Transcript Principles of Medical Ethics

Patient rights and
Doctor-patient relationship
病人權利與醫患關係
Dr. Derrick K. S. Au
區結成醫生
Kowloon Hospital & Hong
Kong Eye Hospital
The oldest code of medical ethics:
Hippocratic Oath (4th Century BC)
Several parts of the oath have been
revised over the years, e.g. “To consider dear to me, as my parents, him who
taught me this art; to live in common with him
and, if necessary, to share my goods with him…”
“Nor will I give a woman a pessary to procure
abortion;”
“I will not cut for stone, even for patients in
whom the disease is manifest; I will leave this
operation to be performed by practitioners,
specialists in his art.”
Code of Professional Conduct
(Hong Kong Medical Council)
Medicine as a profession is distinguished from other
professions by a special moral duty of care to save lives and
to relieve suffering.
Medical Registration Ordinance (Cap. 161) confers upon the
medical profession considerable freedom of self regulation,
the profession is obliged to abide by a strict code of conduct
which embodies high ethical values, protects patients’
interests, and upholds professional integrity.
Trust is essential to the practice of medicine. There can be
no medicine in the absence of trust. The patient’s trust
imposes upon the doctor a corresponding duty to be
trustworthy and accountable.
http://www.mchk.org.hk/code.htm
Ethics: What is right?
Moral (道德)- comes from Latin ‘mos’(mores);
Ethics (倫理) - comes from Greek ‘ethos’
Both have meaning of customs (風俗), or generally
accepted social norm
But ‘What is right’ is not just a matter of social
norm (e.g. slavery was a social norm at one time)
Professional norm is not always right, it does revise
over time
What is legally permitted is not always right
Ethical principles
Commonly quoted ethical principles:
– Autonomy 自主原則
– Beneficence 行善原則
– Justice 正義原則
– Nonmaleficence 不傷害原則
These are useful but by themselves are
not adequate for ethical decision making
Rights
The great religions of the world have all sought to establish moral codes of
conduct based on divine law.
These are often concerned with the duties and obligations of man to his
fellow human beings, to nature, to God and the whole of creation.
[Ancient Chinese moral philosophers like Confucius (孔子) and Mencius
(孟子) are concerned with similar moral issue, though not as a part of
divine law ]
The idea of 'human rights' is not universal - it is essentially the product of
17th and 18th century European thought. Such secular conception of rights
emphasised duties and privileges that arose from peoples' status or
relationships, rather than abstract rights in the philosophical sense.
Since1948, with the Universal Declaration of Human Rights, . Respect for
human rights is becoming a universal principle of good government.
http://www.universalrights.net/main/histof.htm
Rights / Obligations
A paired concept, for instance:
– People / Government
– Patient / Doctor
– Human being / fellow human beings
Commonly quoted universal human rights:
–
–
–
–
–
right to life;
right to freedom;
right to own property (limiting where government may intrude);
citizenship rights (voting, nationality and participation in public life);
rights to standards of good behaviour by governments (or protection of the rule of
law);
Other social, economic and cultural rights have become important during the
20th century, and raise important and still controversial issues about social
justice and the distribution of wealth.
http://www.universalrights.net/main/histof.htm
WHO: Patient rights understood as
one aspect of basic human rights
World Health Organisation:
Formalized in 1948, the Universal Declaration of Human Rights
recognizes “the inherent dignity” and the “equal and unalienable
rights of all members of the human family”. And it is on the basis
of this concept of the person, and the fundamental dignity
and equality of all human beings, that the notion of patient
rights was developed.
In other words, what is owed to the patient as a human being,
by physicians and by the state, took shape in large part thanks
to this understanding of the basic rights of the person.
http://www.who.int/genomics/public/patientrights/en/
From the perspective of patients’
advocate (病人權益倡議者)
社區組織協會:
「倡議病人權益是為了保障病人在強調專業知識的
醫療制度中，人的自主性及尊嚴不被侵犯。
「經多年推動，病人權益普遍為市民認識及認同，
但與先進社會的標準大相逕庭。由於醫護人員與病
人關係並不平等、加上醫醫相衛的文化、政府及各
醫療機構輕視病人權益，令醫療體系偏離以病人為
本的宗旨。市民的知情權、選擇權、私隱權及投訴
權未獲充分保障。」
www.soco.org.hk/rights/right055_c.htm
WHO: Patient rights can vary in
different countries
World Health Organisation (WHO):
Patients' rights vary in different countries and in different
jurisdictions, often depending upon prevailing cultural and social
norms.
Different models of the patient-physician relationship—which can
also represent the citizen-state relationship—have been
developed, and these have informed the particular rights to
which patients are entitled.
http://www.who.int/genomics/public/patientrights/en/
Patient’s Charter (病人約章)
In year 2000, the Hong Kong Hospital Authority
produced a Patient’s Charter to outline patient rights
and responsibilities in public hospital
HA Patients’ Charter
– Patients’ rights
Right to Medical Treatment (醫治權)
Right to Information (知悉權; 知情權)
Right to Choices (決定權 )
Right to Privacy (私隱權 )
Right to Complaint (申訴權)
HA Patients’Charter
– Patients’ Responsibilities
Give your heath care providers as much information as
you can about your present health, past illnesses, any
allergies…
Follow the prescribed and agreed treatment plan, and
conscientiously comply with the instructions given.
Show consideration for the rights of other patients and
health care providers, by following the hospital rules
concerning patient conduct.
Keep any appointments that you make, or notify the
hospital or clinic as earlyl as possible….
Should not ask health care providers to provide
incorrect information, receipts or certificates.
Should not waste medical resources unnecessarily.
http://www.ha.org.hk/charter/pceng.htm
Hong Kong Medical Association's
Patients' Rights and Responsibilities
Responsibilities:
To play an active and responsible role in the healthcare
process, you should
– be frank to your doctors in revealing your medical
conditions.
– endeavor to co-operate with any agreed form of
management.
– be well informed by your insurers of the detailed scope of
coverage of your medical insurance policies.
– not request doctors to issue incorrect receipts, certificates
or document, or to make incorrect entry into the medical
records.
– be responsible to meet the required fees and charges for
the medical services provided to you.
http://www.hkma.org/english/pubmededu/right.htm
HKMA Patients’ rights
Right of information.
- Charges
- Drugs.
Right of refusal
Right of confidentiality
Medical Reports
- Public medical institutions.
- Private hospitals and practitioners
Complaints
- Public medical institutions.
- Private hospitals and practitioners
Operations
- Public and Private Medical Institutions
HKMA: Right of Information
A patient should have a reasonable and balanced
understanding of the sickness he is suffering from.
You may enquire about what disease you have, if
you need any further examination, and how to cure
the disease. You should also know what treatment
you will receive, whether with drugs or operation,
any side effects after treatment, and the chances
of recurrence.
In other words, in order to know more relevant
facts about your sickness, you should consult your
attending doctor.
In the U.S.
Definition
Patient rights encompass legal and ethical issues in the
provider-patient relationship, including a person's right to
privacy, the right to quality medical care without prejudice,
the right to make informed decisions about care and
treatment options, and the right to refuse treatment.
Many issues comprise the rights of patients in the medical
system, including a person's ability to sue a health plan
provider; access to emergency and specialty care,
diagnostic testing, and prescription medication without
prejudice; confidentiality and protection of patient medical
information; and continuity of care.
http://www.answers.com/topic/patient-rights
The U.S. Patient’s Bill of Rights
Health care reform led to an emergence of health
maintenance organizations (HMOs) and other
managed health care plans.
The rapid change in medical care moved health
care decision making from medical professionals to
business entities, a move many consider to be
detrimental to the health care industry in general.
Establishing a patient's bill of rights has been the
response to this concern.
The Bipartisan Patient Protection Act of 2001 has
been debated and passed by the U.S. Senate and
the U.S. House of Representatives and signed into
law.
In the U.S. Bill of Rights
These basic rights include the right to:
– participate in the development and implementation in the plan of care
– be treated with respect and dignity
– be informed about condition, treatment options, and the possible results and side
effects of treatment
– refuse treatment in accordance with the law, and receive information about the
consequences of refusal
– quality health care without discrimination because of race, creed, gender, religion,
national origin, or source of payment
– privacy and confidentiality, which includes access to medical records upon request
– personal safety
– know the identity of the person treating the patient, as well as any relationship
between professionals and agencies involved in the treatment
– informed consent for all procedures
– information, including the medical records by the patient or by the patient's legally
authorized representative and hospital charges, except for Medicaid and general
assistance
– consultation and communication
– complain or compliment without the fear of retaliation or compromise of access or
quality of care
What is happening to
the doctor-patient relationship?
Some doctors are worried that the
physician-patient relationship, a special
humanism motivated by tradition and
governed by the ethics of medicine, may be
fouled up by the fiscal and economic
constraints likely to occur in the health care
system
- Alvan Feinstein, MD, professor of medicine, Yale University School
of Medicine, New Haven, Conn.
Marwick, Charles. Preservation of Physician-Patient Relationship Seen as Integral to Health Care System Reform
JAMA The Journal of the American Medical Association. Volume 271(12), 23 March 1994, pp 892-893
William C. Hsiao:
William C. Hsiao, PhD, Department of Health Policy and
Management, Harvard School of Public Health, Boston, Mass. "We
have promoted the diffusion of some technologies that may not
be cost-effective and encouraged their overuse…"
"Furthermore, we undercompensate primary care physicians,
discouraging them from rendering their services, and likewise (fail to
encourage) the young medical school graduates to pursue a career
in family care.
"Instead of trying to align the economic incentives to improve costeffectiveness, we are creating an administrative organization
that will intrude on this very personal relationship between
doctor and patients, between the caring physician with the
technical expertise and the patient,"
"Is that the best we can do to preserve this unique relationship?"
Marwick, Charles. Preservation of Physician-Patient Relationship Seen as Integral to Health Care System Reform
JAMA The Journal of the American Medical Association. Volume 271(12), 23 March 1994, pp 892-893
Models of Doctor-Patient Relationship
There are three different kinds of models:
1. PATERNALISTIC (家長式關係)
2. CONTRACTUAL (合約關係)
3. FIDUCIARY (受託關係; Fiduciary duty:受託責任)
http://www.carroll.edu/~msmillie/bioethics/modelsdocpatrelation.htm
Fiduciary relationship in peril?
Over the ages the doctor-patient relationship has been defined, through rules of
ethics and rules of law, as a fiduciary one, as a relationship founded in trust.
When a patient seeks a physician’s help and the physician agrees to give that
help, a special covenant is made. The patient agrees to take the physician into
her confidence, to reveal to him even the most secret and intimate information
related to her health. The physician, in turn, agrees to honor that trust, and to
become the patient’s advocate in all matters related to her health, placing her
interests above all others - including his own personal or financial concerns.
The loss of this doctor-patient relationship has obvious consequences for
patients. Patients, when they are sick and thus least able to fend for
themselves, are left without a true, dedicated advocate as they try to navigate
the hostile halls of the healthcare system, whose chief concern is to find ways of not
spending money on them. Loss of the traditional doctor-patient compact leaves
patients marginalized and floundering within that system at the time they are most
vulnerable.
- Blog of DrRich
The Importance of the Doctor-Patient Relationship, and Why We Can’t Have It Anymore
Posted on January 23, 2009
Paternalistic model:
Strengths and Weaknesses
Paternalistic model: The doctor is the professional.
He/she gives the order, the patient obeys.
Strengths: Emphasizes the expertise and knowledge of
the doctor
Weaknesses:
– Ignores the autonomy of the patient
– Ignores non-health related but morally legitimate values of
the patient
Contractual model:
Strengths and Weaknesses
Contractual model: The doctor and patient "contract" for
each other's mutual benefit; the patient determines or
agrees to the doctor’s decisions.
Strengths:
– Highlights the autonomy of both patient and physician
– Acknowledges cooperative/shared aspects of medical
decision-making
Weaknesses:
– No "contracts" developed or signed in real doctor/ patient
relationships
– Model doesn’t allow for at trusting relationship
Fiduciary model:
Strengths and Questions
Fiduciary model: The patient confidently entrusts his/her health care to
the doctor, who takes on the obligation of working for the benefit of the
patient (Fiduciary: relates to a holding of something in trust for another)
Strengths:
– Preserves the freedom and autonomy of both patient and physician
– The legitimate role of physician knowledge
– The important role of trust in the doctor/patient relationship
Questions raised by skeptics:
1. Patient trust may be manipulated for further economic gain.
2. Patient trust may undermines consumer’s awareness of need for selfprotection
3. Serious illness and fear of death diminish patient autonomy and power
to contract any relationship.
What about Chinese Culture?
Traditional Chinese medical ethics
emphasizes 醫德, based on virtues and
morality, rather than relationship between two
autonomous individuals
Patients as children (醫者父母心) is related
to the ideal image of a benevolent ruler (愛民
如子)
It may be analogous to the concept of
guardianship (監護) in Western culture
A few cases for thought
Case 1: Refusal of treatment
Chest physiotherapy is prescribed for an
elderly cancer patient by the attending doctor,
but he refuses. Must the physiotherapist insist
on carrying out the treatment plan?
Is it unethical to go against the patient’s wish
(to refuse)?
Case 2: Autonomy and family member
A patient’s son insisted that the doctor should
not tell his mother that she has been diagnosed
with chronic leukemia, otherwise he will take her
home against medical advice.
The mother seems to be generally passive and
submissive to the son’s decisions related to her
health care
How should the patient’s right be addressed?
Case 3: Demand of Alternative Medicine
(另類療法)
A 20 year old patient with severe head injury from
traffic accident did not improve with rehabilitation.
He cannot comprehend or communicate
The mother demands the hospital to provide
hyperbaric oxgyen therapy (high pressure oxygen
treatment in a closed chamber)
What is the extent of the mother’s right in this case?
How should the patient’s rights be addressed?
Case 4: Demand of medical treatment
A patient with mental illness demanded to be
treated with the newest psychiatric drugs
The doctor assessed and found that the patient
was not suffering from significant side effect
from the existing drug, which is also one of the
newer drugs that had passed the patent period
(cheap generic drug is locally available)
What is the extent of patient right in this case?
Case 5: Right to die?
A tetraplegic patient on chronic assisted
ventilation wrote to the HKSAR CE to demand
legislation for patient’s right to die and to
legalise euthanasia (安樂死)
Does a patient have ‘right to die’?
Dealing with refusal of treatment
When mentally competent and properly informed,
the patient’s refusal must be respected. [Principle
of respect for autonomy]
Assess mental capacity (精神上的行為能力)
Provide adequate and appropriate information
Treatments can be provided to mentally
incapacitated persons (精神上無行為能力的人 )
based on ‘best interests’ (病人的最佳利益)
principle [Principle of beneficience]
Resolving ethical dilemma related to
autonomy – advice for clinicians
Listen carefully – do not jump to conclusion of
“patient not cooperative” too easily
Gather more information relevant to the case
situation
Consider your own bias and assumptions
Explore reasonable options of compromise
Involve carers and friends trusted by patient as
appropriate
Thank you for your attention