Medical Ethics Basic Concepts of Medical ethics Confidentiality

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