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Ethics & law'


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Ethics & law'

  1. 1. Medical ethics & Law Dr.Prasanna. P Assistant Professor
  2. 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. 3. Ethical codes have been developed by various groups/ professions to regulate their relationship with each other as well as with others.
  4. 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. 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. 6. Basic values in ethics 1.Beneficence – Do good 2.Non Maleficence – Do no harm 3.Autonomy – Freedom 4.Justice - Fairness and equality
  7. 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. 8. Autonomy Patient should have freedom to take decision Informed consent
  9. 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. 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. 11. Indian Medical Council (MCI)  Medical register  Medical education  Recognition of foreign medical qualifications  Appeal against disciplinary actions (within 30 days)  Warning notice
  12. 12. State Medical Council Medical register Disciplinary Control Warning notice
  13. 13. Removal of name from register  Serious Professional Misconduct -professional death sentence  Death  Name entered by fraud / mistake
  14. 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. 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. 16. 6 ‘A’s  Adultery  Advertisement  Abortion (criminal)  Association with unqualified persons in professional matters  Alcohol  Addiction
  17. 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. 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. 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
  20. 20. Red cross emblem  Wrong belief that doctors are entitled to use it  Section 12 – Geneva convention act 1960 prohibits its use. section 13 - punishment
  21. 21. 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
  22. 22.  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.
  23. 23. 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
  24. 24. 7. Children & adults who are incapable 8. To inform about risks 9. With regard to poisons 10. Regarding notifiable diseases 11. Operations
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28.  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.
  29. 29. 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
  30. 30. 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.
  31. 31. 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.
  32. 32. -Employer & employee - Infectious diseases - Veneral diseases - Notifiable diseases - Suspected crime - Self interest - Patients own interest - Negligence suits - Courts of law
  33. 33. 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
  34. 34. Liable if following are present Duty Dereliction Direct causation Damage
  35. 35. Types Civil negligence Criminal negligence
  36. 36. 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
  37. 37. 5. Imprisonment / fine 6. Appeal to higher courts of law Warning, erasure of name To I.M.C
  38. 38. 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
  39. 39. 3. Proof: balance of probabilities 4. Consent & Contributory negligence- good defence 3. Beyond reasonable doubt 4. Not so
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. - 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
  45. 45. 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
  46. 46.  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
  47. 47. 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
  48. 48. 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
  49. 49. 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 .
  50. 50. 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
  51. 51. Examples - Mismatched blood transfusion - Over dosage of medicines - Leaving swabs in the abdomen - Prolonged splinting
  52. 52. 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.
  53. 53.  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
  54. 54. 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
  55. 55. 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
  56. 56. Misadventure 1.Therapeutic misadventure Penicillin Anti snake venom Anti cancer drugs 2.Diagnostic Barium enema- poisoning / rupture 3.Experimental
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. Defence against negligence No duty of care Duty discharged with care & skill and according to prevailing standards Consent Contributory negligence Medical maloccurance Misadventure
  64. 64. Error of judgement Calculated risk III party intervention Res judicata –(S 300 CrPC) Limitation Products liability
  65. 65. Prevention I. Communication a) Be polite, establish good rapport b) NEVER guarantee cure but care c) Prognosis: no exaggeration
  66. 66. d) Give proper & clear instructions - prescriptions - diet - pre- op instructions - use of inhalers
  67. 67. II. Case records Up-to-date, accurate & complete -Patient refusing any particular treatment, investigation -Discharge against medical advice -Consent: own handwriting if literate
  68. 68. 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.
  69. 69. IV. Do not neglect the patient  Reasonable degree of care & skill  Attend regularly  All necessary investigations  Consultation if required  Arrange for a good substitute
  70. 70. V. Do not criticize another doctor VI. Associate with good & qualified staff VII. Cordial working atmosphere VIII. Guard against hazards -Adverse drug reactions
  71. 71. Instruments, equipments etc Well maintained – serviced regularly, repaired or replaced Consent
  72. 72. 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
  73. 73. Classification I. a. Voluntary b. Involuntary c. Non-voluntary II. a. Active b. passive
  74. 74. 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
  75. 75. Against Moral, ethical & religious objections Misuse  No development of science Article 21- right to life
  76. 76. Legal status in India No legal sanction 306 I.P.C & 309 I.P.C Active & involuntary - murder
  77. 77. Consumer protection act 1986 Purpose To protect the interest of consumers Includes services like, household articles, banking, food, transport, entertainment, electricity etc.
  78. 78. Medical profession - included in 1995 Aims to provide cheap & speedy remedy Criticism: Defensive medicine Indemnity insurance Frivolous complaints
  79. 79. S District forum < 20 lakhs State commission >20 lacks < 1crore National commission > 1crore
  80. 80. Consent Means voluntary agreement, compliance or permission. Types: 1. Expressed 2. Implied
  81. 81. Informed written consent Diagnosis Proposed line of Rx Alternatives available Pros & cons Relative chances of success /failure Consequences of refusing Rx
  82. 82. 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
  83. 83. - 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
  84. 84. Informed refusal Paternalism – deprivation of patient autonomy
  85. 85. 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
  86. 86.  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
  87. 87. 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
  88. 88.  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
  89. 89. 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
  90. 90. 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
  91. 91. 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
  92. 92. 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
  93. 93. Unlawful to detain any patient Donating organs Clinical autopsy Defence in civil negligence