Legal Systems Applied in Nursing & Midwifery PDF

LEGAL SYSTEMS APLLIED IN NURSING & MIDWIFERY [NGS 401] PRINCIPLES OF HUMAN RIGHTS AND ETHICS LECTURER: MISS ANITA APPIAH  HEALTH AND HUMAN RIGHTS The WHO Constitution enshrines “…the highest attainable standard of health as a fundamental right of every human b...

LEGAL SYSTEMS APLLIED IN NURSING & MIDWIFERY [NGS 401] PRINCIPLES OF HUMAN RIGHTS AND ETHICS LECTURER: MISS ANITA APPIAH  HEALTH AND HUMAN RIGHTS The WHO Constitution enshrines “…the highest attainable standard of health as a fundamental right of every human being.” “Human right to health” means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment. The right to health includes access to timely, acceptable, and affordable health care of appropriate quality  HEALTH AND HUMAN RIGHTS Achieving the “right to health” is indirectly related to other human rights, including the right to food, housing, work, education, non-discrimination, access to information, and participation. The right to health includes both “freedoms and entitlements” Freedoms include the right to control one’s health and body (e.g. sexual and reproductive rights) and to be free from interference (e.g. free from torture and from non-consensual medical treatment and experimentation)  HEALTH AND HUMAN RIGHTS Entitlements include the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health. Health policies and programmes have the ability to either promote or violate human rights, including the right to health, depending on the way they are designed or implemented.  VIOLATION OF HUMAN RIGHTS IN HEALTH SPHERE Taking steps to respect and protect human rights upholds the health sector’s responsibility to address everyone’s health Overt or implicit discrimination in the delivery of health services violates fundamental human rights Mental health: Many people with mental disorders are kept in mental institutions against their will, despite having the capacity to make decisions regarding their future Reproductive health: women are frequently denied access to sexual and reproductive health care and services in developing and developed countries  VIOLATION OF HUMAN RIGHTS IN HEALTH SPHERE In addition to denial of care, women in certain societies are sometimes forced into procedures such as sterilization, abortions or virginity examinations. The aforementioned are human rights violations that are deeply ingrained in societal values about women’s sexuality.  HUMAN RIGHTS-BASED APPROACHES TO HEALTHCARE The goal of a human rights-based approach is to ensure that all health policies, strategies and programmes are designed with the objective of progressively improving the enjoyment of all people to the right to health The design of a health care system must be guided by the following key human rights standards: 1. Non-discrimination: The principle of non-discrimination seeks to ensure that human rights are exercised without discrimination of any kind based on: Race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth Other status such as disability, age, Marital and family status, sexual orientation and gender identity, health status, place of residence, economic and social situation  HUMAN RIGHTS-BASED APPROACHES TO HEALTHCARE 2. Availability: Adequate health care infrastructure (e.g. hospitals, community health facilities, trained health care professionals), goods (e.g. drugs, equipment), and services (e.g. primary care, mental health) must be available in all geographical areas and to all communities. 3. Universality: Human rights are universal and inalienable. All people everywhere in the world are entitled to them. 4. Accessibility: Access to health care must be universal, guaranteed for all on an equitable basis. Health care must be affordable and comprehensive for everyone, and physically accessible where and when needed.  HUMAN RIGHTS-BASED APPROACHES TO HEALTHCARE 5. Acceptability and Dignity: Health care institutions and providers must respect dignity, provide culturally appropriate care, be responsive to needs based on gender, age, culture, language, and different ways of life and abilities. The healthcare system must respect medical ethics and protect confidentiality. 6. Quality: All health care must be medically appropriate and of good quality, guided by quality standards and control mechanisms, and provided in a timely, safe, and patient-centered manner.  HUMAN RIGHTS-BASED APPROACHES TO HEALTHCARE 7. Accountability: Private companies and public agencies must be held accountable for protecting the right to health care through enforceable standards, regulations, and independent compliance monitoring. 8. Transparency: Health information must be easily accessible for everyone, enabling people to protect their health and claim quality health services. Institutions that organize, finance or deliver health care must operate in a transparent way. 9. Participation: Individuals and communities must take an active role in decisions that affect their health, including in the organization and implementation of health care services.  INTRODUCTION TO ETHICS IN HEALTHCARE Our care for patients should be based on sound judgement and evidence based practice!! Some of these judgements are about having strong sense of what is right or wrong, what we should be doing and shouldn’t be doing as nurses Additionally, nurses also need to consider the ethical implications of their decisions to ensure their actions are in the interest of their patient and not cause harm. However, many situations are not clear-cut and there are times when what seems legal is not ethical or vice versa.  ETHICS IN HEALTHCARE KEY WORDS Ethics : A branch of philosophy Values Clarification: Process of concerned with fundamental analysing one’s own values to principles of right and wrong and understand oneself more what people ought to do completely regarding what is truly important Morality: Behaviour in accordance with customs or Legal liability : Lawful tradition, usually reflecting accountability and obligation personal or religious belief that one has for their actions Values: Beliefs and attitudes that may influence behaviour  ETHICAL THEORIES 1. CONSEQUENTIALISM/ TELEOLOGY An approach to Ethics that argues that the consequences of one's conduct are the ultimate basis for any judgment about the rightness or wrongness of that conduct. Thus, a morally right action is one that produces a good outcome, and the consequences of an action or rule generally outweigh all other considerations (i.e. the ends justify the means). One common type of consequentialism is Utilitarianism (by John Stuart Mill) which is a theory that supports what is best for most people. This theory examines what creates the most happiness for the most people (society). The best action is the one that maximizes utility.  ETHICAL THEORIES Example: The USA system of disaster triage is based upon the concept of utilitarianism. Health care providers triage rapidly, electing to use resources to provide the most care to the greatest number of people, as opposed to expending maximum resources on a single critically ill person who is unlikely to survive  ETHICAL THEORIES 2. DEONTOLOGY (By Immanuel Kant) In contrast to consequentialism, deontology is an approach to ethics in which rules and moral duty are central Derives the rightness or wrongness of one's conduct from the character of the action itself and its adherence to rules rather than the outcomes of the conduct. Thus the action is more important than the consequences Also called ‘duty-’ or ‘obligation-’ or ‘rule-’ based ethics Example: Restraints on older people for their safety is unethical. According to deontology other measures should be utilised. This is because restraining someone against his or her will could be considered a violation of human right.  ETHICAL THEORIES VIRTUE ETHICS Virtue Theory is an approach to Ethics that emphasizes on the individual's character as the key element of ethical thinking, rather than rules about the acts themselves (Deontology) or their consequences (Consequentialism). For instance, when a patient is in need of help; A utilitarian will point to the fact that the consequences of doing so maximizes happiness of those affected by the act of helping. A deontologist points to the fact that, in helping the one in need, the agent is acting in accordance with a moral rule such as “Do unto others as you would be done by”.  ETHICAL THEORIES A virtue ethicist points to the fact that helping the person is exercising the character trait of benevolence. All the three moral theories will agree that helping the person in need is ethically correct PRINCIPLISM Has evolved into a practical approach for ethical decision-making that focuses on the common ground moral or ethical principles of autonomy, beneficence, nonmaleficence, and justice. Ethical Principles (Principlism), is a commonly used ethical approach in healthcare. This is an attempt to bring together the best elements of ethical theories which are compatible with most societal, individual or religious belief systems.  ETHICAL PRINCIPLES IN NURSING They are codes that direct or govern nursing actions. Ethical principles provide criteria on which to base judgments in relation to ethical theories. Autonomy Respect for an individual’s right to self determination. Support of independent decision making Nurses are to teach people how to make their own choices and support people in their individual choices Do not force or coerce people to do things ‘Informed Consent’ is an important outcome of this principle NONMALEFICENCE The obligation to do or cause no harm. Core of medical oath and nursing ethics. In modern times, nonmaleficence extends to making sure you are doing no harm in the beneficent act of using technology to extend life or in using experimental treatments that have not been well tested BENEFICENCE The duty to do good to others and maintain a balance between benefits and harms in terms of health, welfare, comfort, well-being, improve a person’s potential and improved quality of life ‘Benefit’ should be defined by the patient themselves. It’s not what we think that is important BENEFICENCE CONT’D An undesirable outcome of beneficence in which the healthcare provider decides what is best for the client and encourages the client to act against his/her own choices is called Peternalism JUSTICE Treating people fairly and not favouring some individuals/groups over others Respect for peoples rights and the law Distributive Justice – sharing the scarce resources in society in a fair and just manner (e.g. health services, professional time) thus Equitable distribution of potential benefits VERACITY The obligation to tell the truth Before signing of a consent, be truthful about both positive and negative outcomes of the procedure, potential side effects of drugs, prognosis of clients conditions, quality of life after procedure etc. Respect the autonomy of the patient FIDELITY Concept of keeping a commitment and is based upon the virtue of caring. This principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients maintaining the duty to care for all no matter who they are or what they may have done PRIVACY Patient’s right to non-disclosure of information The nurse has a responsibility to protect a persons right to remain private CONFIDENTIALITY Sharing private information on a ‘need to know basis’ The nurse must always maintain patient confidentiality  ETHICAL CODES Ethical codes Provide broad principles for determining and evaluating client care. They set the standards of practice or behaviour Ethical codes includes advocacy, responsibility, accountability and confidentiality These codes are not legally binding The board of Nursing (NMC) has the power to reprimand nurses for unprofessional conduct that results from violation of ethical codes The codes of professional conduct for Nurses in Ghana https://nursinginghana.com/code-professional-conduct-nursing-midwifery- council-ghana/ GHS code of conduct http://www.ghanahealthservice.org/ghs-subcategory.php?cid=2&scid=45  PURPOSE OF CODES OF ETHICS 1. To inform the public about the minimum standards of the profession 2. To help the public understand professional nursing conduct 3. To provide a sign of the profession’s commitment to the public. 4. Identify the fundamental moral commitments of the profession 5. Provide nurses with a basis for professional and self reflection on ethical conduct  ETHICAL DILEMMA Occurs when there is a conflict between two or more ethical principles, where no ‘correct’ decision exist, and the nurse must make choices between two alternatives which are equally unsatisfactory. Results from difference in cultural and religious beliefs Common ethical dilemma’s in nursing include: – Patient’s freedom versus Nurse’s control – Reproductive rights (pro-choice versus pro-life) – Honesty versus Information – The Minor Dilemma – Battle of Beliefs – Resource management  ETHICAL DILEMMA The nurse’s opinion is valuable in resolution of an ethical dilemma because Nurses develop a relationship with the client that is unique among all health care providers Common ethical issues in nursing include – breaches of confidentiality – organ transplant – end of life decisions( DNR) – abortions – care of HIV/AIDS patients  ETHICAL REASONING Process of thinking through what one should do in an orderly systematic manner to provide justification for actions based on principles The process involves:  The nurse gathering all information to determine whether an ethical dilemma exist  The Nurse examining his/her own values  Verbalising the problem  Considering the possible actions  Negotiating the outcome  Evaluating the action taken  ADVOCACY An important nursing responsibility is to act as a Patient Advocate and protect the patient’s rights. An Advocate : – Speaks up for or acts on behalf of the client – Protects the client’s right to self determination and autonomy – Upholds the principle of fidelity – Represents client’s viewpoint to others – Supports client’s decision even if it contradicts his/her personal preferences  ETHICS COMMITTEES They take a multidisciplinary approach to facilitate dialogue regarding ethical dilemmas These committees develop and establish frameworks, policies and procedures to facilitate prevention and resolution of ethical dilemmas Ethical clearance for research  ETHICAL CLEARANCE IN RESEARCH In order for research to result in benefit and minimise risk of harm, it must be conducted ethically. Ethical clearance refers to the obtainment of ethical approval by a researcher to conduct research that adheres to acceptable ethical standards of a genuine research study. The aim of ethical review is to protect the fundamental human rights of human participants of the research Ethical clearance must be obtained before the study is commenced  ETHICAL CLEARANCE IN RESEARCH Making sure that research is ethical focuses primarily on two areas.  The first concerns the rights of patients, staff and learners to be treated as openly and fairly as possible within the research, and to consent fully to taking part  The second focuses on making sure that appropriate scientific principles are applied so that those who rely on research findings to make their clinical, education or other decisions are receiving results that are accurate and the result of sound research design.  ETHICAL CLEARANCE The ethics committee of each health institution ensures that research being conducted in their facility adheres to ethical principles and guidelines for research involving human subjects  THE BELMONT REPORT The ethical principles upon which much research world-wide is conducted are shaped by 'The Belmont Report‘ The Belmont Report is a report created by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, USA, which was the first public national body to shape bioethics policy in the United States. The title of the report : Ethical Principles and Guidelines for the Protection of Human Subjects of Research, issued on 30th September 1978 and published on 18th April 1979  THE BELMONT REPORT The Belmont Report summarizes ethical principles and guidelines for research involving human subjects Three core principles are identified: 1. Respect for persons : The research consent process ensures autonomy for individuals – 'informed' consent, confidentiality of data etc. 2. Beneficence : The intention to do no harm – to maximise possible benefits and minimize possible risks to people involved in research 3. Justice : fairness in distribution of research inclusion and exclusion  BIOETHICS The study of the ethical issues emerging from advances in biology and medicine Addresses issues of human research such as; – the boundaries of life (e.g. abortion, euthanasia) – Surrogacy – the allocation of scarce health care resources (e.g. organ donation, health care rationing) – right to refuse medical care for religious or cultural reasons PATIENT’S CHARTER AND BILL OF RIGHTS  OBJECTIVES At the end of this lesson students should be able to: 1. Define informed consent 2. Mention the types of consent used in healthcare 3. Explain patient’s Bill of rights  PATIENT’S CHARTER A Statement/document of Commitment by the Ministry of Health and government on healthcare expectations and responsibilities. Outlining what service users can and should expect every time they use health services and what service users can do to help deliver safer and more effective health services in a country The charter views healthcare as collaborative effort between health workers, patients/clients and society. The charter provides for and respect the rights and responsibilities of patients/clients and families, health workers and other health care providers  PATIENT’S CHARTER Patients' rights vary in different countries and in different jurisdictions, often depending upon prevailing cultural and social norms There is an international consensus backed by WHO that all patients have a fundamental right to privacy, to the confidentiality of their medical information, to consent to or to refuse treatment, and to be informed about relevant risk to them from medical procedures The GHS and MoH expect health care institutions to adopt the patient's charter to ensure that service personnel as well as patients/clients and their families understand their rights and responsibilities.  FUNCTIONS OF THE PATIENT’S CHARTER The patient’s charter addresses: 1. The Right of the individual to an easily accessible, equitable and comprehensive health care of the highest quality within the resources of the country. 2. Respect for the patient as an individual with a right of choice in the decision of his/her health care plans. 3. The Right to protection from discrimination based on culture, ethnicity, language, religion, gender, age and type of illness or disability.  FUNCTIONS OF THE PATIENT’S CHARTER CONT’D 4. The responsibility of the patient/client for personal and communal health through preventive, promotive and simple curative strategies  CORE VALUES OF MOH/GHS PATIENT’S CHARTER 1. People Centered 4. Discipline - Patient centered -Code of conduct and ethics - Staff centered - Partner friendly 5. Integrity -Maintain highest level of 2. Team work integrity in healthcare -Achieving more together 3. Innovation/excellence - Seek Knowledge - Share Knowledge -Embrace innovation  PATIENT’S BILL OF RIGHTS Patient Bill of Rights is the client’s rights document which provides a list of the client rights and the responsibilities that the healthcare institution/agency cannot violate It reflects acknowledgment of a client’s right to participate in his/her health care with emphasis on client autonomy. All healthcare facilities are required by law to have the client’s Bill of Rights posted in a visible area  RIGHTS OF A MENTALLY ILL PATIENT The Mental Health Act (Act 846) 2012, provides for mental healthcare and highlights the rights of mentally ill people Psychiatric facilities are required by law to have a Client’s Bill of rights posted at a visible area. Rights of a mentally patient includes:  Right to be treated with dignity and respect  Right to communicate with persons outside the hospital  Right to keep clothing and personal effects with them  Right to habeas corpus (written request for release from hospital)  Rights of a Mentally ill Patient Cont’d  Right to civil service status, including right to vote  Right to informed consent  Right to treatment and to refuse treatment  Right not to be subject to unnecessary restraint  Right to marry and divorce  Right to privacy and confidentiality  Right to religious freedom  Right to be employed  Right to an independent psychiatric examination  Right to be treated in the least restrictive setting  Right to refuse participation in experimental treatment or research  PATIENT’S RIGHTS  The patient has the right to quality basic health care irrespective of his/her geographical location.  The patient is entitled to full information on his/her condition and management and the possible risks involved except in emergency situations when the patient is unable to make a decision and the need for treatment is urgent.  The patient is entitled to know of alternative treatment(s) and other health care providers within the Service if these may contribute to improved outcomes.  The patient has the right to know the identity of all his/her caregivers and other persons who may handle him/her including students, trainees and ancillary workers.  PATIENT’S RIGHTS  The patient has the right to consent or decline to participate in a proposed research study involving him or her after a full explanation has been given. The patient may withdraw at any stage of the research project.  patient who declines to participate in or withdraws from a research project is entitled to the most effective care available.  The patient has the right to privacy during consultation, examination and treatment. In cases where it is necessary to use the patient or his/her case notes for teaching and conferences, the consent of the patient must be sought.  The patient is entitled to personal safety and reasonable security of property within the confines of the Institution.  PATIENT’S RIGHTS  The patient is entitled to confidentiality of information obtained about him or her and such information shall not be disclosed to a third party without his/her consent or the person entitled to act on his/her behalf except where such information is required by law or is in the public interest  The patient is entitled to all relevant information regarding policies and regulation of the health facilities that he/she attends.  Procedures for complaints, disputes and conflict resolution shall be explained to patients or their accredited representatives.  Hospital charges, mode of payments and all forms of anticipated expenditure shall be explained to the patient prior to treatment. PATIENT’S RIGHT CONT’D  The patient has the right to a second medical opinion if he/she so desires. PATIENT’S RESPONSIBILITIES The patient is responsible for his/her own health and should therefore co-operate fully with healthcare providers. The patient is responsible for:  Providing full and accurate medical history for his/her diagnosis, treatment, counseling and rehabilitation purposes.  Requesting additional information and or clarification regarding his/her health or treatment, which may not have been well understood.  Respecting the rights of other patients/clients and Health Service personnel  Protecting the property of the Health facility.  PATIENT’S RESPONSIBILITIES  Complying with prescribed treatment, reporting adverse effects and adhering to follow up requests.  Informing his/her healthcare providers of any anticipated problems in following prescribed treatment or advice.  Obtaining all necessary information, which have a bearing on his/her management and treatment including all financial implications.  Acquiring knowledge, on preventive, promotive and simple curative practices and where necessary to seeking early professional help.  Maintaining safe and hygienic environment in order to promote good health.  INFORMED CONSENT Informed consent is the client’s approval (or that of the legal representative) to have his or her body touched by a specific individual after the explanation of procedure. Consents or releases are legal documents that indicate the clients’ permission to perform surgery, perform a treatment or procedure, or give information to a third party The client must be informed in understandable terms, of the risk and benefits of the surgery or treatment, what the consequences may be for not having the surgery or procedure done, treatment options and name of the physician or surgeon performing the procedure.  INFORMED CONSENT A consent must be signed freely by the client without threat or pressure and be witnessed by an adult (18yrs and above) The nurse or any adult can witness a consent only if he/she saw the client or legal representative sign the consent form Even though the nurse may obtain the clients signature on the consent form, obtaining informed consent is the responsibility of the Physician/ surgeon.  TYPES OF CONSENTS 1. ADMISSION CONSENT: Agreement obtained at the time of admission to identify the health care agency’s responsibility to the client 2. IMMUNIZATION CONSENT: An agreement obtained before the administration of certain immunizations. The consent indicates that the client was informed of the benefits and risk of the immunization 3. SURGICAL CONSENT: Consent obtained for all surgical or invasive procedures or diagnostics tests that are invasive. The health care provider, surgeon or anaesthesiologist who performs the procedure is responsible for explanation of procedure, its risks and benefits, and alternative options  TYPES OF CONSENTS 4. BLOOD TRANSFUSION CONSENT: Consent that indicates that the client was informed of the benefits and risks of the transfusion. Some clients hold religious beliefs that would prohibit them form receiving blood transfusion even in a life-threatening situation 5. ANAESTHESIA CONSENT: An agreement obtained before the administration of anaesthesia. The consent indicates that the client was informed of the benefits and risk of anaesthesia  other types of SPECIAL CONSENT are required for the use of restraints, photographing the client, disposal of body parts during surgery, donating organs after death, or performing an autopsy. These are usually defined in line with institutional policies.  5 ESSENTIAL ELEMENTS OF INFORMED CONSENT 1. Consent must be voluntary 2. Must be obtained prior to treatment 3. Patient must be competent with capacity to understand 4. Patient has the right to withdraw consent at anytime 5. The nurse witnesses signature only and must establish patient's understanding (it's the doctor's responsibility to obtain consent)  PATIENTS/CLIENTS WHO CANNOT PROVIDE AN INFORMED CONSENT Minor (less than 18 years old) Client medicated with sedating medications that can affect client’s cognitive abilities Client declared mentally or emotionally incompetent. – Unconscious patients – Clients under the influence of alcohol or drugs – Chronic dementia and other mental deficiency that impairs thought processes and ability to make decisions The next of kin, appointed guardian, or a durable power of attorney has a legal authority to give consent in these instances.  INFORMED CONSENT An informed consent can be waived for urgent medical or surgical interventions in accordance with state statutes and institutional policy A client has the right to refuse information, waive the informed consent (information) and undergo treatment. This decision must be well documented in the medical recorded A client has the right to withdraw consent at any time  INFORMED CONSENT FOR MINORS A minor is a client under legal age as defined by the state statute (usually younger than 18years) A minor MAY NOT give legal consent, consent must be obtained from a parent or the legal guardian. Assent (expression of approval/agreement) by the minor is important because it allows for communication of the minor’s thoughts and feelings CONDITIONS UNDER WHICH CONSENT FOR A MINOR MAY BE WAIVED Parental or guardian consent should be obtained before treatment is initiated for a minor except the in the following cases: 1. In an emergency 2. Situations in which the consent of the minor is sufficient including treatment related to: – Substance abuse – Treatment of a sexually transmitted infection, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) treatment – Birth control services, pregnancy – Psychiatric services CONDITIONS UNDER WHICH CONSENT FOR A MINOR MAY BE WAIVED 3. A court order or other legal authorization has been obtained 4. The minor is an emancipated minor An emancipated minor has established independence from his or her parents through marriage, pregnancy, service in the armed forces, or by a court order An emancipated adult is considered legally capable of signing an informed consent  REFERENCES Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed., pp. 152-153). New York, NY: Oxford University Press. Butts, J. B., & Rich, K. L. (2008). Nursing ethics across the curriculum and into practice (2nd ed., pp. 21-22). Sunbury, MA: Jones and Bartlett. Silvestri, L. A. (2014). Comprehensive review for the NCLEX-RN examination (6th ed., pp. 50-60). St Louis, Missouri: Elsevier Inc.  REFERENCES Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed., pp. 152-153). New York, NY: Oxford University Press. Butts, J. B., & Rich, K. L. (2008). Nursing ethics across the curriculum and into practice (2nd ed., pp. 21-22). Sunbury, MA: Jones and Bartlett. Silvestri, L. A. (2014). Comprehensive review for the NCLEX- RN examination (6th ed., pp. 50-60). St Louis, Missouri: Elsevier Inc.