Dr M.Rashid Anjum Community Medicine Department Army Medical College Rawalpindi.

morals?  What is considered right or wrong behaviour based on social custom?. The study of right and wrong in conduct. A system or code of morals of a particular religion, group, or profession.

A set of moral principles. The study of morality. The philosophical study of moral values and rules.  What is right or wrong based on reason, from

 A system of moral principles that apply

values and judgments to the practice of medicine.

The Physician -- Patient Relationship. The Physician --Physician Relationship. The relationship of the Physician to the

System of Healthcare. The Relationship of the Physician to Society.

 AUTONOMY .

the patient has the right to refuse or choose their treatment.

BENEFICENCE. a practitioner should act in the best

interest of the patient.

NON-MALEFICENCE."first, do no harm" (primum non

nocere).

JUSTICE. fairness and equality

Right to information and self determination. Free and informed consent. Free will and accord - intentional participation in

treatment.
Respect and dignity maintained.

Children? Mentally ill? Mentally impaired?

Persons who lack mental capacity are generally treated according to their best interests

 Actions that serve the best interests of patients. Which practices do in fact help patients?

??

Healing should be the sole purpose of medicine.

Patient s welfare as the first consideration.

First do no harm.
to do them good.

It is more important not to harm your patient, than

non-maleficence is not absolute. Beneficence (doing good) vs Non-Maleficene (doing no harm)

Calculated risk or risk benefit. (double effect)

 Double effect refers to two types of consequences

which may be produced by a single action.

 In a dying patient use of morphine can have the

beneficial effect of easing the pain and suffering of the patient, while simultaneously having the maleficent effect of hastening the demise of the patient through suppression of the respiratory system.

Autonomy & Beneficence/Non-Maleficence may conflict: Example:  Cosmetic Surgery. Autonomy and Beneficence/Non-Maleficence may also overlap. Example: Breach of patients' autonomy may cause decreased confidence for medical services and subsequently less willingness to seek help, which in turn may cause inability to perform beneficence.

Not to discriminate on age, sex, religion, race,

position or rank.
Greater good of society. Respect of the law. Equity and distribution of burden & benefits.

Fair distribution of scarce resources.

Respect for people's rights .

 Consent .

Confidentiality . Communication. Conflicts of interest. Truth Telling.

Explicit
Verbal. Written.

Implied.

is commonly applied to conversations between doctors and patients. Exceptions to the rules : Gunshot wounds. Diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis.  Termination of a pregnancy in an underage patient, without the knowledge of the patient's parents.

Confidentiality

Communication breakdowns between doctor/patient/attendants/family leads to so-called "ethical conflicts"

is a set of conditions in which professional judgment concerning a primary interest tends to be unduly influenced by a secondary interest.

Commercial interests of,  Doctors. 



Unnecessary referrals. Unnecessary prescriptions.

Drug Companies.

Refers to provision of information not simply to enable the patients to make informed choices about healthcare but also about their actual situation. Information should be presented in such a way that it could be understood.

MEDICAL PRACTICE. Code of Medical Ethics for Medical Practitioners. Good Medical Practice statement by GMC. Code of Ethics for RMP s by PM&DC. MEDICAL RESEARCH. Declaration of Helsinki. 1964 (Ethical Principles for Medical Research Involving Human Subjects)

MEDICAL PRACTICE:

Hospital Ethics Committee

MEDICAL RESEARCH:

Research and Ethical Boards

PM&DC:

Disciplinary Committee

Hippocratic Oath.  Ishaq bin Ali Rahawi. Thomas Percival.

Do no harm

460 --- 377 BC. 10th Century. 1803. 1847. 1949. 1964.

( Conduct of a Physician, the first book dedicated to medical ethics)

Code of medical ethics  American Medical Association. Adopted its first code of ethics based on Percival work World Medical Association. Adopted International Code of Medical Ethics Adopted Declaration of Helsinki ( research ethics)

I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I treat with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

DUTIES OF PHYSICIANS IN GENERAL,

A PHYSICIAN SHALL

always maintain the highest standards of professional conduct. A PHYSICIAN SHALL not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patients. A PHYSICIAN SHALL in all types of medical practice, be dedicated to providing competent medical service in full technical and moral independence, with compassion and respect for human dignity.

A PHYSICIAN SHALL

deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception. The following practices are deemed to be unethical conduct: a) Self advertising by physicians, unless permitted by the laws of the country and the Code of Ethics of the National Medical Association. b) Paying or receiving any fee or any other consideration solely to procure the referral of a patient or for prescribing or referring a patient to any source.

A PHYSICIAN SHALL

respect the rights of patients, of colleagues, and of other health professionals and shall safeguard patient confidences. A PHYSICIAN SHALL act only in the patient's interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient. A PHYSICIAN SHALL use great caution in divulging discoveries or new techniques or treatment through non- professional channels. A PHYSICIAN SHALL certify only that which he has personally verified.

A PHYSICIAN SHALL

always bear in mind the obligation of preserving human life. A PHYSICIAN SHALL owe his patients complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond the physician's capacity he should summon another physician who has the necessary ability. A PHYSICIAN SHALL preserve absolute confidentiality on all he knows about his patient even after the patient has died. A PHYSICIAN SHALL give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.

A PHYSICIAN SHALL

behave towards his colleagues as he would have them behave towards him. A PHYSICIAN SHALL NOT entice patients from his colleagues. A PHYSICIAN SHALL observe the principles of the "Declaration of Geneva" approved by the World Medical Association.

AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude which is their due; I WILL PRACTICE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my first consideration; I WILL RESPECT the secrets which are confided in me, even after the patient has died;

I WILL MAINTAIN by all the means in my power, the honor and the noble traditions of the medical profession; MY COLLEAGUES will be my sisters and brothers; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity; I MAKE THESE PROMISES solemnly, freely and upon my honor.

Approved by PM&DC -2001

The code of ethics provides a set of principles prescribed by the Pakistan Medical and Dental Council, which doctors can use as guidelines in the varying situations, in line with their judgment, experience, knowledge and skills.

AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets which are confided in me, even after the patient has died; I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; My colleagues will be my sisters and brothers; and I will pay due respect and honour to them.

I will not permit considerations of age, disease or disability, creed, ethic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient;  I will protect human life in all stages and under all circumstances, doing my utmost to rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of Allah s mercy, extending medical care to near and far, virtuous and sinner and friend and enemy.  I make these promises solemnly, freely and upon my honour. 

Promote the fundamental principle of responsibility of physicians to the right of individuals and societies to stated standards of professional competence, appropriate care, conduct and integrity of Medical and Dental Practitioners; Uphold the ethical principles of medical practice i.e. autonomy, beneficence, non-maleficience, and justice; Ensure the protection of individuals (patients) against harassment, discrimination and exploitation;  Take their responsibilities as a teacher seriously.

Be responsive to cultural and religious sensitivities; and Declare in a transparent manner, any potential conflict of interest. Inculcate these values in students, through instruction and role modeling. Promote the education of the public on health issues and their rights to quality care. Ensure continuation of practice only when in normal physical and mental health. Bring colleagues to comply with these generally accepted norms of practice and expose physicians and dentists deficient in competence, care and conduct.

A physician must have inherent love for humans and humanity.