Medical Ethics
Basic Concepts of Medical
ethics
Confidentiality
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)
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
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’
The declaration of Geneva of
1948
’I will respect secrets confided in me,
even after the patient has died’
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’
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
patient’s treatment
• All identifiable patient data must be protected
• 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
• Patient’s admitted to health care
institutions have the right to expect
physical facilities which ensure privacy
• 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
Privileged communication
(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 antisocial tendencies
minors/insane persons
(2) In the interest of the patient’s family
- Communicable diseases
- AIDS/HIV - to warn the sexual partner
(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
-
(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
(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
(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
- 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
(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
Medical teaching, research and
audit
A doctor can report a case
without revealing the patient’s
identity
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
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 patient’s past medical
history, if the patient has consulted him
before
Consent
In medical practice it refers to the
willingness of a person to subject
himself for examination,
investigation and treatment
• 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
• 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
Consent
Implied Expressed
Verbal
Written
Gesture
Written/witnessed
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
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
• 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
• 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
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
• 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
• All medico—legal 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
• 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
• 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
• 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.
-
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
Instances when consent is not
necessary
• Emergency
• Mandatory vaccination requirements
• Statutes requiring quarantine in cases
of contagious diseases
• Examination under court order