Medical Ethics

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Medical Ethics

• Basic Concepts of Medical ethics

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• Confidentiality

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Confidentiality

• The doctor patient relation ship is an extremely
  confidential one
• All information that the doctor has acquired
  professionally should be kept strictly
  confidential
• (Professional secrecy)

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Confidentiality

• Breach of this duty can lead to a civil law suit
  or criminal defamation if done intentionally
• Divulging such information to a third party (eg.,
  insurance company or employer) should be done
  with consent only

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Hippocratic Oath

• Whatever, in connection with my professional
  practice, or not in connection with it, I see or
  hear, in the life of men, which ought not to be
  spoken of abroad, I will not divulge, as
  reckoning that all such should be kept secret

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The declaration of Geneva of 1948

• I will respect secrets confided in me, even
  after the patient has died

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The international code of Medical Ethics amended
in Venice in 1983

• A physician shall respect the rights of
  patients, colleagues and of other health
  professionals and shall safeguard patient
  confidences
• A physician shall preserve absolute
  confidentiality on all he knows about his patient
  even after the patient is dead

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WHO guide lines on Medical Confidentiality

• All information must be kept confidential
• Information can only be disclosed if the patient
  gives explicit consent, or if the law
  specifically provides
• Consent may be presumed where disclosure is to
  other health care providers involved in that
  patients treatment
• All identifiable patient data must be protected

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• Medical interventions may only be carried out
  when there is a proper respect shown to the
  privacy of the patient. This means that the only
  persons who may be present when an intervention
  is carried out are persons who are necessary for
  the interventions, unless the patient consents or
  require otherwise
• Patients admitted to health care institutions
  have the right to expect physical facilities
  which ensure privacy

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• In some instances the rule of professional
  secrecy does not apply and a doctor will not be
  liable for divulging information to a relevant
  third party (Privileged communications)
• Such communication should be made with caution
  and least embarrassment to the patient

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Privileged communication
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• (1) In the interest of the patient ( conveyed to
  other medical colleagues or parents/guardian)
  - Referral to health personnel who assists in
  the clinical management - Parents/guardian,
  when
• patient refuses to carry out treatment
  patient has suicidal tendencies
• psychopath with violent anti- social
  tendencies
• minors/insane persons

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• (2) In the interest of the patients family
  - Communicable diseases
• - AIDS/HIV - to warn the sexual partner

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• (3) As a Statutory duty laid down by Law
  - notification of infectious diseases
  - registration of births, still births and
  deaths - industrial diseases - public health
  laws (poisons-factories ordinance)
• - PTA Act and other regulations - therapeutic
  abortions
• - drug addicts

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• (4) Notification to police When a crime is
  committed against the patient or by the patient.
  - Assaults, RTA, sexual offences etc
  - Abortion
• - Poisoning - Child abuse

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• (5) In the interest of public good A doctor is
  not only a health care personnel but also a
  citizen of the country with duties to the society
  
• - food handlers with chronic infections
• - unfit for public service - vehicle drivers
  with epilepsy

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• (6) Courts of Law
• doctor may ask court to respect his silence
• may ask permission to write the answer without
  making it public
• court can insist that the doctor answers verbally
  for all in the Court to hear
• Doctors refusal to answer may result in
  imprisonment for contempt of court

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• - All matters voiced in Court are absolutely
  privileged and carry no risk of a subsequent
  action for defamation or breach of confidence
• Reports sent to Court on Court orders are also
  absolutely privileged
• - Statements made to state prosecutors and crime
  investigators is also absolutely privileged
• - A report given to the rival party or a third
  party without the consent of the patient amounts
  to breach of confidence

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• (8) Disclosure in self interest- when a doctors
  own integrity is threatened
• In civil or criminal actions against the doctor
  by the patient, a doctor can defend himself, by
  giving evidence about the patients illness. Eg.,
  patient alleges that the doctor did not treat
  the patient with antibiotics (patient had viral
  infection)
• information may also be disclosed at the
  discretion of the disciplinary proceeding
  committee of the SLMC in an inquiry against a
  doctor

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• Medical teaching, research and audit A doctor
  can report a case without revealing the patients
  identity

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• Medical records
• belong to the hospital authority and not to the
  doctor unless in the case of private patients.
  If records are called for by Court the hospital
  authority must submit them confidentially
• - should not be given to lawyers without prior
  consultation with the legal representatives of
  the hospital when legal action concerning
  negligence of medical or nursing staff in
  concerned
• - records should not be given to
  employers/insurance companies without the consent
  of the patient or if dead/incapacitated without
  consent of next of kin

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• Insurance companies
• - The medical examination for taking out a
  insurance policy is a voluntary act therefore
  consent is implied
• - Should not give information to an Insurance
  Company about a patients past medical history,
  if the patient has consulted him before

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• Consent

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• In medical practice it refers to the willingness
  of a person to subject himself for examination,
  investigation and treatment

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• Consent is valid when
• free, voluntary, without undue influence
• given by a competent person
• is informed
• - information necessary to make therapeutic
  decision
• - relevant information about research
• - relevant medicolegal information

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• Should be taken from the spouse especially when
  it affects the reproductive and sexual functions
  permanently
• Maybe given by a guardian ( proxy consent) in the
  case of the mentally retarded, minors

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Consent

• Implied Expressed

Verbal Written Gesture Written/witnessed
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Implied consent

• The behavior of person indicated that the person
  is willing for examination and treatment
• Consent is implied when
• - a person voluntarily comes to the OPD/clinic
  and sits by the doctor
• - when he gets admitted to a ward
• - a person who comes voluntarily with a MLEF
  for examination
• However this consent is limited to ordinary forms
  of examination, investigation and treatment

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Expressed consent

• When consent is not implied, the doctor has to
  get consent from a competent patient after
  explaining what he is going to do and the
  implications of what is to be done. In other
  words the patient must express his willingness
  for the examination, investigation and treatment
  
• It must be obtained in the presence of a third
  party

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• Gestures
• - patient may say yes by nodding the head or
  say no by moving the head to and fro sideways
  or moving the hand to and fro sideways or by
  simply running away
• - this type of consent is dangerous as the
  doctor really does not know what the patient
  actually means by the gesture
• - a doctor must not be satisfied with consent
  in the form of a gesture

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• Oral
• - patient will express his willingness by word
  of mouth
• Written
• - the patient will express his willingness in
  writing by putting his signature on the BHT/a
  printed form provided by the institution

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Expressed written consent should be taken.

• Before invasive examination/treatment
• - Per vaginal examination
• - Rectal examination
• - Taking blood for investigations
• - Intra venous therapy
• - Chemotherapy , Radiotherapy
• - Surgery
• - Any procedure needing anaesthesia
• Experimental medicines / clinical trials

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• Written and Witnessed
• - the patient will express his willingness in
  writing and the fact such signature was free
  and voluntary and obtained after explaining
  the procedure and the consequences and is
  witnessed by a third party

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• All medicolegal examinations where persons are
  produced from custody require expressed written
  witnessed consent
• - examination for drunkenness - victims of
  sexual offences - assailants of sexual offences
  - suspects/accused produced by police
• - examinations for insanity - any other person
  produced from custody

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• Such consent is also required from next of kin
  for pathological autopsies and removal of organs
• However if such person refuses to subject himself
  for examination, the doctor cannot proceed to
  examine him against his expressed wishes

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• Consent by Others - in the case of minors and
  others who are incapable of giving valid
  consent, the consent of the parent or guardian
  is required - where there in no such parent or
  guardian, a court order may be obtained
• - no examination can be carried out at the
  request of a police officer or an employer
  without consent

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• in the case of school children in state schools,
  even though the consent of the parents is not
  required, the objections of the parent is upheld
  on condition that they arrange their own GP to
  conduct an examination.

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• - Consent for procedures involving marital
  rights such as sterilizations, termination of
  pregnancy the consent of the spouse is obtained
  to preserve family harmony even though it is
  not legally required - If the procedures are
  carried out to save the life or preserve health
  of spouse, there is absolute no need for
  consent of other spouse

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Instances when consent is not necessary

• Emergency
• Mandatory vaccination requirements
• Statutes requiring quarantine in cases of
  contagious diseases
• Examination under court order