Ethics

IMA

STANDING COMMITTEE for MEDICAL ETHICS

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Message

Dr. Sahajananda Prasad Singh IMA National President

Indian Medical Association has organised a brain storming discussion on issues faced by Medical Profession on 9th April 2022 at IMA Headquarters (New Delhi). The topic chosen this time is “Patients’ Rights & Responsibilities vis-a-vis Doctors’ Rights & Responsibilities in Present Scenario”.’

The session is being inaugurated by Dr.Ketan Desai, Chief Patron IMA and organized by IMA Standing Committee for Medical Ethics under the Chairmanship of Dr. Vinay Aggarwal, Past National President IMA with Co-Chairman Dr. Girish Tyagi. The Program was conceived and designed by Dr. Srikumar Vasudevan, Convenor – IMA Ethics Committee.

The Session will be address by eminent persons among the medical professions and will be attended by large number of participants across the country.

Ethical issues faced by Medical Profession has been a burning topic for the Doctors from time immeroral. In the past Medical Council of India had formulated guidelines on medical ethics which were not only stringent but also binding for all medical practitioners. Indian Medical Association has rightly taken up the responsibility of enforcing the medical ethics among its members by forming a strong and dedicated Standing Committee for Medical Ethics.

Since long, we were focusing mainly on patients’ reaquirements as far as treatment is concerned. Few decades ago, Doctor-Patient relationship was at its best due to the un fathomable faith of the patients on the treating doctors. The scenario has gradually changed due to various government regulation in addition to un ethical practives adopted by some of the black sheep in our profession. As a result, the patients have started demanding patients-rights and dictating the doctors on their responsibilities. This has led to practice of Defensive Medicine by the doctors focusing mainly on the Doctors’ rights and patients’ responsibilities.

Hence, the committee has rightly chosen the topic for the discussion today – “Patients’ Rights & Responsibilities vis- a-vis Doctors’ Rights & Responsibilities in Present Scenario”.

Thedelibrationsand recommendationsevolvingoutofthediscussionsduringthesessionwillbehelpfulnotonlytothe medical practitioners but also to the Government to formulate the necessary guidelines.

Message

Dr. Jayesh M. Lele Hon. Secretary General, IMA

Greetings from Indian Medical Association HQs!

It gives me immense pleasure to know that you are releasing an e-Bulletin on the Medical Ethics in the ensuing meeting of 227th CWC at Panchkula Chandigarh on 16th April 2022.

Medical Ethics provides privacy, confidentiality and truthfulness in the doctor-patient relationship. Medical ethics promotes health, wellbeing, respect decision making, dignity, justice and accountability in the medical profession Ideally, for a medical practice to be considered “ethical”, it must respect all four of these principles: autonomy, justice, beneficence, and non-maleficence.

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. 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.

I am confident that the e-Bulletin on Medical Ethics will be very informative, useful and a document of study and reference.

I congratulate you and your team for the wonderful efforts to release this e-Bulletin of Medical Ethics and wishing you all the best.

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Message

Dr. Vinay Agrawal Chairman

Dear Members,

It gives me immense pleasure to inform that the National President Dr. Shajananda Prasad Singh has

nominated me as the Chairman of the Standing Committee for Medical Ethics, which is one of the most prestigious committees of IMA. It will be my endeavour to live up to the high expectations. We have a highly dedicated team, which within a short period of 1 1⁄2 months have released two documents on the Medical Oath & Doctor- Patient Relationship. We have started a monthly webinar on various topics of medical ethics and a monthly e-Bulletin with the prime intention of propagating ethics amongst our members. We have other programmes on the anvil and I am sure we as a team will achieve the desired result with your kind co-operation.

Jai Hind !

Jai IMA!

Message

Dr. Srikumar Vasudevan Convener

E-Bulletin

Dear Members,

Ahealthydoctor-patientrelationshiprestsonthepillarsofmedicalethics. Howeverourmedicalschools,inits

quest to improve technical proficiency have failed to give due importance to medical ethics. This leaves doctors totally unpreparedtodealwithvariousethicalchallengesintheirdaytodaypracticeofmedicine. IndianMedicalAssociation has taken up the responsibility of educating our members regarding the importance of ethics in maintaining the sanctity of our profession. As a part of this endeavour the IMA Standing Committee for Medical Ethics has started various programmes. One of them is to publish an e-Bulletin every month which will deal with the various ethical aspects associated with the practice of modern medicine. This e-Bulletin is the first of the series and I congratulate Dr. Gutta Suresh & Dr. M.N. Menon who were instrumental in making this a reality.

Jai Hind! Jai IMA!

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E-Bulletin

NATURE of PROFESSIONAL ‘OATH’ For

MODERN MEDICINE MEDICAL PRACTITIONERS Dr. Vedprakash Mishra

Men ever since antiquity in the domain of ongoing human civilization and commune living has evolved various modes, modalities and avenues of livelihood for descent, digniied and progressive living. As such, it always resulted in invocation of important modes of gainful livelihoodintermsof ‘Occupation,VocationAndProfession’.

Although, in a colloquial sense the three keywords, occupation, vocation and profession has modes of livelihood are used interchangeably in a free manner, which is neither appropriate nor correct in the literal sense in as much as they are distinct entities on their own. Occupation turns out to be a mode in which the person is required to be occupied with without any formal structured training or orientation for the same for generation of the means of gainful livelihood. However Vocation is a mode of occupation which is availed upon the incumbent on due training and orientation in a structured manner for the said purpose and availed for gainful employment.

As against the deined rubrics of occupation and vocation respectively, profession turns out to be a still different entity in as much as that in regard to structured training and orientation it is akin to vocation, however, the distinguishing features are –

1. The certiied qualiication as in the form of an ‘End certiication’ must be statutorily a recognized qualiication.

2. There must be a recognizing modality statutory in character for the certiied qualiication which is declared as ‘the registering qualiication’.

3. There must be a statutory registering authority granting and maintaining the register of such registrations of the duly qualiied and certiied individuals possessing recognized registering qualiication on solicitation and conferring required privileges to them for the practicing of the said profession for gainful livelihood.

However, medical profession is required to be practiced within the tenets of ‘Ethicality,

Morality and Value ethos’ for the adherence to the core ethical values which are prescribed inter alia codiied by the statutory registering authority for such period as is granted by it. The concerned registration upon expiry of the granted period is renewable subject to fulillment of the prescribed conditions as are laid down by the registering authority.

The registering authority is vested with the statutory jurisdiction to try the breaches by the registered medical practitioner on the count of medical practice in the form of ‘medical negligence, misconduct and also ethical breaches’ if any in accordance with the governing principles prescribed thereat in conformity with the principles of natural justice. However, the

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E-Bulletin

registering authority does not have any suo-motu jurisdiction of taking cognizance of any ethical breach on its own without solicitation thereto by the concerned party.

‘Oath taking’ has been a modality in vogue. Primarily the same is a pledge for adherence to the ethical values of the medical profession and practice by the medical professionals as a part of allegiancetothesame. Asamatteroffact,oathtakingprimarilyisforthepurposesofmakinga ‘promise’ to oneself to uphold the morality, the ethicality and the value ethos of the profession in all its tenets and faithful adherence to the cardinal core principles governing practicing of the same namely –

1. Principles of Beneicence

2. Non malfeasance

3. Autonomy and dignity of patients, 4. Justice,

5. Conidentiality

The ethical charter for medical practitioners prescribed in Charak Samhita predates the Hippocratic Oath almost by two centuries. The original Hippocratic Oath was written in Greek, between the ifth and third centuries BC. The oldest partial remains of the oath date back to 275 AD. The oldest existing version dates to roughly the 10th-11th century. A commonly cited version dates back to 1595.

LIMITATIONS OF HIPPOCRATIC OATH:

1. The old version of Hippocratic Oath recommends that a doctor should give a share of his earnings to his teacher if required and to teach the children of teachers free if they desire.

2. It also prescribes that administering deadly drugs to patients is certainly unethical but at a time when euthanasia in various forms (passive and active) are being practiced in several countries the absolute ban in the oath is not in vogue with time. Further, many physicians are of the view that with rapid development in science and with research and clinical trials being the order of the day, the Oath is inadequate.

3. Moreover there is no mention of the penalty to the transgressors of the oath.

4. In addition the oath is taken the oath is taken in the name of Greek gods. But this naturally

would not be acceptable to other religions.

5. It also forbids abortion. But abortion is legal and acceptable in modern society. Did

Hippocrates actually forbid abortion? Or was it a later Christian addition during translations? This is a contentious issue because the medical texts written by Hippocrates contain detailed descriptions of abortion with no mention of the moral aspects.

6. In those times, surgeons were considered separate from physicians. This oath was then meant only for physicians. Hence, they are asked not to touch the knife. But now, all the doctors are required to take this oath. So, this part of the oath cannot be applicable as a

whole.

In India Charak who is taken as the pioneer of Indian System of Medicine classically called

as ‘Ayurveda’, which is also accorded the status of an ‘Upveda’ evolved an oath to be undertaken

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E-Bulletin

by the practitioners of Ayurvedic Medicine which is designated as ‘Charak’s Shapath’ However, the Charak’s Oath on perusal is observed to have following limitations.

1. This oath relects the feudal past of India. In many areas of this oath, allegiance to the king is stressed repeatedly, which does not augur well with the constitutional ethos as emanating out of the constitutional values embedded therein.

2. The oath relects a certain puritan mentality. Doctors (obviously male) are expected to be celibate and vegetarian and therefore its relevance and adherence in the present contemporary times.

3. This oath stresses on the need to remain under the teacher throughout life. But this mentality cannot hold true in modern society. As such, after passing out of college, the young doctors are expected to fend for themselves. Hence, allegiance to the teacher in the sense as incorporated in the oath is impracticable and therefore redundant.

4. It is said that doctors should perform no sin. But what is sin? The deinition of sin changes with times. For example, 500 years ago, untouchability was an acceptable dictum which is forbidden by the Indian Constitution and the same has been designated as a punishable wrong.

5. This oath forbids accepting gift exclusively from female patients, whereas Code of Medical Ethics forbids gifts from the beneiciaries independent of gender.

6. It is said therein the doctor should not treat anyone who is against the king. But this is a fundamental violation of human rights. Ethically Doctors are required to treat anyone in need without any differentiation or demarcation of any type.

Realistically speaking the ethical values incorporated in both the oaths, but for

contextual co-relates are near similar and that is inevitable as the core ethical values do not go a sea change with the passage of time. One cardinal fact that weighs very heavily is that both the oaths are heavily inluenced by respective religions.

It is in this context, it is pertinent to note that after the Second World War the need for a more secular humanistic medical code was felt which was due to atrocities by Nazi doctors in concentration camps including the Nuremberg Trial which is a sordid and tragic story of heaped human horrors. Similarly, the intangible human horror perpetuate in unit 731 in China by the Japanese Army after the Second World War is a tragic milestone of heaped human brutality beyond depiction.

The end result of irst World War made the entire Global humanity look for peace which resulted in invocation of ‘League of Nations and Human Charter’ generated thereby. However, the humanity not having learnt diligent lessons of consequent of war thereto ended up in secondworldwaramuchlargerrepertoireofhumantragedyandlossbeyond repairs.

The tragic consequences of the Second World War made Global community to attempt to institutionalize Global peace through creation of United Nations Organizations and invocation of Geneva Declaration at Geneva at the Global Convention which is called as Geneva

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E-Bulletin

Convention. It is a universal declaration of human rights which is borne out of international humanitarian law. The cardinal principles governing Geneva declaration is the trinity of –

1. Humanity

2. Impartiality

3. Neutrality

Based on the Geneva Convention and the Universal Declaration of Human Rights so

invoked on the basis of International Humanitarian Law World Medical Association in 1948 with reference to desired ethicality attributable to medical profession and the horrendous breaches thereto during the second world war invoked ‘International Code of Medical Ethics’ in the form of what is designated as ‘Geneva Declaration’. It basically covers medical ethics and ethical guidelines that ought to govern the medical profession at all times including war times and peaceful times.

Geneva Declaration in its operational ambit is a modiied Hippocratic Oath in its core tenets. It has been further modiied appropriately and suitably in 1968 at Sydney Convention, 1983 at Venice Convention, 1994 at Stockholm Convention, Editorial Revisions made thereto in 2005 and 2006 and lastly amended in 2017 at Chicago Convention by the World Medical Association.

Frankly speaking this has resulted in ‘Geneva Declaration’, in terms of its periodic amendments has been made commensurate with the felt needs and to be in tune with the corresponding realities and contemporary times.

This appropriately accommodates the concept of civil liberties and also the autonomy of the Doctors. Health of doctors is also an important issue which has been duly incorporated within the ambit of the Geneva Declaration in terms of its modiication in 2017 at Chicago Convention.

It is equally important to note that India has been at the forefront of evolution of United Nation Organizations, invocation of Geneva Convention and also invocation of Geneva Declaration by the World Medical Association and is a signatory to the same.

It is also a matter of record that India is also a party to the amendments that have been made to the Geneva Declaration by the World Medical Association from time to time with the last amendment made to it in the year 2017 at Chicago Convention.

Historically speaking registerable medical qualiications in India are a generation of recommendations made by the Education Commission in the year 1904 arising out of which Indian Medical Degrees Act, 1916 was enacted. Consequent upon which the registering authority in India came to be invoked in the year 1934 vide enactment of Indian Medical Council Act, 1933-34 wherein the practicing medicine was deined as ‘Western Medicine’.

t is a matter of record that upon independence Indian Medical Council Act, of 1934 was repealed vide enactment of Indian Medical Council Act, 1956 by the Indian Parliament in Free India and the word Western Medicine in terms of its deinition as relected in 1934 Act was rechristened as ‘Modern Medicine’ with MBBS (Bachelor of Medicine and Bachelor of Surgery)

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granted by a duly constituted ‘University’ as deined under section 2(F) of the University Grants Commission Act, 1956 as a registered medical qualiication for the purposes of registering medical graduates for their inclusion in the Indian Medical Register maintained by the Medical Council of India so constituted.

The Medical Council of India on the basis of international code of medical ethics evolved by World Medical Association depicted in Geneva Declaration structured Code of Medical Ethics as a binding regulation invoking its authority vested in it under section 33 of the then Indian Medical Council Act, 1956 which in its amended version is in vogue. As such, the Code of Medical Ethics so prescribed is applicable to the entire country and adherence to it is mandated on part of the registered medical practitioner of modern medicine.

It is in the context of aforesaid reality the professional oath to be undertaken by the modern medical professional ought to be adherence to Code of Medical Ethics which is generated out of International Code of Medical Ethics which is germane to Geneva Declaration brought out by World Medical Association in 1948 and is amended from time to time. It is best suited in all its manifestations in terms of its relevance and applicability to the registered medical practitioners of modern medicine.

In the name of Globalization the geographical boarders have withered out and information explosion has converted the entire Globe into a well interconnected Global village. In the tenets of the same it is imperative for all concerned to decipher the attribution of’preixes’ononecount ortheothercouldbejustobservanceofthe’letter’andnot’spirit’.

It is for this reason the Global realities do make it inevitably necessary for any body and every to keep pace it and be progressively forward looking rather than realigning with conservancy

and hypocrisy alike.

As such, in view of the factual prepositions that have been delineated above it can be

safely and convincingly concluded that Geneva Declaration in the form of Code of Medical Ethics as prescribed by the statutory Indian Registering authorities for modern medical practitioners and adherence thereto ought to be the oath to be availed by all concerned in its letter and spirit alike in the interest of profession, professionals, and practicing of the profession in unison.

E-Bulletin

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Doctor Patient Relationship

Trust is the basis of all relationship. Trust deicit is the basis of all violence. Doctor Patient Relationship is one of the ancient and sacrosanct relationships. Violence against doctors is synonimous and pathognomanic of the times we live in. Not surprisingly the Doctor patient relationship is at its lowest ebb. Doctors have been accused for this deterioration in relationship. Yet there are lot of factors which are systemic in nature and consequently outside the realms of the profession.

Curative medicine suffers from the pangs of evidence based protocols inlicted by the hospital industry. Preventive medicine suffers from the dehumanisation inlicted by the public health overreach reducing patients to numbers and targets. In the cacophony between the hospital based care and the public health misadventures the casualty is the time tested art of medicine. We can safely conclude that one of the major faultlines in the Doctor Patient Relationship lies in the loss of art of medicine.Medicine is as much an art as much it is a science. Clinical Medicine as practised in yesteryears was the judicious mix of both. Both evidence based medicine and public Health programmes have no use for art of medicine. Art of medicine includes attitude, etiquette, empathy, discretion etc all blending into body language, diction and touch.

The major changes of the recent decades are the shift from single doctor care to hospital based care and the shift from clinical medicine to evidence based medicine. The tectonic change that has happened in this shift is that the patient is dehumanized. He loses his identity as a human being. The insults heaped on an individual patient is much more in public Health. The dry faceless approach of public Health can never capture the pain,anxiety and apprehension of a patient nor does it has any sensitivity to the conidentiality quotient of the Doctor patient relationship. It is certainly not a part of the art of healing. It is only interested in crunching big numbers and dogmas like accessibility and affordability.

These changes inside Health care though relating to the fraternity are not governed by it. It is like a free fall where there are no options. Now if we look outside the fraternity there are a whole lot of factors which operate. Foremost is the change in value system of the society. Materialistic consumerist values have replaced values like patience, acceptance and austerity. Out there is a world which thinks that anything is purchasable and at whatever the cost. The expectations that modern medicine can deliver anything does not help either. Add to this lytic cocktail the internet and the half baked information it dishes out.

Commercialization of medical education,advent of For Proit Hospitals and entrenched incentive system of the private sector have changed the perception about Healthcare establishments. Doctors, being the face of Health care delivery face the brunt of the ire. As of today the situation appears to be a Black Hole.

The solution lies in the medical profession revalidating its identity and reasserting its leadership of Healthcare. It has to distance itself from the Healthcare industry. Governments can help by recognizing and legislating one from the other. Once we are able to establish our identity separate from that of Hospital industry, that will be the irst step in the journey to regain the trust in Doctors Patient Relationship.

Dr. R.V. Asokan

E-Bulletin

Past Honorary Secretary General, IMA

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E-Bulletin

MEDICAL RECORDS… CERTIFICATES

Dr. M.N. Menon Member

IMA Ethics Committee

1.3 1.3.1

1.3.2

(a) (b) (c)

(d) 1.3.3

(i)

(ii) (iii) (iv)

Maintenance of medical records:

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.

Doctors have a responsibility to maintain the medical records of patients properly in order to safeguard the confidentiality of patients personalinformation.

To manage medical records responsibly, physicians or the individual responsible for the institutions medical records should: Ensure institution has a clear policy about managing medical records of patients.

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

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 72 hours.

Ensure that records that are to be discarded are destroyed to protect confidentiality.

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

Ensure restriction of data entry and access only to authorized persons

Routinely monitor/audit access to records

Ensure data security and integrity

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

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(v) 1.3.4

(a)

Reveal patient information according to the ethical guidelines of

confidentiality.

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.

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) (ii) (iii) (iv)

(d)

1.3.5 (a)

(b)

1.3.6

Possible breach of privacy or confidentiality

Difficulty in confirming the identity of the parties

Possible delays in response

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.

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

Issuance of Medical certificate

No medical certificate should be issued in absentia or predated.

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.

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

E-Bulletin

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STANDING COMMITTEE for MEDICAL ETHICS

Naonal President :

Dr. Sahajananda Prasad Singh Hony. Secretary General : Dr. Jayesh Lele

Chairman :

Dr. Vinay Agarwal

Advisor :

Dr. Vedprakash Mishra

Co‐ Chairman :

Dr. Girish Tyagi

Convener :

Dr. Srikumar Vasudevan

Members :

Dr. Rajendra Airan Dr. L.V.K Moorthy Dr. M.N. Menon

Dr. Karan Singh Punia Dr. Dhiren.C.Patel Dr. Bijuli Goswami Dr. Cheran.B

Dr. Gutta Suresh Dr. L.P. Thangavelu Dr. Sunil Kumar

Dr. Vallabh Mundra

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