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. Ethical codes have been developed by
various groups/ professions to
regulate their relationship with each
other as well as with others.
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. 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. Basic values in ethics
1.Beneficence – Do good
2.Non Maleficence – Do no harm
3.Autonomy – Freedom
4.Justice - Fairness and equality
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
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. 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. Indian Medical Council (MCI)
Medical register
Medical education
Recognition of foreign medical
qualifications
Appeal against disciplinary actions (within
30 days)
Warning notice
13. Removal of name from register
Serious Professional Misconduct
-professional death sentence
Death
Name entered by fraud / mistake
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. 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. 6 ‘A’s
Adultery
Advertisement
Abortion (criminal)
Association with unqualified persons in
professional matters
Alcohol
Addiction
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. - 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. 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.
21. Red cross emblem
Wrong belief that doctors are entitled to use it
Section 12 – Geneva convention act 1960
prohibits its use.
section 13 - punishment
22.
23.
24. 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
25. 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.
26. 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
27. 7. Children & adults who are incapable
8. To inform about risks
9. With regard to poisons
10. Regarding notifiable diseases
11. Operations
28. 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
29. 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
30. 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
31. 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.
32. 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
33. 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.
34. 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.
35. -Employer & employee
- Infectious diseases
- Veneral diseases
- Notifiable diseases
- Suspected crime
- Self interest
- Patients own interest
- Negligence suits
- Courts of law
36. 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
37. Liable if following are present
Duty
Dereliction
Direct causation
Damage
39. 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
40. 5. Imprisonment / fine
6. Appeal to higher
courts of law
Warning, erasure of
name
To I.M.C
41. 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
42. 3. Proof: balance of
probabilities
4. Consent &
Contributory
negligence- good
defence
3. Beyond reasonable
doubt
4. Not so
43. 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
44. 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
45. 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
46. 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
47. - 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
48. 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
49. 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
50. 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
51. 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
52. 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 .
53. 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
54. Examples
- Mismatched blood transfusion
- Over dosage of medicines
- Leaving swabs in the abdomen
- Prolonged splinting
56. 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
57. 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
58. 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
60. 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
61. 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
62. 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
63. 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
64. 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
65. 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
66. Defence against negligence
No duty of care
Duty discharged with care & skill
and according to prevailing
standards
Consent
Contributory negligence
Medical maloccurance
Misadventure
69. d) Give proper & clear instructions
- prescriptions
- diet
- pre- op instructions
- use of inhalers
70. II. Case records
Up-to-date, accurate & complete
-Patient refusing any particular
treatment, investigation
-Discharge against medical advice
-Consent: own handwriting if literate
71. 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.
72. IV. Do not neglect the patient
Reasonable degree of care & skill
Attend regularly
All necessary investigations
Consultation if required
Arrange for a good substitute
73. V. Do not criticize another doctor
VI. Associate with good & qualified
staff
VII. Cordial working atmosphere
VIII. Guard against hazards
-Adverse drug reactions
75. 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
77. 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
78. Against
Moral, ethical & religious objections
Misuse
No development of science
Article 21- right to life
79. Legal status in India
No legal sanction
306 I.P.C & 309 I.P.C
Active & involuntary - murder
80. Consumer protection act 1986
Purpose
To protect the interest of consumers
Includes services like, household
articles, banking, food, transport,
entertainment, electricity etc.
81. Medical profession - included in 1995
Aims to provide cheap & speedy remedy
Criticism:
Defensive medicine
Indemnity insurance
Frivolous complaints
82. S
District forum
< 20 lakhs
State commission
>20 lacks < 1crore
National commission
> 1crore
85. 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
86. - 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
88. 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
89. 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
90. 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
91.
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
92. 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
93. 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
94. 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
95. 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
96. Unlawful to detain any patient
Donating organs
Clinical autopsy
Defence in civil negligence