Ethical Guidelines for Health Care Professionals (PDF)

Ethical guidelines for good practice in the health care professions Protecting the Public and Guiding the Professions Ethical guidelines for good practice in the health care professions The following Booklets are separately available: Booklet 1: General ethical guidelines for health care profes...

Ethical guidelines for good practice in the health care professions Protecting the Public and Guiding the Professions Ethical guidelines for good practice in the health care professions The following Booklets are separately available: Booklet 1: General ethical guidelines for health care professions 3 Booklet 2: Ethical and professional rules of the Health Professions Council of South Africa as promulgated in government gazette R717/2006 20 Booklet 3: National Patients’ Rights Charter 79 Booklet 4: Seeking patients’ informed consent: The ethical considerations 86 Booklet 5: Confidentiality: Protecting and providing information 103 Booklet 6: Guidelines for the management of patients with HIV infection or AIDS 119 Booklet 7: Guidelines withholding and withdrawing treatment 133 Booklet 8: Guidelines on Reproductive Health management 146 Booklet 9: Guidelines on Patient Records 162 Booklet 10: Guidelines for the practice of Telemedicine 173 Booklet 11: Guidelines on over servicing, perverse incentives and related matters 193 Booklet 12: Guidelines for the management of health care waste 208 Booklet 13: General ethical guidelines for health researchers 262 Booklet 14: Ethical Guidelines for Biotechnology Research in South Africa 278 Booklet 15: Research, development and the use of the chemical, biological and nuclear weapons 294 Booklet 16: Ethical Guidelines on Social Media 307 Booklet 17: Ethical Guidelines on Palliative Care 320  HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS GENERAL ETHICAL GUIDELINES FOR THE HEALTH CARE PROFESSIONS BOOKLET 1 PRETORIA SEPTEMBER 2016 Health Professions Council of South Africa Post Office Box 205 Pretoria 0001 Telephone: (012) 338 9300 Fax: (012) 328 4863 E-mail: [email protected] Website: http://www.hpcsa.co.za  i THE SPIRIT OF PROFESSIONAL GUIDELINES Practice as a health care professional is based upon a relationship of mutual trust between patients and health care practitioners. The term “profession” means “a dedication, promise or commitment publicly made”.1 To be a good health care practitioner, requires a life-long commitment to sound professional and ethical practices and an overriding dedication to the interests of one’s fellow human beings and society. In essence, the practice of health care professions is a moral enterprise. In this spirit the HPCSA presents the following ethical guidelines to guide and direct the practice of health care practitioners. These guidelines form an integral part of the standards of professional conduct against which a complaint of professional misconduct will be evaluated. [Note: The term “health care practitioner” in these guidelines refers to persons registered with the HPCSA]. 1 Pellegrino, ED. Medical professionalism: Can it, should it survive? J Am Board Fam Pract 2000; 13(2):147-149 (quotation on p. 148).  ii TABLE OF CONTENTS Acknowledgements......................................................................................................................... iii 1. Introduction....................................................................................................................... 1 2. Core ethical values and standards for good practice......................................................... 2 3. How to resolve ethical dilemmas....................................................................................... 3 4. What it means to have a duty............................................................................................ 4 5. Duties to patients.............................................................................................................. 5 6. Duties to colleagues and other health care practitioners................................................. 10 7. Duties to patients of other health care practitioners......................................................... 10 8. Duties to themselves....................................................................................................... 11 9. Duties to society.............................................................................................................. 11 10. Duties to the health care profession................................................................................ 12 11. Duties to the environment................................................................................................ 12  iii ACKNOWLEDGEMENTS The Health Professions Council of South Africa wishes to thank the following persons for their contributions towards the revision of the guidelines:  The Committee for Human Rights, Ethics and Professional Practice of the Health Professions Council of South Africa for initiating and advising the review process.  Ms RM Kekana (Chairperson), Prof A. Dhai, Prof D J. McQuoid-Mason, Ms V Amrit, Rev G Moerane, Dr C Vincent-Lambert, Mr R Mjethu and Dr TKS Letlape,  Prof A. Dhai, Prof D.J. McQuoid-Mason, Dr N Msomi and LIFElab for the development of the ethical guidelines for Biotechnology Research in South Africa.  Prof D. J McQuoid-Mason for his editorial advice on the booklets  Adv Mathibeli as the legal advisor, Ms N Manciya as Committee coordinator and Mr N Sipeka as the Council secretariat.  GENERAL ETHICAL GUIDELINES FOR THE HEALTH CARE PROFESSIONALS 1. INTRODUCTION 1.1 Being registered as a health care professional with the Health Professions Council of South Africa (HPCSA) confers on us the right and privilege to practise our professions. Correspondingly, practitioners have moral or ethical duties to others and society. These duties are generally in keeping with the principles of the South African Constitution (Act No. 108 of 1996) and the obligations imposed on health care practitioners by law. 1.2 This first booklet on general ethical guidelines contains value-oriented principles and express the most honourable ideals to which members of the health care profession should subscribe in terms of their conduct 1.3 More specific ethical guidelines and rules are derived from these general ethical guidelines. They offer more precise guidance and direction for action in concrete situations. They also make it possible for the HPCSA to implement sanctions against transgressors. 1.4 It is impossible, however, to develop a complete set of specific ethical prescriptions applicable to all conceivable real-life situations. In concrete cases, health care professionals may have to work out for themselves what course of action can best be defended ethically. This requires ethical reasoning. 1.5 This booklet lists thirteen core ethical values and standards that underlie professional and ethical practice in health care professions, and gives a short explanation of how one makes practical decisions through ethical reasoning. It then explains what a duty is, and catalogues the general ethical duties of health care professionals [Note: In this booklet, the expressions “professional” or ‘”practitioner” are used interchangeably to refer to health care practitioners]. [Note: Environmental Health Practitioners do not see patients]  2 2. CORE ETHICAL VALUES AND STANDARDS FOR GOOD PRACTICE 2.1 Everything ethically required of a professional to maintain good professional practice is grounded in core ethical values and standards – the latter are the directives that follow the core values. These core values and standards are presented as a linear list for the sake of simplicity. 2.2 In concrete cases, the demands of these core values and standards may clash, thus making competing demands on health care practitioners. The only way to address such clashes is through ethical reasoning. 2.3 The core ethical values and standards required of health care practitioners include the following: 2.3.1 Respect for persons: Health care practitioners should respect patients as persons, and acknowledge their intrinsic worth, dignity, and sense of value. 2.3.2 Best interests or well-being: Non-maleficence: Health care practitioners should not harm or act against the best interests of patients, even when the interests of the latter conflict with their own self-interest. 2.3.3 Best interest or well-being: Beneficence: Health care practitioners should act in the best interests of patients even when the interests of the latter conflict with their own personal self-interest. 2.3.4 Human rights: Health care practitioners should recognise the human rights of all individuals. 2.3.5 Autonomy: Health care practitioners should honour the right of patients to self- determination or to make their own informed choices, and to live their lives by their own beliefs, values and preferences. 2.3.6 Integrity: Health care practitioners should incorporate these core ethical values and standards as the foundation for their character and practice as responsible health care professionals. 2.3.7 Truthfulness: Health care practitioners should regard the truth and truthfulness as the basis of trust in their professional relationships with patients. 2.3.8 Confidentiality: Health care practitioners should treat personal or private information as confidential in professional relationships with patients - unless overriding reasons confer a moral or legal right to disclosure. 2.3.9 Compassion: Health care practitioners should be sensitive to, and empathise with, the individual and social needs of their patients and seek to create mechanisms for providing comfort and support where appropriate and possible. 2.3.10 Tolerance: Health care practitioners should respect the rights of people to have different ethical beliefs as these may arise from deeply held personal, religious or cultural convictions. 2.3.11 Justice: Health care practitioners should treat all individuals and groups in an impartial, fair and just manner.  3 2.3.12 Professional competence and self-improvement: Health care practitioners should continually endeavour to attain the highest level of knowledge and skills required within their area of practice. 2.3.13 Community: Health care practitioners should strive to contribute to the betterment of society in accordance with their professional abilities and standing in the community. 3. HOW TO RESOLVE ETHICAL DILEMMAS 3.1 The core values and standards referred to above are the foundation that grounds the general ethical guidelines in these booklets. Being general, such guidelines may be applied to many different concrete cases. 3.2 Questions arise as to how health care practitioners may use these guidelines to make practical decisions or choices about the provision of health care. For example, how does a guideline apply in a specific case? And, how do health care practitioners handle difficult situations where two (or more) principles appear to be in conflict? 3.3 Briefly, what is needed is ethical reasoning. In general, such ethical reasoning proceeds in four steps: 3.3.1 Formulating the problem: Determine whether the issue at hand is an ethical one once this has been done it must be decided whether there is a better way of understanding it. 3.3.2 Gathering information: All the relevant information must be collected - such as clinical, personal and social data. Consult authoritative sources such as these guidelines, practitioner associations, respected colleagues and see how practitioners generally deal with such matters. 3.3.3 Considering options: Consider alternative solutions in light of the principles and values they uphold. 3.3.4 Making a moral assessment: The ethical content of each option should be weighed by asking the following questions: 3.3.4.1 What are the likely consequences of each option? 3.3.4.2 What are the most important values, duties, and rights? Which weighs the heaviest? 3.3.4.3 What are the weaknesses of the health care practitioner’s individual view concerning the correct option? 3.3.4.4 How would the health care practitioner himself or herself want to be treated under similar circumstances. – 3.3.4.5 How does the health care practitioner think that the patient would want to be treated in the particular circumstances? 3.3.5 Discuss your proposed solution with those whom it will affect 3.3.6 Act on your decision with sensitivity to others affected 3.3.7 Evaluate your decision and be prepared to act differently in the future (Adopted from WMA – Medical Ethics Manual)  4 4. WHAT IT MEANS TO HAVE A DUTY 4.1 Ethical guidelines express duties. A duty is an obligation to do or refrain from doing something. 4.2 If we have a duty to another person, it means we are bound to that person in some respect and for some reason. We owe that person something, while he or she holds a corresponding right or claim against us. 4.3 An example of a right with a corresponding duty is the following: Suppose a health care practitioner reaches an agreement with a colleague that the latter will do a locum for him while he is away on family business: The colleague has a duty to do the locum and the health care practitioner has a right to the colleague’s services. At the same time the colleague has a right to fair remuneration and the health care practitioner has a duty to compensate her/him. 4.4 To have a duty is to ask the question “What do I owe others?” To have a right is to ask the question “What do others owe me?” 4.5 Duties may be ethical, legal or both at once, and operate in the personal, social, professional or political spheres of our lives. 4.6 Healthcare practitioners fulfil different roles. Accordingly, they have different kinds of duties: 4.6.1 As human beings we have “natural duties”, namely unacquired general duties simply because we are members of the human community - for example the natural duties to refrain from doing harm, to promote the good, or to be fair and just. As is the case with everyone, health care professionals owe these duties to all other people, whether patients or not, and quite independently of our professional qualifications. 4.6.2 As professionals we have “moral obligations”, namely general duties we acquire by being qualified and licensed as professionals, that is, professionals entering into contractual relationships with patients - for example the professional duties to provide health care, relieve pain, gain informed consent, respect confidentiality, and be truthful. 4.6.3 Institutional duties: Institutional duties are imposed upon health care practitioners working in specific institutions. They are specific to the health care practitioner’s particular institutionalised role, for example the duties of a practitioner employed by a company, a health care practitioner working in a governmental research agency, or a doctor engaged in private practice. These duties are contained in employment contracts, job descriptions, conventional expectations etc. Institutional duties must be consistent with the ethical and legal duties of health care practitioners. 4.6.4 Legal duties: Legal duties are duties imposed by the common law and by statute law (for example, the National Health Act (Act No. 61 of 2003) or the Health Professions Act, 1974) that require health care practitioners to follow certain procedures and to use particular skill and care when dealing with patients.  5 4.7 The duties listed in these general guidelines mostly fall into the second category – the general but acquired duties of a health care practitioner as a professional. 4.8 No duty is absolute or holds without exception irrespective of time, place or circumstance. This is not surprising, since different duties may prescribe quite opposite decisions and actions in a specific concrete or real-life situation.For example, our duties to our patients may compete with our duties to our employer. Or our duty to respect a patient’s confidentiality may clash with our duty to protect innocent third parties from harm. (HIV/AIDS examples are particularly perplexing.) These are instances of conflicts of interest or dual loyalties. 4.9 No list of such duties is ever complete, but the catalogue of duties below presents a fairly comprehensive picture of what it is, in general, that binds any health care provider as a professional to his or her patients, as well as to others. However, it should be noted that these duties, if not honoured without justification, may constitute the basis for sanctions being imposed on professionals by the Health Professions Council of South Africa. 4.10 Any classification of duties is arbitrary, because specific duties may be owed to different parties simultaneously. Therefore, the classifications used below should be viewed only as a rough guide. However, underlying these duties is a set of core ethical values and standards of good practice that are regarded as basic ethical principles. (see above para 2). 5. DUTIES TO PATIENTS 5.1 PATIENTS’ BEST INTERESTS OR WELL-BEING Health care practitioners should: 5.1.1 Always regard concern for the best interests or well-being of their patients as their primary professional duty. 5.1.2 Honour the trust of their patients. 5.1.3 Be mindful that they are in a position of power over their patients and avoid abusing their position. 5.1.4 Within the normal constraints of their practice, be accessible to patients when they are on duty, and make arrangements for access when they are not on duty. 5.1.5 Make sure that their personal beliefs do not prejudice their patients’ health care. Beliefs that might prejudice care relate to patients’ race, culture, ethnicity, social status, lifestyle, perceived economic worth, age, gender, disability, communicable disease status, sexual orientation, religious or spiritual beliefs, or any condition of vulnerability. 5.1.6 If they feel that their beliefs might affect the treatment they provide, they must explain this to their patients, and inform them of their right to see another health care practitioner.  6 5.1.7 Not refuse or delay treatment because they believe that patients’ actions have contributed to their condition, or because they – the health care practitioners - may be putting their own health at risk. 5.1.8 Apply their mind when making diagnoses and considering appropriate treatment. 5.1.9 Respond appropriately to protect patients from any risk or harm 5.1.10 Respond to criticism and complaints promptly and constructively. 5.1.11 Not employ any intern, health care provider in community service, or health care practitioner with restricted registration with the HPCSA, as a locum tenens - or otherwise - in their own or any associated health care practice. 5.1.12 Inform their patients if they are in the employ of, in association with, linked to, or have an interest in any organisation or facility that could be interpreted by an average person as potentially creating a conflict of interest or dual loyalty in respect of their patient care. 5.1.13 In emergency situations, provide health care within the limits of their practice and according their education and/ or training, experience and competency under proper conditions and in appropriate surroundings. If unable to do so, refer the patient to a colleague or an institution where the required care can be provided. Adequately educated and/or trained To qualify as adequately educated and/or trained: i. The individual practitioner must have successfully completed an educational training programme approved and accredited by the HPCSA within the field of practice and category of registration. ii. The individual practitioner must have successfully completed a training programme in a training entity/institution/hospital that has been accredited by the professional board, for training in that particular profession or discipline and for that particular competency. iii. The individual practitioner must, in order to be regarded as trained, have undergone an initial training period under the supervision, as defined in clause (i) above, of an entity accredited by the professional board for such purposes, and been credentialed in the successful completion of such training as defined. iv. The individual practitioner must have completed undergraduate or postgraduate training, the duration of which was laid down by the professional board. v. The individual practitioner must be evaluated and credentialed as having met the requirements of the training programme by an entity accredited by the Professional board (e.g. Colleges of Medicine, Universities, etc). vi. A short course will serve to enhance or maintain skills that have been credentialed and registered by the professional board.  7 vii. The application of such training in care of the patient will be judged by the professional board by the standards and norms considered reasonable for the circumstances under which the intervention took place. b. Sufficiently experienced To be regarded as sufficiently experienced, a practitioner must: i. Have performed a minimum number of interventions annually to remain proficient, taking into account and judged by the standards and norms considered reasonable by the professional board, for the circumstances under which the intervention took place. ii. With regard to the introduction of new interventions within the practitioners’ scope of professional practice, have undergone further appropriate training and credentialing as approved by the professional board.” c. Under proper conditions and appropriate surroundings All interventions shall take place under appropriate conditions and surroundings. These are subject to judgment by the professional board as to what is considered reasonable in the circumstances and conditions, under which the intervention took place. No practitioner must embark upon an intervention unless it is in the patient’s interest, and that it would be considered safe to do so, under the prevailing conditions and surroundings. The practitioner will be judged on what requirements would be reasonable to ensure that patient safety was protected. 5.2 RESPECT FOR PATIENTS Health care practitioners should: 5.2.1 Respect the privacy, confidentiality and dignity of patients. 5.2.2 Treat patients politely and with consideration. 5.2.3 Listen to their patients and respect their opinions. 5.2.4 Avoid improper relationships with their patients and those who are accompanying the patient (for example, sexual relationships or exploitative financial arrangements). 5.2.5 Guard against human rights violations of patients, and not allow, participate in or condone any actions that lead to violations of the rights of patients. 5.2.6 inform the patient of the choice of having a chaperone in the room during an intimate examination 5.2.7 inform the patient if the practitioner will be having a chaperone in the room during an intimate examination  8 5.3 INFORMED CONSENT Health care practitioners should: 5.3.1 Give their patients the information they ask for or need about their condition, its treatment and prognosis. 5.3.2 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. 5.3.3 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. 5.3.4 Apply the principle of informed consent as an on-going process 5.3.5 Allow patients access to their medical records For detailed information consult the HPCSA Ethical Booklet on Informed Consent 5.4 PATIENT CONFIDENTIALITY Health care practitioners should: 5.4.1 Recognise the right of patients to expect that health care practitioners will not disclose any personal and confidential information they acquire in the course of their professional duties, unless the disclosure thereof is: made in accordance with patient’s consent; made in accordance with the court order to that effect; required by law; or In the interest of the patient. Section 14 and 15 of the NHA. 5.4.2 Not breach confidentiality without sound reason and without the knowledge of their patients 5.4.3 When claiming from medical schemes explain to patients the significance of ICD-10 coding and get the permission of patients to breach confidentiality when making a medical scheme claim. For detailed information consult the HPCSA Ethical Booklet 5 on confidentiality: Protecting and Providing information 5.5 PATIENT PARTICIPATION IN THEIR OWN HEALTH CARE Health care practitioners should: 5.5.1 Respect the right of patients to be fully involved in decisions about their treatment and care even if they are not legally competent to give the necessary consent. 5.5.2 Respect the right of patients to refuse treatment or to take part in teaching or research.  9 5.5.3 Inform their patients that they have a right to seek a second opinion without prejudicing their future treatment. For detailed information consult the HPCSA Ethical Booklet 3 on the National Patients’’ Rights Charter 5.6 IMPARTIALITY AND JUSTICE Health care practitioners should be aware of the rights and laws concerning unfair discrimination in the management of patients or their families on the basis of race, culture, ethnicity, social status, lifestyle, perceived economic worth, age, gender, disability, communicable disease status, sexual orientation, religious or spiritual beliefs, or any condition vulnerability. For detailed information consult the HPCSA Ethical Booklet 3 on National Patients’’ Rights Charter 5.7 ACCESS TO CARE Health care practitioners should: 5.7.1 Promote access to health care. If they are unable to provide a service, they should refer the patient to another health care practitioner or to a health care facility where the required service can be obtained, provided that in an emergency situation practitioners shall be obliged to provide care in order to stabilize the patient and then to arrange for an appropriate referral to another practitioner or facility. Section 5 of the NHA For detailed information consult the HPCSA Ethical Booklet 3 on Patients’’ Rights Charter 5.8 POTENTIAL CONFLICTS OF INTEREST Health care practitioners should: 5.8.1 Always seek to give priority to the investigation and treatment of patients solely on the basis of clinical need. 5.8.2 Avoid over-servicing: They should recommend or refer patients for necessary investigations and treatment only, and should prescribe only treatment, drugs or appliances that serve the needs of their patients. Rule 23A of the Ethical Rules of Conduct 5.8.3 Declare to their patients – verbally and by a displayed notice – any financial interest they may have in institutions, diagnostic equipment, or the like to which they make referrals, if the holding of such interest is permitted by the HPCSA. Rule 24 of the Ethical Rules of Conduct 5.8.4 Refrain from coercing patients or their family members to provide them (health practitioners) with gifts or any other undue benefit.  10 6. DUTIES TO COLLEAGUES AND OTHER HEALTH CARE PRACTITIONERS 6.1 REFERRALS TO COLLEAGUES AND POTENTIAL CONFLICTS OF INTEREST Health care practitioners should: 6.1.1 Act in their patients’ best interests when making referrals and providing or arranging treatment or care. They should not ask for, or accept, any undue inducement or incentive, from colleagues to whom they refer patients because it may affect or be seen to affect the health care practitioner’s judgement. 6.1.2 Treat patients referred to them in the same manner in which they would treat their own patients. 6.1.3 Not service a patient in more than one capacity or charge fees based on more than one consultation where health practitioners are registered with more than one statutory council or professional board or in one or more categories within the same professional board. Adhere to the guideline on self-referral and other referrals mentioned in Booklet 11 on Guideline on Over – Servicing, Perverse incentives and Related Matters (par 3.5). 6.2 WORKING WITH COLLEAGUES Health care practitioners should: 6.2.1 Work with and respect other health-care professionals in pursuit of the best health care possible for all patients. 6.2.2 Not discriminate against colleagues, including health care practitioners applying for posts, because of their views of their race, culture, ethnicity, social status, lifestyle, perceived economic worth, age, gender, disability, communicable disease status, sexual orientation, religious or spiritual beliefs, or any condition of vulnerability. 6.2.3 Refrain from speaking ill of colleagues or other health care practitioners. Rule 12 of the ethical Rules of conduct. 6.2.4 Not make a patient doubt the knowledge or skills of colleagues by making comments about them that cannot be fully justified. 6.2.5 Support colleagues who uphold the core values and standards embodied in these guidelines. 6.2.6 Advise colleagues who are impaired to seek professional assistance. 7. DUTIES TO PATIENTS OF OTHER HEALTH CARE PRACTITIONERS Health care practitioners should: 7.1 Act quickly to protect patients from risk due to any reason.  11 7.2 Report violations and seek redress in circumstances where they have a good or persuasive reason to believe that the rights of patients are being violated. 7.3 Report impaired colleagues who are a danger to the health of their patients in order that such colleagues may be provided with the necessary support to overcome their impairment and prevented from harming patients (See HPCSA Booklet 2 on Ethical and Professional Rules of the HPCSA Rule 25) For detailed information consult the HPCSA Ethical Booklet 11 on Guideline on Over – Servicing, Perverse incentives and Related Matters. 8. DUTIES TO THEMSELVES 8.1 KNOWLEDGE AND SKILLS Health care practitioners should: Maintain and improve the standard of their performance by keeping their professional knowledge and skills up to date throughout their working life. In particular, they should regularly take part in educational activities that would enhance their provision of health services. Acknowledge the limits of their professional knowledge and competence. They should not pretend to know everything. Observe and keep up to date with the laws that affect professional health care practice in general and their practice in particular (for example, the provisions of the National Health Act (Act No. 61 of 2003)). Update their skills and knowledge of ethics, human rights and health law as provided for in accredited Continuing Professional Development programmes. For detailed information consult the HPCSA Ethical Booklet 16 on Continuing Professional Development. 8.2 MAINTAINING A PROFESSIONAL PRACTICE Health care practitioners should: 8.2.1 Keep their equipment in good working order. 8.2.2 Maintain proper hygiene in their working environment. 8.2.3 Keep accurate and up-to-date patient records 8.2.4 Refrain from engaging in activities that may affect their health and lead to impairment. 8.2.5 Ensure that staff members employed by them are trained to respect patients’ rights; in particular the right to confidentiality  12 9. DUTIES TO SOCIETY 9.1 ACCESS TO SCARCE RESOURCES Health care practitioners should: 9.1.1 Deal responsibly with scarce health care resources. 9.1.2 Refrain from providing a service that is not needed. 9.1.3 Refrain from unnecessary wastage, and from participating in improper financial arrangements, especially those that escalate costs and disadvantage individuals or institutions unfairly. 9.2 HEALTH-CARE POLICY DEVELOPMENT Health care practitioners should include ethical considerations, legal requirements and human rights in the development of health care policies. Do they have a responsibility to develop policy? 10. DUTIES TO THE HEALTH CARE PROFESSION 10.1 REPORTING MISCONDUCT Health care practitioners should: 10.1.1 Report violations and seek redress in circumstances where they have good or persuasive reason to believe that the rights of patients are being violated and / or where the conduct of the practitioner is unethical 10.1.2 Where it is in their power, protect people who report misconduct from victimisation or intimidation. 10.2 ACCESS TO APPROPRIATE HEALTH CARE Health care practitioners should promote access to health care. If they are unable to provide a health service, they should refer the patient to another health care practitioner or health care facility that can provide the service. 11. DUTIES TO THE ENVIRONMENT 11.1 CONSERVATION OF NATURAL RESOURCES Health care practitioners should recognise that they have a responsibility to ensure that in the conduct of their affairs they do not in any way contribute to environmental degradation. 11.2 DISPOSAL OF HEALTH CARE WASTE Health care practitioners should protect the environment and the public by ensuring that health care waste is disposed off legally and in an environmentally friendly manner  HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS ETHICAL AND PROFESSIONAL RULES OF THE HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA BOOKLET 2 PRETORIA SEPTEMBER 2016 1 Health Professions Council of South Africa Post Office Box 205 Pretoria 0001 Telephone: (012) 338 9300 Fax: (012) 328 4863 E-mail: [email protected] Website: http://www.hpcsa.co.za 2  ETHICAL AND PROFESSIONAL RULES Practice as a health care professional is based on a relationship of mutual trust between patients and health care practitioners. The term “profession” means “a dedication, promise or commitment publicly made”.1 To be a good health care practitioner, requires a life-long commitment to sound professional and ethical practices and an overriding dedication to the interests of one’s fellow human beings and society. In the course of their professional work health care practitioners are required to subscribe to certain rules of conduct. To this end the Health Professional Council of South Africa has formulated a set of rules regarding professional conduct against which complaints of professional misconduct will be evaluated. These rules are reproduced in this booklet. 1 Pellegrino, ED. Medical professionalism: Can it, should it survive? J Am Board Fam Pract 2000; 13(2):147-149 (quotation on p. 148).  4 TABLE OF CONTENTS SCHEDULE.................................................................................................................................... 7 DEFINITIONS................................................................................................................................. 7 INTERPRETATION AND APPLICATION....................................................................................... 9 ADVERTISING AND CANVASSING OR TOUTING........................................................................ 9 INFORMATION ON PROFESSIONAL STATIONERY.................................................................. 10 NAMING OF A PRACTICE........................................................................................................... 10 ITINERANT PRACTICE................................................................................................................ 11 FEES AND COMMISSION............................................................................................................ 11 PARTNERSHIP AND JURISTIC PERSONS................................................................................. 11 SHARING OF ROOMS................................................................................................................. 12 COVERING................................................................................................................................... 12 SUPERSESSION.......................................................................................................................... 12 IMPEDING A PATIENT................................................................................................................. 13 PROFESSIONAL REPUTATION OF COLLEAGUES................................................................... 13 PROFESSIONAL CONFIDENTIALITY......................................................................................... 13 RETENTION OF HUMAN ORGANS............................................................................................. 13 SIGNING OF OFFICIAL DOCUMENTS........................................................................................ 14 CERTIFICATES AND REPORTS.................................................................................................. 14 ISSUING OF PRESCRIPTIONS.................................................................................................... 15 PROFESSIONAL APPOINTMENTS............................................................................................. 15 SECRET REMEDIES.................................................................................................................... 15 DEFEATING OR OBSTRUCTING THE COUNCIL OR BOARD IN THEPERFORMANCE OF ITS DUTIES......................................................................................... 15 PERFORMANCE OF PROFESSIONAL ACTS............................................................................. 16 EXPLOITATION............................................................................................................................ 16 MEDICINE AND MEDICAL DEVICES.......................................................................................... 16 FINANCIAL INTERESTS IN HOSPITALS.................................................................................... 17 REFERRAL OF PATIENTS TO HOSPITALS............................................................................... 18 REPORTING OF IMPAIRMENT OR OF UNPROFESSIONAL, ILLEGAL OR UNETHICAL CONDUCT............................................................................................................... 18 RESEARCH, DEVELOPMENT AND USE OF CHEMICAL, BIOLOGICAL AND NUCLEAR CAPABILITIES........................................................................................................... 19 4  5 MULTIPLE REGISTRATION......................................................................................................... 19 MAIN RESPONSIBILITIES OF HEALTH PRACTITIONERS........................................................ 20 REPEAL........................................................................................................................................ 20 ANNEXURES................................................................................................................................ 21 5  6 ETHICAL AND PROFESSIONAL RULES OF THE HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA NOTE This Booklet contains the Draft Regulations concerning the ethical and professional rules that the Health Professions Council of South Africa (HPCSA) has recommended to the Minister of Health. Health care practitioners who decide not to follow the guidance in this Booklet (including the Annexure), must be prepared to explain and justify their actions and decisions to patients and their families, their colleagues and, if necessary, to the courts and the HPCSA. 6  7 GOVERNMENT NOTICE DEPARTMENT OF HEALTH No. R. 717 4 August 2006 as amended by Government Notice No. R 68 of 2 February 2009. HEALTH PROFESSIONS ACT, 1974 (ACT NO. 56 OF 1974) ETHICAL RULES OF CONDUCT FOR PRACTITIONERS REGISTERED UNDER THE HEALTH PROFESSIONS ACT, 1974 The Health Professions Council of South Africa, in consultation with the professional boards, has, under section 49 of the Health Professions Act, 1974 (Act No. 56 of 1974), made the rules in the Schedule. SCHEDULE Definitions 1. In these rules, any word or expression to which a meaning has been assigned in the Act shall bear such meaning and, unless the context indicates otherwise - “Act” means the Health Professions Act, 1974 (Act No. 56 of 1974); “annexure” means an annexure to these rules; “association” means a form of where two or more practitioners practise for their own account, but share communal assets or facilities; “board” means a professional board established in terms of section 15 of the Act; “canvassing” means conduct which draws attention, either verbally or by means of printed or electronic media, to one’s personal qualities, superior knowledge, quality of service, professional guarantees or best practice; “close collaboration” means consultation by a practitioner at one stage or another in the treatment of a patient with another practitioner and the furnishing by the latter practitioner, at the end of such treatment, of a report on the treatment to the practitioner whom he or she consulted; “dental specialist” means a dentist who has been registered as a specialist in a speciality or subspeciality in dentistry in terms of the Regulations relating to the Specialities and Subspecialities in Medicine and Dentistry, published under Government Notice No. R. 590 of 29 June 2001; 7  8 “dispensing optician” means a person registered as such in terms of the Act and the Rules for the registration of Dispensing Opticians, published under Government Notice No. R. 2339 of 3 December 1976; “impairment” means a mental or physical condition which affects the competence, attitude, judgement or performance of professional acts by a registered practitioner; “independent practice” means a practice where a registered health profession is conducted by a health practitioner without the supervision of another health practitioner; “itinerant practice” means a practice which a practitioner conducts on a regular basis at a location other than at his or her resident practice address; "'medical device' means a medical device as defined in section 1 of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965); “medical scientist” means a person registered under the Act as a biomedical engineer, clinical biochemist, genetic counsellor, medical biological scientist or medical physicist; “medical specialist” means a medical practitioner who has been registered as a specialist in a speciality or subspeciality in medicine in terms of the Regulations relating to the Specialities and Subspecialities in Medicine and Dentistry, published under Government Notice No. R. 590 of 29 June 2001; “optometrist” means a person registered as such under the Act; “pharmaceutical concern” means a company registered as such under the Pharmacy Act, 1974 (Act No. 53 of 1974); “practitioner” means a person registered as such under the Act and, in the application of rules 5, 6 and 9 of these rules, also a juristic person exempted from registration in terms of section 54A of the Act; “private practice” means the practice of a health practitioner who practises for his or her own account, either in solus practice, or as a partner in a partnership, or as an associate in an association with other practitioners, or as a director of a company established in terms of section 54A of the Act; “public company” means a company registered as such under the Companies Act, 1973 (Act No. 61 of 1973); “public service” means a service rendered by the state at the national, provincial or local level of government and includes organizations which function under its auspices or are largely subsidized by the state or recognized by a board for the purposes of these rules; “resident practice” means a place where a registered health practitioner conducts his or her practice on a daily basis; 8  9 ”rooms” means a physical structure, with an exclusive entrance and walled all round for the privacy of patients, the preservation of their confidentiality and the safe keeping of records, where a practitioner conducts his or her practice; “section” means a section of the Act; “specialist” means a practitioner who is registered as a specialist in a speciality or subspeciality (if any) in terms of the Regulations relating to the Specialities and Subspecialities in Medicine and Dentistry, published under Government Notice No. R. 590 of 29 June 2001, and who confines his or her practice to such speciality or subspeciality; “supervision” means the acceptance of liability by a supervising practitioner for the acts of another practitioner; and “touting” means conduct which draws attention, either verbally or by means of printed or electronic media, to one's offers, guarantees or material benefits that do not fall in the categories of professional services or items, but are linked to the rendering of a professional service or designed to entice the public to the professional practice. Interpretation and application 2. (1) Failure by a practitioner to comply with any conduct determined in these rules or an annexure to these rules shall constitute an act or omission in respect of which the board concerned may take disciplinary steps in terms of Chapter IV of the Act. (2) Conduct determined in these rules or an annexure to these rules shall not be deemed to constitute a complete list of conduct and the board concerned may therefore inquire into and deal with any complaint of unprofessional conduct which may be brought before such board. (3) At an inquiry referred to in subrule (2) the board concerned shall be guided by these rules, annexures to these rules, ethical rulings or guidelines and policy statements which the board concerned or council makes from time to time. Advertising and canvassing or touting 3. (1) A practitioner shall be allowed to advertise his or her services or permit, sanction or acquiesce to such advertisement: Provided that the advertisement is not unprofessional, untruthful, deceptive or misleading or causes consumers unwarranted anxiety that they may be suffering from any health condition. (2) A practitioner shall not canvass or tout or allow canvassing or touting to be done for patients on his or her behalf. 9  10 Information on professional stationery 4. (1) A practitioner shall print or have printed on letterheads, account forms and electronic stationery information pertaining only to such practitioner’s – (a) name; (b) profession; (c) registered category; (d) speciality or subspeciality or field of professional practice (if any); (e) registered qualifications or other academic qualifications or honorary degrees in abbreviated form; (f) registration number; (g) addresses (including email address); (h) telephone and fax numbers; (i) practice or consultation hours; (j) practice code number; and (k) dispensing licence number (if any). (2) A group of practitioners practising as a juristic person which is exempted from registration in terms of section 54A of the Act or a group of practitioners practising in partnership, shall print or have printed on letterheads, account forms and electronic stationery information pertaining only to such juristic person or partnership practitioners’ - (a) name; (b) profession; (c) registered category; (d) speciality or subspeciality or field of professional practice (if any); (e) registered qualifications or other academic qualifications or honorary degrees in abbreviated form; (f) registration number; (g) addresses (including email address); (h) telephone and fax numbers; (i) business hours; (j) practice code number; (k) exemption from registration in terms of section 54A of the Act; and (l) dispensing licence number (if any). (3) A practitioner shall not use prescription forms or envelopes on which the name or address of a pharmacist is printed. Naming of a practice 5. (1) A practitioner shall use his or her own name or the name of a registered practitioner or practitioners with whom he or she is in partnership or with whom he or she practises as a juristic person, as a name for his or her private practice. (2) A practitioner referred to in subrule (1) may retain the name of such private practice even if another practitioner, partner of such partnership or member of such juristic person is no longer part of such private practice: Provided that the express consent of the past practitioner or, in the case of a deceased 10  11 practitioner the consent of the executor of his or her estate or his or her next- of-kin, has been obtained. (3) A practitioner shall not use, in the name of his or her private practice, the expression “hospital”, “clinic” or “institute” or any other expression which may give the impression that such private practice forms part of, or is in association with, a hospital, clinic or institute. Itinerant practice 6. A practitioner may conduct a regularly recurring itinerant practice at a place where another practitioner is established if, in such itinerant practice, such practitioner renders the same level of service to patients, at the same fee as the service which he or she would render in the area in which he or she is conducting a resident practice. Fees and commission 7. (1) A practitioner shall not accept commission or any material consideration, (monetary or otherwise) from a person or from another practitioner or institution in return for the purchase, sale or supply of any goods, substances or materials used by him or her in the conduct of his or her professional practice. (2) A practitioner shall not pay commission or offer any material consideration, (monetary or otherwise) to any person for recommending patients. (3) A practitioner shall not offer or accept any payment, benefit or material consideration (monetary or otherwise) which is calculated to induce him or her to act or not to act in a particular way not scientifically, professionally or medically indicated or to under-service, over-service or over-charge patients. (4) A practitioner shall not share fees with any person or with another practitioner who has not taken a commensurate part in the services for which such fees are charged. (5) A practitioner shall not charge or receive fees for services not personally rendered, except for services rendered by another practitioner in his or her employment or with whom he or she is associated as a partner, shareholder or locum tenens. (6) A practitioner shall explain to the patients the benefits, costs and consequences associated with each service option offered. Partnership and juristic persons 8. (1) A practitioner may practise in partnership or association with or employ only a practitioner who is registered under the Act and who is not prohibited under any of the annexures to these rules or any ethical rulings from entering into such partnership or association or being so employed: Provided that, in the case of employment, the practitioner so employed either provides a supportive 11  12 health care service to complete or supplement the employing practitioner's healthcare or treatment intervention or is in the same professional category as the employing practitioner. (2) A practitioner shall practise in or as a juristic person who is exempted from registration in terms of section 54A of the Act only if such juristic person complies with the conditions of such exemption. (3) A practitioner shall practise in a partnership, association or as a juristic person only within the scope of the profession in respect of which he or she is registered under the Act. (4) A practitioner shall not practise in any other form of practice which has inherent requirements or conditions that violate or potentially may violate one or more of these rules or an annexure to these rules. Sharing of Rooms 8. A practitioner shall not share his or her rooms with a person or entity not registered in terms of the Act. Covering 9. (1) A practitioner shall employ as a professional assistant or locum tenens, or in any other contractual capacity and, in the case of locum tenens for a period not exceeding six months, only a person - (a) who is registered under the Act to practise in independent practice; (b) whose name currently appears on the register kept by the registrar in terms of section 18 of the Act; and (c) who is not suspended from practising his or her profession. (2) A practitioner shall help or support only a person registered under the Act, the Pharmacy Act, 1974 (Act No. 53 of 1974), the Nursing Act, 1978 (Act No. 50 of 1978), the Social Service Professions Act, 1978 (Act No. 110 of 1978), the Dental Technicians Act, 1979 (Act No. 19 of 1979), or the Allied Health Professions Act, 1982 (Act No. 63 of 1982), if the professional practice or conduct of such person is legal and within the scope of his or her profession. Supersession 10. A practitioner shall not supersede or take over a patient from another practitioner if he or she is aware that such patient is in active treatment of another practitioner, unless he or she – (a) takes reasonable steps to inform the other practitioner that he or she has taken over the patient at such patient’s request; and (b) establishes from the other practitioner what treatment such patient previously received, especially what medication, if any, was prescribed to such patient 12  13 and in such case the other practitioner shall be obliged to provide such required information. Impeding a patient 11. A practitioner shall not impede a patient, or in the case of a minor, the parent or guardian of such minor, from obtaining the opinion of another practitioner or from being treated by another practitioner. Professional reputation of colleagues 12. A practitioner shall not cast reflections on the probity, professional reputation or skill of another person registered under the Act or any other Health Act. Professional confidentiality 13. (1) A practitioner shall divulge verbally or in writing information regarding a patient which he or she ought to divulge only - (a) in terms of a statutory provision; (b) at the instruction of a court of law; or (c) where justified in the public interest. (2) Any information other than the information referred to in subrule (1) shall be divulged by a practitioner only – (a) with the express consent of the patient; (b) in the case of a minor under the age of 12 years, with the written consent of his or her parent or guardian; or (c) in the case of a deceased patient, with the written consent of his or her next-of-kin or the executor of such deceased patient’s estate. Retention of human organs 14. (1) A practitioner shall only for research, educational, training or prescribed purposes retain the organs of a deceased person during an autopsy. (2) The retention of organs referred to in subrule (1) shall be subject – (a) to the express written consent given by the patient concerned during his or her lifetime; (b) in the case of a minor under the age of 14 years, to the written consent of such minor’s parent or guardian; or 13  14 (c) in the case of a deceased patient who had not previously given such written consent, to the written consent of his or her next-of-kin or the executor of his or her estate. Signing of official documents 15. A student, intern or practitioner who, in the execution of his or her professional duties, signs official documents relating to patient care, such as prescriptions, certificates (excluding death certificates), patient records, hospital or other reports, shall do so by signing such document next to his or her initials and surname printed in block letters. Certificates and reports 16. (1) A practitioner shall grant a certificate of illness only if such certificate contains the following information – (a) the name, address and qualification of such practitioner; (b) the name of the patient; (c) the employment number of the patient (if applicable); (d) the date and time of the examination; (e) whether the certificate is being issued as a result of personal observations by such practitioner during an examination, or as a result of information which has been received from the patient and which is based on acceptable medical grounds; (f) a description of the illness, disorder or malady in layman’s terminology with the informed consent of the patient: Provided that if such patient is not prepared to give such consent, the practitioner shall merely specify that, in his or her opinion based on an examination of such patient, such patient is unfit to work; (g) whether the patient is totally indisposed for duty or whether such patient is able to perform less strenuous duties in the work situation; (h) the exact period of recommended sick leave; (i) the date of issue of the certificate of illness; and (j) the initial and surname in block letters and the registration number of the practitioner who issued the certificate. (2) A certificate of illness referred to in subrule (1) shall be signed by a practitioner next to his or her initials and surname printed in block letters. (3) If preprinted stationery is used, a practitioner shall delete words which are not applicable. 14  15 (4) A practitioner shall issue a brief factual report to a patient where such patient requires information concerning himself or herself. Issuing of prescriptions 17. (1) A practitioner authorized in terms of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965), to prescribe medicines shall issue typewritten, handwritten, computer-generated, pre-typed, pre-printed or standardized prescriptions for medicine scheduled in Schedules I, 2, 3 and 4 of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965), subject thereto that such prescriptions may be issued only under his or her personal and original signature. (2) A practitioner authorized in terms of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965), to prescribe medicines shall issue handwritten prescriptions for medicine scheduled in Schedules 5, 6, 7 and 8 of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965), under his or her personal and original signature. Professional appointments 18. (1) A practitioner shall accept a professional appointment or employment from employers approved by the council only in accordance with a written contract of appointment or employment which is drawn up on a basis which is in the interest of the public and the profession. (2) A written contract of appointment or employment referred to in subrule (1) shall be made available to the council at its request. Secret remedies 19. A practitioner shall in the conduct and scope of his or her practice, use only – (a) a form of treatment, apparatus or health technology which is not secret and which is not claimed to be secret; and (b) an apparatus or health technology which proves upon investigation to be capable of fulfilling the claims made in regard to it. Defeating or obstructing the council or board in the performance of its duties 20. A practitioner shall at all times cooperate and comply with any lawful instruction, directive or process of the council, a board, a committee of such board or an official of council and in particular, shall be required, where so directed to – (a) respond to correspondence and instructions from the council, such board, a committee of such board or an official of council within the stipulated time frames; and (b) attend consultation at the time and place stipulated by the council, such board, a committee of such board or an official of council. 15  16 Performance of professional acts 21. A practitioner shall perform, except in an emergency, only a professional act - (a) for which he or she is adequately educated, trained and sufficiently experienced; and (b) under proper conditions and in appropriate surroundings. Exploitation 22. A practitioner shall not permit himself or herself to be exploited in any manner. Medicine and medical devices 23. (1) A practitioner shall not participate in the manufacture for commercial purposes, or in the sale, advertising or promotion of any medicine or medical device or in any other activity that amounts to selling medicine or medical devices to the public or keeping an open shop or pharmacy, (2) A practitioner shall not engage in or advocate the preferential use or prescription of any medicine or medical device which, save for the valuable consideration he or she may derive from such preferential use or prescription, would not be clinically appropriate or the most cost-effective option. (3) The provisions of subrules (1) and (2) shall not prohibit a practitioner from - (a) owning shares in a listed company; (b) manufacturing or marketing medicines whilst employed by a pharmaceutical concern; (c) whilst employed by a pharmaceutical concern in any particular capacity, performing such duties as are normally in accordance with such employment; or (d) dispensing in terms of a licence issued in terms of the Medicines and Related Substances Act, 1965. (4) A practitioner referred to in subrule (3) shall display a conspicuous notice in his or her waiting room and also duly inform his or her patient about the fact that he or she - (a) owns shares or has a financial interest in a listed public company that manufactures or markets the medicine or medical device prescribed for that patient; or (b) is in the employ of or contractually engaged by the pharmaceutical or medical device company that manufactures such medicine or medical device, 16  17 and shall, subject to subrule (5), obtain the patient's informed written consent prior to prescribing such medicine or medical device for that patient."; and (5) A practitioner may prescribe or supply medicine or a medical device to a patient: Provided that such practitioner has ascertained the diagnosis of the patient concerned through a personal examination of the patient or by virtue of a report by another practitioner under whose treatment the patient is or has been and such medicine or medical device is clinically indicated, taking into account the diagnosis and the individual prognosis of the patient, and affords the best possible care at a cost-effective rate compared to other available medicines or medical devices and the patient is informed of such other available medicines or medical devices, (6) In the case of a patient with a chronic disease the provision of subrule (5) shall not apply. Financial interests in hospitals 23A. A practitioner may have a direct or indirect financial interest or shares in a hospital or any other health care institution: Provided that - (a) such interests or shares are purchased at market-related prices in arm's length transactions; (b) the purchase transaction or ownership of such interest or shares does not impose conditions or terms upon the practitioner that will detract from the good, ethical and safe practice of his or her profession; (c) the returns on investment or payment of dividends is not based on patient admissions or meeting particular targets in terms of servicing patients; (d) such practitioner does not over-service patients and to this end establishes appropriate peer review and clinical governance procedures for the treatment and servicing of his or her patients at such hospital or health care institution; (e) such practitioner does not participate in the advertising or promotion of the hospital or health care institution, or in any other activity that amounts to such advertising or promotion; (f) such practitioner does not engage in or advocate the preferential use of such hospital or health care institution; (g) the purchase agreement is approved by the council based on the criteria listed in paragraphs (a) to (f) above; and 17  18 (h) such practitioner annually submit a report to the council indicating the number of patients referred by him or her or his or her associates or partners to such hospital or health care institution and the number of patients referred to other hospitals in which he or she or his or her associates or partners hold no shares. Referral of patients to hospitals 24. (1) A practitioner who has a direct or indirect financial interest or shares in a private clinic or hospital shall refer a patient to such clinic or hospital only if a conspicuous notice is displayed in his or her waiting room indicating that he or she has a financial interest or shares in that clinic or hospital and the patient is duly informed about the fact that the practitioner has an interest or shares in the clinic or hospital to which the patient is referred and the patient's informed written consent is obtained prior to such referral. (2) Deleted (3) Deleted (4) Deleted (5) Deleted (6) A practitioner may admit a patient to such private clinic or hospital: Provided that such practitioner - (a) has ascertained the diagnosis of the patient concerned through a personal examination of such patient or by virtue of a report by another practitioner under whose treatment such patient is or has been; (a) has informed such patient that such admission in such private clinic or hospital was necessary for his or her treatment; and (b) has obtained such patient’s consent for admission to such private clinic or hospital. Reporting of impairment or of unprofessional, illegal or unethical conduct 25. (1) A student, intern or practitioner shall - (a) report impairment in another student, intern or practitioner to the board if he or she is convinced that such student, intern or practitioner is impaired; (b) report his or her own impairment or suspected impairment to the board concerned if he or she is aware of his or her own impairment or has been publicly informed, or has been seriously advised by a colleague to act appropriately to obtain help in view of an alleged or established impairment, and 18  19 (c) report any unprofessional, illegal or unethical conduct on the part of another student, intern or practitioner. Research, development and use of chemical, biological and nuclear capabilities 26. (1) A practitioner who is or becomes involved in research, development or use of defensive chemical, biological or nuclear capabilities shall obtain prior written approval from the board concerned to conduct such research, development or use. (2) In applying for written approval referred to in subrule (1), such practitioner shall provide the following information to the board concerned: (a) Full particulars of the nature and scope of such research, development or use; (b) whether the clinical trials pertaining to such research have been passed by a professionally recognized research ethics committee; (c) that such research, development or use is permitted in terms of the provisions of the World Medical Association’s Declaration on Chemical and Biological Weapons; and (d) that such research, development or use is permitted in terms of the provisions of the applicable international treaties or conventions to which South Africa is a signatory. Multiple registration 27. A health practitioner who holds registration with more than one statutory council or professional board or in one or more categories within the same professional board shall at all times ensure that - (a) no conflict of interest arises from such multiple registration in the rendering of health services to patients; (b) patients are clearly informed at the start of the consultation of the profession in which the practitioner is acting; (c) informed consent regarding the profession referred to in paragraph (b) is obtained from the said patient; (d) patients are not consulted in more than one capacity or charged fees based on more than one such consultation; and 19  20 (e) no patients may be serviced by the same health practitioner in more than one capacity (f) the ethical rules applicable at a given moment to the profession in which the practitioner is acting, are strictly adhered to. Main responsibilities of health practitioners 27A. A practitioner shall at all times (a) act in the best interests of his or her patients; (b) respect patient confidentiality, privacy, choices and dignity; (c) maintain the highest standards of personal conduct and integrity; (d) 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; (e) keep his or her professional knowledge and skills up to date; (f) maintain proper and effective communication with his or her patients and other professionals; (g) except in an emergency, 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; and (h) keep accurate patient records. Repeal 28. The Rules Specifying the Acts or Omissions in respect of which Disciplinary Steps may be taken by a Professional Board and the Council, published under Government Notice No. R. 2278 of 3 December 1976 and Government Notice No. R. 1379 of 12 August 1994, as amended by Government Notice No. R. 1405 of 22 December 2000 are hereby repealed. 20  21 ANNEXURES ANNEXURE 1 PROFESSIONAL BOARD FOR DENTAL THERAPY AND ORAL HYGIENE RULES OF CONDUCT PERTAINING SPECIFICALLY TO THE PROFESSIONS OF DENTAL THERAPY, ORAL HYGIENE AND DENTAL ASSISTANTS A dental therapist, student in dental therapy, an oral hygienist, a student in oral hygiene and a dental assistant shall adhere to the following rules of conduct in addition to the rules of conduct referred to in rules 2 to 27. Failure by such dental therapist, student in dental therapy, oral hygienist and student in oral hygiene to comply with the rules of conduct listed herein shall constitute an act or omission in respect of which the board may take disciplinary steps in terms of Chapter IV of the Act. Performance of professional acts by dental therapist 1. A dental therapist – (a) shall confine himself or herself to clinical diagnosis and practice in the field of dental therapy in which he or she was educated and trained and in which he or she has gained experience, regard being had to both the extent and the limits of his or her professional expertise; (b) shall communicate and co-operate with dentists, dental specialists, dental therapists and other registered practitioners in the diagnosis and treatment of a patient; (c) shall not conduct a private practice unless he or she has met the requirements of the board and practised for at least one year under the control and supervision of a dentist or another dental therapist approved by the board; (d) shall refer the following cases to a dentist or dental specialist for treatment: (i) Pulpal exposure, excluding the emergency treatment thereof; (ii) impacted teeth; and 21  22 (iii) oral diseases and dental abnormalities, such as tumours, mucosal diseases, developmental defects and infections; (e) shall not remove the roots of teeth by any way other than the use of hand instruments or make any incision into the soft tissues during such removal; and (f) shall not manufacture or repair dentures or other dental appliances which involve the taking of impressions. Performance of professional acts by oral hygienist 2. An oral hygienist – (a) shall confine himself or herself to clinical practice in the field of oral hygiene in which he or she was educated and trained and in which he or she has gained experience, regard being had to both the extent and the limits of his or her professional expertise; (b) shall communicate and cooperate with dentists, dental therapists and other registered practitioners in the treatment of a patient; and (c) shall not conduct a private practice unless he or she has met the requirements of the board. Performance of professional acts by dental assistant 3. A dental assistant shall perform professional acts only under the supervision of a registered practitioner and shall limit such acts to acts directly related to his or her education and training in dental assistance. Performance of professional acts by student in dental therapy 4. A student in dental therapy shall perform professional acts only under the supervision of a registered practitioner and shall limit such acts to acts directly related to his or her education and training in dental therapy. Performance of professional acts by student in oral hygiene 22  23 5. A student in oral hygiene shall perform professional acts only under the supervision of a dentist, dental therapist, an oral hygienist or other registered practitioner and shall limit such acts to acts directly related to his or her education and training in oral hygiene. 23  24 ANNEXURE 2 PROFESSIONAL BOARD FOR DIETETICS RULES OF CONDUCT PERTAINING SPECIFICALLY TO THE PROFESSION OF DIETETICS A dietitian, food service manager, nutritionist, student in dietetics, student in food service management and student in nutrition shall adhere to the following rules of conduct in addition to the rules of conduct referred to in rules 2 to 27. Failure by such dietitian, food service manager, nutritionist, student in dietetics, student in food service management and student in nutrition to comply with the rules of conduct listed herein shall constitute an act or omission in respect of which the board may take disciplinary steps in terms of Chapter IV of the Act. Performance of professional acts by a dietitian 1. A dietitian – (a) shall confine himself or herself to the performance of professional acts in the field of dietetics in which he or she was educated and trained and in which he or she has gained experience; and (b) shall not fail to communicate and cooperate with other registered practitioners in the treatment of a patient. Performance of professional acts by assistant dietitian 2. An assistant dietitian - (a) shall perform professional acts in dietetics only under the supervision of a dietitian or nutritionist; (b) shall limit the acts referred to in paragraph (a) to acts directly related to his or her education and training in dietetics; and (c) shall not conduct a private practice. 24  25 Performance of professional acts by food service manager 3. A food service manager shall confine himself or herself to the performance of professional acts in the field of food service management in which he or she was educated and trained and in which he or she has gained experience. Performance of professional acts by nutritionist 4. A nutritionist – (a) shall perform professional acts only under the supervision of a registered practitioner and shall limit such acts to acts directly related to his or her education and training; and (b) shall not conduct a therapeutic private practice. Performance of professional acts by assistant nutritionist 5. An assistant nutritionist - (a) shall perform professional acts in nutrition only under the supervision of a nutritionist or dietitian; (b) shall limit the acts referred to in paragraph (a) to acts directly related to his or her education and training; and (c) shall not conduct a private practice. Performance of professional acts by student in dietetics 6. A student in dietetics shall perform professional acts only under the supervision of a registered practitioner and shall limit such acts to acts directly related to his or her education and training. Performance of professional acts by student in food service management 25  26 7. A student in food service management shall perform professional acts only under the supervision of a registered practitioner and shall limit such acts to acts directly related to his or her education and training. Performance of professional acts by student in nutrition 8. A student in nutrition shall perform professional acts only under the supervision of a registered practitioner and shall limit such acts to acts directly related to his or her education and training. 26  27 ANNEXURE 3 PROFESSIONAL BOARD FOR EMERGENCY CARE PRACTITIONERS RULES OF CONDUCT PERTAINING SPECIFICALLY TO THE PROFESSION OF EMERGENCY CARE A basic ambulance assistant, an emergency care assistant, ambulance emergency assistant, operational emergency orderly, a paramedic student basic ambulance assistant, student emergency care assistant, student ambulance emergency assistant or student paramedic shall adhere to the following rules of conduct in addition to the rules of conduct referred to in rules 2 to 27. Failure by such basic ambulance assistant, emergency care assistant, ambulance emergency assistant, operational emergency orderly and paramedic or student basic ambulance assistant, student emergency care assistant, student ambulance emergency assistant, student operational emergency orderly or student paramedic to comply with the additional rules of conduct listed herein shall constitute an act or omission in respect of which the board may take disciplinary steps in terms of Chapter IV of the Act. Performance of professional acts by basic ambulance assistant, emergency care assistant, ambulance emergency assistant, operational emergency orderly or paramedic 1. Notwithstanding the provisions of rule 21, a basic ambulance assistant, an emergency care assistant, ambulance emergency assistant, operational emergency orderly or a paramedic – (a) shall not perform any professional act or exercise any capability in respect of any incident, other than the acts set out in the relevant protocol or annexure to such protocol approved by the board; and (b) shall not hand over the responsibility for the treatment of a patient to any person who is less qualified or experienced than himself or herself, unless such basic ambulance assistant, emergency care assistant, ambulance emergency assistant, operational emergency care orderly or paramedic assumes full responsibility for the acts falling within his or her scope of practice. 27  28 Performance of professional acts by student basic ambulance assistant, student emergency care assistant, student ambulance emergency assistant or student paramedic 2. A student basic ambulance assistant shall perform professional acts only under the supervision of a registered emergency care assistant and, in the case of a student emergency care assistant, student ambulance emergency assistant, student operational emergency care orderly or student paramedic only under the supervision of a medical practitioner or a paramedic and shall limit such acts to acts directly related to his or her education and training. 28  29 ANNEXURE 4 PROFESSIONAL BOARD FOR ENVIRONMENTAL HEALTH PRACTITIONERS RULES OF CONDUCT PERTAINING SPECIFICALLY TO THE PROFESSION OF ENVIRONMENTAL HEALTH An environmental health practitioner, environmental health assistant, a food inspector and a student in environmental health shall adhere to the following rules of conduct in addition to the rules of conduct referred to in rules 2 to 27. Failure by such environmental health practitioner, environmental health assistant, food inspector and student in environmental health to comply with the rules of conduct listed herein shall constitute an act or omission in respect of which the board may take disciplinary steps in terms of Chapter IV of the Act. Performance of professional acts by environmental health practitioner 1. An environmental health practitioner – (a) shall confine himself or herself to practising in the field of environmental health in which he or she was educated and trained; and (b) shall not conduct a private practice without meeting the requirements of the board. Performance of professional acts by environmental health assistant 2. An environmental health assistant – (a) shall perform professional acts only under supervision of an environmental health practitioner; (b) shall confine himself or herself to practising in the field of environmental health in which he or she was educated and trained; and (c) shall not conduct a private practice. Performance of professional acts by food inspector 29  30 3. A food inspector – (a) shall perform professional acts only under the supervision of an environmental health practitioner; (b) shall confine himself or herself to practising in the field of environmental health in which he or she was educated and trained; and (c) shall not conduct a private practice. Performance of professional acts by student in environmental health 4. A student in environmental health shall perform professional acts only under the supervision of an environmental health practitioner. 30  31 ANNEXURE 5 PROFESSIONAL BOARD FOR MEDICAL TECHNOLOGY RULES OF CONDUCT PERTAINING SPECIFICALLY TO THE PROFESSION OF MEDICAL TECHNOLOGY A medical technologist, medical technician, an intern medical technologist and a student in biomedical technology shall adhere to the following rules of conduct in addition to the rules of conduct referred to in rules 2 to 27. Failure by such medical technologist, medical technician, intern medical technologist and student in biomedical technology to comply with the rules of conduct listed herein shall constitute an act or omission in respect of which the board may take disciplinary steps in terms of Chapter IV of the Act. Performance of professional acts by medical technologist 1. A medical technologist – (a) shall confine himself or herself to practising in the specific discipline of medical technology in which he or she was educated, trained and registered; (b) shall not conduct a private practice without obtaining - (i) postgraduate experience of at least two years; and (ii) prior written approval from the board; and (c) shall, if he or she does not comply with the provisions of paragraph (b), perform professional acts only under the direction of a medical practitioner or medical scientist who is registered in the relevant discipline: Provided that this prohibition shall apply only to acts excluded, as determined by the board. Performance of professional acts by medical technician 2. A medical technician – (a) shall confine himself or herself to practising in the specific discipline of medical technology in which he or she was educated, trained and registered; (b) shall perform professional acts only under the supervision of a medical practitioner or medical technologist who is registered in the relevant discipline; and 31  32 (c) shall not conduct a private practice. Performance of professional acts by intern medical technologist 3. An intern medical technologist – (a) shall perform professional acts only under the supervision of a practitioner who is registered in the relevant discipline; (b) shall limit the acts referred to in paragraph (a) to acts directly related to his or her education and training as part of the formal internship in his or her discipline of study; (c) shall not conduct a private practice; and (d) if he or she has completed his or her internship, shall not perform any professional acts until he or she has satisfied all the academic requirements for registration as a medical technologist and has been registered as such. Performance of professional acts by student in medical technology 4. A student in medical technology – (a) shall perform professional acts only under the supervision of a practitioner who is registered in the relevant discipline; and (b) shall limit the acts referred to in paragraph (a) to acts directly related to his or her education and training in his or her discipline of study. Performance of professional acts by laboratory assistant 5. A laboratory assistant – (a) shall confine himself or herself to performing acts in the specific discipline of medical technology in which he or she is educated, trained and registered; (b) shall perform professional acts only under the supervision of a medical practitioner or medical technologist who is registered in the relevant discipline; and (c)