“Justice consists not in being neutral between right and wrong, but in finding out the right and upholding it, wherever found, against the wrong.”
—Theodore Roosevelt1
INTRODUCTION
Medicine is a profession that incorporates science and technology for caring the sick. In twentieth century with advancement in medical science, patient care has become more effective with better medications having fewer side effects. Surgery has moved towards less invasive modes of management, with lesser morbidity and faster recovery. With so much advancement in the field of medicine, the medical fraternity is becoming dependent on technology. Market forces also tend to influence decision making by the doctors. Amidst all these developments, the medical practitioners often face ethical and legal challenges in their clinical practice. Keeping in mind the recent trends of medicolegal issues, the importance of ethical standards in practice of medicine becomes even more relevant.
MEDICAL ETHICS
Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. It guides the medical practitioners in their behavior and decision making related to their relationship with patients, colleagues and society. A physician is expected to be compassionate towards his patient, willing to take time to explain all the aspects of illness. The fundamental values of medicine insist that every physician has an obligation to keep the patient's interest above everything else. The basic principles of medical ethics that guide the medical practitioners in clinical decision making are:
- Autonomy
- Beneficence
- Nonmaleficence
AUTONOMY
Autonomy literally described as self-rule, is the principle that recognizes the rights of individuals to self-determination. In medical profession, respecting the patient's autonomy requires the medical practitioners to give full information and get permission before doing anything to the patient, i.e., informed consent prior to treatment. Apart from ethical concerns, informed consent is also a legal duty. Another implication of respecting the patient's autonomy is medical confidentiality. Medical practitioner impliedly promises his patients that he will keep confidential the information confided to him. Keeping promises is a way of respecting people's autonomy. Every effort should be made to ensure that confidentiality is maintained. However, in medical practice absolute confidentiality cannot exist. Often, it becomes necessary to share patient's information with other healthcare providers, so as to provide appropriate patient care. In healthcare system, safeguarding confidentiality is far more challenging. With the advent of electronic health records, the risk of misuse of patient's confidential information has increased manifold. While discussing the patient's condition at the bedside where other patients are also present, confidentiality is not protected. There are occasions when law mandates disclosure of the confidential information, like informing to the police about medicolegal cases, reporting certain notifiable diseases, disclosing professional secrets to the court if asked to do so. While treating the patients suffering from mental illness, physician has a duty to disclose and warn others if the patient threatens to be violent.
Respect for patient's autonomy obligates the physicians not to deceive patients, and tell the truth about their diagnosed illness, unless they clearly wish not to be told about the illness. In the practice of medicine, sometimes there are situations where telling the absolute truth may not be the best option. Medical professionals often have to give bad news of poor prognosis or impending death to the patients. They should weigh the benefit against the detriment before disclosing the truth as it may be more ethical to withhold the truth partially for the time being and disclose it in bits over time to avoid overwhelming the patient or relatives. In medical practice, there are situations that challenge the principle of autonomy and create ethical dilemmas in decision making.
BENEFICENCE
Beneficence refers to the actions that promote wellbeing of others. It is the moral obligation to do good for others and to help them in active way. In medical practice, it means taking actions that are beneficial to the patients based on the patient's point of view as well.
NONMALEFICENCE
Nonmaleficence is a concept of not causing harm to others. This principle is well expressed in the Latin phrase, primum non nocere which means first do no harm.3 It is not enough to just prevent intentional harm, but, one must be appropriately cautious not to cause harm. In the practice of medicine, however, almost all treatments carry some risk of harm. It is important to know how likely it is, that the proposed treatment will cause harm to the patient. This needs empirical information from the reliable medical research about the probabilities of various harms and benefits possible with the proposed intervention. This concept also explains the need for practicing ‘evidence based medicine’. The obligation to provide net benefit over harm requires the medical professionals to be clear about the risks present and their probability, when they make assessments of benefit over harm. The medical practitioner, must therefore, 5consider the principles of beneficence and non-maleficence together and try to produce net benefit over harm. A single action may have combined implications of beneficence and nonmaleficence, which in medical ethics is referred to as double effect. A classic example of the double effect is administration of high dose of morphine to relieve pain in a patient suffering from advanced stage of malignancy. Such an act has combined effect of beneficence (relieving the pain) and maleficence (respiratory suppression leading to death of the patient).
Conflict Between Autonomy and Beneficence/Nonmaleficence
Sometimes the patient may disagree with the proposed treatment, which the physician believes to be the best for the patient, on the basis of medical literature. This usually occurs when patient's interest clashes with patient's welfare leading to conflict between the principles of autonomy and beneficence. For example, a Jehovah patient may refuse blood transfusion due to religious or cultural views. Also, the patient may want unnecessary treatment which may cause medically unnecessary potential risks as in case of hypochondria or cosmetic surgery. In such ethical dilemmas, usually the physician, just to nurture healthy physician-patient relationship, submits to the principle of autonomy and acts as per the patient's desires. In such a situation, the physician must do his best efforts to balance the patient's welfare with interest. In such cases, if complication/undesired outcome occurs, the chances of allegation of medical malpractice is higher and it is far more challenging for the treating medical professional to defend his actions. He must get the written informed consent signed by the patient; documenting in detail the treatment to be followed and the probability of risks involved.
Justice
Justice is the moral obligation to act on the basis of fairness. In simplistic sense, justice refers to equality. However, it does not mean treating all individuals the same. It is important to treat equals equally and to treat unequals unequally, in proportion to their morally relevant inequalities. Medical practitioner must recognize the competing moral concerns and take fair decisions. In the context of healthcare resources, justice requires providing sufficient healthcare to meet the needs of all who need it and if this is impossible, to provide healthcare resources in proportion to the extent of individual's need for healthcare.
Paternalism versus Autonomy: What Serves the Patient Best?
Paternalism
Paternalism comes from the Latin word, pater which means to act like a father or to treat another person like a child. Paternalism propounds that someone can better protect the interests of others, based on the value that father knows what is best for the children. Paternalism has a long history in the medical profession. From the days when the Hippocratic principles were developed, the physician has been recognized as a guardian who uses his specialized knowledge and experience to decide the patient's benefit. The primary theory behind the Hippocratic Oath is the principle of beneficence which clearly reflects in the original oath as the resolve to serve ‘for the benefit of the sick, according to the physician's ability and judgment’. The relation between physician and the patient resembled that between a caring father and his child, hence the term paternalism. Such father-child relationship stood firm and unchallenged for centuries. Until much of the twentieth century, the society acknowledged that the physicians were in the best position to make medical decisions on behalf of the patients.6
Does Paternalism Really Serve the Purpose?
Medical ethics obligates the medical practitioner to do what is in the best interest of the patient? The real challenge is the interpretation: What is the best interest of the patient? In patient-physician interaction, there is asymmetric information, as the physician has access to technical knowledge and skill which the patient lacks, and the patient has access to personal preferences that are at times difficult to express. This bifocal vision may result in different perceptions and the physician's opinion may not coincide with the patient's view. The physician's efforts to do the best for the patient may advertently or inadvertently disregard the patient's wishes.
When the patient is not in a position to act voluntarily or autonomously, the paternalistic approach to prevent the patient from doing harm to himself, seems justified. For instance, emergency treatment to save the life of a dying patient at the critical time when there is no time to wait for patient's autonomy, termed as weak paternalism, might be morally justified. On the other hand, strong paternalism, which overrides the clearly voluntary action, is difficult to justify.
Paternalism is argued on the notion that, 'It is the patient's life or health which is at stake, not the physician's…so it must be the patient, not the physician, who must be allowed to decide whether the game is worth the candle.”4 John Stuart Mill, a British philosopher expressed that a competent person's freely made decision should never be over-ridden, even for that person's own good. He wrote: “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because in the opinion of others, to do so would be wise or even right.”5
Changing Ethos: Paternalism to Patient Autonomy
The paternalistic philosophy has a long history from the time of Hippocrates well into the twentieth century until 1960s. After this long era of unchallenged and well accepted paternalism, tremendous changes occurred that transformed the predominantly paternalistic ideology: Doctor knows the best to patient autonomy or self-determination. In present era, the medical paternalism has come under criticism through the concept of patient's authority to take decision on his medical needs. The concept of patient autonomy or self-determination has emerged as dominant ethos in the medical practice.6 While taking the medical decisions; it requires that medical benefits be weighed, not only against medical risks, but nonmedical values as well. For illustration, a medical decision that advises a couple to refrain from reproduction due to the genetic risks they may face in having children, has not addressed the ethical issue from the couple's perspective. In such a situation patient autonomy empowers the couple, after receiving all the necessary medical information, to take the final decision to have their children or not.
Supporters of paternalism may criticize that, offering full information and allowing patients to take crucial medical decisions may lead to unwise and irrational decisions even by technically competent patients. However, this criticism does not offer any explanation, why a person is presumed as requiring protection from his so called unwise decisions once they become medical patients, and yet are otherwise thought entitled to take decisions outside the medical set-up (like choosing a life partner, selecting a career). There are situations that 7challenge the principle of pure autonomy and make it complicated to follow on a consistent basis. For example, children, mentally incapacitated patients and patients who are otherwise incompetent to take decisions will be unable to exercise autonomy.
The principles of autonomy providing moral right to the patients to control their own treatment, may be conceived as imparting obligation to the physicians to respect the medical decisions of their patients. Does that mean, physicians have an obligation to do whatever patients say? Nonetheless, a physician should keep in mind that the obligation towards patient's decisions is not absolute as the same is to be weighed upon with other ethical values deserving commitment from the physician. Physicians are bound by their obligation to the medical profession which may supersede the duty to respect patient's choice. For example, patient's wish to be helped to die cannot be fulfilled as it violates the values of medical profession. A more challenging situation may arise when a dying patient (or his family) asks for continuing treatment which is futile as per physician's opinion. In continuing treatment that will do no good to the patient may be viewed as contrary to the values of medical profession particularly in the backdrop of limited resources and does not obligate the physician to respect the patient's wishes. Obligation to practice patient autonomy cannot be taken as simplistic directive to comply with all the expressed wishes of the patient, as the same may come into conflict with other moral values of the medical values.
Acting in the patient's best interest is one of the most fundamental convictions of the medical profession. But, what serves the patient best? is sometimes an ambiguous decision indeed. Although it is the patient who has to bear the consequences of medical decisions, absolute freedom of patient without necessary deliberations can be counterproductive in patient care. There are many factors that affect even the competent person's ability to make rational choices. Instead of evaluating the choices simultaneously people in reality evaluate them in succession and in this process they often choose the first option that they consider to offer satisfactory outcome, even though that choice may not be the most rational outcome. These limitations have been called ‘bounded rationality’. Decisions of a competent patient which are rational within the constraints of this ‘bounded rationality’ may not appear rational to the physician without considering these constraints. The exercise of autonomy may fulfil the patient's desire but may not necessarily serve the patient best.
Having said all this, a primary concern remains here, i.e., what serves the patient best? One thing is clear that to serve the patient best, patient's involvement in decision making is inevitable, rather the most accepted concept in the current scenario. Generally accepted and much referred concept of shared decision making lays emphasis on ‘active participation from both patient and professional in decision making process, and agreement on decision’. Both patient and physician discuss the preferences and facts into the decisional process to reach a shared decision. This decision might involve a compromise between the parties as they may not consider it to be the best decision, yet both accept it as treatment to be followed. Trying to find a compromise, which both parties are committed to agree on, will nurture the patient-physician relationship, than simply allowing the patient to make the decision on his own.8
Ethical Guidelines for Medical Practitioners
In India ethical guidelines for medical practitioners were framed by Medical Council of India (MCI) in the year 2002, titled Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002. An abridged form of the Code of Ethics has been provided below. (The full version may be downloaded from www.mciindia.org).
INDIAN MEDICAL COUNCIL (PROFESSIONAL CONDUCT, ETIQUETTE AND ETHICS) REGULATIONS
Chapter 1: Code of Medical Ethics
- A physician shall uphold the dignity and honor of his profession. Reward or financial gain will be a subordinate consideration.
- Only the doctors having qualification recognized by MCI and registered with MCI/State Medical Council(s) are allowed to practice Modern system of Medicine or Surgery.
- A physician should affiliate with associations of allopathic medical professions.
- Physicians should attend CMEs for at least 30 hours every 5 years.
Maintenance of Medical Records
- Physicians shall maintain the medical records of their indoor patients for 3 years from the date of start of the treatment in a standard proforma. If any request is made for medical records by the patients/authorized attendant or legal authorities, the same may be duly acknowledged and documents shall be issued within 72 hours.
- A physician shall maintain a register of medical certificates giving full details of certificates issued. When issuing a medical certificate enter the identification marks of the patient and keep a copy of the certificate.
- Try to computerize medical records for quick retrieval.
Display of Registration Numbers
- Physician shall display their registration numbers in his clinic and in all his prescriptions, certificates, money receipts given to his patients.
- Physicians shall display as suffix to their names only recognized medical degrees or such certificates/diplomas and memberships/honors which confer professional knowledge or recognizes any exemplary qualification/achievements.
Use of Generic Names of Drugs
Every physician should, as far as possible, prescribe drugs with generic names and he shall ensure that there is a rational prescription and use of drugs.
Highest Quality Assurance in Patient Care
Physician shall not employ any attendant who is neither registered nor enlisted under the Medical Acts in force and shall not permit such persons to attend, treat or perform operations upon patients wherever professional discretion or skill is required.9
Exposure of Unethical Conduct
A physician should expose incompetent or corrupt, dishonest or unethical conduct of members of the profession.
Payment of Professional Services
Physician should announce his fees before rendering service and not after the operation or treatment is under way. 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.
Evasion of Legal Restrictions
The physician shall observe the laws of the country in regulating the medical profession and shall also not assist others to evade such laws. He should cooperate in observance and enforcement of sanitary laws and regulations in the interest of public health.
Chapter 2: Duties of Physicians to their Patients
Obligations to the Sick
- Though a physician is not bound to treat each and every person asking his services, he should be ever ready to respond to the calls of the sick and the injured.
- A physician should try to make his visits at the hour indicated to the patients.
- 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.
- When a patient is suffering from an ailment which is not within the range of experience of the treating physician, he may refuse treatment and refer the patient to another physician.
Secrecy
- Confidences entrusted by patients to him should never be revealed unless it is a legal requirement.
- Physician must determine whether his duty to society requires him to disclose confidential information to protect a healthy person against a communicable disease.
Prognosis
Physician should neither exaggerate nor minimize the gravity of a patient's condition. He should ensure that the patient or his family have such knowledge of the patient's condition as will serve the best interests of the patient and the family.
Never Neglect the Patient
- Physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family.
Engagement for an Obstetric Case
When a physician engaged to attend an obstetric case is absent and another is sent for and delivery accomplished, the acting physician is entitled to his professional fees, but should secure the patient's consent to resign on the arrival of the physician engaged.
Chapter 3: Duties of Physician in Consultation
Unnecessary Consultations should be Avoided
In case of serious illness and in doubtful or difficult conditions, physician should request consultation. Such consultation should be in the interest of the patient only. Consulting pathologists/radiologists or other diagnostic laboratory investigations should be done judiciously.
Statement to Patient after Consultation
All statements to the patient/representatives should take place in presence of the consulting physicians, except as otherwise agreed. Differences of opinion should not be divulged unnecessarily but when there is irreconcilable difference of opinion the circumstances should be frankly and impartially explained to the patient/representative.
Treatment after Consultation
- Attending physician may make subsequent variations in the treatment if any unexpected change occurs. At the next consultation, reasons for such variation should be discussed/explained. Same privilege and obligations belong to the consultant who treats patient in emergency, during the absence of attending physician.
- The attending physician may prescribe medicine at any time for the patient, whereas the consultant may prescribe only in case of emergency or as an expert when called for.
Patients Referred to Specialists
When the attending physician refers the patient to a specialist, a case summary should be given to the specialist, who should communicate his opinion in writing to the attending physician.
Fees and Other Charges
- Physician shall display his fees and other charges on the board of his chamber and/or the hospitals he is visiting. Prescription should make clear if the physician himself dispensed any medicine.
- Physician shall write his name and designation in full along with registration number in his prescription letterhead. (In government hospital where the patient load is heavy, name of the prescribing doctor must be written below his/her signature).
Chapter 4: Responsibilities of Physicians to Each Other
Conduct in Consultation
No insincerity/rivalry should be indulged in during consultations. No statement/discussion should be carried on, which would impair the confidence reposed in physician in charge of the case.11
Consultant not to take Charge of the Case
- When a physician has been called for consultation, he should normally not take charge of the case, especially on the solicitation of the patient.
- The consultant shall not criticize the referring physician and shall discuss the diagnosis treatment plan with the referring physician.
Appointment of Substitute
- If a physician requests another physician to attend his patients during his temporary absence, professional courtesy requires the acceptance of such appointment only when he has the capacity to discharge the additional responsibility along with his other duties.
- The physician acting under such an appointment should give the utmost consideration to the interests and reputation of the absent physician and all such patients should be restored to the care of the latter upon his return.
Visiting Another Physician's Case
- When it becomes the duty of a physician occupying an official position to see and report upon an illness or injury, he should communicate to the physician in attendance so as to give him an option of being present.
- The physician occupying an official position should avoid remarks upon the diagnosis or the treatment that has been adopted.
Chapter 5: Duties of Physician to Public and Paramedical Profession
- Physicians should disseminate advice on public health issues. They should play their part in enforcing the laws of the community.
- Physicians, especially those engaged in public health work, should enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and communicable diseases.
- The physician should notify the communicable disease under his care, in accordance with the laws, rules and regulations. When an epidemic occurs a physician should not abandon his duty for fear of contracting the disease himself.
Chapter 6: Unethical Acts
Physician shall not aid or abet or commit any of the following unethical acts.
Advertising
- Soliciting of patients directly or indirectly, by a physician, group of physicians or institutions or organizations is unethical. A physician shall not make use of him (or his name) as subject of any form of advertising or publicity through any mode either alone or in conjunction with others which tantamount to invite attention to him or to his professional position, skill, qualification, achievements, attainments, specialities, appointments, associations, affiliations or honors and/or of such character as would ordinarily result in his self-advertisement.
- 12A physician shall not give to any person, whether for compensation or otherwise, any approval, recommendation, endorsement, certificate, report or statement with respect of any drug, medicine, nostrum remedy, surgical, or therapeutic article, apparatus or appliance or any commercial product or article with respect to any property, quality or use thereof or any test, demonstration or trial thereof, for use in connection with his name, signature, or photograph in any form or manner of advertising through any mode nor shall he boast of cases, operations, cures or remedies or permit the publication of report thereof through any mode.
A physician is permitted to make a formal announcement in press regarding the following:
- Starting practice
- Change of type of practice
- Changing address
- Temporary absence from duty
- Resumption of another practice
- Succeeding to another practice
- Public declaration of charges.
Printing of self-photograph, or any such material of publicity in the letter head or on sign board of the consulting room or any such clinical establishment shall be regarded as acts of self-advertisement and unethical conduct on the part of the physician. However, printing of sketches, diagrams, picture of human system shall not be treated as unethical.
Patent and Copyrights
A physician may patent surgical instruments, appliances and medicine or copyright applications, methods and procedures. However, it shall be unethical if the benefits of such patents or copyrights are not made available in situations where the interest of large population is involved.
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 him 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.
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.
Abovementioned provisions shall apply to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study/work. However, there is no prohibition on payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision.13
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.
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.
Euthanasia
- Practicing euthanasia shall constitute unethical conduct. However, the question of withdrawing supporting devices to sustain cardiopulmonary function even after brain death shall be decided by a team of doctors and not merely by the treating physician alone.
- A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor in charge of the patient, Chief Medical Officer/Medical Officer in charge of the hospital and a doctor nominated by the in-charge of the hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organ Act, 1994.
Code of conduct for Doctors and Professional association of doctors in their relationship with Pharmaceutical and allied Health sector industry.
In dealing with Pharmaceutical and allied health sector industry, a physician shall follow the stipulations given below:
- Gifts: A physician shall not receive any gift from any pharmaceutical or allied health care industry and their sales people or representatives.
- Travel facilities: A physician shall not accept any travel facility inside the country or outside, from any pharmaceutical or allied healthcare industry or their representatives for self and family members for vacation or for attending conferences, seminars, workshops, CMEs, etc., as a delegate.
- Hospitality: A physician shall not accept individually any hospitality like hotel accommodation for self and family members under any pretext.
- Cash or monetary grants: A physician shall not receive any cash or monetary grants from any pharmaceutical and allied healthcare industry for individual purpose in individual capacity under any pretext. Funding for medical research, study, etc., can only be received through approved institutions by modalities laid down by law/rules/guidelines adopted by such approved institutions, in a transparent manner. It shall always be fully disclosed.
- Medical research: A physician may carry out or participate in research projects funded by pharmaceutical and allied healthcare industries. A physician is obliged to know that the fulfilment of the following items (i) to (vii) will be an imperative for undertaking any research assignment/project funded by industry–for being proper and ethical.A physician shall ensure that:
- Research proposal(s) has the due permission from the competent concerned authorities.
- Research project(s) has the clearance of national/state/institutional ethics committees/bodies.
- It fulfills all the legal requirements prescribed for medical research.
- Source and amount of funding is publicly disclosed at the beginning itself.
- Undue animal experimentations are not done and when these are necessary they are done in a scientific and a humane way.
- While accepting such an assignment a medical practitioner shall have the freedom to publish the results of the research in the greater interest of the society by inserting such a clause in the MoU or any other document/agreement for any such assignment.
- Maintaining professional autonomy: In dealing with pharmaceutical and allied healthcare industry, a medical practitioner shall always ensure that there shall be no compromise either with his/her own professional autonomy and/or with the autonomy and freedom of the medical institution.
- Affiliation: A physician may work for pharmaceutical and allied healthcare industries in advisory capacities, as consultants, as researchers, as treating doctors or in any other professional capacity. In doing so, physician shall always ensure that:
- His professional integrity and freedom are maintained.
- Patient's interests are not compromised in any way.
- Such affiliations are within the law.
- Such affiliations/employments are fully transparent and disclosed.
- Endorsement: A physician shall not endorse any drug or product of the industry publicly. Any study conducted on the efficacy or otherwise of such products shall be presented to and/or through scientific bodies or published in scientific journals in a proper way.
Chapter 7: Misconduct
The following acts of commission or omission on the part of a physician shall constitute professional misconduct rendering him/her liable for disciplinary action.
Violation of the Regulations
If a physician commits violation of any of these regulations.
Adultery or Improper Conduct
Abuse of professional position by committing adultery or improper conduct with a patient or by maintaining an improper association with a patient will render a physician liable for disciplinary action.
Conviction by Court of Law
Conviction by a Court of Law for offences involving moral turpitude/Criminal acts.
Sex Determination Tests
- Sex determination test shall not be undertaken with intention to terminate a female fetus, unless there are other absolute indications for termination of pregnancy as specified in the MTP Act, 1971.
Signing Professional Certificates, Reports and Other Documents
- Physicians may be required to give certificates, notification, reports and other similar documents in their professional capacity for subsequent use in the courts or for administrative purposes, etc.
- Any physician who is shown to have signed or given under his name and authority any such certificate, notification, report or similar document which is untrue, misleading or improper, is liable to have his name deleted from the Register.
- Physicians shall not contravene the provisions of the Drugs and Cosmetics Act and regulations made there under. Prescribing steroids/psychotropic drugs when there is no absolute medical indication or selling Schedule H and L drugs and poisons to the public except to his patient; in contravention of the above provisions shall constitute gross professional misconduct on the part of the physician.
- Performing or enabling unqualified person to perform an abortion or any illegal operation for which there is no medical, surgical or psychological indication. A physician shall not issue certificates of efficiency in modern medicine to unqualified or nonmedical person.
- A physician should not contribute to the lay press articles and give interviews regarding diseases and treatments which may have the effect of advertising himself or soliciting practices; but is open to write to the lay press under his own name on matters of public health, hygienic living or to deliver public lectures, give talks on the radio/TV/internet chat for the same purpose and send announcement of the same to lay press.
- An institution run by a physician for a particular purpose such as a maternity home, nursing home, private hospital, rehabilitation center or any type of training institution, etc., may be advertised in the lay press, but such advertisements should not contain anything more than the name of the institution, type of patients admitted, type of training and other facilities offered and the fees.
- It is improper for a physician to use an unusually large sign-board and write on it anything other than his name, qualifications obtained from a University or a statutory body, titles and name of his speciality, registration number including the name of the State Medical Council under which registered. The same should be the contents of his prescription papers. It is improper to affix a sign-board on a chemist's shop or in places where he does not reside or work.
- Physicians shall not disclose the secrets of a patient that have been learnt in the exercise of their profession except: (1) In a court of law under orders of the Presiding Judge; (2) In circumstances where there is a serious and identified risk to a specific person and/or community; and (3) notifiable diseases. In case of communicable/notifiable diseases, concerned public health authorities should be informed immediately.
- The physicians shall not refuse on religious grounds alone to give assistance in or conduct of sterility, birth control, circumcision and medical termination of pregnancy when there is medical indication, unless the medical practitioner feels himself/herself incompetent to do so.
- Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed.
- In the case of running of a nursing home by a physician and employing assistants to help him, the ultimate responsibility rests on the physician.
- Physician shall not use touts or agents for procuring patients. Physician shall not claim to be specialist unless he has a special qualification in that branch.
- In vitro fertilization or artificial insemination shall not be undertaken without informed consent of the female patient and her spouse as well as the donor. Such consent shall be obtained in writing only after the patient is provided, at her own level of comprehension, with sufficient information about the purpose, methods, risks, inconveniences, disappointments of the procedure and possible risks and hazards.
Chapter 8: Punishment and Disciplinary Action
The offences and misconduct given above do not constitute a complete list of the infamous acts which calls for disciplinary action. MCI or State Medical Councils can also deal with any other form of professional misconduct on the part of a registered practitioner.
- Any complaint with regard to professional misconduct can be made to the appropriate Medical Council for Disciplinary action. Upon receipt of any complaint, the appropriate Medical Council would hold an enquiry and give opportunity to the registered medical practitioner to be heard in person or by pleader.
- If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner. Deletion from the Register shall be widely publicized in local press as well as in the publications of different Medical Associations/Societies/Bodies.
- In case the punishment of removal from the register is for a limited period, the appropriate Council may also direct that the name so removed shall be restored in the register after the expiry of the period for which the name was ordered to be removed.
- Decision on complaint against delinquent physician shall be taken within 6 months. During the pendency of the complaint the appropriate Council may restrain the physician from performing the procedure or practice which is under scrutiny. Professional incompetence shall be judged by peer group as per guidelines prescribed by MCI.
- Where either on a request or otherwise the MCI is informed that any complaint against a delinquent physician has not been decided by a State Medical Council within 6 months from the date of receipt of complaint by it and further the MCI has reason to believe that there is no justified reason for not deciding the complaint within the said prescribed period, the MCI may: (1) Impress upon the concerned State Medical council to conclude and decide the complaint within a time bound schedule; (2) May decide to withdraw the said complaint pending with the concerned State Medical Council straightaway or after the expiry of the period which had been stipulated by the MCI in accordance with para (1) above, to itself and refer the same to the Ethical Committee of the Council for its expeditious disposal in a period of not >6 months from the receipt of the complaint in the office of the MCI.
- 17Any person aggrieved by the decision of State Medical Council on any complaint against a delinquent physician, can appeal to MCI within 60 days from the date of receipt of the order passed by the said Medical Council. If MCI is satisfied that the appellant was prevented by sufficient cause from presenting the appeal within the aforesaid 60 days, may allow it to be presented within a further period of 60 days.
CONCLUSION
With the advances in medical sciences as well as changing moral principles of the community at large, clinicians are frequently facing dilemmas in many facets of daily medical practice. Besides, there is anxiety amongst the medical practitioners regarding increasing trends of complaints and lawsuits, many of them are due to inability to comprehend and resolve ethical dilemmas in clinical settings. In addition to moral obligations, clinicians are also bound by legal framework regulating medical practice. It is now well-accepted that legal and ethical considerations are inseparable part of good medical practice. The clinician should remain attentive to the patient's perspective and control their behavior so that the patient's best interest is taken care of at all times.
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