Medico-Ethics and Medicolegal- Notes.pptx

Ethical issues and concepts related to healthcare in general.

1. Medico-Legal issues

2. Public Health: Definition The science and the art of: Preventing disease, prolonging life, and promoting physical health and efficiency This is achieved through organized community efforts for: sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, and the organization of medical and nursing service for the early diagnosis and preventive treatment of disease.”

3. Public Health Law. Definition: Study of legal powers and duties of state, in collaboration with its partners ( health care; business; the community; the media and academia) to ensure conditions for people to be healthy (to identify; prevent and ameliorate risks to health in the population) and of the limitations on the power of the state to constrain the autonomy, privacy , liberty , proprietary, or other legally protected interests of individuals for the common good. The prime objective of public health law is to pursue the highest level of physical and mental health in the population, consistent with the values of social justice.

4. Definition cont. Enforced rules devised by the State to govern the behaviour of its members for the mutual benefits of all. Observance of the rules must be guaranteed by some kinds of sanction directed against the rule breakers. However in addition, doctors are bounded by certain specific rules stipulated in statutes as well as code of professional conduct laid down by the official regulating authority: Medical Council, and administrative codes set by the institutions. Formation of a legal framework regarding the practice of medicine, violation of which may lead to criminal or civil liability, or disciplinary actions.

5. Emerging Themes Government power and duty: Health as a Salient Value Coercion and limits on state power Government’s partners in the “public health system” The population of focus Communities and civic participation The prevention, orientation and Social justice

6. Principles of the Ethical Practice of Public Health (Source: Public Health Leadership Society 2002) Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. Public health should achieve community health in a way that respects the rights of individuals in the community. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members .

7. Principles of the Ethical Practice of Public Health cont. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. Public health should seek the information needed to implement effective policies and programs that protect and promote health. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

8. Principles of the Ethical Practice of Public Health cont. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

9. Principles of the Ethical Practice of Public Health cont. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. Public health institutions should ensure the professional competence of their employees. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

10. Why consider Ethics in Public Health Law Exploration of ethical questions that arise in public health practice , for example the H. Influenza Vaccine allocation, Hepatitis Vaccine allocation, etc Enrichment of the understanding of public health profession’s roles and professional values Development of participant’s capabilities to participate in deliberations and public health exchanges about ethical issues in order to strengthen community trust and cooperation

11. Cardinal features of medical ethics Beneficence Non-maleficence Autonomy or self determination Social justice Patient-Doctor relationship It is a professional contract It is a legal contract It calls for professional duties and responsibilities It has legal obligations

12. Chapter 253, Laws of Kenya Establishes the medical practitioners and dentists board States that a legally licensed private medical/dental practitioner is legally allowed to charge fees for professional services rendered Any person seeking professional services in such settings must understand and accept the obligation of paying fees

13. Definitions of Law in Public Health and Ethics in public Health Law in PH: Provides authority, limitations on state power, incentives and disincentives for behavior, often allows for much professional discretion. Law : Formal institution-statutes, regulations and court decision Public proceedings with a “reasonable person” standard Ethics in PH: provides ongoing analysis, deliberations about and justification for PH action and policy, often when the law is indeterminate Ethics: less formal- moral norms; values; professional codes; previous cases Publicly justifiable positions based on ethical reasoning Law and ethics complement each other

14. Ethics vs. Law Ethics: what one should or should not do, according to principles or norms of conduct e.g : Gather more information about the problem, how to manage the information collected What to be done to protect and promote the health of the public Ethics codes are not produced by democratically-elected legislatures Enforcement mechanisms are usually informal, may be complex, even unconscious Law: what one must or must not do, according to legal dictates Laws are created by democratically-elected legislatures in democracies Laws come with explicit penalties for infractions and a formal enforcement system

15. Definitions Medicine: The science and art of diagnosing, treating, and preventing disease. Law: A system that provides for rights between parties. Civil Law concerns disputes among private parties (individuals, businesses, corporations). Criminal law concerns enforcement of societal rules against individuals . Sources of the law: constitution;

16. Law and medical ethics are both dynamic and are in a constant state of change with time due to changing circumstances and societal values. New legislation and court decisions give rise to changes of the law and new ethical issues emerge in response to challenges created by new technology, law or other influence. Wide variation of the law from country to country because of factors regarding religion, culture, traditions, political systems and social standards.

17. Medical Ethics In all countries, medical practice controlled by laws & regulations Professional work governed by a ‘code of conduct’ – not imposed by law, but voluntary agreement within the profession This ‘ code of conduct ’ for professional self-regulation is broadly called ‘ medical ethics’

18. Medical ethics cont’d Some aspects have been taken over by national laws such as ‘breach of medical confidentiality’ or ‘abortion’. Broad principles of medical ethics are universal Formulated by national medical associations & international organizations such as the World Medical Association T his context applies to Western medicine; many other systems such as Chinese, Ayurvedic medicine of India, traditional medicine – all have their own conventions & codes of conduct

19. Historical Origins Ancient Greece through Asian, North African and European Medicine Greek tradition of medicine, epitomized by the Hippocratic School on the island of Cos about 400BC flourished at a geographical crossroads in Eastern Mediterranean Absorbed by the Roman Empire, kept alive during the Dark Ages by Arabic doctors in North Africa, Spain etc until the time of European Renaissance in medieval times. The Greek code of conduct survived & in principle is still the basis of today’s of ethical behaviour – The ‘Hippocratic Oath’

20. Hippocratic Oath – a general translation “I swear by Apollo the physician and Aesculapius and health and All-heal and all the gods and goddesses, that according to my ability and judgment, I will keep this Oath and this stipulation – to hold him who taught me this art, equally dear to me as my own parents, to make him partner in my livelihood: when he is in need of money, to share mine with him; to consider his family as my own brothers and to teach them this art, if they want to learn it, without fee or indenture …I will use treatment to help the sick according to my ability and judgment

21. Hippo. Oath- General translation cont. But never to injury or wrongdoing. Neither will I administer poison to anybody when asked to do so nor will I suggest such a course. Similarly, I will not give a woman a pessary to produce abortion. But I will keep holy both my life and my art…Into whatsoever houses I enter, I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further, from seduction of females or males, of freeman or slaves. And whatever I shall see or hear in the course of my profession or not spoken of abroad, I will not divulge, reckoning that all should be kept secret. While I carry this oath, and not break it, may it be granted me to enjoy life and the practice of the art, respected by all men: but should I transgress it, may the reverse be my lot.”

22. Modern form of the Hippocratic Oath ‘Declaration of Geneva’ 1948 Followed serious violations by Fascist doctors in Germany and Japan during world war II 1939-1945 International community re-stated the oath Amended by WMA in Sidney in 1968 (definition of death), in Oslo in 1970 (therapeutic abortion), in Munich in 1973 (racial, political & other discrimination), in Tokyo in 1975 (doctor’s attitude to torture & other degrading treatment), Helsinki in 1975 (human experimentation & clinical trials), Lisbon in 1981 (rights of patients), in Venice in 1983 (terminal illness).

23. Modern Hippocratic Oath I solemnly pledge myself to consecrate my life to the service of humanity. I will give to my teachers the respect and gratitude which is their due. I will practice my profession with conscience and dignity. The health of my patients will be my first consideration. I will respect the secrets which are confided in me, even after the patient has died. [CONFIDENTIALITY] I will maintain by all means in my power, the honour and noble traditions of the medical profession. My colleagues will be my brothers. I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patients. [EQUITY] I will maintain the utmost respect for human life from its beginning and even under threat I will not use my medical knowledge contrary to the laws of humanity. [MALFICIENCE & BENEFICIENCE] I make these promises solemnly, freely and upon my honour .

24. International Code of Medical Ethics Derived from the modern Hippocratic Oath & includes: Duties of physicians in general Duties of physicians to the sick Duties of physicians to each other Medical ethics in practice Medical confidentiality Consent to medical treatment

25. Mutual Rights and Duties Rights and duties/responsibilities of doctors have developed in parallel with the doctor’s ability to diagnose and manage health problems This (the doctor’s ability to diagnose and treat) has, in turn, been affected by improvement in science and technology In the greater part of 20 th century, Patient-Doctor Relationship (PDR) was characterized by professional paternalism The scene is changing rapidly and the patient is increasingly being regarded of an equal partner in the PDR Rights are cherished by everybody and regarded as the highest level of expectations/requirements

26. Mutual rights and Duties cont. But demands of rights MUST be reciprocated by exercise of responsibility In the context of this lecture series, issues related to mutual rights and duties/responsibilities will feature in several topics, such as, consent, confidentiality, PDR and professional fees This creates an inevitable overlap and consequent repetition - which is advantageous Mutual rights and duties of doctors and patients MUST be exercised in tandem with the cardinal principles of medical ethics

27. Examples of Rights and duties Right to choose (the doctor, the patient and the health institution) The right to consent to treatment The right to refuse treatment The right confidentiality The right to privacy The right to know The right to seek a second opinion The right to discharge or be discharged The right to refer or be referred The right to transfer or be transferred

28. Duty of the patient to: To seek clarification on any issues arising out of DPR To comply with the advice and instructions of the doctor for maximal results To trust the doctor and know the doctor is acting in good faith and has the good will To understand that the doctor is human and to understand that the doctor is liable to make unintentional mistakes in the course of caring for him/her

29. Duties of physicians in general Always maintain the highest standards of professional conduct Not permit motives of profit to influence free and independent exercise of professional judgment on behalf of patients Be dedicated to providing competent medical service in full technical and moral independence, with compassion and respect for human dignity Deal honestly with colleagues and strive to expose those physicians deficient in character or competence or who engage in fraud or deception

30. Duties of physicians in general cont´d Respect rights of patients, colleagues and other health professionals, safeguard patient confidences Act only in the patient’s interest when providing medical care which might weaken the physical and mental condition of the patient Use great caution in divulging discoveries or new techniques or treatment through non-professional channels Certify only that which he has personally verified

31. Unethical conduct Self-advertising by physicians Paying or receiving any fee or other consideration to procure the referral of a patient or for prescribing or referring a patient to any source

32. Patient care cases Allegations of Negligence Arrival Delay Inadequate Assessment Inadequate Treatment Patient Transport Delay No Transport Provided

33. Duties of physicians to the sick Always bear in mind the obligation of preserving life Always owe complete loyalty to his patients and to all the resources of his science Whenever an examination or treatment is beyond the physician’s capacity, he should summon another physician who has the necessary ability Observe absolute confidentiality on all he knows about his patient even after the patient has died Give emergency care as a humanitarian duty unless he is assured that others are willing & able to give such care

34. Duties of the physician to each other Behave towards his colleagues as he would have them behave towards him Observe the principles of the Declaration of Geneva, approved by the World Medical Association

35. Medical Ethics in Practice ‘The patient is the centre of the medical universe, around which all efforts of doctors revolve’. The doctor exists for the patient & not the other way round. The doctor must never do anything which is not in the interest of the patient and all considerations of money, politics, class, race, religion or nationality are irrelevant in the doctor-patient relationship. From this springs all other aspects of ethical behaviour, including interaction of doctor & doctor, doctor with society & government General guiding principle is ‘peer conduct’; some action may not be illegal, but may not be acceptable behaviour of medical colleagues; reinforced by professional disciplinary procedures

36. Medical Confidentiality Although much of the original Hippocratic oath has changed, the clause of secrecy or confidentiality has remained the same since it was written, some 2400 years ago. Secrecy indispensable to good medical practice Only situations where the strict duty of medical confidentiality may be broken:

37. Circumstances in which medical confidentiality may be ‘breached ’ With permission of the patient To other doctors To relatives e.g to parents of a child; those who have to care for the patient at home Statutory (legal) requirements – official notification of birth, deaths, stillbirths, infectious diseases, therapeutic abortions, occupational diseases, drug addictions etc In courts of law where a doctor is a witness

38. Circumstances in which medical confidentiality may be ‘ breached ’cont . The police – in some countries the police have power to demand disclosure of medical information, not automatic In the public good – in some countries it is a crime for a doctor not to report criminal injuries, esp connected to terrorist acts e.g. In Northern Island, compulsory for a doctor to report firearm or explosive injuries Disclosure to lawyers – do not have automatic right to obtain medical information & records without patient’s permission; in many countries, a lawyer in a civil case must apply to court for ‘disclosure’

39. Disclosure to Lawyers, Insurance company When asked by a lawyer or insurance company for a medical report, doctor must first ascertain patient has granted permission. If lawyer acting for a patient, such permission is assumed, but the lawyer must specify this. If not sure, request for a written permission or doctor may be sued by the patient & disciplined by regulatory medical board for unethical conduct

40. Some medical confidentiality dilemmas A bus driver with severe hypertension which could cause him to crash a busload of children An airpilot with angina A food-handler with an enteric infection A teacher with tuberculosis Action by Doctor: Strict medical exams for those with public responsibility by employer/licensing authority to pick up an illness that may endanger the public Doctor can advise/persuade patient to change his job

41. Medical Consent No adult person need accept medical treatment unless they wish to do so. Permission for diagnosis & treatment is essential or the doctor may be sued for assault if he touches or even attempts to touch an unwilling person. Most assault cases in a medical context involve some injurious effect of a surgical operation or othe invasive procedure to which the patient did not give full consent.

42. Medical Consent cont´d In cases of children, parents/guardians give consent, the age of consent varies from country to country, in some places 13y or 16 In cases for mental disease or defect – either relatives, the medical institution or a legally appointed authority gives permission on behalf of that patient In an emergency e.g. patient unconscious or in shock, no permission is necessary (decision made in good faith in the interest of the patient)

43. Types of Consent to medical treatment 1. Implied Consent Most medical practice falls into this category When a patient comes to hospital, walks into a Doctor’s consultation, it implies he is willing to be examined & treated Use of a stethoscope to auscultate the chest preceded by a courteous ‘Would you mind taking off your shirt for me to listen to your chest?’ – is actually a request for consent – but is only limited to basic history taking, physical exam. Does not include intimate exam such as rectal or vaginal exam nor invasive procedures, for which specific permission must be requested after an explanation of what is to be done & why.

44. 2. Express Consent For more complex procedures than ordinary clinical examination, specific permission must be obtained from the patient – ‘Express consent’: All surgical procedures, especially those under anaesthesia Any internal examination, either intimate manual or any form of endoscopy; for a repeat at another date, another express consent must be obtained Often written, but not necessarily so; written consent for surgical procedures must be witnessed by another person present at the signing to prevent allegation that consent was forged, or obtained under pressure or duress. Dilemma if during an operation, an expected finding necessitates change of procedure

45. Informed Consent No consent is legally valid unless the patient understands for what he is giving permission A paternalistic attitude by doctors to keep the patient ignorant is wrong & no longer acceptable Patient is now entitled to be told everything, with the proviso that a doctor can withhold that information which, in his clinical judgment may be harmful to the patient’s health and recovery Controversy of patients’ access to their own medical records; practice now moving to a completely open system

46. Informed Consent cont´d Both good clinical practice & legally advisable for a full explanation of nature, reason & risks of any surgical or diagnostic procedure to the patient before seeking consent. It is the right of the patient to consider & weigh the risks, pain & discomfort & decline or accept the procedure Dilemma that complete disclosure may put off patients to access appropriate diagnosis & therapy; therefore better to give the probability rather than absolute risk – a risk-benefit equation Concept of possible risk also extends to drugs where possible side-effects should be explained to patients

47. Medical Malpractice Covers all defects in the professional behaviour of doctors Falls into two groups Where standard of medical care given to a patient is considered inadequate, i.e. medical negligence Where personal professional behaviour falls below that which is expected of a doctor, i.e. professional misconduct

48. Medical Negligence Not all mishaps occurring during medical treatment are due to negligence, i.e. doctor guilty of careless or incompetent actions. All patients have a right to expect a satisfactory standard of medical care from their doctor although the doctor can never guarantee a satisfactory outcome of treatment A famous British Judge said, ‘Doctors are not insurers’, meaning that biological factors prevent a wholly predictable result. Unlike the law of contract, where a manufacturer must produce an end product exactly as the customer expected.

49. Medical negligence cont’d When a patient can prove that he suffered harm as a result of a doctor’s failure to provide reasonable standard of care, he is entitled to financial compensation (‘damages’) – An attempt to restore the patient financially to the position he would have been in had the negligence not occurred, especially in relation to loss of earnings from employment In most countries, this is a civil matter where a patient brings a personal action against the doctor or hospital In some countries, the government may intervene and bring a criminal prosecution against the doctor.

50. Before a case of negligence can succeed, a patient must prove that: The doctor had a duty of care towards him (and) That there was failure in that duty of care (which) Resulted in physical or mental damage.