Bioethics 2010

FACULTAS MEDICINAE ET CHIRURGIAE
PRAYER BEFORE
Oh Lord Our God,
May the inpouring of the Holy Spirit
Purify our hearts and
make them fruitful by the
sprinkling with the dew of His grace.
We ask this through
Our Lord Jesus Christ, Your Son,
Who lives and reigns with You
and the Holy Spirit,
One God forever and ever.
Amen.

VICTORIA EDNA G. MONZON, M.D., FPCP, FPCC, FSGC
Professor, Department of Bioethics & Department of Medicine
Faculty of Medicine and Surgery
University of Santo Tomas, Manila
Chair, Ethics Committee, UST Hospital,
Philippine Heart Center

PROFESSIONAL RELATIONSHIPS
( BIOETHICS III )

PROFESSIONAL RELATIONSHIPS
( BIOETHICS III )
 OBJECTIVES:
After working through this topic we should be
able to:
• Understand the basic foundation of patient-
doctor , doctor-doctor, doctor-nurse and other
allied professional relationships, including drug-
industry relationship .
• Recognize the patient’s rights and
responsibilities, as well as physician’s rights
and responsibilities.
• Explain why all patient’s are deserving of
respect and equal treatment.
• Recognize the different ethical principles that
may guide us in our clinical decision making.

METHODS OF LEARNING
•LECTURES
•INTERACTIVE
LEARNING
•CASE STUDIES
•RESEARCH

EVALUATION
•PRELIMS 30%
•CLASS STANDING 30%
•FINALS 30%
•ATTENDANCE 10%

SACREDNESS OF LIFE
• Human life is sacred because from
its beginning it involves the
creative action of God and it
remains forever in a special
relationship with the Creator, who
is its end; no one can under any
circumstance claim for
himself/herself the right directly to
destroy an innocent human being.

INNATE DIGNITY OF HUMAN LIFE
• Human dignity is not dependent on the way
others value us otherwise this would make it
conditional.
• All people have inalienable rights that must be
recognized and respected by civil society and
those with political authority.
• These rights depend neither on single individual
nor on parents; nor do they represent concession
made by society and the state, they belong to
human nature and are inherent in the person by
virtue of the creative act from which the person
took their origin.
• From this perspective human dignity is
unconditional.

THEOLOGICAL BASES OF HUMAN
DIGNITY
1. Man is created unto the
image and likeness of God.
2. Jesus Christ redeemed man
from his sin.
3. Man possesses an ultimate
destiny.
4. Man is a moral being.

Historical
Evolution
of
Bioethics

16th Century B.C. Egyptian Papyri:
•Outline methods of
establishing diagnosis
•Making decisions
whether to treat or not
•What therapy is
appropriate

•As long as physicians followed
the rules even if the patient
dies they are not held liable.
•If they transgressed, or tried a
new form of treatment and the
patient died, they lose their
own lives.

• Set surgical fees according to
the social status of the patient.
• Established punishment for poor
technical performance.
2000 BC (500 years before Moses brought
down the ten commandments) Hammurabi
devised a code of laws for those who
practiced medicine and surgery.

Jewish Medical Ethics
emphasized:
•Close relationship of medicine
and religion.
•Primacy in all its norms of
respect for human life.
•Excelled in judicious
applications of absolute norms
to individual cases.

Greeks absorbed the Egyptian and Babylonian
experiences with whom they traded:
• Aesculapius was their medical
model who was believed to have
treated the Greek army at the
siege of Troy.
• Priests of Aesculapius healed
with magic and little science.
• Stresses equality of cure for rich
and poor.

460-377 BC Hippocratic writings introduced
the tradition of clinical observation and
critical reasoning.
• Oath which has been the touchstone of
Western Bioethics.
• Hippocratic corpus became the
hippocratic ethics, essential feature is
the physician’s responsibility to the
patient.
• In contrast with Aesculapius medicine,
it tolerated different standards of care
for the rich and the poor.

• Hindu medical ethics are similar to
those of the Babylonians and the
Greeks.
• Hindu Oath of initiation into the medical
profession: “Day and night; thou shalt
endeavor for the relief of patients with
all their heart and soul. Thou shalt not
desert or injure thy patient even for the
sake of thy living.”

 Chinese medicine established a canon
written between 200 BC and AD 200 Which
holds:
• That the physician should have mercy on
the sick.
• Pledge himself to relieve suffering
among all classes, aristocrat or
commoner, poor or rich, aged or young,
beautiful or ugly, enemy or friend, native
or foreigners educated or uneducated,
all are to be treated equally.
• “He should look upon the misery of the
patient as if it were his own.”

• Roman Medical ethics was influenced by stoic
philosophy and with emphasis on virtue and
duty.
• Galen (AD 130-201) was a Greek – philosopher
who worked in Rome and sought to advocate
the science of medicine.
• All aspiring physicians were required to learn
his teachings specially in therapeutics.

• During the middle ages medical science
and philosophy were sustained and
brought to the west by the Arabs and their
allies as they moved along the
Mediterranean littoral and into Spain.
• Moses Maimonides (AD 1135-1204) one of
the greatest physician philosophers
compiled the canon of Jewish law and
medicine which has remained influential to
this day. He condemned “thirst for profit”
and ambition for “renown and admiration.”

 St. Thomas Aquinas (ad 1224-1274) integrated
the philosophy and ethics of Aristotle with
Christian Theology and developed the classical
doctrine of virtue ethics.
 In AD 1200 Frederick II involved the state in the
governance of medicine.
• Established progressive rules for the
education of future physicians
• Their method of practice
• Charges for their services
• Mechanism for assuring the purity of drugs.

• In 1520 Royal College of physicians of
London drew up a penal code for
physicians which in 1543 the “penal” was
changed to “ethical” to avoid implication of
criminality.
• John Gregory (1724-1773) gave lectures on
the duties and qualification of physicians.
• Thomas Percival’s medical ethics (1803)
originally commissioned to address
conflicts among physicians surgeons and
apothecaries at Manchester infirmary
addressed the following:

• Rules governing inter-professional
behavior serve the dual purpose of
maintaining the profession and
serving the well-being of society.
• Public criticism of colleagues
undermine the credibility of the
professional which might ultimately
damage the reputation of the
profession.
Percival’s Ethics

• Percival’s medical ethics
became the foundation of the
modern Anglo-American
professional ethics.
• It has many features in
common with Hippocratic
oath but is more socially
aware.

• Half a century later American
medicine was involved in a dispute
among several schools of medicine.
• The group that eventually became
known as orthodox practitioners
formed the American Medical
Association in 1847 and drafted their
code of ethics which followed
Percival’s ethics.

It contained three sections:
•Duties of physicians to
patients
•Obligations of patients to
their physicians
•Duties of physicians to
each other and to the
profession at large.

This underwent several
revisions:
•1948 World Medical Association
adopted the declaration of
Geneva which was designed for
those being admitted to the
medical profession, represented
a revision of the Hippocratic
oath.

•1949 Nuremberg code was
drafted because of the atrocities
committed by the Nazi physician
researchers.
•1964 Helsinki declaration which
emphasized the concept of
voluntary consent for human
research subjects.

Some Religious contributions:
 Protestant Thoughts:
• 1930 – Anglican’s openness to
contraception, sterilization and
abortion (Lambeth Conference)
• Openness to decisions to refuse
life-prolonging treatment.
Patient’s rights movements has
affinity with Protestant thought
including Anti-paternalism.

Roman Catholicism:
 Roman Catholic scholars since the
middle ages have written on medical
ethical problems from the
perspective of Christian theological
ethics.
•Papal statements on abortion,
contraception and sexual ethics.
•Issues on the care of the terminally
and critically ill patients.

Roman Catholicism:
• Opposition to active killing of
terminally ill on grounds of mercy.
• Justifiability of withdrawal and
withholding extraordinary means of life
supports
• Developed the principle of double
effect
• Ethical and Religious directives for
Catholic health care services. It is a
compendium of Catholic positions on
the full range of medical ethical
issues.

Professionally generated
ethics documents:
Prayers such as that
attributed to Jewish
physician philosopher Moses
maimonides:
•Express gratitude to a deity
•Ask for divine assistance in
developing one’s skills and
meeting one’s responsibilities.

•Oaths are vows taken by
individuals entering a
profession to uphold specified
obligations. E.g. Hippocratic
Oath
•Codes – are collective
summaries of the moral ideals
and conduct that are expected
of the professional.

The Hippocratic Oath
A.D. 1995 Re-statement of the Oath of Hippocrates
(Circa 400 B.C.)
I SWEAR in the presence
of the Almighty and before
my family, my teachers and
my peers that according to
my ability and judgment I
will keep this Oath and
Stipulation:

HIPPOCRATIC OATH
TO RECKON all who have taught me this
art equally dear to me as my parents and in
the same spirit and dedication to impart a
knowledge of the art of medicine to others.
I will continue with diligence to keep
abreast of advances in medicine. I will treat
without exception all who seek my
ministrations, so long as the treatment of
others is not compromised thereby, and I
will seek the counsel of particularly skilled
physicians where indicated for the benefit
of my patient.

I WILL FOLLOW that method of treatment
which according to my ability and judgment, I
consider for the benefit of my patient and
abstain from whatever is harmful or
mischievous. I will neither prescribe nor
administer a lethal dose of medicine to any
patient even if asked nor counsel any such thing
nor perform act or omission with direct intent
deliberately to end a human life. I will maintain
the utmost respect for every human life from
fertilization to natural death and reject abortion
that deliberately takes a unique human life.

With purity, holiness and beneficence I will
pass my life and practice my art. Except for
the prudent correction of an imminent danger,
I will neither treat any patient nor carry out
any research on any human being without the
valid informed consent of the subject or the
appropriate legal protector thereof,
understanding that research must have as its
purpose the furtherance of the health of that
individual. Into whatever patient setting I
enter, I will go for the benefit of the sick and
will abstain from every voluntary act of
mischief or corruption and further from the
seduction of any patient.

Whatever in connection with
my professional practice or not in
connection with it I may see or
hear in the lives of my patients
which ought not be spoken abroad
I will not divulge, reckoning that
all such should be kept secret.

While I continue to keep this Oath
unviolated may it be granted to me to
enjoy life and the practice of the art
and science of medicine with the
blessing of the Almighty and respected
by my peers and society, but should I
trespass and violate this Oath, may the
reverse be my lot.
Adapted and endorsed by 35 inter-faith ethicists and physicians.
Copyright, 1995, Value of Life Committee, Inc.; P.O. Box 35279; Brighton,
MA 02135.

INTERNATIONAL CODE OF
ETHICS
• The international code of ethics was
adopted by the third general assemblyof
the World Medical Association,London,
England, Oct. 1949, ammended by the
22nd World Medical Assembly in Sidney,
Australia,Aug. 1968 and by the 35th
World Medical Assembly in Venice, Italy,
October 1983 and the WMA general
assembly in South Africa, October 2006.

DUTIES OF PHYSICIANS IN
GENERAL
• A Physician shall always exercise
his/her independent professional
judgment and maintain the highest
standards of professional conduct.
• A Physician shall respect a competent
patient’s right to accept or refuse
treatment.
• A Physician shall not allow his/her
judgment to be influenced by personal
profit or unfair discrimination.

DUTIES OF PHYSICIANS
• A Physician shall be dedicated to providing
competent medical service in full professional
and moral independence, with compassion and
respect for human dignity.
• A Physician shall deal honestly with patients
and colleagues , and report to the appropriate
authorities those physicians who practice
unethically or incompetently or who engage in
fraud or deception.
• A Physician shall not receive any financial
benefits or other incentives solely for referring
patients or prescribing specific products.
• A Physician shall respect the rights and
preferences of patients, colleagues and other
health care professionals.

DUTIES OF PHYSICIANS
• A Physician shall recognize his/her
important role in educating the
public but should use due caution
in divulging discoveries or new
techniques or treatment through
non- professional channels.
• A Physician shall certify only that
which he/she has personally
verified.

DUTIES OF THE PHYSICIAN
• A Physician shall strive to use
health care resources in the best
way to benefit patients and their
community.
• A Physician shall seek appropriate
care and attention if he/she suffers
from mental or physical illness.
• A Physician shall respect the local
and national code of ethics.

DUTIES OF PHYSICIANS TO
PATIENTS
• A Physician shall always bear in mind the
obligation to respect human life.
• A Physician shall act in the patient’s best
interest when providing medical care.
• A Physician shall owe his/her patients
complete loyalty and all the scientific
resources available to him/her. Whenever
examination or treatment is beyond the
physician’s capacity, he/she should consult
with or refer to another physician who has
the necessary ability.

PATIENTS
• A Physician shall respect a
patient’s right to confidentiality. It
is ethical to disclose confidential
information when the patient
consents to it or when there is a
real and imminent threat of harm
to the patient or to the others and
this threat can be only removed
by a breach of confidentiality.

PATIENTS
• A Physician shall give an emergency
care as a humanitarian duty unless
he/she is assured that others are willing
and able to give such care.
• A Physician shall in situation when
he/she is acting for a third party ensures
that the patient has full knowledge of
that situation.
• A Physician shall not enter into sexual
relationships with his/her current
patient or into any other abusive or
exploitative relationship.

COLLEAGUES
• A Physician behave towards colleagues as
he/she would have them behave towards
him/her.
• A Physician shall not undermine the
patient-physician relationship of colleagues
in order to attract patients.
• A Physician shall when medically
necessary , communicate with colleagues
who are involved in the care of the same
patient. This communication should
respect patient confidentiality and be
confined to necessary information.

PHILIPPINE MEDICAL
ASSOCIATION CODE OF ETHICS
 Code of Ethics of the Medical Profession in the
Philippines
Article I
GENERAL PRINCIPLES
Section 1. The primary objectives of the practice of medicine is service to
mankind irrespective or race, creed or political affiliation. In its practice,
reward of financial gain should be a subordinate consideration.
Section 2. On entering his profession a physician assumes the obligation of
maintaining the honorable tradition that confers upon him the well
deserved title of “friend of man”. He should cherish a proper pride in his
calling, conduct himself as a gentleman, and endeavor to exalt the
standards and extend the sphere of usefulness of his profession. He should
adhere to the generally accepted principles of the International Code of
Medical Ethics adopted by the Third General Assembly of the World Medical
Association at London, England in October, 1949 as part of his professional
conduct.

PMA CODE OF ETHICS
 Section 3. In his relation to the state and to the community, a
physician should fulfill his civic duties as a good citizen,
conform to the laws and endeavor to cooperate with the
proper authorities in the due application of medical
knowledge for the promotion of the common welfare.
Section 4. In his relation to the state and to the community, a
physician should fulfill his civic duties as a good citizen,
conform to the laws and endeavor to cooperate with the
proper authorities in the due application of medical
knowledge for the promotion of the common welfare.
Section 5. With respect to the relation of the physician to his
colleagues, he should safeguard their legitimate interests,
reputation, and dignity-bearing always in mind the golden
rule “whatever ye would that man should do unto you, do
you even so to them.”
Section 6. The ethical principles actuating and governing a
clinic or a group of physicians are exactly the same as those

 Article II
DUTIES OF PHYSICIANS TO THEIR PATIENTS
Section 1. A physician should attend to his patients faithfully
and conscientiously. He should secure for them all possible
benefits that may depend upon his professional skill and care.
As the sole tribunal to adjudge the physician’s failure to fulfill
his obligation to his patients is, in most cases, his own
conscience, and violation of this rule on his part is
discreditable and inexcusable.
Section 2. A physician is free to choose whom he will serve. He
may refuse calls, or other medical services for reasons
satisfactory to his professional conscience. He should,
however, always respond to any request for his assistance in
an emergency. Once he undertakes a case, he should not
abandon nor neglect it. If for any reason he wants to be
released from it, he should announce his desire previously,
giving sufficient time or opportunity to the patient or his family
to secure another medical attendant.

 Section 3. In cases of emergency, wherein
immediate action is necessary, a physician
should administer at least first aid treatment
and then refer the patient to a more qualified
and competent physician if the case does not
fall within his particular line.
Section 4. In serious cases which are difficult
to diagnose and treat, or when the
circumstances of the patient or the family so
demand or justify, the attending physician
should seek the assistance of his colleagues
in consultation.

 Section 5. A physician must exercise good faith and strict honesty in
expressing his opinion as to the diagnosis, prognosis, and treatment of the
cases under his care. Timely notice of the serious tendency of the disease
should be given to the family or friends of the patients, and even to the
patient himself if such information will serve the best interest of the patient
and his family. It is highly unprofessional to conceal the gravity of the
patient’s condition, or to pretend to cure or alleviate a disease for the
purpose of persuading the patient to take or continue the course of
treatment, knowing that such assurance is without accepted basis. It is also
unprofessional to exaggerate the condition of the patient.
Section 6. The medical practitioner should guard as a sacred trust anything
that is confidential or private in nature that he may discover or that may be
communicated to him in his professional relation with his patients, even after
their death. He should never divulge this confidential information, or anything
that may reflect upon the moral character of the person involved, except
when it is required in the interest of justice, public health, or public safety.
Section 7. The medical profession not being a business and service its
primary concern, a physician should not charge exorbitant or excessive fees.
In determining the amount of the fee, he should always consider the financial
status of the patient, the nature of the case, the time
consumed, his professional standing and skill and the average fees charged
by physicians of the same standing in the same locality.

 Article III
DUTIES OF PHYSICIANS TO THE COMMUNITY
Section 1. Physician should cooperate with the proper authorities in the
enforcement of sanitary laws and regulations and in the education of the
people on matters relating to the promotion of the health of the individual as
well as of the community. They should enlighten the public on the
dangers of communicable diseases and other preventable diseases, and on all
the measures for their prevention and cure, particularly in times of epidemic or
public calamity. On such occasions, it is their duty to attend to the needs of the
sufferers, even at the risk of their own lives and without regard to financial
returns. At all times, it is the duty of the physician to notify the properly
constituted public health authorities of every case of communicable disease
under his care in accordance with the laws, rules and regulations of the health
authorities of the Philippines.
Section 2. It is the duty of every physician, when called upon by the judicial
authorities, to assist in the administration of justice on matters which are
medico-legal in character.
Section 3. It is the duty of physicians to warn the public against the dangers
and false pretensions of charlatans and quacks, since, their deceitful practice
may cause injury to health and even loss of life.
Section 4. A physician should never cover up, help, aid or act as a dummy of

 Section 5. Solicitations of patients, directly or indirectly,
through solicitors or agents, is unethical. Modest advertising
may be allowed through professional cards, classified
advertising, directories of signboard. In all these
advertisements only the name, title or profession, office
hours and office and residence addresses should appear. In
case of physicians specializing on a definite branch of
medicine, the speciality may be advertised by stating
“Practice limited to (speciality)” or by merely stating:
“Obstetrician”, “Orthopedic surgeon”, “Ophthalmologist”,
etc. Advertising and publishing personal superiority,
possession of special certificates or diplomas, post-graduate
training abroad, specific methods of treatment or operative
techniques or advertising former connection with hospitals
or clinics are likewise unethical. Guaranteeing or warranting
treatments
or operations is objectionable.

 Section 6. No physician should advertise through the radio,
television or movies not allow the publication or reports or
comments on cases or methods of treatment in any
newspaper or magazine. Only medical articles which will
contribute to the knowledge and education of the public on
general health matters may be published and the author
may be identified provided the article is neither self-
laudatory not in any way related to his clinical practice. In
case any picture of a laudatory article is published by any
body without the consent or knowledge of the physician
concerned, the latter should make a written protest and
disclaimer to be published in the same newspaper or
magazine where the original article in question was
published. A copy of this letter should also be furnished the
component society to whom the physician belongs and to
the PMA
Secretariat.

 Section 7. The physician-columnist must be well informed and up-
to-date in the subject matter of his column. The scope of the
medical column should be in the form of general information, of
education value and of public interest, such as needs for yearly
periodic consultations, preventive measures, formation of good
health habits, explanation of need for diagnostic sides, emergency
measures, and other topics of general interest to the health of the
public. Medical columns should not make specific diagnosis or
therapy or be projected to individual cases. The physician-columnist
should not be in active clinical practice. If however, the physician-
columnist is in active clinical practice, his authorship must be in the
form of pseudonym or the columns may be published under the
sponsorship of a medical society or a specialty society to which he
belongs.
Section 8. Humanity requires every physician to render his services
gratuitously to poor and indigent persons who are in need of his
attendance. The endowed institution and organization for mutual
benefit or for accident, sickness or life insurance or for analogies
purposes have no claim upon physicians for unremunerated service.

 Article IV
DUTIES OF PHYSICIANS TO THEIR COLLEAGUES AND TO THE
PROFESSION
Section 1. Physicians should labor together in harmony, each giving
freely to others whatever advantage he may have to contribute.
Section 2. A physician should willingly render gratuitous service to a
colleague, to his wife and minor children or even to his father or mother
provided the latter are aged and are being supported by the colleague.
He should however, be furnished the necessary traveling expenses and
compensated for all medicines and supplies necessary in the treatment
of the patient. This provision shall not apply to physicians who are no
longer in practice nor to physicians who are engaged only or purely in
business.
Section 3. In difficult and serious cases or in those which are outside the
competence of the attending physician, he should always suggest and
ask consultation. Only experienced physicians who are senior to the
attending physician or who have had special training and experience in a
particular line of medicine should be selected by the latter as
consultants.

 Section 4. Out of consideration for the object of consultation and for
the physician’s duty to uphold the honor and dignity of his
profession, no physician should meet in consultation with anyone
who is not qualified by law to practice medicine. In arranging for a
consultation the attending physician should fix the hours of the
meeting. However, it is his duty to make the appointment in a way
satisfactory to the consultant.
Section 5. Every physician participating in a consultation should
endeavor to observe punctuality. Unless the cause of delay is
known, if the attending physician does not arrive within a
reasonable time after the appointed hour, the consultant should,
according to the circumstances attending the case, be at liberty
either to regard the consultation as postponed or to see the
patients alone. In the latter case, he should leave his conclusions in
writing in a sealed envelope. On the other hand, if the consultant
does not appear at the fixed time, the attending physician, after a
reasonable period of waiting, and with the consent of the patient, or
his family, may either arrange for another consultation or give
permission for the consultant to examine the patient and forward to
him a written opinion, the consultant must see to it that the opinion
is under seal and that his statements are courteously worded.

 Section 6. The attending physician should give the consultant all
necessary information relating to the case. This should be done in a
place away from the patient and his family. After this, the
consultant should be brought in and introduced to the patient by
the attending physician, who may examine the patient again, if he
thinks it necessary to note any possible change before turning his
patient over to the consultant. The latter then should proceed to
make a thorough examination. During the examination, the
attending physician may make patient remarks or observation.
While in the presence of the patient or of his family, the consultant
should not make any remarks about the diagnosis, etiology,
prognosis, or treatment or hint of any possible error of the
attending physician.
Section 7. In a secluded place away from the patient, the physicians
should discuss the case and determine the course of treatment to
be followed. Neither statement nor discussion of the case should
take place before the patient or his family or friend, not only to save
the attending physician from possible embarrassment, but also to
prevent all possible misapprehension which susceptible lay persons
might easily derive from the plain discussion usually unavoidable in
such cases.

 Section 8. Once the discussion is terminated, the
result of the deliberations should be announced.
The duty of announcing it to the patient’s family
or friends should be mutually arranged between
the attending physician and the consultant, and
no opinion or information should be announced
without previous deliberation and concurrence.
Section 9. Differences of opinion should not be
divulged; but when there is an irreconcilable
disagreement, the circumstances should be
frankly, courteously, and impartially explained
to the patient’s family or friends.

 Section 10. When a consultation is over and the physician in charge is
designated, the latter shall be responsible for the care and treatment of the
patient. He may, however, suggest calling in any other physician whom he
regards as competent to help or to advise. He may at anytime change or
abandon the course of treatment outlined and agreed upon at the
consultation, if and when, in his opinion, such action is required by the
condition of the patient. If he does this, he should at the next consultation
state his reasons for departing from the course previously agreed upon
because
it is his duty to follow the treatment, outlined and refrain from changing if for
trivial motives. If an emergency occurs and the physician in charge is not
available, the consultant should attend to the case until the arrival of his
colleague, but should not take further charge of it except with the consent of
the attending physician.
Section 11. Cases which appear to be out of the proper line of practice of the
physician in charge or refractory in spite of the usual clinical treatment, or
with a grave prognosis should be referred to those who specialize in that class
of ailments. It is desirable that the patient brings with him a letter of
introduction giving the history of the case, its diagnosis and treatment, and all
the details that may be of service to the specialist. The latter should, in turn
reply in writing to the physician in charge, giving his opinion of the case
together with the course of treatment he recommends. These opinions or
suggestions must be regarded as strictly confidential.

 Section 12. A physician should observe utmost caution, tact and
prudence, both in words and in action, as regards the professional
conduct of another physician, particularly when it concerns a
patient previously treated by the latter or actually under his care. In
his dealings with patients not under his care, he should not say or
do anything that might lessen the patient’s confidence reposed in
the attending physician.
Section 13. Whenever a physician is compelled to make a social or
business call on a patient under the professional care of another
physician, he should not make inquiries or comments as to the
etiology diagnosis, treatment, or prognosis of the case. The most
that may be mentioned is the general physical condition of the
patient or other topics foreign to the case.
Section 14. A physician should not take charge of or prescribe for a
patient already under the care of another physician, unless the case
is one of emergency, or the physician in attendance has
relinquished the case, or the services of the attending physician has
been dispensed with.

 Section 15. A physician should never examine or treat a hospitalized patient
without the latter’s knowledge and consent except in cases of emergency, but
in the latter instance, the physician should not continue the treatment but
return the patient to his attending physician after the emergency has passed.
Section 16. A physician called upon to attend a patient of another physician
either because of an emergency, or because the family physician asks for it, or
is not available should attend only to the patient’s immediate needs. His
attendance ceases when the emergency is over or on the arrival of the
physician in charge after he has reported the condition found and treatment
administered; and he should not charge the patient for his services without
the knowledge of the attending physician.
Section 17. Whenever in the absence of the family physician several
physicians have been simultaneously called in an emergency case because of
the alarm and anxiety of the family or friends, the first to arrive should be
considered as physician in charge, unless the patient or his family has special
preference for some other one among those who are present. As a matter of
courtesy, the acting physician in charge should request, at the start, that the
family physician be called. When the patient is taken to the hospital, the
attending physician of the hospital, likewise should communicate with the
family physician so as to give him the option of attending the case.

 Section 18. Public interest demands that the relation between
government and private physicians should be friendly and cordial
for the promotion and protection of public health depend greatly
upon the cooperation of government and private physicians.
Section 19. The physician should carefully refrain from making
unfair and unwarranted criticism of other physicians and, even in
justified circumstances, criticism should be made in a constructive
way and only directly and privately to the physicians involved.
Whenever there is an irreconcilable difference of opinion, or conflict
of interest between physicians, which cannot be adjusted by both
sides alone, the matter should be referred to a committee of
impartial physicians or other competent bodies for arbitration.
Section 20. When a physician is requested by a colleague to take
care of a patient during his temporary absence or when because of
an emergency he is asked to see the patient of a colleague, the
physician should treat the patient in the same manner and with the
same delicacy
as he would have wanted his own patient cared for under similar
conditions. The patient should be returned to the care of the
attending physician as soon as possible

 Section 21. When a physician attends a woman in labor in the absence of
another who has been engaged to attend, such physician should relinquish the
patient to the one first engaged upon his arrival. The physician is entitled to
compensation for the professional services he may have rendered.
Section 22. A true physician does not base his practice on exclusive dogma or
sectarian system for medicine is a liberal profession. It has no creed, no party,
no master. Neither is it subject to any bond except that of truth. A physician
should keep abreast of the advancement of medical
science; contribute to its progress; and associate with his colleagues in any of
the recognized medical societies, so that he may broaden his horizon through
the exchange of ideas, and in order that he may contribute his time, energy,
and means towards making these societies represent the ideas of the
profession. The medical journal is one of the most important instruments
through which these objectives may be accomplished. It is therefore
necessary that editors and members of editorial boards of medical journals
should possess adequate qualifications. And to the end in view all editors and
members of the editorial boards of national medical journals will be
recommended by the Philippine Association of Medical Writers, Inc. to the
Executive Council, and in case of specialty and component medical society
journals, the appointment of editors an members of editorial boards will be
left at the discretion of their respective affiliate specialty or component
medical societies concerned. Furthermore, the contents of medical journals
should conform to accepted standards as provided for by the Philippine
Association of Medical Writers, Inc.

 Section 23. A physician should be upright, diligent, sober, modest and well-
versed in both the science and the art of his profession. Extravagance,
intemperance, and superstitious are most destructive to the professional
reputation, influence, and confidence; and they are not only financially but
also morally disastrous.
Section 24. Advertising by means of untruthful or improbable statements in
newspapers or other publications, or exaggerated announcements on shingles
and signboards, calculated to mislead or deceive the public, or made in
manner not consistent with good moral and right professional dealings with a
patient, is unprofessional. Announcements in newspaper, or in signboards or
shingles, should be restricted to the facts about the location of clinics, office
hours, and limitation of practice. It is equally incompatible with honorable
standing in the profession to solicit patients by circulars, by advertisements,
of by personal relations to procure patients indirectly through solicitors or
agents.
Section 25. It is unprofessional for a physician to help or to employ
unqualified persons for the purpose of evading the legal restriction governing
the practice of medicine.
Section 26. It is degrading to the good name of the medical profession to
prescribe, dispense or manufacture secret remedies or to promote their use in
any way. It is likewise unprofessional to promise or boast or radical cures or
to exhibit publicly testimonial of success in the treatment of diseases.

 Section 27. It is degrading to the professional character for physicians to
deliberately to prolong the progress of treatment of diseases for questionable
motives, or to establish an unjust competition among physicians in the
community by unwarranted lowering of fees.
Section 28. When a patient is referred by one physician to another for
consultation or for treatment whether the physician in charge accompanies
the patient or not, it is unprofessional to give or to receive commission by
whatever term it may be called or under any guise or pretext
whatsoever. It is unprofessional for a physician to pay or offer to pay, or to
receive or solicit commission for the purpose of gaining patients or for
recommending professional service.
Section 29. Physicians should expose without fear or favor, before the proper
medical or legal tribunals, corrupt or dishonest conduct of members of the
profession. All questions affecting the professional reputation of a member or
members of the medical society should be considered only before proper
medical tribunals, in executive sessions or by special or duly appointed
committees on ethical relations. Every physician should aid in safeguarding
the profession against the admission to its ranks of those who are unfit or
unqualified because of deficiency in moral character or education.

 Article V
DUTIES OF PHYSICIANS TO ALLIED PROFESSIONALS
Section 1. Physicians should cooperate with and safeguard the interest,
reputation, and dignity of every pharmacist, dentist, and nurse; because all of
them have as their objective the amelioration of human suffering. But, should
they violate their respective professional ethics, they thereby forfeit all claims
to favorable considerations of the public and of physicians.
Section 2. Physicians should never sign or allow to be published any
testimonial certifying the efficacy value and superiority and recommending
the use of any drug, medicine, food product, instrument or appliance or any
other object or product related to their practice specially when
published in a lay newspaper or magazine or broadcast through the radio or
television. When such testimonials are published or broadcast without his
knowledge and consent, he should immediately make the necessary
rectification and order the discontinuance thereof.
Section 3. A physician should neither pay commissions to any person who
refers cases to or help him in acquiring patient nor receive commission from
druggist, laboratory men, radiologists or other co-workers in the diagnosis
and treatment of patients for referring patients to them.

 Article VI
AMENDMENTS
Section 1. The House of Delegates of the
Philippine Medical Association, upon
recommendation of the Executive Council, by a
majority vote of all the delegates may amend or
repeal this Code or adopt new Code of Ethics of
the Medical Profession in the Philippines. Any
amendment shall be a part of this Code of
Medical Ethics and such amendments shall
become effective after thirty (30) days following
the completion of its publication in the Official
Gazette.

 Article VII
PENAL PROVISIONS
Section 1. This Code of Ethics shall be published in the Official
Gazette to have the force and effect of law. Copies of this Code shall
be distributed every year to all physicians during their Annual
Conventions and published once a year in all medical journals
published in the Philippines for the proper information and guidance
of all physicians both in private practice and in the government
service and shall also be distributed among all new physicians
immediately following their oath taking. It shall be included in the
curriculum of all medical schools as part of the course of study of
legal medicine, ethics and medical jurisprudence.
Section 2. Violation of anyone of the provisions of this Code of
Ethics shall constitute unethical and unprofessional conduct and
therefore a sufficient ground for the reprimand, suspensions, or
revocation of the certificate of registration of the offending
physician in accordance with the provisions of Section 24,
paragraph (12) of the Medical Act of 1959, Republic Act 2382.

Oh god, Who teaches
the hearts of the faithful
by the light of the Holy Spirit:
Grant, by the same Spirit,
That we may relish what is right,
And ever rejoice in His consolation.
We ask this through
Our Lord Jesus Christ, Your Son,
Who lives and reigns with You
and the Holy Spirit,
One God forever and ever.
Amen.
FACULTAS MEDICINAE ET CHIRURGIAE
PRAYER AFTER

HEALTH CARE PROFESSION
• Professio – a promise
• A promise to help people
achieve goods necessary
for human fulfillment
• A vocation, a calling to
serve humanity

Medical Profession
The primary objective of
the medical profession is to
render service to humanity;
reward or financial gain is a
subordinate consideration.
AMA Principles of Medical Ethics
Codes of Medical Ethics: Current Opinions with Annotations, 1997.

PHYSICIAN
• Must take care of themselves
both physically and spiritually.
• If physicians are to be healers
to care for persons as total
persons they must be total
persons themselves.
• Must not forget the spiritual
dimension in medical care for if
we do, then we will just be mere
technicians.

PHYSICIAN
Physician must uphold and
respect:
• Sanctity of life of the
disenfranchised and marginalized.
• Sanctity of life of the rich, powerful
and the wicked among us.
• Sanctity of life of the people who
look at you and at times spit on
your face.

Virtues of Health Care
Professional
• Truthfulness
• Compassion
• Humility
• Prayerfulness
• Prudence
• Fortitude
“Two things go to the making of a
doctor – great scientific
competence and a great heart”
Dr. Paul Tournier

Role of Virtues in Medical
Practice
Virtues and character play a
significant role in deliberation
about a course of action.
• Medical profession’s prime objective
is to render service to humanity
(reward or financial gain being
subordinate consideration).
• Physician must be an upright man,
pure in character and diligent and
conscientious in caring the sick (AMA
code).

Role of Virtues in Medical
Practice
• By the virtue of prudence and
courage and steadfastness we should
denounce in a professional way those
physicians deficient in character or
competence who may endanger the
lives of patients.
• Virtues of benevolence, care and
compassion, respect for autonomy,
and justice must be practiced so that
patients will entrust their lives into
our hands.

Doctor-Patient Relationship
• Based on mutual
trust and
confidence
• Contract VS.
Covenant
• Shared
responsibilities

It involves:
 Patient’s best interest first
• Best care
• Fidelity, truthfulness, prudence
compassion
 Respecting patient as person
• Getting free & informed consent
• No using, manipulating or exploiting
(not to use as a means merely)
 Promoting social justice
• Being a patient’s advocate, not his
adversary

PATIENT’S RIGHTS
• PATIENTS HAVE THE
RIGHT TO RECEIVE
ADEQUATE
INFORMATIONS FROM
THEIR ATTENDING
PHYSICIAN.
• THEY HAVE THE RIGHT
TO HAVE THEIR
QUESTIONS ANSWERED

PATIENT’S RIGHTS
• PATIENTS ARE ENTITLED TO
HAVE COPIES OF THE RESULTS
OF THEIR WORK UPS.
• THEY HAVE THE RIGHT TO
ACCEPT OR REFUSE
RECOMMENDED TREATMENT.
• PATIENT HAS THE RIGHT TO
RESPECT AND HUMAN DIGNITY
AND TIMELY ATTENTION TO
HIS/HER NEEDS.

PATIENT’S REFUSAL TO ACCEPT
MEDICAL ADVICE
• RELATED TO FAILURE OF
COMMUNICATION OR
TRUST IN THE PHYSICIAN –
PATIENT RELATIONS.
• IT MAY BE DUE TO
PERSONAL OR RELIGIOUS
REASON.
• MAY BE DUE TO
CONFUSION BECAUSE OF
CONTRADICTORY
INFORMATIONS GIVEN BY
THOSE ATTENDING TO
HIM/HER

Responsibilities of
Conscientious Physicians:
• Physicians must be
knowledgeable, competent and
skilled in determining the
patient’s diagnosis, prognosis,
the range of treatment choices,
including the risks and benefits
and alternative choices and the
patient’s preferences.

Responsibilities
• Physicians must be capable
and willing to communicate
effectively with patients and
advise them so they can make
informed decisions regarding
their own treatment or non-
treatment preferences.

Responsibilities
• Physicians have a responsibility to
respect the treatment decisions of
competent patients.
• If unable to honor the wishes of
competent patient, he may withdraw
from the case as long as the patient is
provided sufficient advance warning
and alternate care is assured or he/she
may seek the assistance of the court
if she/he feels morally constrained to
do so.

Responsibilities
• Physicians should elicit
from all competent patients
specially from patients at
high risk of dying or
becoming incompetent –
his treatment preferences
regarding life-sustaining
treatment.

Responsibilities
• In cases of incompetent
patient, physician must
determine who is the
surrogate decision maker
who should be consulted
and whether legal guidance
is necessary.

• Physicians should not break the
confidential nature of the patient –
physician relationship by
discussing the competent
patient’s care with persons who
are not authorized by the patient
to be made aware of patient’s
diagnosis, prognosis and
treatment.

PHYSICIAN’S RIGHTS
• Physician has the right to be respected.
• He has the right to choose his patient as
long as it is not an emergency or is not
within his expertise.
• He has the right to refuse patient’s wish if
it is contrary to the natural moral law.
• He has the right to be given the proper
renumeration for the services he has
rendered.

Principles Involved:
• Beneficence
• Non-maleficence
• Respect for person
• Justice

BENEFICENCE
• Beneficence can suggest act of
mercy, kindness and charity.
• It asserts an obligation to help
others further their importance and
legitimate interests.
• Obligation to weigh and balance the
possible goods against possible harms
of an action.
• “Parable of the Good Samaritan”

 NON-MALEFICENCE
• Primum non-nocere – first do no harm.
• This tenet addresses unprofessional
behavior, verbal, physical and sexual
abuse of patients and uninformed and
undisclosed experimentation on patients
with drugs and procedures that have the
potential to cause harmful side effects
• Breach of physician patient
confidentiality which results in harm to
the patient is another example of non-
maleficence.

 RESPECT FOR PERSON
• Free and informed
consent
• Confidentiality
• Truth-telling
• Autonomy

INFORMED CONSENT
• It is the voluntary acceptance of
physician’s recommendations for
treatment or research investigations
by competent patients or surrogates
who ave been furnished with truthful
information regarding the risks,
benefits and alternatives of the
proposed interventions.

ELEMENTS OF INFORMED
CONSENT
• Competence
• Adequate information
• Understanding or
comprehension
• Voluntariness

INFORMED CONSENT
• SURROGATE
Represents the
patient’s interests
and previously
expressed wishes in
the context of the
medical issues, they
are usually
designated before
critical illness.
• Types of
Surrogate:
Durable power of
attorney
Patient’s family or
the court.
Moral surrogate who
best knows the
patient and has the
patient’s interest at
heart.

INFORMED CONSENT
• SURROGATE decision maker
represents patient’s best
interest or may use
substituted judgment.

CONFIDENTIALITY
• The physician’s obligation to preserve
the principle of medical confidentiality
is based on a concern for protecting the
physician-patient relationship and a
desire to respect patients right to
privacy.
• A physician’s duty to observe the
principle of confidentiality is a very
important moral obligation, but not an
absolute obligation or one’s only
obligation.

To whom should medical information be
disclosed ?
• To the competent patient
• If the patient is unable to comprehend
the information, to whoever is in
charge and makes decision for the
patient (parent of a child)
• To those who may be afflicted by
patient’s health (children,
subordinates, innocent 3rd party,
employers, employees)

CONFIDENTIALITY
In case of HIV patient who refuses to
inform third parties who may not be
infected yet but will surely have future
contact with the individual, what can
possibly be done:
1.Attempt to persuade the infected
patient to cease endangering the 3rd
party or to notify the third party of the
risk.
2. If persuasion fails, notify the authority
who can intervene.
3. If the authority takes no action or is
not available, tell the patient that you are
going to notify the 3rd party of the risk.

Possible grounds for violating the
principle:
• The principle may come into conflict
with the rights of the patient himself.
• That it may conflict with the right of
an innocent 3rd party.
• Serious conflict between the
principle and the rights or interest of
society in general.
• When he is called to testify in court.

TRUTH TELLING
• Patients have the right to the truth
about their health because they have
the primary responsibility for their
health.
• The question should not be “Should we
tell?”, but rather, “how do we share this
to the patient?”.

Why should the truth be told?
• As persons are human, moral quality
is taken from us if we are denied
whatever knowledge is available.
• That the doctor is entrusted by patient
with what he learns but the facts are
theirs, not the doctor’s and to deny
them to patients is to steal from them
what is their own.

TRUTH TELLING
• The right to know the truth does not
apply to all truths.
• As far as truth telling, what is at stake
is honesty.
• A part of the truth which the doctor
owes the patient is:
• That the doctor can not be absolutely
correct.
• We are obliged to tell the truth as we
see it according to our best knowledge.

TELLING THE TRUTH
• A decision to reveal a grave
prognosis which maybe “ethical”
in itself maybe unethical if the
physician tells the patient
bluntly and then withdraws,
without offering any emotional
support to help the patient
resolve his feelings.

TRUTH TELLING
Patient’s right to the truth vs.
Non-maleficence
Issues:
•Has the patient a right to know the truth?
Has the doctor an obligation to tell it?
•What is truth? Deception?
•What if the patient does not want the truth or
does not ask for the truth?
•Can the physician initially disclose information to
the family without the patient’s consent?

DISCLOSURE OF MEDICAL
ERROR
 POTENTIAL BENEFITS TO
PATIENTS
• Allow the patient to obtain timely and appropriate
treatment to correct problems resulting in the
mistake.
• Prevent the patient from worrying needlessly about
the cause of the medical problem.
• Provides patient with the information needed to
make informed decisions.
• May allow the patient to obtain compensation for
lost earnings or to pay for care needed by the injury,
or to get a bill written off.
• Encourages more trust to the physician.

DISCLOSURE OF MEDICAL
ERROR
 POTENTIAL HARMS TO
PATIENTS
• The knowledge may cause alarm,
anxiety, and discouragement .
• It may destroy patient’s trust and
confidence.
• Patients may get disillusioned with
the medical profession in general.
• It may cause them to refuse
beneficial treatments or reduce their
adherence to beneficial treatment
regimens or habits.

DISCLOSURE OF MEDICAL ERRORS
POTENTIAL BENEFITS TO PHYSICIANS
• He may feel relieved after
admitting the mistake.
• He may get absolution for the
mistake.
• It may decrease the likelihood
of legal liability

 BENEFITS TO PHYSICIAN
• Disclosing mistakes may help us
learn and improve our practice.
• Admitting the mistake may also
help us accept responsibility and
may help us improve our practice.
• We can learn from mistakes made
by others so we can avoid making
similar mistakes.

POTENTIAL HARM TO
PHYSICIANS
• Patient may become angry and upset.
• Get the risk of a malpractice suit which
may cause psychological and financial
stress.
• Loss of referrals, admitting priveleges,
insurance preferred consultation and
even licensure,
• May damage reputation,trust and
confidence not only of patients but also
of colleagues.

RESPECT FOR PERSON
AUTONOMY
Greek word:
autos (self) nomes (rule)
Respecting patient’s right to
self determination and
pursuit of one’s own life
plan

Elements:
1.Decision making
capacity
2. Freedom
voluntariness
• In clinical practice, the lack of
decisional capability should be
proved and not presumed.

JUSTICE means giving
everyone his due ;
distributing benefits and
harm equally.

DISTRIBUTIVE JUSTICE
•Allocation of scarce medical
resources fairly
•Distribute benefit and harm
equally
MACRO - ALLOCATION
MESO - ALLOCATION
MICRO - ALLOCATION
• Triage

Principle of
Justice
•Macro-
allocation
•Meso-
allocation
•Micro-
allocation
• Triage

ENDING UP DOCTOR-PATIENT
RELATIONSHIPS
 If a doctor wants to end the
relationship with his/her patient it
must be done in a professional and
fair manner.
 A doctor may only end a relationship
if he/she is confident that the patient
is not acutely in need of immediate
care or the care of the patient has
been accepted by another doctor
who can best served the patient.

ENDING UP RELATIONSHIPS:
 The relationship may end after any
length of time either because the
patient is moving to another place
or chooses another doctor.
 There may be a breakdown of the
relationships and in such situation
it is decided by either to
discontinue the relationship.

ENDING
 Any decision by a doctor to
discontinue the relationship
should be done on the
grounds that the doctor is
prepared to justify the
decision if called on to do
so.

Process for Discontinuing Care
 The process to end the
professional relationship must be
made clear, so the patient no
longer has any expectations of
care from his/her doctor.
 Tell the patient that the
relationship is ended and should
provide the reason why it has been
discontinued.

 Refer the patient to another doctor of
the patient’s choice ( in the case of
the specialist of which the condition
why patient was referred has been
resolved )back to the attending
general practitioner.
 Give a letter of referral and all
relevant information about the
patient to the new doctor or to the
original general practitioner who
referred the patient.

Doctor-Doctor Relationship
Based on Principle of
Solidarity
Should have harmonious
relationship and work for
best interest of the patients
Sharing of knowledge and
expertise

Avoid professional
jealousy, rivalry and
insincerity
We should not indulge in
fault findings
Refrain from making unfair
and unwarranted criticism
against a colleague

If it is justified then, it
should be constructive and
made directly and privately
to the physician concerned.
If both parties cannot be
reconciled refer to proper
authorities or a competent
body for decision .

INDICATIONS FOR
REFERRAL
 When a physician feels the need for
assistance in developing medical advice
for a patient as the case is not within
his expertise, consultation may be
recommended.
 When discordance develops between a
physician’s recommendation and a
patient’s decision despite respectful
persuasion a referral for a second
opinion may be offered or sought for,
for the best interest of the patient.

INDICATIONS
 Physician should recommend
that a patient obtain a second
opinion whenever he believes it
would be for the best interest of
the patient.
 Patients are free to obtain
second opinions on their own
initiatives with or without their
physician’s knowledge.

RESPONSIBILITIES OF THE
ATTENDING PHYSICIAN
 Under these circumstances
an independent opinion
should be sought from
another informed physician
chosen by the physician or
the patient through
consultation with each
other.

RESPONSIBILITIES
 It is unethical for
physicians asking a
second opinion to
recommend a course of
action as matter of
collusion.

RESPONSIBILITIES
 When recommending a referral or for
a second opinion the physician should
explain the reasons for the referral
and tell patients they are free to
choose the physician to whom they
will be referred.
 With the patient’s consent the
referring physician should provide all
the necessary informations including
the results of all workups done to the
referral consultant.

RESPONSIBILITIES
 When a patient initiates or
requests for a referral or a
second opinion, it is
inappropriate for the primary
attending to terminate the
patient – physician relationship
solely because of the patient’s
decision to obtain the second
opinion.

RESPONSIBILITIES of the
REFERRAL CONSULTANT
 The referral consultant should
have no vested interest in the
outcome and should make every
effort not to pre-empt or interfere
with the original physician-
patient relation and not to
undermine confidence or
authority.

Responsibilities
The ethical consideration
of all physicians giving
further evaluations or a
second opinion is to
ascertain that the best
interests of the patient are
served.

RESPONSIBILITIES:
 Referral Consultant has an
obligation to the referring or
primary physician to discuss
jointly the total health care
needs and recommendations
so that clear and
understandable advice may
be given to the patient.

RESPONSIBILITIES
 After evaluating the patient
the referral consultant
should provide the patient
with a clear understanding of
the opinion, whether or not it
agrees with the
recommendations of the
primary physician.

Ethics of Referrals
 Specify nature of referral
 Avoid collusion with referring
consultant
 Avoid undermining referring
consultant
 Communicate findings and
evaluation to referring consultant
 Avoid cross-referral
 No fee-splitting

Criticism of colleague
 It is unethical and harmful
for a physician to disparage
without good evidence the
professional competence,
knowledge qualifications or
services of another physician
to a patient or to a review
body.

It is also unethical to
imply by word, gesture
or deed that a patient
has been poorly
managed or mistreated
without good evidence.

 Such improper behavior specially
when used to induce a person to
become one’s patient is
unethical.
 It is unethical for a physician not
to report fraud, professional
misconduct, incompetence or
abandonment of a patient by
another physician.

Doctor-Nurse Relationship
• Primary bond is mutual concerns for
patients.
• Respect nurses as sharer of
responsibility and team member and
not just a subordinate.
• Since they spend more time with
patients listen to what they say as
expressed by patients.

NURSING VOCATION
• It is to the nurse that the patient
is entrusted for the greater part
of the day
• It is the nurse who receives the
patient after the operation, and
who by unobtrusive, modest and
effective aid, makes possible the
success of the efforts of doctor
and surgeon.adszx

RESPONSIBILITIES OF NURSES
• Fundamental role of mediation between
doctors and patients.
• They must decide whether or not to call the
doctor when they find that the patient has
suddenly become worse or must decide
whether or not to give the patient a calming
substance the doctor has left up to their
judgment to use at appropriate moment.
• They must work as a team with the other
health care providers for the best interest of
patient.

RESPONSIBILITIES OF NURSES
• A nurse must not cooperate in
immoral practices.
• The nurse who finds her/himself
involved in practices of which
one’s conscience cannot
approve, will make every effort
possible to bear witness to
her/his personal conviction –
“Conscientious objection.”

Ethical Dilemmas for Nurses:
Physician’s orders vs Patient’s Rights
Should nurses follow physician’s
orders when:
• They have good reasons to believe
that the orders are mistaken
• The physician refuse to admit that
he might be mistaken.
• Following orders may jeopardize
patient’s safety or well-being.

Ethical Dilemmas for Nurses:
Physician’s orders vs Patient’s Rights
• What should nurses do if
they have good reasons
to believe that physicians
are violating their
patient’s rights to self-
determination.

• Occasionally situations do arise
where the nurse has reason to
suspect that a certain order may
be erroneous and could cause
harm to the patient.
• Under such circumstances the
nurses legally as well as morally
obligated to question the order.

• According to law, a nurse
can be held negligent when
she knowingly implements
orders with the knowledge
that their implementation
will cause harm to the
patient.

• The fact that she is following a
doctor’s order is not in itself a
defense.
• What are the nurse’s rights when
she refuses to carry out an order
that she believes is morally
indefensible?
• What is she to do when confronted
with the problem of being
expected to engage in practices
that violate her own conscience?

• Philippine Nursing
Association’s Code of
Ethics stipulates that
obligation to the patient
takes precedence over
the nurse’s duties to
colleagues and employer.

PHYSICIAN-PHARMACEUTICAL
INDUSTRY RELATIONSHIPS
VICTORIA EDNA G. MONZON,M.D.,FPCP,FPCC,FSGC
Professor, Dept. of Bioethics & Dept. of Medicine
UST, FACULTY OF MEDICINE & SURGERY
Chair, Ethics Committee, UST Hospital & Philippine Heart Center

 The physician –pharmaceutical
industry relationship has a common
goal and that is: to serve the best
interest of the patient.
 Physicians prescribe reliable,
effective and affordable drugs.
 Pharmaceutical industry
manufactures or provide good quality
effective and affordable drugs.

Doctor-Pharmaceutical
Industry Relationship
• Physician’s decision about
patient care must not be based
on monetary, scientific or
academic gain.
• We must not be influenced by
external financial incentives that
would cause us to act in a
manner contrary to our best
professional judgment

Physician-Pharmaceutical
Industry Relationship
• Pharmaceutical Companies’
support for continuing medical
education is commendable.
• Updating physicians’ knowledge
leads to better health care.

• However, continuing
medical education is our
primary responsibility and
not of the pharmaceutical
industry.

All educational activities conducted or
supported by drug companies should:
• Benefit patients
• Enhance medical practice
through accurate information for
appropriate use.
• Preserve the independence of
health care professionals
PHAP, Code Of Ethics, 2006

Industry initiated conferences
• Primary objective must be
educational and should not be
used as promotional tool.
• Physician acting as faculty
members in such conferences
have a special obligation to be
sure that unbiased information
is presented.

• Physician-initiated program
• Programs must be organized and
conducted primarily as
educational.
• Industry should not specify
speakers or topics
• Attendees subsidized by industry
must truly attend the conference.

• Any gifts accepted by
physician should primarily
entail a benefit to patients
and should not be of
substantial value, textbook,
modest meals may be
appropriate.

• We should not require
pharmaceutical industry to
subsidize our private needs
and personal activities.

Physician/Pharmaceutical
Relationships
Ethical Issues:
• These sponsorships and
“giveaways” are paid for by
patients.
• To what extent do the costs
of pharmaceutical activities
add to the costs of drugs?

Relationships
• Extent to which receiving these
“giveaways” affects the prescriptive
habits of the sponsored physician
• “Pakikisama” and “utang na loob”
are cultural givens that demand
return for favors.
• The patients’ best interest is not best
served when a physician prescribes
less than the best or more expensive
medicines to repay a favor previously
received.

Relationships
ETHICAL ISSUES
• Extent to which these conferences
improve physicians’ knowledge.
• Many presentations are purely
promotional and are biased towards a
certain product.
• At conventions and international
conferences, some physicians spend
time touring, socializing and shopping
rather than attending scientific
sessions.

Physician / Pharmaceutical
Industry Responsibilities
Role of the Physician
• Each physician must take on the
responsibility of reviewing
his/her relationship with the
industry.
• This is part of his/her continuing
responsibility to his/her patients.

PHYSICIAN / DRUG
INDUSTRY RELATIONSHIP
Role of the Industry
• Must take on the
responsibility of reviewing
its offers to physicians.
• Their review is part of its
continuing responsibility to
justice.

Other Issues
•Physician’s professional
fees should be received
for services rendered
directly to a patient.

Professional Fees:
• Are not payments measured
by the value of the service
provided (which is truly
priceless) but a stipend to
be measured only by what
professionals need to live
and work without
distraction.

Guidelines
• Patient’s ability to pay
• The usual standard fee charged in that
locality or institution with similar
condition and expertise of the
physician
• The gravity of the condition
• The physician’s expertise and
experience
• The time of the day that you were
called in

Sharing fees:
• The offering or receiving
of a shared fee from
another physician
involved in the care of
the patient without the
patient’s knowledge is
unethical. (Fee-splitting)

• It is also unethical to receive a
commission or “kickback” from
anyone, including a company that
manufactures or sells medical
instruments or medications that
maybe used in the care of patients.
• It is also unethical to provide or
receive commissions or rebates on
diagnostic work ups done.

Secret remedies:
• The use of secret
remedies cannot be
condoned, whether or not
there is financial gain.
• Development and sale of
secret remedy are
unethical.

Two things we have to remember as
members of the healing ministry of
Christ:
• We have to let our patient see
Christ in us.
• We have to see Christ in each and
every patient we see because He
has said it “ If you do it to the
least of your brethren you have
done it to ME”

Sample Cases
1. J. Paul, a 60-year-old male
accident victim, had crush injury of
left leg. Dr. Dugtong orthopedic
surgeon operated on patient with
poor healing. After 3 months,
patient transferred to another
surgeon Dr. N. Putol who amputated
the leg. JP is charging Dr. Dugtong
of negligence.

2. Mrs. Ara Miles underwent
hysterectomy by Dra.
Paanak. After a few weeks,
Ara complained of passing
urine through her vagina.
She complained of
malpractice.

3. Mr. Kawawa is
complaining against Dr.
Guapito of immorality for
co-habiting with his wife,
a nurse in Dr. Guapito’s
hospital.

4. Tita Ganda is
complaining against Dr.
Mali for misdiagnosing
her daughter’s illness as
ordinary colds when it
turned out to be Dengue
Fever.

5. The son of Mr. J. R. was
admitted in an emergency room,
transferred to ICU and died after
4 hours. Mr. J.R. is complaining
against Dr. Tahimik for not
telling him & his family what
was going on and for charges by
MD’s he never saw.

STUDENT- PROFESSOR
RELATIONSHIP
Declaration of Geneva:
• “ I will give to my teachers the
respect and gratitude which is
their due.”
• Although present day medical
education involves multiple
student-teacher interactions
rather than the one on one
relationship of former times, it is
still dependent on the goodwill
and dedication of practicing
physicians.

STUDENT- PROFESSOR
• Medical Students and
other medical trainees
owe a debt of gratitude to
their teachers without
whom medical education
would be reduced to self-
instruction.

TEACHER’S OBLIGATIONS
• They have an obligation to treat their
students respectfully and to serve as
good role models in dealing with
patients.
• The so called “hidden curriculum” of
medical education ( standards of
behavior exhibited by practicing
physicians ) is much more influential
than the explicit curriculum of
medical ethics.

TEACHERS’ OBLIGATIONS
• They have an obligation not to
require students to engage in an
unethical practices like the following
which were reported in medical
journals:
• Medical students obtaining
informed consent for medical
treatment in situations where a fully
qualified health professionals should
be the one to do it.

• Performing pelvic examinations
on anesthetized or newly dead
patient without prior consent.
• Performing unsupervised
procedures that although minor
are considered by some
students to be beyond their
competence.

• Teachers need to ensure that
they are not requiring students
to act unethically.
• Students concerned about
ethical aspects of their
education should have access to
such mechanisms where they
can raise concerns.

STUDENTS OBLIGATIONS
• Medical students are expected
to exhibit high standards of
ethical behavior as appropriate
for future physicians.
• They should treat other students
as their colleagues and be
prepared to offer help when it is
needed.

STUDENTS’ OBLIGATIONS
• They may also be prepared to
give corrective advice in regard
to unprofessional behavior.
• They should also contribute fully
to shared projects and duties
such as study assignments and
on – call services.

MEDICAL STUDENTS PERFORMING
PROCEDURES ON FELLOW STUDENTS
• In the context of learning basic clinical
skills, medical students must be asked
specifically to consent to procedures being
performed by fellow students.
• Instructors should explain to students how
the procedures will be performed , making
certain that students are not placed in
situations that violate their privacy and
sense of propriety. Confidentiality,
consequences and appropriate management
of a diagnostic finding should also be
discussed.

MEDICAL STUDENTS
• Students should be given the choice of
whether to participate prior to entering
the classroom and there should be no
requirement that students provide a
reason for their unwillingness to
participate.
• Students should not be penalized for
refusal to participate. Thus instructors
must refrain from evaluating students’
overall performance in terms of their
willingness to volunteer as “patient.”

MEDICAL STUDENT INVOLVEMENT IN
PATIENT CARE
• Patients and the public benefit from the
integrated care that is provided by health
care teams that include medical students.
Patients should be told of the identity and
training status of individuals involved in
their care and all health care professionals
share the responsibility for properly
identifying themselves.
• Students and their supervisors should
refrain from using terms that may be
confusing when describing the training
status of students.

MEDICAL STUDENT INVOLVEMENT
• Patients are free to choose from whom
they receive treatment. When medical
students are involved in the care of
patients, health care professionals
should relate the benefits of medical
students participation to patients and
should ensure that they are willing to
permit such participation.
• Generally attending physicians are best
suited to fulfill this responsibility.

MEDICAL STUDENT INVOLVEMENT
• In instances where the patient will be
temporarily incapacitated
(anesthetized) and where student
involvement is anticipated,
involvement should be discussed
before the procedure is undertaken
whenever possible .
• In instances where a patient may not
have the capacity to make decisions ,
student involvement should be
discussed with the surrogate decision
maker whenever possible.

RESIDENT PHYSICIAN’S INVOLVEMENT IN
PATIENT CARE
• Residents and fellows have dual roles
as trainees and caregivers. First and
foremost they are physicians and
therefore should always regard the
interests of patients as paramount.
• To facilitate both patient care and
educational goal, physicians involved in
the training of residents and fellows
should ensure that the health care
delivery environment is respectful of
the learning process as well as the
patient’s welfare and dignity.

RESIDENTS’/FELLOWS
• Training must be structured to provide
residents and fellows with appropriate
faculty supervision and availability of
faculty consultants and with graduated
responsibility relative to the level of
training and expertise.
• Residents/Fellows interactions with
patients must be based on honesty.
They should clearly identify
themselves as members of a team that
is supervised by an attending
physician.

RESIDENTS/FELLOWS
• If a patient refuses care from a
resident / fellow, the attending
physician should be notified.
• If after discussion the patient does
not want to participate the physician
may exclude residents/fellows from
that patient’s care or transfer the
patient’s care to another physician or
non- teaching service or to another
health care facility.

RESIDENTS/FELLOWS
• Residents/Fellows should participate
fully in established mechanisms for
error reporting and analysis in their
training programs and hospital
system.
• They should cooperate with the
attending physicians in the
communication of errors to patients.

RESIDENTS / FELLOWS
• Residents/ Fellows are obligated to monitor
their own health and level of alertness so that
these factors do not compromise their ability to
take care of patients safely.
• Residency/Fellowship programs must offer
means to resolve educational or patient care
conflicts that can arise in the course of
training.
• All parties involved must regard patient’s
welfare as the first priority. Conflict resolution
should not be punitive but should aim in helping
them finish their training successfully .
• If conflict remains unresolved this may be
elevated to the higher body responsible for the
trainees.

SEXUAL HARASSMENTS BETWEEN SUPERVISORS –
TRAINEES / STUDENTS
 Sexual Harassment may be defined as
sexual advances, requests for sexual
favors, and other verbal or physical conduct
of a sexual nature when:
• Such conduct interferes with an
individual’s work or academic performance
or creates an intimidating, hostile or
offensive work or academic environment.
• Accepting or rejecting such conduct
affects or may be perceived to affect
employment decisions or academic
evaluations concerning the individual.
Sexual harassment is unethical.

ETHICS COMMITTEE
VICTORIA EDNA G. MONZON, M.D.,
FPCP, FPCC, FSGC (USA)
Professor
Department of Bioethics & Department of Medicine
UST Faculty of Medicine and Surgery
Chair, Ethics Committee, UST Hospital & Philippine Heart Center

Committee Composition
• Membership should be
multidisciplinary
• Must have a well balanced
representation from medical, nursing
and administrative staffs.
• Representatives from pastoral care,
social work and other areas involved in
patient care.
• A lawyer can be an effective
committee member as long as he is
careful not to put legal concern above
ethical concerns.

• A liaison from the administration
should be an active member of
the committee.
• A committee that does not have
the full support of the
administration is doomed to fail.

Committee Expertise
• The ethical expertise of individual
members will vary and be an
ongoing development with each
participant.
• The members must have an
openness and a willingness to
contribute, to participate, to study
and to learn.

ETHICS COMMITTEE
Functions:
• Provide ethics education
programs for its member and
staffs.
• Serves as a consultative
body for those responsible for
making ethical decisions.
• Formulate policies.

Other Functions
• In the absence of Institutional
Review Board or ERB it can
review research protocols on
its ethical aspects.
• It can also serve as advocates
for legislative development on
health and contributes its
share to public debate on
health care issues.

I. Education
• Most important function
• Committee members are
responsible first of all for
educating themselves.
This can be done through:
• Shared reading and discussion
of current ethical issues.
• Shared study and discussion of
classic cases in the ethical and
medical literature.

• Through role playing of actual or
fictitious cases.
• Through the use of multi-media
resources.
• Through the study and development
of ethical policies for
recommendation to the
administration.
• Through a discussion of actual
cases within the institution itself
always with care to maintain
confidentiality.

EDUCATION….
• It should engage in
continuing education of its
members and on going
training for house staffs to
ensure the highest quality
clinical ethics consultations.

II. Consultative Function
• Meant to facilitate
appropriate moral decisions
and decision making among
patients, surrogates,
physicians, nurses and other
caregivers.

Who can request for
consultation?
•The attending physician
•The nurse in charge
•The patient
•Members of the family
•Anybody involved in the case

Functions as Consultative Body
• To assist the decision makers
by clarifying institutional
policy.
• To appropriately explain or
interpret hospital policies
when needed.
• To raise questions or
alternatives not considered by
the decision makers.

• To clarify the patient’s rights and
responsibilities as well as professional
and institutional rights and
responsibilities.
• To clarify an ethical principle applicable
to the particular case.
• To foster an appropriate understanding
and respect for the human dignity of the
patient, the family, and the professional
care givers.

How much authority do ethics
committee have?
• It does not have a binding
judgment.
• It is just recommendatory.
• It is there to help physician,
patient and family members
understand what the ethical
constructs and possibilities are.
• It is not a moral police force
looking for unethical physicians.

The committee should not
exercise decision-making power
• It may dissuade caregivers from
seeking the committees help.
• It may persuade others to seek
help for inappropriate reasons
(to shift responsibility away from
those to whom it belongs).

• A committee must not exercise
the moral authority that rightly
belong to the attending physician
and the patient or to those
professionals and others
immediately involved in the
patient’s care.

WHAT ARE SOME COMMON
ETHICAL PROBLEMS?
The following are some examples of
ethical problems that can arise in the
hospital:
• What should a patient or surrogate do
when he/she cannot understand what
caregivers are saying, but tests and
treatments continue anyway?
• Who should communicate or decide
for themselves?

COMMON ETHICAL PROBLEMS
• What should family members or caregivers
do when they strongly disagree with the
doctor’s recommendation and uncertain
about what is best for the patient?
• When should life prolonging treatments be
started, continued or stopped?
• What should family members and
caregivers do when a patient refuses
treatment that promises to be medically
beneficial?

ISSUES WHICH MIGHT GIVE
RISE TO THESE QUESTIONS:
•Withholding / withdrawing
aggressive life support
•Patient’s dementia or incapacity
to make informed decision
•DNR/DNAR Policy guidelines
•Organ and tissue donation and
transplantation

Committee members who engage
in consultations should possess
the following:
• An appropriate
understanding of the
purpose and role of
the ethics committee.

•A broad understanding of
ethical and legal principles.
•Experience with case studies
and case methods.
•Thorough understanding of
the ethical policies of the
institution.

III. ADVISORY FUNCTION
• Administration should make use of the
committee for reviewing proposed
policies on clinical care or employee
relations or even on managed care
contracts.
• Committee can offer an important
perspective to the development of
administrative policies and protocols.
• It can be the principal drafters of
treatment – decision and patient –rights
policies.

Meetings of the Committee
•Regularly scheduled periodic
meeting of the committee.
•Emergency, for consultation
on cases.
•Educational for updating
members
•Orientation of new members

Bioethics 2010

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