IMA CODE OF ETHICS

Indian medical association

IMA CODE OF MEDICAL ETHICS 2021

Prepared by

IMA Standing Committee for Medical Ethics

IMA CODE OF MEDICAL ETHICS 2021

Prepared by

IMA Standing Committee for Medical Ethics

Dr. J.A. Jayalal Dr. Jayesh Lele

National President, IMA Honorary General Secretary, IMA

Dr. Vinay Agarwal

Chairman

Contents

Dr. Srikumar Vasudevan

Convener

IMA Standing Committee for Medical Ethics

Chairman : Vice-Chairman : Convener : Members :

Dr.Vinay Agarwal Dr.Rajendra Airan Dr.Srikumar Vasudevan Dr.L.V.K Moorthy Dr.M.N. Menon Dr.Karan Singh Punia Dr.Dhiren.C.Patel Dr.Bijuli Goswami Dr.Cheran.B

Dr. Jayesh Lele

Hony. Secretary General, IMA

Dr. J.A. Jayalal

National President, IMA

CONTENTS

Message………………………………………………………………………… 3

Prologue………………………………………………………………………………………………………….. 4

Chapter 1 CODE OF MEDICAL ETHICS………………………………………….. 6

Chapter 2 DUTIES OF PHYSICIANS TO THEIR PATIENTS………………….. 20

Chapter 3 DUTIES OF PHYSICIAN IN CONSULTATION……………………… 35

Chapter 4 RESPONSIBILITIES OF PHYSICIANS TO EACH OTHER……….. 39

Chapter 5 DUTIES OF PHYSICIAN TO THE PUBLIC AND TO THE PARAMEDICAL PROFESSION………………………………………………………………………… 41

Chapter 6 UNETHICAL ACTS……………………………………………………… 43 Chapter 7 MISCONDUCT……………………………………………………………. 57 Chapter 8 PUNISHMENT AND DISCIPLINARY ACTION……………………. 63

Dear Members,

MESSAGE

Indian Medical Association is the largest professional organisation of modern medicine doctors. It plays a very important role in maintaining the honour and dignity and upholding the interest of the medical profession.

The practice of medicine unlike other profession is unique because it deals with persons when they are most vulnerable. The patients who are heavily dependent on the knowledge and skill of the doctor are often forced to accept the opinion of the doctor because of their ignorance regarding medical care and lack of other options at that moment of time. The doctor–patient relationship is thus loaded heavily in favour of the doctor. The incongruity of this relationship is addressed by medical ethics which regulates the behaviour of the medical professionals. Medical ethics is the internal regulatory mechanism which guarantees the patient that a doctor would strive to do his best to ensure patient welfare above any other personal interest.

It is of paramount importance to maintain the sanctity of this doctor-patient relationship which is dependent heavily on trust. Indian Medical Association is of the firm view that it has a huge responsibility to establish and promote the highest possible standards of ethical behaviour and care by physicians.

IMA has thus brought out this “IMA CODE OF MEDICAL ETHICS” prepared by the IMA Standing Committee for Medical Ethics in propagating medical ethics among its members.

Dr.Vinay Agarwal

Chairman,IMA Standing Committee for Medical Ethics

Dr. Srikumar Vasudevan

Secretary Standing Committee for Medical Ethics

PROLOGUE

Medical Profession without Ethics would be as uncivilised as it could be. It is imperative that the key components of „humanization‟ and „socialization‟ need to be inbuilt in the entire professional conduct of the medical profession so that it transcends beyond the principles of utilitarianism and attains the required levels of „humanism‟ in the interest of men, mankind and humanity as a whole. It is true that Code of Medical Ethics is enforceable by the registering statutory authority that grants registration to practice modern medicine to a professional who has acquired registering medical qualification. Consequently the medical professional bestowed upon with the privileges of practicing medicine within the tenants of „Ethicality‟, „Morality‟ and „Value Ethos‟ germane to the profession embodied in a prescribed form which has been designated as „Code of Medical Ethics‟.

It is equally true that registering authority is vested with the disciplinary jurisdiction over the registered medical practitioner in case of any breach, deviation and distortion of the binding provisions of Code of Medical Ethics that any and every point of time. The said disciplinary jurisdiction entitles the disciplinary authority to invoke such penalty as is warranted commensurate with the nature of the wrong. In that context the registering authority functions as a „quasi- judicial‟ authority.

Indian Medical Association having character of „Medical Association‟ obviously have a limitation of not having any disciplinary jurisdiction and resultant authority thereto on matters of breach of Code of Medical Ethics and rightly so because a duplication of the disciplinary authority is neither desired nor is warranted. However, the Association is definitely vested with the „Moral Authority‟ over its entire membership in as much as the purity and sanctity of the profession has to be taken as „Sacrosanct‟ and needs to be upheld at all costs, come-what-may.

It is in tune with this moral authority that the present draft should include the provisions and modalities of trying the breach of Code of Medical Ethics by its members through invocation of penalties like „Warning‟, „Censure‟, „Temporary suspension of membership for a specified period, and permanent withdrawal of membership commensurate with the nature of wrong following the required stipulated procedure ensuring that principles of natural justice are met with in totality.

Short Title and Commencement: These Regulations may be called the Indian Medical Association Code of Medical Ethics 2021.

Each applicant, at the time of being enrolled as a member of Indian Medical association (IMA) shall be provided with a copy of the IMA CODE OF MEDICAL ETHICS.

CHAPTER I

. CODE OF MEDICAL ETHICS

A. Duties and responsibilities of the Physician in general:

1.1 Character of Physician (Doctors with qualification of MBBS

with or without post graduate degree/ diploma

1.1.1 A physician shall uphold the dignity and honour of his profession.

1.1.2 The prime object of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration. Who-so-ever chooses his profession, assumes the obligation to conduct himself in accordance with its ideals. A physician should be an upright man, instructed in the art of healings. He shall keep himself pure in character and be diligent in caring for the sick; he should be modest, sober, patient, prompt in discharging his duty without anxiety; conducting himself with propriety in his profession and in all the actions of his life.

1.1.3 No person other than a doctor having qualification recognised by National Medical Commission and registered with National Medical Commission/State Medical Council (s) is allowed to practice Modern system of Medicine or Surgery. A person obtaining qualification in any other system of Medicine is not allowed to practice Modern system of Medicine in any form.

1.2 Maintaining good medical practice:

1.2.1 The principal objective of the medical profession is to render service to humanity with full respect for the dignity of profession and man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. Physicians should try continuously to improve medical knowledge and skills and should make available to their patients and colleagues the benefits of their professional attainments. The physician should practice methods of healing founded on scientific basis and should not associate professionally with anyone who violates this principle. The honoured ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also the health care needs of the society.

1.2.2 Patient’s Rights & Doctor’s Responsibilities

The successful care of patients depends on a mutually respected and combined effort by the patient, doctor and other staff. This mutually respected relationship can be accomplished by acknowledging patients‟ rights.

These include the right

(a) To be respected, given dignity, and timely response to their needs.

(b) To be informed effectively and be given the opportunity to discuss the benefits, risks, and costs of treatment.

(c) To ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered.

(d) To accept or refuse any recommended medical management if they have the capacity to make decisions.

(e) To ensure that the patient‟s privacy and confidentiality is respected by the doctor and other staff.

(f) To obtain copies or summaries of their medical records. (g) To obtain a second opinion.

(h) To expect that their doctor coordinate with other health care professionals in the best interest of the patients.

(i) To expect the doctor will not discontinue medically indicated further treatment without giving them sufficient notice.

(j) To expect that doctors would make an attempt to take appropriate measures to restore their rights when they have been denied by any institution or following government laws or notifications.

Doctors face an ethical dilemma when they are accountable both to their patients and to a third party which could include the government, judiciary, family members or the management of the health care institution in which the doctor is an employee. The ethical challenge is how to protect the patient‟s interest in the face of pressures from the third party.

1. In situations like notified diseases or child abuse etc reporting by doctor is mandatory. It should be done without reluctance but patients should be informed about the same. The doctor should attempt to guard their professional independence to determine the best interests of the patient and should observe the normal ethical requirements of informed consent and confidentiality.

2. In situations where clinical autonomy of the doctors are curbed by the employer by determining how their patients have to be treated, the doctor should campaign vigorously for the interest of their patients and should not hesitate in reporting to the regulatory bodies or medical associations.

1.2.3 Patient Responsibilities

The successful care of patients depends on a mutually respected and combined effort by the patient and doctor. This mutually respected relationship can be accomplished only when patients satisfy certain responsibilities.

They should

(a) Be honest with their doctor and should not hide any treatment details.

(b) Reveal the complete medical and personal history as much as possible.

(d) Fulfil their financial obligations with regard to medical care. (e) Refrain from behaviour that places the health of others at risk. (f) Not knowingly participate in medical fraud.

(g) Refrain from being abusive or unruly in the clinical settings and preventing the healthcare workers from discharging their rightful duties.

(h) Accept care from medical students, residents, and other trainees under appropriate supervision.

(i) Participate in medical education for the mutual benefit of patients and the health care system.

1.2.4 Membership in Medical Society: For the advancement of his profession, for the uniformity of the treatment at large, to be part of National policy in health and related subjects, a physician shall affiliate with associations and societies of modern medical science and involve in activity and the functioning of such bodies. No

physician should be denied participation in medical society activities or membership, medical education and training, employment and remuneration on the basis of religion, caste, creed and gender.

1.2.5 A Physician should participate in professional meetings, conferences, workshops as part of Continuing Medical Education programmes, recognized by respective State Medical Councils/ National Medical Commission for at least 30 hours every five years, out of which 3 hours should be on medical ethics organized by reputed professional academic bodies or any other authorized organisations. The compliance of this requirement shall be informed regularly to National Medical Commission or the State Medical Councils as the case may be. This fulfilment will be sufficient for renewal of registration with State Medical Councils/ Medical Council of India.

As attendees of CME programs, physicians should:

(a) Select programs that are of high quality and are related to their educational needs.

(b) Choose programs involving medical ethics and its application in their professional activities.

(d) Should not accept any sort of offer from any commercial organisation other than the doctor‟s employer to compensate the physician for the time spent or expenses incurred to participate in the CME activity.

It is an accepted fact that pharmaceutical or medical device companies play a crucial role in successfully conducting high quality CMEs. However they should not directly or indirectly influence the outcome or content of these meetings. Financial relationship between

such companies and doctors who organize CME meetings should be transparent about financial details

1.3 Maintenance of medical records:

1.3.1 Every physician shall maintain the medical records pertaining to his/her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the National Medical Commission.

1.3.2 Doctors have a responsibility to maintain the medical records of patients properly in order to safeguard the confidentiality of patients‟ personal information.

To manage medical records responsibly, physicians or the individual responsible for the institution‟s medical records should:

(a) Ensure institution has a clear policy about managing medical records of patients.

(b) Ensure that medical records of patients cannot be accessed by unauthorized staff.

(c) If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 7 working days.

(d) Ensure that records that are to be discarded are destroyed to protect confidentiality.

1.3.3 Electronic Medical Records: Physicians or Health Care Institutions, who collect or store patient information electronically, must:

(i) Ensure restriction of data entry and access only to authorized persons

(ii) Routinely monitor/audit access to records

(iii) Ensure data security and integrity

(iv) Describe how the confidentiality of the data is protected if requested by the patient or appropriate authorities.

(v) Reveal patient information according to the ethical guidelines of confidentiality.

1.3.4 Communication with Patients electronically

When physicians communicate with patients using electronic media they have to maintain the same ethical responsibilities to patients as they do during other clinical encounters.

(a) When a doctor decides to communicate electronically with patients he should ensure protection of privacy and confidentiality of patient information.

(b) When a patient initiates electronic communication the doctor should inform the patient about the limitations of these channels

(i) Possible breach of privacy or confidentiality

(ii) Difficulty in confirming the identity of the parties

(iii) Possible delays in response

(c) However patients should have the right to accept or decline electronic communication before confidential information is transmitted which should be documented in the medical record.

(d) Before proceeding treatment an electronic informed consent should be taken from the patient or surrogate attendant.

1.3.5 Issuance of Medical certificate

(a) No medical certificate should be issued in absentia or predated.

(b) A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate.

He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report.

The medical certificate shall be prepared as in Appendix 1.

1.3.6 Efforts shall be made to computerize medical records for quick retrieval.

1.4 Display of registration numbers:

1.4.1 Every physician shall display the registration number accorded to him by the State Medical Council / National Medical Commission in his clinic and in all his prescriptions, certificates, money receipts given to his patients. The registration number displayed should be from the State in which he is practising.

1.4.2 Physicians shall display as suffix to their names only recognized medical degrees or such certificates/diplomas and memberships/honours which confer professional knowledge or recognizes any exemplary qualification/achievements registered with the State Medical Council / National Medical Commission.

1.5 Use of Generic names of drugs: Every physician should, as far as possible, prescribe drugs with both brand and generic names legibly and preferably in capital letters and he/she shall ensure that there is a rational prescription and use of drugs.

1.6 Highest Quality Assurance in patient care:

1.6.1 Every physician should aid in safeguarding the profession against admission to it of those who are deficient in moral character or education. Physician shall not employ in connection with his professional practice any attendant who is neither registered nor enlisted under the Medical Acts in force and shall not permit such persons to attend, treat or perform operations upon patients wherever professional discretion or skill is required.

1.6.2 Doctors have the responsibility to ensure that the care patients receive is safe, prompt, effective and reasonable. They should actively engage in efforts to improve the quality of health care by

(a) Keeping themselves updated with the latest developments by participating in continued medical educational programs, certification courses and workshops on topics including medical ethics.

(b) Communicating effectively with patients, families, and professional colleagues.

1.6.3 Judicious allocation of resources: Physicians are primarily responsible for initiating most of the healthcare expenditure but with the growing dominance of hospital management doctors often face ethical challenges in deciding what is best for their patients. The decision to choose between potential patients for a particular treatment which is in limited supply must be based solely on medical criteria and without discrimination.

Another type of ethical challenge is when physicians have to decide allocation of scarce resources like intensive care beds, organs for transplantation etc. knowing very well that those who are denied may suffer, and even die, as a result.

Physicians could adopt the following criteria in deciding how to allocate the limited health resources judiciously for the welfare of patients:

(a) First priority should be given to those patients for whom immediate medical intervention will avoid premature death.

(b) Use an impartial, transparent mechanism to decide which patients should receive the resource(s) when there are not significant differences among patients who need the limited resource(s).

(c) Discuss and take into confidence patients who were denied the limited resources about the existing allocation policies. Explain the applicable allocation policies or procedures to patients who are denied access to the scarce resource(s) and to the public.

Some physicians who hold administrative positions or serve on committees where policies are decided regarding allocation of resources should not use their position to advance the cause of their patients over others with greater needs.

1.7 Exposure of Unethical Conduct: A Physician should expose, without fear or favour, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession.

Reporting of a colleague who involves in unethical behaviour is necessary

(a) To maintain the dignity of the profession

(b) To maintain its status as a self-regulating profession

(d) To safeguard the trust existing in the doctor-patient relationship.

(e) Since it is often only a physician who can recognise the professional misconduct of another doctor.

However no physician should make a false allegation against another colleague in a bid to attack his reputation for unworthy personal motives.

Physicians who realises that a colleague is engaging in unethical practice should:

(a) In the first instance if possible approach the colleague and inform him that his or her behaviour is unsafe or unethical.

(b) If there is no change inform about the conduct to the peer review body of the medical association, hospital or medical college to assess its possible impact on patient care and advice the erring colleague to take corrective measures.

(c) As a last resort the physician can report to the State Medical Council or National Medical Commission. However he may report directly to the State Medical Council or National Medical Commission when the conduct in question poses an immediate threat to the health and safety of patients or violates licensing board‟s rules and regulations.

(d) Protect the privacy and confidentiality of any patients who may be involved to the greatest extent possible.

Physicians who receive reports of alleged unethical conduct by a professional colleague, resident physician or medical student should:

(i) Evaluate the reported complaint unsympathetically and impartially.

(ii) Maintain its secrecy until it is resolved.

(iii) Ensure that the identified contentious issues are resolved

(iv) Inform the appropriate authorities for requisite action if the contentious issues are not resolved.

(v) Inform the reporting physician when appropriate action has been taken, except in cases of anonymous reporting.

1.8 Preventing Violence & Abuse against patients

Physicians have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse against the vulnerable patients.

1.9 Reporting of Adverse Events

Physicians have an ethical responsibility to respond to any adverse reaction to a drug or medical device by

(a) Communicating that information to the professional community

(b) Promptly reporting serious adverse events requiring hospitalization, death, or medical or surgical intervention to the appropriate regulatory agency.

1.10 Review by associates

Physicians have mutual responsibilities to ensure that their colleagues maintain ethical standards during their professional activities. Peer review, by the ethics committees of medical associations, hospitals and medical colleges should scrutinize professional conduct of physicians to promote professionalism and maintain patient trust.

Physicians who are involved in reviewing the conduct of colleagues, medical students and residents should:

(a) Themselves be adhering to the highest ethical principles

(b) Ensure that the members of the reviewing body include persons who have a comparable level of qualification or training.

While reviewing the conduct of colleagues physicians should adhere to principles of a fair and objective hearing, including:

(i) Specifying the charges

(ii) Ample time to respond to the notice

(iii) Right to be present and to disprove the allegations

1.11 Payment of Professional Services: The physician, engaged in the practice of medicine shall give priority to the interests of patients.

The personal financial interests of a physician should not conflict with the medical interests of patients. It is unethical to enter into a contract of “no cure no payment”. Physician rendering service on behalf of the state shall refrain from anticipating or accepting any consideration. Doctors should not advise, conduct or charge for unnecessary medical services. Doctors should not make deliberate false claims to increase the payment they receive.

Regarding fees, physicians should:

(a) A physician should announce his fees before rendering service and not after the operation or treatment is under way.

(b) Remuneration received for such services should be in the form and amount specifically announced to the patient at the time the service is rendered.

(c) Charge only for the service(s) they have personally rendered or for services performed under his direct personal supervision.

(d) Claim his/her professional charges separately when services are provided by more than one physician.

1.12 Evasion of Legal Restrictions: The physician shall observe the laws of the country in regulating the practice of medicine and shall also not assist others to evade such laws. He should be cooperative in observance and enforcement of sanitary laws and regulations in the

interest of public health. A physician should observe the provisions of the State Acts like Drugs and Cosmetics Act, 1940; Pharmacy Act, 1948; Narcotic Drugs and Psychotropic substances Act, 1985; Medical Termination of Pregnancy Act, 1971; Transplantation of Human Organ Act,1994; Mental Health Act, 1987; Environmental Protection Act, 1986; Pre–natal Sex Determination Test Act, 1994; Drugs and Magic Remedies (Objectionable Advertisement) Act, 1954; Persons with Disabilities (Equal Opportunities and Full

Participation) Act, 1995 and Bio-Medical Waste (Management and Handling) Rules, 1998 and such other Acts, Rules, Regulations made by the Central/State Governments or local Administrative Bodies or any other relevant Act relating to the protection and promotion of public health.

CHAPTER 2

DUTIES OF PHYSICIANS TO THEIR PATIENTS

2.1 Obligations to the Sick

2.1.1 Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties. In his treatment, he should never forget that the health and the lives of those entrusted to his care depend on his skill and attention. A physician should endeavour to add to the comfort of the sick by making his visits at the hour indicated to the patients. A physician advising a patient to seek service of another physician is acceptable; however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient.

Doctors should not decline

(a) To accept a patient requiring emergency care.

(b) Patients for whom they have promised the responsibility to provide care.

(d) Patient merely on his infectious disease status.

However, doctors are not ethically bound to accept all probable patients.

A doctor may refuse treatment to a prospective patient, or provide specific care to an existing patient, in certain limited conditions:

(a) If the patient‟s condition is beyond the physician‟s competence or skill and refer the patient to another physician.

(b) If the care requested by the patient is known to be unscientific or is not medically indicated.

(d) If the treatment or care requested is discordant with the law of the land or the medical ethics.

(e) If the patient or those accompanying him are disruptive or threatens the doctor, staff, or other patients.

(f) If the doctor lacks the resources needed to provide safe, competent, respectful care for the patient.

2.2. Communication & Consent

2.2.1 Informed consent: It is one of the fundamental concepts of medical ethics. It is based on the principle of “patient autonomy”. A mentally competent adult patient has the right to make decisions regarding any diagnostic procedure or therapy. The patient has the right to be informed in a manner he understands best regarding the purpose of any test or treatment, what the results would imply, and what would be the consequences of withholding consent.

A proper informed consent requires the physician to

a. Evaluate the patient‟s ability to understand relevant medical information to make an independent, voluntary decision.

b. Provide all the information for the patients to make their decisions.

c. Explain complex medical diagnosis, prognosis and treatment regimes in a language patient understand.

d. Ensure that patients understand the available treatment options, including the advantages and disadvantages of each,

e. Clarify doubts that patients may have.

f. Understand whatever decision the patient has reached.

Although the term „consent‟ implies acceptance of treatment, informed consent applies equally to refusal of treatment or to choose alternative treatments.

It is not uncommon for family members of patients to plead with physicians not to tell the patients that they are dying but the doctor should not comply with such requests.

2.2.2 Futile Treatment:

There are instances where patients demand medical service that they feel can benefit them even when the doctors are convinced that the service can offer no medical benefit for the patient‟s condition. As a general rule a patient or a patient‟s surrogate, should be involved in determining futility in his or her case. The physician has no obligation to offer a patient futile or non-beneficial treatment.

The principle of informed consent incorporates the patient‟s right to choose from among the options presented by the physician. Doctors should refuse such requests if they are convinced that the treatment would produce more harm than benefit. They should also refuse if the treatment is unlikely to be beneficial, even if it is not harmful or if there is limited resources after convincing the patient or the patient‟s surrogate about the futility of the treatment.

2.2.3 Decision-Making for Incompetent Patients:

When a patient lacks the capacity to make a proper decision, for example children, individuals affected by certain psychiatric or

neurological conditions, and those who are temporarily unconscious or comatose, the physician has an ethical responsibility to:

(a) Identify an appropriate surrogate to make decisions on the patient‟s behalf

(b) Ensure that the patient‟s surrogate is given the same respect as the patient.

(d) Consult the institutional ethics committee where there is no proper surrogate available.

In a situation where an emergency medical intervention is needed from a patient who is unconscious or otherwise unable to express his/her will and a surrogate is not available, the consent of the patient may be presumed, unless the patient has previously expressed beyond any doubt that he/she would refuse consent to the intervention in that situation.

Problems arise when multiple surrogate decision makers for example different family members, do not agree among themselves or when they do agree, their decision according to the physician‟s opinion is not in the best interest of the patient. If the disagreement could not be resolved by the physician‟s mediation then the decision could be settled through institutional ethics committee or legal avenues.

2.3 Medical practitioner having any incapacity detrimental to the patient or which can affect his performance vis-à-vis the patient is not permitted to practice his profession

Working at a hectic pace and working without adequate rest could affect the mental and physical health of physicians. This could adversely affect the medical care being provided leading to medical mishaps. It could even lead to chronic fatigue, substance abuse and even suicide.

When their health is compromised, physician should

(a) Assess honestly of their ability to continue practice

(b) Discontinue their practice if there is a possibility of compromise in the care being provided to patients.

However physicians who are impaired deserve empathetic care. Hence physicians have an ethical responsibility to:

(a) Establish a mechanism to identify such impaired colleagues and report about such colleagues to the appropriate concerned authorities

(b) Ensure that the impaired colleagues stop practicing and receive help, guidance and treatment.

2.4 Patience, Delicacy and Secrecy : Patience and delicacy should characterize the physician. Confidences concerning individual or domestic life entrusted by patients to a physician and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the State. Sometimes, however, a physician must determine whether his duty to society requires him to employ knowledge, obtained through confidence as a physician, to protect a healthy person against a communicable disease to which he is about to be exposed. In such instance, the physician should act as he would wish another to act toward one of his own family in like circumstances.

2.4.1Privacy in health care: It is the right of patient to maintain information about oneself, free from the knowledge of others. It relates to autonomy of the patient and is essential for building the trust of the doctor- patient relationship.

Physicians must ensure patient privacy to the greatest extent possible since

(i) Most patients are capable of noticing disrespect for their privacy and they usually suffer deeply unwanted exposure and intrusion.

(ii) The violation of privacy is humiliating regardless of the harm done.

(iii) Patients resent the act of exposure, even if the information disclosed is of little practical consequence.

Patient privacy involves:

(a) Physical privacy- It is a concept of privacy which recognizes the need for bodily privacy and environmental privacy. Physicians have the responsibility to ensure the physical privacy of the patients while examining.

(i) Patient‟s body is never fully exposed; only the part under examination is.

(ii) Healthcare professionals use gloves when touching intimate parts of the body.

(b) Informational privacy- Secrecy, confidentiality, anonymity and protection of patient data would come under this form of privacy. It calls for access to personal information to be limited and this is especially true with respect to health information, present and past. Limiting access to medical and insurance records are fundamental protections required under the principle of confidentiality in the professional-patient relationship.

(c) Decisional privacy can be understood as having control over intimate aspects of personal identity involving cultural & religious affiliations. Under decisional privacy a person can expect to be allowed to make their own decisions and act on their decisions if they so choose free from state, governmental or health professional‟s interference.

(d) Expressive privacymeans control over expressed thoughts and opinions and personal communications with others.

(e) Associational privacy involves privacy over personal relationships with family members and other intimates.

Specific permission is needed in order to publish medical data, which must also be anonymized.

2.4.2 External observers to clinical procedures

When individuals who are not involved in providing care but seek to observe clinical procedures, e.g., for educational purposes, physicians have the responsibility to safeguard patient privacy by permitting such observers to be present during the procedures only when:

(a) The patient has given consent to the presence of the observers.

(b) The observer understands and has agreed to adhere to standards of medical privacy and confidentiality.

(c) Doctors should not accept payment from outside observers to allow those observers to be present during a clinical procedure.

When the patient lacks decision-making capacity outside observers should be permitted only with the consent of an authorized decision maker.

2.4.3 Audio-visual Recording of Patients for Educational purposes

Physicians must ensure patient privacy and confidentiality before allowing audio or visual recording of clinical procedures.

While recording for purposes of educating health care professionals, physicians should:

(a) Obtain consent from the patient (or the authorized decision maker) prior to recording.

(b) Ensure that all persons (clinical or nonclinical) present during recording agree to comply with the principle of patient‟s privacy and confidentiality.

(c) Restrict the recording of procedures involving only patients who have decision-making capacity. Recording should be permitted on patients lacking decision-making capacity only in rare circumstances and only if the authorized decision maker gives consent.

(d) Inform the patient (or authorized decision maker)

(i) about the purpose of recording& the intended audience

(ii) about the potential breach of privacy or confidentiality of participating

(iii) that the participation is voluntary and a decision not to participate (or to withdraw) will not affect the quality of patient care

(iv) that the patient has the option to withdraw consent at any time and if so, what will be done with the recording

(v) that use of the recording will be limited to educational purposes only.

(e) Ensure that the doubts of the patient or authorised decision maker are cleared before and after recording.

(f) Respect the decision of a patient to withdraw consent.

(g) Be aware that the act of recording may affect patient‟s behaviour during a clinical procedure and thereby affect the film‟s educational content and value. This should not affect the quality of patient care.

(h) Be aware that the information gathered during such recordings should be accorded the same protection, properly stored and destroyed as managing any other medical records.

2.4.4 Confidentiality

Confidentiality is defined as the principle of maintaining the security of information derived from an individual in the circumstances of a professional relationship.All identifiable patient information whether written, computerised, visual or audio recorded or simply held in the memory of health professionals, is subject to the duty of confidentiality. Doctors have an ethical responsibility to protect the confidentiality of patients which is based on autonomy and trust.

In confidentiality the principle of autonomy is invoked due to the fact that personal information about a patient belongs to him or her and should not be made known to others without his or her consent.

Patients without fear of a breach of confidentiality should be able to communicate symptoms that often they may feel are embarrassing, stigmatising, or indeed trivial. Without this trusting relationship patients may not divulge vital informationwhich could affect the doctor‟s efforts to provide effective treatment. They may even not seek medical attention at all

The patient‟s right to confidentiality are as follows:

• Information about a patient’s health status, medical condition, diagnosis, prognosis and treatment and all other personal information must be kept confidential, even after death.

• All identifiable patient data must be protected. The protection of the data depends on the manner of its storage.

Breaches of confidentiality may occur in most healthcare institutions because many individuals like doctors, nurses, laboratory technicians, students, staff of the records department etc. gain access to a patient‟s health records. Doctors routinely inform the family members of a deceased person about the cause of death. These breaches of confidentiality are usually justified, but they should be kept to a minimum necessary and those who gain access to confidential information should be made aware of the need not to spread it any

further than is necessary for the patient‟s or descendants‟ benefit. Where possible, patients should be informed that such breaches occur.

Doctors may disclose the patient‟s personal health information without the specific consent of the patient

(a) To other health care personnel for the purpose of providing care

(b) To the concerned authorities when disclosure is required by law. For eg – patients who suffer from designated diseases, those deemed not fit to drive and those suspected of child abuse. Physicians should be aware of the legal requirements for the disclosure of patient information.

(c) To other third parties when the doctor feels that patient might seriously harm one-self or other individuals and the expected harm is believed to be imminent, serious (and irreversible), unavoidable except by unauthorised disclosure, and greater than the harm likely to result from disclosure

While disclosing patients‟ personal health information, doctors should:

(a) Disclose only the minimum necessary information

(b) If possible inform the patient about the disclosure.

For any other disclosures, doctors should obtain the consent of the patient (or lawful surrogate) before disclosing personal health information.

2.4.5 Confidentiality after death

Patients should be given the same respect for the confidentiality of their personal information after death as they were when alive. Doctors have a responsibility to protect patient information obtained post mortem. Doctors may disclose autopsy results to those decision maker(s) who gave consent for the procedure.

Doctors may disclose a patient‟s personal health information after his death only:

(a) If the patient had given prior consent or instruction.

(b) To those persons to whom the patient had given consent

(d) When the doctor feels that revealing of information would prevent harm to, or benefit individuals or the community

(d) For medical research or education if personal identifiers have been removed.

In all situations, physicians should reveal only minimum necessary information.

2.4.6 Patient information outside an existing doctor-patient relationship

Physicians may sometime have to assess an individual‟s health or disability on behalf of an employer, insurer, or other third party. In such situations, physicians have a responsibility to protect the confidentiality of patient information.

In cases of claims for medical insurance there is a possibility of breach of confidentiality

When conducting third-party assessments physicians may disclose information to a third party:

(a) Only following a written or documented consent of the individual. (b) As required by law

When disclosing information to third parties, physicians should:

(d) Ensure that individually identifying information is removed before releasing aggregate data or statistical health information about the related population.

(e) Inform patients about the purpose(s) for which the access would be granted.

(f) Physicians should decline any sort of incentives for the information being provided.

2.4.7 Representatives of medical manufacturers in clinical settings

Representatives of medical device manufacturers may sometimes have to be present in clinical settings while care is being given to patients and during medical workshops. Their presence raises certain ethical challenges like patient autonomy, privacy, and confidentiality.

Thus when physicians invite industry representatives into the clinical setting they should:

(a) Verify if the representative has the requisite qualifications to provide the desired assistance.

(b) Ensure that the representative will uphold the respect for patient privacy and confidentiality.

2.5 Prognosis: The physician should neither exaggerate nor minimize the gravity of a patient‟s condition. He should ensure himself that the patient, his relatives or his responsible friends have such knowledge of the patient‟s condition as will serve the best interests of the patient and the family.

2.6 The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Provisionally or fully registered

medical practitioner shall not wilfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

Once a doctor consents to treat a patient he has an obligation to support continuity of care. If the doctor is aware of any future impediments to continuity of care he should inform the patient adequately before.

However there may be conditions where a doctor has the right to terminate the doctor –patient relationship like

a. if the patient requires another doctor with different skills or if the treatment is beyond the capacity of the treating doctor

b. the physician‟s moving out or stopping practice,

c. both the patient and the doctor have conflict of interest.

d. the patient refuses to comply with the physician‟s advice.

When considering withdrawal from care of a patient, the doctor must:

(a) Inform the patient or authorized decision maker adequately before for them to secure another doctor.

(b) Enable appropriate transfer of care.

Many doctors especially those in the public sector, often have no choice of the patients they treat. Some patients are violent and pose a threat to the safety of the doctor and his staff. Others can be described as abusive or unruly. With such patients, a doctor must balance his responsibility to promote the well-being of the patients with his own and his staff‟s safety and well-being. They should attempt to find ways to honour both of these obligations. If this is not possible, they should try to make alternative arrangements for the care of the patients.

2.7 Special doctor-Patient Relationships 2.7.1 Treating Family members

A doctor treating a family member poses several ethical challenges involving professional neutrality, patient autonomy, and informed consent. When the patient is an immediate family member the doctor‟s personal feelings may influence his or her professional judgment.

(a) Despite feeling reluctant he may be forced to provide care.

(b) While taking the medical history he may knowingly avoid complex areas

(d) He may treat problems that are beyond his expertise.

On the other hand patients may feel uncomfortable receiving care from a family member.

(a) A patient may knowingly hide sensitive information.

(b) May be reluctant to undergo examination of intimate parts by a doctor who is an immediate family member.

(d) Family members may be hesitant to reveal their preference for another doctor or their disagreement with doctor‟s treatment for fear of offending him.

In general, doctors should refrain from treating members of their own families. However they may do so under limited circumstances:

(a) In emergencies or in situations where there is no other qualified physician available.

(b) For short-term, minor problems.

When treating family members, doctors have a further responsibility:

(a) Proper documentation of the treatment provided.

(b) Avoid giving sensitive or intimate care especially for a minor patient who is uncomfortable being treated by a family member.

2.7.2 Unruly Behaviour by Patients

The doctor-patient relationship is based on trust and both should respect each other‟s dignity and rights.

Violence or abusive language or insulting behaviour on the part of either doctor or patient can undermine this trust and thus deteriorate the doctor-patient relationship. Thus a doctor has the liberty to terminate the patient-physician relationship with a patient who uses derogatory language or acts in a manner detrimental to the doctor or his staff.

2.8 Engagement for an Obstetric case: When a physician who has been engaged to attend an obstetric case is absent and another is sent for and delivery accomplished, the acting physician is entitled to his professional fees, but should secure the patient‟s consent to resign on the arrival of the physician engaged.

CHAPTER 3

DUTIES OF PHYSICIAN IN CONSULTATION

3.1 Unnecessary consultations should be avoided:

3.1.1 However in case of serious illness and in doubtful or difficult conditions, the physician should request consultation, but under any circumstances such consultation should be justifiable and in the interest of the patient only and not for any other consideration.

Deliberately treating excessively or hospitalizing a patient for a prolonged period for financial gain of the doctor or the health care institution with which the physician is affiliated is considered to be unethical.

In ideal healthcare there is a consensual approach by the doctors, patient and the administrators of the health care institutions. Disagreements among physicians about the final outcome of treatment or care and the means of achieving it should be made clear and resolved by the members of the team so as not to compromise their relationships with the patient.

Disagreements between the healthcare providers and administrators regarding the allocation of resources should be resolved within themselves and not discussed in the presence of the patient.

The following guidelines can be useful for resolving such conflicts:

• First priority must be to resolve the conflicts informally, through direct negotiations between the persons who disagree and moving to a more formal procedure only when informal methods have been unsuccessful.

• The opinions of all those directly involved should be given due consideration.

• If the dispute is about which options of treatment the patient should be offered, the informed choice of the patient, or authorized surrogate decision-maker, should be given the primary consideration in resolving disputes.

• If, after reasonable effort, agreement could be reached through dialogue, the decision of the physician who heads the team having the right or responsibility for making the final decision should be accepted.

If the physicians cannot accept the decision that prevails as a matter of professional judgement or personal morality, they should be allowed to withdraw from participation in carrying out the decision, after ensuring that the person receiving care is not at risk of harm or abandonment.

3.1.2 Consulting pathologists /radiologists or asking for any other diagnostic Lab investigation should be done judiciously and not in a routine manner.

3.2 Consultation for Patient’s Benefit: In every consultation, the benefit to the patient is of foremost importance. All physicians engaged in the case should be frank with the patient and his attendants.

When physicians seek or provide consultation about a patient‟s care or refer a patient for health care services, including diagnostic laboratory services, they should:

(a) Inform the patient about the reason for the conducting the investigations or referral consultations and also the result and recommendations following the consultation.

(b) Share patients‟ health details maintaining the ethical principles of confidentiality.

(c) Doctor should not terminate a doctor-patient relationship solely because the patient consulted a health care professional whom the doctor had not recommended.

3.3 Punctuality in Consultation: Utmost punctuality should be observed by a physician in making themselves available for consultations.

3.4 Statement to Patient after Consultation:

3.4.1 All statements to the patient or his representatives should take place in the presence of the consulting physicians, except as otherwise agreed. The disclosure of the opinion to the patient or his relatives or friends shall rest with the medical attendant.

3.4.2 Differences of opinion should not be divulged unnecessarily but when there is irreconcilable difference of opinion the circumstances should be frankly and impartially explained to the patient or his relatives or friends. It would be opened to them to seek further advice as they so desire.

3.5 Treatment after Consultation: No decision should restrain the attending physician from making such subsequent variations in the treatment if any unexpected change occurs, but at the next consultation, reasons for the variations should be discussed/ explained. The same privilege, with its obligations, belongs to the consultant when sent for in an emergency during the absence of attending physician. The attending physician may prescribe medicine at any time for the patient, whereas the consultant may prescribe only in case of emergency or as an expert when called for.

3.6 Patients Referred to Specialists: When a patient is referred to a specialist by the attending physician, a case summary of the patient should be given to the specialist, who should communicate his opinion in writing to the attending physician.

3.7 Fees and other charges:

3.7.1 A physician shall clearly display his fees and other charges on the board of his chamber and/or the hospitals he is visiting. Prescription should also make clear if the Physician himself dispensed any medicine.

3.7.2 A physician shall write his name and designation in full along with registration particulars in his prescription letter head.

Note: In Government hospital where the patient–load is heavy, the name of the prescribing doctor must be written below his/her signature.

CHAPTER 4

RESPONSIBILITIES OF PHYSICIANS TO EACH OTHER

4.1 Dependence of Physicians on each other: A physician should consider it as a pleasure and privilege to render gratuitous service to all physicians and their immediate family dependants.

While treating peers, physicians must follow the same ethical principles as when treating any other patient.

Physicians who provide medical care to a colleague should:

(a) Ensure that the personal or professional relationship the physician may have with the patient does not influence his independent professional judgment and treatment advices.

(b) Respect the privacy and confidentiality of the peer patients.

(d) Realise the discomfort of the peer to reveal sensitive information and undergo examination of intimate parts by a doctor who is well known to him/her.

(d) Should respect the autonomy of the patient doctor to take decision regarding his treatment by providing all the necessary information.

(e) Repeatedly enquire if the doctor-patient wants a second opinion from another physician.

4.2 Conduct in consultation: In consultations, no insincerity, rivalry or envy should be indulged in. All due respect should be observed towards the physician in-charge of the case and no statement or remark be made, which would impair the confidence reposed in him. For this purpose no discussion should be carried on in the presence of the patient or his representatives.

4.3 Consultant not to take charge of the case: When a physician has been called for consultation, the Consultant should normally not take charge of the case, especially on the solicitation of the patient or friends. The Consultant shall not criticize the referring physician. He / she shall discuss the diagnosis treatment plan with the referring physician.

4.4 Appointment of Substitute: Whenever a physician requests another physician to attend his patients during his temporary absence from his practice, professional courtesy requires the acceptance of such appointment only when he has the capacity to discharge the additional responsibility along with his / her other duties. The physician acting under such an appointment should give the utmost consideration to the interests and reputation of the absent physician and all such patients should be restored to the care of the latter upon his/her return.

Multiple Surgeons

When one or more surgeons participate in performing a surgical intervention, the surgeon has an ethical responsibility to:

(a) Inform the patient the surgeons who are participating in the procedure and whether they will do so under the doctor‟s personal supervision or not.

(b) The informed consent for the intervention obtained from the patient or surrogate should mention the surgeons involved in the procedure.

4.5 Visiting another Physician’s Case: When it becomes the duty of a physician occupying an official position to see and report upon an illness or injury, he should communicate to the physician in attendance so as to give him an option of being present. The medical officer / physician occupying an official position should avoid remarks upon the diagnosis or the treatment that has been adopted.

CHAPTER 5

DUTIES OF PHYSICIAN TO THE PUBLIC AND TO THE PARAMEDICAL PROFESSION

5.1 Physicians as Citizens: Physicians, as good citizens, possessed of special training should disseminate advice on public health issues. They should play their part in enforcing the laws of the community and in sustaining the institutions that advance the interests of humanity. They should particularly co-operate with the authorities in the administration of sanitary/public health laws and regulations.

5.2 Public and Community Health: Physicians, especially those engaged in public health work, should enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and communicable diseases. At all times the physician should notify the constituted public health authorities of every case of communicable disease under his care, in accordance with the laws, rules and regulations of the health authorities. When an epidemic occurs a physician should not abandon his duty for fear of contracting the disease himself.

5.3 Allied Health Professionals

The professional relationship between physicians and allied health professionals such as nurses, pharmacists, physiotherapists, laboratory technicians, and many others is based on mutual respect and trust because they play an important role in patient care by implementing the orders of the doctors properly. With the rapid growth in technology, scientific knowledge and its clinical applications, patient care is now a team effort in which the views of the allied health professionals are given due consideration by the physician who is the team leader.

Hence it is ethically proper for physicians to:

(a) Consider the concerns of the allied health professionals diligently and explain the order so that it is implemented appropriately

(b) Employ and work collectively only with properly qualified and trained allied health professionals.

CHAPTER 6 UNETHICAL ACTS

A physician shall not aid or abet or commit any of the following acts which shall be construed as unethical –

6.1 Advertising:

6.1.1 Soliciting of patients directly or indirectly, by a physician, by a group of physicians or by institutions or organisations is unethical. A physician shall not make use of him / her (or his / her name) as subject of any form or manner of advertising or publicity through any mode either alone or in conjunction with others which is of such a character as to invite attention to him or to his professional position, skill, qualification, achievements, attainments, specialities, appointments, associations, affiliations or honours and/or of such character as would ordinarily result in his self-aggrandizement. A physician or a group of physicians or by institutions or organisations shall not give to any person, whether for compensation or otherwise, any approval, recommendation, endorsement, certificate, report or statement with respect of any drug, medicine, nostrum remedy, surgical, or therapeutic article, apparatus or appliance or any commercial product or article with respect of any property, quality or use thereof or any test, demonstration or trial thereof, for use in connection with his name, signature, or photograph in any form or manner of advertising through any mode nor shall he boast of cases, operations, cures or remedies or permit the publication of report thereof through any mode.

A medical practitioner is however permitted to make a formal announcement in press regarding the following:

(1) On starting practice.

(2) On change of type of practice.

(3) On changing address.

(4) On temporary absence from duty. (5) On resumption of another practice. (6) On succeeding to another practice. (7) Public declaration of charges.

A physician in such circumstances while advertising himself or herself shall not provide any false or misleading statement. The communication designed should be in a simple and easily understandable manner because often the medical terms or illustrations are beyond the comprehension of ordinary individuals.

The communication may include

(i) Name, qualifications of the physician.

(ii) Place and time of practice

(iii) Fees including charges for specific services and methods of payment

(iv) Photograph of the physician may be included but not displaying awards and achievements.

The services being provided by a physician or a health care institution may be made only if they are factually substantiated.

Endorsements by patients regarding the physician‟s skill or about the treatment and quality of professional service being provided by the health care institutions should be avoided because they could be misleading, incomplete and false.

6.1.2 Printing of self photograph, or any such material of publicity in the letter head or on sign board of the consulting room or any such clinical establishment shall be regarded as acts of self-advertisement

and unethical conduct on the part of the physician. However, printing of sketches, diagrams, picture of human system shall not be treated as unethical.

6.2 Patent and Copy rights: A physician may patent surgical instruments, appliances and medicine or Copyright applications, methods and procedures. However, it shall be unethical if the benefits of such patents or copyrights are not made available in situations where the interest of large population is involved.

6.3 Running an open shop (Dispensing of Drugs and Appliances by Physicians): – A physician should not run an open shop for sale of medicine for dispensing prescriptions prescribed by doctors other than himself or for sale of medical or surgical appliances. It is not unethical for a physician to prescribe or supply drugs, remedies or appliances as long as there is no exploitation of the patient. Drugs prescribed by a physician or brought from the market for a patient should explicitly state the proprietary formulae as well as generic name of the drug.

Since physicians have an ethical responsibility as prescribers and dispensers of drugs and medical devices they should:

(a) Prescribe drugs, devices, and other treatments based solely on the medical need of the patient.

(b) Sell drugs from their own clinic only if it is for the convenience of the patient.

(c) Avoid any kind of monetary payment or compensation from a drug company or device manufacturer for prescribing its products.

(d) Respect patient autonomy to decide from where to buy the drug or device.

(e) Not refer patients to a pharmacy or a device selling shop that the physician owns or manages.

6.4 Rebates and Commission:

6.4.1 A physician shall not give, solicit, or receive nor shall he offer to give solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee for medical, surgical or other treatment.

6.4.2 Gifts from Patients

Though patients offer gifts to doctors with good intentions there is a possibility that it could also be to lure the doctor to offer better or preferential treatment. Accepting gifts could dampen the sanctity of the doctor-patient relationship.

The doctor should thus consider prudently before accepting or declining a gift.

When offered a gift by a patient the doctor should:

(a) Refuse if it is disproportionately expensive.

(b) Ensure that it does not influence the patient‟s medical care.

(c) Decline it if the doctor believes accepting the gift would bring in an unwanted emotional bondage between the doctor and patient.

6.4.3 Fee Splitting

Payment by or to a physician or health care institution solely for referral of a patient without rendering any other service is fee splitting and is unethical.

Physicians should not accept:

(a) Any sort of payment in cash or kind for referring a patient to another physician or health care institution for treatment or diagnostic purpose.

(b) Any sort of payment in cash or kind for referring a patient for research study.

6.4.4 Provisions of para 6.4.1 shall apply with equal force to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study / work. Nothing in this section, however, shall prohibit payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision.

6.5 Secret Remedies: The prescribing or dispensing by a physician of secret remedial agents of which he does not know the composition, or the manufacture or promotion of their use is unethical and as such prohibited. All the drugs prescribed by a physician should always carry a proprietary formula and clear name.

6.6 Sale of Health-Related Products

“Health-related or Wellness products” are products other than prescription items that, according to the manufacturer or distributor, benefit health. Selling or recommending such items by the physician in exchange for money directly or indirectly could bring in financial conflict of interest. This raises ethical concerns and lowers the professional dignity.

If a physician decides to sell or recommend health-related products he has to ensure that

(a) Only those products whose benefit claims are validated by an authorised scientific body is being promoted

(b) He is not financially benefited directly or indirectly

(d) All details regarding the benefits, risks and contraindications regarding the products are informed to the patients.

(e) The products are easily available to patients and avoid having dealership of the product.

6.7 Human Rights: The physician shall not aid or abet torture nor shall he be a party to either infliction of mental or physical trauma or concealment of torture inflicted by some other person or agency in clear violation of human rights.

6.7.1 Torture

Physicians

(a) Must oppose torture in any form.

(b) Must not participate in torture whatever be the reason.

(d) Who treat torture victims should not be prosecuted.

(e) Should not treat individuals to assess their health status so that torture can begin or continue.

6.7.2 Medical Testimony

Medical evidence is very important in a variety of legal and administrative activities. Doctors being professionals with specialized knowledge and experience have a huge responsibility to ensure proper delivery of justice.

Whenever physicians serve as witnesses they must: (a) Present their qualifications accurately

(b) Testify honestly

(d) Give evidence in a simple and easily understandable manner because often the medical jargons are beyond the comprehension of ordinary individuals.

(e) Not allow their evidences to be influenced by financial obligations.

Physicians who serve as expert witnesses must:

(a) Testify according to their qualification status, experience and knowledge.

(b) Provide impartial and independent opinion. (c) Ensure that their testimony:

(i) echoes the current scientific thought and standards of care that have gained acceptance

(ii) does not reject a particular accepted theory or procedure just because it is not being used by the witness

(iii) should consider standards and facilities that existed at the time the event under review occurred when testifying about a standard of care.

6.8 Euthanasia: Practicing euthanasia shall constitute unethical conduct. However on specific occasion, the question of withdrawing supporting devices to sustain cardio-pulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone. A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor in charge of the patient, Chief Medical Officer / Medical Officer in charge of the hospital and a doctor nominated by the in-charge of the

hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organ Act, 1994.

6.9 Code of conduct for doctors in their relationship with pharmaceutical and allied health sector industry.

There are situations where there is an actual conflict of interest between patients on one hand and pharmaceutical companies, medical device manufacturers and other commercial organizations who frequently offer physicians expensive gifts and other benefits. The motive for compliments is to entice the doctor to prescribe or use the company‟s products, which may not be the best option for the patient and / or may enhance the health expenditures.

6.9.1 Gifts to Physicians from Industry

Gifts to doctors from pharmaceutical and medical device companies may often bring in an element of bias in the professional judgment during patient care.

To maintain the trust which is the cornerstone of a healthy doctor- patient relationship physicians should:

(a) Decline cash gifts and gift cards of any amount from anyone who can possibly have a direct influence on the physicians‟ treatment recommendations.

(b) Decline any gifts for which favours are expected or implied. (c) Accept a gift in-kind only when the gift:

(i) is of minimal value.

(ii) will benefit patients, including patient education

Academic institutions, medical organisations may accept special funding to support medical students‟, residents‟, & physician‟s

participation in professional meetings, including educational meetings, provided:

(i) the program identifies recipients based on independent institutional criteria; and

(ii) funds are distributed to recipients without specific attribution to sponsors.

6.9.2In dealing with Pharmaceutical and allied health sector industry, a medical practitioner shall follow and adhere to the stipulations given below:-

SECTION

ACTION

6.8.1 In dealing with Pharmaceutical and allied health sector industry, a medical practitioner shall follow and adhere to the stipulations given below:-

a) Gifts: A medical practitioner shall not receive any gift from any pharmaceutical or allied health care industry and their sales people or representatives.

Gifts more than Rs. 1,000/- upto Rs. 5,000/- : Censure Gifts more than Rs. 5,000/- upto Rs. 10,000/-: Removal from Indian Medical Register or State Medical Register for 3 (three) months.

Gifts more than Rs. 10,000/- to Rs. 50,000/- : Removal from Indian Medical Register or State Medical Register for 6(six) months.

Gifts more than Rs. 50,000/- to Rs.1,00,000/- : Removal from Indian Medical Register or State Medical Register for 1 (one) year.

Gifts more than Rs. 1,00,000/-: Removal for a period of more than 1 (one) year from Indian Medical Register or State Medical Register.

b) Travel facilities: A medical practitioner shall not accept any travel facility inside the country or outside, including rail, road, air, ship, cruise tickets, paid vacations etc. from any pharmaceutical or allied healthcare industry or their representatives for self and family members for vacation or for attending conferences, seminars, workshops, CME programme etc. as a delegate.

Expenses for travel facilities more than Rs.1,000/- upto Rs. 5,000/-: Censure

Expenses for travel facilities more than Rs. 5,000/- upto Rs. 10,000/-: Removal from Indian Medical Register or State Medical Register for 3 (three) months. Expenses for travel facilities more than Rs.10,000/- to Rs. 50,000/-: Removal from Indian Medical Register or State medical

Expenses for travel facilities more than more than Rs. 50,000/- to Rs. 1,00,000/-: Removal from Indian Medical Register or State Medical Register for 1 (one) year.

Expenses for travel facilities more than Rs.1,00,000/-: Removal for a period of more than 1 (one) year from Indian Medical Register or State Medical Register.

c) Hospitality: A medical practitioner shall not accept individually any hospitality like hotel accommodation for self and family members under any pretext.

Expenses for Hospitality

more than Rs. 1,000/- upto Rs. 5,000/-: Censure Expenses for Hospitality more than Rs. 5,000/- upto Rs. 10,000/-: Removal from Indian Medical Register or State Medical Register for 3 (three) months.

Expenses for Hospitality

more than Rs. 10,000/- to Rs. 50,000/-: Removal from Indian Medical Register or State medical Register for 6 (six) months.

Expenses for Hospitality

more than more than Rs. 50,000/- to Rs. 1,00,000/: Removal from Indian Medical Register or State Medical Register for 1 (one) year.

Expenses for Hospitality

more than Rs. 1,00,000/-: Removal for a period of more than 1 (one) year from Indian Medical Register or State Medical Register.

d) Cash or monetary grants:- A medical practitioner shall not receive any cash or monetary grants from any pharmaceutical and allied healthcare industry for individual purpose in individual capacity under any pretext. Funding for medical research, study etc. can only be received through approved institutions by modalities laid down by

Cash or monetary grants

more than Rs. 1,000/- upto Rs. 5,000/-: Censure

Cash or monetary grants more than Rs.5,000/- upto Rs. 10,000/-: Removal from Indian Medical Register or State Medical Register for 3 (three) months.

law / rules / guidelines adopted by such approved institutions, in a transparent manner. It shall always be fully disclosed.

Cash or monetary grants

more than Rs. 10,000/- to Rs. 50,000/-: Removal from Indian Medical Register or State Medical Register for 6 (six) months. Cash or monetary grants more than more than Rs. 50,000/- to Rs. 1,00,000/-: Removal from Indian Medical Register or State Medical Register for 1 (one) year. Cash or monetary grants more than Rs1,00,000/-: Removal for a period of more than 1 (one) year from Indian Medical Register or State Medical Register.

e) Medical Research: A medical practitioner may carry out, participate in, work in research projects funded by pharmaceutical and allied healthcare industries. A medical practitioner is obliged to know that the fulfillment of the following items (i) to (vii) will be an imperative for undertaking any research

assignment/project funded by industry – for being proper and ethical. Thus, in accepting such a position a medical practitioner shall :-

(i) Ensure that the particular research proposal(s) has the due permission from the competent concerned authorities. (ii) Ensure that such a research project(s) has the clearance of national/state/institutional ethics

First time censure, and thereafter removal of name from Indian Medical Register or State Medical Register for a period depending upon the violation of the clause.

committees/ bodies.

(iii) Ensure that it fulfils all the legal requirements prescribed for medical research.

(iv) Ensure that the source and amount of funding is publicly disclosed at the beginning itself.

(v) Ensure that proper care and facilities are provided to human volunteers, if they are necessary for the research project(s).

(vi) Ensure that undue animal experimentations are not done and when these are necessary they are done in a scientific and a humane way.

(vii) Ensure that while accepting such an assignment a medical practitioner shall have the freedom to publish the results of the research in the greater interest of the society by inserting such a clause in the MoU or any other documents/agreement for any such assignment.

Maintaining Professional

f) Autonomy :- In dealing with pharmaceutical and allied healthcare industry a medical practitioner shall always ensure that there shall never be any compromise either with his/her own professional autonomy and/or with the autonomy and freedom of the medical institution.

First time censure, and thereafter removal of name from Indian Medical Register or State Medical Register for a period depending upon the violaton of the clause.

g) Affiliation:- A medical practitioner may work for pharmaceutical and allied healthcare industries in advisory capacities, as consultants, as researchers, as treating doctors or in

First time censure, and thereafter removal of name from Indian Medical Register or State Medical Register for a period

any other professional capacity.

In doing so, a medical practitioner shall always :-

(i) Ensure that his professional integrity and freedom are maintained.

(ii) Ensure that patients interest are not compromised in any way.

(iii) Ensure that such affiliations are within the law.

(iv) Ensure that such affiliations/ employments are fully transparent and disclosed.

depending upon the violaton of the clause.

h) Endorsement:- A medical practitioner shall not endorse any drug or product of the industry publically. Any study conducted on the efficacy or otherwise of such products shall be presented to and/or through appropriate scientific bodies or published in appropriate scientific journals in a proper way.

First time censure, and thereafter removal of name from Indian Medical Register or State Medical Register for a period depending upon the violaton of the clause.

CHAPTER 7 MISCONDUCT

The following acts of commission or omission on the part of a physician shall constitute professional misconduct rendering him/her liable for disciplinary action

7.1 Violation of the Regulations: If he/she commits any violation of these Regulations.

7.2 If he/she does not maintain the medical records of his/her indoor patients for a period of three years as per regulation 1.3 and refuses to provide the same within 7 days when the patient or his/her authorised representative makes a request for it as per the regulation 1.3.2.

7.3 If he/she does not display the registration number accorded to him/her by the State Medical Council or the National Medical Commission in his clinic, prescriptions and certificates etc. issued by him or violates the provisions of regulation 1.4.2.

7.4 Adultery or Improper Conduct: Abuse of professional position by committing adultery or improper conduct with a patient or by maintaining an improper association with a patient will render a Physician liable for disciplinary action as provided under the National Medical Commission Act, or the concerned State Medical Council Act. When there is an existing doctor-patient relationship it is unethical for a doctor to have a romantic or sexual relationship with his patient or person accompanying the patient. Such relationships may be due to exploitation of the vulnerability of the patient or the accompanying person, or following the confidential information gathered during patient care. It could also be because they may feel unable to resist sexual advances of physicians for fear that their treatment will be jeopardized. This emotional involvement with a patient or the accompanying person could affect the clinical judgment of a physician and could result in the doctor‟s inability to take

dispassionate decisions about the patient‟s health care. Thus a physician should terminate the existing doctor-patient relationship before initiating a romantic or sexual relationship with a patient or accompanying person.

However such a relationship between a doctor and a former patient is unethical if it is initiated by exploiting the trust, confidential information derived from the previous professional relationship.

7.5 Conviction by Court of Law: Conviction by a Court of Law for offences involving moral turpitude / Criminal acts.

7.6 Sex Determination Tests: On no account sex determination test shall be undertaken with the intent to terminate the life of a female foetus developing in her mother‟s womb, unless there are other absolute indications for termination of pregnancy as specified in the Medical Termination of Pregnancy (Amendment) Act 2021. Any act of termination of pregnancy of normal female foetus amounting to female foeticide shall be regarded as professional misconduct on the part of the physician leading to penal erasure besides rendering him liable to criminal proceedings as per the provisions of this Act.

7.7 Signing Professional Certificates, Reports and other Documents: Registered medical practitioners are in certain cases bound by law to give, or may from time to time be called upon or requested to give certificates, notification, reports and other documents of similar character signed by them in their professional capacity for subsequent use in the courts or for administrative purposes etc.

Such documents, among others, include the ones given at Appendix – 2.

Any registered practitioner who is shown to have signed or given under his name and authority any such certificate, notification, report

or document of a similar character which is untrue, misleading or improper, is liable to have his name deleted from the Register.

7.8 A registered medical practitioner shall not contravene the provisions of the Drugs and Cosmetics Act and regulations made there under. Accordingly,

a) Prescribing steroids/ psychotropic drugs when there is no absolute medical indication;

b) Selling Schedule „H‟ & „L‟ drugs and poisons to the public except to his patient; in contravention of the above provisions shall constitute gross professional misconduct on the part of the physician.

7.9 Performing or enabling unqualified person to perform an abortion or any illegal operation for which there is no medical, surgical or psychological indication.

7.10 A registered medical practitioner shall not issue certificates of efficiency in modern medicine to unqualified or non-medical person.

(Note: The foregoing does not restrict the proper training and instruction of bonafide students, midwives, dispensers, surgical attendants, or skilled mechanical and technical assistants and therapy assistants under the personal supervision of physicians.)

7.11 Physician’s Relationships with Media

A physician should not contribute to the lay press articles and give interviews regarding diseases and treatments which may have the effect of advertising himself or soliciting practices; but is open to write to the lay press under his own name on matters of public health, hygienic living or to deliver public lectures, give talks on the radio/TV/internet chat for the same purpose and send announcement of the same to lay press.

Physicians who speak to the representatives of the media on health- related matters of patient(s) on behalf of organizations or health care institutions have the responsibility to safeguard the patient‟s privacy & confidentiality. The physicians should:

(a) Obtain consent from the patient or the patient‟s authorized representative before releasing information.

(b) Reveal only that information specifically approved by the patient or patient‟s representative or that is already in the public domain.

Physicians who involve with the media should be aware of their ethical obligations to patients, the public, and the medical profession.

Physicians should:

(a) Ensure that the medical information they provide is:

(i) Accurate & updated

(ii) Informs about the known risks and benefits

(iii) Based on valid scientific evidence and the knowledge gained from professional experience.

(b) Confine to their area of medical expertise and be aware of the limitations of their medical knowledge.

(d) Protect patient privacy and confidentiality unless the patient has given specific consent.

7.12 An institution run by a physician or a group of physicians for a particular purpose such as a maternity home, nursing home, private

hospital, rehabilitation centre or any type of training institution etc. may be advertised in the lay press, but such advertisements should not contain anything more than the name of the institution, type of patients admitted, type of training and other facilities offered and the fees.

7.13 It is improper for a physician to use an unusually large sign board and write on it anything other than his name, qualifications obtained from a University or a statutory body, titles and name of his speciality, registration number including the name of the State Medical Council under which registered. The same should be the contents of his prescription papers. It is improper to affix a sign-board on a chemist‟s shop or in places where he does not reside or work.

7.14 The registered medical practitioner shall not disclose the secrets of a patient that have been learnt in the exercise of his / her profession except –

i) in a court of law under orders of the Presiding Judge;

ii) in circumstances where there is a serious and identified risk to a specific person and / or community; and

iii) notifiable diseases.

In case of communicable / notifiable diseases, concerned public health authorities should be informed immediately.

7.15 The registered medical practitioner shall not refuse on religious grounds alone to give assistance in or conduct of sterility, birth control, circumcision and medical termination of Pregnancy when there is medical indication, unless the medical practitioner feels himself/herself incompetent to do so.

7.16 Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an

operation which may result in sterility the consent of both husband and wife is needed.

7.17 A registered medical practitioner shall not publish photographs or case reports of his / her patients without their permission, in any medical or other journal in a manner by which their identity could be made out. If the identity is not to be disclosed, the consent is not needed.

7.18 In the case of running of a nursing home by a physician and employing assistants to help him / her, the ultimate responsibility rests on the physician.

7.19 A Physician shall not use touts or agents for procuring patients.

7.20 A Physician shall not claim to be specialist unless he has a special qualification in that branch and have registered his/her special qualification in Indian Medical Register.”

7.21 No act of invitro fertilization or artificial insemination shall be undertaken without the informed consent of the female patient and her spouse as well as the donor. Such consent shall be obtained in writing only after the patient is provided, at her own level of comprehension, with sufficient information about the purpose, methods, risks, inconveniences, disappointments of the procedure and possible risks and hazards.

7.22 Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind.

Violation of existing ICMR guidelines in this regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines shall also be construed as misconduct.

CHAPTER 8

PUNISHMENT AND DISCIPLINARY ACTION

8.1 It must be clearly understood that the instances of offences and of Professional misconduct which are given above do not constitute and are not intended to constitute a complete list of the infamous acts which calls for disciplinary action, and that by issuing this notice the National Medical Commission and or State Medical Councils are in no way precluded from considering and dealing with any other form of professional misconduct on the part of a registered practitioner.

Circumstances may and do arise from time to time in relation to which there may occur questions of professional misconduct which do not come within any of these categories. Every care should be taken that the code is not violated in letter or spirit. In such instances as in all others, the National Medical Commission and/or State Medical Councils have to consider and decide upon the facts brought before the National Medical Commission and/or State Medical Councils.

8.2 It is made clear that any complaint with regard to professional misconduct can be brought before the appropriate Medical Council for Disciplinary action. Upon receipt of any complaint of professional misconduct, the appropriate Medical Council would hold an enquiry and give opportunity to the registered medical practitioner to be heard in person or by pleader. If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner. Deletion from the Register shall be widely publicized in local press as well as in the publications of different Medical Associations/ Societies/Bodies.

8.3 In case the punishment of removal from the register is for a limited period, the appropriate Council may also direct that the name so removed shall be restored in the register after the expiry of the period for which the name was ordered to be removed.

8.4 Decision on complaint against delinquent physician shall be taken within a time limit of 6 months.

8.5 During the pendency of the complaint the appropriate Council may restrain the physician from performing the procedure or practice which is under scrutiny.

8.6 Professional incompetence shall be judged by peer group as per guidelines prescribed by National Medical Commission.

8.7 Where either on a request or otherwise the National Medical Commission is informed that any complaint against a delinquent physician has not been decided by a State Medical Council within a period of six months from the date of receipt of complaint by it and further the National Medical Commission has reason to believe that there is no justified reason for not deciding the complaint within the said prescribed period, the National Medical Commission may-

(i) Impress upon the concerned State Medical council to conclude and decide the complaint within a time bound schedule;

(ii) May decide to withdraw the said complaint pending with the concerned State Medical Council straightaway or after the expiry of the period which had been stipulated by the National Medical Commission in accordance with para (i) above, to itself and refer the same to the Ethical Committee of the Council for its expeditious disposal in a period of not more than six months from the receipt of the complaint in the office of the National Medical Commission

8.8 Any person aggrieved by the decision of the State Medical Council on any complaint against a delinquent physician, shall have

the right to file an appeal to the National Medical Commission within a period of 60 days from the date of receipt of the order passed by the said Medical Council:

Provided that the National Medical Commission may, if it is satisfied that the appellant was prevented by sufficient cause from presenting the appeal within the aforesaid period of 60 days, allow it to be presented within a further period of 60 days.

APPENDIX – 1

1. FORM OF CERTIFICATE RECOMMENDED FOR LEAVE OR EXTENSION OR COMMUNICATION OF LEAVE AND FOR FITNESS

Signature of patient

or thumb impression ___________________________________________

To be filled in by the applicant in the presence of the Government Medical Attendant, or Medical Practitioner.

Identification marks:-

1. __________________________ 2. __________________________

I, Dr. _____________________________________ after careful examination of the case certify hereby that _______________ whose signature is given above is suffering from __________________ and I consider that a period of absence from duty of____________________ with effect from __________________ is absolutely necessary for the restoration of his health.

I, Dr. ________________________ after careful examination of the case certify hereby that ______________________ on restoration of health is now fit to join service.

Place ___________________ Signature of Medical attendant.

Date ________________ Registration No. ___________________

(Medical Council of India / State Medical Council of ……………… State) Note:- The nature and probable duration of the illness should also be specified . This certificate must be accompanied by a brief resume of the case giving the nature of the illness, its symptoms, causes and duration.

APPENDIX – 2

LIST OF CERTIFICATES, REPORTS, NOTIFICATIONS ETC. ISSUED BY DOCTORS FOR THE PURPOSES OF VARIOUS ACTS / ADMINISTRATIVE REQUIREMENTS

a) Under the acts relating to birth, death or disposal of the dead.

b) Under the Acts relating to Lunacy and Mental Deficiency and under the Mental illness Act and the rules made thereunder.

c) Under the Vaccination Acts and the regulations made thereunder. d) Under the Factory Acts and the regulations made thereunder.

e) Under the Education Acts.

f) Under the Public Health Acts and the orders made thereunder.

g) Under the Workmen‟s Compensation Act and Persons with Disability Act. h) Under the Acts and orders relating to the notification of infectious diseases. i) Under the Employee‟s State Insurance Act.

j) In connection with sick benefit insurance and friendly societies.

k) Under the Merchant Shipping Act. l) For procuring / issuing of passports.

m) For excusing attendance in courts of Justice, in public services, in public offices or in ordinary employment.

n) In connection with Civil and Military matters.

o) In connection with matters under the control of Department of Pensions. p) In connection with quarantine rules.

q) For procuring driving licence.