient.
It is not sufficient for the doctor only to talk about the medical condition of the patient. The doctor must clearly inform the patient about his fees and charges and must be able to tell the patient about the cost of investigation, or treatment and what may be additional costs.
The doctor must also realize and accept that the patient has the right to refuse totally or partially to give consent.
3. How informed consent is obtained
When informed consent is required it is usually obtained in a written form. Each country or each medical institution may have its own system and protocol of obtaining informed consent and have specific forms for it. In case of a fully competent adult patient the consent is obtained from the patient and usually one of the relatives or a hospital staff sign it as a witness. A typical form for obtaining consent is provided in the box in this chapter to give you an idea.
4. Implied consent
There are certain situations where consent of the patient is said to be implied by his/her actions. For example – a doctor has seen a patient in OPD, gave him written advice and prescription and asks the patient in writing to come to minor OT the next day morning for a simple procedure like an FNAC. If the patient attends the minor OT for the procedure as advised, in that case the consent of the patient for the procedure shall be taken as implied even if written consent in the form is not taken before the procedure. However one should always remember that the concept of implied consent has serious limitations and it may not always be accepted by authorities or law. Therefore it is always safe and prudent to take a written consent even in situations where implied consent can be imputed.
5. Conditions where informed consent is required
Let us now discuss these conditions one by one where informed consent is required.
When a patient comes for consultation it is understood that such consultation will require physical examination which involves general and systemic examination and the implied consent of the patient for such clinical examinations is universally presumed to exist. However, if some internal examinations such as per rectal or in case of women pervaginal examinations (in case of Obstretical, Gynecological or female urological consultation) are required, it is always prudent to take a informed consent even though such examinations are considered universally as consulting room examinations.
Further good conduct demands that when a male doctor is examining a female patient, a female attendant or a nurse should be present.
Let us now discuss the conditions where informed consent is required.
Investigation procedures – Both non invasive and invasive specially when it requires some oral or IV contrash, radio isotopes etc. These may include IVP, urograms, CT, MRI and Bone scan, Pet scans, Thyroid scans etc.
1. Investigative procedures that may require either local or general anesthesia. In such cases in hospital settings, the doctor performing the procedure as well as the anesthetist may obtain separate consents.
2. Investigative procedures that may put the patient in some kind of increased risk even without drugs, contrash, anaesthesia etc. Such as treadmill test, Stress Echocardiography ect.
3. All invasive investigative procedures involving instruments /scopes such as upper GI and lower GI endoscopies, Bronchoscopy, Cystoscopy direct laryngoscopy etc.
4. Blood transfusions.
5. Injection or infusion of dangerous drugs – for example chemotheraperetic drugs in cancer chemotherapy.
6. Application of such devices as splints, plasters and other external devices that may require manipulation and may result in prolonged immobilization of the patient fully in a part. Or in other words, in the treatment of fractures.
7. All minor surgical procedures.
8. All major surgical procedures.
9. In cases where any kind of anaesthesia is required the surgeon or the treating doctor or the anaesthelist separately informs the patient regarding the steps they intend to take, the risks and benefits thereof and obtains separate consent.
In large hospital settings it is usually the junior doctors, residents and sometimes nurses who obtain the signature of the patient in the consent form in a routein way. This is a bad practice. The consent should be obtained by the treating doctor and the anaesthetist personally and they should ensure that the patient has understood properly and voluntarily given consent.
6. When informed consent is not required
There may be certain situations where it may not be possible to obtain informed consent of the patient. There situations are as such.
1. In dire medical emergencies.
2. Unconscious patient.
3. Patient who is mentally not competent to give consent.
4. Infants, children.
In certain situation of dire medical emergencies to save the life of the patient it may not be possible to obtain informed consent of the patient or of the legal guardians, relatives beforehand. In such situations the doctor should proceed to do whatever is required with the best interest of the patient in mind. For example one may have to do an emergency tracheostomy or a DC cardioversion to save life. One way to overcome this problem is to obtain from all hospitalized patient consent for all emergency life saving measures that may be required. But this may also not be possible at times when say an unconscious patient is brought to the doctor at the hospital emergency who has no relative or legal guardians. Such patient may urgently require emergency instigations and even major surgery – for example in a case of Road traffic accident. Then what the doctor should do. The first duty of the doctor is to save the life of the patient. If there is a second doctor or a superior they should be consulted. In their absence the nurses and paramedics should be involved in the decision making and after the procedure is done all that has happened should be properly recorded. In the cases are medico legal cases appropriate authorities need to be informed. It should be duly recorded in the notes and preferably another medical person should bear witness.
Who are the persons who can give informed consent?
Whenever informed consent cannot be obtained from the patient either due to unconsciousness, mental incompetence or the patient being minor or a child, then informed consent is to be obtained from. 1) Parents incase of children (2) spouse (3) Adult children (4) Brothers and sisters (5) other blood relatives and legal guardians. In certain situations for both adult and children patients there may be government or court appointed legal guardians. In such cash they are the persons who can give consent on behalf of the patient.
If informed consent is not taken?
Not obtaining an informed consent except in situations described above is considered as a very serious lapse on part of the doctor. It can be both a serious negligence as well as misconduct. If there is any complaint against the doctor or some investigation or litigation then failure to obtain an informed consent will create very serious difficulties for the doctor. He or she may be considered as seriously negligent if in such cases death or permanent disability of the patient has occurred and may be punished. Punishment may be both an ethical grounds which can result in suspension or cancellation of registration and also according to civil and criminal laws of the country. In addition the doctor may have to pay compensation.
(A sampler – A form of taking informed consent is provided in the appendix for guidance)
Part -2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
F) End of life decisions
1. Introduction - It is the doctor, who has to face the final reality of death and in this situation he /she is often expected to take part in two extreme way. First is the prolonging the life of the dying, often terminally ill patient, by any means and second is to assist in hastening of death by euthanasia or assisted suicide. And between these two extremes the doctor has to face various situations with potential ethical dilemmas.
There may be such situation where the patients diagnosis and medical condition precludes the hope of healing or even maintenance of health. Death then becomes inevitable. These are also called terminal situations. Advancement of science has now made it possible that in such situations the end of life can be prolonged for some time. However such acts require lots of advance technology and facility which are not available everywhere and are likely to be very costly. Further the attitude towards dying and death varies from culture to culture and there is no uniformity.
2. Ethical duty of the doctor in end of life situation :
In such terminal or end of life situations it is the ethical duty of the doctor to
a) Make natural death peaceful and dignified – The doctor must realize that death at the end of life is inevitable and natural and they must be able to recognize the dying phase and consider it as important part and fact of life. The doctor must respect this and try to make natural death as peaceful and dignified as possible. The physician should be compassionate, kind and caring to the patient and try to maintain optimal quality of life till the end.
b) Provide palliative care – Clinical management of pain in terminally ill patients is very important to alleviate suffering and to make the final exit peaceful and dignified. Doctors shall acquire necessary competence to practice palliative care to relieve the pain, symptoms and distress of the patients. And if the doctor is not competent or equipped to provide that care he /she shall advice such care to the patient and attendents.
c) Understand and address the psychological and social needs of terminally ill patients and in doing so try to obtain necessary help from other competent people.
d) Respect and address the spiritual needs and requests of the patient and provide all help for meeting such needs.
e) Avoid prescribing or employing any unproven means that do not provide benefit to the patient.
f) Respect and try to follow any written wish or instruction of the patient given beforehand within the ambit of law and regulations. In case the patient had designated a substitute decision maker on his/her behalf on writing, the doctor shall try to involve the substitute decision make in all aspects of terminal care.
3. Euthanasia – ‘Euthanasia means knowingly and intentionally performing an act that is clearly intended to end another person’s life’. (WMA- Medical ethics manual)
Request for euthanasia comes from a patient voluntarily. Such patient is one who usually is mentally competent, is suffering from incurable disease without a known chance of recovery – terminal illness, and may be in great pain and distress.
The thought of euthanasia arises from such thoughts that a patient has as much a right to die as to life. And as in the case of assistance to maintain life, the doctor is the right person the assist in voluntarily sought death too, and the patient has the right to demand such assistance. However, these kind of thinking is not approved by the majority of countries in the world.
Euthanasia is banned by law in most countries of the world. There are only few areas where it is allowed. Most of the International organization holds it to be an abhorant and unethical practice.
A doctor shall never support Euthenesia under any pretext and shall not take part in such an act. They shall be totally guided by the laws of the country in this regard.
4. Assisted Suicide – It means providing a patient with knowledge and means to commit suicide and the means may include knowledge and supply of drugs.
Morally it is just like Euthanasia and the same prohibitions apply.
What is the way out for the doctor in the above two situations? They should encourage, develop palliative care medicine and guide their patient to such facilities.
5. Initiation and withdrawing of potentially life saving measures to the terminally ill patient. These measures include either initiation, or restriction or withdrawal of drugs, resuscitative and intensive care measures including ventillatory support. On the verge of death of a patient, specially when the patient is suffering from incurable terminal illness, the doctor has to face these situations and may have to take decisions and advice the relatives accordingly. In these the doctor has to be guided by his ethical considerations mainly. He should be able to communicate these end of life decisions to the relatives in a humane and compassionate way. A doctor is expected to follow the law of the land and these laws may vary from country to country.
Part -2 : Ethics in clinical practice
Chapter – 1: Doctor patient relationship
G) Patient’s rights
In the last few years a lota of changes have occurred in the world of medicine and one of the changes that has come to the realm of medical ethics and doctor patient relationship is the increased recognition of patient’s rights. An ethical doctor always respects, endorses and supports patient’s rights because ultimately it helps the doctor in ethical and efficient practice.
The basic principles of patient’s rights can be summarized as follow. These are based on the policies adopted by the World Medical Association (WMA).
1. Every patient has the right to good quality medical care.
The patient has the right to appropriate medical care without any discrimination and has the right to choose the doctor according to his or her wish and judgment. Even in selection of the doctor of choice the patient is entitled to a fair selection procedure if the doctor is very busy and is the only specialist of the particular field required by the patient. The doctor is duty bound to ensure the quality of medical treatment for the patient. The patient also has the right to continuity of medical care and doctor cannot discontinue to treat a patient midway without making proper alternative arrangements.
2. Right to freedom of choice –The patient has the right not only to choose the doctor but also the hospital for treatment whether public or private.
The patient has the right of second opinion.
3. Right of free decision or self determination – The patient has the right to make free and informed decision regarding himself or herself regardless of consequences and to give or withdraw consent to any procedure or treatment and the patient has the right to all the information required for taking such a decision.
4. Rights of an unconscious and legally incompetent patient - For life saving treatment of either an unconscious patient or a mentally incompetent or a minor patient the doctor should obtain informed consent from legally entitled representative and always act in the best interest of the patient (see chapter on informed consent).
5. Procedures against patient’s will - Procedures against the patients will shall ordinarily not carried be out expect in exceptional cases when specifically permitted by law and conforming to medical ethics.
6. Right of information – Patients have the full right to information regarding his or her condition and procedure or treatments advised.
7. Right of confidentiality – All patients are entitled to the right of confidentiality and privacy and doctor shall not release any information to anyone else without the permission of the patient. (see also chapter on confidentiality)
8. Right to health education – Patients shall have the right to health education that shall enable him/her to make informed choices.
9. Right to dignity – A patient’s right to human dignity, privacy, culture and values shall be fully respected. Further the patient is entitled to all relief possible according to the current state of knowledge. A patient has the right to good, humane terminal care to make dying as comfortable and dignified as possible.
10. Right to religious assistance – The patient has the right to receive or decline religious assistance according to his/her religious faith and belief during treatment.
In addition to these rights adopted by WMA the doctor should realize that a patient under any situation of life, even when he/she is legally detained and is a prisoner has equal rights to like any other patients. It is the duty of the doctor to uphold these rights.
It is ethically incumbent on a doctor to recognize that the patient has all the above rights and the doctor should endorse, respect and support these rights and should not do anything that would curtail these rights. When any law or government or institutional action tends to curtail these rights the doctor should pursue all democratic and legal ways to help restore them.
Part -2 : Ethics in clinical practice
Chapter – 2: Equality and Social Justice
Everybody should have equal and unrestricted access to health’ is the general principle that usually underlies modern medical thoughts. However, this lofty principle is not always easy to achieve because of different political, social and economic reasons. Disparity rather than equality and discrimination rather than social justice are the usual norms. The question of equal opportunity to everyone is the central theme of social justice as it embraces all disadvantaged, dispossessed and marginalized groups.
The policies that provide access to healthcare facilities in a country are so traditionally? Formulated that they usually provide maximum advantage to the most well off section whereas they should have been made to provide benefit to the least well off. Like any other fields, equality and social justice is denied the health sector also. The saddest part is that the policies force the doctors to work under such conditions where they become instruments of denying equality and social justice to their patients. While the doctors as a professional group should always strive to have the policies of the country modified to provide equal opportunity to all citizens, individually they try to help all patients that come to them.
How these unequal treatment really occur in the society? Till 19th century slavery was prevalent European colonies and America. Abolition of slavery is a relatively recent phenomenon. In those times the slaves were not considered to be equal to free men in those societies and the doctors by and large also behaved in the same way. During the Apartheid, discrimination against blacks and coloured people was institutionalized. The remnants of such discriminations are still there is many parts of the world. People are still denied equal opportunity even in health sector on the basis of race, religion, colour, beliefs, preferences - including sexual preferences and gender. Women are not treated with equal respect in many countries. In many societies, like in India, great social discrimination still prevails in the name of caste. Religions differences is another basis of social discrimination and inequality in many parts of the world.
The concept of social and political equality developed only from 18th century. The democratic thoughts promoted the concept of political equality of all men (and latter of women). The United Nations in its universal declaration of Human rights (1948) declared ‘All human beings are born free and equal in dignity and rights’. From such concepts slowly the thought of human rights in the modern context developed. From there on the rights of individuals, the patients’ rights also great crystallized.
In this context it is the ethical duty of a doctor to avoid all kinds of discrimination and to uphold human rights. The declaration of Geneva says that a doctor shall not ‘permit considerations of age, disease or disability, creed, ethnic origin gender, nationality, political affiliation, race, sexual orientation, social 5tanding or any other factor to intervene between my duty and my patients’. All doctors should follow this declaration in letter and spirit.
A just, equitable and transparent allocation of the scarce healthcare resources go a long way towards mitigation of inequality and ensuring social justice. The doctors are ethically duty bound to do so. Also see the chapter on allocation of healthcare resources.
What kind of policy is followed by a particular government is health sector and resource allocation determines how much social justice is ensured.
If only market principles are applied in the health sector when only those who can play get access to the facilities increase disparity in the society. On the other hand if resources are allocated according to the principle of maximum benefit to all they may be insufficient. Hence to ensure justice and equality the access to health facilities and resources should be strictly according to need and should embrace and favour the poor and historically disadvantaged sections of the society.
Health after all cannot only be an individual responsibility, it has to be a social responsibility of the government and the nation. The doctors should actively start advocacy for such reforms in the interest of social justice and equality.
Part -2 : Ethics in clinical practice
Chapter - 3 : Code of conduct of good practice
Introduction
The ethical code of conduct for doctors is really country specific as it includes laws, rules and regulations of the country made for the doctors to follow. The medical regulatory authorities of each country may lay down codes which and supplement the laws. But inspite of such country specific codes the main principles that are laid down by such codes are really universal in nature.
In the second chapter we have already come across ancient codes of India, China and also the Hippocratic codes. All such codes tend to lay down a set of duties, responsibilities on the doctor also mandate a set of behaviour for the doctor. This set of rules for behaviours are togather called the code of conduct for the doctor. Code of conduct means code of ethical conduct. In some countries such a code is also called code of ethical conduct (or ethics) and etiquette.
In the preceding chapters we have discussed about the duties and responsibilities of the doctor towards the patients and society. In this chapter we shall discuss the ethical behavior and conduct a doctor has to follow to practice of what is called good or ethical medical practice. If a doctor does not follow the behavior laid down by codes and do not confirm to the code they may be accused and held guilty of misconduct or infamous conduct in their professional life with very damaging consequences.
The code of conduct lays down explicitly the standards of ethical and professional conduct expected of doctors by their professional peers, and the society. Such codes also let the community / society know what they can expect from doctors.
While all the international codes of ethics like the World Medical Association – Medical Ethics Manual, AMA code of ethics etc. give guidelines to the doctors, Indian code called the ‘Professional conduct, etiquette and ethics regulation, 2002’ is a regulation that is binding on the Indian doctors.
1. Code of Conduct
In modern times a code of conduct for a doctor shall include following guidelines. These guidelines set the standard for a modern doctor to follow for a good and ethical practice. The patients, society, medical regulators, national governments and international bodies all would expect a doctor to follow these guidelines.
You must realize that more important than this code of conduct of the doctor are the personal qualities of the doctor. A doctor must always be caring and compassionate to his patient, behave kindly and be considerate with them, be a truthful and a person of high integrity and moral values, be competent and dependable. The code comes after these attributes. A doctor has to strictly follow this code of conduct. This is necessary to earn the confidence and respect of his patients, colleagues, other health personnel and the society. The important points of such a code of conduct are enumerated below.
I. Patients welfare is the Primary concern of the doctor.
a) Doctors shall always consider the welfare of the patient as their primary concern and practice safe and effective medicine.
b) While examining a patient the doctor shall take a detailed history, do the necessary clinical examinations, formulate a plan of investigation and chart out a course of treatment which the doctor shall explain to the patient (inform) ensure the patient has understood and wherever necessary obtain the consent of the patient.
c) Shall maintain confidentiality and respect patients rights and encourage the patient to take his/her own decision.
d) Shall refer a patient to another practitioner / specialist if some aspect of patient care is not within the competence and field of specialization of the doctor in the best interest of the patient. Shall help the patient to obtain access to the referred specialist if required.
e) Shall never abandon the care of a patient midway without informing the patient and arranging for an alternate doctor to look after the patient. If this is not done a doctor may be accused of not only willful negligence but of a grave misconduct too.
f) Doctors shall always encourage and support the patients to take interest in and responsibility for their own health and should advice them about preventive measures.
g) The doctor shall always take permission of the patient before revealing any information about the diagnosis and any medical matters before the relatives. In a common setting in SE Asia the patient always come to the consultation chamber accompanied by his relatives and friends. The doctor should first talk to the patient alone and obtain permission before revealing.
h) During patient care a doctor shall be careful not to allow his views, likes and dislikes to come between him/her and the care of the patient. The doctor must not be judgmental regarding the weaknesses of the patient and should not be prejudiced even if the doctor knows that a patients behaviour has contributed to his condition. For example a patient may be a hard drinker who has developed cirrhosis and the doctor is a teetotaler, the doctor should not look down upon the patient.
i) Doctor shall always show respect to the patient and shall never discriminate on the basis of race, religion, colour, serial status sex, sexual preferences of the patient.
j) The doctor shall always take care keep himself and the medical team safe while treating a patient who can prove to be a health risk, but shall never deny to treat such a patient.
If the doctor feels that the patient will gain the most from shared decision making with the relations and friends, the doctor shall try to convince the patient stating this and only with the permission of the patient. If the patient wishes to involve his family from the beginning then there is no problem. In case of incompetent patients (unconscious, or mentally incapable patient) the doctor should always opt for it and involve the family members, friends and legal guardians (if any) in shared decision making regarding the patient.
II. Competence
1. A doctor is expected to have acquired the competencies required for his qualification. In legal terms such competence is determined by whether the doctor has a proper, recognized medical degree or not? Such a degree must be one which is recognized by nationally formed boards and registered. Only a recognized and registered doctor has the license to practice his profession. The degree is most important but not enough. To be a competent doctor should also properly learn all the skills expected of him/her.
2. In case of specialization – the doctor shall have the necessary degrees/ diplomas/fellowships/prescribed training in the speciality that are recognized by national registering and recognizing regulatory authorities and government. A specialist should practice only within the limits of his speciality and should not do anything in any other speciality for which he has no competence.
3. The doctor shall not only have the required competence but should maintain this competence and improve on it. Doctor should have adequate knowledge and skills to provide safe clinical case. These should be regularly updated through training CME etc.
4. Doctor shall always practice within the limits of their competence to provide safe treatment to their patients. If this is not done it will not only amount to an unethical practice amounting to serious misconduct, but if any harm occurs to the patient, the doctor may be held responsible for serious negligence as well. All these may carry considerable penalty.
III. Clinical Judgment
a) The doctor shall always strive to provide the patient with optimum treatment options that are available and to do it the doctor must keep abreast of recent knowledge and have adequate information.
b) The doctor shall be able to balance the benefits and potential harms of clinical management options.
IV. Records
Doctors shall maintain adequate records of all their patients. (This point is also dealt elsewhere).
V. Palliative treatment
Doctor shall always be kind, considerate and comforting to all the patients in pain and distress. Even if a cure of the disease is not possible doctor must never abandon the patient but should offer and manage symptomatic and palliative care.
VI. Second opinion and referral
The patient also may want to have a second opinion or request a referral to another doctor or a specialist. Even if the doctor realizes that the patients requests may not be correct, the doctor shall respect the patients’ rights to have a second opinion or a referral and should do so without having any ill feeling.
VII. Consultation with colleagues
A doctor shall never hesitate to consult their colleagues or seniors when required for the best interest of their patients.
VIII. Allocation of resources
The doctor shall always make a fair and principled selection during allocation of scarce resources (see ch..)
IX. Emergency
A doctor shall always respond to an emergency call and shall never refuse to attend an emergency patient. Even if the doctor is not competent to deal with the type of emergency at hand, the doctor shall give the first aid measures, immediate emergency treatment and try his best to have the patient shifted to an centre which is competent to deal with the condition. The doctor must continue to provide the care and attention till such time it is no longer required.
Refusal to attend an emergency call by a doctor on duty or undue delay in attending may be construed as a misconduct and may be changed with negligence also.
X. Right of refusal to treat a patient.
The doctor has the right to refuse to treat a patient in non emergency situations.
The doctor shall however be very careful in such refusals and the refusals must only be an principled or legitimate grounds that are justifiable to self and others.
Some such legitimate grounds are
1) Lack of time to attend to the patient because of an already full schedule.
2) Doctor not having the required competent or specialization needed to attend to the patient.
3) Doctor is sick or indisposed and unable to attend.
Though the doctor does not have to give any reason for refusal, such refusals should not be made lightly or without valid reasons or otherwise the doctor may easily end up practicing discrimination. In these situations it is the conscience of the doctor which matters most.
Part -2 : Ethics in clinical practice
Chapter – 4: Professionalism
A doctor has to develop professional behavior along with acquiring knowledge, competence and skills. And this is a continuous process which continues throughout the working life. With the fast development of science, technology the modalities of treatment are changing continuously and along with it the expectation of the society from doctors also change. A professional doctor should always keep himself abreast of developments and be capable of advising patients regarding modern medical methods. To develop and maintain professionalism a doctor may follow the guideline given below. These guidelines help a doctor to acquire professional behaviors and thus be recognized and respected as a professional.
I. Continuous updating of professional knowledge and performance
For this a doctor is expected to take the following professional steps.
a) Be active member of professional associations: - Each doctor should be an active member of professional bodies. There are such associations for general practitioners and also for each specialty. Each doctor should actively participate in the conference, teaching programmes and social health activities of such associations to keep themselves abreast of the developments. Professional unity and friendships also develop through such professional bodies at the national and the international level and helps to develop doctors as a professional.
b) Continuing Medical Education : Each doctor should regularly participate in continuing medical Education Programmes, workshops, training programmes for keeping abreast of developments in medical science and to keep skills up to date.
In some countries such CME attendance is mandatory and a doctor has to gather a certain number of credit hours annually to enable them to continue practice.
b) Practicing medicine as per the modern standards
2. Professional Behaviour
The doctor must always behave in a professional way so as to earn the trust, respect of the patients and the society. Such professional behaviour comes from following the guideline provided below.
a. Maintaining ethical conduct – It should be the constant endeavour of the patient to maintain ethical conduct all through his professional life. These ethical conducts have been outlined in chapters 3 to 9 and include good doctor patient relationship effective communication with patients, maintaining confidentiality, and privacy of patient, respecting patient autonomy and rights, truth telling and transparency, obtaining informed consent where required, tackling beginning and end of life issues, maintaining code of good conduct etc. A doctor has to maintain all these to become a real professional as well as a good doctor.
c) Not taking advantage of the patient : We have already discussed in the doctor patient relationship that the doctor is always placed at a position of advantage vis-à-vis the patient. Doctors should never take advantage of this position to exploit the patient in any way. There are some boundaries that the doctor should never cross if the doctor wants to maintain high ethical standards and professionalism.
1. Doctor shall never allow a nonprofessional, personal and emotional relation to develop between the doctor and patient. Doctor should be careful not to encourage any such attempt from the side of the patient. Simply put, a doctor shall not fall into love with a patient.
2. Doctor shall never exploit a patient sexually. It is very difficult for a patient to resist any sexual advances by a doctor. The doctor should realize that such sexual relations amount to sexual exploitation and is considered as one of the gravest misconduct on part of the doctor. All the historical codes expressly forbid this.
3. (a) Doctor should never economically exploit a patient and take advantage of patient’s disease to charge more. The professional fees of a doctor or other charges shall either he displayed publicly in the chamber or clearly told at the beginning. The patient should also be warned that due to unforeseen circumstances like development of complications, the cost of treatment may increase. Full transparency should be maintained in money matters and receipts should always be given for all sums received.
(b) Doctors should never encourage a patient to give, lend or bequeath money, valuable gifts except the professional fees, during or after treatment.
4. A doctor shall never try impose his personal beliefs by exploiting the vulnerability of the patient.
3. Medical records
a) To be a good professional a doctor shall be meticulous in maintaining clear and accurate medical records of the patient which should contain all the date from complains, history, examination and investigation findings, details of treatment including information given to the patient, from time to time.
b) It is the primary responsibility of the treating doctor to ensure that records are properly kept. In case of hospitalized patients this is must. In case of chamber or OPD patients as elaborate a record as possible should be kept.
c) The records should be properly safeguarded and safely stored. The period of storage may sometimes be determined by law. Hospital records are permanently kept.
d) The records should be kept in such a way that those cannot be accessed by unauthorized persons so as to protect patient confidentiality and privacy but can be accessed easily when the need arises.
e) When a patient requires such records for any reason the same should be made available to the patient in the shortest time, without undue delay.
4. Reporting
A doctor is required to provide information to various authorities about their patient according to law. This is called reporting. It usually covers some communicable diseases the reporting of which is required to protect the society from their spread. The doctor should immediately discharge his statutory obligation of reporting such patients to the appropriate authorities (see also chapter on confidentiality) It does not violate the code of confidentiality.
5. Medical reports and certificates
The society and the government places great trust on the doctors and authorize them to issue and sign various certificates which include
a) Birth certificates
b) Death certificates
c) Sickness certificates
d) Health report and certificates
It is presumed that the doctor would be honest, truthful in giving these certificates and never give a false certificate. In many cases the question of money, salary, sickness benefit and insurance matters are associated with these certificates. There is always the scope that such certificates may be misused by unscrupulous persons to gain undue advantage, exemptions from work or appearances in courts or laws etc. Different countries, regulatory boards may have rules for issual of such certificates. Doctors should be very careful in giving such certificates and reports and write only what they believed to be true and accurate. Giving misleading or false certificate by a doctor is considered as highly unprofessional and constitutes a grave misconduct. Therefore
1. Doctors shall certify only what they know and believe to be true.
2. The contents of any report, certificate must be personally verified by the doctor before signing and issual of certificates.
3. Copies of certificates issued should always be kept and a prescribed format (if there is any) should be used.
4. In giving medical opinions in reports the doctor should always be clear, objective and remain within the boundaries of professional competence.
6. Appearance in court
A doctor may have to appear before various authorities including courts of law where they have to appear as expert witnesses. While giving such dispositions or evidence, a doctor must be totally truthful, objective and should give his opinion only within the ambits of his /her own competence.
7. Dealing with Medico legal cases
A doctor has to deal with medico legal cases during their working life. Doctor in government employment have to routinely attend to and give medical reports in medico legal cases which can range from simple injury, assault, knife or gunshot injury, rape and even suicide and homicide. When required and authorized they have also to perform autopsies. The laws of each country clearly lays down the scope of such medico legal situations where a doctor has to examine and give report. In these situations, to maintain sound professional behavior, a doctor shall –
a) Learn about the legal requirement of dealing such medico legal cases.
b) Carryout thorough examination and keep a detailed, truthful record of all such examinations.
c) Notify police or any such authorities whenever required under the law.
d) In performing autopsies shall follow laws on the matter scrupulously and perform a thorough procedure.
e) Shall give detailed, truthful reports whenever and wherever they have to be given and reports shall be given without undue delay.
f) Shall always take help of superiors, authorities, professional colleagues where such help is required.
8. Medical Insurance
A doctor shall be very careful in questions of medical insurance matters of his patients. If a health status report has to be given to a medical insurance company and the doctor agrees to do it, a truthful report must be submitted. All data regarding the patient’s illness should be recorded. The patient cannot ask the doctor in this case to hold back any information as the patient has willingly come to the doctor to be examined and reported for insurance.
1. Similarly when a medical certificate is required for insurance payment the same should be given objectively and truthfully.
2. Doctors themselves should take out adequate medical insurance.
9. Advertising and Endorsement
Medical codes of different countries may lay down different rules for advertising by doctor. Usually a doctor is allowed to advertise in
a) Beginning of practice,
b) Change of practice,
c) Addition of newer skills/facilities to the practice,
d) Closure of practice.
Doctors are expected to follow rules of common decency and decorum in advertisement. It is expected that while advertising a professional doctor shall.
a) Publish only such information about the medical services which are true, factual and verifiable.
b) No unjustified claims should be made and unverifiable information be given.
c) Advertisements should be of decent in size. The signboards in chamber should also be of decent size.
d) Only th0se degrees /diplomas/fellowships which are recognized by law in the country and are registrable short be used, in the advertisement.
e) No guarantee of cure, unjustifiable claims should be there in the advertisement that may mislead the patient.
f) No testimonials are to be used.
g) No comparison with other doctors are to be made.
h) When giving interviews to the media the doctor should be careful not to advertise or promote him/her self.
i) Doctor should never endorse any medical or other commercial products in any way.
10. Investigations / Inquiry
A doctor may have to face investigation or inquiry regarding a patient he/she has treated when a complaint has been lodged against the doctor. Sometimes a doctor may have to serve as a member in such an investigation or enquiry sometimes against another doctor. In such cases a doctor must.
a) Fully cooperate with the legitimate inquiry procedure and reveal all the information that are sought for. If a patient has complained then the code of confidentiality does not apply while giving information about the patient before the inquiry committee.
b) Should be calm, considerate, thorough and without having any bias or preconceived notions when a doctor has to conduct an inquiry against another doctor or any person of the medical profession.
c) Doctor has the right to refuse any information if the doctor has reasonable grounds to believe that the evidence given in an enquiry may lead to criminal proceedings against him.
11. Complaints
How a doctor behaves when a complaint has been lodged against him/her also shows his professionalism.
a) Doctors must realize that a patient has legitimate right to make any complaint against a doctor in legitimate forums.
b) Doctors should cooperate fully to resolve the issue and give prompt open and constructive response.
c) Doctor should ensure that the treatment of such a patient is not compromised due to complaint and it is advisable that such a case is referred to another doctor.
12. Curriculum vitae
While submitting a curriculum vitae to any place a doctor should ensure that only correct, truthful verifiable information is given without any misrepresentation about qualifications, experience and position.
13. Professionalism and cultural sensitively
We are living in s multiethnic and polycultural world. Patients come from various ethnic, religious, linguistic and cultural backgrounds. In such a situation a professional doctor must.
1. Show respect for all the cultures and acquire knowledge of culture, cultural needs of the patients the doctor serves.
2. Never discriminate patients on the basis of cultural differences such as caste, creed, language, religion and ethnic origins.
3. Should respect and try to understand minority cultures
4. Be aware of dietary habits dictated by culture and religion and advice the patients on that basis. For example doctor should know that Hindus don’t eat beef, Jews and Muslims don’t eat pork, Muslims eat only halal meat according to religious customs. In addition a large section of patients may be culturally vegetarian (in distinction to adopted vegetarianism). The doctor’s advice should take these factors into consideration.
14. Professional conduct in case of adverse situations
At any stage of management of a patient unforeseen complications and events can occur. The need of explaining risks and likely complications by the doctor has already been emphasized (see sections of truth telling and disclosure and informed consent). In the event of development of adverse reactions and complications a professional doctor must.
1) Understand and acknowledge that adverse events or complications have occurred.
2) Act immediately to address the problem and try to rectify it. In this the doctor must seek necessary help and advice.
3) Try to provide prompt relief to the patient’s distress.
4) Explain to the patient promptly and fully about the adverse occurrences and without alarming the patient should explain the measures taken to combat and rectify them along with the short and long term consequences of the occurrences.
5) Discuss with relatives and legal guardians in case the patient is unconscious or incompetent .
6) Inform the relevant authorities and complete all necessary official formalities.
15. Professional conduct in closing practice.
While closing practice in one area or retiring the doctor should try to give an advance notice and try to help the current patients by referring and handing them over to other doctors along with their records.
16. Working with professional colleagues and other healthcare personal
During their working life doctors have to work with doctors and other healthcare personals. A doctor is expected to maintain good professional relations with other doctors and various categories of healthcare providers. In a team of different healthcare providers the doctor is at the apex of the pyramid. The doctor not only has to lead and guide but has to be capable of taking the whole team forward together. This is necessary in the interest of providing best care to the patient.
Professional conduct in this situation demands that
1. A doctor shall be courteous, cordial, considerate and understanding towards fellow doctors and all other professional co-workers.
2. The doctor shall realize that modern medicine is essentially a teamwork and learn to work in a team both as a simple member as well as a leader.
3. The doctor shall acknowledge the contribution made by the each fellow doctor and other members of the healthcare team.
4. A doctor shall learn to delegate, handover and refer the patientcare duties and responsibilities to his professional colleagues wherever and whenever necessary and while doing so shall safeguard the best interest of the patient.
5. Senior doctors shall take special care to instruct, teach, appreciate and encourage their junior colleagues and other members of health case personals under them and shall ensure safe working environment and safe working hours to them so as to avoid stress and fatigue which may adversely affect good care of the patients.
6. The doctor shall always be truthful, transparent and just in their dealings with other doctors and healthcare professionals.
7. A doctor shall not hesitate to point out any lacking or lapse on part of their colleagues and co-workers and help them to rectify such shortcomings so that patient care is not jeopardized.
8. Doctors shall be clear and transparent in the financial matters with their colleagues and co-workers.
9. A doctor shall not hesitate to report any serious ethical lapses and serious lack of competence amongst their colleagues and other healthcare provides which are not rectifiable at his/her level to the appropriate authorities. This needs to be done because these can seriously jeopardize safety of patients.
10. During working a doctor shall constantly endeavour to minimize the risks that are inherent in medical care and take all the steps to protect the fellow doctors, all other healthcare workers and himself from the risks. Similarly the patients should also be protected from the risks that are identified.
A doctor may have to treat another doctor or members of other health care provider groups. A doctor should treat such patients exactly in the same way other patients are treated. It is also the professional duty of the doctor to report to the authorities if such patients are seriously debilitated and are no longer capable to provide safe and effective health care to their patients
17. Professional conduct of doctors in situations where there are conflicts of interest.
There are situations where conflicts of interest may arise between doctor, patient and a third party. Such conflicts may hamper the judgment and performance of doctors. Such conflicts can arise due to financial, profession or personal reasons. Such situations must be identified, disclosed and appropriate measures taken to resolve such conflicts of interest which may involve referring the patient to some other doctor.
18. Professional conduct of medical teachers
Some of the doctors may take up jobs in medical teaching institutions where they shall instruct, train the next generation of doctors to prepare them for safe and effective healthcare. Such doctors may also partly teach other groups of healthcare professionals. These doctors have a dual duty – that of a physician and treating doctor and that of a teacher. Professionalism in these situation demands that.
1. Medical teachers shall keep themselves abreast of the latest development in medical sciences, theories, practices, skills and research pertaining to their own specialties so as to be able to impart to their students the most advanced knowledge.
2. Medical teachers shall seek to develop the necessary skills, techniques, practices, attitudes and love for teaching that are required of a good and effective teacher. Formal training in teaching methodology is most desirable.
3. Medical teachers shall make use of all modern methodology and teaching aid in their teaching and integrate classroom teaching with the teaching in wards with live patients as teaching materials.
4. Medical teachers shall treat their students with respect and patience and try to instill in their student greatest respect for life, human rights, honourable and ethical practices and for the person of the patient even for those who are dead.
5. Medical teachers shall make clear the role and scope of students in the teaching learning process involving patients. They shall teach the students correct behaviour with the patient and the need of obtaining patients cooperation in teaching activities. Both medical teachers and students (future doctors) should recognize and respect the patient’s right not to consent.
6. Supervision is necessary in the teaching learning process of medical education. During supervision of studies medical teachers should be kind, supportive, encouraging towards their students and shall treat everyone equally and with respect.
Medical teachers shall be honest, objective and constructive in assessing the performance of the students (as well as colleagues where necessary) and ensure that students become competent doctors. No discrimination, favouratism, shall be encouraged and indulged in. Medical teachers shall always provide feedback on performance and provide insight to their students (who may be doctors also) with a view of encouraging better performance.
Part -2 :
Chapter – 5: Medical Negligence
In this chapter you would learn
a. What is Medical Malpractice and Medical negligence.
b. What is meant by competence to treat and how it is acquired.
c. What are the different types of Medical negligence.
d. What are the common situations where a doctor can be held negligent.
e. Punishments a doctor may be subjected to in cases of medical negligence.
Questions and exercises
a. List the conditions or situations where a treating doctor can be held negligent.
b. List some examples of acts of omissions and acts of commissions from what you have covered till now in this book.
c. What are the types of medical negligence a doctor may commit.
d. Why medical negligence occurs – give your own reasons after going through this chapter.
Exercise
Try to search the net for some landmark cases of Medical negligence and discuss them with your friends and ethics teachers.
Introduction : Medical Malpractice – Medical Negligence
In today’s world doctors and common citizen alike are quite familiar with the words – ‘medical malpractice’ and ‘medical negligence’. These words denote a vast and a complex subject that is closely related with law. The essence of medical malpractice and negligence is serious shortcomings in the process of providing healthcare by the doctors. Medical negligence is considered as a type of medical malpractice along with medical misconduct or infamous conduct.
The Oxford Medical Dictionary tells us that the word malpractice originates from the Greek word ‘Praxis’ which means an action. Malpractice therefore denotes a bad action – meaning ‘illegal, corrupt or careless professional behaviour’. This definition of malpractice gives us a fair idea of medical negligence. Let us see how medical negligence can be defined.
Defining medical negligence
Medical negligence has been defined in various ways. Some of the legal definitions are quite complicated. In a simple way professional medical negligence of a doctor can be defined as lack of reasonable degree of competence, skill, care or acts of omissions and acts of commissions such as willful negligence, rash and reckless action on part of a doctor in the treatment of a patient that leads to bodily injury, disability of loss of life of the patient.
The Taber’s cyclopedia Medical Dictory tells us as follows
Medical Negligence is defined as absence of reasonable care and skill, or willful negligence of a medical practitioner in the treatment of a patient which causes bodily injury or death of a patient. Negligence is defined as doing something that one is not supposed to do, or failing to do something that one is supposed to do. In other words negligence is defined as the failure to act as a reasonably prudent person with the same knowledge, experience and background would do under similar circumstances, this failure to act causes injury or damage to a person. There are four elements of negligence: duty owed, breach of duty or standard of care, proximate cause or causal connection (between the breach and damages) and damages or injuries.
Defining some of the terms
The terms used above can be explained as follows.
a) Act of omissions – means not doing certain things which a reasonable doctor under the circumstances would do.
b) Act of commission – means doing certain things which a careful and reasonable doctor under the circumstances would not do
c) Willful negligence – means neglecting a patient willfully
d) Rash action – means when the consequence of the action is known to the doctor but the doctor foolishly thinks that such consequences shall not occur as a result of the act.
e) Reckless action – means ice when the doctor knows the consequence of the action but does not care whether the result occurs from the act.
The acts of omissions, commissions, lack of competence all these amounts to a breach of duty on the part of the doctor to treat the patient safely. So, one can say that breaches of duty that leads to damages suffered by the patient which can be distress, bodily injury and damage and even death and thus amounts to Medical negligence.
Competence to treat : A doctor must be competent to treat a patient
Competence on part of a doctor is one of the very core topics of medical negligence. Whenever there is an allegation of negligence against a doctor invariably one of the first question that is asked is whether the particular doctor was competent to treat that patient or not? Has the doctor done something for which he or she was not trained, or did not have the required degree, certificate and skills? Therefore the question of competence needs to be discussed a little.
A doctor must be medically, scientifically and legally competent to treat a patient. Lack of competence on any count may make it possible for a doctor to be accused of Medical negligence in treating the patient. Competence to treat is considered as a central theme in the sphere of Medical negligence.
When a patients comes to a doctor and the doctor accepts to examine and treat the patient – Doctor Patient Relationship is said to be established between the two. An important legal aspect of such an relationship is that is that it can also be called a ‘contract’ between the doctor and patient. This contract is for examination, diagnosis and treatment with an intention to heal the patient. It implies that the doctor will manage and the treat the patient with reasonable skill and competence. This contract does not impaly that undertaking the treatment is a guarantee to heal. It is not. But it is a solemn commitment that he doctor shall manage the patient with knowledge, skill, care and competence. Though the contract does not guarantee cure, still it invites moral, ethical and legal responsibilities on part of the doctor.
The society also recognizes this contract. It is also a contract of the doctor with the society too. And therefore the society gives license and autonomy to the doctor to practice the art of healing as a competent professional.
Therefore you must realize that ‘COMPETENCE TO TREAT IS OF CENTRAL IMPORTANCE’ in Doctor patient relationship and also in the matter of Medical Negligence. If a doctor is not competent to treat the treatment is not only illegal. It is totally unethical too.
“Every Doctor who enter into the medical profession has a duty to act with reasonable degree of care and skill. This is what is known as ‘implied undertaking’ by a member of the medical profession that he would use a fair, reasonable and competent degree of skill.”
The famous and oft repeated quote from ‘Balam vs Iriern Management Committee’ (1957) underlines the question of competence and duty.
The Supreme Court of India held that when the contract is established between doctor and patient, the doctor owes the patient certain duties. These are duty of care in deciding whether to undertake the case, duty of care in administration of treatment to give and the duty of care in the administration of that treatment. The apex court also held that a breach in any of the above duties can give a cause for medical negligence for which the doctor shall be liable. (Mittal vs State of Uttar Pradesh).
It goes without saying that to perform these duties to avoid medical negligence the professional doctor has to be competent.
How competence to treat is acquired
Competence to treat is determined by various laws, rules and regulation which determines medical education, registration and licensing of doctors in each country. It usually includes.
a) A medical student shall have a formal medical education from on approved medical school. The eligibility to study medicine, the course content or curriculum, the standard of training and assessment should all be determined by a competent national authority.
b) The degree awarded should be nationally recognized and registered by appropriate national authority. Usually these are professional councils constituted by law with powers of registration and medical governance.
c) The doctor shall acquire the necessary skills required for the degree he/she possesses by training and supervised work.
d) The doctor should continuously upgrade his /her knowledge, skills and competence during the working life by approved means.
e) In addition to possessing the degrees and licence (registration) required by law, a doctor should possess all the professional, ethical and humane attributes already discussed in this book.
Only when these conditions are met a doctor acquires competence to treat a patient.
Type of Medical Negligence
Depending on the result of medical negligence the charge of medical negligence is sometimes graded. Such grading is usual both for ethical and legal matters.
a. Civil negligence – When milder degrees of medical negligence occurs without causing any permanent disability, or death of the patient, then it is legally termed as a civil liability.
i. It usually occurs due to lack of care, simple errors of judgment, accident, simple acts of omission etc.
ii. It still can be considered as a misconduct and appropriate ethical action, fines and some penal action can be taken.
b. Criminal negligence – Though it is quite difficult to define legally it usually denotes high degree of medical negligence- which occurs due to
i. Serious lack of competence – both legal and professional, or
ii. Serious lack of care resulting in grave mistakes during treatment or serious acts of willful rash or reckless action during in treatment, that results in serious, permanent disability or even death of the patient.
iii. In case of criminal negligence a doctor is usually prosecuted by one of the organs of the state.
One must also try to define what is meant by reasonable skill which is expected of a doctor and for lack of which a doctor can be held to the negligent.
Reasonable skill means the skills that an ordinarily competent person shall ordinarily exercise in a similar situation in the profession. So the basic minimum skills that are required in a particular medical situation are called reasonable skill. Jurists have held that it is not necessary for every professional to possess the highest level of expertise in that branch which he/she practices. Doctors who profess to exercise a special skill should also have the basic or ordinary skills of his profession and speciality.
Some of the common situations where a doctor can be held negligent
It is not possible to list all the situations where a doctor can be held negligent. It would be too exhaustive. Further the question of negligence is situation specific also. The list below gives just a sampler of negligence. A doctor may be held negligent for -
1. Not possessing the requisite skills that a doctor has professed to have possessed.
2. Not exercising reasonable care and competence in exercising skills the doctor has professed to have possessed or doctor does possess.
3. Failure to take adequate and reasonable precaution.
4. Improper diagnosis. This may be as a result of not doing investigations or procedures that were required.
5. Performing procedures and reporting the results for which the doctor is not trained.
6. Causing surgical injuries – injury to organs/nerves/ blood vessels during surgery – which should not have happened.
7. Objects left within the body – leaving of sponges, towels, small instruments within the abdominal cavity or other parts during the course of surgery.
8. Adverse reactions caused by improper, injudicious use of drugs and even when such drugs were correctly used not preparing the patient, or not taking adequate measure beforehand.
9. Failure to take informed consent before haperdous or anaesthesia or chemotherapy where the patient had developed untoward complications can also constitute negligence.
10. Improper transfusion – mismatched blood transfusion, failure to identify, remedy or manage the reactions of such transfusions early, wrong transfusion, over transfusion etc.
11. Operation or other interventions on a wrong part of patient. For example right eye was to be operated but left eye was touched.
12. Mistaken patient identities.
Negligence and Misconduct
All cases of medical negligences are considered as misconduct or infamous conduct on the part of the treating doctor (see chapter on misconduct). For such negligence amounting to misconduct there can be penalties also.
Punishment for Medical Negligence
A doctor held to be negligent can be tried and punished in three kinds of forum and these can go an simultaneously. Therefore a doctor must be very careful to avoid such situations.
Courts of laws can try the cases of negligence either in a civil court or criminal court defending on the quantum and seriousness of the charge. If found guilty a civil court usually awards damages to the patient but imprisonment is also not impossible. A criminal court tries serious cases of negligence under criminal law usually where disability or death of the patient has occurred, where the negligent doctor has been held to be ‘rash’ and ‘reckless’ as well. These are very serious matters and a criminal court tries the doctor under various sections of the criminal laws of the country and can punish with long imprisonment, fines or both.
The second forum which tries the doctor for negligence is consumer courts established under laws specific to countries. They usually establish deficiency in service and negligence and award financial compensations to the patient.
In addition to these legal courts a negligent doctor may be investigated by professional registering and regulatory authorities which have disciplinary power. These are usually the Medical Councils of a country established by law but may be other authorities also. These bodies usually take up such cases on complaint and rarely suo moto also. Here the doctors conduct is examined ETHICALLY – and determine the questions of professional competence, exercising of skills, questions of negligence and medical misconduct. When these are proved the regulatory authorities can punish a doctor by
1. Issual of warning, censure
2. Suspension of license (or registration)
3. Permanent cancellation of license to practice (or registration for most severe offences.
Medical students and young doctors would do it well to try to remember these words regarding medical negligence throughout their student and professional life.
Part -2
Chapter - 6 : Professional Misconduct
In this chapter you would learn
1. What is meant by the terms professional misconduct and infamous conduct
2. How and when doctor can be accused of committing a medical misconduct.
Questions an exercise
a. Try to list the situations which according to you constitutes medical misconduct of a treating doctor.
b. Identify some typical situation in medical practice such as advicing for an operation etc and try to identify areas around it where a doctor may commit a medical misconduct.
I. Introduction : Medical Malpractice and Professional Medical misconduct
Professional Medical Misconduct is considered as another form of Medical Malpractice. It is a very serious subject and all the medical students and young doctors should know what it is and what constitutes misconduct. Some authorities have further divided medical misconduct into two varieties (1) Medical misconduct and (2) Infamous conduct while many discuss them under one heading - medical misconduct.
II. Defining medical misconduct.
Two landmark decisions of British courts have sought to define what constitutes professional medical misconduct and infamous conduct of a doctor. Thus medical misconduct has been defined as follows “the medical men in the pursuit of his profession, has done something with regard to which it would be reasonably regarded as disgraceful or dishonourable by his professional breathren of good repute and competence” (Allison vs General Council of Medical education & regulation).
Infamous conduct has further been defined as “infamous conduct meant serious misconduct judged according to the rules written or unwritten which governed the profession (Rex Vs General Council). Both these judgments are quoted from Mehta’s Text book of Medical Ethics.”
In this book we have discussed about the code of conduct a doctor is supposed to follow during his professional life. The violation of the provisions of the code of conduct by acts of omission or commission constitutes medical or professional misconduct which renders the doctor liable for disciplinary action.
The codes of ethical conduct is usually issued in the country by Medical Regulatory Authorities constituted by law such as Medical Councils. Sometimes the Health Ministries or other authorities determined by Government may issue these codes. Sometimes these codes are recommendations and may not have the force of law. Even then these codes are to be followed by the doctors of the country and their ethical conduct or otherwise is still determined with the help of these recommended codes. But in some countries the codes of ethics are issued as regulations under an act. Then they have the force of law and are binding on the doctors. In India the ‘Professional conduct, etiquette and ethics regulations 2002 of Indian Medical Council is such an binding regulation whereas the code of conduct for doctors in Australia is still a set of recommendations.
If you just go to the contents page of this book you will see that from the 3rd chapter onwards to the previous chapter the ethical conduct a doctor is expected to follow during his active professional life has already been laid down. Violation of any of these by acts of omission and commission by the doctor can be considered as misconduct and if serious, as an infamous conduct. Misconduct also includes medical negligence discussed in the last chapter and therefore there is naturally some overlap between the two discussions.
The outline of penalties for a medical misconduct has already been discussed in the chapter of medical negligence.
Situations where a doctor can be alleged for misconduct
Violation of any of the ethical code of conduct can result is a misconduct. Each code may have some country specific provisions in the code; the violations of which may be considered as misconduct. For example in India the violation of health related acts are considered as violation of the code and ethical misconduct.
Usually the following specific violations are considered as misconduct.
1. Obtaining registration / license to practice fraudulently.
2. Fraudulently practicing the profession of medicine beyond its authorized scope. (This applies not to quacks but to basic registered medical practitioners – who may lay claim and practice as a specialist when they are not).
3. Adultery and sexual improper conduct by abusing the professional position. These may include sexual impropriety, transgression and violation.
4. Practicing medicine with gross incompetence.
5. Practicing medicine when the ability to do so is impaired due to drugs, alcohol, physical disability, mental or psychiatric disease.
6. Refusing to attend an emergency case during duty hours.
7. Refusing to provide professional treatment to a person on consideration of race, religion, caste, creed, colour, ethnic origin, language or social status.
8. Aiding, allowing, abetting a person who does not possess a legal license to practice to practice and treat patients.
9. Performing unauthorized or illegal medical procedures.
Sex determination tests for unborn child and non medical termination of pregnancy resulting in female foeticide are strictly banned in India by law. Performing such procedures by doctors would constitute a very serious medical misconduct.
10. Signing medical certificates, medical reports, any other document including biodata wrongly, falsely, fraudulently by misrepresenting the facts constitute very serious misconduct.
11. Breaking rules for medical advertisement, publication, research etc.
12. Medical negligence
13. Conviction by a court of law for any crime.
These are only some of the common examples of medical misconduct. These list of examples cannot be an exhaustive one. You must remember that such violations of code as breach of patients confidentiality and privacy, behaving rudely with patient, failure to show care and compassion, violating human rights of patient, willful discrimination, failure to obtain informed consent, non disclosure – in fact all that is put under different codes can constitute medical misconduct which may invite various disciplining steps and penalties as already described.
You must now realize that it is much more easier to become a doctor, even a top specialist in the field, but it is really very difficult to practice medicine with honesty, sincerity, care and compassion in an ETHICAL way as every doctor is expected to do. If this short book makes you aware as to what you need to do and what you should avoid doing to become a ‘good’ and ‘ethical’ doctor the purpose of this book is served.
Part -2 : Ethics in clinical practice
Chapter -7: Ethical issues faced by medical students
Medical students have consciously chosen a profession which is guided and largely governed by the principles of medical ethics. The postgraduate medical students are already full fledged registered doctors whose professional life is regulated by ethical codes, rules and regulations of different countries. The undergraduate medical students are ‘doctors in the making’. The students therefore must realize that they should make extra effort to learn about medical ethics. The medical students shall also note that all the historical codes of medical ethics like the Hippocratic oath, oath of Charaka apply to both the learners as well as doctors. It is always beneficial for medical students if they learn about the principles of medical ethics during their undergraduate days before the initial registration.
The medical students examine patient during their ward postings. They take history, do physical examination of the patient and they also get to see the bed headed ticket and can access other patient data including investigation reports. Thus they have quite a lot of information regarding the admitted patient. The medical student must protect all these information to protect the confidentiality and privacy of the patient and should not discuss these informations loosely, nor disclose such information to anyone including relatives of the patient. The ethical principles of confidentiality should be observed by medical students also.
The patient may ask a student about the diagnosis, prognosis of the conditions they are suffering from. The medical student must realize that they may not be competent enough to answer these questions. In such situations, the medical students should not try to divulge anything but take help of senior doctors of the ward.
Respect for life in general and the patient in particular is another important ethical issue for the medical student. The medical student starts his/her education by dissecting dead bodies and using bones and other tissues for learning. They must remember that the dead bodies belonged to living person.
The student should show respect to the dead. Similarly the medical students should always show respect to the patients and should cultivate qualities of kindness, care and compassion from their student days.
The rights of the patient is another area a medical student must familiarize him/her self with. They should uphold the rights of the patient in all situations.
The medical students shall note that all the medical codes enjoin the students to show proper respect to their teachers. In ancient days a student could learn the art of medicine only by staying with their teachers, working for them and helping them. Medicine is a subject, in the learning of which requires the active participation of the teacher. It is the ethical duty of a medical student to show proper respect to their teachers.
In many countries senior medical students are included in the treating team for patients. Under such situation the medical student is more immediately related with the ethical issues of patient management. They must show exemplary care, caution and professional behaviour under the circumstances.
As already stated, the undergraduate Medical student is ‘a doctor in the making’. The ethical issues they face are similar to that of doctors. They must therefore try to acquire the ethical values from their student days so that in future practice they do not face and problems.
Part -2 : Ethics in clinical practice
Chapter – 8: Relationship with the Pharmaceutical and health industry
Introduction: Interrelation between doctor and industry
There exists a close interrelationship between the doctor and the pharmaceutical and other health sector industries.
The industry invests in development of drugs, instruments, materials, diagnostic techniques, therapeutic measures. All these have to be first tested in actual hospital settings on human patients to determine their safety and efficacy. Then these have to be sold in the market. In all these three phases of development, testing and selling in the market the industry requires the help of the knowledge, and experience of the doctors. Physicians acceptability ensures sale of the products in the market.
The industry on the otherhand provides necessary funds and facilities for medical research and encourages the doctor for it. Such funds may be given for development and testing of an existing drug or product or for development of newer technologies. The industry further supports medical conferences, seminars and continuing medical education programmes for free exchange of ideas and advancement of medical sciences. All these benefit the doctor academically and also benefits the healthcare system and help the patient.
1. Conflict of Interest - With increased private investment in the health sector and commercialization of health as a whole, there is also increased competition between pharmaceutical and medical implement manufacturing companies. This has led to emergence of certain new ethical issues for the doctors. Competition among the laboratories, imaging and investigation setups also have contributed to this. In such a scenario a doctor should be careful to maintain a professional and ethical conduct in their relationship with pharmaceutical and other healthcare related industries.
This interrelationship between the doctor and the industry also create certain situations where there is a conflict of interest between the two which can ultimately affect the care of the patient and also the reputation of the doctor individually and the profession collectively. These situations can be listed as follows
a) Medical conference – Doctors shall not individually receive either cash, air tickets, hotel accommodation etc. for attending medical conferences from the pharmaceutical and health industry. The professional associations however may receive grants for organizing scientific endeavours and they may make provisions for travel bursaries, hotel accommodation etc for their members. But these should be always publicity disclosed and done in a transparent manner.
The doctors receiving sponsorship through the associations should ensure that sponsors such as pharmaceutical companies have no influence in scientific proceedings and the content, presentation, choice of lectures or publication of results.
b) Gifts – it is a well known fact that many pharmaceutical and health care companies seeking patronage for their products offer the doctor many costly gifts, travel and vacation facilities, foreign trips in the guise of attending conference, cash money and other facilities. Doctors must realize that beyond the classical gift of an ordinary pen and pad all others are unethical. A doctor may accept only gifts of nominal value and that too without any obligation to promote or prescribe any particular product.
2. Research – A doctor may carry out research funded by a commercial entity. In doing so a doctor has to ensure that all legal, medical and ethical guidelines governing medical research in the country are scrupulously followed. The source and amount of funding must be publicity disclosed and the doctor should have full freedom to publish the results of such research openly.
3. Affiliation – A doctor entering into any kind of affiliation with the industry even in advisory capacity, must ensure that the professional integrity or patients interests are not compromised and further that such affiliations are transparent and fully disclosed.
Each doctor shall be very careful in their dealings with the pharmaceutical industry, specially at the age of globalization. They must be firm to refuse the lure of unethical gratification and withstood the inappropriate promotion practices of the pharmaceutical industry. The industry should patronize only the medical institutions and professional associations – and not individual doctors.
Part -2 : Ethics in clinical practice
Chapter – 9 : Ethical Issues related with healthcare in the private sector
Introduction
With Globalization there is rapid development of the private sector in healthcare all over the world, specially in the developing economics. Large corporate houses are increasingly investing huge sums of money in developing modern hospitals. In the health education sector too, increased number of medical colleges and teaching institutes for other categories of health care providers are fast developing. The private sector now has a considerable presence and contribution to the healthcare scenario of the countries.
The private sector healthcare institutions are bringing rapid modernization, advanced technology and international level facilities. They have also brought new and more financially rewarding career opportunities to the doctors too. However the private sector, as it is primarily driven by the motive of profit, is also making healthcare quite costly. In majority of populous and developing countries the government or the public sector healthcare facilities shall continue to have a great role to play in the forseable future. This is a fact, a reality, all doctors should recognise, because, from such reorganization shall come the realization that this vital sector of health care should be strengthened and developed in the interest of the health of the patients of the less advantaged socio-economic classes.
The rapid development of the private sector in healthcare has also brought newer ethical issues to the forefront and ethical dilemmas for the doctors. A doctor should be fully aware of these. The doctor must also realize that the ethical principles he/she has to follow are the same whether the doctor works for the private sector or the public sector. The ethical issues that a doctor has to face in the private sector are summarized below:
1. Imposition of restrictive policies
Private management may try to impose certain policies on the doctors working in these institutions. These policies may not only restrict the doctor’s freedom but also the doctor’s autonomy to practice. Further some of these policies may curb the rights of the patients too. In such situations it is the duty of the doctor to point out that such policies are contrary to professional autonomy of the doctors and rights of the patient and they should take steps through their professional associations and other legal platforms to set the things right.
2. Pressures by private management
The management may put pressure on the doctors to perform more so as to earn more revenue and profit for the hospital. They may demand more rapid turnover of patients, more investigations, more procedures, more operations – all with the motive of earning profit but in the guise of improving efficiency. The management can also tempt the doctors with financial package, cuts on the earnings and other allurement in the name of incentive. All these may create an unhealthy atmosphere, jeopardize professional freedom and standards of doctors, create unwanted ethical problems for them and at the same time seriously compromise patient’s health (by causing early discharge in the name of increasing turnover) and lead to financial exploitation of the patients too. The doctors should be aware of these pressures.
3. Divided loyalties
Doctor working both in the public sector and private sector face ethical problems too. Where should the loyality lie. Most such persons are primarily employed in the public sector and also work in the private sector, sometimes legally, after their designated duty hours. Yet many a times their loyalties seem to be with the private sector. It is ethical to work in such a way only if it is expressly allowed by the government to do so. The doctors are expected to follow the conditions of their required jobs in both places.
4. Duty of the doctor
When the private management imposes restrictive policies that goes against the professional autonomy of doctors or the right of the patients or when increased pressure to perform jeopardize professional working atmosphere and patient safety
a) The doctor shall bring such policies and directives to the notice of the management and try for their rectification through friendly and open discussion with the management. The doctor shall also point out their ethical difficulties to follow such policies. In case the management still refuses the doctor may take steps through their professional associations or other legal platforms to set things right.
b) The doctor shall always try to uphold the high ethical and professional standards demanded by the profession.
c) The doctor shall never be a party to exploitation of helpless patients.
d) The doctor shall be guided by ethical considerations in accepting financial packages and incentives and ensure that these do not jeopardize doctor’s or patient’s rights.
Part -2 : Ethics in clinical practice
Chapter – 10 : Ethical issues related to reproductive health : Issues of beginning of life.
Introduction
Ethical issues related to reproductive health can also be termed as ethical considerations in the beginning of life situations.
The beginning of life situations present some unique ethical dilemmas to the doctor. There are different views as well as controversies regarding many of the issues of this situations. A young doctor should have a broad idea as to what are the issues and what are the duties of the doctor. Different countries have different outlook and laws regarding these issues also. What the doctor needs to understand is that these issues are essentially ethical in nature.
In these ethical issues of reproductive health or beginning of life situations the doctor is also primarily guided by his religious, social and ethical beliefs and convictions which may be different from those held the patient. The doctors must be careful not to try to impose their own beliefs and conviction on their patients or discriminate the patients for holding different beliefs.
The doctors, specially those doctors who may be serving under Government, have to follow and implement Government laws, rule, regulations and directives on these areas. Sometimes the personal beliefs of the doctor may come into conflict with the policies of the government. However, all doctors must respect and follow laws of the land. Further they must refer to and follow the guidelines laid down by the professional doctors associations of the country which not only serves as a convenient guideline but also helps the doctor in forming opinion in these issues. In addition the doctor should follow the highest standards of professionalism that are necessary in these special circumstances.
These issues can be briefly stated as under.
1. Contraception – Contraception, both male and female, are measures that are used to prevent unwanted pregnancies. It is now universally recognized that the women has the right to avoid unwanted pregnancies. But there is difference of opinion as to what kind of birth control measures are to be adopted. The Catholic church allows only the natural cyrcle and safe period. Whereas most of the major countries in the world are actively advocating various family planning or contraception measures. It is the duty of a doctor to provide advices on contraception, when requested, to both married and unmarried persons of either sex. In doing so the doctor has to go by the legal and officially approved measures prevalent in each country. The doctor should always keep the welfare of the patient as the first consideration and be guided by professional and ethical codes.
2. Assisted reproduction – When normal conception and reproduction is not possible couples or even individuals may opt for different techniques of assisted reproduction which can include artificial insemination, in vitro fertilization, embryo transfer, Surrogate motherhood or substitute gestation. In all these matters the doctor should be guided by his own ethical considerations, laws and professional guidelines.
3. Medical termination of Pregnancy or abortion – this is also a very controversial issue worldwide. At the heart of the issue lies the question – when does life begin? Whether life begins at the moment of conception in utero or only with the live birth of the child – or when the fetus attains maturity to be able to survive if born. Those who subscribe to the first contention resolutely oppose abortion. For the doctor and also for the patient alike ‘it is a matter of individual conviction and conscience that must be respected’ (W.M.A). The doctor shall recognize that in this subject there are different opinions and these are to be respected. Further the doctor shall scrupulously follow the law of the land as regards abortion or medical termination of pregnancy.
In termination of pregnancy the main issue is the conflict of interest of the mother with the interest of the unborn child. It is usually held that when the life and health of the mother is at stake due to any medical condition by the continuation of pregnancy, then it is the primary duty of the doctor to try to save the life of the mother by deliberate termination of pregnancy. Most of the countries generally subscribe to this view. But there may be exceptions as the controversies and issues referred above may come to play their part in this situation also. The doctor must realize that ‘It is not the role of the medical profession to determine the attitudes and rules of any particular state or community in this matter’ (WMA). Therefore it is the duty of the doctor to
a) Protect the patients, maintain respect for human life, and safeguard the rights of the physician within society.
b) When law of the country provides for medical termination of pregnancy or therapeutic abortion the ethical duty of the doctor is to ensure that within the parameters of law, the procedure should be performed by a doctor competent to do so and it should be done in premises approved by the appropriate authority.
c) If the doctor is not allowed by his personal convictions to perform the procedure, he/she may refer and transfer the case to the care of a competent colleague so that the patients interest and continuity of care is not jeopardized.
4. Prenatal genetic screening – It is done for two reasons.
a) To detect whether the foetus has severe genetic abnormalities.
b) To determine the sex of unborn child.
In the first case a doctor should be very careful to advice and do such genetic screening. These should always be done only in specialized and approved centres by competent people. A general doctor should refer such patients who need or demand such tests to the right person and right place and follow the laws in this regard. It is necessary to do so because on the result of such tests depends the decision to continue the pregnancy or not.
In the second case prenatal sex determination may be banned in certain countries like in India. Because the results of such case may be used for female focticide. The doctor should be guided by law and his/her own ethical concerns.
5. Whether to continue the efforts to prolong life of severely compromised neonates is another ethical issue the doctor has to face. In this situation he/she should follow the laws and procedures prescribed.
6. Research – Production of embryos for stem cell research and research for other measures of assisted reproduction are other areas of ethical concern a doctor has to face in the present times. In such situations the doctor undertaking or participating in such research shall only do so if he/she is competent to do so and that too after ensuring that such research has fulfilled all the legal and ethical rules and laws prescribed in the country.
The scope of this hand book do not allow us to go into the depth of these new and complex ethical problems that scientific advance has brought. It is possibly important to know that they exist.
Part -2 : Ethics in clinical practice
Chapter – 11 : Ethical aspects of treating patients with HIV/AIDS
HIV and AIDS have brought a whole range of ethical questions and dilemmas before the doctor. All doctors should recognize that HIV & AIDS is a relatively new phenomenon and because of its seriousness and because the questions of sex and drug abuse by injection are intimately related with it, there are lots of social prejudices associated with it. Though these are mainly the results of non or misinformation, still they do not make things any easier for the patient. It is therefore necessary that all doctors should learn about this disease thoroughly and play a proactive role in educating the society.
In case of HIV positive and AIDS patients the doctor is supposed to follow certain ethical conducts that are accepted widely. These are -
1. A doctor shall consider the welfare of the patient as the first concern. This apply equally to HIV positive and AIDS patients and the doctor shall attend to these patients with care, kindness, understanding and compassion.
2. No doctor shall refuse to attend and to treat a patient nearly because the patient is HIV positive or suffering from AIDS. To do so shall be considered as a grave misconduct, and a serious violation of medical ethics.
3. No doctor shall refuse to admit, investigate, operate on a patient because of HIV positive status or AIDS. Neither shall they be denied any life saving measure like dialysis, ICU admissions, ventilators etc. The doctors should impress on the authorities to develop such polices and facilities. When such facilities are not available in the working place of the doctor, the doctor shall refer the patient to such doctors or institutions where such facilities are available.
4. If the doctor is not equipped to treat HIV positive persons, AIDS patients and other AIDS related diseases or complications, the doctor shall urgently give whatever preliminary treatment that is required and refer the patient to doctors or centres where such treatment is available.
5. A doctor should take adequate personal protection while treating HIV positive patients and leave no stone unturned to eliminate risk of infection to colleagues, healthcare providers and to other patients. Approved sterilization procedures shall be adopted.
6. In management of HIV & AIDS the doctor shall scrupulously follow the guidelines laid down and measures recommended by the national / local health authorities.
7. The doctor shall maintain strict confidentiality in case of HIV positive and AIDS patients. In this situation the doctor has to follow country specific laws.
8. In some cases it may be necessary for the doctor to disclose the HIV positive status of the patient mainly on following conditions. It is then not only not unethical but desirable too.
HIV positive status of the patient can be revealed to the spouse or sexual partners of the patient if the patient is
1. Unwilling to reveal it himself/herself.
2. When the spouse or the sexual partner or other persons at risk have no other reasonable way of knowing the status of the patient unless told by the doctor.
3. When the patient refuses an offer by the doctor to reveal it.
4. The doctor shall then inform the patient about his/her intention to reveal the information before doing so.
The doctor shall always try to keep himself/herself abreast of the newer developments in management of HIV positive / AIDS patients in the interest of both the doctor and the patients.
Part : 3 – Specific Ethical issues
Chapter - 1 : Ethical aspects of Genetics
Rapid scientific developments in the field of genetics have brought many new and important ethical issues for the doctor. You have already found some mention of these in the various chapters of this book. In this chapter we would like to summarize the main issues.
Genetic advancement has opened the door of many possibilities. It can both cause great benefit as well as harm to individuals. It is the ethical duty of a doctor to see that the benefits are maximized and harms minimized by genetic methods and testing.
a) Maintenance of privacy and confidentiality – Genetic information of a patient is a very sensitive issue. The doctor should ensure that such genetic informations that have come to his/her knowledge are never divulged in an unauthorized way. It is the ethical duty of the doctor to protect the genetic privacy and confidentially of the patient.
b) Family responsibility of the patient – If a patient has a genetic defect or disease and if due to that his/her family members, relatives are at an increased risk of health, then it is the duty of the patient to inform them about it. The duty of the doctor is to educate and convince the patient to do so. If the patient is unwilling to do it the doctor may ask for the permission to do it him/her self. If that is also refused, the doctor has to make an ethical judgment whether to disclose this information or not.
c) Protection of genetic material – Tissue samples and data of the patient can reveal genetic secrets of the patient. Such informations may be used to cause harm, or these can result in the patient facing discrimination from employers, insurance companies etc. The doctor has the ethical duty to protect all these tissues and genetic information of the patient.
d) Genetic counseling and testing – A doctor should approach genetic counseling and testing with great seriousness and care. This should never be done by a doctor who is not trained for these jobs. If the doctor feels the patient requires such services the patient must be referred to qualified counselors and approved centres for genetic counseling and testing. In these matters, the doctor must also follow the laws of the country.
e) Care in ordering genetic tests – A doctor shall exercise sufficient care and judgment in ordering genetic tests. The doctor must also realize that there are serious limitations to the predictive ability of genetic tests specially for adult onset conditions – say such as breast cancer. These reports should be used with great caution.
f) In genetic testing informed consent is must. The doctor should never advice or conduct a genetic test without obtaining informed consent.
g) Prenatal genetic testing – Prenatal genetic testing is done for two main reasons. The first is to know whether the unborn child is suffering from serious genetic or chromosomal abnormality or not – and whether if such a child is born it would have a healthy life; although genetic testing may not be able to give totally accurate results in many cases. The second reason is to know the sex of the unborn child. The doctor must realize that in both these cases the end result may be medical termination of pregnancy or abortion. Therefore the doctor has to be very careful and should follow strictly the laws of the land. For example prenatal sex determination is banned in India to prevent female feticide. So the Indian doctor should not do such genetic testing to determine the sex of the unborn child.
h) Genetic testing and insurance – Medical insurance companies may refuse to insure people who have genetic diseases or even who have genetic predisposition to develop certain adult onset diseases like breast cancer. Even if such tests are carried out in midlife and some genetic abnormality is detected, the insurance companies may refuse to insure further. This may became a very great problem in countries where healthcare is dependent on medical insurance. Sometimes the insurance companies may ask the treating doctor of such information. The doctor must realize that such genetic information about patients should not be disclosed to anyone including insurance companies without the sanction of law. To do otherwise would be unethical.
i) Inappropriate use of genetic testing – Certain types of genetic testing has the potential for misuse. One common example is paternity testing, commonly known as DNA fingerprinting test. Such testing can be used to establish identity of a patient too. These tests and their results can be commonly misused. Therefore the doctors shall be very careful in ordering or doing such tests and shall protect the results of such tests and shall do it by following the provisions of the law of the land very strictly.
Never ethical issues in the realm of medical genetics are emerging everyday due to rapid development of scientific knowledge in this sector. For example the questions of patenting a gene, ownership of collected genetic material, research and commercial use of such material etc are the newly emerging areas where the doctor may be intimately related. In many of these areas the guidelines or laws are not in place as these are new frontiers of science. In all these situations a doctor has to be very careful and must be guided by the time tested ethical principles of doing maximum good, causing no harm and maintaining confidentiality, patients rights and sanctify of life.
Part : 3 – Specific Ethical issues
Chapter - 2 : Ethics of transplantation and organ donation
Organ transplantation is one of the major medical advances of the last century. The past years of the present century has seen further refinement and also development of newer techniques like stem cell technology, foetal donors and tissue engineering. It is a great medical advance because it provides the gift of life to a person with terminal failure of vital organs.
The whole process of transplantation requires participation of multiple agencies. Apart from the donor, the patient – who is the recipient and the doctor who performs the transplantation, the hospital where it is performed, relatives, other human beings, law, society, religion, government – all participate in the process. The demand for organs is always far greater than that of supply resulting in long waiting lists and waiting time which may even lead to the death of the patient.
In every step of this life saving procedure the doctor has a great role to play. Each step presents to him some unique ethical issues which we would try to discuss below.
I. Ethical Issues in organ donation
a) Live donation – An organ or tissue can be donated by a live person. The person can be related or unrelated to the patient. A doctor must follow the laws of the land in both related and unrelated transplantations. Live related donors, specially identical twins give best results in transplantation.
It is the ethical duty of the doctor to correctly advice the patients and the relatives in this regard and to ensure that a proper informed consent is obtained for the procedure. The doctor must further ensure that the donor is a mentally competent person and not someone who is not mentally competent or a child who may be not be able to fully comprehend the consequences of donation.
Organ transplantation from unrelated live donors presents many medical and ethical problems. Medically speaking the results of such transplantations may not be equally good like related donors with a common gene pool. Further unrelated organ transplantation may encourage such practices as sell of organs and exploitation of the poor people to gather organs for the rich patients. Agents and touts find out poor people in need of money and entice them to sell their organs. Doctors also sometimes get involved in such nefarious activities. Such unrelated donor transplantations may be banned or restricted by law in most of the countries of the region and doctors must be very vigilant in such cases.
In countries where such procedures are allowed, it is the ethical duty of doctors to obtain informed consent from the donor and to ensure that the donor’s rights are fully protected. They must also ensure that donors are not duped or exploited by unscrupulous touts or agents. The doctor should follow the legal provisions of the country in letter and spirit to avoid any legal and ethical problems.
It is the ethical duty of the doctor to take care of all live donors during the process of donation and afterwards and such persons are also to be treated by the doctors at par with the recipient. Both are patients and both are to be treated, cared for, equally.
b) Cadaver donation – Harvesting organs from cadavers for transplantation is a better option as it has the least of the ethical problems. Such donation is possible when the deceased had expressed a clear will for donation of his/her organs before death. Such organs can be easily collected. Further, parents, relatives, legal guardians of a person who has died may consent to donate the organs even if the person has not clearly expressed a wish for it.
Such donations can be made in case of brain dead people on life support system. Consent for such donation should always be obtained in writing. It is the legal and ethical duty of the treating doctor to obtain such informed consent. In this regard also the relevant laws of the country must be followed.
Automatic harvest of organs from all suitable dead persons requires laws to this effect. Without such laws a doctor cannot collect organs without premortem donation by the person or postmortem donation by relatives or legal guardians.
c) Foetal tissue transplant – Transplantation of tissue from foetuses dead due to natural reasons is easy but use of such tissue from foetuses obtained from abortion is complex and present with ethical problems. Such problems become compounded when there are religious prohibitions on abortion. Whether tissue transplant from aborted foetuses amounts to supporting abortion or not are ethical dilemmas a doctor may have to face and solve according to his/her own ethical principles and religious beliefs.
II. Ethical issues regarding the recipient
From the viewpoint of the recipient the freely given donation of an organ is a greatest gift one can get.
The doctor should realize that nobody has any claim to tissues or organs of any other person – even of their children, parents or siblings. It is the ethical duty of a doctor to clarify this matter when such claims are sought to be made. Donation of organs by a patient’s nearest ones has always to be an informed and voluntary decision without any pressure.
Proper informed consent from the recipient need to be obtained by the treating doctor. The full implications, risks, adverse reactions including tissue rejection, treatment thereof, rehabilitation and total costs to be incurred should be fully explained to the patient and consent obtained beforehand. Failure to do so would be unethical for the doctor.
Ethical Issues of organ allocation
Organs and tissues available for allocation are always in short supply and the demands are always more. There may be long waiting lists. It is always an ethical dilemma for a doctor who is incharge of allocation to determine whom to allocate the organ. The doctor knows fully well that such a choice may lead to saving life of one but may also lead to the death of another patient.
Therefore the doctor should take a decision in selecting the recipient on medical and scientific criteria alone and this should involve a fair selection procedure, consideration of all cases who are eligible for the particular organ (This means with whom the organ tissue matches and is fit to be transplanted) and it should be done in a transparent manner. The person who is liking to benefit most from the transplant should get the first chance. In such selection a doctor should never allow any sort of discrimination on the basis of race, religion, colour, beliefs etc. to influence the selection process. Unless the doctor follows a principled, fair and transparent process he/she would not be acting ethically. (See also the chapters on social justice and resource allocation).
There are other ethical issues in the field of organ and tissue transplantation in such procedures as Xenotransplant or animal to human transplant, stem cell and foetal transplants. In all these new and emerging areas which are yet to become standard treatment modalities, specific ethical issues are also emerging along will the development of the process. At this point of time we can only acknowledge that they do exist and are emerging and the student must be aware of these issues.
Organ and tissue transplantation being a new and a very important life saving measure present the doctors with some new and unique ethical issues. We must recognize these and try to formulate the correct ethical stand for doctors to take. The professional associations have a great role to play in this aspect.
Part : 3 – Specific Ethical issues
Chapter - 3 : Ethical aspects of treating the mentally ill
Mentally ill patients are always in need of greater understanding, compassion and care by the doctor. Sometimes they are not in control of their own actions. The doctors must realize that the mentally ill patients also have as much right as other patients and are entitled to all considerations of confidentiality, privacy and dignity. Many a times patients suffering from some psychiatric disease and neurological conditions may not be competent to take decisions for themselves. (Similar situations occur in cases of very young children and temporarily unconscious patients). In such situation substitute decision making is required which can be done by the doctor or by other persons who may be legally appointed by authorities as substitute decision makers.
1. The doctor can be the sole decision maker only if other family members or legally appointed guardians are not available. It occurs usually in situations where unconscious and unaccompanied persons are brought to the emergency. Then the doctor can take a decision keeping the best interest of the patient in mind. Such decisions and circumstances shall be recorded clearly. Help from authorities, other doctors, even other health care providers shall be taken in appropriate situations
2. When a legally entitled decision maker is available, the doctor shall discuss with that person and informed consent shall be obtained from him/her. Such legal decision makers are appointed by the authorities.
3. In the absence of a legal decision maker but when family members of the patient are present, the doctor shall discuss and obtain informed consent from spouse, adult children or brothers or sisters – usually in that order. If the family members take an unanimous decision it is best. But if there is serious disagreement the doctor may take the consent of the senior most member. If the family disagreement is such that no consent is given then the doctor has to approach the authorities in the best interest of the patient.
4. Doctors must be careful in case of psychiatric patients who are judged to pose a danger to themselves or to others. They may have to be confined and restrained for treatment against their will. Doctors shall record the necessity for such actions before starting and follow the legal provisions of the country, if any, in this matter. During the procedure the doctor shall exercise care, understanding and show respect for patient’s rights and human right.
Part - 3 : Specific Ethical issues
Chapter - 4 : Ethical issues in treating children.
Children, even young adults, constitute the largest vulnerable group in the society. They are vulnerable because a child is dependent physically, mentally, emotionally and financially on their parents and guardians both in health and disease, home and hospital. Moreover the child is also a frequent victim of abuses both physical and sexual. The child therefore presents a special stratum of the society where the treating doctor has to face some unique dilemmas in treatment. Though a child should be ideally treated by trained and competent doctors, a general medical doctor may have to examine and treat the child in the first place. Therefore it is necessary for all doctors to know the ethical issues involved in treating a child properly.
The United Nation convention on the right of the child. 1989 recognizes that a child has the right to the enjoyment of the highest attainable standard of health and to facilities for treatment of illness and rehabilitation of health and calls upon all the U.N. member countries to ensure that no child is deprived of these.
This declaration also lays the definition of a child. Any human being of either sex from the time of the birth to the end of the seventeenth year is generally considered as a child.
The rights of the child is no different from that of an adult patient with suitable modifications wherever required. The doctor has the responsibility to acknowledge and promote these rights and work for getting the material and human resources needed to fulfill them.
Some of the salient ethical issues in treatment of a child are discussed below.
a) Confidentiality – Confidential information given to the doctor by children should not be divulged to the parents straightway. It the doctor feels that some such information needs to be divulged to the parents in the best interest of health and treatment of the child then the doctor should first discuss it with the child, try to convince the child as to why such information is required to be told in the parents and then only it should be divulged. The parents also need to be explained about this requirement.
b) Informed consent - In case of infants and very young children the doctor gets informed consent form parents or legal guardians. But in case of a child of is sufficient maturity the doctor has to take the child into confidence too and try to explain the procedure in simple understandable language and obtain the co-operation, assent and consent of the child. The doctor must remember that a child has as much right to consent as well as to refuse a particular treatment as that of an adult.
c) Health education and prevention health care – Doctor should realize that a child is entitled to necessary health education and preventive healthcare including immunization. A doctor should try to ensure that these requirements are met and a child is fully immunized as per the prevailing law of the country.
d) The health interest of the child is of primary concern – The doctor should realize that the health interest of the child is the most important concern he/she has to address. If the parents refuse treatment and/or want to take away a hospitalized child prematurely when the child has not recovered fully for any reason including economic ones, the doctor should try to reason with them and express the risks involved. If even after that the parents refuse, the doctor has to approach higher authorities which may include hospital, or other designated authorities and do everything in his/her power in the health interest of the child so that the child recovers and is out of danger.
e) Being vigilant for detecting child abuse - the doctor should be always vigilant to detect any kind of child abuse and should take necessary steps to combat and eradicate child abuses such as – all forms of neglect, negligent treatment, verbal, physical and mental violence, coerction, maltreatment, injury or abuse including sexual abuse. The appropriate authorities must be notified in these cases. These authorities can be police, court, child welfare departments or any other authority notified by the government.
f) Treating with respect – A doctor should always treat children with respect and listen to their views. Questions should be encouraged and answers and information should be given truthfully and in a language they can understand. The child and parents must be involved in the treatment decisions in a harmonious way. A child should be never discriminates for status, belief convictions of their parents.
Part : 3 – Specific Ethical issues
Chapter - 5 : Resource allocation in the healthcare system
Introduction
Social health resources like hospital beds, facilities for investigation, supply of life saving drugs, access to advanced investigations (CT, MRI, PET Scans, Angiographies etc.) and treatment options as ICU beds, etc are always scarce and in short supply, especially when they are free or subsidized by public money, social funding etc. These resources are always related to the health needs of society and the individual. The society entrusts the task of allocation of these social resources to the doctor mostly.
These healthcare resource allocations occur at 3 levels. At the top is the macro level. It consists of the total budgetary allocation for health and its distribution according to national and social priorities. The second or the middle level is the Institutional level where policies of rescoure allocation at the level of institution are fixed up. The third level is the micro level which can also be called the operational level where it is the doctor who decides to whom healthcare resources like ICU beds, investigative facilities are distributed in day to day practice. The physicians, placed at different levels, have a major say in allocation of these resources (80% according to WMA). At the micro level it is the physician who take the decision of allocation of these resources fully. The decisions at all the three levels are mainly ethical in nature as they involve principled moral and ethical stands. At the micro level, where the physicians decisions are immediate and direct, these decision also have an immediate ethical questions involved.
1. Ethical duties of the doctor in allocation of healthcare resources.
At the micro level, the physician’s patient relationship is considered to be an one to one relation and the physician is expected to uphold the interest of his own patient alone. This is a highly individualistic approach. With the concept of equity and justice that has come in, the doctor is supposed to allocate the resources as per Medical needs only. In WMA declaration of rights of the patient it is stated that – “in circumstance where choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. The choice must be based on medical criteria and made without discrimination.”
Therefore it is the ethical duty of the doctor to do the following
a) The doctor shall uphold the patients right of access to the level of healthcare that is necessary for him or her. The doctor should also actively help the patient in this.
b) The doctor shall always strive for and support a transparent and equitable allocation of healthcare resources.
c) In selecting the recipients of the healthcare resources the doctor shall always follow a fair and principled procedure and ensure that no patient is discriminated on non medical grounds.
d) Doctors shall try to ensure that such allocation of health care resources is done on medical criteria alone.
e) The physician shall avoid wasteful practices even when patients demand it. Over prescription of drugs are to be avoided. For example Antibiotics should not be prescribed unnecessarily. The doctor must ensure that the services provided are likely to benefit the patient.
f) Physicians should always advocate with the authorities to increase these health care resources for benefit of more patients.
In emergency physicians who have control over the access of scarce and hitech medical resources like an ICU bed, CT or MRI scans, very expensive drugs, dialysis facilities or allocation of organ for transplantation etc should allocate these to the medically most deserving patient knowing fully well that those who are denied the facility may suffer, and even die as a result. In such cases unless the physicians goes by medical criteria he/she may not be able to ethically justify the decision to himself and others. This egalitarian approach, where resources are distributed strictly by need coupled with restorative consideration where resource are also allocated to favour the historically disadvantaged, is usually a good practical approach.
Part : 3 – Specific Ethical issues
Chapter - 6: Ethics of Public health and health promotion
Introduction – Doctor and Society
The Doctor has a role in and responsibilities towards the Society. There is intimate relationship between the doctor and the society. In a civilized society it is held that the physician is a professional person and medical practice is a profession.
The profession of medicine has some very special characters. This profession is an occupation where the practitioner i.e. the physician is a person who is –
• Dedicated to the well being of others more than to his own self
• Highly educated, knowledgeable, trained in possession of necessary skills and competence.
• Maintains a high level of moral and ethical values.
• Enjoys a high level of autonomy and self regulation.
The doctor through his attention to individual patients serves the society.
The society in its turn bestows on this profession and its practitioners a very high level of respect, allows them to function with very wide ranging autonomous powers, which are most of the times exercised more by the self regulation of by the doctor than by any external regulation; entrusts them with certain responsibilities and grants then certain privileges.
The society trusts the physicians and the physicians keeps this trust by treating competently, compassionately, ethically and not by misusing the privileges granted by the society.
The WMA has in its Medical Ethics Manual beautifully summarized this relationship as such.
“Medicine is today, more than ever before, a social rather than a strictly individual activity. It takes place in a context of government and corporate organization and funding. It relies on public and corporate medical research and product development for its knowledge base and treatments. It requires complex healthcare institutions for many of its procedures. It treats diseases and illnesses that are as much social as biological in origin.”
The doctors must realize that they are basically indebted to society and not necessary to Government. Government and society are not synonymous though Government is said to represent society but it is not always so. For example, the Government of an apartheid regime cannot be representative of society. Society is larger and wider than Government and the doctor owes his primary allegiance to this broader society.
The doctor duty and responsibility to the society includes the following main topics.
The WHO has identified the public health functions and competencies required of doctors in this sphere and these have been accepted by all the regional countries. All doctors need to familiarize themselves with these functions and national rules and regulations on public health issues.
1. Public health duties of a doctor – The doctor has a duty to help maintain the health standards in a society. These duties are called the public health duties. Sometimes a government fixes these duties by laws or regulation too. Doctors are morally and ethically bound to perform these public health duties towards the society and non performance of such duties may be held unethical.
Social responsibility of the doctors demand that all doctors shall engage in public health activities individually, as groups and through various platforms and agencies. There duties include
• Activities to protect the public from communicable diseases.
• Activities to protect the public from spread in non communicable and lifestyle disease.
• Joining in vaccination campaigns
• Joining in Emergency response to contagious diseases.
• Offer services in natural calamities and other disasters.
• Promote safe health polices and programme – such as safe drinking water and spread of hygienic practices, promoting breast feeding, immunization coverage identifying population at high risk for particular diseases, etc.
• Public advocacy and action for remedy of certain public health hazards like polluted water and environment, unsafe food, toxic product in daily use items, use abuse and spread of tobacco, alcohol and drugs etc.
• Providing outreach health service to poor and marginalized people, rural poor, slum dwellers and all those who have no or very less access to health facilities.
• Taking part in disease surveillance, investigation and control programmes. Helping as an individual and professional group to prevent spread of such highly contagious diseases as Avian Influenza or swine flu.
• Health education – including sexual health education to promote safe sexual practices to prevent HIV/AIDS and socially transmitted diseases.
• To advocate and practice protection of environment by promoting proper disposal of biomedical and other hazardous wastes.
2. Educating society – Doctors have to educate the society regarding health and disease. This is done by participating in public health educational programmes.
3. Protection of Environment – Doctors should be active in environmental protection. They should realize that degradation of environment leads to disease and health problems.
4. Trying to effect health friendly laws – Doctor should actively work for promulgation laws that would promote health and give truthful judicial testimony before courts of law regarding public health problems.
5. Standing up for fundamental rights – When laws and Governmental action denies the fundamental human and health rights of the members of the community, it is the social duty of the doctor to pursue appropriate means to try to restore them (WMA)
6. Physicians shall oppose torture - Physicians should stand up for human rights of prisoners who become their patients and should resolutely oppose torture and should never take part in it. Under such situations where the fundamental rights of the patients are in jeopardy it is the social duty of the doctor to try to upheld the professional and ethical standards fully and they must bring such violations to the notice of authorities, professional associations and WMA if need be.
7. Allocation of scarce healthcare resources Doctor should allocate scarce health resources of the society most judiciously (This is discussed in detail in a separate chapter in this book).
8. Loyality of physicians – Physicians have the first loyality to their patients whose welfare they have to uphold. But there are other agencies – who may be called third parties, who also demand the loyality of the physician. They can be employers (hospitals, corporate healthcare management institutions) Insurance companies, Government including its organs such as police, military, executive, investigation agencies, and even the family members.
All these agencies may interfere and demand to know information about the patient, demand that the doctor do certain things which may go against the best interest of the patient and things if done may violate ethical principles of the doctor. It is sometimes very difficult on the part of the doctor to resist such pressures. In such cases – when there is conflict of interests, what should the doctor do? In situations where the society’s interests are at stake, e.g. in case of notifiable diseases, the doctor should hold the interest of the society above that of the individual. When employers, hospitals or corporate houses that own hospital take such policies that restrict the freedom of the doctor to treat, the doctor should reason and discuss these issues so that the wrong can be rectified amicably. If necessary, they should be ready to protest and take up the matter through professional associations.
You would realize from this lengthy discussion that the distillate mainly consist of doctor’s duties towards the society. If a doctor fails in these, it may be considered as an individual failure on the part of a doctor but may not always be held unethical. However in certain cases certain actions may be judged as unethical inviting censure and even penalties.
Part : 3 – Specific Ethical issues
Chapter - 7 : Ethical issues of dealing with other systems of medicine
A doctor trained in western or modern system of medicine – called allopathic, must realize that there exists in this world some very ancient and traditional systems of medicine which have also provided immense relief to suffering people of the world. Some of these systems have a history of thousands of years and predates the modern system. In India there are three main traditional systems like Ayurveda, Siddha and Unani together called ‘Ayush’ or ‘life’. In China there is the traditional Chinese medicine (TCM) which has very long history. In each country there may be such systems of medicine. Further, the system of homeopathy is also practiced in many parts of the world including India.
These traditional systems have a philosophy, theories and practices of their own and also make and prescribe their own medicines which are mostly based on herbs, medicinal plants and organic and inorganic chemicals obtained from nature. In the present times there is not only a great interest in these systems but these also being rapidly developed scientifically and their teachings have also become formal, institutional and scientifically structured with proper course, curriculum and assessment methods. In many countries the government recruits them into the government health services.
The doctor must also realize that the modern system of medicine has greatly benefitted from the wealth of knowledge these traditional systems encompass and have borrowed freely from it.
A doctor should therefore show due respect to these other system of medicines and their practitioners that are recognized by the respective national governments.
The doctor must not say or do anything that would lower the prestige of these systems and their practitioners. Criticism if any, should always be with a constructive motive of helping and not denigrating the system and such criticism should be based on scientifically published data alone.
The doctor shall always treat the practitioners of these other system of medicine with respect and treat them as friends and fellow travelers. A doctor should always try to learn from these systems ad also teach its practitioners if requested.
However, a doctor trained and practicing the modern system of medicine shall never practice or prescribe drugs, measures from the other traditional systems of medicine unless he/she has acquired the necessary formal competence and legal sanction to do so. Otherwise the doctor may be accused of unethical and illegal actions.
Part : 3 – Specific Ethical issues
Chapter - 8 : Country specific situations
In each country, the cultural vales of that country and the laws of the country sometimes present some unique country and culture specific ethical issues. The doctor must be aware of these issues and try to take an ethical stand on these. Two such issues are illustrated as examples.
1. Gender discrimination and female focticide – In most of the countries in the world there is some amount of gender discrimination against the female gender. Women are always discriminated in education, job, nutrition, social freedom and even in access to medical treatments. Sometimes it may take the extreme form of sex determination of the unborn child and causing abortion of the foetus if it happens to be a girl child. Such female focticide is not only illegal but highly unethical also. But it is very sad that many doctors are indulging in such inhuman acts. Doctors should never indulge in such prenatal sex determination and female focticide. A doctor may be legally punished and the license to practice may be revoked for such activities in India.
2. Female genital mutilation – another such inhuman cultural practice being conducted in some countries in the garb of questionable religious sanction is female genital mutilation. Doctors have to treat such patients when complications occur. Sometimes some doctors also perform such procedures. These are areas where unless these practices are banned by law, the individual ethical values of the doctor comes to play. A doctor should always think before performing any procedure whether such a procedure is scientifically required and beneficial to the patient. In case of these culture and country specific practices which pose ethical dilemmas to the doctor, the doctor should always be guided by scientific considerations alone.
Part – 4 : Research ethics
Chapter - 1 : Principles of research ethics and research publication
Medical research in each country may be guided by the national laws and each country may have separate rules and regulations for medical research involving animals. Therefore medical research in a country is essentially guided by these laws.
In the present era medical research is assuming greater importance. Such medical research may involve human beings, human tissue samples, and data regarding health and disease of patients and in addition may include laboratory animals. Human stemcells also have come to the picture recently. In conducting medical research there are some general ethical principles of research which need to be kept in mind. Doctors must realize that -
1. Participation in a research project involving patients and healthy subjects is voluntary. It requires informed consent of the voluntary participants in writing. No research involving human subject can be undertaken without their consent. To do so would be highly unethical, and illegal too.
2. All such volunteers must be accorded due respect and the risks and side effects must be clearly explained to the participants.
3. All efforts must be taken to protect the participants from any harm and their privacy and confidentiality shall be strictly protected.
4. The doctor researcher must act with absolute honesty and integrity.
5. All medical research projects involving human beings, human tissue even human data must only be undertaken when they have been approved by national /state/ local agencies which are empowered by law to accord such approval. Such approval is usually given by ethics committees of such agencies.
6. During submission of such research proposals by the doctor researchers to the ethics committees of such agencies the following things shall be fully disclosed
- Amis and objectives of the research project in clear terms.
- Likely or expected results.
- Risks and side effects.
- Source and amount of funding.
7. If the research is sponsored, funded by pharmaceutical industry or health industry the full extent of involvement of such industry, funding etc have to be revealed.
8. Doctor researchers should never take advantage of the patients under their care. The doctor shall realize that any patient participant in a research proposal can withdraw from the research at anytime and the doctor shall ensure that such withdrawal does not adversely affect their care and doctor patient relationship.
9. When children or mentally incompetent subject are involved in research who are not capable of informed consent, then such consent shall be obtained from parents, legal guardians or authorities.
10. All research proposals must also be approved by institutional ethics committees where they are carried out.
11. Research shall strictly follow the approved project and there shall be a mechanism of monitoring, supervision and regular reporting. Adverse effects and unexpected outcomes shall be immediately reported.
12. When medical students are conducting research they shall be taught the ethical procedure of research and they shall be guided, encouraged and supervised closely by their teachers.
2. Ethics of Research Publication
Publication of research findings also involve lots of ethical issues. There have been instances where doctors have been found guilty of unethical practices in publications which may include (a) Plagiarism (b) Fabrication of data (c) Duplicate publication (d) ‘Gift’ authorship and (e) Slanted publication to benefit sponsors. To maintain ethical standards in publication a doctor shall,
1. Be honest and truthful in reporting, and presenting the findings of research.
2. Not hesitate to publish reports which are contrary to expected results and which go against the interest of the sponsors and funding agencies.
3. Ensure that informed consent was obtained from the patients when patient data has been published. This becomes quite an important issue when rare and interesting cases are reported.
4. Conform to laid down procedures and present or publish the paper /data only in approved scientific platforms.
5. Never indulge in plagiarism, using data from other authors without permission and due acknowledgement and never indulge in data fabrication, gift authorship.
6. When more than one author and researchers are involved in research and publication, due acknowledgement of individual roles and contributions must be made by accepted procedures.
Chapter on Annexure
Annexure-1
THE OATH OF HIPPOCRATES
I swear by Apollo the Physician and by Asclepius and by Health [the god Hygieia] and Panacea and by all the gods as well as goddesses, making them judges [witness], to bring the following oath and written covenant to fulfillment, in accordance with my power and my judgment;
To regard him who has taught me this techne2 [art and science] as equal to my parents, and to share, in partnership, my livelihood with him and to give him a share when he is in need of necessities, and to judge the offspring [coming] from him equal to [my] male siblings, and to teach them this techne, should they desire to learn [it], without fee and written covenant,
And to give a share both of rules and lectures, and of all the rest of learning, to my sons and to the [sons] of him who has taught me and to the pupils who have both made a written contract and sworn by a medical convention but by no other.
And I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from [what is] to their harm or injustice I will keep.
And I will not give a drug that is deadly to anyone if asked [for it], nor will I suggest the way to such a counsel.
And likewise I will not give a woman a destructive pessary.
And in a pure and holy way I will guard my life and my techne.
I will not cut, and certainly not those suffering from stone, but I will cede (this) to men (who are) practitioners of this activity.
Into as many houses as I may enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice, especially from sexual acts both upon women's bodies and upon men's, both of the free and of the slaves.
And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings-things that should not ever be blurted out outside - I will remain silent, holding such things to be unutterable [sacred, not to be divulged].
If I render this oath fulfilled, and if I do not blur and confound if [making it to no effect] may it be [granted] to me to enjoy the benefits both of life and of techne, being held in good repute among all human beings for time eternal. If, however, I transgress and perjure myself, the opposite of these.
Annexure-II
The Oath of Charaka prescribed for the intending physicians starting their study of Ayurveda under a Guru or teacher
The main points of the elaborate oath is placed below in a simplified form
1. In presence of the Seared fire, the priests and the physicians the teacher shall instruct the initiate.
2. The initiate shall lead a pure life, be celibate (applicable to students at the start of the course) eat pure food, speak only the truth and be free from envy, malice and violence and shall carry no arms.
3. The initiate shall regard his teacher as his chief, the Guru and father. He shall stay with the teacher, serve him obediently like a son. He shall conduct himself with humility, behave and act without arrogance, and will always help his teacher and strive for the glory of the teacher alone. He shall study what is taught with and undistracted mind and reflect on it constantly.
4. The initiate shall always act with the aim of welfare of all creatures on this earth. This only would ensure his success, fame, wealth as a physician (and get him a place in heaven after death).
5. With all his heart and soul the initiate (and physician) shall desire the welfare and relief of the patient. He shall never do anything that injures a patient. He shall never abandon a patient, never commit adultery even on thought, never covet others possessions, never be a drunkard or a sinful man never associate with crime and criminals. He shall always be modest in attire and appearance, strive always to acquire knowledge.
6. He shall be very careful with women and shall only attend to her in presence of guardian or husband and shall not accept any offering from her unless approved by her husband or guardian.
7. He shall enter a house only in presence of a person permitted by the patient and after entry his whole thought, intellect, speech shall only be devoted to helping the patient.
8. He shall refuse to treat persons who hate or are hated by the king or the public, who are wicked; criminals and dishonorable people.
9. He shall speak words that are gentle and he shall be pure, righteous, pleasing, worthy, true, wholesome and moderate.
Annexure-III
Standards for ancient traditional medical ethics of China laid down by Physician Sun Simiao in 7th century AD.
1. Be erudite in medical knowledge and diligent in learning: all doctors should progress constantly and keep improving their skill of the medical art and technical know-how.
2. Be sympathetic to patients and serve them wholeheartedly. Serve all patients equally, regardless of their age, sex, wealth, rank, nationality and intelligence. Treat all patients as if they were your own relatives and their illness as if it were your own suffering. Meet the patient at any time or any place when a doctor's help is needed, notwithstanding any danger.
3. Be painstakingly careful in diagnosing a disease. Think carefully when prescribing treatment. Be objective and avoid any personal considerations of responsibility or being swayed by personal feelings.
4. Be solemn in one's conduct without making any personal demands: no humor, demands for money, or sexual issues should be raised.
5. Be respectful to one's tutor and profession. Avoid any arrogance and rashness. Do not criticize other doctors' skill or conduct in the presence of a patient. Do not be arrogant about one's own achievement. Learn from other doctors to ensure one's own progress, only charlatans are jealous of other doctor's superb skills.
Annexure-IV
The Oath of a Muslim Physician
Praise be to Allah (God), the Teacher, the Unique, Majesty of the heavens, the Exalted, the Glorious, Glory be to Him, the Eternal Being who created the Universe and all the creatures within, and the only Being Who contained the infinity and the eternity. We serve no other god besides Thee and regard idolatry as an abominable injustice.
Give us the strength to be truthful, honest, modest, merciful and objective. Give us the fortitude to admit our mistakes, to amend our ways and to forgive the wrongs of others.
Give us the wisdom to comfort and counsel all towards peace and harmony. Give us the understanding that ours is a profession sacred that deals with your most precious gifts of life and intellect. Therefore, make us worthy of this favoured station with honor, dignity and piety so that we may devote our lives in serving mankind, poor or rich, literate or illiterate, Muslim or non-Muslim, black or white with patience and tolerance with virtue and reverence, with knowledge and vigilance, with Thy love in our hearts and compassion for Thy servants, Thy most precious creation.
Hereby we take this oath in Thy name, the Creator of all the Heavens and the earth and follow Thy counsel as Thou has revealed to Prophet Mohammad (pbuh). "Whoever killeth a human being, not in liew of another human being nor because of mischief on earth, it is as if he hath killed all mankind. And if he saveth a human life, he hath saved the life of all mankind." (Qur'an V/35)
This medical oath which is a composite from the historical and contemporary writings of physicians of Islamic World, was officially adopted by I.M.A. in 1977.
Islamic Medical Association of North America.
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