Legal Issues in Medical Practice: Medicolegal Guidelines for Safe Practice VP Singh
Page numbers followed by b refer to box, f refer to figure, and t refer to table.
Abortion 15
Abscess 89
epidural 245
substance 65
verbal 61, 107
Accident 336
aspiration, risk of 320
Accreditation Council for Graduate Medical Research 114
Acitretin 302
Acquired immunodeficiency syndrome 24
Active Surveillance Programs 96
Addressing patient's emotions 115
Adult medical service 277
Adverse drug reaction 195
Advisory committee 216
Age-related macular degeneration 272
Air conditioning
engineers 81
function of 81
Airborne communicable diseases 80
prevention of 81
Airborne Infection Control Program 81
Airborne infection isolation room 80
Alcohol 186
based preparations 213
consumption 321
Allergic reaction
history of 253
severe 309
Ambulatory care 87
American Association of Blood Banks 302
American Association of Orthopedic Surgeons 262
American Board of Internal Medicine's 114
American College of Obstetricians and Gynecologists 240
American College of Radiology 75, 290
American Society of Anesthesiologists 336
American Society of Heating 81
Amikacin 97
Aminoglycoside 97, 98
Amoxicillin 98
Anaphylactic reactions, severe 309
Anesthesia 338
awareness 331, 332
deaths 331
mishaps 245
procedure 336
refused 338
regional 256
related problems 337
role of 256
medicolegal issues in 328, 329
safety in 339
specialty of 328
Animal anatomical waste 219
Ankle injuries 264
Anonymity 18
Anorexia 280
Antenatal care, errors in 241
Antibiotic 43
choice of 97
resistant organism 88
therapy, initial 97
Anticipate violence, signs to 65t
Anti-hepatitis C virus 296
Antipseudomonal cephalosporin 97
Antipseudomonal penicillin 97
Anxiety 41
Anxiousness, signs of 65
Appeal 172, 218
Arthroplasty 264
Aseptic precautions 101
Aspergillus 81
Asphyxia 195197, 281
birth 241
Aspiration pneumonia 97
Atomic Energy Act 213
Atomic Energy Regulatory Board 75
Authorization Committee 207
Autopsy 331
Back disorders 264
lumbago 264
sciatica 264
Balloon pumps 43
Bile duct, common 257
Bio-medical waste 212214, 218, 224
bags, tracking 223
categories 219t
categories of 223
handling of 215
management 217, 226
and handling rules 213, 222, 225
safe 226
records of 225
treatment 217
and disposal facility 214
and disposal of 224
facilities, common 214
untreated 218
Biotechnology 221
waste 219
Birth, wrongful 241
Blood 43
administering 311
and blood components, guidelines for 304
and transfusion safety program 304
borne pathogens 302
components, administration of 306t
donate 297
issue and usage records 310
pack, checking 312
pressure 149
prior to transfusion, collecting 311
safety and availability 304
screening, challenges of 301
storage centres 302
supply, stewardship of 299
test 202
utilization 84
Blood bag 312b
number of 309
Blood banks 295, 302
activity of 295
Blood collection 297
records 309
Blood donation 297
and transfusion 294
camps 302
Façade of non-remunerated 297
informed consent in 301
non-remunerated 294, 297, 300
number of 302
regular 315
voluntary 297
Blood donor
selection and donor referrals, guidelines for 302
unpaid 315
Blood group
tested for 309
transfusion, wrong 314
Blood products 140, 302, 308
to transfusion, storing 311
Blood transfusion 140, 294, 300, 308, 313, 315
alternatives to 303
mismatched 295
documentation of 309
litigation related to 313
medicolegal issues in 294
process 305
safety 304
services 294
system, conventional 303
Bloodstream 200
infection, central line-associated 91
Body tissues 18
Bolam's rule 165, 257
Bone marrow transplant 81
Bradycardia 245
Brain death, declaration of 206
Canadian Medical Protective Association 33
Canadian Patient Safety Institute 36
Canadian system, tests of 98
Candida 90
Carbapenems 97
Carbon dioxide 82
Cardiac arrest 195, 245
Cardiac surgery 332
Cardiopulmonary resuscitation 40, 140
event, documentation of 140
Care and liability, duty of 329
Carotid artery stenosis 321
Cataract 102
surgery 271
Cause-effect relationship 289
Cefepime 97
Cefoperazone 98
Cefoxitin 97
Ceftazidime 97
plus 97
vancomycin 97
Central Licence Approving Authority 296
Central Pollution Control Board 217, 218
Central Supervisory Board 230
Cephalometric radiographs, pretreatment 321
Cesarean section 243, 332
Chemical liquid waste 220
Chemical waste 213, 220
diseases of 277
disorders of 277
Chlorinated plastic bags 223
Chromosomal abnormalities 241
Ciprofloxacin 97
Civil law 176
damages in 164
Clavulanate 98
Clindamycin 97
Clinical documentation guidelines 150
Clinical records 150b
Clinician satisfaction, improved 110
Clostridioides difficile infection 88
Clostridium difficile 99
Cognitive errors 74
Cognitive impairment 74
Communication 108, 275, 290, 305, 330
assessment tool 114
barriers 74, 113, 282
behavior change 297
channel 108
effective 108, 109
good 107
in healthcare 109
ineffective 113
model, basic 108f
nonverbal 108
openness 74
practice good 282
principles of good 110
skills 62, 108, 109, 114, 115, 282
for doctors 109
in healthcare 107
lack of training in 113
of healthcare practitioners 107
of healthcare workers 114
types of 108
unambiguous 305
verbal 108
with attendants 111
with referring doctor and patient 290
leaders 64
role of 63
Compensation 179
Competency assessment 306
Complainant's advocate 174
Complainant's allegation 101
Complaint Under Act 225
Conception, wrongful 242
Conducting medical interview 111
Confusion 41
age for 125, 279
role of 248
Consultation, conduct in 10
Consumer court 143, 172
function 170
pecuniary jurisdictions of 187
Consumer forum, members of 172
Consumer Protection Act 141, 142, 170
complaints under 170
in dental professionals 324
Contemplating suicide 61
Corneal flap 270
Corneal thinning 270
Corporate hospitals 61, 64
Cosmetic surgery 5, 270
improper 53
techniques 115
Court of law, expert witness in 248
Criminal case, appearing in 173
Crisis reform models 181
Crooked tree, famous engraving of 261f
Cylinders, storage of 83
Cystic fibrosis 241
Cystic lesions 321
Cytomegalovirus 89
Dalfopristin 97
Data privacy and security 134
certificate, cause of 137
wrongful 242
Decision making
capacity 52
assess 54
involve patient in 111
process, document shared 253
Defence lawyer, selection of 170
Delirium 41
Dental care, quality in 319
Dental pain 320
Dental practice
medicolegal aspects of 319
no negligence' occasions in 323
Dental practitioners 319
diagnosis of malignancy in 321
medicolegal issues in 319
negligence in 322
Depression 41
underlying 300
Diabetes 100
Dialysis 43
Diameter indexed safety systems 82
Director General Armed Forces Medical Services 218
Directorate General of Health Services 142
Disastrous consequences 173
Disc lesions 264
Discharge against medical advice
duty of doctor in 52
predictors of 50, 51t
validity of 52
Discharge notes 154
Discharge process, documented 140
emotional facet of 288
severity 40
transmission, risk of 81
Disposal facilities 217
Distressing symptoms 245
District Level Monitoring Committee 217
District-wise committee 68
Doctor's defence 101, 102, 196, 198, 201, 202
bonding 70
communication 114
relationship 157, 250, 290, 335
Doctors and professional association, code of conduct for 13
Doctors for criminal
negligence, prosecution of 167
rashness, prosecution of 167
Documentation 146, 275, 305, 330
adequate 56
and informed consent 265
benefits of good quality 147
errors in 148
incomplete 54
incorrect 54
legal importance of 146
of procedures 140
Documented policies 138, 139
Documenting instructions 157
Documenting patient's refusal 157
ethical principles relating to 299
maintenance charge 206
organ transplantation, deceased 210t
screening 302
Drugs 331
delivery systems 99
intoxications 65
resistant bacteria 98
Drugs and Cosmetics Act 15, 295, 296
Drugs and Cosmetics Rules 295, 296
Dryness 270
Dutasteride 302
Duty of care 162
Dyspnea 41
Eagle's eye 237
Easy to accept cause-effect relationship 289
Ectasia 270
Ectopic pregnancy 242
Effective laws, implementation of 69
Electronic health records 133
preservation 134
Electronic medical records 77, 144
Electronic protected health information 133
acute 254
error in diagnosis during 280
medical care 283
surgery 332
Emergency department 50, 62, 74
safety factors in 74t
Empathy skills 62
Empiric therapy, principles of 97
Encephalocele 241
End of life
care 40
decisions 40
issues, legal aspects of 45
Endorsement 14
Endoscopy room 75
Engender litigation, complications 252
Engineering design plays 80
Enterobacter cloacae 98
Enterococcus 90
Environment Law 212
Environment Protection Act 213, 225
penalties under 225
Epidural hematoma 245
Epithelial cells 90
Equipment 330
disposable 101
Error and omission policy 186
Erythromycin 97
Esthetic dentistry 322
advisory committee 47
law and policy 33
Etretinate 302
Euglycemia 256
Euthanasia 13, 44, 45
active 44
debate on 45
nonvoluntary 44
passive 44, 45
voluntary 44
Evolution 122
Eye surgery, types of 270
Facial trauma, cases of 320
Facility management and safety committee 84
Fallopian tubes 129
Family planning operation 247
Fascia 89
Fatigue 74
Faulty surgical technique 247
Fear 41
Female feticide, prevent 234
Femtosecond laser assisted cataract surgery 271
Femur, fracture of 264
Fetal anomalies, missed diagnosis of 244
Fetal autopsy 244
Fetomaternal disorders 240
Fetomaternal physiological derangement 240
Fight against violence, essential in 67
Finasteride 302
Fingerpointing, avoid 173
Fistula formation 258
Fluid replacement, adequate 256
Fluoroquinolone 97, 98
Foreign objects
ingestion of 320
inhalation of 320
Fractured surgical needle 321
Future litigation, protection against 51
Gas cylinders rules 82
Gastrointestinal tract 88
Gene therapy 269
Generic names of drugs, use of 8
Genetic counseling center 229
Gifts 13
Glassware 221
Glaucoma 275
Glutaraldehyde 213
Good clinical records, advantages of 151t
Gossypiboma 246
Gossypium 246
Gram-negative organisms 98
combination therapy 98
monotherapy 98
Gram-positive organisms 98
Growth hormone 302
Gynecological causes 239
Gynecology, medicolegal issues in 245
hygiene 80
injuries 264
washing 99
Harassment 61
Haunting nightmare 175
Hazardous chemicals rules, storage and import of 213
Hazardous waste 212
court 182
system 183
protected 133
technology 78
coverage 239
purpose 19
related literacy 69
low 63
commercialization of 287
high 52
lower 181
delivery, aspects of 109
documentation in 145
establishments 212, 223
expenditure, escalating 87
expensive 239
facilities, implementation of rules in 217
organization 84, 104, 133
provider 134
research and quality, agency for 94
risk management in 83
sector 61
anticipate violence in 64
managing violence in 65
preventing violence in 65
standards 73
strategies for safety in 74
system 33, 151
workers, occupational safety of 225
Healthcare-associated infection 79, 87, 88, 92, 93, 95, 96, 98, 100, 101
common 89
documented 97
indicators of 96
legal provisions applicable to 103
management of 97
medicolegal aspects related to 99
sources of 88
strategies for management of 97
type of 88
Heart disease, congenital 281
Hemolytic reactions, acute 308
Hemorrhage, postpartum 241, 246
Hemostats, application of 257
Hepatitis 302
antibodies 297
B 302
infection 295
surface antigen 296
C 101, 302
infection, suffered 101
test 101
virus 101
Herpes simplex 89
Herpes zoster 89
Hippocratic oath 5
Home care 87
replacement therapy 246
secretion 245
Hospital acquired infections, prevent 95f
Hospital administrators, preventive tips for 67
Hospital management 338
Hospital readmissions 53
Hospital waste 212
management 212
Hospital-acquired infection
burden of 92
incidence, trend in 92t
indicators to control 96t
preventing 92
strategies for prevention of 93t
Hospitality 13
Hospitalization, reason for 154
Human anatomical waste 219
Human blood 295
Human embryos 303
Human immunodeficiency virus 24, 295, 302
infection 26, 313
risk of 23
transmission of 26
positive 23, 25
right of 23
status, disclosure of 24
screening 25, 26
status 23, 25
testing 24, 25
guidelines on 24
informed consent for 24
Human life, loss of 176
Human organ 207
Human Organ Transplantation Act 45
implications to 45
Human rights 13
Humerus fracture 264
Hydrocephalus 241
Hyperbilirubinemia, management of 281
Hypochlorite 213
Hypochondria 5
Hypoglycemia, neonatal 281
Hypotension 245
severe 309
Hypothetical considerations 179
Hypoxia 195
Hysterectomy 245
Ideal indemnity insurance policy 190
Imipenem 97
Immune systems 100
Incisional infection, superficial 89
Indemnity insurance policy 191
Indian Council of Medical Research 19
Indian Evidence Act 142
Indian Medical Association 217
Indian Medical Council 8
Regulations 8
Indian Penal Code
related to consent, sections of 126b
relevant sections of 196
section 269 104
section 270 104
section 304a 103
section 337 103
section 338 104
Indian Radiology and Imaging Association 228
Indian Society of Anesthesiologists 329, 336
Ineffective communication
consequences of 113
legal risks of 283
Infection 89, 270
anaerobic bacterial 97
bacterial 309
blood and urine 200
chain 80f
control 79, 84
aspect of 77
committee 104
measures 100
practical guidelines for 80
deep incisional 89
developing 87
exogenous 88, 102
eye 102
high risk of 302
hospital 88
organ surgical site 89
postoperative 96
prevent 80
prevention and control 80
initiatives 94
protozoal 309
spread of 80, 104
surgical site 87, 89
transmission of 91
type of 102
viral 309
Infectious agent 80
Infectious diseases 81
spread of 81
Infectious hazards of transfusion 309
Infectious waste 212
Inflammation 270
Influenza 81
and communication technology 134
disclosure of 124
via speech 108
Informed consent 274
documentation of 128
medicolegal aspects of 121
role of 291
Injury, assessment of 162
Inpatient medical records 142
Institute of medicine 31, 32
Insulin 43
factors influencing amount of 187
schemes 69
Intensive care units 62, 87
International Society of Blood Transfusion 298
Interpersonal behavior 324
Intoxicant 186
Intraocular lens implants 269
Intraocular pressure 272
Intra-operative monitoring, standards for basic 336
Intrauterine fetal death 243
Intrusive palliative procedures 43
case of 280
diagnosis of 280
Irrational implementation 234
Isolation rooms 77
Isotretinoin 302
Jecker's modification 41
commission 264
national patient safety goals 94
replacement 257
Judgment, error of 333
Judicial decision 25, 122
on informed consent 129
on radiological errors 289
Judicial precedents 195
Judicial process, lack of faith in 64
administration of 19
legal requirement of 19
Karmachari of hospital 155
Kidney transplant 200
Klebsiella 95
Knee ligament 264
Laryngeal nerve injury, recurrent 257
Laser assisted in situ keratomileusis 270
complications 270
Laudable pus 257
Law against violence, strengthening 67
Lawful Act 196
claim 56
managing risk of 274
Legal liability 186
Legal restrictions, evasion of 9
Legionella 90
Legionellosis infection 97
Life, wrongful 241
Life-prolonging interventions, guidelines for limiting 42b
Life-saving surgery 43
withdrawal of 42, 43
withholding of 42, 43
illness 41
reaction 308
situations 300
Linezolid 98
Lion's heart 237
Liquid waste, disposal of 215
Listen actively 111
causes of 263
in orthopaedics, causes of 264b
process, key role in 146
protection against 323
risk of 53
Living donation and transplantation, medicolegal aspects of 207
Loneliness 41
Macula 272
Malaria 296, 302
parasite 202
crisis reform, part of 182
liability crisis 180
litigation 269
Malpractice lawsuits 169, 249
obstetric cases vulnerable to 240
prevent risk of 123
risk of 319
vulnerable to 281
Measles 80, 81
in preventing violence, role of 69
role of 64
Medical acts 8
Medical advice
cases of Discharge against 52
causes of discharge against 50, 50b
compliance with 109
consequences of discharge against 52
discharge against 49, 51, 52, 55, 55b, 56, 57t
leave against 49, 51, 56, 140
legal status of discharge against 51
managing discharge against 54
medicolegal aspects of discharge against 49
reason for discharge against 53
risk of discharge against 50
Medical air 82
Medical and legal implications 241
Medical care 132
continuity of 146
Medical certificate 155b
issuing 155
of cause of death 137
Medical condition 74
complex 74
Medical confidentiality 4, 23, 25
guidelines on 20
Medical Council for Issuance of Medical Certificate 156b
Medical Council of India 115, 138, 155b
guidelines 136, 150
regulations 20, 143
Medical decision 6
making 18
Medical Defense Union 270
Medical documentation 145, 147
critical issues in 154
good 152
illegible 149
quality of 146
Medical documents, cases compelling 147
Medical education, competency-based 116
Medical emergencies 128, 320
Medical errors 3133, 113
consequences of disclosing 33
disclosure of 32, 33
guidelines on disclosing 34
types of 32b
Medical establishments 186
Medical ethics 3, 6
code of 8
Medical futility 41, 44
Medical gases 82
safety measures related to 82
Medical Injury Compensation Reform Act 181
Medical interview
prior to start of 110
with patient 110
Medical jousting 266
Medical laws, awareness of 325
Medical liability 180
crisis 183
Medical literature, basis of 5
Medical maloccurrence 249
Medical malpractice
insurance 180, 183
liability crisis 180
litigation 107, 169
Medical negligence 157, 161, 163, 165, 176179, 183, 185, 253, 270
allegations of 190
burden of proof of 164
cases 68, 101, 142, 176, 182
compensation in 176
crime 163
essential components of 161
guilty of 201
issue of 143
lawsuits of 170, 291
liability lawsuits, cases of 190
types of 163
vital issues in 164
Medical practice
confidentiality in 18
disclosure in 18
ethics of 3
part of good 17
Medical practitioner 5, 53, 175
benefits of disclosure to 34
care required by 200
complaints against 169
ethical guidelines for 8
feels 15
harms of disclosure to 34
Medical profession, values of 7
Medical professionals 291
criminal liability of 167
for criminal negligence 198
landmark judgments related to 195
Medical Protection Society 270
Medical record 77, 132, 135, 144
categories of 135
complete and accurate 137
component of 132
confidentiality of 135
department 137
destruction of 173
guidelines on 136
judicial decision related to 143
maintenance of 8
medicolegal aspects of 132, 141
reflects continuity 137
regulation governing 147
review of 138
Medical research 13, 19
Medical science and technology, recent advancement in 85
Medical specialty 66
Medical Teaching Program, integral part of 115
Medical termination of pregnancy, incomplete 241
Medical vacuum 82
confusion 74
errors 283
management of 141
Medicine 3, 285
branches of 240
defensive 180183
discarded 220
expired 220
incorporate philosophy of 66
neonatal 281
practice of 3, 121
safe practice of 203
tradition of 60
aspects 208, 297
autopsy 258
awareness 239
cases 138, 208
claims against gynaecologists, survey of 240
conflicts 287
in orthopedics 264b
preventing 265
donations 206
examination 125
implications 253
issues 237, 245, 283
recent trends of 3
risk factors 252
safety 71
Meningitis 281
Meningomyelocele 241
Meniscal injuries 264
Meropenem 97
Metallic body implants 221
Metronidazole 97
Microbiological examination 102
Microbiology 221
Micro-chip implants 269
infecting 87
source of 91
Ministry of Environment, Forest and Climate Change 217, 218
Ministry of Health and Family Welfare 78, 215, 296
Ministry of Urban Development 79
Misadventures 336
Misconduct 14
adultery 14
conviction by court of law 14
improper conduct 14
sex determination tests 14
violation of regulations 14
Mishaps 336
Missed ectopic pregnancy 241
Missed test results 74
Modern medicine 73
Morbidity, high 53
Morphine, high dose of 5
Mortality 53
Motor Accident Claim Tribunal Act 142
Motor Vehicles Act 219
Multidrug-resistant organisms 96
Multiple anecdotal reports 60
Multiple gestation 241
Myomectomy 246
Nasal septum, margin of 195
National Academy of Sciences 31
National Accreditation Board for Hospitals and Healthcare providers 136
guidelines 136
National Acquired Immunodeficiency Syndrome Control Organization 295
guidelines 23
National Blood Policy 294296, 298, 301
and guidelines 301
National Blood Program, development of 295
National Blood Transfusion
Council 294
Program 294
National Commission 129, 143, 173
National Consumer Dispute Redressal Commission 179, 278
National Healthcare Safety Network 88
National Patient Safety
agency 264
goals 95
Nature of disease, diagnosis and 127
Nature, multidisciplinary in 139
Nausea 41
Negligence 197, 199
by professionals 199
causing death by 103, 196
per se 164
test for establishing 166
Negligible health impacts 224
Neonatal intensive care 281
Neonatal resuscitation 281
Neuromuscular blocking agent 332
Nitrogen 82
Nitrous oxide 82
No objection certificate 207
No-fault compensation 182
Non-hazardous waste 212
Non-heart-beat donors 45
Noninjurious assault 61
Nonmonetary incentives 297
Nonseasonal perspiration 65
Nontransplant organ retrieval centers 206
Normothermia, maintaining 256
Nosocomial infection 88
Numerous medicolegal issues 259
case, engagement for 10
medicolegal issues in 240
regional anesthesia, complications of 245
ultrasonography in 244
Obstetric anesthesia 244
practice of 244
Obstetrics and gynecology
medicolegal issues in 239
practice 239
Ocular diseases 269
Ocular trauma 272
and penalties 230
cognizance of 68
penalties for 225
Omission, allegation of 286
Oncology 81
Oopherectomy 245
Operation table, death on 329
Operation theater 330
Ophthalmic practice, vulnerable domains in 270
Ophthalmology 269
medicolegal issues in 269, 270
Oral care 41
Oral cavity 90
Organ donation 209, 273
and transplantation 208
programme 211
counseling for 206
deceased 209
Organ failure, number of 211
Organ retrieval
centers 209
charge 206
Organ transplant 204
surgery 257
policy 139
services of 139
Original complainant 202
Oropharynx 321
practice 320
therapy 321
treatment, complication of 320
Orthodontists 321
Orthopedia 261
medicolegal issues in 261
medicolegal risks in 262
practice evidence-based 266
scope of consent in 263
surgeons, reasons of litigation against 263
surgery 261
Orthopedist in court of law 267
Osteoarthritis 264
Ovaries 129
Oxygen 82
Pacemakers 43
and suffering 181
component 181
persistent 320
treatment of 41
Palliative care
at end of life 40
wards 41
Paraverbal communication 108
Parental permission 279
Parental refusal to medical treatment 282
Parenteral and enteral fluids 43
Patent and copyrights 12
Paternalism 5, 6
versus autonomy 5
Paternalistic philosophy 6
Patient burden 113
Patient centered documentation and record keeping 152
Patient handling and movement assessment 79
Patient related factors 62
Patient safety
and risk management 73
in pediatrics 280
initiatives 71
Patient's allegation 102, 196, 198, 201, 202
Patient's interest 19
Patient-doctor relationship 267
Patient-physician relationship 107
PC-PNDT Act 227, 229, 230, 234, 292
Pediatrician 278
Pediatrics, medicolegal issues in 277, 278
hemorrhage, uncontrolled 246
inflamatory disease 246
pain syndrome 246
Penalty and compensation 68
Permanent vegetative state 46
Personal document 135
Personal information 134
Persons with Disabilities Act 79
Persons with Disabilities, rights of 79
Phacoemulsification 271
Phagocytes 98
Phenolic derivatives 213
Physical assault causing injury 61
duties of 9
in consultation, duties of 10
preventive tips for 65
related factors 62
responsibilities of 10
to public and paramedical profession, duties of 11
Piperacillin 97, 98
adherent 241
microscopic examination of 244
previa, undiagnosed 241
Placental umbilical cord blood transfusion 303
Plaintiff sought damages 129
Planned surgery, deviation from 254
pyrolysis 224
regain, rapid 296
Plasmodium falciparum 202
atypical 97
ventilator associated 90
Poddar's treatment 23
Pollution Control Committee 216, 219
Poor clinical records, disadvantages of 151t
Poor insurance claim settlement 53
Postanalysis disclosure 36
Post-traumatic stress
disorder 331
syndrome 61
Pre-anesthesia assessment 140
Preconception and Prenatal Diagnostic Techniques Act 227, 285
Preconception and Prenatal Diagnostic Test Act 142
high-risk 243
hypotensive syndrome of 245
medical disorder in 243
Premature baby 242
Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act 147, 227
Pretransfusion blood sampling 308
Pretreatment screening, incidental findings on 321
Professional indemnity 185
insurance 185, 325
policy 190
Professional practices 337
Professional services, payment of 9
Proliferative diabetic retinopathy, stage 272
Proliferative vitreoretinopathy 272
Proxy, consent by 279
Pseudomonas aeruginosa 97, 98
infection 98
Public and community health 20
Public health authorities 15
Public hospitals, problems of 63
Public lectures 15
Public safety 19
Publishing diagnostic errors regularly 291
Punishment and disciplinary action 16
Pyrexia 280
Quality healthcare 180, 283
Quasi-judicial courts 170
Quinupristin 97
Radiation dose 76
Radioactive waste 213
Radiological errors, types of 286
Radiological negligence 289
Radiologist's rapport 288
average diagnostic standard in 287
avoiding litigation in 290
errors in 285, 291
limitations of 288
medicolegal issues in 285
Radius and ulna, fractures of 264
Reaction, severe 308
Reasonable care 166
Reasonable skill and care 325
legal relevance of 325
social relevance of 325
Rebates and commission 12
disposal of 310
keeping 228
preservation of 141
storage of 310
Recording information, process of 145
Red blood cells 303
sources of 303
Red Crescent Societies, league of 298
Registered medical practitioner 207
Registration numbers, display of 8
Rejoinder and affidavits 171
Renal failure, acute 149
Res ipsa loquitor 165, 247, 334
doctrine of 335
Resident doctor 112
Respiratory rate 295
Respiratory suppression 5
Respiratory syndrome, severe acute 81
Respiratory trouble 202
Retina 272
artificial 269
Retinal conditions 272
Rheumatic fever, acute 149
Rhythm abnormalities 140
Rifampicin 97, 98
Right to Information Act
and medical confidentiality 21
and medicolegal cases 22
Risk identification 84
sources of 84
Risk management 83
activities, evaluation of 84, 85
practice 320
process of 83
programs, implementation of 85
development of 84
implementation of 84
Robust system 294
Root resorption 320
Rubbing hands, frequently 65
Rubella 89
Rupture uterus 246
Sadness 41
Safe blood administration 308
Safe handling of treated wastes 224
Safe operation theater setup 266
Safe transfer, methodology of 139
Safer healthcare system 182
Safety encourages teamwork 74
Safety habits, certain 66
Sands of Sahara syndrome 270
Scope and legal interpretation 161
Secrecy and data security 18
Sedation, consent for 140
Seizures, neonatal 281
Sensitive personal information 134
Sepsis 281
Serratia marcescens 98
Sex determination tests 20
Sex ratio, declining 234
Sex, prenatal determination of 231
Sexual harassment 61
Sexual offenses 162
Sexual violence, victims of 279
Shock 309
Sick, obligations to 9
Single photon emission 75
Skill and care, medical relevance of reasonable 325
Skin 258
incision 89
problems 41
habits 100
history of 321
Soiled waste 219
Solicit patient assent 279
Spondylolisthesis 321
Standard operative procedure 295
Staphylococcus 90, 200
aureus 95, 98
State blood transfusion councils 295
State Commission 173
State Consumer Dispute Redressal Commission 323
State Pollution Control Board 216, 218, 219
Stem cell 269
derived blood cells 303
Sterilization operation, cases of 248
Stillbirths 243
Streptococcus pneumoniae 98
Strong and effective laws 67
Strong paternalism 6
Stylohyoid ligaments 321
Suboptimal visual outcome 270
Suicide, physician assisted 45
Sulbactam 98
Summoning medical records by courts 142
Supreme Court's observation 201
on criminal negligence 197
on expert medical opinion 203
on negligence 199
consent in 256
medicolegal issues in 252
never events' in 258
preoperative period in 253
wrong site 258, 259, 264
wrong-procedure 265t
Surgical complications 248, 256
Surgical items, retained 258
Surgical mishaps 245
deaths due to 331
Surgical objects, retained 246
Surgical procedure, documentation before 141
Surrogate decision-maker 54
Susbequent and postanalysis disclosure 38
Sword of Damocles 263
Syphilis 89, 302, 303
Systemic diseases, missing serious 273
Systemic lupus erythematosus 273
Tapping hands 65
Tarasoff case 23
Tay-Sachs disease 241
Tazobactam 98
Teaching communication skill 115
Technical mishaps 331
Teicoplanin 98
Temporomandibular disorder 319, 320
cause of 320
Testis, torsion of 280
Therapeutic interventions 87
Therapeutic privilege 128
Therapeutic relationship, dissolution of 51
Threatening behavior 61
Tibia, fracture of 264
Tonsils, removal of large 280
Toothache 320
Tort system 183
Total hip replacement 263
Total knee replacement 263
Toxic waste 213
Toxoplasmosis 89
Transfusion 310
adverse effects of 308
associated circulatory overload 308
code of ethics relating to 298
practice of 295
noninfectious hazards of 308
process, documenting 312
reaction 313
acute 308
adverse 302
investigation of 313
technology 294
transmitted diseases, risk of 294
Transient neurologic complications 245
Transmission 80, 92
Transplant coordinators in hospitals 206
Transplantation of Human Organ Act 204, 273
Transplantation of Human Organ and Tissues Rules 204
Treatment after consultation 10
Treatment and disposal 218
Trisomy 21 241
Trypanosoma cruzi 303
Tuberculosis 80, 81, 89
Ultrasound machine, registration of 227
Unethical Acts 11
Unethical conduct, exposure of 9
Unipolar electrocautery 257
Unique hospital identity number 137
Upper respiratory tract 90
Urinary tract infection, catheter-associated 91
Urticaria 309
Uterine bleeding, dysfunctional 246
Uterus 129
Vaccine injury 283
Vaginal birth after cesarean 240, 243
Valid consent, conditions for 125
Vancomycin 97, 98
resistant enterococci 95
Vasopressors 43
Venereal disease 25
Ventilation, function of 81
Ventilator 43
Vertebra 321
Violations, penalties for 231t
against doctors 60
factors predisposing to 61
prohibition of 68
Vis-à-vis parenteral nutrition 281
Vis-à-vis surgery 280
Vision, lost 102
Vitreoretinal surgeons 272
Voluntariness 124, 125
Vomiting 280
clinical laboratory 221
contaminated 221
management rules 225
pharmaceutical 213
Water (Prevention and Control of Pollution) Act 215
Weak and ineffective laws 63
White blood cell 90
Wisconsin Department of Regulation and Licensing 289
Wisconsin radiologist 289
death on operation table 329
examination of 172
World Blood Donor Day 315, 316
World Federation of Society of Anesthesiologists 329
World Health Assembly 308
World Health Organization 41, 79, 94, 215, 258, 298, 302
Chapter Notes

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1Ethics in Healthcare: The Guiding Values!
  • Chapter 1 The Ethics of Medical Practice
  • Chapter 2 Confidentiality and Disclosure in Medical Practice2

The Ethics of Medical PracticeCHAPTER 1

VP Singh,
Parmod Goyal
“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
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 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
  • Justice.24
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 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 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 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 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.
Should Physicians do Whatever Patients say?7, 8
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.
What Serves the Patient Best?9, 10
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
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.
  • 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.
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.
  • Physicians shall not willfully commit an act of negligence that may deprive his patients from necessary medical care.10
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.
  • 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.
  • 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:
    1. Research proposal(s) has the due permission from the competent concerned authorities.
    2. Research project(s) has the clearance of national/state/institutional ethics committees/bodies.
    3. It fulfills all the legal requirements prescribed for medical research.
    4. Source and amount of funding is publicly disclosed at the beginning itself.
    5. 14Proper care and facilities are provided to human volunteers, if they are necessary for the research project(s).
    6. Undue animal experimentations are not done and when these are necessary they are done in a scientific and a humane way.
    7. 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.
  • Any act of termination of pregnancy of normal female fetus amounting to female feticide is a professional misconduct by the physician leading to penal erasure besides rendering him liable to criminal proceedings as per the provisions of this Act.15
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.
  • 16Physicians shall not publish photographs or case reports of his/her patients without their permission, in any medical or other journal in a manner by which their identity could be made out. If the identity is not to be disclosed, the consent is not 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.
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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