1.0 VALUES, COMPETENCE, AND RESPONSIBILITY
The physician-patient is based on brotherhood. The patient is a fellow human
being in suffering and not an ‘object’ or a ‘case’
The physician should follow the following values in his professional work:
good intentions, avoiding doubtful things, leaving alone matters that do not concern him, loving for others what she loves
for herself, causing no harm, giving sincere advice, avoiding the prohibited, doing good acts, renouncing greed, avoiding
sterile arguments, respect for life, basing decisions and actions on evidence, following the dictates of conscience, righteous
acts, quality work, guarding the tongue, avoiding anger and rage, respecting and not transgressing God’s limits, consciousness of God in all circumstances, performing good acts to wipe out bad ones, treating people
with the best of manners, restraint and modesty, maintaining objectivity, seeking help from God, and avoiding oppression or
transgression against others.
The physician should be professionally competent, balanced, have responsibility
(amanat) and accountability. He must work for the benefit of the patients and the community.
2.0 CONSENT
No medical procedures can be carried out without informed consent
of the patient except in cases of legal incompetence.
The patient has the purest intentions in decisions in the best
interests of his or her life. Others may have bias their decision-making.
The patient must be free and capable of giving informed consent.
Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal
competence of the patient, recommendation of the physician on the best course of action, decision by the patient, and authorization
by the patient to carry out the procedures. Consent is limited to what was explained to the patient except in an emergency.
Physician assisted suicide, active euthanasia, and voluntary euthanasia are
illegal even if performed after informed consent by the patient.
The patient is free to make decisions regarding choice of physicians
and choice of treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of an
advance statement (advance directive, living will).
Refusal to consent must be an informed refusal (patient understands what he
is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission
of the court. Doubts about consent are resolved in favor of preserving life.
Spouses and family members do not have an automatic right to consent. A spouse
cannot overrule the patient’s choice.
Advance directives, proxy informed consent by the family are made for the
unconscious terminal patient on withholding or withdrawal of treatment.
A do not resuscitate order (DNR) by a physician could create legal complications.
The living will has the following advantages: (a) reassuring the patient that
terminal care will be carried out as he or she desires (b) providing guidance and legal protection and thus relieving the
physicians of the burden of decision making and legal liabilities (c) relieving the family of the mental stress involved in
making decisions about terminal care.
The disadvantage of a living will is that it may not anticipate all developments
of the future thus limiting the options available to the physicians and the family.
The device of the power of attorney can be used instead of the living will
or advance directive. Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b)
decide in the best interests of the patient.
Informed consent is still required for physicians in special practices such
as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons may have to carry out examinations on
suspects without informed consent.
3.0 CONSENT OF THE INCOMPETENT
Competent children can consent to treatment but cannot refuse treatment. The
consent of one parent is sufficient if the 2 disagree. Parental choice takes precedence over the child’s choice. Courts
can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic
or non-therapeutic research on children.
Mental patients cannot consent to treatment, research, or sterilization because
of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit,
in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order.
Suicidal patients tend to refuse treatment because they want to die.
There are controversies about nutrition, hydration, and treatment for patients
in a persistent vegetative state since the chance of recovery is low. T
There is no moral difference between withholding and withdrawing futile treatment.
Labor and delivery are emergencies that require immediate decisions but the
woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal
interest. Birth plans can be treated as an advance directive.
4.0 DISCLOSURE AND TRUTHFULNESS
As part of the professional contract between the physician and the patient, the physician must tell
the whole truth. Patients have the right to know the risks and benefits of medical procedure in order for them to make an
autonomous informed consent. Deception violates fidelity. If disclosure will cause harm it is not obligatory. Partial disclosure
and white or technical lies are permissible under necessity. Disclosure to the family and other professionals is allowed if
it is necessary for treatment purposes. Physicians must use their judgment in disclosure of bad news to the patient.
5.0 PRIVACY AND CONFIDENTIALITY
Privacy and confidentiality are often confused. Privacy is the right to make decisions
about personal or private matters and blocking access to private information. The patient voluntarily allows the physician
access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained
within the confines of the Law even after death of the patient. In routine hospital practice many persons have access to confidential
information but all are enjoined to keep such information confidential.
Confidentiality includes medical records of any form. The patient should not make unnecessary
revelation of negative things about himself or herself. The physician can not disclose confidential information to a third
party without the consent of the patient. Information can be released without the consent of the patient for purposes of medical
care, for criminal investigations, and in the public interest. Release is not justified without patient consent for the following
purposes: education, research, medical audit, employment or insurance.
6.0 FIDELITY
The principle of fidelity requires that physicians
be faithful to their patients. It includes: acting in faith, fulfilling agreements, maintaining relations, and fiduciary responsibilities
(trust and confidence). It is not based on a written contract. Abandoning the patient at any stage of treatment without alternative
arrangements is a violation of fidelity. The fidelity obligation may conflict with the obligation to protect third parties
by disclosing contagious disease or dangerous behavior of the patient. The physician may find himself in a situation of divided
loyalty between the interests of the patient and the interests of the institution. The conflict may be between two patients
of the physician such as when maternal and fetal interests conflict. Physicians involved in clinical trials have conflicting
dual roles of physicians and investigators.
