ETHICS FOR

MEDICAL AND
ALLIED HEALTH
SCIENCES

Compiled by:
Dr.Srijith
Associate Professor
Forensic Medicine
KFMSR

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 Principles of Medical Ethics
Principle 1: Respect for autonomy
The first moral principle reflects the ethical norm of “respecting the
decision-making capacities of autonomous individuals”. Autonomy
rests on at least two essential conditions, i.e, liberty (a person’s
independence from controlling influences) and agency (a person’s
physical and mental capacity to act).
In order to experience liberty, a patient needs to have full access to
all information related to his/her health and medical care. Thus, a
provider’s obligation to respect patient autonomy implies that the
provider must disclose all objective information related to close calls
and adverse events to the patient and/or (if the patient is
incapacitated) the patient’s family.
Furthermore, an ethical disclosure needs to compensate for the
discrepancy in medical knowledge between providers and patients.
In order to optimize such efforts, the provider needs to have the
knowledge to “translate” the information into a language that is
understood by the particular patient, the motivation to translate the
medical information, and the skills to conduct the disclosure
accordingly.
Patients have a right to know and must understand when errors
have occurred in their care, even if they have not been harmed by
them, in order to consent properly to necessary follow-up
treatments and future medical care. In the event of a medical error,
patients want to be informed about their care. Patients are unable to
understand their health situation and make competent judgments
about corrective treatments and their continuing medical care unless
they are informed about the events that led up to the incident, the
consequences of the error on their health, and the treatments and
side effects that are available to repair them.

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Principle 2: Nonmaleficence
Nonmaleficence refers to the ethical norm of avoiding causation of
harm. It rests on the dictum that the healthcare provider’s obligation
not to injure or harm patients and to refrain from actions that would
harm them, where harm is not always a predictable outcome but
based on the probabilities of side effects and complications.
Adverse events imply maleficent conduct because harm was not
prevented. However, subsequent nondisclosure or incompetent
disclosure conduct can be maleficent as well. Providers may decide
to exercise their largely discredited “therapeutic privilege” and
choose not to disclose an error “for the patient’s benefit”. Such
nondisclosure might cause serious additional harm to a patient if it
impedes or delays necessary medical intervention. A patient may
incur complications, for example, because s/he lacked information
that would have allowed him or her to receive appropriate treatment
on time.
The conduct of error disclosure can also be a harmful act if it is
performed incompetently. In response to an error, patients want to
hear an empathic disclosure and a sincere apology from their
provider.

Principle 3: Beneficence
The third principle of medical ethics states that “one ought to help
others”. They entail active contributions to patient welfare rather
than merely refraining from doing harm. Keywords that illustrate this
principle include mercy, kindness, charity, altruism, love, and
humanity. Thus, beneficence encompasses active Samaritan-like acts
that are conducted to benefit others, such as protecting and
defending the rights of others, preventing harm from occurring to
others, removing conditions that will cause harm to others, helping
persons with disabilities, and rescuing persons in danger.

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The principle of beneficence obliges providers to help patients who
have been harmed by an error (i.e., in the case of adverse events).
Such help needs to occur on multiple levels. For example, providers
may offer emotional support (i.e., caring and empathy), tangible
support (i.e., financial help, or assistance in completing tasks),
affectionate support (e.g., expression of positive emotions), and
supportive social interaction (e.g., to convey a sense of social
companionship and integration). These forms of support have been
associated with increased well-being and thus directly indicate
beneficent conduct.

Principle 4: Justice
Justice reflects the moral obligation of fairness, a norm that demands
equal distribution of benefits, risks, and costs among all involved
groups. Neglecting the justice principle in this particular context
compromises other ethical principles, particularly respect for patient
autonomy. Justice can be of three types: distributive justice, rights
based justice and legal justice.

Privileges and Rights of Patients

i. Access to health care facilities and emergency services regardless

of age, sex, religion, social or economic status.
ii. Choice: To choose his own doctor freely.
iii. Continuity: To receive continuous care for his illness from
doctor/institution.
iv. Comfort: To be treated in comfort during illness and follow-up.
v. Complaint: Right to complain and redressal of grievances.
vi. Confidentiality: All information about his illness should be kept
confidential.

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vii. Dignity: To be treated with care, compassion, respect without
any discrimination.
viii. Information: Should receive full information about his diagnosis,
investigations, treatment plans, alternative therapy, procedures,
diagnosis, complications and side-effects.
ix. Privacy: To be treated in privacy.
x. Refusal: Can refuse any specific or all measures.
xi. Records: Can have access to his records and demand summary or
other details.
Duties of a patient

i. He should furnish the doctor with complete information about the

facts and circumstances of his illness.
ii. He should strictly follow the instructions of the doctor as regards
diet, medicine and lifestyle.
iii. He should pay a reasonable fee to the doctor

Consent

Definition: Consent means voluntary agreement, compliance or

permission.
Types
Consent is of two types:
1. Implied: When the patient presents himself at the doctor's clinic
or outpatient, it is held to imply that he is agreeable to be examined.
This does not imply to procedures more complex than inspection,
palpation, percussion and auscultation. For other examinations, like
rectal and vaginal and withdrawal of blood for diagnostic purposes,
expressed permission should be obtained.

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2. Expressed: Specifically stated by the patient in distinct and explicit
language. It can be:
i. Oral/verbal consent is obtained for relatively minor examinations
or therapeutic procedures, preferably in presence of disinterested
party, like nurse.
ii. Written consent is to be obtained for:
• All major diagnostic procedures
• General anaesthesia
• Operations.

Consenting Ages for Treatment

• The age of consent for medical examination and treatment is
legally accepted as > 12 years.
• For a child < 12 years of age, or a patient of unsound mind, his/her
guardian or person in whose custody he/she is, can give consent.
• For any invasive and diagnostic procedures, general anesthesia and
surgical operations, age of consent is > 18 years.
• Medico-legal examination is a contract between the doctor and the
patient which has got some legal consequences. The age of consent
for such examination is > 18 years.

Rules of Consent
i. Consent should be free, voluntary, clear, intelligent, informed,
direct and personal. There should be no undue influence, fraud, and
misrepresentation of facts, compulsion, coercion or other
consequences.
ii. Informed consent is legally not required to be in writing, but
provides evidence that consent was in fact obtained, if necessity
arises.

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iii. Any procedure beyond routine physical examination, such as
operation, blood transfusion or collection of blood requires
expressed consent.

Therapeutic privilege: It enables the doctor to withhold from patient

the information (as to risk), if the disclosure would pose serious
psychological threat to the patient (e.g. malignancy or unavoidable
total results). However, he should disclose full information to a
competent relative of the patient.

Loco parentis: In an emergency involving children, when their

parents or guardians are not available, consent is taken from the
person-in-charge of the child, e.g. a school teacher can give consent
for treating a child who becomes sick during a picnic away from
home, or the consent of the principal of a residential school.

Medical negligence
Negligence refers to doing something which a person is not
supposed to do (act of commission) or not doing something which a
person is supposed to do (act of omission).

Medical negligence refers to lack of reasonable care or wilful

negligence by the health care worker resulting in bodily injury or
death of a patient.

Examples of medical negligence:

 Making a wrong diagnosis in the absence of skill and

knowledge.
 Administration of incorrect type/quantity of drugs, especially
by injection.

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  Failure to refer a patient to hospital or for specialist opinion.
 Toxic results of drug administration.
 Retention of instruments, tubes, towels, sponges and swabs in
operation sites.
 Missed foreign bodies in eyes and wounds, especially glass.
 Incompatible blood transfusion.

Types of medical negligence:

1) Civil negligence

2) Criminal negligence

3) Contributory negligence

4) Composite negligence

5) Corporate negligence

Civil negligence:

 Simple absence of care and skill

 Trial by Civil court
 Liable to pay damages
 Consent for act is a good defence

Criminal negligence:

 Gross negligence, inattention or lack of competence

 Trial by Criminal Court
 Can be imprisoned or fine or both
 Consent for act is not a defence

Contributory negligence:

 Combined negligence of health care worker and patient

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  Good defence for the doctor in civil cases, but not in criminal
cases
 Example: Doctor has prescribed medications but has failed to
explain the adverse effects to the patient(doctor
negligent),patient takes medications, experiences severe
adverse effects but fails to inform the doctor(patient negligent)

Composite negligence:

Injury is caused as a result of combined negligence of 2 or more

persons involved in patient care

Corporate negligence:

It is the failure of those in hospital administration/management to

follow the established standard of conduct.
It occurs when hospital:
• Provides defective equipment or drugs.
• Selects or retains incompetent employees including doctors.
• Fails in some other manner to meet the accepted standard of care
and such failure results in injury to a patient to whom the hospital
owes a duty.

Code of conduct
It contains standards of ethical behaviour for healthcare workers in
their professional relationships. At the time of registration, all the
health care workers are self-warned about certain unethical
practices (infamous conduct) and the disciplinary action by the
governing council (sometimes it is also called as warning notice). The
applicant should certify that he/she had read and agreed to abide by
the declaration and submit a declaration duly signed.

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Infamous conduct
Any conduct of the health care worker which might reasonably be
regarded as disgraceful or dishonourable as judged by professional
men of good repute and competence. It involves abuse of
professional position.
6 A ‘s of infamous conduct:
1) Association with unqualified persons
2) Adultery
3) Advertising
4) Addiction
5) Abortion (criminal)
6) Alcohol

Warning notice
The governing council can issue warning notices in relation to certain
unethical practices which are regarded as 'infamous conduct' in a
professional respect.

Professional secrecy/medical confidentiality

Definition: The health care worker is obliged to maintain the secrets

that he comes to know concerning the patient in the course of a
professional relationship except when he is required by the law to
divulgethe secrets or when the patient has consented for its
disclosure.
• It is a fundamental rule that whatever a health care worker sees or
hears in the life of his patient must be treated as totally confidential.
Disclosure would be failure of trust and confidence.
• The patient can sue the health care worker for damages or face
disciplinary action if the disclosure is voluntary and has resulted in
harm to the patient and is not in the interest of public.
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Following principles should be followed:
i. The health care worker should not answer any query by third
parties, even when enquired by close relatives; either with regard to
the nature of illness or any subsequent effect of such illness on the
patient, without his/her consent.
ii. If the patient is major (≥ 18 years), health care worker should not
disclose any facts about the illness without his consent to parents or
relatives even though they may be paying the hospital fees. In case
of minor or insane person, guardians or parents should be informed
of the nature of illness.
iii. A health care worker should not disclose the illness of his patient
without his consent, even when requested by a public or statutory
body, except in case of notifiable diseases. If the patient is minor or
insane, consent of the guardian should be taken.
iv. Even in case of husband and wife, the facts relating to the nature
of illness of one must not be disclosed to the other, without the
consent of the concerned person. Particular caution is required over
the disclosure of sexual matters, such as pregnancy, abortion or
venereal disease, as disclosure might cause conflict between them.
v. In divorce and nullity cases, no information should be given
without the consent of the concerned person.
vi. When a domestic servant is examined at the request of the
master, the health care worker should not disclose any facts about
the illness to the master without the consent of servant, even though
the master is paying the fees. Similarly, the health care worker of
firm or factory should not disclose without the patient's consent.
vii. The health care workers in government service are also bound by
code of professional secrecy, even when the patient is treated free.
viii. Any information regarding a dead person may be given only after
obtaining the consent from a relative.

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 Privileged Communication

Definition: It is a statement, made bonafide upon any subject matter

by a health care worker to the concerned authority, due to his duty
to protect the interests of the community or of the state.
• It is an exchange of information between two individuals in a
confidential relationship and an exception to professional secrecy.
• To be privileged, it must be made to the person who has a duty
towards it. If made to more than one person or to a person who has
not got a direct interest in it, the plea of privilege fails. Physician
should first persuade the patient to obtain his consent before
notifying the proper authority.
Examples
i. Civic benefit: If a patient poses a potential threat of grave harm’ to
the safety or health of patient and the public, the health care worker
must decide whether to inform the authority about the condition.
• For example, a engine or bus driver, pilot or ship navigator may be
suffering from epilepsy, hypertension, alcoholism, drug addiction,
poor visual acuity or colour blindness; or a teacher with tuberculosis
or a person with infectious diseases (e.g. enteric infection) working
as a cook. In all these cases, the proper course is for the health care
worker to explain the risks to the patient and to persuadehim to
allow the doctor to report the problem to his employers.
ii. Notifiable clauses: The health care worker has a statutory duty to
notify births, deaths, still births, infectious diseases, therapeutic
abortions, drug addictions, epidemic and food poisoning to public
health authorities.
iii. Suspected crime: If the health care worker learns of a crime, such
as assault, terrorist activity, traffic offence or homicidal poisoning by

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treating the victim or assailant, he is bound to report it to the
nearest Magistrate or police officer.
iv. Patient's own interest: The health care worker may disclose
patient's condition to his relatives so that he may be properly
treated, e.g. to warn parents/guardians of patient's melancholia or
suicidal tendencies.
v. Self-interest: In case of civil and criminal suits by the patient
against the health care worker, evidence about patient's condition
may be given.
vi. Negligence suits: When a health care worker is employed by
opposite party to examine a patient who has fileda suit for
negligence, the information thus acquired is not a professional secret
and the health care worker may testify to such information.
vii. Court of law: Thehealth care worker cannot claim professional
secrecy concerning the facts about illness of his patient in court of
law.

Euthanasia

Definition: Euthanasia (Greek, good death) denotes producing

painless death of a person suffering from hopelessly incurable and
painful disease.
Types
It can be of two types
i. Active euthanasia
ii. Passive euthanasia
Active euthanasia Passive euthanasia
Definition Positive merciful act, to Discontinuing or
end useless not life-sustaining
suffering or a meaningless measures to

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 existence prolong life
Principle Act of commission Act of omission
Procedure Administration of lethal Allowing death by
doses of not resuscitating a
opium/barbiturate/sodium terminally ill or
thiopental and then a incapacitated
muscle relaxant patient
Followed in Netherlands and Belgium India and some
states of USA

Reasons for Euthanasia

i. Unbearable pain.
ii. High cost of medical treatment.
iii. Right to commit suicide.
iv. People should not be forced to stay alive.

Legal status in India

Recently, Supreme Court has allowed passive euthanasia in patients
with permanent vegetative state but rejected active euthanasia. The
decision has to be taken to discontinue life support either by parents
or spouse or other close relatives or in the absence of any of them—
by a person or a body acting as a `next friend’.

Medical records

Definition: Refers to any document used to note the progress in the

diagnosis or treatment of a patient. They are an integral part of
patient care. Any responsible health care worker involved in the
treatment of the patient can make entries in the medical records.

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What constitutes medical records?
1) Clinical : Hospital case sheet , consent forms, referral letters,
discharge summary, records of hospital expenditure, birth, death
certificate, fitness, sickness certificates etc.
2) Investigation reports: X-ray, CT, MRI, Pathology, Microbiology,
Biochemistry reports, ECG, EEG etc.
3) Medicolegal: Medico legal Reports, Postmortem Reports, Death
certificate, audiovisual records, consent forms, registers.
4) Research: Clinical trial forms, clinical research data.

Importance of maintaining proper medical records:

 Provides a document to know the progress of a patient
 Establishes continuity in patient care
 In medicolegal cases, they help refresh knowledge about a
particular case and shall be considered documentary evidence
in the Court of Law.

Retention of medical records:

 Outpatient records-1 year
 Inpatient records-3 years
 Medicolegal case records-10 years
 In case of negligence suits-Indefinite

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 Consumer Protection Act (COPRA)

Purpose: This Act was brought into existence in 1986 for the
protection of interests of the consumer and for settlement of
consumer disputes, within a limited time frame and with fewer
expenses. This enables a patient to make a complaint to a redressal
forum in respect of a defective (negligent) service, if the service has
been paid for.
Redressal Agencies
It is established at three different levels:
i. District forum headed by the District Judge, situated in each
district of the State. The jurisdiction to entertain complaints is
limited to those where the value of services is < ` 20 lakhs.
ii. State Commission headed by a Judge of a High Court, situated in
the capital of each State. The jurisdiction to entertain complaints is
>20 lakhs and <1 crore.
iii. National Commission is the apex consumer body headed by a
Judge of the Supreme Court, situated in New Delhi and run by the
Central Government. The jurisdiction to entertain complaints is >1
crore
Limitation period: The District forum, State Commission and
National Commission will not admit a complaint, unless it is filed
within 2 years from the date of occurrence of the cause of action.
Appeals
1) Any appeal against the order of the District forum or the State
Commission under this Act must be filed within 30 days of the order
2) Any person who is aggrieved by an order of the National
Commission has a right to appeal to the Supreme Court (appellate
authority) within a period of 30 days from date of the order.

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 Functions of Medical Council of India /National
Medical Commission

Maintenance of Indian Medical Register

• It contains the names, addresses and qualifications of the medical
practitioners who are registered with any State Medical Council.
• Removal of the name from the register of the concerned State
Medical Council will lead to its removal from Indian Medical Register.
ii. Regulation of standard of undergraduate and postgraduate
medical education
• The Council maintains the standards of undergraduate medical
education. The Council prescribes courses and criteria which a
medical institute should fulfil for a particular course of study.
• The Council sends inspectors to see that the college is adequately
spaced, staffed and equipped as per MCI stipulations. The inspector
may also visit the institution during the examinations to assess the
standard of education.
• On the basis of the reports of the inspectors, the MCI recommends
the recognition or non recognition of the medical qualification to the
Central Government.
• Such an inspection is held for every medical qualification when it is
introduced and every 5 years thereafter.
• The Council has the authority to prescribe standards of
postgraduate medical education for the guidance of the universities.
iii. Permission for establishment of new medical college, new
course of study and increase in seats:
It requires the permission of the Central Government obtained after
the recommendations of the Council which may either approve or
disapprove the scheme.

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iv. Recognition of medical qualification granted by universities in
India: Any university which grants a medical qualification not
included in the 1st Schedule may apply to the Central Government, to
have such qualification recognized, and the Central Government,
after consulting the Council, may amend the 1st Schedule.
v. De-recognition of medical qualification: It can make
representation to the Central Government to withdraw recognition
of a medical qualification of any college, if on receipt of report from
inspectors it feels that the standards of resources, training/ teaching
are not satisfactory.
vi. Recognition of foreign medical qualifications under the scheme
of reciprocity: The Council may enter into negotiations with the
authority in any country outside India under a scheme of reciprocity
for the recognition of medical qualifications.

Transplantation of Human Organs and Tissues Act,

1994
This Act was enacted for the removal, storage and transplantation of
human organs for therapeutic purposes and for the prevention of
commercial dealings in human organs. Under this Act 'human organ'
means any part of a human body consisting of a structured
arrangement of tissues which, if wholly removed, cannot be
replicated by the body.
Organs and tissues that can be transplanted: Liver, kidney,
pancreas, pancreatic islet cells, small intestine, lung, heart, corneas,
skin graft, blood vessels, bone and hand.
Authority for removal of human organs
1. Any donor (> 18 years of age) may authorize the removal before
his death of any organ of his body for therapeutic purposes.

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2. If any donor had in writing (in presence of 2 or more witnesses)
authorized the removal of any organ after his death for therapeutic
purposes, the person lawfully in possession of dead body should
allow the doctor all reasonable facilities for removal.
3. When no such authority is there, person lawfully in possession of
dead body can authorize the removal of any organ of the deceased
person.
4. When human organ is to be removed, the medical practitioner
should satisfy himself, that life is extinct in such body or where it is a
case of brainstem death, the death has been certified by:
i. The doctor in-charge of hospital in which the brainstem death has
occurred.
ii. An independent doctor, being a specialist nominated by the above
in-charge from the panel of names approved by Appropriate
Authority.
iii. A neurologist or a neurosurgeon, nominated by the in-charge
from the panel.
iv. The doctor treating the person whose brainstem death has
occurred.
Under any circumstances, brainstem death tests should not be
performed by transplant surgeons or any doctor in the transplant
team or a member of the Authorization Committee.

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