ETML Lecture Five 03 September 2024 PDF

ETML Lecture Five 03 SEPTEMBER 2024 MRS TASH PILLAY ( MBA -HEALTHCARE LEADERSHIP)  INTRODUCTION South Africa is a democratic state in which human dignity, equality and the advancement of human rights are respected, promoted and protected in te...

ETML Lecture Five 03 SEPTEMBER 2024 MRS TASH PILLAY ( MBA -HEALTHCARE LEADERSHIP)  INTRODUCTION South Africa is a democratic state in which human dignity, equality and the advancement of human rights are respected, promoted and protected in terms of the Constitution of the Republic of South Africa. In particular Section 27 (1) guarantees the right of access to health care services. For many decades the vast majority of the South African population has experienced either a denial or violation of fundamental human rights, including rights to health care services. To ensure the realisation of the right of access to health care services as guaranteed in the Constitution of the Republic of South Africa (Act No 108 of 1996), the Department of Health is committed to upholding, promoting and protecting this right and therefore proclaims the PATIENTS' RIGHTS CHARTER as a common standard for achieving the realisation of this right. Equally, Practitioners should adhere to the stipulations of this charter as it relates to them.  The right to health is fundamental to the physical and mental well-being of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of an adequate standard of living. The right to health care services is provided for in three sections of the South African Constitution. These provide for access to health care services including reproductive health and emergency services; basic health care for children, and medical services for detained persons and prisoners. Universal access is provided for in section 27(1)(a) which states that "Everyone has the right to have access to health care services, including reproductive health care...“ Section 27(1)(b) provides for the State to " take reasonable legislative and other measures, within its available resources to achieve the progressive realisation of the right." The progressive realisation does not imply that the state can defer indefinitely, efforts for the full realisation of the right. State parties are to "move as expeditiously as possible towards the full realisation of the right " and are required to take immediate steps to provide minimum core entitlements. Section 27(3)states that no one can be denied emergency medical treatment. Section 28(1)(c) provides for "basic health care services" for children, while section 35(2)(e) provides for "adequate medical treatment" for detainees and prisoners at the State's expense.  According to section 7(2) of the Constitution the State is obliged to respect, protect, promote and fulfil all the rights in the Bill of Rights. In the case of the right to health, these fourfold obligations are defined in General Comment No.14 and include the following: The obligation to respect the right, obliges the State to refrain from denying or limiting access to health care services to anyone. These should be available to all on a non-discriminatory basis. The obligation to protect include, inter alia, adopting legislation and other measures to ensure equal access to health care facilities provided by third parties; to ensure that privatisation does not constitute a threat to the availability, acceptability and quality of services provided; and to control the marketing of medicines by third parties. The obligation to promote requires the State to disseminate appropriate information; foster research and support people to make informed choices. The obligation to fulfil requires that the State facilitates and implements legislative and other measures in recognition of the right to health and adopts a national health policy with detailed plans on how to realise the right. The State is also obliged to provide the right for people in disaster situations or in dire need when an individual or group is unable, for reasons beyond their control, to realise that right themselves with the means at their disposal.  Since 1994 there have been several court cases which have served to add to the normative content of the right to health care. These have thrown light on the concepts of "available resources" and "reasonable measures" in terms of section 27 (1) (b) of the Constitution. In the Soobramoney case the Constitutional Court opined that the scarcity of resources available to the State were constraints to the enjoyment of the right by the appellants, given the socio-historical context of South Africa. In the Grootboom case, the Constitutional Court defined the parameters of what constitutes "reasonable measures". In addition to these, it concluded that measures that do not include meeting the needs of the most vulnerable groups in society, were unreasonable. Furthermore, it was stated that implementation plans that failed to be "reasonable" would not meet the State's obligations in terms of section 7(2) of the Constitution. Another important case dealt with the prevention of mother to child transmission of HIV in which the Treatment Action Campaign (TAC) requested that the anti-retroviral drug, Nevirapine be made available to all HIV positive pregnant women in the public health sector. In this case the Constitutional Court upheld the High Court order to make Nevirapine available to all HIV positive pregnant women. This judgement is of great significance given the high prevalence of HIV/AIDS in the country and the growing number of AIDS orphans.  The Patients' Rights Charter The Patients‘ Rights Charter was developed as a way to safeguard against inequalities that were experienced during Apartheid. The Charter is therefore the standard we use to achieve the realisation of the right of access to healthcare in South Africa. What is BATHO PELE? , it means “PEOPLE FIRST”, it is the governments “White Paper” on transformation of the public service delivery in healthcare and was launched in October 1997. The spirit of Batho Phele is respecting the dignity of the people we serve and acknowledging their rights to those public services. This is important because it means that the citizens needs and expectations should be placed first. Service providers have a moral and legal responsibility to deliver the best possible service with Batho Pele being the moral criteria used to assess the quality standard of service delivery.  Why were these created? Health care during apartheid (1948-1993): Formation of severe health disparities – Bantustans or homelands – stripping black South Africans of their SA citizenship (approx. half a million) Forcefully relocating them to communities without local economies, no labour laws, no land rights for women and neglect for health care (understaffed, resourced, limited state allocations) – T The doctor to patient ratio in the Bantustans was 1:15 000 compared to 1:1700 in the rest of the country. Health services in Bantustans were systematically underfunded. Migrant labour recruits into cities directing affecting ill health. Rise in poverty-related diseases (malnutrition ) Maternal, infant and child mortality was high (50% infant rates in Ciskei in 1980) Apartheid - related mental disorders in people of colour TB rates and deaths higher among people of colour Teenage pregnancies and unsafe terminations escalated  Service Standards A standard is defined as a “basis of measurement” or a “definite level of excellence” ₋ The criteria of a standard include the following: ○ SPECIFIC ○ MEASURABLE ○ ACHIEVABLE ○ REALISTIC ○ TIME-BOUND This criteria can be applied to service delivery and mean that service standards should be specific statements of the level of performance required and promised that ultimately contain characteristics associated with excellence Guidelines for Setting Standards 1. Meaningful to user 2. Comply with national standards 3. Based on consultation 4. Attainable yet challenging 5. Affordable 6. Owned by managers 7. Communicated 8. Performance measured and reported 9. Reviewed and updated Is this being done for Patient’s Rights Charter? Patients‘ Rights Charter (PRC) This charter encompasses both the patients‘ rights and their responsibilities. It is the standard used to Realize the right of access to healthcare 1. Healthy and Safe Environment Everyone has a right to a healthy and safe environment that will ensure their physical health or well being. Including adequate water supply, sanitation and waste disposal. As well as protection from environmental danger such as pollution, ecological degradation or infection. 2. Participation in Decision Making Every citizen has the right to participate in the development of health policies. Everyone has the right to participate in decision making on matters affecting one’s own health  (3) Access to Healthcare Receiving timely emergency care at any health facility that is open, regardless of one’s ability to pay. Treatment and Rehabilitation that must be known to the patient to enable the patient to understand such treatment or rehabilitation and the consequences thereof. Provision for special needs in the case of newborn infants, children, pregnant women, the aged, disabled persons, patients in pain, person living with HIV or AIDS patients. Counselling without discrimination, coercion or violence on matters such as reproductive health, cancer or HIV/AIDS. Palliative Care that is affordable and effective in cases of incurable or terminal illness. A Positive Disposition displayed by health care providers that demonstrates courtesy, human dignity, patience, empathy and tolerance. Health Information that includes information on the availability of health services and how best to use such services and such information shall be in the language understood by the patient. (4) Knowledge of Health Insurance/Medical Aid Scheme A member of a health insurance or medical aid scheme is entitled to information about that health insurance or medical aid scheme. As well as to challenge, where necessary, the decision of such health insurance or medical aid scheme relating to the member (5) Choice of Health Services Everyone has a right to choose a particular health care provider for services or a particular health facility for treatment. Provided that such a choice shall not be contrary to the ethical standards applicable to such health care provider or facility. (6) Treated by a named Healthcare Provider Everyone has a right to know the person that is providing health care and therefore must be attended to by only a clearly identified health care provider. (7) Confidentiality & Privacy Information concerning one’s health including information concerning treatment may only be disclosed with informed consent, except when required in terms of law or order of court. (8) Informed Consent Everyone has the right to be given full and accurate information about the nature of one’s illnesses, diagnostic procedure, the proposed treatment and risks associated therewith and the costs involved. (9) Refusal of Treatment A person may refuse treatment and such refusal shall be verbal or in writing, provided that such refusal does not endanger the health of others. (10) Second Opinion Everyone has the right on request to be referred for a second opinion to a health provider of one’s choice. (11) Continuity of Care No one shall be abandoned by a healthcare professional or a healthcare facility which initially took responsibility for one’s health without appropriate referral or hand over. (12) Complaints Everyone has the right to complain about the health care services, to have such complaints investigated and to receive a full response on such investigation. Patient Responsibilities (1) Take care of their own health (2) Care for and protect the environment (3) Respect the rights of other patients and healthcare providers (4) Utilise the healthcare system and not abuse it (5) Know their local health services (6) Provide healthcare providers with relevant and accurate information (7) Advise healthcare providers on their wishes regarding death (8) Comply with prescribed treatment or rehab (9) Enquire about related costs and arrange payment (10) Take care of health records in their possession Comprehensive health care is a joint responsibility between the patient and the medical team. To achieve better health results, patients must understand their illness, follow their treatment and discuss any concerns or disagreements they might have with their health care workers.  Healthcare Professionals Responsibilities Healthcare providers have a significant role to play in the improvement and preservation of health for the public. Healthcare professionals play a key role in the maintenance and improvement of public health. Keep his/her professional knowledge and skills up to date. Observe the laws of the country, especially in relation to his/her professional practice. Maintain the highest standards of personal conduct and integrity. Take care of their own health, safety and wellness, and encourage their colleagues to do the same. Act in the best interests of his/her patients. Respect patient confidentiality, privacy, choices and dignity  Provide adequate information about the patient's diagnosis, treatment options and alternatives, costs associated with each such alternative and any other pertinent information to enable the patient to exercise a choice in terms of treatment and informed decision-making pertaining to his or her health and that of others. Maintain proper and effective communication with his or her patients and other professionals. Obtain informed consent from a patient or, in the event that the patient is unable to provide consent for treatment himself or herself, from his or her next of kin/ guardian/ medical proxy. Keep accurate patient records. Participate in activities that contribute to the improvement of the community and the betterment of public health. Expose without fear or favour, any incompetent, corrupt, dishonest or unethical conduct by members of the profession. Safeguard the profession against admission to it of persons who are deficient in moral character, education or skill; and Not permit unqualified, unlisted or unregistered persons to attend to, treat or perform procedures on patients whenever professional skill or discretion is required.  Health Professions Council of South Africa Health Professionals Council of South Africa is a statutory body that acts as a law for practicing healthcare professionals. Was established to provide for control over the education, training and registration for practicing of health professions registered under the Health Professions Act. In order to protect the public and guide the professions, council ensures that practitioners uphold and maintain professional and ethical standards within the health professions and ensure the investigation of complaints concerning healthcare practitioners and to ensure that disciplinary action is taken against any persons who fail to obey and act accordingly. As a statutory body, the HPCSA is guided by a formal regulatory framework and this includes the Health Professions Act 56 of 1974. This Act governs all healthcare practitioners activities, clearly defines the scope of each profession which it mandates to register with HPCSA, and sets clear processes to be followed by HPCSA in achieving our statutory mandate. Being registered as a healthcare professional with the Health Professions Council of South Africa (HPCSA) confers one the right and privilege to practise a profession. Correspondingly, practitioners have moral and ethical duties to others and society in general. These duties are, in part, in keeping with the principles of the South African Constitution (Act No. 108 of 1996) and the obligations imposed on healthcare professionals by law.  CORE ETHICAL VALUES AND STANDARDS FOR GOOD PRACTICE All ethical obligations required of professionals to uphold good practice are rooted in fundamental ethical values and standards. These standards act as directives derived from core values, which are presented here in a linear format for clarity. In practical situations, the demands of these core values and standards may conflict, creating competing obligations for healthcare practitioners. Resolving such conflicts necessitates ethical reasoning. The core ethical values and standards that healthcare practitioners are expected to adhere to include the following: Respect for Persons: Healthcare practitioners should respect patients as individuals, recognizing their inherent worth, dignity, and value. Non-maleficence: Healthcare practitioners should avoid causing harm or acting against the best interests of patients, even when this conflicts with their own interests. Beneficence: Healthcare practitioners should act in the best interests of patients, prioritizing these interests over their personal self-interests. Human Rights: Healthcare practitioners should acknowledge and respect the human rights of all individuals.  Autonomy: Healthcare practitioners should respect the right of patients to self-determination, allowing them to make informed choices and live according to their own beliefs, values, and preferences. Integrity: Healthcare practitioners should integrate these core ethical values and standards as the foundation of their character and practice as responsible professionals. Truthfulness: Healthcare practitioners should uphold truth and honesty as fundamental elements of trust in their professional relationships with patients. Confidentiality: Healthcare practitioners should treat personal or private information as confidential in their professional relationships with patients, except in cases where overriding ethical or legal reasons justify disclosure. Compassion: Healthcare practitioners should be sensitive to and empathetic towards the individual and social needs of their patients, striving to provide comfort and support whenever possible. Tolerance: Healthcare practitioners should respect individuals' rights to hold different ethical beliefs, which may stem from deeply held personal, religious, or cultural convictions. Justice: Healthcare practitioners should treat all individuals and groups fairly and impartially. Professional Competence and Self-Improvement: Healthcare practitioners should continuously seek to achieve the highest level of knowledge and skill within their field of practice. Community: Healthcare practitioners should aim to contribute positively to society, reflecting their professional capabilities and their standing in the community.  WHAT IT MEANS TO HAVE A DUTY AS A HEALTHCARE PROFESSIONAL Ethical guidelines articulate our duties—obligations to either act or refrain from acting in specific ways. Having a duty to another person means being bound to them in some way, based on specific reasons. It means we owe them something, while they possess a corresponding right or claim against us. Consider a healthcare practitioner who arranges for a colleague to cover for them while they attend to family matters. In this scenario, the colleague has a duty to fulfill the locum role, and the healthcare practitioner has the right to expect this service. Conversely, the colleague has the right to fair compensation, which the healthcare practitioner has a duty to provide. To recognize a duty is to ask, "What do I owe others?" To recognize a right is to ask, "What do others owe me?“ Duties can be ethical, legal, or both, and they operate across various areas of our lives—personal, social, professional, and political. Healthcare practitioners assume multiple roles, each accompanied by distinct types of duties  Natural duties: These are inherent responsibilities we hold simply by being members of the human community, such as the duties to avoid harm, promote good, and act fairly. Healthcare professionals, like all individuals, owe these duties to everyone, regardless of their professional status. Moral obligations: These are duties acquired through professional qualifications and licensure, encompassing responsibilities such as providing care, alleviating pain, obtaining informed consent, respecting confidentiality, and being truthful. Institutional duties: These are specific to the healthcare practitioner's role within particular institutions, shaped by employment contracts, job descriptions, and conventional expectations. They must align with ethical and legal duties. For example, duties might differ for a practitioner in private practice versus one in a government agency. Legal duties: These are obligations imposed by laws, such as the National Health Act (Act No. 61 of 2003) or the Health Professions Act, 1974, requiring practitioners to adhere to certain procedures and exercise skill and care in patient interactions. The duties outlined in these guidelines predominantly fall into the category of acquired professional duties. No duty is absolute or universally applicable regardless of context. Different duties can demand opposing actions in specific situations. For example, a duty to maintain patient confidentiality might conflict with the duty to protect third parties from harm. Such conflicts illustrate dual loyalties or conflicts of interest. Although the list of duties here is comprehensive, it is not exhaustive. However, these duties provide a general framework of the obligations that bind healthcare providers to their patients and others. Failure to uphold these duties without justification can result in sanctions from the Health Professions Council of South Africa. Any classification of duties is inherently arbitrary, as specific duties can apply to different parties simultaneously. Thus, the classifications should serve as a general guide, underscored by core ethical values and standards of good practice, which are considered fundamental ethical principles.  DUTIES TO PATIENTS PATIENTS’ BEST INTERESTS OR WELL-BEING Adequately educated and/or trained Sufficiently experienced Under proper conditions and appropriate surroundings RESPECT FOR PATIENTS: Respect the privacy, confidentiality and dignity of patients. INFORMED CONSENT: Healthcare practitioners are obliged to give their patients the information they ask for or need about their condition, the treatment and prognosis. Give information to their patients in the way they can best understand it. The information must be given in a language that the patient understands and in a manner that takes into account the patient’s level of literacy, understanding, values and belief systems. Healthcare practitioners must also refrain from withholding from their patients any information, investigation, treatment or procedure the health care practitioner knows would be in the patient’s best interests. Apply the principle of informed consent as an on-going process. Allow patients access to their medical records. PATIENT CONFIDENTIALITY PATIENT PARTICIPATION IN THEIR OWN HEALTH CARE IMPARTIALITY AND JUSTICE ACCESS TO CARE ALLOCATION OF CRITICAL SCARCE HEALTHCARE RESOURCES: ETHICAL CONSIDERATIONS POTENTIAL CONFLICTS OF INTEREST CASE 1 A 20-year old college student living in the college hostel is brought by a friend to the Emergency Department (ED) because of unrelenting headache and fever. He appeared drowsy but was responsive and had fever (40°C), and neck rigidity on examination. Lumbar puncture was done, and spinal fluid appeared cloudy and showed increased white cells; Gram stain showed Gram- positive diplococci. Based on the diagnosis of bacterial meningitis, appropriate antibiotics were begun, and hospitalization was instituted. Although initial consent for diagnosis was implicit, and consent for lumbar puncture was explicit, at this point, the patient refuses treatment without giving any reason, and insists to return to his hostel. Even after explanation by the physician as to the seriousness of his diagnosis, and the absolute need for prompt treatment (i.e., danger to life without treatment), the patient is adamant in his refusal. COMMENT ON CASE 1 Because of this refusal, the medical indications and patient preferences are at odds. Is it ethically right to treat against his will a patient who is making a choice that has dire consequences (disability, death) who gives no reason for this decision, and in whom a clear determination of mental incapacity cannot be made (although altered mental status may be presumed)? Here the principle of beneficence and principle of autonomy are in conflict. The weighing of factors: (1) patient may not be making a reasoned decision in his best interest because of temporary mental incapacity; and (2) the severity of life-threatening illness and the urgency to treat to save his life supports the decision in favor of beneficence (i.e., to treat). Case 2 A 56-year old male lawyer and current cigarette smoker with a pack-a-day habit for more than 30 years, is found to have a solitary right upper lobe pulmonary mass 5 cm in size on a chest radiograph done as part of an insurance application. The mass has no calcification, and there are no other pulmonary abnormalities. He has no symptoms, and his examination is normal. Tuberculosis skin test is negative, and he has no history of travel to an endemic area of fungal infection. As lung cancer is the most probable and significant diagnosis to consider, and early surgical resection provides the best prospects for cure, the physician, in consultation with the thoracic surgeon, recommends bronchoscopic biopsy and subsequent resection. The patient understands the treatment plan, and the significance of not delaying the treatment. However, he refuses, and states that he does not think he has cancer; and is fearful that the surgery would kill him. Even after further explanations on the low mortality of surgery and the importance of removing the mass before it spreads, he continues to refuse treatment. COMMENT ON CASE 2 Even though the physician's prescribed treatment, that is, removal of the mass that is probably cancer, affords the best chance of cure, and delay in its removal increases its chance of metastases and reaching an incurable stage − the choice by this well informed and mentally competent patient should be respected. Here, autonomy prevails over beneficence. The physician, however, may not abandon the patient and is obligated to offer continued outpatient visits with advice against making decision based on fear, examinations, periodic tests, and encouragement to seek a second opinion.