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Presentation
at a training program ‘Applying the Principles of Ethics to Clinical
Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar
Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the
Ethics Committee King Fahad Medical City
Professionalism
·
Concept of
professionalism
·
Development of
professionalism
·
Types of
professional organizations
·
6 dimensions of
professionalism – ABIM (American board of internal medicine) : altruism, accountability, excellence, duty,
honor and integrity, respect for others
·
Negative
‘dimensions’ of professionalism – ABIM: abuse of power and sexual harassment,
conflicts of interest, professional arrogance, physician impairment, fraud in
research.
·
Proposed 7
dimensions of professionalism; faith (iman), consciousness (taqwat),
best character (ahsan al akhlaq), excellent performance (itqaan al
‘amal), strife toward perfection (ihsan), responsibility (amanat),
self-accountability (muhasabat al nafs).
·
Best teaching
of professionalism is by apprenticeship
Case scenario 1
The Director of
the residency program stopped 2 consultants from teaching because he thought
that their work was not professional. They protested that they could not
practice proper medicine because of the time pressure too many patients to see
in a short time.
Case scenario 2
A hospital
director refused to employ a newly graduated resident with good recommendations
and high grades because he remembered him as a very unprofessional and
dishonest student.
Case scenario 3
The hospital
director was planning to terminate the contract of the best cardiovascular
surgeon in the hospital because of immoral behaviors outside work. In 10 years
of working at the hospital no ethical or professional infraction was reported
on him.
Physician professional relationships and duties[*]
·
Physician roles
·
Doctor’s duty
to the profession 1
·
Doctor’s duty
towards colleagues
Case scenario 1
The Ministry of Health issued a new policy that all doctors in its
hospitals must be engaged in research and that research would be included in
professional performance evaluation. There was a great protect by physicians
who said they hardly had enough time for their patients where would they find
the time to do research? How would you solve this problem?
Case scenario 2
The hospital manager disciplined a physician who was 2 hours late
for his cardiac follow up clinic because he was in a community program on
prevention of cardiovascular disease. What do you think about this? What
principles will you use?
Case scenario 3
Hospital director wanted to discipline a doctor who refused to
treat a patient with chronic bronchitis and had refused to give up smoking with
the result that he had to come to the emergency room 2 or 3 times a week
Relations with the pharmaceutical industry and conflicts of
interest
·
Conflict of
interest is Financial or non-financial benefit that affects professional
judgment and practice
·
Do small gifts
affect the doctor’s judgment and prescription habits?
·
Are physicians
influenced to add medicine to the hospital formulary?
·
Do gifts affect
physician reporting of research results?
·
What
pharmaceutical companies offer physicians: Free drug samples, Expenses for
attending conferences, Payments as consultants, Payments for giving lectures, Payments for research, Drug company
representatives give drug information? Accurate?
biased
Scenario 1
A physician involved in a multi-center clinical trial and receiving
substantial financial compensation was told by the pharmaceutical company to
terminate the study and he never asked for the reason. What do you think could
be the underlying reason?
Scenario 2
A researcher was offered a fully paid conference package with his
family when he published a paper favorable to the drug being introduced by the
pharmaceutical company. The next year he published an unfavorable report about
another drug of the company. No conference package was offered and his wife was
asking him why they did not go overseas this year. Explain.
Medical practice and medical errors 1
·
Definition of
Medical Error
·
Definition of
Malpractice
·
Definition of
Negligence
·
Types of
negligence: Contributory negligence, Comparative negligence,
·
Intentional
negligence
·
The 4 elements
of negligence: (a) existence of a duty, (b) breach of the duty, (c) injury
resulting from breach of duty, and (d) burden of proof of the causal connection
between breach of duty and injury.
Medical practice and medical errors 2
·
Liabilities: (a)
Physician liability: Battery for lack of informed consent, Errors, Neglect
of duty: (b) Vicarious liability arises when a physician fails to
supervise a junior or a trainee working under him or her. (c) hospital liability (d) manufacturer
liability
·
The basis of
liability: Breach of contract, Tort of negligence, Breach of confidence
·
Damages and compensation: Damages for
personal injury, Damages for death, Damages for wrongful birth or wrongful
life, Other forms of damage
·
Disclosure of
errors: The physician involved in treating a patient is required to inform
the patient of any error. The disclosure must be immediate and complete.
Examples of negligence in general
Treatment without informed consent,
false imprisonment or confinement, intentional infliction of emotional
distress, defamation (slander if verbal and libel if written), abandonment of a
patient, breach of confidentiality, negligent use of drugs and devices, negligent
referrals when a physician fails to refer a patient to the right specialist,
Failure to warn about risks, Failure to report a notifiable disease,
professional errors that may be ordinary/extraordinary, harmful/ non-harmful.
Examples of negligence in obstetrics
and gynecology
Injuries at birth to both mother and
fetus: congenital deformities, wrongful life, stillbirth, psychiatric injury,
inappropriate care due to lack of current knowledge, errors of skill or
judgment, wrongful termination of pregnancy due to failure to do a pregnancy
test before gynecological surgery, failed abortion when an abortion is
attempted but is not completed, negligence in fetal screening in which an
anomaly is seen at amniocentesis,
maternal blood sampling, or fetal blood sampling but it is not followed up,
negligence in prescribing for a pregnant woman, false diagnosis of maternal
disease that affects the fetus, mistakes in obstetric analgesia and anesthesia,
negligence in labor and delivery by failure to detect fetal distress resulting
in brain damage.
Examples of negligence in psychiatry
Sexual
misconduct, failure to prevent suicide or attempted suicide, failure to prevent
patient violence, wrong medication, negligent diagnosis, abandoning a patient, breach
of confidentiality, early discharge, failure to hospitalize leading to suicide,
failure to commit leading to murder, failure to control symptoms leading to
suicide or injury to a 3rd party, negligent certification of mental
status.
The Boolam case: legal test of
negligence
The judge ruled that doctors could
not be found negligent if they acted according to a professional opinion
accepted by a reasonable body of medical opinion even if there could exist a
contrary opinion by another responsible body of medical opinion.
The Bolitho case:legal test of negligence
A patient suffered brain damage because the doctor failed to
intubate in a home setting.
The court ruled that doctors are
expected to follow responsible medical opinion but would not be found negligent
in cases in which that opinion did not stand up to logical analysis. The court
thus set a principle that the court could over-rule medical opinion that was
not logical in a specific case. The implication of this was that medical
opinion was not the final arbiter of the standard of care to be used in
defining negligence.
Notes