se3- L3 Ethical and Legal Issues Related to Medical Practice

13 legal roles

in practicing medicine Rule # 1 : Competent

patients have the

right to refuse medical

treatment

Patients have almost absolute control over their own

bodies.

Patients have an almost absolute right to refuse

treatment.

The lesser chance of recovery, the greater right to refuse

treatment.

Incompetent patients have the same rights, but must be

exercised differently (via a surrogate)

Rule #2: incompetent

patient Physician rely

on advance directives

or orders.

Advance directives (orders ).

• Living will: written document expressing

wishes

Care facilities must provide information

at time of admission or previous admission if

its on going order

Health power of attorney(legal

representatives):

designating the surrogate(Substitute)

decision-maker

"Speaks with the patient's voice"

Beats all other decision rules

• In end-of-life circumstances, if power of

attorney person directly contradicts the

living will, follow the living will

Rule #3: Assume that the

patient is competent unless

clear behavioral evidence

Indicates otherwise.

• Competence is a legal, not a medical issue.

• A diagnosis, by itself, tells you little about a patient's

competence.

• Clear behavioral evidence would be:

Patient is grossly psychotic and dysfunctional as

Patient's physical or mental state prevents simple

communication

When surrogates make

decisions for a patient, they should

use the following criteria in this

orderRule 4

Subjective standard

هدف Actual intent •

, advance directive

• What did the patient say in the past?

Substituted judgment

• Who best represents the patient?

• What would patient say if he or she

could?

Best-interest standard

• Burdens versus benefits

• Interests of patient, not preferences of

the decision-maker

Rule 5 : Feeding tube is a medical

treatment and can be withdrawn at the

patient's request

Not considered killing the patient, but stopping

treatment at patient's request.

• A competent person can refuse even life saving

hydration and nutrition

Rule 6: Do nothing to actively assist

the patient to die sooner

Active euthanasia موت الرحمة and assisted suicide

are on difficult ground or end stages of the disease .

Passive : (allowing to die = OK) as in patient sign

not for active resuscitation if CPR or Advanced CPR.

Active : (killing = NOT OK)

• Palliative and rehabilitation: Do all you can to

reduce the patient's suffering (e.g. .giving pain

medication like narcotics

Rule 7: The physician decides

when the patient is dead

Rule 7: The physician decides

when the patient is dead

If the physician thinks continued treatment is

futile (the patient has shown no

improvement), but the surrogate or family

insists on continued treatment, the treatment

should continue.

• If there are scientifically 100 % no more

treatment options ( as if the patient is

cortically dead), but the family insists on

treatment,; treatment will stop but with

explanation and family counselling

Rule 8: Never abandon a patient

(through out management

Lack of financial resources are never been

reasons to stop treatment of a patient.

Annoying or difficult patient is still your

patient.

You can not ever threaten abandonment

during emergency. But you can transfer

stable patient to other doctor care, depend

on the specialty

Rule 9: Keep the physician-patient

relationship within bounds

Intimate social contact with anyone who is or

has been a patient is prohibited.

* Do not date patient or parents of pediatric

patients or children of geriatric patients.

•Do not treat friends or family.

•Patient medical information must to remain

private

Rule 10: Stop harm from

happening

Beyond "do no harm;' you must stop anyone

from hurting himself or others.

• Harm can be spreading disease, physical

assault, psychological abuse, neglect,

infliction of pain or anything which produces

notable distress

Rule 11: Always obtain

informed consent in case of

procedure

Full, informed consent requires that the

patient has received and understood related

information:

•Description of procedure.

• Purpose and Benefits will get by having the

procedure.

• Risks of having the procedure.

• Availability of alternatives

Exceptions to informed

consent)(informed consent in case of

procedure)

❑Emergency no time

Health and Disease

❑Therapeutic privilege (unconscious, confused, physician deprives patient of autonomy in interest of health}

❑Waiver by patient

❑Patient is incompetent

Consent of the patient

Consent can be oral.

• A signed paper by the patient has not red

or has not understood : will NOT constitute

informed consent.

• Written consent can be revoked orally at

any time

Rule 12: Special rules apply with

children

• as a

• as a rule, Children younger than 18 years

are minors and are legally incompetent.

القاصر Exceptions: (emancipated minors

)المتحرر

• If older than 13 years and taking care of

self, i.e., living alone, treat as an adult.

• Marriage makes a child emancipated

(unbounded),

• Pregnancy or giving birth, in most cases,

does not

Rule 1 3: Parents cannot

withhold life- or limb-saving

treatment from their children

parents refuse permission to treat child:

If immediate emergency, go ahead and treat.

If not immediate, but still critical (e.g., juvenile

diabetes), generally the child is declared a ward

of the court and the court grants permission.

If not life- or limb-threatening (e.g., child needs

minor stitches or vaccination ), listen to the

parents

Note that the child cannot give permission. A

child's refusal of treatment is irrelevant