MEDICAL ETHICS AND MEDICO-

LEGAL PROBLEMS
• ASSIGNMENT FOR GROUP ONE STUDENTS
1 Addisu Mossie
2 Addisu Mequanint
3 Gissila Anbesse
4 Betelihem Daniel
5 Derartu Tesfaye
 ETHICS
SESSION OBJECTIVES
Determine common problems in Health professional conduct.
Determine the goal of Medical Ethics
Understand malpractice and contract in Medical Ethics
List the component of Informed consent
 INTRODUCTION
• What is ethics?
• What is the difference between ethics and morality
• What is medical ethics?
• What are medico legal problems
• In thinking about standards of conduct, it will be
useful to distinguish between “ethics” and “morality”.
• Morality consists of a society’s most general
standards. These standards apply to all people in
society regardless of their professional or institutional
roles.
• Moral standards include those rules that most people
learn in childhood, e.g. “don’t lie, cheat, steal, harm
other people, etc.”
• Many ethicists maintain that moral duties and
obligations override other ones: so, “if I have a moral
duty not to lie, then I should not lie even if my
employment requires me to lie.”
 Ethics are not …

• Ethics is not the same as feelings

• Ethics is not religion
• Ethics is not following the law
• Ethics is not following culturally accepted norms
• Ethics is not science
 Ethics are …

• Moral Principles
• What is good and bad
• What is right and wrong
• Based on value system
• Ethical norms are not universal – depends on the sub
culture of the society
4.to distinguish between Ethics and Law
• (1) some actions that are illegal may not be unethical.
• (2) some actions that are unethical may not be illegal. (secret)
• (3) laws can be unethical or immoral. (Nazi’s)
• (4) we use different kinds of mechanisms to express, teach,
inculcate, and enforce laws and ethics.
 2.Medical ethics
• The expressions “professional ethics” and “medical ethics” were coined by
Thomas Percival.

• Medical ethics is a special kind of ethics only as it relates to a

particular realm of facts and concerns and not because it embodies or
appeals to some special moral principles or methodology.
 Goals of medical ethics
It is, to cure sometimes; to relief often and to comfort always.
• In all situations avoid harm
• the benefit always must weight the risk
• restoration of complete health and relief of symptoms
• maintenance of compromised functions without deterioration
• saving or prolonging life
• patient education
 H
• Hipocrates
 Hippocratic tradition
• “into whatever houses I enter, I will enter to help the sick, and I will
abstain from all intentional injustice and harm, especially from abusing
the bodies of man or woman, bond or free.”
 Cont…….

a physician must recognize responsibility to

patients first and foremost, as well as to
society, to other health professionals, and to
self. These are not laws, but standards of
conduct which define the essentials of
honorable behavior for the physician
 Four basic Principles of Medical Ethics

• Autonomy
• Beneficence
• Non maleficience
• Justice
 Autonomy
• Patient has freedom of thought, intention
and action when making decisions
regarding health care procedures
• For a patient to make a fully informed
decision, she/he must understand all
risks and benefits of the procedure and
the likelihood of success.
 Beneficence
• The practitioner should act in “the best
interest” of the patient - the procedure be
provided with the intent of doing good to
the patient
 Non maleficence

• “Above all, do no harm,“ – Make sure that the

procedure does not harm the patient or others
in society
 Cont……

• Physicians are obligated not prescribe medications

they know to be harmful.
• Some interpret this value to exclude the practice of
euthanasia
• Violation of non-maleficence is the subject of
medical malpractice litigation
MEDICO LEGAL ISSUES

Medico legal issues in health care provider and in the

practice of anesthesia
 Patient-Physician Contract
• Physician rights • Physician responsibilities
• Set up a practice within the boundaries • Use due care, skill, judgment, and
of his or her license to practice medicine diligence

• Select where to set up an office and

establish office hours • Keep knowledge up-to-date

• Specialize • Perform to the best of his or her ability

• Decide which services to provide and • Furnish complete information and

how those services will be provided instructions to the patient
 Patient-Physician Contract
• Patient responsibilities
• Follow physician’s instructions and cooperate with care

• Provide relevant information to the physician

• Follow the physician’s orders for treatment

• Pay the fees charged for services provided

 Rights of patients

patient has the right be respected

right to complete the current information on diagnosis and
treatment if he/she able to understand
 right to be informed prior to the start of any procedure or treatment
 right to know name of the person responsible for the procedure
to refuse treatment to the extent to permitted by the law
 Rights of patients
 communication and records to be confidential
 transferred to another facility after complete information
 obtain information about the relationship between this hospital
and the other about his care
 to expect reasonable continuity of care
 examine and receive an exploration of his bill.
 know about the medical records
 Cont……
• Dr must do his duty in good faith,for benefit of the patient
& with consent.
• Good Faith refers to act with due competence,due care &
due caution.
• Competence The act done with possession of knowledge &
skill for the intervention being done.
• Due Care Timely fulfillment of medical needs of the
person.
• Caution Anything done without caution will be rash. To
anticipate, prevent adverse consequence & deal with adverse
consequences.
• Benefit It may be Physical,Physiological or functional
 MEDICOLEGAL PROBLEMS IN
ANESTHESIA
Anesthesiology is considered to be a high-risk medico-legal liability
specialty
In the U.S., in the 1980’s, professional liability insurance premiums began
to skyrocket.
Anesthesiologists represented 3% of the insured physicians but accounted
for 11% of the total dollars paid for patient injuries
Surgeons & anesthesiologists are sued about once every 4 to 5 years;
 cont…….
• It was said “To err is only human”. Physicians, and in particular, anesthesiologists
are human and they are bound to commit mistakes on occasion. However, their
mistakes lead to morbidity and mortality. Malpractice is defined by Columbia
Encyclopedia as the “…failure to provide professional services with the skill usually
exhibited by responsible and careful members of the profession, resulting in injury,
loss, or damage to the party contracting those service.
 ASA Closed Claims Database
• Since 1998, the American Society of Anesthesiologists have been collecting data on
personal damage insurance claims filed against anesthesiologists, that have been settled
and closed. Tells us what kind of lawsuits were successful from the patient’s end!

• The uniqueness of the ASA Closed Claims database is that it reflects the consumer’s
perspective.

• This point can not be emphasized enough because one of the best measures of quality
of care comes from the patient’s perspective
27
 ASA Closed Claims in OB
• Total 5300 cases. 635 (12%) related to OB anesthesia. 71% of these are
related to cesarean section.

• Obstetric anesthesia might be a particularly high-risk subspecialty.

28
Comparison of Obstetric vs. Non-obstetric Claims
29
Why did OB patients submit claims?
• OB claims have higher proportion of “minor” injuries – i.e.
headache, backpain, emotional distress, compared to non-OB
claims

• Maybe more minor claims because of increased incidence of

these problems in OB patients. However, patient statements
reveal many were unhappy with the care and felt ignored and
mistreated.

• Perhaps malpractice litigation serves not only for payment for

injury but also emotional vindication
30
• What can help?
Careful personal conduct
• Establish good rapport
• Early pre-anesthetic evaluation
• Provide realistic expectation
• Regularly review potential major and minor risks

31
The “Four C’s”

32
An accurate contemporaneous anaesthetic
record is essential
 CONSENT
• Consent is defined as agreement in sentiment,opinion,a
course of action etc.
• Law recognizes consent as good defence for causing
injury which is based on the percept that every individual
knows what is best for oneself.
• Law cannot provide immunity against all types of
criminal offences.
• Offences can be there completely independent of consent.
• Consent can be either implied or expressed which can
again be oral or written.
 CONSENT
• Consent should be patient’s own & he should be legally
& mentally competent. No one-else is competent.
• Free consent:- Means consent must be free from
force,coercion,fraud, & inducement.
• Informed consent:-It must state who is consenting to
whom & for what purpose & should be given having
understood nature & consequences of the act.It could be
orally expressed One has to be told about possible basic
risks, likely benefits & alternatives available,
irrespective of his education standard,in the language
the patient understand.
• Consent must be recorded.
 CONSENT
• Implied Consent:- Consent need not be expressed
or articulated.
• It includes consent by acts,conduct & consent
presumed but never given.
• It is permitted in special circumstances like when
patient is not competent by age, physical or mental
condition, when guardian is not available&
patient’s condition is life threatening( To prevent
death or grievous hurt.
• Surrogate consent :-Any body who is in valid
custody of the individual is permitted to give
consent
 Exceptions” to informed consent

• Emergencies – if there is no time to get a person’s consent, but it is likely

that they would have consented
• Therapeutic Privilege – a provider’s determination that knowing the
complete truth might harm the patient; rarely used
• Incompetent Patients – since the patient cannot consent, one must find
out who is authorized to consent on their behalf
• Age below 18 years
• Patient on antipsychotic drugs and intoxication
 CRIMINAL CULPABILITY &
CONSENT
• Sec. 87IPC states that nothing is an offence if done,
not intending or knowing by the doer that it would
cause death, or grievous hurt, by the harm that may
cause, if this is done with the consent of the person
who got injured,the later being above 18yrs.,whether
expressed or implied to suffer that harm.
• Age of consent especially to risk harm,is 18 yrs
which is the age of majority under Indian majority
Act 1875.
• Consent for medical examination can be given by
any person above 12 Yrs.
 cont…….

• Sec.92 covers acts done in good faith for the benefit of a

person,without his consent not being an offence,if;
-it was impossible for the person to show his consent,or
-he was incapable of giving consent,or
-no guardian or other person having lawful charge of him was
available in time to consent.
 MEDICAL NEGLIGENCE

• Failure to follow the medical norms is negligence.

• Norms are case specific,situation specific & context specific.
• To prove negligence four (4D’s)-
a) Duty to care
b) Deficiency in duty
c) Damage occurred to patient
d) Damage should be direct consequence of the act
MALPRACTICE IN ANAESTHESIA
First avoid mal practice by itself, if something happens in practice
to be protected legally.
 take detail medical history
 appropriate lab tests
 appropriate physical examination
 appropriate preoperative visit
 MALPRACTICE IN ANAESTHESIA
 having proper documents
 receiving informed consent
• single most important factor in whether or not the law suit filed is the
rapport that anaesthetist has with the patient.
 TASKS OF ANAESTHETISTS
• proper answers to the compliant performance with an attorney
• educate your attorney about the medical fault
• Discovery
• gathering of facts and clarification
• assess or harass the defendant law and a witness she/he will make
 TASKS OF ANAESTHETISTS
• It is important to be factually prepared further
deposition
• Review of notice and records, medical records,
publications of articles ,curriculum vitea
• Oral testimony of any person(deposition)
• The defendant should appear competent, conscious and
carrying in the court.
• Answer to the questions should be b brief to the point
 DEATH CERTIFICATE

• It should not be issued in following circumstances:-

i. when cause is uncertain
ii. when foul play is suspected
iii. un-natural deaths.
 How to avoid a lawsuit

• To avoid a lawsuit, the anesthesiologist should receive a signed “informed

consent” of the patient or of his/her legal guardian was he/she underage or
incapacitated to make his/her own decision. The consent should be
preferably written rather than a verbal one since it would hold much better in
court7. The consent form should include a reasonable and clear explanation
of the procedure, describing the risks that might occur with specific patients
due to their particular conditions. In the rare case the patient does not wish to
be informed of the procedure and risks, then that should be mentioned in the
consent form and preferably countersigned by the patient7.
 Conclusion
• The anesthesiologist has a duty to his/her self: he/she should maintain a
competent and skilled level throughout his/her practice.
The anesthesiologist should maintain his/her physical, mental and sensory
health and should seek medical care if he/she doubts his/her capacities
during which he/she should decrease or cease his/her medical practice.
 Thank you

Any comments and questions?