Deontology

1. ‘Are we truthfully
the
“GOOD DOCTORS”??’
(Updated)

2. Medical Deontology
THE FADING SCIENCE
&
NEED OF THE HOUR!!

3. PROF. MRIDUL M. PANDITRAO
Professor
Bharati Vidyapeeth Medical
College, Pune

4. Introduction
Whenever We deal with a Patient--
“Simple & Pertinent question!”
• “Was I ‘Good’ to my patient?
• (“Did I do everything ‘Good’ and nothing ‘Bad’ ??)”
• (Was there any ‘vested interest’ involved or was I purely
‘altruistic’ ???)

5. Introduction
• Notwithstanding unprecedented advances the Medical Science
• Alas! The fundamental Value System of its practitioners has
crumbled
• The Principles and the Foundations of the “Noble Profession”???
• The need and greed of Lucre is the ‘Principal Principle’
• That is ruling this ‘Materialistic’ world

6. Introduction
• Original guidelines of the Fathers of Medicine fading away!
• The necessity in these testing times to introspect deeply
• Reinvent the vanishing science of
‘Medical Deontology’.

7. ‘Medical Deontology’.
The term is constituted by two words,
Deon(Greek) – ‘duty’ or ‘obligation’ and Logos(Greek) –
meaning opinion, word ….
 Defined as
“ A discipline for the study of norms of conduct for the health
care professionals, including moral and legal norms as well as
those pertaining more strictly to professional performance!”
Fineschi V, Turillazzi E, Caten C.The new Italian code of medical ethics. Journal ofMedical Ethics 1997; 23: 239-244. jme.bmj.com

8. Definition
“Set of
Ethical Standards and Principles of behavior of Medical
Practitioners while executing their professional duties
Professional Ethics of Medical Workers
Principles of Behavior of Medical Personnel directed
toward gaining maximum benefit of treatment for the
patients!”

9. Core Issues
Intricately inter-related 3 sub-divisions:
Medical Jurisprudence
Medical Ethics
Medical Hodegetics

10. Sub-divisions
Medical Jurisprudence or Law
• Jur (Latin) meaning Law …….. prudentia (Latin) meaning
knowledge
• Also known as Forensic Medicine,
• Can be defined as the “science which applies the principles
and practice of the different branches of medicine to the
elucidation of doubtful questions in courts of justice”

11. Medical Ethics
• ethica (Latin) from (Greek) ethice –
• teaching of morals,
• defined as a “system of moral principles: that applies values
and judgments to the practice of medicine”
• As a scholarly discipline it encompasses
– its practical application in clinical settings
– as well as works on its
• History,
• Philosophy
• Theology
• Sociology
Sub-divisions

12. Sub-divisions
Medical Hodegetics from (Arabic - ُ
‫َّات‬‫ي‬ِ‫ق‬‫ال‬ْ‫أخ‬
ُ
‫ب‬ِ‫الط‬ )
• literally means, guidelines for the study of medicine
• The guidelines
– which cover the ideal principles
– which must be learnt while studying medicine
– as were once envisioned by the ancient “Fathers of the Medicine!

13. Duties of Medical Practitioners
Two main types of duties
Scientific - the section of medical science,
studying ethical and moral aspects of medical workers’ activity
Practical – the area of medical practice
the tasks of which are the formation and application of ethical
standards and rules of the professional medical activities

14. Medical Deontology includes:
Problems of-
Observing medical confidentiality
The extent of the medical worker’s responsibility for the life and
health of the patient
Relationships of medical workers to each other.

15. Triad of Medical deontology
,
Problems of inter-personal mutual relations in three basic directions
Medical
Worker
The
Patient
Medical
co-
worker
Patient’s
Relatives

16. Historical Aspects
Plethora of literature from circumspective and varied backgrounds
Indian “The Book of Life” (“Ayurveda” about 5000 years old)
“The Laws of Hammurabi” (Laws of Ancient Babylon, about 3000 yrs)
“About the physician”, "The Oath" and "The Law“
by Hippocrates (5th -4th centuries B. C.)
The term "ethics", meaning “a concept of human morals” introduced
by Aristotle (384-322 B. C.).

17. Historical
• towards the middle Ages:
– “The Canon of Medical Science” and “Ethics” by Ibn Sina (Avicenna,
10-11 centuries),
– Jeremy Bentham (English philosopher, lawyer, priest; 1748-1832),
• who introduced the notion of Deontology as meaning “… the teaching on the
due behaviour of a person while achieving his end” (18 century).

18. Historical
Some references in Russian medicine,
Matvey Yakovlevich Mudrov (1776-1831)
• “The Word Concerning Piety and Moral Qualities of a Hippocratic Physician”
• “The Word Concerning the Ways of Teaching and Learning the Practical
Medicine”
 Nikolay Ivanovich Pirogov (1810-1881) are noteworthy
• “Letters from Heidelberg” and
• “The Diary of an Old Doctor”.

19. Historical
The controversial Nuremberg process(1947),
• Depicting the Verdict to the Nazi physicians, (“The
Nuremberg Code”,)
• postulates not only legal also moral regulations of medical
/human experiments.

20. Historical
Post 1947
• World Medical Association was created
• Its main actions were:
– the adoption of “The Geneva Declaration”
– the oath of a physician – the doctor (1948),
– the International Code of Medical Ethics (1949),
– “The Helsinki Declaration of Human Rights” (1964)
– “The Helsinki-Tokyo Declaration” (1975), and
– “The International Declaration on Human Rights” (1983).

21. Quotes!
In the ancient Indian Medicine Teacher used to tell his disciples:
• “You now leave your
passions, anger, greed, madness, vanity, pride, envy,
roughness, buffoonery, falsity, laziness and any vicious behavior
From now on, you will have your hair and your nails shortly cut,
wear red clothes, conduct a pure life”.
A passage from the ancient Indian Book of Medicine : “AYURVEDA”

22. Quotes!
Ibn Sina (Avicenna) had already demanded a special approach to
the patient:
• “You should know that every separate person possesses the special
nature inherent in him personally.
• It seldom happens, or it is absolutely impossible, that somebody
would have the nature identical with his”

23. Primary Principle
PRIMUM NON NOCERE !
(Latin) - FIRST, DO NO HARM
• This maxim is & must always be the
• Main Ethical Principle in Medicine!

24. Values/Principles in Medical Deontology
Six of the fundamental values/principles are:
• Autonomy
• Beneficence
• Non-Maleficence
• Justice
• Dignity
• Truthfulness and Honesty

25. Values/principles
Autonomy
• the patient has the right to refuse or choose their
treatment. (Voluntas aegroti suprema lex.)
• The principle of autonomy recognizes the rights of
individuals to self determination.
• This is rooted in society’s respect for individuals’ ability
to make informed decisions about personal matters.

26. Autonomy
• A 38 years old male ASA I with AVN Rt. Femur for THR
• Comes for Pre-Anaesthesia Check up
• Counselling done, found fit for both GA and Regional
• Pros & Cons of both explained
• Not convinced for regional
• Insists on GA
• ????

27. Values/principles
Beneficence
• a practitioner should act in the best interest of the patient.
(Salus aegroti suprema lex.)
• The term beneficence refers to actions that promote the
wellbeing of others.
• In the medical context, this means taking actions that serve the
best interests of patients.

28. Beneficence
• Anything
• Everything
• Everywhere
• Any time
any doctor does for the patient is an example of Beneficence!

29. Values/principles
Non-Maleficence
• embodied by the primary principle
• "first, do no harm," or the Latin, primum non nocere
• Many consider that should be the main or primary
consideration (hence primum):
• & it is more important not to harm your patient, than to do
them good ( Beneficence)!

30. Non- Maleficence!
• Poly trauma victim is brought to Emergency Dept.
• Driving under the influence of alcohol
• Anaesthesiologist is called for intubation
• Over-enthusiastic intern decides to try out intubation
• Attempts twice, unsuccessful!
• Gastric contents regurgitate, drowning the airways
• Patient gone in Sudden Cardiac Arrest
• ?????

31. Values/principles
Justice!
• concerns the distribution of scarce health resources
and
• the decision of who gets what treatment (fairness and
equality)
• Irrespective of caste/ creed/ religion/ gender/ status/ class/
financial condition

32. Justice!
• Covid-19 epidemic uncontrolled!
• 65 years old female brought in emergency dept
• Severe respiratory distress, needs ventilator
• Followed by a 25 years old male
• Severe Respiratory Distress, Needs ventilator,
• only one remaining!
• ?????

33. Values/principles
Dignity
• the patient
• (and the person treating the patient)
• have the right to dignity.

34. Dignity!
• An elderly female
• Hard of hearing, mildly senile and bit confused
• Brought to the OT for a procedure under spinal
• Anaesthesiologist makes three attempts, fails
• Frustrated, starts shouting at the patient for not co-operating!!
• Tries again, but patient become agitated and flustered
• Shouts again and refuses the treatment!
• ??????

35. Values/principles
Truthfulness & Honesty
the concept of Informed Consent has increased in importance
since the historical events of the
• “Nuremberg Experiments of Nazi Doctors (1940s)
• ( Nuremberg trial of Nazi Doctors: 1947)
&
• Infamous Tuskegee Syphilis study (1932-72)

36. Truthfulness and Honesty
• WWII: Nuremberg Concentration Camps in Germany!
• Auschwitz, Dachau, Buchenwald, Ravensbruck……. Many !
• As such Jewish inmates living in animal like conditions
• Nazi Doctors’ experiments on inmates, even on children
• Creation of conjoint twins by stitching twins together, bones/
muscles/ nerves transplantation without anaesthesia, head injury,
malaria, immunization, fertility, mustard gas, bombs
• ?????
• 1947: Famous Nuremberg Trial
• Led to concept of “ Informed Consent”

37. Truthfulness and Honesty
• Tuskegee Syphilis Study: Town in Alabama, USA
• 600 Black males with Latent syphilis, promised of free treatment
• Told only for 6 months but carried on for 40 years
• To find out the end stage effects of syphilis was hidden motive
• Penicillin:Treatment was available & could have cured them
• Never told about diagnosis, never treated for syphilis
• 25% died, 10 % infected their spouses, many children born with
congenital syphilis
• ???????????

38. Additional Principles
We can add some more principles such as
• Medical privacy - allows a person to keep their medical
records from being revealed to others.
• Confidentiality - is commonly applied to conversations
between doctors and patients
– This concept is commonly known as patient-physician privilege
– Legal protections prevent physicians from revealing their
discussions with patients, even under oath in court of Law

39. Medical Privacy
• An interesting case of a beautiful young female
• Treating doctor very keen on following it up
• Does thorough job of investigating her
• But still a bit doubtful and not sure
• On social media, amongst his peer group
• Shares her medical record, pictorial and other information
• ???????

40. Confidentiality
Scenario:1
• A young promiscuous male had unprotected commercial sex
• Contracted a sexually transmitted disease
• Confirmed by the doctor and called for councelling
• After informing about his condition, he urges doctor Not to
disclose to his wife or Family
• Adamant about this request
• ???????

41. Confidentiality
Scenario:2
• A legal Trial is going on about one criminal
• The prosecution Lawyer has summoned the Doctor
• He is pestering the doctor
• To divulge some information that has been confided to Dr.
• Doctor refuses to give information: as Privileged information
• lawyer keeps pestering
• Judge admonishes the lawyer
• ???????

42. Additional Principles
• Fidelity - is the quality of being faithful or loyal to one’s
patients as if it is the service rendered in relation with the
cause of ‘LORD ALMIGHTY’
• Veracity- Truth telling or Obligation to full and honest
disclosure,
– of the information, concerns or any such matter,
– in context with a patient’s health/ disease state to himself/herself
and their near and dear ones.

43. Fidelity
• Does Not require any explanation
• It can be considered as a deeper extension of Beneficence
• Without bringing in any religion/ caste/ creed the doctor is bound
by his “Hippocratic Oath”
• To provide the best possible service to his patient as if to the divine
power he/she believes in
• With CPA/ medico-legal wrangles, this value slowly disappearing
• ???

44. Veracity
• A young patient, only child of devoted parents
• After a mild illness, diagnosed to have a life threatening illness
• Life expectancy minimal
• Parents are devastated, are pressurizing doctor not to tell to
the patient
• Doctor in dilemma, whether to divulge the truth or Not
• ?????

45. Epilogue
• Providing service with adequate skill, precision and expertise is
not enough
• In addition what matters the most is to judge, if it was
appropriate, necessary and not tinged with ‘vested interest’
• If and when we are questioned by our own morality, about
these issues
• Then we must stop there for a moment, introspect and be our
own ‘Devil’s Advocates’, if necessary.

46. Epilogue
• The ‘stark and naked materialism’ has reached monstrous
proportions
• The society on the whole has started looking at the
physician community
• With very suspicious and negative attitude
• But there is other side to this sad story!!!

47. Epilogue
As the medicine is technologically evolving,
• There is a paradigm shift towards the protocol based practice,
• So that there is very little margin for error!!
• Sadly, in the pursuit of ‘perfection’, ‘standardization’ and ‘quality’,
• The clinicians tend to forget, that we are not dealing with the
‘mechanical objects’, but the living beings!
• Those living beings, requiring to be treated with the attitude of
respect, understanding and kindness!
• Which according to them, may have much more significance than
only ‘quality assurance’.

48. Epilogue
• On the other hand, even the physicians/clinicians
• should not be considered as, the
perfect mechanical devices or robots
• The picture is painted in only either black or white, viz;
– ‘there can only be and must be the perfection in the service
– if there is error that needs to be punished’,
• as is usually projected by the popular media and legal
fraternity, especially in India

49. Epilogue
• These advocates of model of perfectionism, maintain,
– that, the better efforts will lead to perfection in the service,
especially in medicine,
– As we are dealing with living human beings
– So if there is error, that needs to be punished severely and swiftly
– because then there will be no further room for error.
• This ideology fundamentally is flawed,
• Because, nobody, even its advocates are not ‘perfect’
themselves.

50. Epilogue
We
• Medical professionals are also to certain extent adding fuel to
the ‘fire’
• By getting embroiled in the ‘blame game’ and ‘mud-slinging’ in
the event of ‘an error’
• All these usually tend to culminate
• Into nasty, ugly and avoidable legal wrangles.

51. Epilogue
• So in the end, attitude on the part of doctors, while dealing
with their patients/ their relatives is of
• divulge only what is ‘ needed to know’
• Because the process becoming more and more complex
• This ‘lack of communication’ can be considered as one of the
main causes of ‘litigation’.

52. Conclusion
• As this vicious process of
– self- perpetuating and self-destructive hostilities, Is relentlessly
unfolding,
• WE the Senior members of Medical Profession/ Teachers/
Trainers need to seriously ponder over the prevailing situation
and start re-inventing,
• The now almost certainly forgotten/ near extinct science of
“ Medical Deontology”
• In the interest of ‘Future Generation’ of the physicians!

53. Conclusion
• A physician should behave according to these principles while
she(he) treats her(his) patient.
• These principles were also moral virtues of the physicians in
the past!!!!

54. Conclusion
• It is my conviction, passionate belief and moral principle
• “To try and adhere to these principles as solemnly and
sincerely as possible”
• It is recommended to all the practicing, experienced or/ and
conscientious doctors
• Try to inculcate these values, goals, moral attitude and
aptitude in the
“Younger generation of medical professionals!”

55. All The Best!