Patient rights and Doctor-patient relationship Dr

1
Patient rights and Doctor-patient
relationship?????????

• Dr. Derrick K. S. Au
• ?????
• Kowloon Hospital Hong Kong Eye Hospital

2
The oldest code of medical ethics Hippocratic
Oath (4th Century BC)

• Several parts of the oath have been revised over
  the years, e.g. -
• To consider dear to me, as my parents, him who
  taught me this art to live in common with him
  and, if necessary, to share my goods with him
• Nor will I give a woman a pessary to procure
  abortion
• I will not cut for stone, even for patients in
  whom the disease is manifest I will leave this
  operation to be performed by practitioners,
  specialists in his art.

3
Code of Professional Conduct (Hong Kong
Medical Council)

• Medicine as a profession is distinguished from
  other professions by a special moral duty of care
  to save lives and to relieve suffering.
• Medical Registration Ordinance (Cap. 161) confers
  upon the medical profession considerable freedom
  of self regulation, the profession is obliged to
  abide by a strict code of conduct which embodies
  high ethical values, protects patients
  interests, and upholds professional integrity.
• Trust is essential to the practice of medicine.
  There can be no medicine in the absence of trust.
  The patients trust imposes upon the doctor a
  corresponding duty to be trustworthy and
  accountable.
• http//www.mchk.org.hk/code.htm

4
Ethics What is right?

• Moral (??)- comes from Latin mos(mores)
• Ethics (??) - comes from Greek ethos
• Both have meaning of customs (??), or generally
  accepted social norm
• But What is right is not just a matter of
  social norm (e.g. slavery was a social norm at
  one time)
• Professional norm is not always right, it does
  revise over time
• What is legally permitted is not always right

5
Ethical principles

• Commonly quoted ethical principles
• Autonomy ????
• Beneficence ????
• Justice ????
• Nonmaleficence ?????
• These are useful but by themselves are not
  adequate for ethical decision making

6
Rights

• The great religions of the world have all sought
  to establish moral codes of conduct based on
  divine law.
• These are often concerned with the duties and
  obligations of man to his fellow human beings, to
  nature, to God and the whole of creation.
• Ancient Chinese moral philosophers like
  Confucius (??) and Mencius (??) are concerned
  with similar moral issue, though not as a part of
  divine law
• The idea of 'human rights' is not universal - it
  is essentially the product of 17th and 18th
  century European thought. Such secular conception
  of rights emphasised duties and privileges that
  arose from peoples' status or relationships,
  rather than abstract rights in the philosophical
  sense.
• Since1948, with the Universal Declaration of
  Human Rights, . Respect for human rights is
  becoming a universal principle of good
  government.

http//www.universalrights.net/main/histof.htm
7
Rights / Obligations

• A paired concept, for instance
• People / Government
• Patient / Doctor
• Human being / fellow human beings
• Commonly quoted universal human rights
• right to life
• right to freedom
• right to own property (limiting where government
  may intrude)
• citizenship rights (voting, nationality and
  participation in public life)
• rights to standards of good behaviour by
  governments (or protection of the rule of law)
• Other social, economic and cultural rights have
  become important during the 20th century, and
  raise important and still controversial issues
  about social justice and the distribution of
  wealth.

http//www.universalrights.net/main/histof.htm
8
WHO Patient rights understood as one aspect of
basic human rights

• World Health Organisation
• Formalized in 1948, the Universal Declaration of
  Human Rights recognizes the inherent dignity
  and the equal and unalienable rights of all
  members of the human family. And it is on the
  basis of this concept of the person, and the
  fundamental dignity and equality of all human
  beings, that the notion of patient rights was
  developed.
• In other words, what is owed to the patient as a
  human being, by physicians and by the state, took
  shape in large part thanks to this understanding
  of the basic rights of the person.
• http//www.who.int/genomics/public/patientrig
  hts/en/

9
From the perspective of patients advocate
(???????)
?????? ???????????????????????????,?????????????
??????,??????????????,?????????????????????????
?????????????????????????????,????????????????????
?????????????????????? www.soco.org.hk/rights/rig
ht055_c.htm
10
WHO Patient rights can vary in different
countries

• World Health Organisation (WHO)
• Patients' rights vary in different countries and
  in different jurisdictions, often depending upon
  prevailing cultural and social norms.
• Different models of the patient-physician
  relationshipwhich can also represent the
  citizen-state relationshiphave been developed,
  and these have informed the particular rights to
  which patients are entitled.
• http//www.who.int/genomics/public/patientrig
  hts/en/

11
Patients Charter (????)

• In year 2000, the Hong Kong Hospital Authority
  produced a Patients Charter to outline patient
  rights and responsibilities in public hospital

12
HA Patients Charter Patients rights

• Right to Medical Treatment (???)
• Right to Information (??? ???)
• Right to Choices (??? )
• Right to Privacy (??? )
• Right to Complaint (???)

13
HA PatientsCharter Patients
Responsibilities

• Give your heath care providers as much
  information as you can about your present health,
  past illnesses, any allergies
• Follow the prescribed and agreed treatment plan,
  and conscientiously comply with the instructions
  given.
• Show consideration for the rights of other
  patients and health care providers, by following
  the hospital rules concerning patient conduct.
• Keep any appointments that you make, or notify
  the hospital or clinic as earlyl as possible.
• Should not ask health care providers to provide
  incorrect information, receipts or certificates.
• Should not waste medical resources unnecessarily.

http//www.ha.org.hk/charter/pceng.htm
14
Hong Kong Medical Association's Patients' Rights
and Responsibilities

• Responsibilities
• To play an active and responsible role in the
  healthcare process, you should
• be frank to your doctors in revealing your
  medical conditions.
• endeavor to co-operate with any agreed form of
  management.
• be well informed by your insurers of the detailed
  scope of coverage of your medical insurance
  policies.
• not request doctors to issue incorrect receipts,
  certificates or document, or to make incorrect
  entry into the medical records.
• be responsible to meet the required fees and
  charges for the medical services provided to you.
  
• http//www.hkma.org/english/pubmededu/right.htm

15
HKMA Patients rights

• Right of information.- Charges
• - Drugs.
• Right of refusal
• Right of confidentiality
• Medical Reports
• - Public medical institutions.
• - Private hospitals and practitioners
• Complaints- Public medical institutions.
• - Private hospitals and practitioners
• Operations- Public and Private Medical
  Institutions

16
HKMA Right of Information

• A patient should have a reasonable and balanced
  understanding of the sickness he is suffering
  from.
• You may enquire about what disease you have, if
  you need any further examination, and how to cure
  the disease. You should also know what treatment
  you will receive, whether with drugs or
  operation, any side effects after treatment, and
  the chances of recurrence.
• In other words, in order to know more relevant
  facts about your sickness, you should consult
  your attending doctor.

17
In the U.S.

• Definition
• Patient rights encompass legal and ethical issues
  in the provider-patient relationship, including a
  person's right to privacy, the right to quality
  medical care without prejudice, the right to make
  informed decisions about care and treatment
  options, and the right to refuse treatment.
• Many issues comprise the rights of patients in
  the medical system, including a person's ability
  to sue a health plan provider access to
  emergency and specialty care, diagnostic testing,
  and prescription medication without prejudice
  confidentiality and protection of patient medical
  information and continuity of care.
• http//www.answers.com/topic/patient-rights

18
The U.S. Patients Bill of Rights

• Health care reform led to an emergence of health
  maintenance organizations (HMOs) and other
  managed health care plans.
• The rapid change in medical care moved health
  care decision making from medical professionals
  to business entities, a move many consider to be
  detrimental to the health care industry in
  general. Establishing a patient's bill of rights
  has been the response to this concern.
• The Bipartisan Patient Protection Act of 2001 has
  been debated and passed by the U.S. Senate and
  the U.S. House of Representatives and signed into
  law.

19
In the U.S. Bill of Rights

• These basic rights include the right to
• participate in the development and implementation
  in the plan of care
• be treated with respect and dignity
• be informed about condition, treatment options,
  and the possible results and side effects of
  treatment
• refuse treatment in accordance with the law, and
  receive information about the consequences of
  refusal
• quality health care without discrimination
  because of race, creed, gender, religion,
  national origin, or source of payment
• privacy and confidentiality, which includes
  access to medical records upon request
• personal safety
• know the identity of the person treating the
  patient, as well as any relationship between
  professionals and agencies involved in the
  treatment
• informed consent for all procedures
• information, including the medical records by the
  patient or by the patient's legally authorized
  representative and hospital charges, except for
  Medicaid and general assistance
• consultation and communication
• complain or compliment without the fear of
  retaliation or compromise of access or quality of
  care

20
What is happening to the doctor-patient
relationship?

• Some doctors are worried that the
  physician-patient relationship, a special
  humanism motivated by tradition and governed by
  the ethics of medicine, may be fouled up by the
  fiscal and economic constraints likely to occur
  in the health care system
• - Alvan Feinstein, MD, professor of medicine,
  Yale University School of Medicine, New Haven,
  Conn.

Marwick, Charles. Preservation of
Physician-Patient Relationship Seen as Integral
to Health Care System Reform JAMA The Journal of
the American Medical Association. Volume
271(12), 23 March 1994, pp 892-893
21
William C. Hsiao

• William C. Hsiao, PhD, Department of Health
  Policy and Management, Harvard School of Public
  Health, Boston, Mass. "We have promoted the
  diffusion of some technologies that may not be
  cost-effective and encouraged their overuse"
• "Furthermore, we undercompensate primary care
  physicians, discouraging them from rendering
  their services, and likewise (fail to encourage)
  the young medical school graduates to pursue a
  career in family care. 
• "Instead of trying to align the economic
  incentives to improve cost-effectiveness, we are
  creating an administrative organization that will
  intrude on this very personal relationship
  between doctor and patients, between the caring
  physician with the technical expertise and the
  patient,"
• "Is that the best we can do to preserve this
  unique relationship?"

Marwick, Charles. Preservation of
Physician-Patient Relationship Seen as Integral
to Health Care System Reform JAMA The Journal of
the American Medical Association. Volume
271(12), 23 March 1994, pp 892-893
22
Models of Doctor-Patient Relationship

• There are three different kinds of models
• 1. PATERNALISTIC (?????)
• 2. CONTRACTUAL (????)
• 3. FIDUCIARY (???? Fiduciary duty????)
• http//www.carroll.edu/msmillie/bioethics/modelsd
  ocpatrelation.htm

23
Fiduciary relationship in peril?

• Over the ages the doctor-patient relationship has
  been defined, through rules of ethics and rules
  of law, as a fiduciary one, as a relationship
  founded in trust. When a patient seeks a
  physicians help and the physician agrees to give
  that help, a special covenant is made.  The
  patient agrees to take the physician into her
  confidence, to reveal to him even the most secret
  and intimate information related to her health. 
  The physician, in turn, agrees to honor that
  trust, and to become the patients advocate in
  all matters related to her health, placing her
  interests above all others - including his own
  personal or financial concerns.
• The loss of this doctor-patient relationship has
  obvious consequences for patients.  Patients,
  when they are sick and thus least able to fend
  for themselves, are left without a true,
  dedicated advocate as they try to navigate the
  hostile halls of the healthcare system, whose
  chief concern is to find ways of not spending
  money on them. Loss of the traditional
  doctor-patient compact leaves patients
  marginalized and floundering within that system
  at the time they are most vulnerable.
• - Blog of DrRich

The Importance of the Doctor-Patient
Relationship, and Why We Cant Have It
Anymore Posted on January 23, 2009
24
Paternalistic modelStrengths and Weaknesses

• Paternalistic model The doctor is the
  professional. He/she gives the order, the patient
  obeys.
• Strengths Emphasizes the expertise and knowledge
  of the doctor
• Weaknesses
• Ignores the autonomy of the patient
• Ignores non-health related but morally legitimate
  values of the patient

25
Contractual modelStrengths and Weaknesses

• Contractual model The doctor and patient
  "contract" for each other's mutual benefit the
  patient determines or agrees to the doctors
  decisions.
• Strengths
• Highlights the autonomy of both patient and
  physician
• Acknowledges cooperative/shared aspects of
  medical decision-making
• Weaknesses
• No "contracts" developed or signed in real
  doctor/ patient relationships
• Model doesnt allow for at trusting relationship

26
Fiduciary modelStrengths and Questions

• Fiduciary model The patient confidently
  entrusts his/her health care to the doctor, who
  takes on the obligation of working for the
  benefit of the patient (Fiduciary relates to a
  holding of something in trust for another)
• Strengths
• Preserves the freedom and autonomy of both
  patient and physician
• The legitimate role of physician knowledge
• The important role of trust in the doctor/patient
  relationship
• Questions raised by skeptics
• 1. Patient trust may be manipulated for further
  economic gain.
• 2. Patient trust may undermines consumers
  awareness of need for self-protection
• 3. Serious illness and fear of death diminish
  patient autonomy and power to contract any
  relationship.

27
What about Chinese Culture?

• Traditional Chinese medical ethics emphasizes ??,
  based on virtues and morality, rather than
  relationship between two autonomous individuals
• Patients as children (?????) is related to the
  ideal image of a benevolent ruler (????)
• It may be analogous to the concept of
  guardianship (??) in Western culture

28
A few cases for thought
29
Case 1 Refusal of treatment

• Chest physiotherapy is prescribed for an elderly
  cancer patient by the attending doctor, but he
  refuses. Must the physiotherapist insist on
  carrying out the treatment plan?
• Is it unethical to go against the patients wish
  (to refuse)?

30
Case 2 Autonomy and family member

• A patients son insisted that the doctor should
  not tell his mother that she has been diagnosed
  with chronic leukemia, otherwise he will take her
  home against medical advice.
• The mother seems to be generally passive and
  submissive to the sons decisions related to her
  health care
• How should the patients right be addressed?

31
Case 3 Demand of Alternative Medicine (????)

• A 20 year old patient with severe head injury
  from traffic accident did not improve with
  rehabilitation.
• He cannot comprehend or communicate
• The mother demands the hospital to provide
  hyperbaric oxgyen therapy (high pressure oxygen
  treatment in a closed chamber)
• What is the extent of the mothers right in this
  case?
• How should the patients rights be addressed?

32
Case 4 Demand of medical treatment

• A patient with mental illness demanded to be
  treated with the newest psychiatric drugs
• The doctor assessed and found that the patient
  was not suffering from significant side effect
  from the existing drug, which is also one of the
  newer drugs that had passed the patent period
  (cheap generic drug is locally available)
• What is the extent of patient right in this case?

33
Case 5 Right to die?

• A tetraplegic patient on chronic assisted
  ventilation wrote to the HKSAR CE to demand
  legislation for patients right to die and to
  legalise euthanasia (???)
• Does a patient have right to die?

34
Dealing with refusal of treatment

• When mentally competent and properly informed,
  the patients refusal must be respected.
  Principle of respect for autonomy
• Assess mental capacity (????????)
• Provide adequate and appropriate information
• Treatments can be provided to mentally
  incapacitated persons (?????????? ) based on
  best interests (???????) principle Principle
  of beneficience

35
Resolving ethical dilemma related to autonomy
advice for clinicians

• Listen carefully do not jump to conclusion of
  patient not cooperative too easily
• Gather more information relevant to the case
  situation
• Consider your own bias and assumptions
• Explore reasonable options of compromise
• Involve carers and friends trusted by patient as
  appropriate

36
Thank you for your attention