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ETHICAL ISSUES IN MEDICAL PRACTI

 ETHICAL ISSUES IN MEDICAL PRACTICE

Jagriti Singh

Advocate Allahabad High court



 

Medical practitioner are good citizens, possessed of special training should disseminate advice on public health issues. They should play their part in enforcing the laws of the community and in sustaining the institutions that advance the interests of humanity. They should particularly co-operate with the authorities in the administration of sanitary/public health laws and regulations.

Medical ethics has developed into a well based discipline which acts as a bridge between theoretical bioethics and bedside. The aim is “to improve the quality of patient care by identifying, analyzing and attempting to resolve the ethical problems that arise in practice”. Medical practitioners are also bound by laws and official regulations. Violation of acts, rules or laws may lead to criminal, civil liabilities and disciplinary actions.

Aim of the law and medical ethics are safeguarding a good standard of medical practice within the community and ensure the health and welfare of the general public. Medical practitioner may face civil or criminal consequences due to breach of prescribed standards.

Legal work of medical council is regarding the practice of medicine, violation of which may lead to criminal or civil liabilities or disciplinary actions. Medical ethics is an applied which involves examining specific controversial issues such as abortion, breach of confidentiality, end-of-life care, rationing of scarce medical resources.

The fundamental principles that apply generally to medicine or health care at large are

  1. Respect of patient’s autonomy.

  2. The principle of non maleficence or duty of avoids harm or injury to patients.

  3. The principle of beneficence or the duty of to do good to your patients, relieve their pain and suffering and to save life if you can,

  4. The principle of justice and fairly.

CODE OF MEDICAL ETHICS (Some important parts)

(Published on 6, April, 2002 in Part III, Section 4 of the Gazette of India) (1)

  1. Declaration: At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same:

    1. I solemnly pledge myself to consecrate my life to service of humanity.

    2. Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.

    3. I will maintain the utmost respect for human life from the time of conception.

    4. I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.

    5. I will practice my profession with conscience and dignity.

    6. The health of my patient will be my first consideration.

    7. I will respect the secrets which are confined in me.

    8. I will give to my teachers the respect and gratitude which is their due.

    9. I will maintain by all means in my power, the honour and noble traditions of medical profession.

    10. I will treat my colleagues with all respect and dignity.

    11. I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2001.(1)

I make these promises solemnly, freely and upon my honour.

  1. Duties and responsibilities of the Physician in general:

    1. Character of Physician - The prime object of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration. Who- so-ever chooses his profession, assumes the obligation to conduct himself in accordance with its ideals. A physician should be an upright man, instructed in the art of healings. He shall keep himself pure in character and be diligent in caring for the sick; he should be modest, sober, patient, prompt in discharging his duty without anxiety; conducting himself with propriety in his profession and in all the actions of his life.

    2. Maintaining good medical practice - The Principal objective of the medical profession is to render service to humanity with full respect for the dignity of profession and man.

    3. Maintenance of medical records - Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma. (by the Medical Council of India)

    4. If any request is made for medical records either by the patients / authorized attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

      1. A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix - 2 of Code of Medical Ethics.

      2. Efforts shall be made to computerize medical records for quick retrieval.

    5. Display of registration numbers:

      1. Every physician shall display the registration number accorded to him by the State Medical Council / Medical Council of India in his clinic and in all his prescriptions, certificates, money receipts given to his patients.

    6. Use of Generic names of drugs - Every physician should, as far as possible, prescribe drugs with generic names and he / she shall ensure that there is a rational prescription and use of drugs.

    7. Payment of Professional Services: The physician, engaged in the practice of medicine shall give priority to the interests of patients. The personal financial interests of a physician should not conflict with the medical interests of patients. A physician should announce his fees before rendering service and not after the operation or treatment is under way. Remuneration received for such services should be in the form and amount specifically announced to the patient at the time the service is rendered. It is unethical to enter into a contract of "no cure no payment". Physician rendering service on behalf of the state shall refrain from anticipating or accepting any consideration.

  2. DUTIES OF PHYSICIANS TO THEIR PATIENTS

    1. Obligations to the Sick - Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties. A physician advising a patient to seek service of another physician is acceptable; however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient.

    2. Prognosis - The physician should neither exaggerate nor minimize the gravity of a patient's condition. He should ensure himself that the patient, his relatives or his responsible friends have such knowledge of the patient's condition as will serve the best interests of the patient and the family.

    3. The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family.

  3. DUTIES OF PHYSICIAN IN CONSULTATION

    1. Unnecessary consultations should be avoided - However in case of serious illness and in doubtful or difficult conditions, the physician should request consultation, but under any circumstances such consultation should be justifiable and in the interest of the patient only and not for any other consideration.

    2. Consulting pathologists /radiologists or asking for any other diagnostic Lab investigation should be done judiciously and not in a routine manner.

    3. Punctuality in Consultation: Utmost punctuality should be observed by a physician in making themselves available for consultations.

    4. Fees and other charges - A physician shall clearly display his fees and other charges on the board of his chamber and/or the hospitals he is visiting.

    5. A physician shall write his name and designation in full along with registration particulars in his prescription letter head.

    6. Note: In Government hospital where the patient-load is heavy, the name of the prescribing doctor must be written below his/her signature.

  4. UNETHICAL ACTS : A physician shall not aid or abet or commit any of the following acts which shall be construed as unethical –

    1. Advertising - Soliciting of patients directly or indirectly, by a physician, by a group of physicians or by institutions or organizations is unethical. A physician shall not make use of him / her (or his / her name) as subject of any form or manner of advertising or publicity through any mode either alone or in conjunction with others which is of such a character as to invite attention to him or to his professional position, skill, qualification, achievements, attainments, specialties, appointments, associations, affiliations or honours and/or of such character as would ordinarily result in his self aggrandisement. A medical practitioner is however permitted to make a formal announcement in press regarding the following:

        1. On starting practice.

        2. On change of type of practice.

        3. On changing address.

        4. On temporary absence from duty.

        5. On resumption of another practice.

        6. On succeeding to another practice.

        7. Public declaration of charges.

    2. Running an open shop (Dispensing of Drugs and Appliances by Physicians): - A physician should not run an open shop for sale of medicine for dispensing prescriptions prescribed by doctors other than himself or for sale of medical or surgical appliances. It is not unethical for a physician to prescribe or supply drugs, remedies or appliances as long as there is no exploitation of the patient. Drugs prescribed by a physician or brought from the market for a patient should explicitly state the proprietary formulae as well as generic name of the drug.

    3. Rebates and Commission - A physician shall not give, solicit, or receive nor shall he offer to give solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee for medical, surgical or other treatment.

    4. Secret Remedies: The prescribing or dispensing by a physician of secret remedial agents of which he does not know the composition, or the manufacture or promotion of their use is unethical and as such prohibited. All the drugs prescribed by a physician should always carry a proprietary formula and clear name.

    5. Human Rights: The physician shall not aid or abet torture nor shall he be a party to either infliction of mental or physical trauma or concealment of torture inflicted by some other person or agency in clear violation of human rights.

  5. RED CROSS is “Geneva Cross” - Every Medical Practitioners is not entitled to use Red Cross. It is the right only the members of medical service of any army. The Government of India had issued press notices in 1938 that such user was illegal. Section 12 of Geneva Conventions Act, 1860 (as prevailing in India) prohibits use of “Red Cross”.

7.Not for medico legal- This line does not support and save any medical professional, you are save by your act, rules, circulars and your honestly service only.

8. Medico Legal Case – Doctors are looked upon by a common man as the only hope when a person is hanging between life and death but they avoid their duty when they know that it is medico legal case.

A medico-legal report prepared by a specialist has a much stricter criteria for proof of identification of the subject examined (one can use photographs, thumb impression, marks of identification etc) to avoid fraud.

This does not mean that the doctor is not liable for any medico-legal case arising from wrong report or diagnosis.

Render services to humanity with full respect for the dignity of man. Dr. Lakshmanan Prakash Vs State 1999(4) Crimes 404(2)



 

  1. Conviction by Court of Law - Conviction by a Court of Law for offences involving moral turpitude / Criminal acts

    1. Sex Determination Tests: On no account sex determination test shall be undertaken with the intent to terminate the life of a female foetus developing in her mother's womb, unless there are other absolute indications for termination of pregnancy as specified in the Medical Termination of Pregnancy Act, 1971. Any act of termination of pregnancy of normal female foetus amounting to female foeticide shall be regarded as professional misconduct on the part of the physician leading to penal erasure besides rendering him liable to criminal proceedings as per the provisions of this Act.

    2. If you are running a nursing home and if you employ assistants to help you, the ultimate responsibility rests on you.

    3. No physician shall use touts or agents for procuring patients.

    4. Examination of Medical Practitioner - Witness of medical practitioner is an expert only; infact is really of an advisory character and not as witness. Therefore, a doctor cannot prove the occurrence. Rama Vs State, AIR 1969 Goa, 116(3)

    5. Medical Report - Medical Report can be used by doctor for refreshing his memory, it is not a document. Suresh Kumar Vs State of U.P. 1992(2) Crimes 872 (All)(4)

    6. Conflict in medical advice - If conflict between the medical evidence and eye-witness, it is well settled that if the direct evidence is satisfactory and reliable, it should not be over ridden by medical evidence. Punjab Singh Vs State of Haryana, AIR 1984 SC 1233(5)

    7. Positive evidence cannot be over ridden by the medical evidence. – Piara Singh and others Vs State of Punjab, AIR 1977 SC 2274(6)

    8. Negligence of Doctors - A person who using such skills and knowledge, treats another person in emergency, could not be convicted even though his diagnosis and treatment were entirely incorrect and a mere mistake or error of judgment, will not be sufficient.

    9. Wharton’s Law Lexicon’ 14th Edition, at page 685 says - In law there are three degrees of negligence (1) Lata culpa, Gross Neglect connotes careless state of mind which may amount to recklessness or indifference, (2) Leis culpa, ordinary neglect refers to a breach of a legal duty to take care, and (3) Levissima culpa, slight neglect is a careless conduct without reference to any duty to take care. (7)

    10. It can be termed “criminal” only when the medical person exhibits a gross lack of competence or inaction and wanton indifference to his patient’s safety and which is found to have arisen from gross ignorance or gross negligence.

    11. Where operation of cataract was performed by a qualified doctor in the recognized Indian method of treatment with the consent of the patient who lost his eye-sight after operation, held the doctor was not criminally liable. R.P.Dhanda Vs Bhurela, 1987 MP LJ 27(8)

    12. Failure of anesthetist to check-up during pre-operative anesthesia as to whether the patient would withstand 3 ml local anesthesia administered through spinal cord. Held, it may amount to criminal negligence. Dr. Lakshmanan Prakash Vs State, 1999(4) Crimes 404(9)

    13. Thus a doctor cannot be held criminally responsible for patient’s death unless his negligence or incompetence showed such disregard for life and safety of his patient as to amount to a crime against the state. R.V.Adomalo (Supra)

    14. Doctor follows a practice acceptable to the medical profession of that day, he cann’t be held liable for negligence merely because a better alternative course or method of treatment was also available. Medical professional cann’t also be held liable simply because a more skilled doctor would not have chosen to follow a resort to that practice or procedure which accused followed. -Jacob Mathew Vs State of Punjab & Another,2005 (2) SCC 334(10)

Conclusion

Medical ethics are safeguarding a good standard of medical practice within the community and ensure the health and welfare of the general public.

REFERENCE

  1. Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002. Published on 6, pril,2002 in Part III, Section 4 of the Gazette of India

  2. 1999(4) Crimes 404

  3. All India Reporter 1969 Goa, 116

  4. 1992(2) Crimes 872 (All)

  5. All India Reporter 1984 Sc 1233

  6. All India Reporter 1977 Sc 2274

  7. ‘Wharton’s Law Lexicon’ 14th Edition

  8. 1987 Mp LJ 27

  9. 1999(4) Crimes 404

  10. 2005 (2) Supreme Court Cases 334