Ethics and
Professionalism in
Surgery
Dr ibtisam albader
Mubarak al kabeer hospital
26March 2013
Islam and the Promotion of Science
• Stressing the importance and respect of
learning. For example, the first word revealed
to Prophet Mohammad (peace and blessings be
upon him) was “READ.”
• In that time, a captured enemy was freed if he
paid a ransom or taught ten Muslims reading
and writing.
• The general philosophy in Islamic medicine is
that the healer is Allah Most High and the
doctor is the instrument that Allah uses to heal
the people.
• The doctor-patient relationship is stronger in
Islam than it is in modern medicine as he has
responsibilities, which Allah on the Day of
Judgment will ask about
Certification!
Practicing physicians: Only qualified physicians
were allowed by law to practice medicine.
In CE 931, the Caliph Al-Mugtadir from the
Abbasid dynasty, ordered the Chief CourtPhysician Sinan Ibn-Thabit to SCREEN the 860
physicians of Baghdad, and only those
qualified were granted license to practice.
Early teachings I
Al-Tabari, the chief physician in 970
CE, described the Islamic code of
ethics in his book Fardous Al
Hikma
Remember this!
• The physician should be modest, virtuous and merciful. He should wear
clean clothes, be dignified, and have well groomed hair and beard. He
should select his company to be persons of good reputation. He should
be careful of what he says and should not hesitate to ask forgiveness if
he has made an error. He should be forgiving and never seek revenge. He
should be friendly and a peacemaker. He should avoid predicting
whether a patient will live or die, only Allah knows. He should not lose his
temper when his patients keep asking questions, but should answer
gently and compassionately. He should treat alike the rich and the poor,
the master and the servant. God will reward him if he helps the needy.
He should be punctual and reliable. He should not wrangle about his
fees. If the patient is very ill or in an emergency, he should be thankful,
no matter how much he is paid. He should not give drugs to a pregnant
woman for an abortion unless necessary for the mother's health. He
should be decent towards women and should not divulge the secrets of
his patients. He should speak no evil of reputable men of the community
or be critical of any other’s religious belief. He should speak well of his
colleagues. He should not honor himself by shaming others."
Ishaq bin ali al-rahawi (854-931)
• This is an excerpt from Transactions of the
American Philosophical Society, Vol. 57, Part 3,
1967. "Medical Ethics of Medieval Islam with
Special Reference to Al-Ruhawi's Practical
Ethics of the Physician", translated by Martin
Levey. Permission for printing of excerpts
from TAPA has been obtained
Ishaq bin ali al-rahawi
(854-931)
1.The loyalty and the faith of the Physician, and Ethics He Must Follow to improve His Soul and Morals.
2. Care of the Physician's Body
3. What the Physician Must Avoid and Beware of
4. Directions of the Physician to the Patient and Servant
5. Manners of the Visitors
6. Care of Remedies by the Physician
7. What the Physician Asks the Patient and the Nurse
8. What the Patient May Conceal from the Physician
9. How the Healthy and ill Must Take Orders of the Physician
10. Training of Servants by the Patient before Illness
11. Patient and Visitors
12. Dignity of the Medical Profession
13. Respect for the Physician
14. Physicians and Peculiar Incidents to Aid Treatment
15. Medical Art for Moral People
16. Examination of Physicians
17. Removal of Corruption of Physicians
18. Warning against Quacks
19. Harmful Habits
20. Care of the Physician Himself
Ishaq bin ali al-rahawi (854-931)
First medical peer review
• Visiting physician must make duplicate notes of a
patient condition on every visit
• When a patient was cured or died , the notes were
examined by a local medical council of other
physicians, who would review the practicing physician
notes to decide whether his/her performance have
met the required standards of medical care.
• If the reviews were negative the practicing physician
could face a law suit from a maltreated patient.
Principles of Medical EthicsRevised and adopted by the AMA
House of Delegates (June 17, 2001
)
• I. A physician shall be dedicated to providing competent medical
care, with compassion and respect for human dignity and rights.
• II. A physician shall uphold the standards of professionalism, be
honest in all professional interactions, and strive to report
physicians deficient in character or competence, or engaging in
fraud or deception, to appropriate entities.
• III. A physician shall respect the law and also recognize a
responsibility to seek changes in those requirements which are
contrary to the best interests of the patient.
• IV. A physician shall respect the rights of patients, colleagues, and
other health professionals, and shall safeguard patient confidences
and privacy within the constraints of the law.
Principles of Medical EthicsRevised and adopted by the AMA
House of Delegates (June 17, 2001)
• V. A physician shall continue to study, apply, and advance scientific
knowledge, maintain a commitment to medical education, make
relevant information available to patients, colleagues, and the public,
obtain consultation, and use the talents of other health professionals
when indicated.
• VI. A physician shall, in the provision of appropriate patient care,
except in emergencies, be free to choose whom to serve, with whom
to associate, and the environment in which to provide medical care.
• VII. A physician shall recognize a responsibility to participate in
activities contributing to the improvement of the community and the
betterment of public health.
• VIII. A physician shall, while caring for a patient, regard responsibility
to the patient as paramount.
• IX. A physician shall support access to medical care for all people.
Principles of Health care
Ethics
• Bioethicists often refer to the four basic principles
of health care ethics when evaluating the merits
and difficulties of medical procedures. Ideally, for
a medical practice to be considered "ethical", it
must respect all four of these principles:
autonomy, justice, beneficence, and nonmaleficence.
Autonomy
Requires that the patient have autonomy of
thought, intention, and action when making
decisions regarding health care procedures/
decision making. Therefore, the decisionmaking process must be free of coercion or
coaxing. In order for a patient to make a fully
informed decision, she/he must understand all
risks and benefits of the procedure and the
likelihood of success.
Justice
= Equity
The idea that the burdens and benefits of
treatment / access must be distributed equally
among all.
Beneficence
Requires that the procedure be provided with
the intent of doing good for the patient
involved. Demands that health care providers
develop and maintain skills and knowledge,
continually update training, consider individual
circumstances of all patients, and strive for net
benefit.
Non-maleficence
• Primum non nocere = FIRST DO NO HARM
Requires that a procedure does not harm the
patient involved or others in society.
• Weigh benefit vs. harm !
Respect for persons
The patient (and the person treating the
patient) have the right to be treated with
dignity.
Last but not least
• Truthfulness and honesty - the concept of
informed consent
AMA
• Informed consent is more than simply getting a
patient to sign a written consent form. It is a
process of communication between a patient and
physician that results in the patient's
authorization or agreement to undergo a specific
medical intervention.
• In the communications process, you, as the
physician providing or performing the treatment
and/or procedure (NOT A DELEGATED
REPRESENTATIVE), should disclose and discuss
with your patient:
AMA
• The patient's diagnosis, if known
• The nature and purpose of a proposed treatment or procedure
• The risks and benefits of a proposed treatment or procedure
• Alternatives (regardless of their cost or the extent to which the
treatment options are covered by health insurance)
• The risks and benefits of the alternative treatment or procedure
• The risks and benefits of not receiving or undergoing a treatment or
procedure.
• In turn, your patient should have an opportunity to ask questions to elicit
a better understanding of the treatment or procedure, so that he or she
can make an informed decision to proceed or to refuse a particular
course of medical intervention
AMA
• communications process itself be documented.
• Good documentation can serve as evidence in a
court of the law that the process indeed took
place.
• A timely and thorough documentation in the
patient's chart by the physician providing the
treatment and/or performing the procedure can
be a strong piece of evidence that the physician
engaged the patient in an appropriate discussion.
AMA
• A well-designed, signed informed consent
form MAY also be useful, BUT an overly broad
or highly detailed form actually can work
AGAINST YOU.
AMA
• Forms that serve mainly to satisfy all legal
requirements (stating for example that "all
material risks have been explained to me")
may not preclude a patient from asserting that
the actual disclosure did not include risks that
the patient unfortunately discovered after
treatment
DO NOT STAND IN A COURT OF LAW
Example , imaging
•
Dallas medical liability defense attorney Linda M. Stimmel recently represented a group
of physicians who were sued after a patient experienced a poor outcome following
coronary artery bypass grafting. During discovery, the plaintiff attorney called into
question whether the doctors had reviewed patient films and lab reports during a
consultation.
•
“I'm sure the physicians reviewed them, but they didn't note that in their charting,”
said Stimmel, who was featured in a January report on charting errors by AHC Media, a
publisher and provider of continuing medical education. “It was alleged in the lawsuit
that the physician didn't take the time to look at the computer and go over the labs. By
the time [the doctors] are deposed, it's three years later and they say, 'I'm sure I looked
at that,' but there's no charting to back it up.”
•
The case eventually SETTLED.
•
Legal experts say they are noticing more liability cases that involve faulty medical
charting, whether or not the documentation relates to the claim itself. Plaintiff
attorneys use such discrepancies to show carelessness, sloppiness or
dishonesty
Example, EHR
• Dr. Davenport recalled a recent case where a woman who
underwent a mastectomy visited her physician for an exam
of the remaining breast. The doctor found nothing wrong.
After the visit, the electronic template mistakenly entered
that both of the woman's breasts were “normal” in the
chart, Dr. Davenport said. Months later, a lesion was
discovered in the patient's remaining breast, and she sued
the doctor.
• “Obviously it's something that a physician can try to
explain, but it makes a physician look sloppy and, at worst,
untruthful,” he said. The case settled “because the
defense did not want to take the case to trial because of
the carelessness of the charting. It was an otherwise
defensible case.”
Example, EHR
• Copying and pasting information from one chart to
another also can prove to be detrimental in medical
liability cases, Cohen said. This is especially true if a
chart looks exactly the same after visits to several
doctors because each has re-pasted the same note.
• In one such case, Cohen said a common word was
misspelled five times throughout the record of a
neurologically impaired infant.
• “There were other medical issues involved, but those
coupled with the poor documentation during a critical
time period did not help with the defense,” he said
Kuwait 1981
• The first International Conference on Islamic Medicine held in Kuwait in
January 1981 published the oath of Muslim doctor, which says
• I swear by God, the Great, to regard God in carrying out my profession.
To protect human life in all stages and under all circumstances, doing my
utmost to rescue it from death, malady, pain and anxiety. To keep
peoples’ dignity, cover their privacies, and lock up their secrets. To be, all
the way, an instrument of God’s mercy, extending my medical care to
near and far, virtuous and sinner, friend and enemy. To strive in the
pursuit of knowledge and harness it for the benefit, but not the harm, of
Mankind. To revere my teacher, teach my junior, and be brother to
members of the medical profession. To join in piety and charity. To live
my faith in private and in public, avoiding whatever blemishes me in the
eyes of God, His apostle and my fellow faithful. And may God be witness
to this oath.”