Ethics & law'

FMT- PPT

1. Medical ethics & Law
Dr.Prasanna. P
Assistant Professor

2. Medical Ethics
Medical ethics is defined as the moral
principles which should guide the
members of the medical profession in
their dealings with each other, their
patients and the state.

3. Ethical codes have been developed by
various groups/ professions to
regulate their relationship with each
other as well as with others.

4. Medical etiquette
Conventional laws of courtesy observed b/n
members of the medical profession
Self imposed duty upon each doctor
Forensic medicine – deals with crimes
against human beings in which medical
examination & evidence are required.

5. A doctor may be called to testify
1.As an ordinary witness
2.As the medical officer
3.As an expert to give his opinion

6. Basic values in ethics
1.Beneficence – Do good
2.Non Maleficence – Do no harm
3.Autonomy – Freedom
4.Justice - Fairness and equality

7. 
Do good
A doctor should act in the best
Interest of the patient
 Do no harm
Eg:- should not prescribe drugs
which are known to be harmful

8. Autonomy
Patient should have freedom to
take decision
Informed consent

9. Indian medical council Act
1956
The medical council was constituted by the
act
The first schedule of the Act – Recognized
Medical qualifications granted by Universities
in India
The second schedule – those granted
outside India

10. The Third schedule
- Part I: Contains those granted by medical
institutions not included in the first schedule
- Part II: contains those granted outside India,
but not included in second schedule

11. Indian Medical Council (MCI)
Medical register
Medical education
Recognition of foreign medical
qualifications
Appeal against disciplinary actions (within
30 days)
Warning notice

12. State Medical Council
Medical register
Disciplinary Control
Warning notice

13. Removal of name from register
Serious Professional Misconduct
-professional death sentence
Death
Name entered by fraud / mistake

14. Warning Notice
RMP is required to observe certain
prescribed rules of the conduct
Gives list of examples of offences which
constitute serious professional misconduct
 It has the right to consider any new forms of
alleged misconduct not included in the list

15. INFAMOUS CONDUCT
Conduct of the doctor which might
reasonably be regarded as disgraceful &
dishonorable which is judged by professional
men of good repute & competence
•It involves an abuse of professional position

16. 6 ‘A’s
Adultery
Advertisement
Abortion (criminal)
Association with unqualified persons in
professional matters
Alcohol
Addiction

17. Dichotomy
Touts
Professional secrets
Conviction- immoral & criminal acts
Not notifying notifiable diseases
Refusing Rx- on basis of caste, religion,
race, sex, nationality, some diseases
(A.I.D.S)
False/misleading certificates

18. - Refusing to Rx emergency cases
- Abuse of dangerous drugs act/scheduled
drugs act.
- Owning a chemist shop/ surgicals
- Adopting unfair means - Secret remedies
- Patient snatching
- Association with unqualified people
- Violation of PNDT (prohibition of sex
selection) Act 1994

19. Not abet / aid torture- human rights violation
Publish photos/case reports
Failure to obtain consent- both spouses in
sterilization / in vitro fertilization
•Violating I.C.M.R. guidelines in clinical drugs
trails or other research .
•Euthanasia

21. Red cross emblem
Wrong belief that doctors are entitled to use it
Section 12 – Geneva convention act 1960
prohibits its use.
section 13 - punishment

24. Rights of a R.M.P.
To practice medicine
To choose a patient
To dispense medicine
To posses & supply dangerous drugs
To add title, descriptions etc to the name
To recover fees

25. Appointment to govt & public hospitals
To issue medical certificates
To give evidence as expert witness
Entitled to carry out medico-legal autopsies
Can remove cornea/eyes of a deceased
person.

26. Duties of a R.M.P.
1.To exercise reasonable degree of skill,
care& knowledge during Rx
2.Attendance & examination
3.To furnish proper & suitable medicines
4.To give instructions
5.To control & warn
6.To inform & warn third parties

27. 7.Children & adults who are incapable
8.To inform about risks
9.With regard to poisons
10.Regarding notifiable diseases
11.Operations

28. Operation
Explain the purpose,nature & extent
Informed written consent
Anaesthetist
Utmost care – wrong side, blood
group,wrong patient, sterilized instruments
etc
No experiments- standard procedure
Post-op care & care after discharge

29. Duties with regard to
Consultation
1.Not sure of diagnosis
2.Obscure/Unexpected developments
3.Serious complications
4.Operation/procedure – risk to life
5.Affect intellectual, reproductive
functions
6.In an emergency
7.Assault case

30. 8. Therapeutic abortion- 12-20weeks
9. Operation-mutilation/destructive in

nature-on unborn child
10. In cases where criminal abortion is
done & then comes
11. If facilities are inadequate
12. If patient volunteers

31. Unnecessary consultation – avoided
Conduct in consultation – no insincerity/
rivalry. Do not criticize referring doctor
Should not totally take charge of the case
-must discuss diagnosis & Rx plan with
referring doctor.

32. PROFESSIONAL SECRECY
Implied contract
Amounts to breach of contract, trust &
confidence.
Amounts to injury
Spouse, parents, employer or govt
Accused & convict
Insurance companies
Divorce or nullity cases

33. Privileged communications
It’s a statement made bonafide upon any
subject matter by a doctor to the
concerned authority, due to his duty to
protect the interests of the community or
of the state.
 It should be unbiased, bonafide & without
any malice.

34. The interest of public cannot be
held at jeopardy/risk, because
of sole interest of one
particular patient who due to
his particular type of illness,
may endanger the safety of
larger section of the society.

35. -Employer & employee
-Infectious diseases
-Veneral diseases
-Notifiable diseases
-Suspected crime
-Self interest
-Patients own interest
-Negligence suits
-Courts of law

36. Professional negligence
Absence of reasonable care & skill
0R
Willful negligence of a medical practitioner
in the treatment of a patient which may
cause bodily injury or death of the patient

37. Liable if following are present
Duty
Dereliction
Direct causation
Damage

38. Types
Civil negligence
Criminal negligence

39. Negligence & misconduct
1.Absence of care & skill
2. Duty of care – must
3. Damage must be
present
4. Trial by courts
Disgraceful &
dishonorable conduct
Need not be present
Need not be present
By S.M.C

40. 5. Imprisonment / fine
6. Appeal to higher
courts of law
Warning, erasure of
name
To I.M.C

41. Differences
Civil Negligence
1.Simple absence of care
& skill
2. No specific/outright
violation of law
Criminal Negligence
Gross, wicked,
criminal, culpable –
scant regard for
patient’s safety
2. Clear violation of law-
sec 304(A) I.P.C

42. 3. Proof: balance of
probabilities
4. Consent &
Contributory
negligence- good
defence
3. Beyond reasonable
doubt
4. Not so

43. 5. Trial – civil court
6. Dispute between two
parties
7. Punishment –
compensation
8. Can be tried twice for
the same offence
5. Criminal court
6. Government & doctor
7. Imprisonment +/-
fine
8. Cannot be tried

44. Civil negligence
Simple absence of care & skill
This question arises when
a)Patient/relative brings a civil suit against
doctor
b)When a doctor brings a civil suit for
realization of fees against the patient

45. Damage may be in the form of
1. Physical & mental suffering
2. Prolongation of hospital stay
-Increased expenses
-Loss of daily earnings
3. Reduction in enjoyment
4. Reduction in life expectancy
5. Death

46. Instances
-Failure to obtain consent
-Wrong diagnosis due to absence of care
& skill
-Failure to attend / make alternative
arrangements
-No proper instructions/post-op care
-Failure to immunize/perform sensitivity
tests

47. -If the act of the doctor causes others
to catch a disease from his patients
-Discharging patient prematurely
-Not advising X-ray/F.N.A.C/biopsy or
other necessary investigations
-Not advising consultation when required

48. Criminal negligence
Gross lack of competence
Gross inattention
Gross recklessness
Gross negligence in the selection &
application of remedies
Willful, wanton
Extreme departure from the ordinary
standard of care

49. Here a doctor shows gross lack of
competence , gross inattention or inaction,
gross recklessness or gross negligence in
the selection & application of remedies.
Utter disregard about the safety of the
patient
It involves an extreme departure from the
ordinary standard of care

50. Punishment
-Imprisonment with or without fine
-If the patient dies the doctor will be
prosecuted u/s 304(A) I.P.C
“ Whoever causes death of any person by any
rash & negligent act not amounting to
culpable homicide shall be punished with
imprisonment up to 2 years with or without
fine

51. Examples
-Amputation of wrong part or wrong patient
-Leaving behind instruments, sponges/swabs
etc
-Gross mismanagement of a delivery case
-Administration of wrong substance to eye
-Performing criminal abortion

52. To establish negligence
There is a usual & normal practice
That practice was not adopted
The course was one which no
professional man of ordinary skill
would have taken .

53. Res ipsa loquitor
1.In the absence of negligence the
injury/damage would not have occurred
ordinarily
2.The doctor had exclusive control over
injury producing instrument or treatment
3.Patient was not guilty of contributory
negligence

54. Examples
-Mismatched blood transfusion
-Over dosage of medicines
-Leaving swabs in the abdomen
-Prolonged splinting

55. Contributory negligence
Concurrent negligence/unreasonable
conduct on the part of the
patient/attendant which coupled
with doctor’s negligence caused the
damage complained of, as a direct
cause with out which the injury
would not have occurred.

56. Failure to give accurate history
Failure to co-operate with the doctor in
carrying out all reasonable & proper
instructions
Failure to take suggested treatment
Discharge A.M.A
Neglecting follow-up

57. Good defence in civil cases
Only a partial defence
If the doctor is negligent & only the patient
is negligent it is called negligence of the
patient.
Limitations :
1. The last clear chance doctrine
2. The avoidable consequences rule

58. Medical maloccurance
Bio-physiological actions & reactions to
different drugs are different & extremely
variable.
-Tolerance
-Idiosyncrasy
Must be aware of unexpected, unexplained
&even rare effects
Not a blank cheque

59. Misadventure
1.Therapeutic misadventure
Penicillin
Anti snake venom
Anti cancer drugs
2.Diagnostic
Barium enema- poisoning / rupture
3.Experimental

60. Calculated risk
In certain management maneuvers there may
be certain amount of inevitable risk.
-amniocentesis- 1% risk of abortion
-C/S – 0.1% risk of maternal mortality
1.Justification for risk taken
2.Preventive measures taken

61. Products liability
Physical agent which caused the injury or
death of the patient during treatment
Faulty, defective, negligently designed
instruments or inadequate operating
instructions- fault of manufacturer
If it functioned satisfactorily for many
years, later due to wear & tear or if not
handled properly – doctor is at fault

62. Drugs
-Lack of care & skill in R&D wing
-Contamination or wrong drug/dosage
-They should provide package inserts
which mention its effects, side-
effects, C.I., dosage, routes,
frequency & duration of
administration

63. Novus actus interveniens
“An unrelated action intervening”
A person is not only responsible for
his actions, but also for the logical
consequences of those actions
An element of negligence is
essential

64. Vicarious liability
“An employer is responsible not only for his own
negligence but also for the negligence of his
employees”.
Respondent superior (let the master answer)
Captain of the ship
-E-E relationship
-Employees conduct must occur within the
scope of employment
- This should occur while on job

65. Borrowed servant doctrine
An employee may serve more than one
employer
Junior doctor/intern
Nursing staff
Pharmacist
Usually surgeon not responsible for
negligence of anaesthetist & vice-versa

66. Defence against negligence
No duty of care
Duty discharged with care & skill
and according to prevailing
standards
Consent
Contributory negligence
Medical maloccurance
Misadventure

67. Error of judgement
Calculated risk
III party intervention
Res judicata –(S 300 CrPC)
Limitation
Products liability

68. Prevention
I. Communication
a) Be polite, establish good rapport
b) NEVER guarantee cure but care
c) Prognosis: no exaggeration

69. d) Give proper & clear instructions
- prescriptions
- diet
- pre- op instructions
- use of inhalers

70. II. Case records
Up-to-date, accurate & complete
-Patient refusing any particular
treatment, investigation
-Discharge against medical advice
-Consent: own handwriting if literate

71. III. Up-date knowledge
M.C.I stipulates 30 hrs of C.M.E. in five
years
Must keep abreast with the latest
developments

Always practice standard procedure of
Rx -never experiment.

72. IV. Do not neglect the patient
Reasonable degree of care & skill
Attend regularly
All necessary investigations
Consultation if required
Arrange for a good substitute

73. V. Do not criticize another doctor
VI. Associate with good & qualified
staff
VII. Cordial working atmosphere
VIII. Guard against hazards
-Adverse drug reactions

74. Instruments, equipments etc
Well maintained – serviced
regularly, repaired or replaced
Consent

75. EUTHANASIA-”good death”
Synonyms- mercy killing, assisted suicide,
physician assisted suicide, aid in dying etc
It refers to infliction of painless
death on an individual suffering
from severe intractable pain or
discomfort, arising out of terminal
illness or condition

76. Classification
I.
a.Voluntary
b.Involuntary
c.Non-voluntary
II.
a.Active
b.passive

77. For
Duty of doctor is moving away from
the obligation to preserve life “ at
all costs" towards a more flexible
duty to provide good palliative
terminal care.
Dying with dignity
Cost factor

78. Against
Moral, ethical & religious objections
Misuse
 No development of science
Article 21- right to life

79. Legal status in India
No legal sanction
306 I.P.C & 309 I.P.C
Active & involuntary - murder

80. Consumer protection act 1986
Purpose
To protect the interest of consumers
Includes services like, household
articles, banking, food, transport,
entertainment, electricity etc.

81. Medical profession - included in 1995
Aims to provide cheap & speedy remedy
Criticism:
Defensive medicine
Indemnity insurance
Frivolous complaints

82. S
District forum
< 20 lakhs
State commission
>20 lacks < 1crore
National commission
> 1crore

83. Consent
Means voluntary agreement,
compliance or permission.
Types:
1.Expressed
2.Implied

84. Informed written consent
Diagnosis
Proposed line of Rx
Alternatives available
Pros & cons
Relative chances of success /failure
Consequences of refusing Rx

85. Full disclosure
Can cause more anxiety in an
already tensed & emotionally
disturbed patient.
What to reveal depends on
-patient’s personality
-Level of education
-Physical & mental status
-Normal practice in that society

86. - Don’t inform such risks- if unsure
-Normally all major risks are to be
informed
-Exception – frank psychosis or
psychoneurosis
-therapeutic privilege
-Make a note in case sheet
explaining the reasons &
intentions

87. Informed refusal
Paternalism – deprivation of
patient autonomy

88. Rules of consent
Needed for every medical examination
If implied no need of formal consent
Oral consent-presence of III party
beyond routine physical examination –
written consent
These are essential to prove that the
consent was taken, in the court
No prescribed Proforma –should be in a
proper form & suitable for the situation

89. Not to be taken at the time of admission
but before the procedure/examination
To be valid- no blanket consent
Victim exam – consent must

- 53(a) CrPC: accused examination even
without consent by the request of SI

90. 53 (b) CrPC – when the accused
happens to be a women
54 CrPC

87 IPC - > 18yrs –valid consent to
suffer any harm which may result
from an act not intended or not
known to death or grievous hurt
88 IPC – done in good faith and for
his benefit

91. 
Children < 12yrs & an insane person
cannot give valid consent
89 IPC – Parent/guardian’s consent
Loco parentis
90 IPC– consent given under fear of
injury or due to misunderstanding
consent by an insane/intoxicated
who is unable to understand the
nature & consequences of the act

92. 92 IPC – Any harm caused to a person
in good faith, even without consent is
not an offence if the situation is such
that it is impossible for that person
to give consent & has no guardian or
other person in lawful charge of him
from whom it is possible to obtain
consent in time to do the act for his
benefit

93. Nothing is said to be done in good
faith which is done without due
care & attention – 52 IPC
Open consent- in case where
diagnosis is not known.
Consent of hostel inmates
Vaccination- Law gives consent

94. A person can be treated with out
consent for the benefit of the
society
Consent given for committing a
crime like criminal abortion – invalid
For contraceptive sterilization,
consent of both H & W

95. In other types of operation the
consent of other spouse is not
needed
But it is advisable:
- danger to life
- may destroy / limit sexual function
- may cause death of unborn child

96. Unlawful to detain any patient
Donating organs
Clinical autopsy
Defence in civil negligence