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Lecture
for 4th year medical students Faculty of Medicine King Fahad Medical
City on 12th March 2012 by Dr Omar Hasan Kasule Department of
Bioethics Sr. Faculty of Medicine
1.0 RESPECTING
RIGHTS OF THE PATIENT: THE RIGHT TO AUTONOMY
1.1
INFORMED CONSENT
No
medical procedures can be carried out without informed consent of the patient
except in cases of legal incompetence. The patient has the purest intentions in
decisions in the best interests of his or her life. Others may have bias their
decision-making. The patient is free to male decisions regarding choice of
physicians and choice of treatments.
Physician
assisted suicide, active euthanasia, and voluntary euthanasia are illegal.
Informed
consent requires disclosure by the physician, understanding by the patient, voluntariness
of the decision, legal competence of the patient, offering the patient
alternative approaches with recommendation of the physician on the best course
of action, decision by the patient, and authorization by the patient to carry
out the procedures.
Consent
can be by proxy in the form of the patient delegating decision making or by
means of a living will. Advance directives, proxy informed consent by the
family are made for the unconscious terminal patient on withholding or
withdrawal of treatment.
Consent
is limited to what was explained to the patient except in an emergency.
Refusal
to consent must be an informed refusal (patient understands what he is doing).
Refusal to consent by a competent adult even if irrational is conclusive and
treatment can only be given by permission of the court.
Doubts
about consent are resolved in favor of preserving life.
Spouses
and family members do not have an automatic right to consent. A spouse cannot
overrule the patient’s choice.
A
do not resuscitate order (DNR) is signed for cases in the death process for
whom intervention in the form of aggressive cardio-respiratory support has no
net and lasting benefits. It should not be misused as a form of euthanasia.
2.0 DISCLOSURE
AND TRUTHFULNESS
As
part of the professional contract between the physician and the patient, the
physician must tell the whole truth. Patients have the right to know the risks
and benefits of medical procedure in order for them to make an autonomous
informed consent. Deception violates fidelity. If disclosure will cause harm it
is not obligatory. Partial disclosure and white or technical lies are
permissible under necessity. Disclosure to the family and other professionals
is allowed if it is necessary for treatment purposes. Physicians must use their
judgment in disclosure of bad news to the patient.
3.0 PRIVACY AND
CONFIDENTIALITY
Privacy
and confidentiality are often confused. Privacy is the right to make decisions
about personal or private matters and blocking access to private information.
The patient voluntarily allows the physician access to private information in
the trust that it will not be disclosed to others. This confidentiality must be
maintained within the confines of the Law even after death of the patient. In
routine hospital practice many persons have access to confidential information
but all are enjoined to keep such information confidential. Confidentiality
includes medical records of any form. The patient should not make unnecessary
revelation of negative things about himself or herself. The physician can not
disclose confidential information to a third party without the consent of the
patient. Information can be released without the consent of the patient for
purposes of medical care, for criminal investigations, and in the public
interest. Release is not justified without patient consent for the following
purposes: education, research, medical audit, employment for insurance.
4.0 FIDELITY
The
principle of fidelity requires that physicians be faithful to their patients.
It includes: acting in faith, fulfilling agreements, maintaining relations, and
fiduciary responsibilities (trust and confidence). It is not based on a written
contract. Abandoning the patient at any stage of treatment without alternative
arrangements is a violation of fidelity. The fidelity obligation may conflict
with the obligation to protect third parties by disclosing contagious disease
or dangerous behavior of the patient. The physician may find himself in a
situation of divided loyalty between the interests of the patient and the
interests of the institution. The conflict may be between two patients of the
physician such as when maternal and fetal interests conflict. Physicians
involved in clinical trials have conflicting dual roles of physicians and
investigators.