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Dr S. K. Roy Chaudhary, M.B.B.S.(Hons);MD; DHM; FIAFM

Professor Emeritus

Dept. of Forensic Medicine

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Ethics �In

Medical Practice

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Ethics is derived from the Greek ethos meaning custom, people, the predominant community spirit

A branch of philosophy dealing with values pertaining to human conduct,

Considering the rightness and wrongness of actions
And the goodness or badness of the motives
And ends of such actions.

So when a doctor 'thinks ethically’, he is thinking about something or someone other than himself, his own desires and self-interests.

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What is Medical Ethics ?

Medical Ethics concerns difficult and subtle questions of rightness, fairness, or equity with respect to doctors conduct with patients, colleague & society
Law does not always establish positive duties ( what people should do) to the extent that professional ethical standards do. It varies from profession to profession. What is required to be done by medical profession may not be so required by another.
Ethical standard of medical profession is far beyond & above any other profession

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Why Study Medical Ethics

As long as the physician is a knowledgeable and skillful clinician, ethics doesn’t matter.
Ethics is learned in the family, and primary schools not in medical colleges.
Medical ethics is learned mainly by observing how senior physicians act, not from books or lectures.
Ethics is important, but our curriculum is already over crowded and there is no room for teaching ‘ethics’.
And finally discussion on medical ethics often makes senior people uncomfortable by reminding them of their own unethical behaviour

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The Hippocratic Oath

. The Hippocratic Oath is perhaps the most widely known of Greek medical texts on Ethics

One of the best known prohibitions is, “Primum non nocere” “Firstly to do no harm"

It is estimated to have been written in the 4^th century B.C.

Non-maleficence (male: badly, wrongly + facio: to do, act)

Non-maleficence(non·ma·lef·i·cence

(non'ma-lef'ĭ-sens), The ethical principle of doing no harm, based on the Hippocratic maxim, primum non nocere, first do no harm.

[non- + L. maleficencia, evildoing, fr. male, badly, wrongly, + facio, to do, act] ), which is derived from the maxim, is one of the principal precepts of bioethics that all healthcare students are taught in school and is a fundamental principle throughout the world. Another way to state it is that, "given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good." It reminds the health care provider that they must consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

INTRODUCTORY NOTE

HIPPOCRATES, the celebrated Greek physician, was a contemporary of the historian Herodotus. He was born in the island of Cos between470 and 460 B.C., and belonged to the family that claimed descent from the mythical Aesculapius, son of Apollo. There was already a long medical tradition in Greece before his day, and this he is supposed to have inherited chiefly through his predecessor Herodotus; and he enlarged his education by extensive travel. He is said, though the evidence is unsatisfactory, to have taken part in the efforts to check the great plague which devastated Athens at the beginning of the Peloponnesian war. He died at Larissa between 380and 360 B.C. The works attributed to Hippocrates are the earliest extant Greek medical writings, but very many of them are certainly not his. Some five or six, however, are generally granted to be genuine, and among these is the famous "Oath." This interesting document shows that in his time physicians were already organized into a corporation or guild, with regulations for the training of disciples, and with an esprit de corps and a professional ideal which, with slight exceptions, can hardly yet be regarded as out of date. One saying occurring in the words of Hippocrates has achieved universal currency, though few who quote it to-day are aware that it originally referred to the art of the physician. It is the first of his "Aphorisms": "Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”

HIPPOCRATIC OATH

(I have chosen sentences from large number of translations to compile this Oath- Dr. S. K. Roy Chaudhary)

I SWEAR by Apollo the Physician and Aesculapius and Hygieia and Panaceia and all the gods, and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; and to regard his offspring as equal to my brothers in male lineage and to teach them this art–if they desire to learn it–without fee and covenant; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according the law of medicine, but to none others

I WILL FOLLOW that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to cause abortion.

WITH PURITY AND WITH HOLINESS I will guard my life and my art. I will not use the knife, even upon those suffering from stones, but will withdraw in favour of such men who are trained in this craft. Into whatever homes I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, be they freemen or slaves.

WHATEVER I SEE OR HEAR, in the lives of my patients, whether in connection of my treatment, or not in connection with it, which ought not to be spoken of abroad, I will keep to myself, reckoning such things shameful to be spoken about.

IF I FULFILL THIS OATH AND DO NOT VIOLATE, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come. But if I transgress it and swear falsely, may the opposite be my lot.

Adopted by the General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968.

CIRP Introduction

The World Medical Association is an association of national medical associations. This oath seems to be a response to the atrocities committed by doctors in Nazi Germany. Notably, this oath requires the physician to "not use [his] medical knowledge contrary to the laws of humanity." This document was adopted by the World Medical Association only three months before the United Nations General Assembly adopted the Universal Declaration of Human Rights (1948) which provides for the security of the body.

The original text of the Hippocratic Oath is usually interpreted as one of the first statements of a moral of conduct to be used by physicians, assuming the respect for all human life, even unborn. Most Christian tradition interprets the original Hippocratic Oath as a condemnation of abortion and infanticide. According to Margaret Mead:

“ For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill... With the Greeks the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect – the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child...^[9] ”

Engraving of Hippocrates by Peter Paul Rubens, 1638.^[10]

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HIPPOCRATIC OATH

I SWEAR by Apollo the Physician and Aesculapius and Hygieia and Panaceia and all the gods, and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

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TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; and to regard his offspring as equal to my brothers in male lineage and to teach them this art–if they desire to learn it–without fee and covenant; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according the law of medicine, but to none others

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I WILL FOLLOW that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to cause abortion.

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WITH PURITY AND WITH HOLINESS I will guard my life and my art. I will not use the knife, even upon those suffering from stones, but will withdraw in favour of such men who are trained in this craft. In to whatever homes I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, be they freemen or slaves.

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WHATEVER I SEE OR HEAR, in the lives of my patients, whether in connection of my treatment, or not in connection with it, which ought not to be spoken of abroad, I will keep to myself, reckoning such things shameful to be spoken about.

IF I FULL FILL THIS OATH AND DO NOT VIOLATE, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come. But if I transgress it and swear falsely, may the opposite be my lot.

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09/08/2022

The Hippocratic oath appears to be more strongly influenced by followers of Pythagoras than Hippocrates but the medical profession throughout the world now attributes it to Hippocrates. It spread all over the Christian world and the area under their dominance as the oath taken by physicians. In some versions, pagan gods and goddesses were replaced by the Christian gods and also assumed the shape of a cross. In 1948 replaced by its modernized version.

12^th Century Byzantine

HIPPOCRATIC OATH

(I have chosen sentences from large number of translations to compile this Oath- Dr. S. K. Roy Chaudhary)

I SWEAR by Apollo the Physician and Aesculapius and Hygieia and Panaceia and all the gods, and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; and to regard his offspring as equal to my brothers in male lineage and to teach them this art–if they desire to learn it–without fee and covenant; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my sons and to the sons of him who has instructed me and to pupils who

have signed the covenant and have taken the oath according the law of medicine, but to none others

I WILL FOLLOW that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to cause abortion.

WITH PURITY AND WITH HOLINESS I will guard my life and my art. I will not use the knife, even upon those suffering from stones, but will withdraw in favour of such men who are trained in this craft. Into whatever homes I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, be they freemen or slaves.

WHATEVER I SEE OR HEAR, in the lives of my patients, whether in connection of my treatment, or not in connection with it, which ought not to be spoken of abroad, I will keep to myself, reckoning such things shameful to be spoken about.

IF I FULFILL THIS OATH AND DO NOT VIOLATE, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come. But if I transgress it and swear falsely, may the opposite be my lot.

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17^th Century title page from Marco Aurelio Severino. Viper Pythia 1651).

The snake symbolized rejuvenation and healing to many ancient cultures. Depicted here are different snake symbols used including the single-snake staff of Asclepius and the double snake of the caduceus. �

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Caduceus With its two intertwined snakes grasping a staff was adopted by Indian Medical Association and many other medical bodies as the "ancient" symbol of their profession. But in the ancient world, the caduceus was a symbol of Hermes, the Roman Mercury, who was primarily a messenger god linked with commerce.

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Asclepius

Images of Asclepius are generally recognizable by his beard and staff with a single snake. In this image, he is accompanied by his small, mysterious attendant, Telesphoros. One of the earliest Greek gods of healing. Healers and those in need of healing invoked his name in prayers and healing ceremonies in temples as well as at home.

Marble statue in the Louvre. Engraving by Jenkins (London, 1860).

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Thomas Percival M.D. FRS FRSE FSA (1740–1804) was an English physician and author, best known for crafting perhaps the first modern code of medical ethics.

Thomas Percival was the founder of modern codes of medical ethics and also coined the word ‘ Medical Ethics’. He drew up a pamphlet with the code in 1794 in Manchestor and published an expanded version in 1803 a small book which became a prominent landmark in the progress and evolution of medical ethics.

No later work has modified in any material degree the precepts and practices defined by Percival for the conduct of a physician.

Code of Ethics 2002 of Medical Council of India also emanates from Percival’s book

In 1761 he went to study Medicine at Edinburgh University, Edinburgh being at the forefront of this field. He did further postgraduate study at Leyden University in Holland and obtained his doctorate (MD) in 1765.^[4]

He became a fellow to the Royal Society, through a recommendation by his friend and patron Lord Willoughby de Parham, the same year. In 1771 he hosted Benjamin Franklin in Manchester, who went on to be a guest of Rev. John Michell at Thornhill Rectory; other guests being Joseph Priestley and Messrs. Smeaton, Pringle and Ingenhousz. In 1787 he was elected a Fellow of the Royal Society of Edinburgh. His proposers were Andrew Dalzell and Henry Duncan. He was elected a Foreign Honorary Member of the American Academy of Arts and Sciences in 1789.^[5]

Percival had been asked by the Manchester Royal Infirmary to help with an internal dispute and became particularly concerned with the divisions that had arisen among the different branches of the profession – the physicians, surgeons, and apothecaries with their different backgrounds of training (university, hospital, and apprenticeship respectively). But he did not merely concern himself with intra-professional relationships: he also laid down a code for conduct towards patients, whether rich or poor, and his ideas were rapidly taken up by the USA, Australia, and Canada — in fact, the ethical code introduced by the newly formed American Medical Association in 1847 used several passages taken directly from his book.

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Percival’s Book was also the source of the AMA’s Code of Medical Ethics

1847

&

Is also the basis of Code of Medical Ethics 2002 by MCI

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Nuremberg Germany

Twenty of the 23 defendants were medical doctors (Viktor Brack, Rudolf Brandt, and Wolfram Sievers were Nazi officials) and were accused of having been involved in Nazi human experimentation and mass murder under the guise of euthanasia. Josef Mengele, one of the leading Nazi doctors, had evaded capture.

The judges in this case, heard before Military Tribunal I, were Walter B. Beals (presiding judge) from Washington, Haro Sebring fromFlorida, and Johnson T. Crawford from Oklahoma, with Victor C. Swearingen, a former special assistant to the Attorney General of the United States, as an alternate judge. The Chief of Counsel for the Prosecution was Telford Taylor and the chief prosecutor was James M. McHaney. The indictment was filed on October 25, 1946; the trial lasted from December 9 that year until August 20, 1947. Of the 23 defendants, seven were acquitted and seven received death sentences; the remainder received prison sentences ranging from 10 years to life imprisonment.

The accused faced four charges, including: Conspiracy to commit war crimes and crimes against humanity as described in counts 2 and 3;

War crimes: performing medical experiments, without the subjects' consent, on prisoners of war and civilians of occupied countries, in the course of which experiments the defendants committed murders, brutalities, cruelties, tortures, atrocities, and other inhuman acts. Also planning and performing the mass murder of prisoners of war and civilians of occupied countries, stigmatized as aged, insane, incurably ill, deformed, and so on, by gas, lethal injections, and diverse other means in nursing homes, hospitals, and asylums during the Euthanasia Program and participating in the mass murder of concentration camp inmates.

Crimes against humanity: committing crimes described under count 2 also on German nationals.

Membership in a criminal organization, the SS.

The tribunal largely dropped count 1, stating that the charge was beyond its jurisdiction.

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Declaration of Geneva (A Pledge)

War crimes by doctors dictated that the WMA must seek to become the Authoritative voice on global standards for medical ethics and professional conduct, rather than focus solely on protecting the interests of the profession
Declaration of Geneva is one of the World Medical Association’s (WMA) oldest policies adopted by the 2nd General Assembly in Geneva in 1948
Since amended in 1968, 1983, 1994, editorially revised in 2005 and 2006 and amended in 2017.
It is a modernised version of Hippocratic Oath
The Oath should be read along with the more specific and detailed International Code of Medical Ethics, which followed the Declaration of Geneva.

After only two years of preparation, 27 national medical associations met in Paris on September 18th, 1947 for the inauguration of a new global physicians’ association, the World Medical Association (WMA). The lead-up to this first Assembly was paralleled by the Nuremberg trial against Nazi doctors, which was a key driver of the mission focus of the new WMA. This terrible episode in the history of medicine dictated that the organization must seek to become the authoritative voice on global standards for medical ethics and professional conduct, rather than focus solely on protecting the interests of the profession. Effectively coordinating an international organization was anything but easy in the late 1940s. There was no internet, e-mail, mobile phones, personal computers, fax, or even photocopiers. For many physicians, attending the Assembly required a cross-continental, multi-day journey across a deeply scarred planet, by train and ship and only in exceptional circumstances by plane. Yet the commitment of these founding WMA members( Including Indian Medical Association) to their vision was even greater than the challenges they faced in achieving it. Prof. Dr Eugène Marquis, France, was elected as the first President of WMA, Dr Jar. Stucklik, Czechoslovakia, was elected President-Elect, Dr Otto Leuch, Switzerland, was elected Treasurer, and Dr Charles Hill, UK, was elected as temporary Honorary Secretary. The first Council, composed of 10 members, was elected, and the World Medical Association was fully launched in Peris on 17-18 Sept. 1947. In 1948, the executive board, known as the Council, established the Secretariat of the WMA in New York City to provide a close liaison with the United Nations and its various agencies. Dr Louis H. Bauer was appointed as Secretary General. The WMA Secretariat remained in New York City until 1974 when for financial reasons and in order to operate within the vicinity of Geneva-based international organisations (WHO, ILO, ICN, ISSA, etc.) it was transferred to its present location in Ferney-Voltaire, France. That vision, and the accompanying goals, ideals, and unity of purpose, are as relevant today as they were during those early days. They are now ours to carry on.

1983105Monaco35 Gen Assembly 106-107 Council meeting Venice, Italy presided by Dr .A.G.N. Sinha, India

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Function �Of �Medical Council of India�Includes

Control of the ethical standard of medical practitioners

To maintain Indian Medical Register. Names of all persons enrolled on any state medical register is is included ii. To remove names if it is removed from the state medical register

The Council received 479 matters of Ethical nature during the year (2003-4) under review. Out of 479 complaints, 172 have been referred to the concerned State Councils/authorities for necessary action, 102 of these are awaiting clarification/details from complainants and/or comments from the concerned Doctors etc. while 205 complaints stand disposed by this Council. During the year of 2008, the MCI had got 499 complaints and it went up to 684 in 2009. The total number of complaints received during 2010 was 904, of which punishment was given only in 18 cases, MCI data said. Delhi Medical Council receives 25-30 medical negligence complaints every month'

an 11-year-old boy lost one of his legs due to casual attitude of four doctors at two of Delhi's premium government hospitals – Hindu Rao and Safdarjung –

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Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002

Chapter I- CODE OF MEDICAL ETHICS

A. Declaration:
B. Duties and responsibilities of the Physician in general:

Chapter II- Duties of physicians to their patients
Chapter III Duties of physician in consultation
Chapter IV Responsibilities of physicians to each other
Chapter V Duties of physician to the public and to the paramedical profession

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Ethics Regulation (Cont.)

Chapter VI- UNETHICAL ACTS :
Chapter VII- MISCONDUCT :
Chapter VIII- Punishment and disciplinary action
Appendix - 1 Declaration(Copy of Geneva)
Appendix – 2 Form of certificate for leave or fitness
Appendix-3 Format for medical record� (see regulation 3.1)
Appendix –4 List of certificates, reports, notifications etc. Issued by doctors �

CERTIFICATES ISSUED BY REGISTERED MEDICAL PRACTITIONERS

Under the acts relating to birth, death or disposal of the dead. Under the Acts relating to Lunacy and Mental Deficiency and under the Mental illness Act and the rules made there under. Under the Vaccination Acts and the regulations made there under. Under the Factory Acts and the regulations made there under. Under the Education Acts. Under the Public Health Acts and the orders made thereunder. Under the Workmen’s Compensation Act and Persons with Disability Act. Under the Acts and orders relating to the notification of infectious diseases. Under the Employee’s State Insurance Act. In connection with sick benefit insurance and friendly societies. Under the Merchant Shipping Act. For procuring / issuing of passports. For excusing attendance in courts of Justice, in public services, in public offices or in ordinary employment. In connection with Civil and Military matters. In connection with matters under the control of Department of Pensions. In connection with quarantine rule. For Issue of Driving Licence

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Chapter I- �CODE OF MEDICAL ETHICS�A. Declaration:�(Physician’s Oath)

At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same:

I solemnly pledge myself to consecrate my life to the service of humanity.
Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.

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(Physician’s Oath)

3. I will maintain utmost respect for human life from the time of conception.
4. I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
5. I will practice my profession with conscience and dignity.

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The Oath

6. The health of my patient will be my first consideration.
7. I will respect the secrets which are confided in me even after the patient has died.
8. I will give to my teachers the respect and gratitude which is their due.
9. I will maintain by all means in my power, the honour and noble traditions of medical profession.
10. I will treat my colleagues with all respect and dignity.
11. I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002.

I make these promises solemnly, freely and upon my honour

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TO PUT THE PATIENT FIRST.

“The most important thing is caring, so do it first, for the caring physicians best inspires hope and trust.” Hope and trust are the basis for any treatment. A physician who cannot generate trust will face more challenges than the one who receives the trust of the patients. A patient with hope is far better off than one without.

Sir William Osler, FRS, FRCP 12/7/1849 – 29/12/1919)

He has frequently been described as the Father of Modern Medicine and one of the "greatest diagnosticians ever to wield a stethoscope". was a Canadian physician and one of the four founding professors of Johns Hopkins Hospital Maryland USA Ranked top hospital for 21 years 1991-2011. Johns Hopkins Hospital and the school of medicine are the founding institutions of modern American medicine and the birthplace of numerous medical traditions including rounds, residents and housestaff.^[5] Many medical specialties were formed at the hospital including neurosurgery, by Harvey Cushing; cardiac surgery by Alfred Blaloc;^[6] and child psychiatry, by Leo Kanner.^[7]^[8] Osler created the first residency program for specialty training of physicians, and he was the first to bring medical students out of the lecture hall for bedside clinical training.^[1]

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Duties and responsibilities of the Physician in general:�

Character of Physician

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

Physician means:-Doctors with qualification of MBBS or MBBS with post graduate degree/ diploma or with equivalent qualification in any medical discipline):

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.

1.2 Maintaining good medical practice:�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 �The honoured ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also to society.�1.2.2 Membership in Medical Society: For the advancement of his profession, a physician should affiliate3 A Physician should participate in professional meetings as part of Continuing Medical Education programmes, for at least 30 hours every five years, organized by reputed professional academic bodies or any other authorized organisations. The compliance of this requirement shall be informed regularly to Medical Council of India or the State Medical Councils as the case may be.�� with associations and societies of allopathic medical professions and involve actively in the functioning of such bodies.�

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Duties and Responsibilities of the Physician in General

Maintaining good medical practice:

Membership in Medical Societies:
CME attendance-30 hours in 5 years to improve treating ability constantly�

Maintaining good medical practice:�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 �The honoured ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also to society.�1.2.2 Membership in Medical Society: For the advancement of his profession, a physician should affiliate3 A Physician should participate in professional meetings as part of Continuing Medical Education programmes, for at least 30 hours every five years, organized by reputed professional academic bodies or any other authorized organisations. The compliance of this requirement shall be informed regularly to Medical Council of India or the State Medical Councils as the case may be with associations and societies of allopathic medical professions and involve actively in the functioning of such bodies.

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Duties in General(Cont.)

Maintenance of medical records

Medical record to be maintained as per prescribed proforma & preserved at least for 3 years
Supply to the patients / authorised attendant or legal authorities treatment record within 72 hours.
A Register shall be maintained for the Medical Certificates issued
Efforts shall be made to computerize medical records for quick retrieval.

Display of registration numbers

In Clinic, on prescriptions, certificates & receipts.
Suffix only recognised qualifications, membership/honours/exemplary achievement

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 Medical Council of India and attached as Appendix 3.�1.3.2. 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.�1.3.3 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 2.�1.3.4 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 / Medical Council of India in his clinic and in all his prescriptions, certificates, money receipts given to his patients.�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

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Duties in General(Cont.)

Use of Generic names of drugs

Preferably use generic names, and ensure a rational prescription and use of drugs.�

Highest Quality Assurance in patient care

Safeguard against admission of those who are deficient in moral character or education. �

Exposure of Unethical Conduct
Charges for Professional Services

To be displayed in clinic, fixed before the operation
No contract of ‘No cure No fee’

1.5 Use of Generic names of drugs: Every physician should, as far as possible, prescribe drugs with generic names and he / she shall ensure that there is a rational prescription and use of drugs.�1.6 Highest Quality Assurance in patient care: 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.�1.7 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.�1.8 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. A physician should announce his fees before rendering service and not after the operation or treatment is under way. Remuneration received for such services should be in the form and amount specifically announced to the patient at the time the service is rendered. 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.

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Patience, Delicacy and Secrecy

Facts revealed by patient or detected during medical attendance should never be revealed

Unless their revelation is required by the laws of the State. Or
Done with patient’s Consent
Privileged Communication-Revelation in the interest of Society- Colour blind train driver
Under Courts Order
Research – If allowed by ethical Committee but identifying data hidden including in photograph
In patients own Interest

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Duties to Patients

The Patient must not be neglected

Free to choose his patients
But in Emergency Must attend
Not to deprive his Patients of his best care
Not to withdraw from the case without giving adequate notice
Not to proceed on leave without arranging a substitute

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RESPONSIBILITIES OF PHYSICIANS TO EACH OTHER

A physician should consider it as a pleasure and privilege to render gratuitous service to all physicians and their immediate family dependants.
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.
Consultant not to take charge of the case

4. RESPONSIBILITIES OF PHYSICIANS TO EACH OTHER A physician should consider it as a pleasure and privilege to render gratuitous service to all physicians and their immediate family dependants.�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.

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UNETHICAL ACTS

Advertising:

Soliciting patient prohibited even by hospitals
Announcement in Press

On starting practice. On change of type of practice. On changing address. On temporary absence from duty. On resumption of another practice. On succeeding to another practice.

Running an open medicine shop- Prohibited
Fixing your name plate/ sign board at a medicine shop or practicing in a room attached to it.
Fixing of name plate/ sign board at a place where the doctor neither lives or practices.
Having unduly large, flashy or ornate signboard.�

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 instituti

ons 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 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:

On starting practice. On change of type of practice. On changing address. On temporary absence from duty. On resumption of another practice.

On succeeding to another practice.

Public declaration of charges.

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.�

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UNETHICAL ACTS(Cont.)

Rebates and Commission:

Dichotomy,(Fee splitting)- Prohibited

Secret Remedies

Dispensing by a physician of secret remedial agents, or the manufacture or promotion of their use is unethical

Human Rights:

The physician shall not aid or abet torture

Euthanasia

Constitute unethical conduct
Withdrawing life supporting devices even after brain death, shall be decided only by a team of doctors

he U.S. states of Oregon, Washington, Montana, and in the Kingdom of the Netherlands, Belgium, Luxembourg, Switzerland, doctor can prescribe euthanasia with the patient's consent

Euthanasia (from the Greek εὐθανασία meaning "good death": εὖ, eu (well or good) + θάνατος, thanatos (death)) refers to the practice of ending a life in a manner which relieves pain and suffering. According to the House of Lords Select Committee on Medical Ethics, the precise definition of euthanasia is "a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering.“

Euthanasia is categorized in different ways, which include voluntary, non-voluntary, or involuntary and active or passive. Euthanasia is usually used to refer to active euthanasia, and in this sense, euthanasia is usually considered to be criminal homicide, but voluntary, passive euthanasia is widely non-criminal

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 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 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 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.

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DANCING WITH THE PORCUPINE

Doctors Association with Pharmaceutical Companies

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Infamous Conduct in Professional Respect

Lord Justice Lopez 1894 Defined As:-
"If a medical man in the pursuit of his profession has done something with regard to it which will be reasonably regarded as disgraceful or dishonourable by his professional brethren of good repute and competency, then he is guilty of infamous conduct in a professional respect."

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Lord Justice Scrutton- 1930

"Infamous conduct in a professional respect means no more than serious misconduct judged according to the rules, written or unwritten, governing the profession.“
The term ‘serious professional misconduct’ was substituted by the Medical Act 1969 for ‘Infamous Conduct’

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MISCONDUCT (Liable for disciplinary action)

Violation of this Regulation
Adultery or Improper Conduct or improper association with patient.
Conviction by Court of Law:

for offences involving moral turpitude / Criminal acts.

Sex Determination Tests

For female foeticide

Signing Professional Certificates, Reports etc.

Which is untrue misleading or improper.

Contravention the provisions of the Drugs and Cosmetics Act

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 72 hours 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 Medical Council of India 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 Indian Medical Council Act, 1956 or the concerned State Medical Council Act.��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 Act, 1971. 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 –4. 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,

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

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.

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Infamous Conduct(Cont.)

Performing or enabling unqualified person to perform an abortion or any illegal operation.
Issuing of certificates of efficiency in modern medicine to unqualified or non-medical person.
Writing in press which has effect of advertising
Hospital may be advertised but only type of patient admitted and fee

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 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.��7.12 An institution run by a physician 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.

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Infamous Conduct(Cont.)

Refusal of treatment on religious ground
Failure to take

Informed consent in writing 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.

Publishing of photographs or case reports in which the patient is identified without their permission.
A Physician shall not use touts or agents for procuring patients. ��

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.

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Infamous Conduct(Cont.)

A Physician shall not claim to be specialist unless he has a special qualification in that branch (recognised by MCI).
Invitro fertilization or artificial insemination only with informed consent of the female patient and her spouse as well as the donor.
Violation of existing ICMR guidelines on human research ��

7.20 A Physician shall not claim to be specialist unless he has a special qualification in that branch.�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.

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Take Home Message

Dress decently-neither flashy nor shabby- to inspire respect among patients
Be punctual in every public duty
Be modest in your conduct and behaviour
Have genuine care and compassion for the patient
Inspire hope and trust in patients by your confident, knowledgeable caring approach
Always take proper consent

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At least do not harm the patient by your treatment or cause less harm than good
Be always ready to accept your ignorance and consult wiser colleagues in complicated cases.
Never say ‘No’ to a patient in emergency. If need be take him to the proper hospital in your vehicle
So far as is practicable prescribe generic medicine
Unless specifically indicated costly substitutes should be avoided
Consider it a privilege and do not charge from doctors and their immediate dependents

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Remember to say “Sorry” & “Thank You” at appropriate places.
Conduct research by developing a habit of counting and be truthful.
Remember poverty has a genuine claim on your services
Neither smoke nor drink at least publicly.

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Doctor’s Life Is about putting Patients' needs above your own fears.

&

To Serve the Suffering Humanity You Have to Suffer Yourself

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"Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.” Hippocrates

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