160423 - PHYSICIAN CONDUCT and MISCONDUCT

Presentation at an ‘Internship Day’ workshop Ibn Sina National College for Medical Studies, Jeddah on 23 April 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Faculty of Medicine, King Fahad Medical City

Values, Competence, And Responsibility - 1

• 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.

Values, Competence, And Responsibility - 2

• 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. 

Medical Decisions - 1

• 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. 

Medical Decisions - 2

• 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 the 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.

Medical Decisions - 3

• 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.
• The living will have 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. 

Medical Decisions - 4

• 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.

Consent of the Incompetent - 1

• 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. 

Consent of the Incompetent - 2

• There are controversies about nutrition, hydration, and treatment for patients in a persistent vegetative state since the chance of recovery is low.
• 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. 

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 procedures in order for them to make an autonomous informed consent.
• Deception violates fidelity.
• If disclosure will cause harm it is not obligatory.
• Partial disclosure? White or technical lies?
• Disclosure to the family and other professionals is allowed if it is necessary for treatment purposes.
• Physicians must use their judgment in the disclosure of bad news to the patient. 

Privacy and Confidentiality - 1

• 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 the death of the patient.
• In routine hospital practice, many persons have access to confidential information but all are enjoined to keep such information confidential. 

Privacy and Confidentiality - 2

• Confidentiality includes medical records of any form.
• The patient should not make an 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.
• The release is not justified without patient consent for the following purposes: education, research, medical audit, employment, or insurance.

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).
• Fidelity 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.

Abuse of Professional Privileges - 1

• Un-ethical research on patients is abuse of professional privilege. This usually takes the form of research without informed patient consent.
• Abuse of treatment privileges consists of unnecessary treatment, iatrogenic infection, and allowing or abetting an unlicensed practitioner.
• Abuse of prescription privileges is manufacturing, possessing, and supplying a controlled drug without a license; prescription of controlled drugs not following procedures; diverting or giving away controlled substances; dispensing harmful drugs; sale of poisons; and writing prescriptions using secret formulas.
• Financial fraud may be pharmacy fraud (billing for medicine not supplied), billing fraud (billing for services not performed), equipment fraud (using equipment that is really not needed or using equipment of poorer quality), or supplies fraud. 

Abuse of Professional Privileges - 2

• It is illegal to get financial advantage from prescriptions to be filled by pharmacies owned by the physician. Kick-backs are unethical and illegal.
• False or inaccurate documentation is a breach of the law and includes issuing a false medical certificate of illness, false death certification, and false injury reports.
• Court action could be brought against a physician for the following crimes against the person: manslaughter (voluntary & involuntary); euthanasia (active and passive): battery for forced feeding or treatment; criminal liability for patient death; induced non-therapeutic abortion; iatrogenic death; abusive therapy involving torture; intimate therapy; rape and child molestation; and sexual advances to patients or sexual involvement. 

Private Mis-conduct Derogatory to Reputation: Muru’at

• Breach of trust is a cause for censure because a physician must be a respected and trusted member of the community.
• Sexual misbehavior such as zina and liwaat are condemned. 
• Physicians can abuse their position by abuse of trust (eg harmful or inappropriate personal and sexual relations with patients and their families), abuse of confidence (eg disclosure of secrets), abuse of power/influence (eg undue influence on patients for personal gain), and conflict of interest (when the physician puts personal selfish interests before the interests of the patient).
• Other forms of misconduct are in-humane behavior such as participation in torture or cruel punishment, abuse of alcohol and drugs, behavior unbecoming, indecent behavior, violence, and conviction for a felony.

Business Mis-Conduct - 1

• Physicians in private practice must adopt good business practices. 
• Halal transactions are praised. An honest businessman is held in high regard.
• Leniency in asking for payment is encouraged especially when serving in poor communities. 
• Full disclosure is needed in any transaction. 
• Measures and scales must be fulfilled when dispensing drugs. 
• Bad business practices are condemned. There is no blessing in immoral earnings. Unethical competition is prohibited. Cheating is condemned. Also condemned are financial fraud including criminal breach of trust, fee-splitting, and bribery. 

Business Mis-Conduct - 2

• Sale of the goodwill of practice is allowed. Also allowed is agreement among partners that they will not set up a rival practice on leaving the partnership. Entering into a compact with pharmacists or laboratories involving fee-splitting and unnecessary referrals is not moral.
• Treatment regimens cannot be patented as intellectual property.
• Physicians are entitled to a reasonable fee. Medical fees cannot be fixed. They are based on mutual agreement between the physician and the patient.

Conflict of Interest

• A physician who at the same time is the manager of a for-profit hospital could be tempted to put the profit motive before good health care by cutting down expenditure on necessary treatment.
• An occupational physician may find himself fulfilling his professional duties to the patient and protecting the financial interests of his employer.