Health Professional - Patient Relationship PDF

HEALTH PROFFISSIONAL - PATIENT RELATIONSHIP  HEALTH PROFISSIONS PATIENT RELATIONSHIP The Health professions -patient relationship is the corner stone of medical practice and therefore of medical ethics.  As noted before Declaration of Geneva requires of the physician that “The health of...

HEALTH PROFFISSIONAL - PATIENT RELATIONSHIP  HEALTH PROFISSIONS PATIENT RELATIONSHIP The Health professions -patient relationship is the corner stone of medical practice and therefore of medical ethics.  As noted before Declaration of Geneva requires of the physician that “The health of my patient will be my first consideration,” The International Code of Medical Ethics states, “A physician shall owe his patients complete loyalty and all the resources of his science.” This chapter will deal with six topics that pose particularly vexing problems to physicians & Health professionals in their daily practice:  Respect and equal treatment Communication and consent Decision-making for incompetent patients  Confidentiality  Beginning-of-life issues End-of life issues.  Respect and equal treatment Universal Declaration of Human Rights (1948), which states in article 1, “All human beings are born free and equal in dignity and rights.” Many other international and national bodies have produced statements of rights, either for all human beings, for all citizens in a specific country, or for certain groups of individuals (‘children’s rights’, ‘patients’ rights’ ‘consumers’ rights’, etc.).  Unfortunately, though, human rights are still not respected in many countries The medical profession has had somewhat conflicting views on patient equality and rights over the years. On the one hand, physicians have been told not to “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”  At the same time physicians have claimed the right to refuse to accept a patient, except in an emergency. Although the legitimate grounds for such refusal include a full practice, (lack of) educational qualifications and specialization, if physicians do not have to give any reason for refusing a patient, they can easily practice discrimination without being held accountable.  A physician’s conscience, rather than the law or disciplinary authorities, may be the only means of preventing abuses of human rights in this regard. The WMA’s International Code of Medical Ethics implies that the only reason for ending a physician-patient relationship is:  if the patient requires another physician with different skills:“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.”  The physician’s moving or stopping practice. The patient’s refusal or inability to pay for the physician’s services.  Dislike of the patient and the physician for each other, The patient’s refusal to comply with the physician’s recommendations, etc. The reasons may be entirely legitimate, or they may be unethical. When considering such an action, physicians should consult their Code of Ethics and other relevant guidance documents and carefully examine their motives.  They should be prepared to justify their decision, to themselves, to the patient and to a third party if appropriate.  If the motive is legitimate, the physician should help the patient find another suitable physician or, if this is not possible, should give the patient adequate notice of withdrawal of services so that the patient can find alternative medical care. If the motive is not legitimate, for example, racial prejudice, the physician should take steps to deal with this defect. Many physicians, especially those in the public sector, often have no choice of the patients they treat. Some patients are violent and pose a threat to the physician’s safety.  physicians must balance their responsibility for their own safety and well-being and that of their staff with their duty to promote the well-being of the patients. They should attempt to find ways to honour both of these obligations. If this is not possible, they should try to make alternative arrangements for the care of the patients.  Another challenge to the principle of respect and equal treatment for all patients arises in the care of infectious patients. The focus here is often on HIV/AIDS, not only because it is a life-threatening disease but also because it is often associated with social prejudices. Medical ethics do not permit categorical discrimination against a patient based solely on his or her sero positivity for HIV.  COMMUNICATION AND CONSENT 1. Informed consent is one of the central concepts medical ethics. 2. The right of patients to make decisions about their healthcare has been enshrined in legal and ethical statements throughout the world.  COMMUNICATION AND CONSENT The Rights of the Patient (WMA) Declaration on the Rights of the Patient states: The patient has the right to self-determination, to make free decisions regarding himself/herself.  The physician will inform the patient of the consequences of his/her decisions.  A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions. The patient should understand clearly what is the purpose of any test or treatment, what the results would imply, and what would be the implications of with holding consent. PUBLIC HEALTH LAW 2004(Palestine) Article (60) The rights of the patient in the health institution Each patient in the health institution has the right to: 1. Obtain immediate care in case of emergency. 2. receive a clear explanation of the proposed treatment and has the approval to accept or rejection of this treatment. 3. Approve or refuse to participate in research or training conducted in the health institution. 4. Respect for his privacy, dignity and religious and cultural beliefs. 5. Complaints against the health institution or one of its employees. 3.Competent patients have the right to refuse treatment, even when the refusal will result in disability or death. 4. Explicit consent is given orally or in writing. 5.There are two exceptions to the requirement for informed consent by competent patients: Situations where patients voluntarily give over their decision making authority to the physician or to a third party. Instances where the disclosure of information would cause harm to the patient. 6.The physician has no obligation to offer a patient futile or non beneficial treatment. 7.They should also feel free to refuse if the treatment is unlikely to be beneficial, even if it is not harmful, although the possibility of a placebo effect should not be discounted. If limited resources are an issue, they should bring this to the attention of whoever is responsible for allocating resources.  DECISION-MAKING FOR INCOMPETENT PATIENTS Many patients are not competent to make decisions for themselves. Examples include young children, individuals affected by certain psychiatric or neurological conditions, and those who are temporarily unconscious or comatose. These patients require substitute decision makers, either the physician or another person (e.g., husband or wife, adult children, brothers and sisters, etc.). In such cases physicians make decisions for patients only when the designated substitute cannot be found, as often happens in emergency situations.  CONFIDENTIALITY All identifiable information about a patient's medical condition, diagnosis, prognosis and treatment and all other information of a personal kind, must be kept confidential, even after death. Exceptionally, the patient’s relatives may have a right of access to information that would inform them of their health risks.  Confidential information can only be disclosed if the patient gives explicit consent or if expressly provided for in the law. Information can be disclosed to other healthcare providers only on a strictly "need to know" basis unless the patient has given explicit consent. All identifiable patient data must be protected.  The protection of the data must be appropriate to the manner of its storage. Human substances from which identifiable data can be derived must be likewise protected.  BEGINNING-OF-LIFE ISSUES Many of the most prominent issues in medical ethics relate to the beginning of human life. These issues cannot be treated in detail here but it is worth listing them so that they can be recognized as ethical in nature and dealt with as such. Each of them has been the subject of extensive analysis by medical associations, ethicists and government advisory bodies, and in many countries there are laws, regulations and policies dealing with them.  CONTRACEPTION: although there is increasing international recognition of a woman’s right to control her fertility, including the prevention of unwanted pregnancies. “Contemporary Fuqaha state that contraception is permitted, if the husband and wife agree, as there is nothing in the Quran or Sunnah to prohibit it.  Any method of birth control that destroys the Nutfah at any stage of its development is prohibited in Islam, because it is akin to taking a human life. ASSISTED REPRODUCTION : for couples (and individuals) who cannot conceive naturally there are various techniques of assisted reproduction, such as artificial insemination and in-vitro fertilization and embryo transfer, widely available in major medical centres. This is permissible by many scholars according to some of the shar'i rules Surrogate or substitute gestation is another alternative.  It is prohibited to use the fertilized egg in another woman, and precautions must be taken to prevent the fertilized egg from being used in an illegal pregnancy PRENATAL GENETIC SCREENING : Genetic tests are now available for determining whether an embryo or foetus is affected by certain genetic abnormalities and whether it is male or female. Depending on the findings, a decision can be made whether or not to proceed with pregnancy. Physicians need to determine when to offer such tests and how to explain the results to patients. ABORTION – this has long been one of the most divisive issues in medical ethics, both for physicians and for public authorities. The WMA Statement on Therapeutic Abortion acknowledges this diversity of opinion and belief and concludes that “This is a matter of individual conviction and conscience which must be respected.”  A physician should not cause a pregnant woman to abort, unless when medical considerations call for it, the mother’s health and life being threatened. Abortion, however, is permissible before the end of the fourth month of pregnancy when it is definitely established that continued pregnancy involves a risk of a serious injury to the mother.  This, however, should be confirmed by a medical committee of specialists of no less than three members, one of whom familiar with the disease for which the termination of pregnancy is recommended. The committee members should prepare a report in which they specify the definite risk that threatens the mother’s health if the pregnancy continues.  When abortion is recommended, the mother and her husband or guardian should be advised of the fact and their written consent obtained. All other exceptional cases , including pregnancy resulting from rape, should be referred to the authorities of Islamic fatwa and legislation, and to the laws and regulations in force.  SEVERELY COMPROMISED NEONATES – because of extreme prematurity or congenital abnormalities, some neonates have a very poor prognosis for survival. Difficult decisions often have to be made whether to attempt to prolong their lives or allow them to die.  END-OF-LIFE ISSUES EUTHANASIA : means knowingly and intentionally performing an act that is clearly intended to end another person’s life and that includes the following elements: The subject is a competent, informed person with an incurable illness who has voluntarily asked for his or her life to be ended; the agent knows about the person’s condition and desire to die, and commits the act with the primary intention of ending the life of that person; The act is undertaken with compassion and without personal gain. ASSISTANCE IN SUICIDE: means knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counselling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs. Euthanasia and Physician-Assisted Death Human life is sacred, and it should never be wasted except in the cases specified by shari'a and the law. This is a question that lies completely outside the scope of the medical profession. A physician should not take an active part in terminating the life of a patient,  even if it is at his or his guardian’s request, and even if the reason is severe deformity; a hopeless, incurable disease; or severe, unbearable pain that cannot be alleviated by the usual pain killers. The physician should urge his patient to endure and remind him of the reward of those who tolerate their suffering.  Two issues deserve particular attention: euthanasia and assistance in suicide. This particularly applies to the following cases of what is known as mercy killing: 1. The deliberate killing of a person who voluntarily asks for his life to be ended 2. Physician-assisted suicide 3. the deliberate killing of newly born infants with deformities that may or may not threaten their lives. The following cases are examples of what is not covered by the term “mercy killing”: A. The termination of a treatment when its continuation is confirmed, by the medical committee concerned, to be useless, and this includes artificial respirators, in as much as allowed by existing laws and regulations; B. declining to begin a treatment that is confirmed to be useless; C. The intensified administration of a strong medication to stop a severe pain, although it is known that this medication might ultimately end the patient’s life. The end