PHC 216-All Slides edited.pdf

Medical Ethics Today The BMA's Handbook of Ethics and Law Third Edition British Medical Ethics Department Chapter 2 Consent, Choice and Refusal: Adults with Capacity Chapter 3 Treating Adults who Lack Capacity  Medical Ethics  ‘Medical Ethics’ is one subset of...

Medical Ethics Today The BMA's Handbook of Ethics and Law Third Edition British Medical Ethics Department Chapter 2 Consent, Choice and Refusal: Adults with Capacity Chapter 3 Treating Adults who Lack Capacity  Medical Ethics  ‘Medical Ethics’ is one subset of the broader disciplines of ‘healthcare ethics’ and ‘bioethics’. It overlaps with both but focuses on the duties of doctors.  Nowadays, ‘ethics’ can either mean conforming recognized standards of practice or describe the general study of morality.  Doctors have a duty to provide ‘benefit’ to the sick, respect confidentiality and demonstrate integrity. Such values, often labelled ‘Hippocratic’. Key Concepts in Medical Ethics Many of the most commonly used ethical terms are self-evident, others may require some interpretation  Self-determination or autonomy  Honesty or integrity  Confidentiality  Fairness and equity  Harm and benefit The Nature and Purpose of Consent Legal Ethical Consent is trigger that allows Patients’ views should be treatment. respected. Some interventions can be harmful (side effects, etc). Health Care is a partnership between doctor and patient. Some interventions could be considered assault or Adult patients with capacity battery. have the right to choose what happens to their bodies. The patient's consent is then the trigger that allows treatment or examination to take place. Seeking consent from patients, therefore, forms a crucial pan of the practice of almost every doctor. It is central to the partnership between doctor and patient. Patients should be listened to and their views respected in the course of discussion Consent is central to good medical practice. Consent should be perceived as a continuing process rather than a one-off decision. Consent is a legal requirement. Seeking consent is also a moral requirement and the British Medical Association (BMA) believes that respect for others and their rights lies at the heart of this issue. Society values individuals and their dignity. Many medical and surgical interventions could be harmful but are acceptable because the expected benefits outweigh the harms. Patients agree to the invasive procedures of medicine, which, under any other circumstances, could lead to criminal charges. Doctors must be aware that if they fail to seek consent from patients who have the capacity they could be vulnerable to criminal prosecution for battery or assault, or a challenge in civil law for negligence or breach of the patient's human rights. Adult patients with capacity have both an ethical and a legal right to self-determination and to respect for their autonomy.  General principles patient gives consent when he has capacity, is adequately informed and voluntarily agrees to treatment. Before examining or treating adult patients with capacity, doctors must obtain patient consent, except in emergencies for example where compulsory treatment is authorized by mental health legislation. Adults are always presumed to have capacity unless demonstrated otherwise. Unexpected or apparently irrational decisions do not mean a patient lacks capacity, but may indicate a need for further information or explanation. For consent to be valid the patient must: o have capacity o be offered sufficient information to make an informed decision o be acting voluntarily and free from undue pressure o be aware that he or she can refuse. Patients may have capacity to make some healthcare decisions but not others. Their capacity may also fluctuate over time. Patients may give explicit or express consent orally, in writing or by o there means They may also imply consent non-verbally. adult patients with capacity are entitled to refuse treatment, even where treatment would clearly benefit their health. The only exception to this rule is where the treatment is for a mental disorder and the patient is detained under mental health legislation.  Capacity to give valid consent ln order to give valid consent, the patient must have capacity; to have capacity to make decisions about medical treatment, patients should be able to: - understand (with the use of communication aids, if appropriate) in simple language what the medical treatment is, its nature and purpose, and why it is being proposed for them - understand its principal benefits, risks and alternatives - understand in broad terms what be the consequences of not receiving the proposed treatment - Retain the information for long enough to make an effective decision - Weigh the information, balancing the risks and benefits, to arrive at a choice - communicate their decision. The Mental Capacity Act 2005 in England and Wales sets out a statutory framework for making decisions for people who lack the capacity to make such decisions themselves. The process of seeking consent informed patients indicate their consent through actions, such as opening their mouth for examination. Consent that is indicated in this way is often termed 'implied' consent and applies only to the immediate procedure, and not necessarily to subsequent tests or treatment that flow from it. Consent that is given orally, in writing or via there other means of communication available to the patient, is known as 'explicit', or 'express‘ consent. - A patient's capacity (competence) should be assessed on an individual basis and should not be assumed on grounds of disability, age, appearance or the fact that the patient's decisions appear to others to be irrational or unjustified. - Capacity is decision specific and patients' abilities can fluctuate over time. - Patients should not be regarded as incapable of making or communicating decision unless all practical steps have been taken to maximize their ability to do so. - Patients with capacity can make advance decisions or appoint a welfare attorney to make healthcare decisions on their behalf in the event that they lose capacity.  Informed Consent (Type of information to be given) To be informed, the patient must be told in plain language: Purpose of a proposed investigation or treatment and what it will involve Diagnosis and prognosis Uncertainties about the diagnosis or prognosis Conflicts of interest that the doctor may have Likelihood of success for each option Potential benefits, risks and burdens Purpose of a proposed investigation or treatment and what it will involve Options for further investigations Other options for treating or managing the condition - Any bills they will have to pay - Their right to seek a second opinion. The legal duty to inform patients, as part of the doctor's duty to exercise reasonable care and skill, was established by the House of Lords in 1985.20 The doctor can delegate the responsibility to someone else, provided make sure that the person who delegates to: - is suitably trained and qualified - has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved - understands, and agrees to act in accordance with, the guidance in this booklet.  The GMC draws the following central conclusions from the ruling in the Chester case: - Patients should be told of any possible significant adverse outcomes of a proposed treatment. - In this case, a small but well-established risk of a serious adverse outcome was considered by the House o f Lords to be 'significant'. Withholding information The GMC advises that, in the rare event that a doctor decides to withhold information on the basis that providing it would have a deleterious effect on the patient's health, this view, and the reasons for it, should be recorded in the patient's notes and the doctor must be prepared to explain and justify that decision. Doctors withholding information for this reason are advised to keep the decision under regular review and to consider whether information could be given to the patient later causing them serious the mere fact that the patient might become upset by hearing the information, or might refuse treatment, is not sufficient to act as a justification‘. The GMC recommends that written consent should be obtained in cases where: - the investigation or treatment or procedure is complex or involves significant risks - there may be significant consequences for the patient's employment, or social or personal life - providing clinical care is no the primary purpose of the investigation or treatment - the treatment is part of a research programmed or is an innovative treatment designed specifically for the patient's benefit.  continued participation in Consent should be perceived as a treatment is an indication that they have not continuing process rather than a one-off changed their minds decision. duration Scope of Consent  Consent generally remains valid unless the patient indicates otherwise, although consent should be reaffirmed if there has been a significant lapse of time between the initial agreement and the actual procedure, or if the situation has changed since consent was given  If treatment involves a number of invasive or complex procedures over a period of time, it may be necessary to obtain explicit, or written, consent for each intervention.  Consent covers only those procedures to which the patient has actually agreed; where there are foreseeable complications that could arise, these should be discussed as part of the consent process. Consent is valid only insofar as it applies to the treatment Exceeding consent  Refusal of Treatment Adult patients with capacity have the right to refuse any medical treatment ❖ Exception: compulsory treatment authorized under mental health legislation Can refuse even if refusal results in ❖ Permanent physical injury or death ❖ Permanent physical injury or death of a viable fetus Must have all information to make an informed consent before making an informed refusal Should be offered care and symptom management appropriate to their needs Refusal should be documented in health records ❖ Patients may be asked to sign a form or declaration confirming their refusal in cases of [advance decisions refusing treatment], there is no question of the patient committed suicide, nor therefore of the doctor having aided or abetted him in doing so. It is simply that the patient has, as he is entitled to do declined to consent to treatment which might or would have the effect of prolonging his life, and the doctor has, in accordance with his duty, complied with his patient's wishes Organ donation from live donors There are two different types of living donor. in the first, an organ becomes available as a result of a procedure carried out primarily for the benefit of the donor. The most common scenario is what is known as a 'domino' transplant, in which a patient needing new lungs has his or her heart and lungs removed and replaced by organs from a cadaveric donor. The patient's own heart is then available for transplantation to another person. Recipients are asked to consent both to the clinical procedure itself and to the donation of other organs removed in the course of the treatment. The second type of live donation - an altruistic donation from healthy donors - raises more issues around consent. like kidney transplants ,it is also possible for living donors to donate segments of liver, lung or bowel, although the numbers doing so are small. Expanding the pool of donors The Human Tissue and the Human Tissue (Scotland) Act 2006 also expanded the pool of potential living donors by specifically permitting two new types of living donation - 'paired and pooled donation' and 'altruistic non-directed donation'. Limits to an Individual's Choices Procedures carried out for the benefit of others Organ donation from live donors Safeguards for living organ donation Ethical issues ❖ Requests for the amputation of healthy limbs ❖ Procedures that will cause death ❖ When physically healthy patients seek procedures that are disabling, legal advice should be sought before proceeding  General Principles The following general principles should be taken into account when considering the medical treatment of a patient lacking capacity to consent. Patient are entitled to the following.  Liberty  Decision-making freedom  Dignity  Having their views taken into account  Bodily integrity  Confidentiality  Having their health needs met  Being free from unfair discrimination  Having the views of people close to them taken into account the doctor proposing to treat the patient that the patient does lack the capacity to decide and that the treatment is in the patient's best interests or for their benefit. The steps are intended as a guide: - consider whether there are alternative ways of treating the patient, particularly equally effective measures that may be less invasive, keep future options open and promote independence - consider whether the proposals impact on the patient's human rights - discuss the treatment within the healthcare team - discuss the treatment with the patient insofar as this is possible - consult relatives, carers and any proxy decision makers - consider any anticipatory statement of the patient's views (valid and applicable advance decisions refusing treatment must be respected) - consult other appropriate professionals involved with the patient's care in the hospital or community - consider the need to obtain a second opinion from a doctor skilled in assessment of capacity or in the proposed treatment - ensure that a record is made of the discussions. Capacity Capacity refers to the everyday ability that individuals possess to make decisions or to take actions that influence their life. A person lacks capacity if he or she cannot make a decision because of impairment of, or a disturbance in the functioning of, the mind or brain. ❖ An assessment of capacity is task-specific Capacity and assessment of capacity can vary by region ❖ Be sure to verify the regulations for the area in which you practice Consent and the alternatives Except for the rare circumstances in which the law allows compulsory treatment for mental disorder, some forensic purposes and some investigations under public health legislation, consent from an adult is required before treatment or examination can take place. where adults lack the capacity to make a necessary decision, it follows that the decision must be made by someone else on their behalf. Proxy decision making and the role of those close to the patient when patients lack the capacity to make decisions, others clearly need to make decisions on their behalf. Families and those close to the adult often feel that they are the natural decision makers, but the law is clear that they are only entitled to consent where they have been appointed as the patient's proxy decision maker.  Assessing Capacity Is the impairment sufficient to affect his or her ability to make the specific decision Person regarded as unable to make a decision if at the time the decision needs to be made, he or she is unable: ❖ To understand the information relevant to the decision ❖ To retain the information relevant to the decision ❖ To use or weigh the information to communicate the decision If an individual fails any part of this test, then they do not have the capacity to make the relevant decision and the entire test is failed. When does a person lack capacity? Is there an impairment of, or disturbance in the functioning of, the mind or brain? If so: is the impairment or disturbance sufficient that the person is unable to make that particular decision? Fluctuating capacity for example, where an individual has a bipolar disorder and may be in a temporary manic phase. 'Next of kin' do not automatically have decision-making rights on behalf of incapacitated adults although they may need to be consulted as part of an evaluation of what is in the best interests of the adult. Consent for Incapacitated Adults Families and those close to the adult are allowed to consent only if they have been appointed as the patient's proxy decision maker Without appointed legal proxies responsibility will usually fall to the doctor in overall charge of the patient's care ❖ Decides on the basis of ✓ The area’s legal requirements ✓ An assessment of the patient's best interests Focus on these 'vulnerable adults' has been growing in recent years. These can include people with Mental disorders or disabling physical conditions, people with drug and alcohol problems, displaced persons such as asylum seekers, and individuals in abusive relationships. It can also include frail older people with some cognitive or physical impairment. In an emergency situation where consent cannot be obtained, doctors should provide treatment that they reasonably believe to be both medically necessary and in the patient's best interests, , unless there is a valid and applicable advance decision refusing the necessary treatment. When is court approval required? - proposals to withdraw or artificial nutrition and hydration from patients in a persistent vegetative state - cases involving an organ or bone marrow donation by a person lacking the capacity to consent - proposals for non-therapeutic sterilization - cases where there is doubt or dispute about whether a particular treatment be in a person's best interests - cases involving ethical dilemmas in untested areas.  Advance decisions refusing treatment  Anyone aged 18 years or over with the necessary mental capacity can make an advance decision to refuse specific medical treatment for a time in future when that treatment is proposed and he or she has lost the capacity to make the decision.  An advance refusal will only apply to life-sustaining treatment where it is in writing, is signed and witnessed, and contains a statement that is to apply even where life is at risk.  In an emergency or where there is doubt about the existence or validity of an advance refusal of treatment, doctors can provide treatment that is immediately necessary to stabilize or to prevent a deterioration in the patient until the existence, and the validity and applicability, of the advance decision can be established  Advance decisions refusing treatment Under the Act, an advance refusal of treatment is binding if:  The person making the decision was 18 or older when it was made, and had the necessary mental capacity.  It specifies, in lay terms if necessary, the specific treatment to be refused and the particular circumstances in which the refusal is to apply.  The person making the decision has not changed his or her mind at a time when he or she had the capacity to do so.  The person making the decision has not appointed, after the decision was made, an attorney to make the specified decision.  The person making the decision has not done anything clearly inconsistent with the decision remaining a fixed decision. Compulsory Treatment Law Allows for Mental disorder Some forensic purposes Some investigations under public health legislation Proxies The term 'proxy' is used to mean a guardian, a welfare attorney or a person authorized under an intervention order, with power in relation to any medical treatment referred to in section 47 of the Act. Proxies can include welfare attorneys, welfare guardians and persons authorized by an intervention order. where the practitioner is aware of the appointment, proxies should be asked to consent to the proposed treatment if it is reasonable and practicable for them to do so. Chapter 4 Children and Young People Who Gives Consent for Children? Views of children and young people must be heard ❖ Decision by a competent young person which is based on an appreciation of the facts demands respect. Parents ❖ Others with parental responsibility, such as grandparents, foster parents, legal guardians Doctors Competency of Young People Children and young people are competent to give consent to medical treatment if they are able to ❖ Understand the nature of the proposed treatment ❖ Understand the purpose of the proposed treatment ❖ Retain the information ❖ Weigh it in the balance to arrive at a decision A young person's competency can fluctuate because of ❖ Their medical condition ❖ Medication ❖ Time of day ❖ Their mood  Consent A willingness to make a choice Includes choosing someone An understanding of the nature and else makes the decision purpose of the proposed procedure The ability to understand that there is a choice Understanding that choices Consent The ability to weigh the information in have consequences the balance and arrive at a decision An understanding of the alternatives to the proposed procedure Understanding of the risks attached to the alternatives An understanding of the proposed procedure's risks and side effects Freedom from undue pressure Consent or Refusal Presume people are competent from 16 years old If a person has the intelligence to be able to understand fully what is proposed, they can be considered competent even if under 16 years of age Competent young people may give valid consent to medical treatment Young people should be encouraged to involve their parents, but are entitled to confidentiality Young people must be given the opportunity to have their views heard, even if their refusal of treatment is not determinative. Doctors should seek legal advice if a competent young person refuses essential medical treatment ❖ Never delay emergency treatment Courts Must Get Involved When Child refuses care, and competency of child is in doubt Doctors are concerned about the willingness of parents to provide essential care following invasive procedures If an agreement cannot be reached, the courts may become involved and make a decision about treatment The courts cannot require doctors to provide contrary to their professional treatment judgement  Doctors’ Responsibilities Never delay taking emergency action. Where concerns about deliberate harm to young people have been raised, doctors must keep clear, comprehensive, accurate, and contemporaneous notes. All doctors working with children, parents and other adults in contact with children must be familiar with relevant local child protection procedures. If a child is at risk of serious harm, the interests of the child override those of parents or caregivers. All doctors working directly with children should ensure that safeguarding and promoting their welfare is an integral part of all stages of the care they offer. When a doctor sees a child who may be at risk, he or she must ensure that systems are in place to ensure follow-up care.  Doctors’ Responsibilities All doctors working with children, parents and other adults in contact with children should be able to recognise and know how to act upon signs that a child may be at risk of abuse or neglect in any living environment. Document the circumstances of a child at risk with as much detail as possible. Any doctor seeing a child who raises concerns must ensure follow-on care; children must not be discharged from hospital without a full examination if there are concerns. When a child at risk is to be discharged from hospital, a documented plan for the future care of the child must be drawn up. Whenever possible, the involvement and support of those who have parental responsibility for, or regular care of, a child should be encouraged, as far as this is in keeping with promoting the best interests of the child or children concerned. They may have their own views about parental involvement.  Doctors’ Responsibilities When a child is admitted to hospital, a named consultant must be given overall responsibility for the child protection aspects of the case. Any child admitted to hospital about whom there are concerns about deliberate harm must receive a thorough examination within 24 hours unless it would compromise the child's care or well-being. Include children and young people in decisions that closely affect them. Listen to and respect the views and wishes of children according to their competence and the level of their understanding. In some cases translation services suitable for young people may be needed. A child at risk should not be discharged from hospital without being registered at an identified GP. All professionals must be clear about their own responsibilities, and which professional has overall responsibility for the child protection aspects of a child's care.  Doctors’ Responsibilities Any doctor caring for conjoined twins must consider: the likely clinical outcome for both with and without intervention the legal and moral rights of both the twins' best interests the views of the parents Chapter 5 Confidentiality  Key Terms The following definitions are the BMA interpretations of the key terms and phrases used throughout this chapter. Anonymised information Information from which individuals cannot reasonably be identified. Requires the removal of name, address, full postcode, identification numbers or any other detail or combination of details that might support identification. Consent Agreement to an action based on knowledge of what that action involves and its likely consequences. Disclosure The provision of access to information about a patient, regardless of the purpose.  Key Terms Express consent Consent that is expressed orally or in writing; also known as explicit consent. An articulation of patient agreement for the disclosure of information, freely given in circumstances where the available options and the consequences have been made clear. Express consent is generally preferable because it is unambiguous. Healthcare Team Comprises the people providing clinical services for a patient, and the administrative and other staff who support the provision of his or her care. Identifiable information Information from which a patient can be identified. Name, address and full postcode will identify a patient; combinations of information may also support identification, even if the name and address are not included.  Key Terms Implied consent In the context of sharing health information, consent that can be inferred if the patient has been informed that information is to be disclosed, the purpose and extent of the disclosure, and that they have a right to object, but have not objected. Patients are normally considered to have given implied consent for sharing information within the healthcare team or with others providing their care. Personal information Information about people that doctors learn in a professional capacity and from which individuals can be identified. Such information is subject to a duty of confidentiality.  Key Terms referred to as reversible anonymization or 'key coding‘ of data. Pseudonymised information. Information from which individuals cannot be identified by the recipient, but which enables information about different patients to be distinguished or to link information about the same patients over time. A 'key' might be retained by the service that coded the information so that it can be reconnected with the patient. Public interest disclosure Exceptional circumstances that justify overriding the right of an individual to confidentiality in order to serve a broader social interest. Decisions about the public interest must take account of both the potential harm that disclosure may cause and the interests of society in the continued provision of a confidential health service.  Confidentiality The General Medical Council guidance states that ‘[P]atients have a right to expect that information about them will be held in confidence by their doctors‘. Information must be readily available patients explaining how their data will be shared within the healthcare team, in order to provide clinical care, unless they object. Consent should usually be sought for the use or disclosure of identifiable personal health information outside the healthcare team. Information may be used more freely if it is effectively anonymised and therefore de-identified data should be used wherever possible for purposes not directly connected with supporting the care of the patient. Disclosures should be kept to the minimum necessary to achieve the purpose. Confidentiality is a fundamental requirement for the preservation of trust between patients and health professionals, and is subject to legal and ethical safeguards. Patients should be able to expect that information about their health which they give in confidence will be kept confidential unless there is a compelling reason why it should not.  Confidentiality Exceptionally, when identifiable data are needed and it is not possible to obtain consent, information be may disclosed, with strict safeguards, either with support under the Health Service (Control of Patient Information) Regulations 2002 in England and Wales, where approval has been obtained, where the balance of public interests supports disclosure. Doctors must always be prepared to justify their decisions about the use of personal health information. Information about patients must be properly protected to prevent malicious, thoughtless or inadvertent breaches of confidentiality. All people who come into contact with personal health information in their work should have training confidentiality and security issues.  Confidential Data Include All information collected in the context of healthcare are confidential ❖ Doctors must take appropriate measures to ensure that the data are kept confidential Any clinical information about an individual's diagnosis or treatment A picture, X-ray, photograph, video, audiotape or other images of the patient Who the patient's doctor is ❖ Which clinics the patient attends and when Any social information that a doctor may learn about ❖ Example: information about family life Anything else that may be used to identify a patient directly or indirectly all identifiable patient information that doctors have learned in a professional capacity is subject to the duty of confidentiality. Once information is anonymized effectively, it is no longer confidential and may be used more freely  Disclosures for Purposes Other Than Health Care Disclosure to courts, tribunals, regulatory bodies, solicitors (lawyers), police, social services and partner organisations Disclosures in the public interest ❖ Health Health ❖ Public safety When a person has a medical condition that puts others at risk, for example a risk of ❖ Serious crime and national security infection or because of dangerous behaviour ❖ Gunshot and knife wounds ❖ Safety in the workplace ❖ Abuse and domestic violence ❖ Informing sexual contacts of patients with a serious communicable disease Spiritual care Disclosure to the media Responding to criticism in the press Employment, insurance, and other affairs  no yes Chapter 6: Health Records  Health Records Records must be  Clear  Accurate  Factual  Legible  Contemporaneous  Appropriately dated  Avoids possible allegations of tampering  Clearly marked with which information the patient does not want revealed to third parties  Health Records Records should include  Presenting symptoms  Reasons for seeking healthcare  Relevant clinical findings  Diagnosis  Options for care and treatment discussed with the patient  Risks and benefits of care and treatment options, as explained to the patient  Decisions about and care treatment  Evidence of the patient's agreement  Action taken  Outcomes  Subsequent additions or amendments to information and the reasons for the changes  Health Records Records may include  Patients' expectations  Patients’ wishes  Advanced decisions to refuse treatment  Living Wills Records should not include  Health professionals' personal views about a patient's behaviour  Exception: include if they have bearing on healthcare  Patients’ Wishes Patient’s request for information not to go to their GP must be respected.  Patients have a right to have inaccurate records amended.  Patients sometimes request the removal of information they feel is not relevant to their health; the information can be deleted provided.  Both parties agree.  It is clear the record has not been inappropriately changed.  Patients sometimes request the removal of information that is relevant; doctors should.  Explain why the information should be included.  Reassure the patient that, except where disclosure is in the public interest or a legal requirement, nobody outside of the care team can access the record without the patient's consent.  Photographs and Videos Six categories of recordings for which consent to make the recordings is implicit and does not need to be obtained separately  Images of internal organs or structures  Images of pathology slides  Laparoscopic and endoscopic images  Recordings or organ functions  Ultrasound images  X-rays  Photographs and Videos  Give patients information about purpose of the recording.  Make recordings only where there is appropriate consent or other valid authority for doing so.  Ensure that patients are under no pressure to give their consent for the recording to be made.  Where practicable, stop the recording if the patient requests or if it is having an adverse effect on the consultation or treatment.  Anonymise or code the recordings before using or disclosing them for a secondary purpose.  Photographs and Videos  Anonymise or code the recordings before using or disclosing them for a secondary purpose.  Disclose or use recordings from which patients may be identifiable only with consent or other valid authority for doing so.  Make appropriate secure arrangements for storing recordings.  Be familiar with, and follow, the law and local guidance and procedures that apply where they work.  Patients’ Access to Their Own Records  Patients and their representatives are entitled to have access to their records and to have copies of them.  Parents with parental responsibility may have access to their child's records if child's best interests and when the child is competent, if he or she gives consent.  People appointed to manage the affairs of mentally incapacitated patients may have access to information necessary to fulfil their function. Sharing content of record whit patients and proxies help to: 1\ strength the doctor patient relationship. 2\ empower patient. 3\ improve accuracy  Patients’ Access to Their Own Records  Patients may authorise a third party, such as a lawyer, to access records on their behalf.  Information may be withheld if revealing it may cause serious physical or mental harm to the patient or, in certain circumstances, it relates to a third party who is not a health professional who has cared for the patient.  Doctors should facilitate information access by patients, and be willing to show them the contents of their records.  Protecting Electronic Health Records  Electronic records are subject to the duty of confidentiality as paper-based records.  Patients must be aware of how their data are shared and stored or have information readily available to them explaining the potential sharing of their health record.  Patients can limit how much information is shared.  Access to clinical information should be restricted to those providing clinical care to the patient.  Patients must be informed about any upload of their clinical data to a national database and have the opportunity to opt out. Electronic records are a computerized lifelong health care records for the individual that incorporate data from all sources and provide treatment. Electronic records keep an automatic audit trail which always maintain a complete record. Chapter 10 Caring for Patients at the End of Life. The term 'approaching the end of life' can also apply to extremely premature neonates whose prospects for survival are known to be very poor, and patients who are diagnosed as being in a persistent vegetative state (PVS) for whom a decision to withdraw treatment and care may lead to their death  Goals of End of Life Care Patients must be afforded dignity and privacy: The usual rules of confidentiality apply. Ø Patients should maintain control over as many aspects of their care as possible, including by advance planning if they wish. Ø Health professionals should be sensitive to patients' cultural and religious backgrounds. Ø Care provided to dying patients includes helping people close to them to come to terms with the situation.  Goals of End of Life Care Denial and collusion are separate but related phenomena. Denial is often temporary and describes a psychological defense mechanism, occurring when a patient or family is unable to accept the reality of what is happening. Collusion is a complex response occurring in those who are well aware of the facts but wish to protect the patient or one another by not acknowledging or discussing them. One aspect of collision occurs when relatives ask that information be withheld from the dying person Goals of End of Life Care Ø It is important to recognise when death is approaching and to help people prepare for it. Ø Compassion and sensitivity are particularly important but honest communication is also essential, while recognising that people's desire for information can vary at different stages of their illness. Ø Effective communication within the health team is vital so that mixed messages are avoided. Withholding Treatment, Nutrition, Hydration Ø Difficult decisions to withhold or withdraw life- prolonging treatment arise if treatment can no longer provide sustained benefit to the patient. Ø Reasons for not providing life-prolonging treatment must be clearly communicated to individuals who have capacity, or those close to people who lack capacity. Ø Efforts should be made to communicate with people who appear to lack capacity. Withholding Treatment, Nutrition, Hydration Ø Advance care planning may indicate whether treatment should be withheld or withdrawn. Ø Treatment cannot be provided if patients have made a valid refusal. Ø Decisions for incapacitated patients are made on the basis of their best interests or what would benefit them. Ø Oral nutrition and hydration should be maintained as long as the patient is willing and able to tolerate it; they cannot be forced on patients who resist or refuse.  Supporting an End of Life Patient Ø Dying patients should have opportunities to discuss matters such as where they want to die. Ø Giving patients the opportunity to plan aspects of their care can have a positive psychological effect. [Many organisations, defined by their country of origin] provide a nationally accepted framework for care in the last hours or days of life. Supporting an End of Life Patient Ø Patients who have made an advance decision to refuse some forms of active treatment can override their advance decision as long as they retain the mental capacity to do so. Ø When patients with capacity approach the stage where the aim shifts from curative to supportive care, decisions about the benefits or otherwise of further active treatment need to be discussed with them. Supporting an End of Life Patient  End of Life Decisions Once it is recognized that the patient’s conditions is incurable, palliative care offers relief from pain and distressing symptoms. It also provides support for the patient's family. Ø Any decision to withhold or withdraw life-prolonging treatment and why should be documented in the patient's notes. Ø Patients with capacity should be involved in decision making about future treatment. Ø Prior to withdrawing or withholding treatment, nutrition and hydration, a senior clinician should talk to the patient.  Code of ethics for Healthcare Practitioners in KSA The Saudi Commission for Health Specialties Department of Medical Education & Postgraduate Studies Chapter 6 HEALTHCARE PRACTITIONER’S DUTIES TOWARDS HIS/HER PROFESSION  Expected conducts of health professionals in KSA Ø The healthcare practitioner should recognize the social value of his/her profession and protect its nobility. Ø He/she raises him/herself above the doubts of committing any criminal acts Ø Hold any traits that are inappropriate for him/herself or his/her profession.  Expected conducts of health professionals in KSA Ø Protect the nobleness of the profession by being careful about how he/she looks and behaves. Ø Complete devotion to the profession, excelling in his/her work by mastering skills, observance of patients’ rights and maintaining [practicing] good manners. Ø Maintain the medical professional standards and work to improve them.  Expected conducts of health professionals in KSA Ø Should strive to provide scientific and practical contributions to the development of the profession, through; v Research v Studies v Writing articles and v Continuous education Ø Should not abuse professional status by achieving privileges, material or moral benefits, apart from those granted through the system and professional customs.  Expected conducts of health professionals in KSA Ø Refrain from any act that would breach his/her honesty, or integrity while dealing with the patient. Ø Should not lose the patient’s confidence through cheating, fraud, or having an inappropriate relationship with the patient or one of his/her family members. Ø Should not earn financial benefits outside any legal means, or whatever is against the standards of the medical profession.  Expected conducts of health professionals in KSA Ø Avoid whatever leads (or could lead) to insulting the profession or demeaning the status of a healthcare practitioner i.e v Maltreatment, or lack of commitment to appointments v Lying v Falsification v Arrogance v Pretending to know what he/she does not, or v Any other obnoxious behaviour  Expected conducts of health professionals in KSA Ø Follow the proper standards for personal behaviour, and public morality when performing all professional or other activities through; v Avoiding any dishonest or violent behaviour v Avoiding alcohol or illicit drugs v Keeping away from unworthy behaviour that demeans him/her as a Muslim and as a healthcare practitioner. Chapter 13 Prescribing and Administering Medication General Principles  The doctor who signs a prescription accepts clinical and legal responsibility for the decision.  Doctors should prescribe medication only when they have sufficient knowledge and experience to be satisfied that it is appropriate for the patient.  It is generally unwise for doctors who prescribe to form business connections with companies that produce, market or promote pharmaceutical products.  General Principles  Unless the patient objects, if the prescribing doctor is not the patient's GP, he or she should communicate with the GP in order to avoid any conflict with existing treatment.  Doctors must not ask for or accept any inducement, gift or hospitality from pharmaceutical companies or others that may affect, or be seen to affect, their judgement.  Doctors can prescribe unlicensed medicines and drugs to be used outside the terms of their license but take on greater responsibilities when doing so. This is particularly true when a course of treatment is innovative or there is little evidence to support its use.  Responsibility for Shared Prescribing  Legal responsibility for prescribing rests with the doctor who signs the prescription.  Hospital consultants have full responsibility for prescribing for inpatients and for specific treatments administered in hospital outpatient clinics.  Responsibility for prescribing should rest with the consultant if the drugs are included in a hospital-based clinical trial and when it is more appropriate for the consultant to monitor the medication because of the need for specialised investigations, or where there are supply problems with the drugs.  Where doctors do not feel they have sufficient knowledge or experience to be satisfied that the treatment is appropriate they should not prescribe.  Responsibility for Shared Prescribing  Where doctors do not feel they have sufficient knowledge or experience to be satisfied that the treatment is appropriate they should not prescribe.  Prescribing off-label where alternative licensed Often necessary such medication exists for economic reasons should in pediatrics only be done when recommended by authoritative guidance bodies.  When a GP takes responsibility for prescribing or dispensing drugs that are not normally dispensed in the community, place a liaison between the transferring hospital and the community pharmacist. Responsibility for Shared Prescribing  When a consultant considers that a patient's condition is stable, he or she may seek the agreement of the GP concerned to share the care.  The consultant may advise the GP which medicine to prescribe.  When a new or rarely prescribed medicine is being recommended, its dosage and administration must be specified and any potential adverse drug reactions to watch out for  When a treatment is not licensed for a particular indication, full justification for the use of the drug should be given by the consultant to the GP. Responsibility for Shared Prescribing  When an inpatient is discharged from hospital, sufficient drugs should be prescribed and dispensed by the hospital pharmacy for pharmacy for at least a 7-day period.  For outpatients, a minimum 14 days' supply should be prescribed and dispensed.  The GP to whose care the patient is transferred should receive notification in good time of the patient's diagnosis and drug therapy in order to maintain continuity.  If that information cannot be transferred to the GP within the timescale, drugs should be prescribed by the hospital for as long a period as is necessary. Responsibility for Shared Prescribing  When clinical, and therefore prescribing, responsibility for a patient is transferred from hospital to GP, the GP must feel fully confident to prescribe the necessary drugs.  Transfer involving drug therapies with which the GP would not normally be familiar should not take place without full agreement between the hospital consultant (or any transferring doctor) and the GP  Pressure from Patients  When faced with patients' requests for particular medication, doctors are not obliged to comply and should do so only if they are satisfied that the treatment requested is the most appropriate option for the particular patient.  Doctors have an ethical duty to use the most economic and efficacious treatment available when the patient is receiving treatment within the NHS.  Pressure from Patients  Doctors must resist pressure from patients to prescribe larger doses of medication than they consider clinically appropriate or for prescriptions to be issued repeatedly without anti-obesity drugs clinical review. and hair loss treatments,  Lifestyle drugs should be prescribed only when the doctor considers them clinically appropriate for the patient and where the actual, or perceived, benefits outweigh any risks.  Prescribing from a Distance If Then the GMC advises that doctors must Doctors  Establish the patient's current medical conditions  have sole responsibility for and history and concurrent or recent use of other a patient medications including non-prescription medicines  are working on behalf of  Carry out an adequate assessment of the another doctor who does patient's condition  are working where a  Identify the likely cause of the patient's condition doctor has prior  Ensure that there is sufficient justification to knowledge of a patient's prescribe the medicines or treatment proposed condition and has the and discuss other treatment options with the authority to access his or patient where appropriate her medical record  Ensure that the treatment and/or medicines are not contraindicated for the patient  Make a clear, accurate and legible record of all medicines Prescribing from a Distance  Prescribing by email or over the telephone could seriously compromise the standard of care provided to patients.  Doctors should think carefully about whether prescribing in this way is in the best interests of their patients.  There are serious safety risks of prescribing in cases where the patient is unknown to the doctor, there is no opportunity for examination and the arrangements for monitoring and follow up are limited. Prescribing from a Distance  Doctors are not obliged to comply with requests from patients to prescribe drugs for relatives in another country.  Those who wish to assist must be aware of the possibility of liability arising and should seek information from the patient's own doctor whenever possible in order to verify the information provided. They also need to give consideration to the practicalities of the arrangement. Chapter 14 Research and Innovative Treatment Chapter 15 Emergency Situations  Innovative Treatment vs. Research Innovative Treatment Research Aim is to achieve the best outcome Aims are for the individual patient when Ø An increased understanding of the biology standard treatment options have no, of diseases so that preventive as well as or only limited, success. diagnostic and therapeutic interventions can be developed Ø Acquire knowledge rather than to benefit participants. Can differ little from research when Follows a predetermined course of action set it involves an unknown or increased out in a protocol with which researchers have risk for the patient. to comply until a defined endpoint is reached. The degree of digression from usual The attempt to derive generalisable new practice is an important knowledge by addressing clearly defined consideration for patients and the questions using systematic and rigorous healthcare team. methods.  Innovative Treatment vs. Research - Experimental therapy involves a more speculative approach to the patient’s care and may be modified to take into account that individual’s response. - Innovative or experimental therapy is devised to try and help a particular patient or group of patients whereas the aim of research is to acquire knowledge rather than to benefit participants.  General principles key principles applicable to research and innovative treatment include the need for: informed consent and voluntary participation of research subjects who have capacity additional safeguards when research involves individuals who cannot give consent or refusal primary consideration to be given to the safety and welfare of the individual participants truth telling, effective communication and clarity of information, including about uncertainties safeguards in proportion to the known or expected risks of harm inclusiveness and fairness in recruiting participants adherence to the law and governance arrangements careful independent scrutiny of research and experimental treatment the confidentiality of participants to be maintained.  Research participants need to know: the purpose of the research and confirmation of its ethical approval why they have been asked to participate whether the individual (if a patient) stands to benefit and, if so, the difference between research and treatment the risks and arrangements for reporting adverse events the meaning of relevant research terms (such as placebos and randomisation) the nature of each procedure, and how often or for how long each may occur the rights and safeguards for participants, including compensation if harm occurs how their health data will be stored, used and published if samples of human material are donated, what they might be used for the names of the researcher and the doctor responsible for their care that they can withdraw from the project and that such a decision will not affect their healthcare.  Patients involved in innovative therapies need to know: why the therapy is proposed in their case the evidence to support its use and the areas of uncertainty about it what ethical review it has received the clinician’s experience with it the alternatives and how the new procedure differs from standard treatment the likely risks and benefits for themselves the measures for safety monitoring and support that will be provided if things go wrong.  Patients involved in innovative therapies need to know: The GMC has some general advice on the involvement of children and young people in research. This emphasises that for patients, the potential therapeutic benefits for them should outweigh the foreseeable risks and, for healthy volunteers, the research should carry only minimal risk and not be against their best interests Children can be entered into research on emergency care, without prior consent, where there is uncertainty about the best option and the trial has REC approval Consent Ø Discuss the risks Assessment of risk is an important part of any decision in healthcare and is notoriously difficult to explain to patients. Ø Information about risk must be given in a balanced way, without bias. Ø Consent may be influenced by various factors, including financial or other incentives Ø Normally, no one can be obliged to participate in either research or new therapies against their will.  Consent Audit is a means of assessing whether clinical performance conforms to good clinical practice. It is defined by the General Medical Council (GMC) as the ‘evaluation of clinical performance against standards or thorough comparative analysis, to inform the management of services’. Research Ethics Committees Ø Voluntary RECS were established in the NHS in the mid 1960s Ø System reorganised by the Department of Health in 1991 (England and Wales) and 1992 (Scotland). Ø Two kinds of RECS v Local Research Ethics Committees (LRECs) v Multi-centre Research Ethics Committees (MRECs)  Research Ethics Committees Research combined with trying to improve patient treatment was termed ‘therapeutic’ or ‘clinical’ research. - Research that simply sought knowledge without claiming to benefit its participants was termed ‘non-therapeutic Ø In KSA, there is a National Committee of Bio Ethics at the King Abdul Aziz City for Science and Technology Ø There are also Local Research Ethics Committees (LRECs) in various cities established by the National Committee.  Factors Considered by RECS include Ø If the chief investigator in the trial is competent and has adequate facilities Ø Possible hazards to trial participants and precautions taken to deal with them Ø Measures for providing information and seeking appropriate consent Ø Whether adequate compensation arrangements are in place in case of any harm arising from the trial Ø Methods of recruitment and any payments to participants Ø Payments to investigators Ø Storage and use of subject identifiable information Core Ethical Issues of Emergency Care Ø The duty to promote patient autonomy when possible and patient-centred services Ø The protection of patient confidentiality, privacy and dignity Ø The duty of care both for patients and, in some cases, families Ø A recognition of the abilities of others in the healthcare team to work across traditional boundaries Ø The obligation to act within one's sphere of competence  Core Ethical Issues of Emergency Care Triage is essential when there are multiple casualties and may occur both at the scene of a disaster and in the emergency department. Medical assessment and pain relief are vital for all the injured, but most attention has to be centred on those with the best chance of survival and recovery. Therefore, in disasters, the common sense rule of triage is to attend to people whose condition does not appear to be fatal but requires immediate attention, without which they will deteriorate seriously Where a patient who is unconscious has been the victim of a serious assault or rape, it may be in that person’s best interests to have forensic samples taken to identify the assailant  Core Ethical Issues of Emergency Care Ø Although there is no legal obligation to do so, the GMC states that doctors are expected to give whatever assistance they can in an emergency. Ø Doctors should not normally intervene beyond or at the limits of their competence, but in an emergency situation this may be the only alternative to permitting serious harm to occur. Ø In emergency settings, doctors may have to make difficult decisions about which patients to treat first. Ø Health professionals need to bear in mind their own need for support in order to continue providing care effectively.. ‫ﯾﺣﺗﺎ ج ﻣﮭﻧﯾو ا ﻟ ﺻ ﺣﺔ إ ﻟ ﻰ ﻣر ا ﻋﺎ ة ا ﺣﺗﯾﺎ ﺟﺎ ﺗﮭم ا ﻟ ﺧﺎ ﺻ ﺔ ﻣن ا ﻟ د ﻋم ﻣن أ ﺟل ﻣوا ﺻ ﻠ ﺔ ﺗﻘد ﯾم ا ﻟ ر ﻋﺎ ﯾﺔ ﺑﺷﻛل ﻓﻌﺎ ل‬ Ø  Core Ethical Issues of Emergency Care. ‫ﯾﺣﺗﺎ ج ﻣﮭﻧﯾو ا ﻟ ﺻ ﺣﺔ إ ﻟ ﻰ ﻣر ا ﻋﺎ ة ا ﺣﺗﯾﺎ ﺟﺎ ﺗﮭم ا ﻟ ﺧﺎ ﺻ ﺔ ﻣن ا ﻟ د ﻋم ﻣن أ ﺟل ﻣوا ﺻ ﻠ ﺔ ﺗﻘد ﯾم ا ﻟ ر ﻋﺎ ﯾﺔ ﺑﺷﻛل ﻓﻌﺎ ل‬ Ø ØNevertheless, the delivery of emergency care sometimes involves situations in which immediate and irreversible decisions have to be made without being able to discuss the implications or knowing the patient's preferences. In such cases, essential treatment should be provided without delay unless the patient is an adult “with capacity who is refusing the treatment proposed ØWhere patients are admitted after a suicide attempt or self-harm, questions of capacity will arise and specialist assessment will be required as a matter of urgency, both to determine capacity and to assess whether mental health legislation can and should be invoked  Summary – duties to families Where family members wish to be present during attempted Witnessed resuscitation a member of staff should be available to provide information and support. If having family members present during attempted resuscitation would hamper the patient’s treatment, or would be contrary to the patient’s known wishes, this should not be permitted. All doctors have general obligations to maximize useful knowledge and, in emergency departments, this may include asking families about participation in research, innovative treatment and education. Asking families about organ and tissue donation. When a patient has died and donation is likely to be an option, this should be raised with the family.. Chapter 18 Education and Training Chapter 19 Teamwork, Shared Care, Referral, and Delegation  General Principles Ø An understanding of medical ethics and law, and the ethical practice of medicine, is essential to being a good doctor. Ø A primary aim of the teaching of medical ethics is to develop a questioning, enquiring and analytical mind. Ø In addition to knowledge of medical ethics and law, teaching should aim to provide medical students with the skills and confidence necessary address difficult ethical dilemmas and to seek advice when necessary.  General Principles The aim of medical education is to provide doctors with the knowledge and skills needed to practice medicine within an ethical and legal framework.  General Principles Ø Education and training is an ongoing necessary, process throughout a doctor's career. Ø Tutors must ensure that teaching, both formal and informal, complies with good ethical practice; careful attention should be paid to consent and confidentiality when medical students are present during consultations. Ø Medical students who witness unethical practice have responsibility to make their concerns known. Ø Teaching institutions have a responsibility to establish accessible mechanisms for students to raise ethical concerns about aspects of their training without fear of repercussions. Consent in the Context of Teaching Ø Medical students develop their clinical skills through steadily increasing involvement with patients v This should be done only with the knowledge and consent of the patients concerned Ø For consent to be valid, patients need to be aware of the following: v Who will be present v Why they will be present v What, if any, involvement they will have with the procedure being undertaken Consent in the Context of Teaching Ø Patients must always be able to refuse v To consent to students being involved in their treatment v To the presence of students during treatment Ø This applies whether training is undertaken in a teaching hospital or in any other clinical setting. The Hidden Curriculum Ø Students learn not only from their formal teaching, but also from their experiences of observing and working with practising doctors. Ø Every doctor who comes into contact with medical students should recognise the importance of role models in developing appropriate behaviours towards patients, colleagues and others. Ø It is also away from patients that that medical students absorb a distinctive 'medical morality', that is sometimes at odds with the interests of their patients. The Hidden Curriculum Ø The example of how their tutors practice can be a far more powerful influence in the development of ethical, or unethical, practice than the edicts of formal ethics teaching. Ø Anecdotal support for the existence of tension has been reported to the BMA by its student members, who describe how they learn about ethics in the classrooms of medical schools but sometimes find that some of their senior colleagues appear to ignore ethical and legal precepts Multi-disciplinary Team Leads Ø Respect the skills and contributions of your colleagues Ø Make sure that colleagues understand the professional status and specialty of all team members, their roles and responsibilities in the team, and who is responsible for each aspect of patient care Ø Make sure that staff are clear about their individual and team objectives, their personal and collective responsibilities for patient and public safety, and for openly and honestly recording and discussing problems Multi-disciplinary Team Leads Ø Communicate effectively with colleagues within and outside the team; you should make sure that that arrangements are in place for relevant information to be passed on to the team promptly Ø Make sure that all team members have an opportunity to contribute to discussions and that they understand and the accept decisions taken Ø Encourage team members to co-operate and communicate effectively with each other Multi-disciplinary Team Leads Ø Make sure that each patient's care is properly co-ordinated and managed, and that patients are given information about whom to contact if they have questions Ø Set up and maintain systems to identify and manage risks in the team's area of responsibility Ø Monitor and regularly review the team's performance and take steps to correct deficiencies and improve quality Multi-disciplinary Team Leads Multi-disciplinary Team Leads Ø Deal openly and supportively with problems the conduct, performance or health of team members through effective and well-publicised procedures Ø Make sure that your team and the organisation have the opportunity to learn from mistakes. Personal Health Data Ø Patient welfare is the first concern. Ø Access to confidential medical information should be on a 'need to know' basis. Ø When care is shared, patients can be at risk if information necessary for their care is not passed on to others providing care. Ø Doctors increasingly need to liaise with colleagues in other disciplines, such as social work, so that all aspects of patient care can be properly integrated. This requires good coordination and the timely sharing of relevant information to ensure good patient care.  Personal Health Data Ø Patient choice in terms of combining private and NHS care, or seeking aspects of treatment in another jurisdiction, is likely to continue. v Make sure pre-treatment investigations and post-treatment aftercare are adequately coordinated, especially if/when they take place in diverse locations. Ø Tools such as integrated care pathways rely on good multi- disciplinary effort. Ø Doctors can refer patients with confidence to CAM therapists who are subject to a statutory regulatory body or if the person carrying out the therapy is a registered health professional Ø. Complementary and Alternative Medicine (CAM) Chapter 20 Public Health Dimensions of Medical Practice  What Do We Mean by Health?  Health is the absence of disease  An absence of any abnormal functioning  Health as well-being  The individual's subjective feeling of well-being.  Health as agency  A necessary condition for the achievement of goals  Health as a social description  Notions of health having an important social dimension cannot easily be reduced to biological functioning World Health Organization (WHO) inclusive definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.  Sick Individuals and sick populations - the prevention paradox epidemiologist Geoffrey Rose distinguished between two possible approaches to understanding the occurrence of illness: Rose sets the ‘population strategy’. - one focusing on sick individuals - one focusing on sick populations He identified two corresponding kinds of a etiological question: one seeking the causes of individual cases of an illness, the other seeking to identify the causes of its population incidence. Health promotion is a core public health function. Goal of public health practice Goals of Public Health Practice  Public health is primarily concerned with the health status of populations.  The majority of doctors have some public health obligations.  Public health practice involves the management of communicable disease, environmental health and risks for non-communicable disease and addresses the underlying conditions for good health, including its social determinants.  Public health practice seeks a recognition of the alignment of individual and public goods in health  Goals of Public Health Practice - Public health practice uses the best available evidence to address the fundamental causes of disease and the requirements for health and well-being, aiming to prevent adverse health outcomes. - promote and protect public health to the greatest extent that is compatible with respecting individual rights -ensure input from all sections of the community, including those who are unable to speak for themselves -aim to ensure that the basic resources and conditions necessary for a minimally acceptable level of health are available to all. seek to priorities interventions that favor underprivileged sections of society - seek the best available information for carrying out its role - provide communities the information that is required for policy decisions and obtain the agreement of those communities, where appropriate, for their implementation - act in a timely manner on available information the resources and the mandate given - incorporate a variety of approaches that respect the diverse beliefs and values in the community - implement policies in a manner that promotes the integrity of the physical and social environment - protect the confidentiality of information where appropriate. Goal of public health practice  Population screening public health specialists are currently exploring in relation to lifestyle-based health problems such as obesity has been described as 'libertarian', 'soft' or 'asymmetric' paternalism. Examples include replacing high-calorie snacks next to tills with fruit, thus reducing the likelihood of 'impulse' purchases of foods with high sugar or fat content.  Benefits and Harms of Population Screening Benefits Harms  The provision of curative  Raised levels of anxiety that have been treatment reported in all forms of screening  The ability to prioritise programmes, including  Treatment services  Cervical  Patient well-being and  Breast satisfaction  General health screening  The promotion of informed  Genetic screening decision making  Some people accept screening without properly considering the implications of receiving an unfavourable result  When receiving the unexpected result, their certainty about their health status shifts to uncertainty causing considerable anxiety  PublicConsiderations Ethical health emergencies-policy for Setting making Public in face Health of future threats Priorities  The importance of fair process  The need for proportionality  Resource allocation  Triage  Medical utility  Social utility  Scientific and medical functioning  Social functioning and critical infrastructure  Management of risk to health professionals The importance of fair process: Public acceptance of rationing decisions, and their cooperation in a health emergency, is more likely if citizens accept the fairness and legitimacy The need for proportionality: it is possible that decisions about access to scarce resources that are taken during the course of an emergency will result in some people dying who would, in less extreme circumstances, have been saved. Resource allocation: provision of health services in the NHS is linked to an assessment of clinical need. Those with the greatest need are given priority and treatment is provided until it becomes futile. Triage: Triage is a form of rationing or allocation of scarce resources under critical or emergency circumstances where decisions about who should receive treatment must be made immediately because more individuals have life threatening conditions than can be treated at once. Medical utility: During an emergency, the main focus of health professionals' attention is on delivering the greatest medical benefit to the greatest number o f people.  Continue.. Social utility: where the emergency results in widespread social and economic disruption, decisions about which groups will have first call on scarce resources will also contain elements of social utility.  limiting social disruption  ensuring maintenance of healthcare systems  ensuring integrity of social infrastructure  limiting economic losses. Scientific and medical functioning: An important aspect of any coordinated response to an emergency such as a pandemic is the need to protect key individuals who are involved in the production of countermeasures, which could include vaccines, antivirals and other essential health products. Social functioning and critical infrastructure: ln addition to those individuals broadly involved in tackling the health aspects of the emergency, many public and private actors are necessary to ensure both the successful delivery o f health interventions and the long-term public safety. These include personnel in the emergency services, security, essential products and services, the maintenance of critical infrastructure such as transportation, utilities, telecommunications and sanitation.  Tobacco control regulation Control measures include: comprehensive ban on advertising and promotion of tobacco products including the sponsorship of sporting events restrictions on broadcasting smoking on television and radio to protect young people age restrictions on the sale of tobacco to young people enforced labelling depicting written health warnings, the disclosure of ingredients, a ban on misleading descriptors like ‘light’ or ‘mild’ and images illustrating the negative health consequences of smoking duty imposed on purchasing and importing tobacco goods ban on smoking in indoor workplaces and indoor public places. Managing the Release of Information in Relationship to a Disease Outbreak  The media can have a positive role in public health promotion but it also has attendant risks  When doctors are commenting on public health stories in the media care must be taken to ensure that only the known facts are disclosed  Care must be taken to ensure that confidential information is not inappropriately disclosed to the media  Before releasing information to the media, advice should be taken from the local public health department and, if appropriate, press officers or communications managers Chapter 21 Reducing Risk, Clinical Error, and Poor Performance the General Medical Council (GMC) requires that doctors: Reducing Risk and Improving Quality  Make care of patients the first concern  Protect and promote the health of patients and the public  Provide a good standard of practice and care  Keep knowledge and skills up to date  Recognise and work within the limits of professional competence  Work with colleagues in ways that best serve patients' interests  Observe and keep up to date with the laws and statutory codes of practice  Reducing Risk and Improving Quality  Take part in regular and systematic medical and clinical audit and respond appropriately to the outcomes of any review, assessment or appraisal of performance  Be willing to take action if they have reason to think patient safety is compromised by inadequate premises, equipment, resources, policies or systems  Be aware of the performance of colleagues and be willing to address problems identified  The duty to protect patients Error and substandard care need to be addressed by managers implementing good governance procedures with which all staff are familiar, including the following: the setting and monitoring of clear quality standards open discussion of errors and situations in which mistakes were narrowly averted efforts to dismantle the blame culture to allow such discussion appropriate systems to rectify the consequences of any error measures to provide people who suffer harm with an explanation and compensation support for healthcare staff who acknowledge their own mistakes and limitations supportive systems for doctors and other health professionals who are themselves sick blame culture contributes to the occurrence of more medical errors. By focusing on individuals, investigations can fail to identify the systemic deficiencies that create situations in which error is likely to occur and also makes health professionals reluctant to admit to mistakes. *Junior doctors should insist on appropriate support.  Duties regarding risk -Clinical error affect the doctor patient relationship -Risk are inherent in clinical procedure -Risk can be symptom of system failure -Risk may be imposed by cost constraints  Recognising and dealing with poor performance Various indicators of poor clinical performance have been identified: errors or delays in diagnosis use of outmoded tests or treatments failure to act on the results of monitoring or testing technical errors in the performance of a procedure uncooperative attitude and behaviour inability to work as a member of a team poor communication with patients. When doctors write references for Appraisal and revalidation are among the colleagues, they must give an honest responses to the problem of under performance. and factual appraisal of performance. They require that doctors periodically Bland references should not be given in demonstrate that their clinical skills are up to order to encourage the mobility of date and they are fit to practise. under-performing colleagues.  Monitoring Quality and Performance  Doctors need to be aware of the main causes of error  Identifying poor performance can be complex and its causes multi-factorial  Successful risk management depends on developing a culture in which mistakes and errors can be openly reported and analysed.  Systems managers have a duty to take all reasonable steps to avoid situations of foreseeable risk or the repetition of errors.  There must also be appropriate support in place for health professionals who are still learning  When problems are identified, local procedures should be the first avenue to be tried, followed by a formal audit or investigation if problems cannot be resolved Addressing Physicians’ Health Issues  All doctors should be registered with a GP and act promptly on any early warning signs, especially where they have a suspicion that their health is affecting their performance  Informal or 'corridor' consultations with colleagues should be avoided  Doctors need to monitor their own health and also take action if colleagues' health gives cause for concern  Addressing Physicians’ Health Issues  Doctors are entitled to the same strict rules of confidentiality as other patients  Doctors should seek and follow advice from a suitably qualified practitioner if they may have been exposed serious communicable disease The alerts contain recommended actions that health organizations should implement within a defined timescale. CHAPTER 10 ETHICS OF FINANCIAL AFFAIRS IN THE HEALTHCARE PROFESSION IN KSA Relevance of ethics in financial affairs in the Healthcare Field  Privatization of healthcare , health insurance companies has brought the healthcare practitioners in contact with the for-profit healthcare sectors  This has led to competition and breach of healthcare professional ethics. Hence, there is a need to refrain from abuse, greed, avidity, extortion, or cheating in any way.  The noble aim of medicine should be a priority rather than earning money.  Ethics related to financial Affairs in the Healthcare Field  Ethics should be considered in the following:  Healthcare practitioner’s fees  Practicing in the private sector  Advertisements and publicity  Participation in the media  Gifts and benefits(Individuals’ gifts, Corporate gifts)  Relationships with pharmaceutical and medical device/equipment companies  Insurance  Healthcare Practitioner’s Fees  Only request standard fees. Must not increase set fees  Must not coerce patients to obtain additional money  Must not expose patients to unnecessary investigations or procedures to increase monetary gains  Must not take fees/commissions for referring patients for medications, medical tests or others  Act in the interest of patients and should not prescribe medication for financial benefit from the pharma companies  Disclose to the organization any financial working relationships with a pharmaceutical company  Practicing in the private sector  Abide by the laws of financial and managerial regulations of the health institution, and the government regulating such practices.  If system permits healthcare practitioner to work in the private sector, in addition to the public sector, the following should be observed:  work in the private sector must not affect that of the government  work in the public sector should not be used as means/ bridge to private work  Must not discriminate patients referred from private sector from other patients in terms of appointments  Practicing in the private sector  Patient’s best interest should be a priority rather than personal or financial interests.  When delegating someone (to treat a patient), delegate only those authorized.  Inform patients about the fees for healthcare before providing service, and provide comprehensive information about the service  Neither perform medical interventions which are not authorized, nor work in a healthcare facility without necessary resources to ensure patients’ safety.  Advertisements and Publicity  Health professionals should abide by the rules regulating advertising.  Advertising materials should contain correct and unambiguous information.  Should not make claims of superiority over others. It should also be free from indecent or offensive statements against public norms.  Refrain from adding skills, titles or qualifications that are false.  Avoid claiming the ability to perform procedures not based on scientific evidence and not efficacious.  Must not advertise facility/hospital services in media, medical guidelines, articles or others.  Participation in the media  Health professionals should not advertise themselves.  They should not praise their expertise and achievements, however, they can state professional status , scientific degree and specialization.  Provide professionally acceptable medical information and explain if the patient personal views contradict what is professionally acceptable.  Gifts and Benefits  Islam permits gifts for spreading passion and love among people, but not if it deviates from this purpose.  For example: health professionals receiving unjustified benefits through financial payments, in-kind benefits - obtained services, facilities, hospitality, training services, loans, compensation, etc.  Gifts and Benefits  Gifts that may deviate from the purpose of spreading love.  Individual’s gifts - bribery is one of the major sins that the Islamic Sharia has prohibited, but health professionals can accept inexpensive gifts like pens, scientific journals or books not linked to any advertisement for a specific product  Corporate gifts - Accept or give bribes to public or private sector linked to the number of prescriptions or medical devices given to patients, etc. However, health professionals can accept meals offered to all participants.  Relationships with pharmaceutical and medical equipment companies  Health professionals should not favour drugs or devices of a company that they have vested interest  Funding of scientific activities by medical companies in healthcare facilities should not be a reason to prefer their products.  Health professionals can accept funding for scientific activities for the sole purpose of serving medical knowledge.  When participating in scientific activities , providing consultations, health professionals can accept reward/expenses in return for participation, but this should not affect professional decisions or future relations with these companies.  Insurance Companies  Adhere to the guidelines regulating healthcare insurance.  Must not prescribe medications or devices of low quality based on the expectations of poor compensation by the insurance company.  Be honest and precise in assessing patients (e.g. in case of accident).  If a shareholder in the insurance company that his/her patient deals with, it should not affect his/her decisions.  Should not allocate insurance companies additional amounts of money beyond the reasonable limit and requirement.  Must not conceal information from the insurance companies with the intention of making the patient gets a lower insurance premium. Greco Arab and Islamic Herbal Medicine and Traditional System Ethics Safety Efficacy and Regulatory Issues Third Edition Bashar Saad and Omar Said Chapter 15 Medical Ethics in Arab and Islamic Medicine  Medical Ethics and Moral Issues and their Islamic Perspective  Islamic morality governs the entire cycle of life  Muslims do not believe in prolonging the life  Everyone was born with a predetermined life-span  Scientists are to assist but not replace God in the creation of death of human beings  Islam places great emphasis on the sanctity of life and the reality of death  Medical Ethics and Moral Issues and their Islamic Perspective  The Holy Quran says "If anyone killed a person, unless it is for murder or spreading mischief on earth, it would be as if he killed all of mankind. And if anyone saved a life it would be as if he saved the lives of all mankind."  Islam gives importance to saving lives (medical treatment or otherwise)  Islam makes it clear that dying is a part of the contract (with God) and that the final decision is up to God.  Preserving the health is equally or more important than the duration of living.  The physician and the family should realize their limitations and not attempt heroic actions for a terminally ill person or to prolong artificially the life (or misery). The heroic measures taken at the beginning of  Medical Ethics and Moral Issues and their Islamic Perspective  Islam is categorically opposed to mercy killing and regards it as an act of murder  The ethical questions of organ transplantation concern the rights of the living donor, the dead body, and the recipient  Islam considers abortion of a viable fetus an infanticide except when to save the life of the mother.  Even in this situation every attempt should be made to save both lives.  According to Hadith at 120 days the angel visits the fetus and blows the spirit into it  Artificial insemination using the husbands sperm, fertilized in the uterus of the wife, or the test tube is allowed  Medical Ethics and Moral Issues and their Islamic Perspective  Islam is categorically opposed to mercy killing and regards it as an act of murder  The ethical questions of organ transplantation concern the rights of the living donor, the dead body, and the recipient  Islam considers abortion of a viable fetus an infanticide except when to save the life of the mother.  Even in this situation every attempt should be made to save both lives.  According to Hadith at 120 days the angel visits the fetus and blows the spirit into it  Artificial insemination using the husbands sperm, fertilized in the uterus of the wife, or the test tube is allowed  The Development of Arab-Islamic Ethics  Ethics and medicine developed by early physicians  Adab al- Tabib or The Ethics of the Physician written by Ishaq ibn "Ali al-Ruhani" (ninth century)  Fardous A/ Hikma (The Paradise of Wisdom) written by Al-Tabari, the chief physician in 970. He wrote the Islamic code of ethics stressing the personal qualities of the physician, the physician's obligations toward his patients, community, and colleagues.  The Development of Arab-Islamic Ethics  The main points of Al-Tabari 's code of medical ethics are:  Personal Characters of the Physician: The physician ought to be modest, virtuous, merciful, and to not use liquor. He should: 1. Wear clean clothes, be dignified, and have well-groomed hair and beard 2. Not join the ungodly and scoffers of truth, nor sit at their table 3. Select his company from among persons of good reputation 4. Be careful of what he says and should not hesitate to ask forgiveness if he makes an error 5. Be forgiving and never seek revenge 6. Be friendly person and a peacemaker 7. Not make jokes or laugh at the improper time or place  Obligation Toward The Community  The physician should speak no evil of reputable men of the community or be critical of any one's religious beliefs  The Development of Arab-Islamic Ethics  Obligations Toward His Colleagues  The physician should speak well of his colleagues  He should not honor himself by shaming others  If another physician has been called to treat his patient, he should not criticize his colleague even if the diagnosis and the recommendations of the latter differ from his own  He has the obligation of explaining the consequences of each method of treatment, since it is his duty to counsel the patient as best he can  He must warn his patient that combining different types of therapy may be dangerous because the actions of different drugs may be incompatible and injurious  Obligations Toward His Assistants  If his subordinate makes a mistake, the physician should not rebuke him in front of others, but correct him privately and cordially