Ethics law philosophy

Institute of Health Management
Dow University of Health Sciences
Aewaz Abbas Rizvi
Ethics Law Philosophy
09.06.2010

Rules of the game
• Punctuality of time
• No use of Mobile Phone
• Resuming sessions on time as per
announcement before the breaks

Total Marks 100
Final Examination  40%
Mid Term Examination  30%
Continues Evaluation  30%
Attendance / Punctuality
Participation / Quizzes / Presentations
Assignments / Case study synopsis

Scope of the course
It should be matter of embarrassment for all of us that our
country have impression of “Land of Corruption” and
“Unethical Business Practices”
Pakistan ranks at high level in the corruption index recently
surveyed by “Transparencies International”.
Competition is getting more intense compounded by globalize
economy but reports indicate involvement in illegal and
unethical practices.
This value base course will help students in making ethical
decisions based on sound principles.
Students should be helped to acquire a clear knowledge of what
is right and wrong to analyze situations from an ethical point of
view, and to make bold ethical decisions in healthcare areas.

Out Lines - Main Topics
Main Topics Main Topics
Definitions Ethics
Law & Philosophy
Medical ethics ?
Laws and
Regulations
Ethics & Business
Major branches of
ethics?
Professionalism and
Ethics
Ethics & Its
Relationship
Ethics in a Business
Environment

Time Lines Days - Wednesday Time 06- 9 p.m.
# Date Items
I 09 Jun 10 • Orientation / Introduction /Course Out Lines
• Definitions Ethics Law & Philosophy
II 16 Jun 10 • Quiz 1
• Medical ethics ? Laws and Regulations
III 23 Jun 10 • Quiz 2
• Professionalism and Ethics
IV 30 Jun 10 • Quiz 3
• Business Ethics & Its Relationship
V 07 Jul 10 • Mid Term Examination
VI 04 Jul 10 • Quiz 4
• Major branches of ethics?
VII 21 Jul 10 • Quiz 5
• Ethics & Business
VIII 28 Jul 10 • Quiz 6
• Ethics in a Business Environment
IX 09 Aug 10 • Quiz 7
• Preparation Guidelines for Final Term Examination
09 Aug 10 • Final Term Examination

 Course is designed in a way to make it
interactive and hands-on loaded with :-
 Presentations on core areas of
Ethics Law and Philosophy.
 Daily Quizzes
 Matching understanding level of participants.
 Case studies
 Creative exercises
 Brain storming sessions
Methodology

 Can you see the old lady?
 Can you see the young lady?
 What did you do to broader
your perspective?
Try to understand all perspectives

Ethics
Ethics (also known as moral philosophy)
A branch of philosophy that addresses
questions about
Morality—that is, concepts such as :-
Good and Bad,
Noble and Ignoble,
Right and Wrong,
Justice, and Virtue.

• Effects of Govt. policy on healthcare operations
• Opportunities for and restrictions on lobbying
activities and other contact with Govt. officials
• Implementation of laws pertaining to healthcare
• Legal responsibilities and liabilities of organizations
and professionals
• Identification of healthcare-related fraud & abuse
Laws and Regulations

Ethics
Major branches of ethics include:
Meta-ethics, about the theoretical meaning and
reference of moral propositions and how their
Truth-values (if any) may be determined;
Normative ethics, about the practical means
of determining a moral course of action;
Applied ethics, about how moral outcomes
can be achieved in specific situations;
Moral psychology, about how moral
capacity or moral agency develops and
what its nature is; and
Descriptive ethics, about what moral values people
actually abide by
Within each of these branches are many different
schools of thought and still further sub-fields of study.

Ethics
If you are planning to infuse strong,
ethical principles throughout your
Co or want to change the culture
• Identify the issue /crisis.
• Select alternative ways to handle ethical issue /crisis.
• Create inspiring examples to successfully deal with
major ethical issue.
• Carefully design code of ethics.
• Practice ethical values in "challenge sessions“
• Practice ethical values in a way that each person should
be to clarify their own perspective and commitment to Co.
• Select with in organization peer coaching groups a
powerful, yet straightforward, means to organize, facilitate
and evaluate challenge sessions.

Ethics
Let's Start With "What is ethics?“
Simply ethics involves learning
• what is right or wrong,
and then doing the right thing – but
"the right thing" is not nearly as
straightforward as conveyed in a great
deal of business ethics literature.

Ethics
Many ethicists assert there's always
a right thing to do based on moral principle,
and others believe the right thing to do
depends on the situation –
ultimately it's up to the individual.)
Ethics includes the fundamental ground
rules by which we live our lives.
Philosophers have been discussing
ethics for at least 2500 years,

Ethics
Many ethicists consider emerging ethical beliefs
to be "state of the art" legal matters, i.e.,
what becomes an ethical guideline today is often
translated to a law, regulation or rule tomorrow.
Values which guide how we ought to behave are
considered moral values, e.g., values such as
respect, honesty, fairness, responsibility, etc.
Statements around how these values are applied
are sometimes called moral or ethical principles.

Ethics
The concept has come to mean various things to
various people,
but generally it's coming to know what it
right or wrong in the
workplace
and doing what's right -- this is in regard to effects of
products/services and in relationships with
stakeholders.

Business Ethics
Business ethics is critical during times of
fundamental change -- times much like
those faced now by businesses, both
nonprofit or for-profit. In times of
fundamental change, values that were
previously taken for granted are now
strongly questioned. Many of these values
are no longer followed. Consequently,
there is no clear moral compass to guide
leaders through complex dilemmas about
what is right or wrong.

Ethics
. Attention to ethics in the workplace
sensitizes leaders and staff to how they
should act. Perhaps most important,
attention to ethics in the workplaces helps
ensure that when leaders and managers
are struggling in times of crises and
confusion, they retain a strong moral
compass. However, attention to business
ethics provides numerous other benefits,
as well

Medical Ethics
Medical ethics is primarily a field of applied ethics,
the study of moral values and judgments as
they apply to medicine.
Medical ethics tends to be understood Narrowly
as an applied professional ethics, whereas
bioethics appears to have worked
more expansive concerns, touching upon the
philosophy of science and the critique of
biotechnology.
Still, the two fields often overlap and the distinction
is more a matter of style than professional consensus.

Medical Ethics
In the early modern period, the field is
indebted to Muslim physicians such as
Ishaq bin Ali Rahawi
(who wrote the Conduct of a Physician,
the first book dedicated to medical ethics)
and
Muhammad ibn Zakariya ar-Razi
(known as Rhazes in the West),
Jewish thinkers such as Maimonides,
Roman Catholic scholastic thinkers
such as Thomas Aquinas

Medical Ethics
Six of the values that commonly apply to
medical ethics discussions are:
1. Autonomy - the patient has the right to refuse
or choose their treatment.
2. Beneficence - a practitioner should act in the
best interest of the patient (duty).
3. Non-maleficence - "first, do no harm" (consequence).

Medical Ethics
4. Justice - concerns the distribution of scarce
health resources, and the decision of who gets
what treatment (fairness and equality).
5. Dignity - the patient (and the person treating
the patient) have the right to dignity.
6. Truthfulness and honesty – the concept of informed
consent has increased in importance in recent years.
Values such as these do not give answers as to how
to handle a particular situation, but provide a useful
framework for understanding conflicts.
When moral values are in conflict, the result may
be an ethical dilemma or crisis.

Medical Ethics
Sometimes, no good solution to a dilemma in
medical ethics exists, and occasionally, the values
of the medical community (i.e., the hospital and its
staff) conflict with the values of the individual
patient,family, or larger non-medical community.
Conflicts can also arise between health care
providers, or among family members.

Medical Ethics
Non-Maleficence : The concept of non-maleficence
is embodied by the phrase, "first, do no harm”.
Many consider that should be the main
or primary consideration (hence primum):
that it is more important not to harm your patient,
than to do them good.
This is partly because enthusiastic practitioners
are prone to using treatments that they believe will do
good,without first having evaluated them adequately
to ensure they do no harm.

Medical Ethics
In practice, however, many treatments carry some
risk of harm.
In some circumstances, e.g. in desperate situations
where the outcome without treatment will be grave,
risky treatments that stand a high chance of
harming the patient will be justified, as the risk of not
treating is also very likely to do harm.
So the principle of non-maleficence is not absolute,
and must be balanced against the principle of
beneficence.

Medical Ethics
Truthfulness and honesty
Informed consent in ethics usually refers to
the idea that a person must be fully-informed
about and understand the potential benefits
and risks of their choice of treatment.
An uninformed person is at risk of mistakenly
making a choice not reflective of his or her
values or wishes.
The value of informed consent is closely related to
the values of autonomy and truth telling.

Medical Ethics
Confidentiality is commonly applied to conversations
between doctors and patients.
This concept is commonly known as patient-physician
privilege.
Legal protections prevent physicians from revealing
their discussions with patients, even under oath in court.
Traditionally, medical ethics has viewed the duty of
Confidentiality as a relatively non-negotiable
tenet of medical practice.

Medical Ethics
Bioethics is an especially difficult field because it regularly
Concerns some of the most troubling topics:
the nature of life, the nature of death,
what sort of life is worth living,
what constitutes murder,
how we should treat people who are in especially
vulnerable and painful circumstances,
just what sort of responsibilities any of has to
other human beings, and so on.
Bioethics is not a wholly independent field –
it must, obviously, draw a great deal from
other ethical discussions.

Medical Ethics
Perhaps the most fundamental principle of all medical
ethics is the idea that for anyone who presumes
to be involved in the treatment of disease or illness,
their primary and overriding duty is to their patient.
There are a variety of ways in which this basic principle can
be expressed.
One of the oldest comes from Hippocrates, an early Greek
physician.

Medical Ethics
Many believe that his Hippocratic Oath mandates
that doctors "first do no harm," but that doesn't actually
appear in the oath (although it does seem to be present
in other writings of his).
Instead, he wrote "I will apply dietetic measures for the
benefit of the sick according to my ability and judgment;
I will keep them from harm and injustice."

“Law is a system of principles and rules
devised by organized society for the
purpose of controlling human conduct.”
– Southwick, A.F. The Law of Hospital and
Health Care Administration (2nd
ed). 1988 page
3.
16.06.2010

16.06.2010
Know the trends and pitfalls in legal fields:
• Criminal law
• Contracts
• Antitrust
• Negligence
• Fraud & abase
• Taxation
• Administrative Law
• Law of Corporations
• Environmental regulation
• others

Criminal Law
Prosecution and conviction for:
Assault
False imprisonment
Violation of civil rights
Defamation (libel and slander)
Environmental pollution
murder

16.06.2010
Contract Law
• Private agreements give rise to certain duties
that are enforceable in a public forum (court
system)
• All physician-patient and institution-patient
relationships are founded in contract – the
patient requests treatment and the provider
agrees to provide it in return for payment
• This establishes certain legally enforceable
duties and expectations

16.06.2010
Contract Law
•Contractual aspects exist in relationships
between a healthcare organization and
–Physicians
–Nurses
–Other employees
–Suppliers
–Payors
–Government
–others

16.06.2010
Corporation Law
Because a corporation has a charter from
the state, it receives certain benefits:
Perpetual existence
Legal personality
“corporate veil” that shields the individual
who created it and those who operate it

16.06.2010
Corporate charters also create
• legal obligations
• Government licensure
• Regulation
• Oversight merely to virtue of
its corporate status

16.06.2010
Negligence/Tort Law
Violation of some proven “standard of care”
or failure to exercise due care under the
circumstances.
Alleged medical malpractice
Healthcare organizations were once
protected by the doctrine of “charitable
immunity”, this is no longer the case

Negligence – failure to:
• Determine the qualification of a physician prior to
granting or renewing staff privileges
• Failure to monitor the qualifications of nurses or
healthcare workers
• Failure to maintain and implement adequate
institutional policies
• Failure to follow the organization’s own bylaws
• Failure to maintain adequate facilities and
equipment
• Failure to comply with “anti-dumping” laws
regarding emergency room patients
16.06.2010

• Supervise the performance of contractors
(including hired physicians)
• Maintain appropriate peer review and quality
assurance functions
• Prevent the unauthorized disclosure of
information from patient records
• Protect patients from healthcare workers who
carry communicable or infectious diseases
• Protect the identities of AIDS or substance
abuse patients
16.06.2010

• Follow standard orders and protocols
• Inform the patient or family when injuries
result from known deviations from the
standard of care
• Counsel persons regarding known or
knowable genetic conditions that would
affect their children

Fraud and Abuse
• False claims
• “Kickbacks” for referrals or Medicare
patients
• Physician self-referrals
Hugh potential for penalties – fines and
expulsion from the Medicare program

Antitrust Laws
• Physicians and healthcare organizations were
once exempted from antitrust statutes because
of their “learned profession” status
• However we are now subject to antitrust laws of
both federal and state governments.
• Mergers
• Consolidations
• Acquisitions
• Reduction of services
• Joint Ventures

Antitrust Laws
• The incentives of antitrust laws (to
preserve and promote competition) seem
counter to the policy imperatives of
healthcare reform (efficiency, lower cost,
reduction of duplication of services).

Antitrust Laws
• Litigation is brought by:
– U.S. Department of Justice
– Federal Trade Commission
– State antitrust agency
• Antitrust action:
– Can take years to litigate
– Cost millions of dollars to defend
– Can cost millions or more in damages and
penalties

Tax Laws
• Tax-exempt organizations must comply
with tax laws’ limitations and requirements
regarding:
– Lobbying activities
– Political campaigning
– Community benefits
– Charitable purposes
– Private inurement
– Unrelated business income

Other Legal Obligations
• Admission and discharge procedures
• “Hill-Burton Act”
• EMTALA – Emergency Medical Treatment
and Active Labor Act
• Involuntary Commitment of Mentally Ill
persons

Informed Consent
• Know the circumstances when consent
can be refused
• Procedures needed to secure and
document informed consent
• Legal aspects of medical records
– Forms and consents
– Standards for retention/disposal
– Rights of ownership and control
– Use as evidence in litigation

Informed Consent
• Know the legal principles affecting consent
for treatment of:
– incompetent adults
– Young minor children
– Mature minors
– Pregnant minors
– Seriously ill newborns whose parents refuse
to consent to care

Informed Consent
• Know the legal principles affecting consent
for:
– Abortion
– Sterilization
– Euthanasia
– Genetic therapies
– Other procedures having religious or ethical
overtones
• Potential liability for “wrongful life” or
“wrongful birth”

Professionalism and Ethics
23.06.2010
The American College of Hospital Administrators
(ACHA) was established in 1933 for the
following hallmarks:
– Public service orientation
– Self-regulation
– A code of ethics
– Expectations, such as assuring competence of
members through continuing professional education
– Samaritanism
– Charity
These hallmarks can be found in the ACHE Code
of Ethics

23.06.2010
• Ethical Policy Statements have also been
developed by ACHE to address specific
concerns of healthcare executives
• These are published on the ache.org
website, and included in the annual report.

23.06.2010
Ethics is often defined as a formal study of
morality.
Sociologists – mores, customs and behavior
found in a culture
Physicians – meeting the expectations of
their profession and society and acting in
certain ways towards patients

23.06.2010
Ethics to Healthcare Executives – special charge
and responsibility to:
• patient
• client
• others served
• The organization
• Its personnel
• Themselves
• The profession
• And ultimately, but less directly, to society

23.06.2010
In the Code, special attention is given to
such issues as:
• Responsibility to those served by the
organization
• Obligations to the profession and the
organization
• Roles in providing health services to the
community and those in need of services
• Conflicts of interest

23.06.2010
The Code encompasses the concept of
moral agency (or advocate) which holds
that healthcare executives are morally
accountable for the implications of their:
Malfeasance (wrongdoing or misconduct,
especially by a public official)
Nonfeasance (failure to do what ought to be
done) and
Misfeasance (the performance of a lawful
action in an illegal or improper manner)

23.06.2010
• ACHE affiliates are obliged to bring to the attention
of the ACHE Ethics Committee any information that
reasonably causes them to believe there has been
an infraction of the Code.
• Alleged infractions of the Code are reviewed by the
Ethics Committee, with the help of other elements
of the ACHE governance structure.
• The Ethics Committee makes a recommendation to
the Board of Governors, which has final authority.
• The Code includes appeals and reviews, which
provide for substantive and procedure due process.

23.06.2010
American Medical Association’s Principles of Medical
Ethics
• Based on work of a 19th
century English physician, Sir
Thomas Percival.
• Subsequent revisions continue to incorporate portions of
the Hippocratic philosophy governing physician-patient
relationships.
• The Principles were last revised in 1980 – which moved
away from previous emphasis on benefits and harms,
and adopted the language of rights and responsibilities.
• The Principles direct members to “strive to expose those
physicians deficient in character or competence, or who
engage in fraud or deception”.

23.06.2010
American Nurses Association’s Code for Nurses
• Philosophy is that the goal of nursing is to
support the client’s responsibility and self-
determination to the greatest extent possible.
• Specific provisions set out the relationships
among nurses, and with nursing, clients,
employers and the public.
• Nurses are expected to act when healthcare and
safety are affected by the incompetent, unethical
or illegal practice of any person.

23.06.2010
Codes of Ethics for professional groups
• Provide for self-regulation
• Must be sufficiently precise so that guidance is
meaningful, both to the members of professional groups
and societies and to those who are charged with
enforcing the code.
• Must be living documents that provide meaningful
guidance to individuals who want to do the right thing,
but who are uncertain as to what that is.
• Education about its ethical code and expectations should
be a part of any continuing education development
program undertaken by a profession

23.06.2010
Four principles that can be used to guide
healthcare executives in developing a
personal ethic:
• Respect for persons (which incorporates
autonomy, confidentiality, fidelity and truth
telling)
• Beneficence
• Nonmaleficence
• Justice

23.06.2010
Principles guiding personal ethics should:
• permeate an organization’s philosophy
• be reflected in its mission statement and
other written expressions of values
• be reflected in all the policies, procedures
and rules used by the organization
• be part of the healthcare executive’s
personal ethic, as well as part of all
decision making

23.06.2010
Institutional Ethics Committees
Interdisciplinary teams to provide
• advice
• Consultation
• Education
• Analysis
for physicians, patients, staff and healthcare
executives.
Focused on biomedical ethical issues and
administrative ethics.

23.06.2010
Infant care Review Committees (ICRC) are
established in response to the Federal
Child Abuse Amendments of 1984.
1. Educate hospital personnel and families
of disabled infants
2. Recommend institutional policies and
guidelines as to withholding medically
indicated treatment
3. Offer counsel and review in such cases

23.06.2010
Institutional Review Board
• Established to meet the requirements of
the department of Health and Human
Services, and other federal and state
agencies in various types of research.
• Prospectively review proposed research
that involves human subjects to determine
whether research subjects will be at risk of
harm and to ensure that legally effective
informed consent will be obtained

23.06.2010
Types of research in healthcare organizations
• Clinical trials – primarily performed in academic
health centers and other teaching hospitals
• Practice of Medicine research – performed in
larger hospitals and HMOs – use of previously
collected data and survey research to evaluate
the practice of medicine
• Patient satisfaction
• Outcomes measurement

23.06.2010
Patient Bill of Rights
• Suggest appropriate ethical relationships
between the patient and the organization
and its employees
• Emphasize maximization of patient
autonomy while recognizing the needs of
the health services organization
• Responsibility of patients in the care
process

23.06.2010
Expectations of Ethical Conduct
• Statements or guidelines established by trade
associations
• Set out expectations for ethical conduct and
relationships with the community, and those
served, and organizational conduct in general.
• Health care providers are expected to
accommodate the religious and social beliefs
and customs of patients whenever possible.

23.06.2010
Cultural and Spiritual Diversity
Equal Employment Opportunity Commission
Create protected classes of persons against whom
it is illegal to discriminate
• Unlawful discrimination
• Sexual harassment
• Intimate or romantic relationships in the
workplace
• Sexual orientation
• Affirmative action
• Diversity programs

23.06.2010
Conflicts of Interest
Occur when one has conflicting duties or
responsibilities and meeting one of them
makes it impossible to meet the other
Example: a decision maker (manager or
corporate director) is also a decision
maker for an organization with which
business is done.

23.06.2010
ACHE Code of Ethics
ACHE affiliates are expected to accept no
gift or benefit “offered with the express or
implied expectation of influencing a
management decision”.
An organizational policy that no gratuities
can be accepted is the cleanest and
clearest approach and leaves nothing to
the potential recipient’s judgment.

30.06.2010
Business Ethics & Its Relationship
 Business and Customers
 Business and Long Term Considerations
 The Company and the Customers
 Criticisms of Advertising
 Ethical Problems in Advertising
 Product Safety and Product Liability
 IFPMA Code of Ethics

30.06.2010
 Business and Long Term Considerations

30.06.2010

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