1. Medical Ethics
and Negigence
Day-1- Dr. S.B.Sinha- Ex President
Biomedical Engineering Society of
India and Consultant Regulatory

2. Introduction
Ethics - signifies moral
values
Medical ethics – moral
principles for registered
medical practitioners in
their dealings with each
other, their patients and
state

3. Introduction
Medical etiquette
conventional laws,
customs of courtesy
and code of conduct
for doctor with his
colleagues

4. Importance of Medical Ethics
Ethical principals such as confidentiality of information, respect for a
person and informed consents are important for patient doctor
relationship.
Application of these principles in specific situations is often problematic ,
since physician, patient and their family may disagree what is right action
in a situation.
The study of ethics prepare a medical professional to deal with them
in rational and principled manner.
Ethics is also important for physian’s interaction with the society and
his fellow colleagues and for conduct of medical research.

5. Four
Principles of
Medical Ethics
Autonomy-
Beneficence-
Confidentiality-
Do no harm-
Equity or justice-

6. Autonomy
Patient has freedom of thought,
intention and action when making
decision regarding healthcare
procedures.
For a patient to make fully informed
decision he must all risks and health
benefits of the procedure and likelihood
of the success.
This includes the need to tell the truth
and be faithful to one’s commitment.

7. Beneficence
The doctor should act in the best interest of
the patient. The procedures should be with
the intent of doing good to the patient.
-----------------------------------------------------------
Patient’s welfare is the first consideration.

8. Confidentiality
Privileged
Communication
Based on Loyalty and Trust.
Maintain confidentiality of all
patient treatment information.
Information to be revealed only for
the benefit of patient and when
ethically and legally required

9. Do No harm
Above all do no harm.
Make sure that the procedure does no harm to the patient and also no harm to the society.
Make balanced judgement while undertaking a double effect. Double effect is an action
which does positive outcome but at the same time has a negative output. For example
providing morphine to a dying patient may reduce the pain but may hasten the dying
process.

10. Equity or justice
 Fair and equitable distribution of available resources. Make informed
decision as to who gets the resources. For example after a tragic incident if
we have limited numbers of Oxygen cylinders the conscious decision
needs to be taken to ensure the Oxygen supply to the patients who are
likely to be saved.
 The burden and benefits of new drugs should be distributed eqally among
all the needy ones.

13. Medical Council of India
 Recognition of medical qualification
Supervision of undergraduate medical education
 Supervision of post graduate medical education
 Recognition of foreign medical education
 Derecognition
 Medical register
 Warning notice
Appeal against disciplinary action

14. State Medical
Council
Medical register
Disciplinary control
Warning notice
Professional death sentence-Erasure of name
from Medical Register because of death of the
professional, penalty for severe medical
negligence.

15. TEA BREAK AT
11.15 AM
We meet at 11.30 AM

17. Duties of physician in General
 Character of the Physician- Uphold the dignity of his profession, render
service to the humanity, should have recognized qualification.
 Maintaining good medical practice- To offer services to the best of his
ability, skills and judgement.
 Medical Records- Shall maintain medical records at least for 3 years.
Shall provide copy of the records to the patient within 72 hours of request
and will maintain a register of all the medical certificates issued by him.
 Display of registration number.
 Use of generic names of drugs.

18. Duties of physician in General
 Highest Quality Assurance in patient care-
 Exposure of Unethical Conducts-
 Payment of professional services- Personal financial interest of the
doctor should not conflict the medical interest of the patient.
 Evasion of legal restriction- Physician shall follow the laws of the land of
the country in which he practices

19. Duties of physician to the patients
 Obligation to the sick- Always respond to the call of sick, refer the patient
if he lacks the experience to treat.
 Patience, dedication and secrecy- Shall treat the patient with patience
and dedication. Secrecy of the patient information shall be maintained and
only divulged in case required by law or society interests.
 Prognosis- Never aggravate or minimize the patient condition.
 Don’t neglect the patient- Once undertaken should not neglect the
patient. Shall always respond to call in Emergency.
 Avoid unnecessary consultation for tests. Make judicious reference for
tests.

20. Duties of physicians towards each
other
 Offer respectful service to their fellow colleagues and their family
members.
 Never criticize a fellow physician.
 Not to take charge of others case unless referred.
 Avoid making remarks on other physicians cases on the treatment unless
this is in patient interest.

21. Unethical Acts
 Advertising
 Patents and copy rights.
 Running and open medical shops.
 Fee splitting/dichotomy -Getting commissions on referrals. -Dichotomy
means fee splitting or giving or receiving commission.
 Violation of human rights.
 Ethuanasia or mercy killings – Is an ethical act. In exceptional
circumstances a committee will decide and not an individual.
 Secret remedies not written-

22. Misconduct of physician
 Violation of any regulations.
 Adultery or any improper conduct.
 Conviction in the court of law.
 Sex determination test- Punishable under PNDT Act.
 Signing false medical certificates, reports and other documents. This
can lead to professional death.

23. Professional
Negligence(malpraxis)
 Negligence - doing something that one is not supposed to do, or failing to do
something that he is supposed to do
 Professional negligence - absence of reasonable care and skill, or wilful
negligence of a medical practioner in the treatment of patient which causes bodily
injury or death of patient.
 Civil Medical Negligence- The failure of a medical practitioner or a physician
to take reasonable care of the patient which he is legally bound to do, is
called civil medical negligence. Civil negligence generally asks for compensation
for the negligence.
 Criminal Medical Negligence- When there is gross negligence on the part of
doctor that leads to the death of a patient it becomes a criminal negligence.
 In Criminal negligence the doctor may be charged under sec 304 A- Criminal
Negligence resulting in death but not amounting to murder

24. LUNCH BREAK at
1.00 PM
We meet after Lunch at 2.00 PM

25. Civil negligence
Following conditions should be satisfied for proving liability of
negligence-
1.Duty-existance of duty of care by the doctor
2.Dereliction-failure on the part of doctor to maintain applicable standard of
care and skill
3.Direct causation- any damage was caused by breach of duty
4.Damage – lost wages, medical expenses and mental duress
 Examples of Civil Negligence are
 Breaking needle during giving of injection, Drug overdose, wrong
diagnosis, Failure to warn side effect & giving proper instruction

26. Criminal Negligence
 Gross negligence resulting in death of a patient charged under 304A
 Sex Determination punishable under PNDT Act.
 Practicing without a professional degree.
 Example of Criminal Negligence are Examples of Criminal Negligence are
 Mismatched blood transfusion, Administration of wrong drug causing loss
of vision or hearing, Cannot conduct normal vaginal delivery, leaving
instrument in abdomen, performed criminal abortion. Doing Sex
determination.

27. Consent
 Agreement, compliance or permission given voluntarily without
compulsion
 Express-Express consent is permission for something that is
given specifically verbally or in writing- example an Emergency
procedure.
 Implied Consent- assumption of permission that is inferred
from actions on the part of the individual. Ex- OPD Treatment.

28. Informed
consent
Informed consent is when a healthcare provider
— like a doctor, nurse, or other healthcare
professional — explains a medical treatment
to a patient before the patient agrees to it.
This type of communication lets the patient ask
questions and accept or deny treatment.
Why informed Consent is necessary-
Consent to treatment forms are an absolute
must when it comes to healthcare. The purpose
of these documents is to ensure that the
patient is fully aware and accepting of a
particular treatment.

29. Informed Consent
 Consent in writing ALWAYS before medico legal examination
 Express consent ALWAYS before any procedure beyond ordinary medical
examination. Express consent (verbal/written) is specifically stated by
the patient. Express verbal consent may be obtained for relatively minor
examinations or procedures, in the presence of a witness.
 Open Consent
 A child below 12 yrs can not give valid consent
 Loco parentis-It refers to an individual who assumes parental status
and responsibilities for another individual, usually a young person,
without formally adopting that person. Example Aunt can be a loco
parentis.

30. Consent-
Legal Aspects
Consent given under fear,
misinterpretation, by insane or
intoxicated person is not valid Sec
90 IPC
It is not an offence, when any
harm is caused by any act done in
good faith, even without consent,
under circumstances when it was
not possible to take the consent
Sec 92 IPC

31. Ethuanasia OR Mercy Killing
 In India, euthanasia OR Mercy Killing is a crime. Section 309 of the Indian Penal
Code (IPC) deals with the attempt to commit suicide and Section 306 of the IPC
deals with abetment of suicide – both actions are punishable. Only those who are
brain dead can be taken off life support with the help of family members.
 Active Euthanasia: positive act of killing with drugs
 Passive Euthanasia: act of omission to continue life sustaining measure
 Involuntary: patient in position to give consent, but decision taken by relatives
and physician
 Non voluntary: patient not in a position to give consent
 Voluntary/Physician assisted suicide: with consent of the patient
 Only Passive Euthanasia is legal in India
 legal in – Albania, Netherlands, Luxenburg

32. Res ipsa loquitur
“the thing or fact speaks for itself”is main consideration in deciding the civil
or criminal negligance
Elements
1. Injury could not have occurred without negligence
2. Defendant had full control over the agency/treatment causing injury
3. Plaintiff did not contribute to the injury
4. Examples- Leaving the swab during operation. Mismatch of blood
transfusion, overdose of drugs, burn from radiotherapy etc.

33. TEA BREAK AT
3.15 PM
We meet at 3.30 PM

34. Defense to negligence claims
 No duty owned to plaintiff- Physician was not treating the patient
 Duty was discharged according to the prevailing standard
 Case of misadventure-Dangerous unforeseeable effects, following use of some
procedure, measures or drugs. It was unintentional.
 It was error of judgment
 it was a Contributory negligence-Concurrent negligent act or unreasonable
conduct on the part of the patient. Example patient not disclosing previous history.
Not a defence in case of criminal negligence.
 Intervention of third party and Croporate Negligence- A third party has intervened
thus physician is not responsible. Corporate Negligence is caused because of
lack of infrastructure of facility
 Limitation of 3 years- Claim not made within 3 years.

35. Where to file a claim
 1. With the State Medical Council.- The state medical council will initiate an
investigation and form a committee to investigate. It can warn or debar the
physician from practice for a limited term or a life ban can be imposed.
 2. With Consumer Forum for Civil claims- Faster
 3. With Court in case of Civil as well as Criminal negligence.- Slower

36. Important Case Studies
 Case-1- Kunal Saha Vs AMRI Kokata-(3 Doctors) Case filed in 1998 .
 Compensation awarded by SC in 2013 of 6.08 Crores
 Case history- The facts of the case is that the wife of the plaintiff was suffering from drug allergy
and the doctors were negligent in prescribing medicine which further aggravated the condition of
patient and finally led to death.
 Case-2- V. Krishan Rao v Nikhil Super Speciality Hospital 2010-
 Compensation awarded- 2 Lakhs- the principle of Res Ipsa Loquitor which means 'thing speak for
itself' was applied and the compensation was given to the plaintiff.
 Case history- Krishna Rao, an officer in malaria department filed a complaint against the hospital for
negligent conduct in treating his wife. His wife was wrongly treated for typhoid fever instead of
malaria fever, due to the wrong medication provided by the hospital.

37. Important Case Studies
 Case-3- Pravat Kumar Mukherjee Vs. Ruby General Hospital
 Compensation ordered 10 Lakhs on huminatarian ground to be paid by Ruby Hall
Ruby Hall
 Case History- complainant were the parents of deceased boy named Samanate Mukherjee a 2nd

38. Case-4
 Title of the Case: Jacob Mathew v. State of Punjab- Judgement dt 5.08.05
 Case History- Jeevan Lal Sharma was in the last stage of cancer and all the
hospitals have refused his treatment. His son went to CMC and requested to treat
reluctantly did. However one day he has respiratory issues and Doctor provided
as the Cylinder was empty patient couldn't survive. FIR U/S 304A was lodged by
Doctor approached the HC and requested quashing of the FIR U/S 482 which HC
appealed in SC against HC Judgment. The honorable Supreme Court decided the
the complaint has not alleged that the accused persons were not qualified doctor
complaint agrees to treat. There is allegation about none availability of oxygen
 Due to hospital management gas cylinder was not available or the oxygen gas
the hospital may be liable in civil law. The doctors (appellant) cannot be held
IPC hence, the honorable Supreme Court allows the appeals and quest the
34 IPC.

39. Bolam and Bolitho Tests
 Court base their judgement of Criminal Negligence
based on the following tests:
 The Bolam Test had stipulated that no doctor can be
found guilty of negligence if they are deemed to
have acted “in accordance with a responsible body
of medical opinion.” The Bolitho Test helped to clarify
what was meant by “a responsible body,” defining it as
one whose opinion had a “logical basis.”