INTRODUCTIONINTRODUCTION

MEDICAL PRACTICE AND STATUTE LAW.MEDICAL PRACTICE AND STATUTE LAW.

ROLE OF COMMON LAW.ROLE OF COMMON LAW.

ROLE OF CONSENT AND ACCOUNTABILITY ROLE OF CONSENT AND ACCOUNTABILITY OF NEGLIGENCE.OF NEGLIGENCE.

VARIOUS SYSTEMS OF HEALINGVARIOUS SYSTEMS OF HEALING

Allopathic SystemAllopathic System

Ayuverdic SystemAyuverdic System

Homeopathic SystemHomeopathic System

Unani TibUnani Tib

Allopathic SystemAllopathic System

Modern , Scientific, Recognized.Modern , Scientific, Recognized.

Achievements:-Achievements:-

Increase in age span, Extinction of many Increase in age span, Extinction of many infectious diseases, Understanding of infectious diseases, Understanding of Psychological illnesses etc.Psychological illnesses etc.

LAWS RELATED TO LAWS RELATED TO ALLOPATHIC SYSTEM OF ALLOPATHIC SYSTEM OF

MEDICAL PRACTICEMEDICAL PRACTICEMedical and dental degree Ordinance Medical and dental degree Ordinance 1980.1980.

Allopathic System (Prevention of misuse) Allopathic System (Prevention of misuse) act 1962.act 1962.

Pakistan Medical and Dental Council Pakistan Medical and Dental Council Ordinance 1962.Ordinance 1962.

Drug Act 1976.Drug Act 1976.

Dangerous Drug Act 1930.Dangerous Drug Act 1930.

MEDICAL AND DENTAL DEGREE MEDICAL AND DENTAL DEGREE ORDINANCE 1980ORDINANCE 1980

Defines scientific medical and dental Defines scientific medical and dental system.system.

Identifies authorities having right of Identifies authorities having right of granting medical degree and diploma.granting medical degree and diploma.

Prohibits unauthorized conformant of Prohibits unauthorized conformant of medical degree and diploma and falsely medical degree and diploma and falsely assuming or using medical or dental title.assuming or using medical or dental title.

IMPORTANT POINTSIMPORTANT POINTS

1. Scientific medical and dental system in 1. Scientific medical and dental system in law means allopathic system of medicine law means allopathic system of medicine including obstetrics, surgery and including obstetrics, surgery and dentistry.dentistry.

2. Only Universities established by an act of 2. Only Universities established by an act of Federal or Provincial Legislature and Federal or Provincial Legislature and College of Physicians and Surgeons, College of Physicians and Surgeons, Pakistan have the right of granting Pakistan have the right of granting degrees and diplomas.degrees and diplomas.

3. The proceedings for contravention of this 3. The proceedings for contravention of this law are initiated in the Court of law are initiated in the Court of Magistrate. The offence is punishable Magistrate. The offence is punishable with maximum of five years rigorous with maximum of five years rigorous imprisonment or fine of fifty thousands or imprisonment or fine of fifty thousands or both. both.

ALLOPATHIC SYSTEM ALLOPATHIC SYSTEM (PREVENTION OF MISUSE) ACT (PREVENTION OF MISUSE) ACT

1962 1962 Defines Registered Medical Practitioner.Defines Registered Medical Practitioner.

Prevents misuse of Allopathic System.Prevents misuse of Allopathic System.

IMPORTANT POINTSIMPORTANT POINTS

Registered Medical Practitioner means a Registered Medical Practitioner means a medical practitioner registered with medical practitioner registered with Pakistan Medical and Dental Council.Pakistan Medical and Dental Council.

No one other than Registered Medical No one other than Registered Medical Practitioner shall:Practitioner shall:Use with his name or address the word Use with his name or address the word ““doctor”doctor” or any of its grammatical or any of its grammatical variations or abbreviations so as to give an variations or abbreviations so as to give an impression that he is entitled to practice impression that he is entitled to practice allopathic medicine.allopathic medicine.

Use medical degree or diploma to give Use medical degree or diploma to give impression that he is a qualified medical impression that he is a qualified medical practitioner or for any purpose connected practitioner or for any purpose connected with allopathic medical practice.with allopathic medical practice.

Perform any surgical operation other than Perform any surgical operation other than circumcision, incision of boils and circumcision, incision of boils and administration of injections.administration of injections.

Prescribe any antibiotic or dangerous drug Prescribe any antibiotic or dangerous drug specified in the rules made under this specified in the rules made under this Ordinance.Ordinance.

Proceedings for contravention of this Act Proceedings for contravention of this Act are initiated by Drug Inspectors in the are initiated by Drug Inspectors in the Court of a Magistrate and the offence is Court of a Magistrate and the offence is punishable with maximum of one year punishable with maximum of one year imprisonment or fine of Rs. 2000/- or both.imprisonment or fine of Rs. 2000/- or both.

PAKISTAN MEDICAL AND PAKISTAN MEDICAL AND DENTAL COUNCIL ORDINANCE DENTAL COUNCIL ORDINANCE

19621962 Have specific objectives of establishing Have specific objectives of establishing

the statutory body of medical practitioners the statutory body of medical practitioners called Pakistan Medical & Dental Council.called Pakistan Medical & Dental Council.

CONSTITUTION OF PAKISTAN CONSTITUTION OF PAKISTAN MEDICAL AND DENTAL MEDICAL AND DENTAL

COUNCILCOUNCIL

Elected Members:Elected Members:→ → 1 from National Assembly.1 from National Assembly.

→ → 1 from Each Medical Institution.1 from Each Medical Institution.

→ → 4 Registered Medical Practitioners.4 Registered Medical Practitioners.

→ → 2 Registered Dental Practitioners.2 Registered Dental Practitioners.

→ → 1 from Each University Granting Medical 1 from Each University Granting Medical Degrees.Degrees.

Nominated Members:Nominated Members:

a) Legal Membera) Legal Member→ → One Legal Member.One Legal Member.

b) b) Medical Members:Medical Members:→ → Director General Health, Pakistan.Director General Health, Pakistan.

→ → 1 from Each Province.1 from Each Province.

→ → 4 from Federal Government Including 2 4 from Federal Government Including 2 from Armed forces.from Armed forces.

FUNCTIONS OF P.M.D.C.

To maintain proficiency of the medical To maintain proficiency of the medical profession.profession.

To maintain Medical register.To maintain Medical register.

To Over see professional conduct of To Over see professional conduct of registered medical practitioner (ethical registered medical practitioner (ethical standard).standard).

POWERS FOR MAINTAINING POWERS FOR MAINTAINING PROFICIENCY OF THE MEDICAL PROFICIENCY OF THE MEDICAL

PROFESSIONPROFESSION

P.M.D.C. canP.M.D.C. canEvaluate courses of studies of medical Evaluate courses of studies of medical qualifications.qualifications.

Prescribe minimum qualifications of Prescribe minimum qualifications of medical teachers.medical teachers.

Inspect medical institutions and Inspect medical institutions and examinations.examinations.

The council is fully empowered to The council is fully empowered to grant grant recognitionrecognition to a medical institution or on to a medical institution or on the basis of any derogatory information the basis of any derogatory information regarding courses of studies, facilities for regarding courses of studies, facilities for medical education or examination medical education or examination refuse refuse recognitionrecognition or with the approval of the or with the approval of the Federal Government also Federal Government also withdraw withdraw recognition that is already approvedrecognition that is already approved. .

MEDICAL REGISTERMEDICAL REGISTER

Medical Register is the register that contains Medical Register is the register that contains names of all the available medical practitioners names of all the available medical practitioners in the country. Every medical practitioner, has in the country. Every medical practitioner, has to register himself with the Council.to register himself with the Council.

The Medical Register has two The Medical Register has two portions:portions:The first having the names of ordinary The first having the names of ordinary medical practitioners who possess only medical practitioners who possess only the basic medical qualification i.e., the basic medical qualification i.e., M.B.B.S.M.B.B.S.

The second having the names of The second having the names of specialists who have also acquired specialists who have also acquired additional medical qualification after additional medical qualification after attaining the basic medical qualification.attaining the basic medical qualification.

The medical registration can be obtained The medical registration can be obtained by submitting an application supported by submitting an application supported with requisite fee and certificates of with requisite fee and certificates of medical proficiency, good moral character medical proficiency, good moral character and citizenship.and citizenship.

Medical Practitioner’s name may be Medical Practitioner’s name may be removed from the register due to non-removed from the register due to non-payment of maintenance fee or if payment of maintenance fee or if practitioner is found guilty of moral practitioner is found guilty of moral turpitude. turpitude.

PREVILEGES AND PREVILEGES AND OBLIGATIONS OF R.M.P.OBLIGATIONS OF R.M.P.

Three Privileges:Three Privileges:1. Employment:1. Employment: Can seek employment against job or Can seek employment against job or

permission for independent practice.permission for independent practice.

2. Certification:2. Certification: Can Issue medical certificate for Can Issue medical certificate for

administrative and judicial purposes.administrative and judicial purposes.

3. Fees:3. Fees: Can charge fees for medical services Can charge fees for medical services

rendered.rendered.

Two Obligations:Two Obligations:1.1. To notify to the council change of To notify to the council change of

address on transfer within a period of 30 address on transfer within a period of 30 days of the change.days of the change.

2.2. Not using any name, title, description or Not using any name, title, description or abbreviation indicating that he possesses abbreviation indicating that he possesses an additional qualification, which is not an additional qualification, which is not conferred to him.conferred to him.

MAINTENANCE OF ETHICAL MAINTENANCE OF ETHICAL STANDARDSTANDARD

Ethical standard is maintained by Ethical standard is maintained by overseeing professional conduct of overseeing professional conduct of registered medical practitioner by the registered medical practitioner by the council critically. council critically. His name can be His name can be suspended or removed altogethersuspended or removed altogether if the if the disciplinary committee of the council finds disciplinary committee of the council finds him guilty of professional misconduct.him guilty of professional misconduct.

DISCIPLINARY DISCIPLINARY PROCEEDINGS AGAINST A PROCEEDINGS AGAINST A MEDICAL PRACTITIONERMEDICAL PRACTITIONER

Court ConvictionCourt Conviction PatientPatient Hospital Admin.Hospital Admin.

PRESIDENT OF P.M.D.C. PRESIDENT OF P.M.D.C. Frivolous complaints rejected. Frivolous complaints rejected.

Doctor asked to explain.Doctor asked to explain.Complaint dismissed. Warning issued.Complaint dismissed. Warning issued.

DISCIPLINARY COMMITTEEDISCIPLINARY COMMITTEE

Name suspended Complaint Name erased Name suspended Complaint Name erased for a period. Dismissed. from register.for a period. Dismissed. from register.

DISTINGUISHED STATUS OF DISTINGUISHED STATUS OF MEDICAL PROFESSIONMEDICAL PROFESSION

Medical Profession is different from all Medical Profession is different from all other professions due to special other professions due to special relationship existing between a medical relationship existing between a medical practitioner and his patient. Medical practitioner and his patient. Medical practitioner has privileged position having practitioner has privileged position having both skill and authority. While patient is at both skill and authority. While patient is at his mercy, dependent and in a state of his mercy, dependent and in a state of complete surrender.complete surrender.

CONTROLLING INFLUENCE CONTROLLING INFLUENCE UPON MEDICAL PRACTITIONERUPON MEDICAL PRACTITIONER

Laws related to medical practice.Laws related to medical practice.

Medical ethics.Medical ethics.

MEDICAL ETHICSMEDICAL ETHICSEthics… derived from the Greek term Ethics… derived from the Greek term “Ethicos”“Ethicos” which stands for rules of conduct which stands for rules of conduct that govern natural disposition in human that govern natural disposition in human beings. beings. Ethics means “Philosophy of Ethics means “Philosophy of Morals”.Morals”. Study of ethic is essentially an Study of ethic is essentially an examination of:examination of:What is wrong & what is right?What is wrong & what is right?What is virtuous & what is evil?What is virtuous & what is evil? in the human conduct.in the human conduct.

Medical ethicsMedical ethics means morality in medical means morality in medical profession. It is code of conduct imposed by profession. It is code of conduct imposed by the profession itself depending upon then the profession itself depending upon then moral values.moral values.

Moral values differ in accordance with the Moral values differ in accordance with the attitude of the society:attitude of the society:e.g.,e.g.,→ → Satti in Hindus.Satti in Hindus.→ → Punishment of Hudood in Muslims.Punishment of Hudood in Muslims.→ → Abortion in Western countries.Abortion in Western countries.→ → Bhuddish – suicide by fire.Bhuddish – suicide by fire.

Can we enforce ethics Can we enforce ethics legally?legally?

No.No.you cannot make people moral you cannot make people moral

by Act of Parliament by Act of Parliament

But But that is precisely what can be that is precisely what can be

donedone

VARIOUS CODES OF MEDICAL VARIOUS CODES OF MEDICAL ETHICSETHICS

The Hippocratic Code.The Hippocratic Code.

International Code of Medical Ethics.International Code of Medical Ethics.

P.M.D.C. Code of Medical Ethics. P.M.D.C. Code of Medical Ethics.

THE HIPPOCRATIC CODETHE HIPPOCRATIC CODE

The oldest known …… 25 centuries old …… The oldest known …… 25 centuries old …… Laid by Hippocrates (Father of Western Laid by Hippocrates (Father of Western

Medicine in Greece in 5Medicine in Greece in 5thth century) …… Used century) …… Used to be sworn by Greek physicians.to be sworn by Greek physicians.

INTERNATIONAL CODE OF INTERNATIONAL CODE OF MEDICAL ETHICSMEDICAL ETHICS

Recommended by World Medical Association Recommended by World Medical Association after 2after 2ndnd World War at its 3 World War at its 3rdrd general general

assembly in Geneva (Declaration of Geneva assembly in Geneva (Declaration of Geneva 1948). It is basically simple and modern 1948). It is basically simple and modern

version of Hippocratic Oath.version of Hippocratic Oath.

P.M.D.C. CODE OF MEDICAL P.M.D.C. CODE OF MEDICAL ETHICSETHICS

Almost same as International Almost same as International Code of Medical Ethics with few Code of Medical Ethics with few

modifications.modifications.

IMPORTANT COMMON POINTS IMPORTANT COMMON POINTS IN VARIOUS MEDICAL CODES IN VARIOUS MEDICAL CODES Indiscriminate service of humanity.Indiscriminate service of humanity.Respect of teachers.Respect of teachers.Respect of colleagues.Respect of colleagues.Respect and care of patient.Respect and care of patient.Respect of the secrets of the patient.Respect of the secrets of the patient.Maintenance of the noble traditions and Maintenance of the noble traditions and honor of medical profession.honor of medical profession.Respect for human life from the time of Respect for human life from the time of conception.conception.

OATH FOR MEDICAL OATH FOR MEDICAL GRADUATESGRADUATES

An oath is administrated to the medical An oath is administrated to the medical graduates at the time of their passing out.graduates at the time of their passing out.

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In the name of Allah, Most Gracious and In the name of Allah, Most Gracious and Merciful.Merciful.

I solemnly pledge thatI solemnly pledge that

I shall abide by the principles laid down in the I shall abide by the principles laid down in the Code of Medical Ethics of the Pakistan Medical Code of Medical Ethics of the Pakistan Medical and Dental Council. and Dental Council.

I further make solemn declaration that:I further make solemn declaration that:

I consecrate my life to the service of humanity.I consecrate my life to the service of humanity.

I will give to my teachers the respect and the I will give to my teachers the respect and the gratitude which is their due.gratitude which is their due.

I will practice my profession with conscience dignity I will practice my profession with conscience dignity and fear of God.and fear of God.

The health of any patient will be my first The health of any patient will be my first consideration.consideration.

I will respect the secrets, which are confined to me.I will respect the secrets, which are confined to me.

I will maintain by all the means in my power, the I will maintain by all the means in my power, the honor and the noble traditions of the medical honor and the noble traditions of the medical profession.profession.

My colleagues will be my brothers and My colleagues will be my brothers and sisters.sisters.

I will not permit consideration of religion, I will not permit consideration of religion, nationality, race, party politics, social nationality, race, party politics, social standings to intervene between my duty and standings to intervene between my duty and my patient.my patient.

I will maintain the utmost respect, for human I will maintain the utmost respect, for human life, from the time of conception; even under life, from the time of conception; even under threat, and will not use my medical threat, and will not use my medical knowledge contrary to the laws of humanity.knowledge contrary to the laws of humanity.

I make these promises solemnly, free and I make these promises solemnly, free and upon my honor. upon my honor.

FACTORS RESPONSIBLE FOR FACTORS RESPONSIBLE FOR DETERIORIATION OF ETHICAL DETERIORIATION OF ETHICAL

VALUES IN MEDICAL PRACTICEVALUES IN MEDICAL PRACTICE

Materialism:Materialism: Tendency to be more concerned Tendency to be more concerned

with material than spiritual value or an with material than spiritual value or an abnormal desire for wealth. “Get rich abnormal desire for wealth. “Get rich quick” Syndrome.quick” Syndrome.

Decline in Religious Influence:Decline in Religious Influence: Decline in Religious influence on Decline in Religious influence on

the character resulted in Lack of Fear of the character resulted in Lack of Fear of Allah. Allah.

Commercialism:Commercialism: To exploit mainly for profit. Medical To exploit mainly for profit. Medical

practice is often called and industry or business. practice is often called and industry or business. Objective is maximum profit with minimum input. It Objective is maximum profit with minimum input. It lead to a change from lead to a change from

Mission ------------- to ------------- Commission.Mission ------------- to ------------- Commission.

e.g., “percentage” from the Labs, Pharmaceutical e.g., “percentage” from the Labs, Pharmaceutical concerns and Hospitals etc.concerns and Hospitals etc.

Science & Technology:Science & Technology: Newly developed intricate Newly developed intricate

procedures whose ethical value is doubtful e.g., procedures whose ethical value is doubtful e.g., Artificial insemination, Surrogate motherhood, Artificial insemination, Surrogate motherhood, Organ transplantation, Cloning.Organ transplantation, Cloning.

PROFESSIONAL PROFESSIONAL MISCONDUCTMISCONDUCT

Lord Justice Lopes LJ defined it in 1894.Lord Justice Lopes LJ defined it in 1894.

“ “If a medical man in pursuit of his profession If a medical man in pursuit of his profession has done something which would be reasonably has done something which would be reasonably regarded as disgraceful or dishonorable by regarded as disgraceful or dishonorable by

his professional brethren of good repute his professional brethren of good repute and competency,and competency, then he is guilty of infamous then he is guilty of infamous

conduct in professional respect.”conduct in professional respect.”

EXAMPLESEXAMPLES

Abuse of Medical Practitioner’s Abuse of Medical Practitioner’s Privileges:Privileges:

1.1. Issuing false medical certificate.Issuing false medical certificate.2.2. Prescribing drugs of addiction for abuse.Prescribing drugs of addiction for abuse.3.3. Disclosing of patient’s secret. Disclosing of patient’s secret.

Abuse of Doctor-Patient Abuse of Doctor-Patient Relationship:Relationship:

1.1. Indecent assault on patient.Indecent assault on patient.2.2. Adultery with patient.Adultery with patient.

Abuse of Professional Knowledge:Abuse of Professional Knowledge:1.1. Criminal abortion.Criminal abortion.

Abuse of Financial Opportunities:Abuse of Financial Opportunities:1.1. Dichotomy or fee splitting.Dichotomy or fee splitting.

2.2. Commission in labs, medicine, bogus bills.Commission in labs, medicine, bogus bills.

Association with Unqualified Association with Unqualified Persons in Professional WorkPersons in Professional Work (Covering):(Covering):

e.g., Administration of anesthetic to enable e.g., Administration of anesthetic to enable such a person to perform operation. such a person to perform operation.

Advertising and Canvassing with a Advertising and Canvassing with a View to have Unreasonable Gains:View to have Unreasonable Gains:

e.g., Advertisements and interviews in print e.g., Advertisements and interviews in print and electronic media. and electronic media.

Disregard of the Responsibilities to Disregard of the Responsibilities to the Patient:the Patient:

e.g., Persistent failure to attend the patient e.g., Persistent failure to attend the patient through idleness or carelessness.through idleness or carelessness.

Conduct Discredible to the Medical Conduct Discredible to the Medical Profession:Profession:

e.g., Notification of the conviction being guilty e.g., Notification of the conviction being guilty of fraud, forgery or theft.of fraud, forgery or theft.

Personal Tendencies Dangerous to Personal Tendencies Dangerous to the Patients:the Patients:

e.g., Alcoholism and drug addiction.e.g., Alcoholism and drug addiction.

Profiting at the Expense of his Profiting at the Expense of his Colleagues:Colleagues:

e.g., Deprecation of other doctors. e.g., Deprecation of other doctors.

PROFESSIONAL SECRETPROFESSIONAL SECRETIs one Is one which a doctor come to know in his which a doctor come to know in his professional capacityprofessional capacity e.g., during history taking, e.g., during history taking, on examination or privacy of domestic life.on examination or privacy of domestic life.

Any information received by a medical Any information received by a medical practitioner during the doctor patient practitioner during the doctor patient relationship is a sacred trust with the doctor.relationship is a sacred trust with the doctor.

Maintenance of secrecy is not Maintenance of secrecy is not only a moral only a moral obligation but also a legal oneobligation but also a legal one and a practitioner and a practitioner is liable to damage for its neglect.is liable to damage for its neglect.

PRIVILEGED COMMUNICATIONPRIVILEGED COMMUNICATION

A communication made by a doctor to a A communication made by a doctor to a proper authority who has corresponding legal, proper authority who has corresponding legal, social and moral duties to protect the public.social and moral duties to protect the public.

TYPES OF PREVILEGED TYPES OF PREVILEGED COMMUNICATIONCOMMUNICATION

Absolute Privilege:Absolute Privilege: Any statement made in the Any statement made in the

court of law. All matters voiced in the court court of law. All matters voiced in the court of law are absolute privilege professional of law are absolute privilege professional dictates are completely ignored.dictates are completely ignored.

Qualified Privilege:Qualified Privilege: Statement made to protect Statement made to protect

an interest, which may be one’s own or of an interest, which may be one’s own or of another’s. All statement, made outside the another’s. All statement, made outside the court by the doctor may be protected.court by the doctor may be protected.

CONDITIONSCONDITIONS

Statement must not be malicious.Statement must not be malicious.

Must have been in good faith.Must have been in good faith.

Must have been in the interest of Must have been in the interest of community.community.

Statement is made only to those who have Statement is made only to those who have an interest or duty to receive it. an interest or duty to receive it.

EXAMPLESEXAMPLESInformation of homicidal poisoning to Information of homicidal poisoning to police.police.Notification of infectious disease to Public Notification of infectious disease to Public Health Authority.Health Authority.Certification of birth and death.Certification of birth and death.Cooks ….. Open T.B., Typhoid infection.Cooks ….. Open T.B., Typhoid infection.Venereal disease – stop to enter Venereal disease – stop to enter swimming pool. swimming pool. Hotel waiter having T.B. or infectious Hotel waiter having T.B. or infectious disease.disease.Bus or engine driver – Hypertension, Bus or engine driver – Hypertension, Epilepsy, Color blindness.Epilepsy, Color blindness.

MEDICAL NEGLIGENCEMEDICAL NEGLIGENCE

Negligence is a Negligence is a “tort”“tort” meaning meaning conduct which creates risk of conduct which creates risk of

causing damage”. It also means causing damage”. It also means “carelessness”.“carelessness”.

ELEMENTS OF NEGLIGENCE ELEMENTS OF NEGLIGENCE (3Ds)(3Ds)

Duty:Duty: Doctor owed a duty to treat the Doctor owed a duty to treat the

patient.patient.

Dereliction:Dereliction: There was breech of the There was breech of the

duty due to his negligent conduct.duty due to his negligent conduct.

Damage:Damage: Patient has suffered damage as Patient has suffered damage as

a result of breach of the duty.a result of breach of the duty.

DUTIES OF A DOCTORDUTIES OF A DOCTOR

Care of patient (private / govt. Service).Care of patient (private / govt. Service).Duty to respond to emergency or night Duty to respond to emergency or night call.call.Standard of skill or knowledge required.Standard of skill or knowledge required.Duty to show reasonable care and skill.Duty to show reasonable care and skill.Duty to have informed consent.Duty to have informed consent.Duty to maintain professional secrecy.Duty to maintain professional secrecy.Knowledge of recent Advances. Knowledge of recent Advances.

NEGLIGENCE ---- LEGAL NEGLIGENCE ---- LEGAL CONSIDERATIONCONSIDERATION

Neither a doctor can be forced to start Neither a doctor can be forced to start treatment nor can a patient be forced treatment nor can a patient be forced

to submit to treatment. When both to submit to treatment. When both agree, they enter into an agree, they enter into an

“Implied contract”“Implied contract” having their own having their own share of responsibilities. share of responsibilities.

Patient’s Share Of Responsibility:Patient’s Share Of Responsibility:(a). To pay the mutually agreed fee.(a). To pay the mutually agreed fee.

(b). To submit himself to the command of(b). To submit himself to the command of

doctor. doctor.

Doctor’s Share Of Responsibility:Doctor’s Share Of Responsibility:(a). To apply skill with competence (a). To apply skill with competence

proportionate to his own claim. proportionate to his own claim.

(b). During application of skill should exercise (b). During application of skill should exercise reasonable care.reasonable care.

The treatment must proceed without The treatment must proceed without interruption till:interruption till:

Mutual agreement between doctor and Mutual agreement between doctor and patient.patient.

Discharge of Doctor by the patient.Discharge of Doctor by the patient.

Death of either party.Death of either party.

Transfer in govt. Service.Transfer in govt. Service.

IMPORTANT POINTSIMPORTANT POINTS

The termination of contract is unilateral.The termination of contract is unilateral.

Unless there is a claim by the sufferer, the Unless there is a claim by the sufferer, the Law does not come in automatically.Law does not come in automatically.

When a case of negligence is brought When a case of negligence is brought forward, the burden of proof normally lies forward, the burden of proof normally lies with the patient. However, in cases with the patient. However, in cases covered by doctrine of covered by doctrine of “RES IPSA “RES IPSA LOQUITOR” LOQUITOR” (Thing speaks for itself),(Thing speaks for itself), the the burden of proof is shifted from patient to burden of proof is shifted from patient to doctor.doctor.

EXAMPLESEXAMPLES

Leaving electric cautery unattended.Leaving electric cautery unattended.

Transfusion of wrong bottle of blood.Transfusion of wrong bottle of blood.

Amputation of the wrong limb.Amputation of the wrong limb.

Leaving swab or instrument in the body.Leaving swab or instrument in the body.

Operation on the wrong patient. Operation on the wrong patient.

PUNISHMENTPUNISHMENT

Section 337-H (PPC):Section 337-H (PPC): Deals with punishment for hurt Deals with punishment for hurt

caused by Negligence. It may be caused by Negligence. It may be Arsh, Daman Arsh, Daman or imprisonment upto three years.or imprisonment upto three years.

Section 319 (PPC):Section 319 (PPC): Deals with the punishment of the Deals with the punishment of the

death due to Negligent act. It may be death due to Negligent act. It may be Diyat and Diyat and imprisonment upto five years.imprisonment upto five years.

TYPES OF NEGLIGENCETYPES OF NEGLIGENCE

Civil Negligence.Civil Negligence.

Contributory Negligence.Contributory Negligence.

Third Party Negligence.Third Party Negligence.

Criminal Negligence.Criminal Negligence.

CIVIL NEGLIGENCECIVIL NEGLIGENCEFailure to exercise reasonable degree of care Failure to exercise reasonable degree of care and skill on part of doctor in the treatment of and skill on part of doctor in the treatment of patient and as a result, health of patient patient and as a result, health of patient suffers. The negligent act must be proved by suffers. The negligent act must be proved by claimant. claimant. For example:For example:Extraction of healthy teeth.Extraction of healthy teeth.Failure to give ATT.Failure to give ATT.Failure to take X-Ray in case of injury.Failure to take X-Ray in case of injury.Civil mal-praxis results in damages but does Civil mal-praxis results in damages but does not effect life so cases are dealt in civil courtsnot effect life so cases are dealt in civil courts. .

CONTRIBUTORY NEGLIGENCECONTRIBUTORY NEGLIGENCEIn this, patient also contributes to the damage In this, patient also contributes to the damage caused by negligent act of doctor. The award of caused by negligent act of doctor. The award of damages will be reduced accordingly. Burden damages will be reduced accordingly. Burden of proof lies on the doctor. of proof lies on the doctor.

For example:For example:

Patient tampers with his dressing and induces Patient tampers with his dressing and induces infection or removes a plaster cast or ignores infection or removes a plaster cast or ignores instructions to return for further treatment / instructions to return for further treatment / follow up.follow up.

THIRD PARTY NEGLIGENCETHIRD PARTY NEGLIGENCE

Negligence of paramedical staff, nurses and Negligence of paramedical staff, nurses and students working under supervision of a students working under supervision of a doctor. The doctor is held equally responsible doctor. The doctor is held equally responsible by virtue of by virtue of doctrine of “respondent superior”doctrine of “respondent superior” (let the master answer) or (let the master answer) or doctrine of doctrine of “caption of the ship”“caption of the ship” now a days being now a days being replaced by replaced by doctrine of “borrowed servant”.doctrine of “borrowed servant”. For example:For example:

Failure to check swabs, paralysis during Failure to check swabs, paralysis during spinal anesthesia or failure to check drug and spinal anesthesia or failure to check drug and its expiry. its expiry.

CRIMINAL NEGLIGENCECRIMINAL NEGLIGENCEIt is described as It is described as gross ignorance, gross gross ignorance, gross carelessness ort gross neglect for the lifecarelessness ort gross neglect for the life which may amount to criminal offence.which may amount to criminal offence. It It reflects disregard for life and safety of others. reflects disregard for life and safety of others. Mere monitory compensation is not sufficient, Mere monitory compensation is not sufficient, wrong doer should also be punished. Cases wrong doer should also be punished. Cases are dealt in criminal courts. are dealt in criminal courts. For example:For example:Injecting anesthetic, in fatal dose.Injecting anesthetic, in fatal dose.Amputation of wrong finger, wrong limb,Amputation of wrong finger, wrong limb, wrong organ. wrong organ. Operation on wrong patient.Operation on wrong patient.

CONSENTCONSENT

Means Means “to agree”“to agree” or active will in the mind of a or active will in the mind of a person to permit doing of act.person to permit doing of act.

REQUIREMENTSREQUIREMENTSIt must be free from fear, force or fraud.It must be free from fear, force or fraud.Must not be obtained by any sharp Must not be obtained by any sharp practice or blackmail.practice or blackmail.The facts of consent must clearly be The facts of consent must clearly be stated.stated.Possible results and complications must Possible results and complications must be explained.be explained.Person must understand what he is Person must understand what he is consenting to.consenting to.Reasonable time interval between consent Reasonable time interval between consent and treatment.and treatment.

INVALID CONSENTINVALID CONSENT

Child.Child.

Insane.Insane.

Unconscious or under the influence of Unconscious or under the influence of drug.drug.

Consent obtained by force, fear, fraud or Consent obtained by force, fear, fraud or threat.threat.

Consent given for illegal purposes e.g., Consent given for illegal purposes e.g., Euthanasia. Euthanasia.

TYPES OF CONSENTTYPES OF CONSENT

Implied.Implied.Informed or Expressed Informed or Expressed (oral/written).(oral/written).

IMPLIED CONSENTIMPLIED CONSENT

Mere action of patient, while he comes Mere action of patient, while he comes to doctor and sits on examination stool to doctor and sits on examination stool with some problem indicate that he is with some problem indicate that he is giving permission for treatment without giving permission for treatment without expressing his consent. expressing his consent.

EXPRESSED CONSENTEXPRESSED CONSENT

Verbal or written both are acceptable under Verbal or written both are acceptable under Law but written is best because if it is kept Law but written is best because if it is kept in record for further reference.in record for further reference.

Oral consent is obtained in the presence of Oral consent is obtained in the presence of third party who is disinterested. May be a third party who is disinterested. May be a nurse or other paramedical staff member.nurse or other paramedical staff member.

REQUIREMENTS FOR REQUIREMENTS FOR INFORMED CONSENTINFORMED CONSENT

Understandable communication between Understandable communication between doctor taking consent and the person doctor taking consent and the person entitled by law to grant consent.entitled by law to grant consent.Doctor should inform the patient about:Doctor should inform the patient about:

1.1. Diagnosis.Diagnosis.2.2. Choice of treatment.Choice of treatment.3.3. Doctors experience.Doctors experience.4.4. Method to be used.Method to be used.5.5. Major or collateral risks.Major or collateral risks.6.6. Type of anesthesia.Type of anesthesia.

7.7. Any alternative available.Any alternative available.

8.8. Prognosis.Prognosis.

9.9. Stay in hospitalStay in hospital

Note:Note: ““Blanket consent” Blanket consent” is not acceptable is not acceptable

in courts.in courts.

SITUATION WHERE CONSENT IS SITUATION WHERE CONSENT IS NOT REQUIRED NOT REQUIRED

Examination of immigrant by port or airport Examination of immigrant by port or airport authorities.authorities.

A person suffering from notifiable disease.A person suffering from notifiable disease.

Handlers of food and dairy man.Handlers of food and dairy man.

Members of Armed forces.Members of Armed forces.

New prisoners to rule out infectious New prisoners to rule out infectious diseases.diseases.

COMPONENTS OF INFORMED COMPONENTS OF INFORMED CONSENTCONSENT

Disclosure of information.Disclosure of information.

Voluntariness.Voluntariness.

Competence.Competence.

CONSENT IN SPECIAL CASESCONSENT IN SPECIAL CASES

Consent by Spouse:Consent by Spouse: In operation interfering with marital rights such In operation interfering with marital rights such

as abortion or sterilization where…… consent as abortion or sterilization where…… consent of the patient as well as spouse is necessary.of the patient as well as spouse is necessary.

If the patient is unconscious, consent of If the patient is unconscious, consent of spouse is valid.spouse is valid.

Consent of Insane:Consent of Insane: By guardian appointed by court of protection. By guardian appointed by court of protection.

Consent in Minors:Consent in Minors: Under 16 years of age ---- Parents or Under 16 years of age ---- Parents or

guardian. However in emergency, if both are guardian. However in emergency, if both are not available, then person in not available, then person in “Loco parentis” “Loco parentis” (e.g., headmaster of the school) may (e.g., headmaster of the school) may consent. For some life saving treatment if consent. For some life saving treatment if parents withhold consent (e.g., refusal to parents withhold consent (e.g., refusal to blood transfusion in Jehovah’s witness) then blood transfusion in Jehovah’s witness) then consent may be obtained through court.consent may be obtained through court.

Consent in Emergency:Consent in Emergency: In unconscious patient with no one available In unconscious patient with no one available

for consent, doctor can give the necessary for consent, doctor can give the necessary treatment to save life, but no more.treatment to save life, but no more.

Note:Note: In emergency situation a In emergency situation a doctor may override a patient’s doctor may override a patient’s objection to treatment in good faith objection to treatment in good faith in his interest.in his interest.

CONSENT FORMCONSENT FORM I,____________NIC number ____________ I,____________NIC number ____________ do hereby consent to ____________do hereby consent to ____________ Operation of ________________Operation of ________________ under anesthesia ________________under anesthesia ________________ I have been explained fully the nature, purpose I have been explained fully the nature, purpose

and inherent risks involved in this surgery and and inherent risks involved in this surgery and the type of anesthesia by Dr. __________. No the type of anesthesia by Dr. __________. No assurance has been given to me that any assurance has been given to me that any particular surgeon will perform the operation.particular surgeon will perform the operation. Signature of the consenter ____________Signature of the consenter ____________

Date ____________ Date ____________

I confirm that all-relevant detail in respect of I confirm that all-relevant detail in respect of the above-referred operation and the above-referred operation and anesthesia has been fully explained to the anesthesia has been fully explained to the consenter who has signed this form.consenter who has signed this form.

Signature of the doctor _____________Signature of the doctor _____________ taking consent.taking consent.

Date _____________ Date _____________