2. PRETEST
1.What are the 4 cardinal pillars of Bioethics?
2. Ethics should be followed in treatment and research protocols
True/False
3.Patients are active participants in Autonomy.
True/False
4.What was the first international instrument on the ethics of medical
research?
a)Nuremberg code
b)Helsinki declaration
5.Advertising is an unethical practice
True/False
3. CONTENTS
• Origin and Definition
• History - Hippocratic Oath
• Nuremberg Code
• Ethical Principles
• Obligations of Physicians to patients
• Obligation of Physicians to colleagues
• Obligation of Physicians to society
• Helsinki Declaration
• Case studies on autonomy and decision making
• Conclusion
4. OriginandDefinition
• The word ethics is derived from the Greek word ‘ethos’ meaning
custom or character.
• Ethics is the philosophy of human conduct.
"the science of the ideal human character and behaviour in situations
where distinction must be made between right and wrong, duty must
be followed and good interpersonal relations maintained”.
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5. HistoryofEthics
• Hippocratic Oath written by Hippocrates,
the father of medicine in 4th century BC.
• Highlights
“I will prescribe regimens for the good of my patients and never do harm to
anyone, I will not prescribe deadly drugs. I will not cut for stone; I will leave
operations to be performed by specialists. All that may come to my
knowledge in the exercise of my profession I will keep secret and not
reveal.”
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6. Nuremberg Code, 1947
• Set of research ethical principles for
human experimentation set as a result of
Nuremberg Trials at the end of the
Second World War.
• They were created in response to the
inhumane Nazi experiments on prisoners
during second world war.
Sulfonamide experiments
Subjects were deliberately wounded on the outer side of their calves. Physicians
then rubbed a mixture of bacteria into the open wounds before sewing them shut.
7.
8. The foundations of bioethics
Background
The fundamental principles of bioethics includes the cardinal
pillars of ethics viz.,
Autonomy
Beneficence
Non-maleficence
Justice
10. Autonomy
• This principle is in line with interactive model of health care wherein
patient is the prominent member in the process of decision making.
• This principle emphasizes the patient's right to make decisions and is
free to determine what will happen on his/her body.
EXAMPLE
• A patient is admitted in labour ward with labour pains. The mode of
delivery of choice which could be given here are normal labour, forceps
delivery and LSCS. However, the Obstetrician attending the case insists
on LSCS.
11. Informed Consent
• The health care professional has to ensure that consent is obtained
before any care is instituted.
• Patients are provided with relevant information such as different
modes of treatment, their risks and benefits, consequences of not
availing the treatment etc.
• Information given should be easily understood facilitating the patient
to make a voluntary consent.
• In case of minors, parents or legal guardians can grant the consent for
the care.
12.
13. Beneficence (To do good)
• The health care professional, before instituting any action or care should question
himself whether such actions will help the patient to recover or to perform his
functions better or not.
• He has to place the interest of the patient above his own interest.
• He has to plan a treatment or order an investigation only if it is necessary.
• In the process of treating a patient –weigh the consequences of treatment Vs no
treatment.
EXAMPLES
• CT lungs in a case of COVID-19 infection with fever, cough &breathlessness
• COVID-19 Pneumonia - treatment attempts should be to maximize the benefits and
minimize the harm.
14. Non-maleficence(Todonoharm)
• Hippocrates, pioneer in Greek medicine has laid an emphasis on non- maleficence
or to do no harm.
• As per this, the first and foremost duty of the health care professional is to ensure
that his actions do not harm the patient in any way.
Examples
• Use of unsterilized instruments, misuse of medicines(Eg.Steroid therapy)
not removing the cotton plug after episiotomy, surgery on wrong side.
15. Justice
• This principle directs health care professional to provide equal treatment to all,
giving to each patient what he/she needs.
• Physicians are bound to treat low socioeconomic people, physically challenged
and mentally retarded. Doctors also have responsibilities for such group of
patients and cannot shy away from the responsibilities bestowed on them by
the society.
• Doctors probably can provide care at a concessional rate or designate certain
time for the care of such patients or support programs for such patients
conducted by local, regional or state bodies.
17. Duties towards society
• The doctor has to assume leadership in the community on matters
pertaining to health.
• People should be urged to seek care without influencing the choice of
doctor.
18. Duties towards professional colleagues
• Every doctor should cherish a proper pride in his/her colleagues and
should not disparage them either by act or word.
• Not undermine the patient-physician relationship of colleagues in order to
attract patients.
• When medically necessary communicate with colleagues who are involved
in the care of the patient. Respect patient confidentiality& be confined to
necessary information.
• If a doctor is consulted by the patient of another doctor and the former
finds that the patient is suffering from previous faulty treatment it is his
duty to institute correct treatment at once with as little comments as
possible and in such a manner as to avoid reflection on his predecessor.
19. Duties towards patients
• Every doctor should be courteous, sympathetic, friendly and helpful.
• Respect human life(Irrespective of caste,creed etc)
• Punctuality in fulfilling his appointments.
• Owe his/her patients complete loyalty
• Confidentiality(threat to patients or unless imminent others)
• Emergency care
• Not enter into sexual relationship ,abusive or exploitative relationship
20. HELSINKI DECLARATION
• Recommendations guiding physicians in biomedical research involving
human subjects.
• Issued by World Medical Association in 1964 in Helsinki, Finland
• Para 1-10 – Introduction
• Para 11-30 – Principles for all medical research
• Para 31-35 – Additional principles for research and medical care
22. Unethical Practices
• Unregistered persons
• Advertising
• Undercutting charges to solicit patients
• Accepting or paying commission
• Use of bogus diploma
• Not referring the patient to the consultant if the planned treatment is
beyond the skills of the doctor.
• Emergency consultation, not sending the patient back to previous
care provider
23. CASE STUDY
Case studies on patient autonomy and decision making
Competency addressed
Identify, discuss and defend medico-legal, socio-cultural and ethical issues as it
pertains to patient autonomy, patient rights and shared responsibility in health
care
Level : KH
24. Disscussion on Medico-legal, Sociocultural and ethical issues
• The law commission of India laid down an act for the medical
treatment of terminally ill patients (protection of patients, medical
practitioners) . According to this law, if a ‘competent’ patient who is
afflicted by ‘terminal illness’ refuses treatment after being duly
informed about all aspects of the disease and treatment, the doctor
is bound to obey the same and withhold or withdraw treatment.
• However, when the patient is ‘incompetent’ (includes minor, person
ofunsound mind) and is unable to take decisions for end of life, the
doctor has to take a decision in the ‘best interests’ of the patient
based upon an informed body of medical opinion of experts.
• The law might not apply in situations where the parents/guardians
insist on continuation of life support measures despite being
explained the inevitable outcome of the same.
25.
26. SUPREME COURT JUDGEMENT
• A recent judgment by the Supreme Court of India has
legalized the withdrawal of life support measures in patients
in persistent vegetative state
• Such a decision to discontinue life supporting measures
can be taken by parents, spouse or doctors attending
patient in the ‘best interest’ of the patient.
• However, it requires an approval from high court, which
can grant the permission for withdrawal of life support
measures to an incompetent person.
• The court appoints a panel of three expert doctors to seek
its medical opinion, preferentially one neurologist, one
psychiatrist, and an other physician.
27. METHOD OF WITHDRAWAL OF LIFE SUPPORT
• Method for withdrawal of life support measures in such cases
are not clearly defined in law.
• It might be difficult for the care giving doctors and staff to pull
the brain dead suddenly out of ventilator.
• Few methods suggested by experts include ‘Do not resuscitate
order’, withholding use of new medications and slow de-
escalation of treatment .
