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Lecture for 4th year medical
students at the Faculty of Medicine Salman University Kharj on 30th
April 2013 by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH
(Harvard)
1.0 VALUES, COMPETENCE, AND RESPONSIBILITY
The physician-patient is based on brotherhood. The patient is a fellow human being in suffering and not an ‘object’ or a ‘case’
The physician should follow the following values in his professional work: good intentions, avoiding doubtful things, leaving alone matters that do not concern him, loving for others what she loves for herself, causing no harm, giving sincere advice, avoiding the prohibited, doing good acts, renouncing greed, avoiding sterile arguments, respect for life, basing decisions and actions on evidence, following the dictates of conscience, righteous acts, quality work, guarding the tongue, avoiding anger and rage, respecting and not transgressing God’s limits, consciousness of God in all circumstances, performing good acts to wipe out bad ones, treating people with the best of manners, restraint and modesty, maintaining objectivity, seeking help from God, and avoiding oppression or transgression against others.
The physician should be professionally competent, balanced, have responsibility (amanat) and accountability. He must work for the benefit of the patients and the community.
2.0 MEDICAL DECISIONS
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 must be free and capable of giving informed consent. Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient, 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 is limited to what was explained to the patient except in an emergency.
Physician
assisted suicide, active euthanasia, and voluntary euthanasia are illegal even
if performed after informed consent by the patient.
The patient is free to make decisions regarding choice of physicians and choice of treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of an advance statement (advance directive, living will).
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.
Advance
directives, proxy informed consent by the family are made for the unconscious
terminal patient on withholding or withdrawal of treatment.
A do not
resuscitate order (DNR) by a physician could create legal complications.
The living will
has the following advantages: (a) reassuring the patient that terminal care
will be carried out as he or she desires (b) providing guidance and legal
protection and thus relieving the physicians of the burden of decision making
and legal liabilities (c) relieving the family of the mental stress involved in
making decisions about terminal care.
The disadvantage
of a living will is that it may not anticipate all developments of the future
thus limiting the options available to the physicians and the family.
The device of the
power of attorney can be used instead of the living will or advance directive.
Decision by a proxy can work in two ways: (a) decide what the patient would
have decided if able (b) decide in the best interests of the patient.
Informed consent
is still required for physicians in special practices such as a ship’s doctor,
prison doctor, and doctors in armed forces. Police surgeons may have to carry
out examinations on suspects without informed consent.
3.0 CONSENT OF THE INCOMPETENT
Competent
children can consent to treatment but cannot refuse treatment. The consent of
one parent is sufficient if the 2 disagree. Parental choice takes precedence
over the child’s choice. Courts can overrule parents. Life-saving treatment of
minors is given even if parents refuse. Parental choice is final in therapeutic
or non-therapeutic research on children.
Mental patients
cannot consent to treatment, research, or sterilization because of their
intellectual incompetence. They are admitted, detained, and treated voluntarily
or involuntarily for their own benefit, in emergencies, for purposes of
assessment, if they are a danger to themselves, or on a court order.
Suicidal patients
tend to refuse treatment because they want to die.
There are
controversies about nutrition, hydration, and treatment for patients in a
persistent vegetative state since the chance of recovery is low. T
There is no moral
difference between withholding and withdrawing futile treatment.
Labor and
delivery are emergencies that require immediate decisions but the woman may not
be competent and proxies are used. Forced medical intervention and cesarean
section may be ordered in the fetal interest. Birth plans can be treated as an
advance directive.
4.0 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.
5.0 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 or insurance.
6.0 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.