Describe the principles of medical ethics and the rights of patients.

Medical Ethics and Patient Rights

• The four principles:
• Autonomy — respect for the person’s right to make their own informed decisions, including decisions the doctor considers unwise
• Beneficence — acting in the patient’s best interest
• Non-maleficence — primum non nocere, first do no harm
• Justice — fairness in the distribution of benefits, risks and resources, and non-discrimination
• The principles conflict, and recognising the conflict is the whole skill — a patient refusing a life-saving transfusion sets autonomy against beneficence; allocating a scarce ventilator sets justice against individual beneficence; and a screening programme sets population benefit against the non-maleficence owed to those it harms by false positives
• Informed consent is the practical expression of autonomy, and its elements should be listed — disclosure of the diagnosis, the proposed procedure, its benefits, risks and complications, the alternatives including doing nothing, and the consequences of refusal; capacity to understand and decide; voluntariness, free of coercion or undue inducement; and comprehension, in a language the person understands
• A signature on a form is evidence of consent but is not consent itself, which resides in the conversation and the understanding it produced
• Capacity is decision-specific and may fluctuate — a person may have capacity for one decision and not another, and capacity is presumed in an adult until shown otherwise
• Refusing a recommended treatment is not by itself evidence of incapacity, which is a point frequently and dangerously assumed
• Confidentiality and its limits — it may be breached with the patient’s consent; where required by law, as with notifiable disease, POCSO and court order; and where there is a serious risk of harm to an identifiable other person
• The classical dilemma is partner notification in HIV, where confidentiality to the patient conflicts with the duty to a partner at risk
• The accepted approach is to counsel and support the patient to disclose themselves, allowing time, and to consider disclosure only as a last resort after informing the patient of the intention
• Other core duties — truth-telling and honesty; competence and keeping up to date; avoiding conflicts of interest, including gifts from pharmaceutical companies and fee-splitting for referrals; maintaining professional boundaries; and a duty to report an unsafe colleague
• Fee-splitting (the "cut practice") deserves naming as a specific Indian problem, since it corrupts referral, inflates cost and directs patients by financial interest rather than by need
• Research ethics — governed by the nuremberg code, the declaration of helsinki, the belmont report and the ICMR National Ethical Guidelines
• Its requirements — institutional ethics committee approval before starting; voluntary informed consent; a favourable risk-benefit ratio; scientific validity, since an invalid study cannot be ethical however well conducted; fair selection of participants, avoiding exploitation of the vulnerable; the right to withdraw at any time without penalty; confidentiality; trial registration; and post-trial access and compensation for research-related injury
• Patient rights, as set out in the charter of patients’ rights — the right to information about diagnosis and treatment; records and reports; emergency care, which cannot be refused for inability to pay; informed consent; confidentiality and privacy, including a female attendant during examination of a woman; a second opinion; transparency in rates and the choice of where to obtain medicines and tests; non-discrimination; safety and quality; choice of alternative treatment where available; a proper referral and transfer; protection from unnecessary participation in research; and a mechanism of grievance redressal
• The emergency care right is enforceable in India, following Supreme Court judgments holding that a doctor and hospital may not refuse emergency treatment for want of payment or on medico-legal grounds
• Patient responsibilities also exist — giving accurate information, following the agreed plan, respecting staff and other patients, and following hospital rules
• A signature is evidence of consent, not consent, which lives in the conversation and the understanding it produced
• Refusing treatment is not evidence of incapacity, and capacity is presumed in an adult until shown otherwise
• Capacity is decision-specific and may fluctuate, so it must be assessed for the decision at hand rather than globally
• Recognising which principles conflict is the skill, since the framework identifies the disagreement rather than resolving it
• Counsel the patient to disclose themselves in HIV partner notification, treating breach as a genuine last resort
• An invalid study cannot be ethical, however carefully it is conducted, since it exposes people to risk for nothing
• Ethics committee approval precedes the study, not the publication, which is a distinction journals now enforce
• Emergency care cannot be refused for payment, which is enforceable in India following Supreme Court judgments
• Fee-splitting corrupts referral, directing patients by financial interest rather than by clinical need
• Report an unsafe colleague, which is a professional duty rather than a matter of personal discretion
• Disclose the alternatives including doing nothing, which is the part of consent most often omitted
• Participants may withdraw without penalty at any time, and must be told so explicitly rather than left to assume it
• Patients have responsibilities too — accurate information, following the agreed plan and respecting staff
• A female attendant should be present when a woman is examined, which is a right rather than a courtesy