Ethics is a voluntarily self-imposed code of conduct by the medical profession.
Medical ethics deals with the moral principles which should guide members of the medical profession in their dealings with each other, their patients, and the State.
Medical etiquette deals with the conventional laws of courtesy observed between members of the medical profession. A doctor should behave with his colleagues as he would have them behave with himself.
Geneva declaration as amended on 6th November 2017:
1) I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
2) THE HEALTH AND WELL - BEING OF MY PATIENT will be my first consideration;
3) I WILL RESPECT the autonomy and dignity of my patient;
4) I WILL MAINTAIN the utmost respect for human life;
5) I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
6) I WILL RESPECT the secrets that are with confided in me, even after the patient has died;
7) I WILL PRACTICE my profession with conscience and dignity and in accordance with a good medical practice;
8) I WILL FOSTER the honor and noble traditions of the medical profession;
9) I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
10) I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
11) I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
12) I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
13) I MAKE THESE PROMISES solemnly, freely, and upon my honor.
BMDC (Bangladesh Medical & Dental Council)
B.M.D.C is the statutory body, who adopted an ethical code for the registered medical practitioner of Bangladesh. (Ref Lecture)
Location: 203, Shaheed Sayed Nazrul Islam Sarani, Bijoy Nagar Road, Dhaka-1000
Requirements for BMDC registration
1. MBBS certificate
2. Internship completion certificate
3. Two copies of passport size photograph attested by the principle of respected medical college
4. Signature in the code of medical ethics.
The function of BMDC (Ref Endeavor)
- Recognition & Registration of medical qualifications & medical professionals
- Recognition of medical & dental qualifications granted by medical & dental institutions in Bangladesh & also granted by institutes outside Bangladesh
- Registration of medical & dental practitioners, by recognizing their qualifications.
- Administrative Function
- It gives warning notice to the medical & dental practitioner for infamous conduct
- It has the legal power to erase the registration of a medical practitioner.
- Action against the use of false title & degree by registered medical & dental practitioners.
- Publication & maintenance of registers of medical & dental practitioners & medical assistants.
- Academic Function
- It maintains the standard of undergraduate & postgraduate medical education (curriculum)
- Approval of journals published by different organizations/association
Conditions of eraser of the name of the registered medical practitioner
1. After the death of the registered medical practitioner.
2. Entries which are made in the error or as a result of fraud.
3. Penal eraser, due to serious professional misconduct. This is also known as Professional Death Sentence. It deprived the practitioner of all the privileges of medical practitioner.
Professional Death Sentence (Lecture)
Means erasure of name of a doctor from medical register due to some serious professional misconduct. It deprived the practitioner of all the privileges of medical practitioner.
Professional Misconduct/ Professional infamous conduct
It is any conduct of the doctor which might reasonably be regarded as disgraceful or dishonorable. It involves an abuse of professional position.
The conduct of the doctor is judged by professional men of good repute and competence.
List of Professional infamous conduct (6A) (Ref Reddy)
1) Adultery arising out of professional relationship
3) Abortion (unlawful)
4) Association with unqualified persons in professional matters
7) Issuing a false, misleading or improper certificate
8) Dichotomy (Fee Splitting)
9) Disclosure of professional secrecy
10) Covering: Assisting someone who has no medical qualifications to attend, treat or perform an operation on some person in respect of matters requiring professional discretion or skill.
11) Refusal to give service on religious grounds.
12) Using touts or agents for procuring patients.
A medical student gets:
BMA (Bangladesh Medical Association) (Ref-Endeavor)
It is an organization of registered medical practitioner of Bangladesh where all the members are elected by registered medical practitioner.
The elected members holds the office for 2 years.
Difference between?B.M.D.C?and?B.M.A: (Ref- Endeavor)
|| Non-government organization
|Here, some members are elected & some are nominated.
||Here, all members are elected
|It holds office for 5 yrs
||It holds office for 2 yrs
|Has a power to punish the doctor
|It maintains the rules & regulations of medical profession & education.
||It tries to establish the rights & privileges of medical practitioners.
It is voluntary sexual intercourse between a married person and a person married or not, other than his/her spouse.
Fee Splitting (Dichotomy)
Receiving or giving?commission?or other benefits from/to a professional colleague or manufacturer or trader in drugs or appliance or a chemist, dentist, etc.
A physician shall not give, offer or receive any gift, commissions, bonus for referring, recommending, or procuring of any patients for medical, surgical or other treatment.
1. It is unethical (Professional infamous conduct)
2. Erasure of name from the registration
Fee sharing (Ref-Lecture)
Fee sharing is sharing of fees generally received by a combined operation among the surgeon, his assistants, and bearer, especially in private clinics.
1. It is ethical
2. No question of ensure of name from registration
This means assisting someone who has no medical qualifications to attend, treat or perform an operation on some person in respect of matters requiring professional discretion or skill.
1. He should not have any personal ownership in patient of any drug, apparatus, instruments, or appliance used in medicine or surgery.
2. He should not ask or receive devotes or commission for prescribing of any agent used therapeutically.
3. A physician must not write prescription in the private formula of which only he or particular pharmacy has the key.
Duties of medical practitioner
1. Duty to exercise a reasonable?degree of skill and knowledge.
2. Duties with regard to attendance and examination.
3. Duty to furnish proper and suitable medicines.
4. Duty to give the instructions.
5. Duty to control and warn.
6. Duty to 3rd parties.
6. Duty to inform patients of the risks.
7. Duty with regard to poison.
9. Duty to notify certain diseases.
10. Duties with Regards to Operations
11. Duties with to consultation.
12. Professional secrecy.
Rights and privileges of a registered medical practitioner:
1. Right to practice medicine
2. Right to choose the patient
3. Right to dispense medicines
4. Right to possess and supply dangerous drugs to his patient
5. Right to add title and description to his name
6. Right to the recovery of fees
7. Right for appointment to public & local hospitals
8. Rights to issue medical certificates
9. Right to give evidence in a court of law as an expert
Rights and privileges of the patient:
1. Choice: To choose his own doctor freely.
2. Access: To health care facilities available regardless of age, sex, religion, economic and social status.
3. DIGNITY: To be treated with care, compassion, respect, and dignity without any discrimination.
3. Privacy: To be treated in privacy during consultation and therapy.
4. Confidentiality: All information about his?illness?and any other is kept confidential.
5. Information: To receive full information about his diagnosis, investigation and treatment plans and alternative.
6. Refusal: Right to consent or refuse any specific or all measures
7. Compensation: Obtain compensation for medical injuries
DUTIES OF A PATIENT: (NTK)
1) He should furnish the doctor with complete information about past illness, and family history of diseases, and the facts and circumstances of his illness.
2) He should strictly follow the instructions of the doctor as regards diet, medicine, mode of life. etc.
3) He should pay a reasonable fee to the doctor.
PHYSICIAN'S RESPONSIBILITY IN CRIMINAL MATTERS: (NTK)
In medicolegal cases treatment gets priority. Thereafter procedural criminal law will operate in order to avoid negligent death.
A doctor who is aware of the commission of crimes, such as murder, dacoity, waging war against the lawful Government etc., is legally bound to report them to the nearest Magistrate or police officer.
The doctor knowing or having reason to believe that an offense has been committed by a patient whom he is treating, intentionally omits to inform the police, shall be punished with imprisonment up to 6 months.
If he treats a person who has attempted to commit suicide, he is not legally bound to report, but if the person dies then he has to inform the police.
Some of the examples where a doctor may refuse to treat the patient could be:
1) Beyond his practicing hours
2) Not belonging to his specialty
3) Illnesses beyond the competence and qualification of the doctor or beyond the facilities available in his set-up/institution.
4) Doctor is unwell or any other family member is ill.
5) Doctor has important social functions in the family.
6) Doctor has consumed alcohol.
7) Patient has been defaulting in payment.
8) Patient or his/her relations are non-cooperative, violent or abusive.
10) Patient refuses to give consent/accept risk.
Professional secrecy (Professional confidentiality)
It is an implied term of the contract between the doctor and his patient. The doctor is obliged to keep secret, all that he comes to know concerning the patient in the course of his professional work.
- In the court of law
- Notifiable disease
- Privileged communication
1. A doctor should not discuss the illness of the patient to other without his/her consent.
2. A doctor should not answer any inquiry by 3rd party even with relatives about the disease without the consent of the patient.
3. In the case of major (>18 years), the doctor should not disclose any fact about the illness to guardian/relatives though they are paying to the doctor.
4. In case of minor (<18 years) or infant consent of guardian must be taken.
5. Even in the case of a husband-wife, the nature of illness cannot?be disclosed.
6. In the case of a domestic servant the doctors should not disclose the fact though the master is paying the fee.
7. When a government doctor examines the government servant he cannot disclose the fact.
8. The medical officer of the firm/factory cannot disclose the fact without consent.
9. A patient under-trial (police custody) has the right not to disclose about his illness. But in case of conviction, he has no such right and the doctor can disclose the result to the authority
10. A doctor should not give any information to an insurance company about a person who has consulted him before, without the patient's consent.
11. The sex of unborn detected during ultrasonography should not be disclosed.
It is a statement made Bonafide upon any subject or matter by a doctor to the concerned authority due to his duty to protect the interest of the community or the state.
If the doctor discloses professional secrets for the purpose of protecting the interest of the community, (under a moral and social obligation), he will not be liable to damages.
Examples of privileged communication/ Exceptions to the general rule of professional secrecy.
If the patient refuses to accept the advice, the doctor can inform the concerned authority about the illness of his patient.
1. Infectious disease (Enteric infection, TB)
If a patient suffering from an infectious disease is employed as cook or waiter in a hotel, or a food-handler with an enteric infection, or a teacher with tuberculosis or other infective diseases, or as children's nurse, etc., he should be persuaded to leave the job until he becomes non- infectious. If the patient refuses to accept this advice, the doctor can inform the head of the employer about the illness of his patient.
2. Venereal Diseases (STD)
If a person is suffering from syphilis, advice not to marry till he is cured.
Swimming pools should be prohibited to those having syphilis or gonorrhea.
3. Servant and employee (Epilepsy: must inform the master)
An engine driver or a bus driver or a ship's officer may be suffering from epilepsy, high blood pressure, alcoholism, drug addiction, or color blindness Notifiable Diseases: A medical practitioner has a statutory duty to notify births, deaths, infectious. diseases, etc., to the Public Health authorities.
4. Suspected Crime
If the doctor learns of a serious crime, such as murder, assault, rape, etc. by treating the victim or assailant, he is bound to give information to the police. Thus, if a doctor treats a person suffering from gunshot or stab wounds due to criminal assault, he must inform the police.
6. Patient's own Interest
The doctor may disclose the patient's condition to some other person, so that he may be properly treated, e.g., to warn the parents or guardians of signs in the patient of melancholia, suicidal tendencies, etc.
7. In Courts of Law
Whatever information is required by the court, for the interest of justice, the doctor is legally bound to narrate the same before the court as per his knowledge. A doctor can disclose and discuss the medical facts of a case with other doctors and paramedical staff, such as nurses, radiologists, physiotherapists. etc. to provide better service to the patient.
Ethical negligence is the violation of the Code of Medical Ethics.
Malpraxis (Professional negligence/Professional malpractice)
It can be defined as absence of reasonable care and skill or willful negligence of a doctor in the course of treatment of a patient which causes some damages, bodily injury or death of the patient.
1. Civil negligence
2. Criminal negligence
3. Corporate negligence
4. Contributory negligence
It indicates such act of negligence on the part of the treating physician which causes some suffering, harm/damage to the patient which can be compensated by paying money and does not come under criminal penal court and does not demand legal punishment. (Lecture)
1. Failure to obtain informed consent to any procedure.
2. Failure to examine patient himself
3. Not ordering X-ray examination where the history suggests the possibility of a fracture or dislocation or presence of a foreign body in a wound.
4. Not reading the X-ray film correctly
5. Making a wrong diagnosis due to the absence of skill or care.
6. Administration of incorrect drugs
7. Giving overdose of medicine and giving poisonous medicines carelessly
It is prosecuted by the State for omission of some wrong which is considered as an offence of the community or State. (Lecture)
1. Willful manipulation of medical record
6. Issuing false medical certificates
4. Gross mismanagement of delivery
2. Criminal abortion
3. Leaving instrument, tubes, sponges in abdomen
5. Amputation of wrong limb
7. Gangrene due to tight ligature?
8. Mismatched blood transfusion
9. Wrong drug in eyes causing loss of vision
It is any unreasonable conduct or absence of ordinary care on the part of the patient or his personal attendant, which combined with the doctor's negligence, contributed to the injury complained of as a direct, proximate cause and without which the injury would not have occurred. (Ref Reddy)
1. Failure to give the doctor accurate medical history
2. Failure to co-operate with his doctor in carrying out all reasonable and?proper?instruction
3. Refusal to take the suggested treatment?
4. Leaving the hospital against the doctor advice
5. Failure to seek further medical assistance if symptoms persist
It is the failure of those persons who are responsible providing the accommodation, facilities, and treatment to follow the established standard of conduct. (Lecture)
1. The hospitals provide defective equipment or drugs
2. Select or retains incompetent employees
3. Negligent action of the hospital administration
4. If a hospital knows or should have known, that one of the patients is likely to be victim of professional negligence by a doctor on its stuff, the hospital is liable, even though that doctor is an independent with stuff privilege at the hospital
Corporate negligence by authority or company and contributory negligence by patient /attendance.
Elements of negligence/ Criteria to be fulfilled to prove medical negligence (Ref-Reddy)
- Duty: Existence of a duty of care by the doctor.
- Dereliction: The failure on the part of the doctor to maintain applicable standard of care and skill.
- Direct causation: The failure to exercise a duty of care must lead to damage.
- Damage: The damage should be of a type that would have been foreseen by a reasonable physician.
The burden of proof: The patient should prove all four elements of negligence by a preponderance of the evidence. It requires enough proof to show that it is more likely than not, that each of the 4 elements of a negligent claim is true.
THE DOCTRINE OF RES IPSA LOQUITUR:
Ordinarily, the professional negligence of a physician must be proved in Court by the expert evidence of another physician. The patient need not prove negligence in case where the rule of res ipsa loquitur applies, which means "the thing or fact speaks for itself". The patient has to merely state what according to him was the act of negligence.
Conditions to be satisfied:
1) that in the absence of negligence the injury would not have occurred ordinarily;
2) that the doctor had exclusive control over the injury producing instrument or treatment;
3) that the patient was not guilty of contributory negligence.
NOVUS ACTUS INTERVENIENS:
A person is responsible not only for his actions, but also for the logical consequences of those actions.
This principle applies to cases of assault and accidental injury. Sometimes, such a continuity of events is broken by an entirely new and unexpected happening, due to negligence of some other person.
e.g., leaving of "ab or a surgical instrument in the abdomen after he repair of an internal injury; accidental substitution ·poisonous drug for therapeutic drug, etc.
In situations, where the doctor is negligent while delivering his services and there is harm to the patient, but the harm is not the direct result of the negligent act of the doctor/initial wrongdoer or the harm is the result of other novel factor, novus actus interveniens (NAI) comes into play as defense for initial wrongdoer. (Ref-ncbi.nml.nih.gov)
Vicarious Liability (liability for act of another):
An employer is responsible not only for his own negligence but also for the negligence of his employees, if such acts occur in the course of the employment and within its scope, by the principle of respondent superior (let the master answer).
Conditions must be satisfied:
1) There must be an employer-employee relationship,
2) the employee's conduct must" occur within the scope of his employment, and
3) while on the job.
It refers to the physical agent which caused the injury or death of the patient during treatment by doctor.
The injury or death of the patient may result from the unexpected by-product of faulty, defective, or negligently designed medical or surgical instruments or inadequate operating instructions. In such cases, the manufacturer becomes responsible for injury or death.
MEDICAL NEGLIGENCE PREVENTION: (NTK)
1) Rapport : Maintain healthy rapport and communication with the patient and with patient's families, with fellow physicians, nurses and paramedical personnel who may commit errors.
2) Rationale : The doctor should use all reliable and relevant information (history, physical examination, laboratory tests, x-rays, etc.) to make diagnosis and formulate the treatment.
3) Records: The record should be carefully prepared : complete, accurate, legible. relevant, timely and generously informative.
4) Remarks: Do not reprimand the patient and his family. Do not criticize any nurse or laboratory or x-ray technician or any other health care personnel within the hearing of the patient.
5) Recipe: Do not prescribe any medicine unless there is an appropriate therapeutic indication for it.
7) Respect: Treat the patient as the physician would wish himself or a member of his family to be treated.
8) Results: Obtain informed consent from the patient. If a bad result occurs, sincere close attention should be given.
9) Risks: The patient and his family must be informed of all anticipated risks
10) Review: Routinely review cases involving morbidity and mortality. Review medical malpractice cases and the testimony by medical experts.
Therapeutic misadventure is a case in which an individual has been injured or had died due to some unintentional act by a doctor or agent of the doctor or the hospital.A misadventure is mischance or accident or disaster.
Misadventure is of three types:
1) Therapeutic (when treatment is being given).
2) Diagnostic (where diagnosis only is the objective at the time).
3) Experimental (where the patient has agreed to serve as a subject in an experimental study).
Euthanasia (mercy killing) means producing painless death of a person suffering from hopelessly non- curable and painful disease.
According to the mode of death:
- Active or Positive Euthanasia (Act of commission)
Giving large dose of drug to hasten death
- Passive or Negative Euthanasia (Act of omission)
Means discontinuing or not using extraordinary life- sustaining measures to prolong life. This includes acts of omission, such as failure to resuscitate a terminally ill or hopelessly incapacitated patient or a severely defective newborn infant.
According to the will/desire of the patient:
1. Voluntary: means at the will of the person. (Patient says to kill)
2. Involuntary: it means against the will of the person i.e compulsory (Guardian says to kill)
3. Non-voluntary: refers to cases of persons incapable of making their wishes known, e.g., in persons with irreversible coma or severely defective infants. Any other says to kill
Euthanasia advocates the administration of lethal doses of opium or other narcotic drugs.
Euthanasia is legally accepted in:
10. In certain part of USA
Consent means voluntary agreement, compliance or permission
1. Implied consent
2. Expressed consent:
Implied consent: The patient implies by his acts that he gives consent to a medical examination.
e.g., Injection on hand
Expressed consent: The consent is stated by the patient either verbally or in written.
e.g., A rape victim gives written consent to examine her including private parts.
Importance of Consent:
1. Without consent any medical practice is an assault in law whatever the result.
2. The medical man may be charged for negligence.
Informed written consent:
Informed written consent is a written consent which includes/implies an understanding by patient of:
1. The nature of his condition
2. The nature of the proposed treatment/procedure.
3. Expectation of the recommended treatment and the likelihood of success.
4. The details of the alternative courses of treatment that is available.
Example: consent is given by patient before operation (amputation of leg)
5. The risks and benefits involved in both the proposed and alternative procedure,
6. The potential risks of not receiving treatment, and the relative chances of success or failure of both procedures,
Exceptions to informed consent:
2) Therapeutic privilege.
3) When a patient waives his right to informed consent and delegates the right to the doctor or a close relative.
Rules of consent (Ref- Reddy) (NiceToKnow)
- Consent is necessary for every medical examination.
- The consent should be free, voluntary, clear, intelligent, informed, direct, and personal. There should be no fraud, misrepresentation of facts, undue influence, compulsion, threat of physical injury. death or other consequences.
- In criminal cases, the victim cannot be examined without his/her consent. The Court also cannot force a person to get medically examined, against his will. A) In cases of rape, the victim should not be examined without written consent.
- B) In medicolegal cases of pregnancy, delivery and abortion, the woman should not be examined without her consent.
- A child under 12 years of age and an insane person cannot give valid consent to suffer any harm which may result from an act done in good faith and for its benefit. The consent of the parent or guardian should be taken. If they refuse, the doctor cannot treat the patient even to save the life.
- A person above 18 years of age can give valid consent to suffer any harm, which may result from an act not intended or not known to cause death or grievous hurt. Loco parentis In emergency involving children, when their parents/guardian are not available, consent is taken from the person in charge of child.
Example: A school teacher can give consent for treating a child who becomes sick during a picnic away from home town, or the consent of the headmaster of a residential school.
- When an operation is made compulsory by law, e.g., vaccination, the law provides the consent.
- A prisoner can be treated forcibly without consent in the interest of the society.
- The nature of illness of a patient should not be disclosed to any third party without the consent of the patient.
- For contraceptive sterilization, consent of both the husband and wife should be obtained.
- The consent of one spouse is not necessary for an operation or treatment of other. A husband ha. no right to refuse consent to any operation. including a gynecological operation, which is required to safeguard the health of his wife. The consent of wife is enough.
Some instance when consent is not necessary: (Lecture)
1. Examine an accused or a change of committing an offence. (e.g.,?rapist)
2. In case of prisoners for the interest of state.
3. In case of mental patient (consent of guardian is needed)
4. Compulsory vaccination
5. Loco parentis
It means conscious, planned feigning or pretending a disease for the sake of gain.
Diseases may be feigned for several reasons, such as by soldiers or policemen to avoid their duties, by prisoners to avoid hard work, by businessmen to avoid business contracts, by workmen to claim compensation, by beggars to attract public sympathy, by criminals to avoid legal responsibility, etc.
In general, the patient should ordinarily be told everything. The doctor has to decide, after taking into consideration all aspects of the patient's personality, physical and mental state, how much can be safely disclosed.
Therapeutic privilege/ Therapeutic exception
This is an exception to the rule of "full disclosure". Full disclosure of remote or theoretical risks involved could result in frightening a patient who is already fearful or who is an emotionally disturbed individual, and who may refuse the treatment when there is really little risk.
It is only in the case of frank psychosis or extreme psycho-neurosis that the patient will be incapable of accepting the information. If possible, the physician should explain the risks to the patient's spouse or next of kin.
Paternalism is an abuse of medical knowledge so as to distort the doctor-patient relationship in such a way that the patient is deprived of his autonomy, or of his ability to make a rational choice. The doctor does not disclose the nature of the iIIness and the proposed treatment depriving the right of patient to accept or reject treatment. (NiceToKnow)
Difference between Civil and Criminal Negligence (Reddy)
||No specific and clear violation of law need be proved.
||Must have specifically violated a particular criminal law in question.
||Simple absence of care and skill
||Gross negligence, inattention or lack of competency.
||Between two parties.
||Between state and doctor.
||The sufferer party is the complainant
||Public prosecutor on the behalf of the sate is the complainant
||Strong evidence is sufficient
||Guilt should be proved beyond reasonable doubt
||Liable to pay damages
||Imprisonment with or without fine
Difference between professional negligence and infamous conduct (Reddy)
|Absence of proper care and skill or wilful negligence.
||Violation of Code of Medical Ethics.
|Duty of care should be present
||Duty of care need not be present
|Damage to person should be present
||Need not be present
|Trial by Courts (Civil or Criminal)
||Trial by BMDC
|Punishment- Fine or imprisonment
||Punishment- Erasure of name or warning
Difference between judicial death Sentence & Professional death sentence/Penal eraser (Ref Endeavor)
|Judicial Death Sentence
||Professional Death Sentence/Penal eraser
|It is the actual death (irreversible stoppage of all vital functions) of a person
||It is the professional death (ending of his/her professional career) of a person
|Causes: Some serious criminal activities (eg. Murder)
||Causes: Some serious professional infamous conduct
|It is given by judicial system of government
||It can be applied by BMDC in case of medical professional
Difference between Active & passive Euthanasia (Ref- Endeavor)
|Positive merciful act to end useless suffering or meaningless existence
||Discontinuing or not using extra ordinary life sustaining measure to prolong life
|It is an act of commission
||It is an act of omission
|Administration of lethal dose of opium or barbiturates/thiopental-Na & then muscle relaxant
||Allowing death by not resuscitating a terminally ill or incapacitated patient or defective newborn infant