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1. PHMSC-DIPARTEMENT OF ANEASTHESIA
PROFESSIONAL ETHICS AND HAZARDS
PART-I
PROFESSIONAL ETHICS
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2. At the end of these course the student is
expected to
 Understand the basic concepts of ethics
 Analyze medical ethics and medico legal problems
 Avoid malpractice and negligence
 Understands ethics and legal aspects
 Respects rights of patients
 Conducts ethical research
 Understands legal and ethical issues
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3. 3
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4. History of Medical Ethics
• Ancient Egypt: Ancient Egyptian Medicine
• Ancient Greek Medicine
The works of Hippocrates
• Ancient Roman Medicine
• Oriental and Islamic Medicine
• Hospitals were later developed throughout the Islamic
world, with the most famous being those in Damascus
and Cairo.
• Medieval Europe was a place that placed less
importance on the value of Public Health facilities
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5. What is Morality?
• The science of human duty; the rules of human
conduct.
• The function of morality is "to combat the deleterious
consequences of human sympathies“
• Its aim is "to contribute to betterment -- or at least
non-deterioration -- of the human predicament“
• Morality is what people believe to be right and good,
while ethics is a critical reflection about morality.
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6. Ethical theories
• There are two broad categories of ethical theories
A Consequentialist theory
• judges the rightness or wrongness of an action
based on the consequences that action has.
• The most familiar example would be utilitarianism--
``that action is best that produces the greatest good
for the greatest number''
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7. Nonconsequentialist theories of ethics
• A nonconsequentialist theory of value judges the
rightness or wrongness of an action based on
properties intrinsic to the action, not on
its consequences.
• Libertarianism--People should be free to do as they
like as long as they respect the freedom of others to
do the same.
• Contractarianism--No policy that causes
uncompensated harm to anyone is permitted
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8. What is Ethics?
• The term is derived from the Greek word ethos which
can mean custom, habit, character or disposition.
• Ethics are standards of conduct (or social norms) that
prescribe behavior.
• It is concerned with what is good for individuals and
society and is also described as moral philosophy.
• A system of moral principles that affect how people
make decisions and lead their lives.
• Thus Ethics is a set of moral principles and a code for
behavior that govern an individual’s actions with
other individuals within society.
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9. What is Law
• Laws are societal rules or regulations that are
obligatory to observe.
• It protects the welfare and safety of society, resolve
conflicts, and are constantly evolving.
• People who break certain laws can be fined,
imprisoned or executed.
• People who violate ethical or moral standards do not
face these kind of punishments unless their action also
violate laws.
• We often “punish” people who disobey moral or
ethical obligations by simply expressing our
disapproval or by condemning the behavior.
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10. What is Bioethics
• Bioethics refers to the moral issues and
problems that have arisen as a result of modern
medicine and medical research.
• Issues in bioethics are usually life-and-death
issues!
• Ethical and bioethical principles can be
personal, organizational, institutional or
worldwide.
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11. Comparing Law and Ethics
• Law, ethics, and bioethics are different but related
concepts.
• Laws are mandatory to which all citizens must adhere
or risk civil or criminal liability.
• Ethics relate to morals and help us organize complex
information and competing values and interests to
formulate consistent and coherent decisions.
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12. Ethics covers the following dilemmas:
How to live a good life
Our rights and responsibilities
The language of right and wrong
Moral decisions - what is good and bad?
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13. What is Professional Ethics?
• Professional ethics are standards of conduct that
apply to people who occupy a professional occupation
or role.
• A person who acquires profession requires ethical
obligations because society trusts them to provide
valuable goods and services that cannot be provided
unless their conduct conforms to certain standards.
• Professionals who fail to live up to their ethical
obligations betray this trust.
• Professional ethics studied by ethicists include medical
ethics.
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14. What is Medical ethics?
• It is a special kind of ethics only as it relates to a
particular realm of facts and concerns and not
because it embodies or appeals to some special moral
principles or methodology.
• It is applied ethics And in medical ethics these familiar
moral rules are being applied to situations peculiar to
the medical world.
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15. Aim of medical ethics
– Give maximum benefit to the patient
– Minimize risk
– Correct diagnosis and management of the patient
– Keep interest of the patient foremost
– Needs of the patient guardian and families
– Less cost to the patient family and society
– Availability of resources
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16. What is Clinical ethics?
• It is a practical discipline that provides a structured
approach for identifying ,analyzing, and resolving
ethical issues in clinical medicine.
• Which aims to improve patient care and patient
outcomes by focusing on reaching a right and good
decision in individual cases.
• It focuses on the medical personnel –p/t relationship
and takes account of the ethical and legal issues that
patients, medical personnel , and hospitals must
address to reach good decisions for individual patients.
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17. The content of clinical ethics includes;
Truth-telling,
Informed consent,
End of life care,
Palliative care,
Allocation of clinical resources, and
 The ethics of medical research.
Honesty,
Competence,
Integrity, and respect for persons.
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18. How do we adhere to professional ethical
standards?
• Adherence to professional ethical standards is
expressed through taking
1-professional oath
2-accepting professional code of ethics
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19. ETHICAL CODE
• Ethical codes, are adopted by organization to
assist members in understanding the
difference b/n 'right' and 'wrong‘ and applying
that understanding to their decisions.
• An ethical code generally implies documents
at three levels:
 CODES OF BUSINESS ETHICS
 CODES OF CONDUCT FOR EMPLOYEES
 CODES OF PROFESSIONAL PRACTICE.
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20. CODES OF BUSINESS ETHICS
• Basically business ethics deal with the moral beliefs of
the owners of the business towards the employees.
CODES OF CONDUCT FOR EMPLOYEES
• A code of conduct for employees sets out the
procedures to be used in specific ethical situations,
such as conflicts of interest or the acceptance of gifts,
and delineate the procedures to determine whether a
violation of the code of ethics occurred and, if so,
what remedies should be imposed.
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21. CODES OF PROFESSIONAL PRACTICE.
• A code of practice is adopted by a profession or by a
governmental or NGO to regulate that profession.
• A code of practice may be styled as a code
of professional responsibility, which will discuss
– Difficult issues,
– Difficult decisions that will often need to be made,
and provide a clear account of what behavior is
considered "ethical" or "correct" or "right" in the
circumstances.
– In a membership context, failure to comply with a
code of practice can result in expulsion from the
professional organization. 21
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22. FOUR ETHICAL 'ISMS‘
• The different 'isms' regard the person uttering the
statement as doing different things.
Moral realism
• Moral realism is based on the idea that there are real
objective moral facts or truths in the universe.
• Moral statements provide factual information about
those truths.
• Example: "It is wrong to murder"
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23. Subjectivism
• Teaches that moral judgments are nothing more than
statements of a person's feelings or attitudes, and
that ethical statements do not contain factual truths
about goodness or badness.
• In more detail: subjectivists say that moral statements
about the feelings, attitudes and emotions of that
particular person or group has about a particular
issue.
• If a person says something is good or bad they are
telling us about the positive or negative feelings that
they have about that something.
• So if someone says 'murder is wrong' they are telling
us that they disapprove of murder.
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24. Emotivism
• Is the view that moral claims are no more than
expressions of approval or disapproval.
• It sounds like subjectivism, but in emotivism a moral
statement doesn't provide information about the
speaker's feelings about the topic but expresses those
feelings.
• When an emotivism says "murder is wrong" it's like
saying "down with murder" or "murder, yecch!" or
just saying "murder" while pulling a horrified face.
• Expressing some ones feelings
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25. Prescriptivism
• It thinks that ethical statements are instructions or
recommendations.
• So if I say something is good, I'm recommending you
to do it, and if I say something is bad, I'm telling you
not to do it.
• For example: "lying is wrong" can be rewritten as
 "people ought not to tell lies".
 "Don't murder people"
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26. Clinical ethics and medico legal problems
Informed Consent
• Legal and moral imperatives for informed consent are
based on the ethical principle of respect for patient
autonomy. “Autonomy”.
• Individuals have the right to determine what happens
to them to the degree that they are capable of doing
so.
• Physicians have a duty to inform p/ts about the risks
and alternatives to treatment, in addition to the
procedures themselves and their consequences.
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27. Competence or Capacity
• Autonomy to make medical decisions cannot exist
in the absence of competence.
• Impairment of capacity can be temporary or
permanent. Examples include
• Some mental illnesses,
• Dementia,
• Immaturity,
• Anxiety,
• Pain, and
• Effects of medications.
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28. How do we recognize competence?
• When assessing a patient for anesthesia care, we
should focus on the following concerns:
1) Can the patient formulate and communicate a
decision?
2) Can the patient receive and understand the
information relevant to the decision?
3) Can the patient understand potential
consequences of the decision, including potential
risks and benefits, even if in a very simplified way?
4) Can the patient express a decision and
communicate values regarding the medical advice
being given? 28
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29. Disclosure
• The informed consent process requires honest
disclosure of medical information to the patient.
Legal implications of Informed Consent
• The informed consent process does not prevent legal
liability when adverse events occur.
• The informed consent process provides one of the few
opportunities that we have to establish that
relationship, however brief, and should not be
underestimated in its medico legal importance.
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30. Informed Refusal
• Informed consent is meaningless if the p/t cannot also
refuse medical therapy because the consent process is
then merely an exercise in p/t acquiescence to the
physician's will.
• Examples of informed refusal in aneasthesia include
• Requests to withdraw or withhold life-supporting care
in the ICU;
• Do-not-attempt-resuscitation (DNAR) orders in the
operating room;
• Cases in which the p/t has objections to certain forms
of therapy, such as a Jehovah's Witness who refuses
blood transfusions;
• Cases in which a p/t refuses preoperative testing,
such as (HIV) or pregnancy testing.
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31. Cont…
• Informed refusal has similar concerns and
requirements as informed consent.
• Despite full information, p/ts may sometimes request
or demand care that is unreasonable, either because
it will adversely affect the performance of surgery or
because it would be associated with unreasonably
high risk.
• When a p/t demands a technique that is
inappropriate or outside the realm of reasonable
practice, the anesthetist is under no ethical obligation
to provide that care.
• No physician can be compelled by a p/t to practice
negligently.
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32. Special Issues in Informed Consent and Informed
Refusal
• Jehovah's Witness Patients
• The Pediatric Patient and Other Patients with
Impaired Competence
• Consent for Laboratory Tests: HIV and Pregnancy
Testing
• Maternal-Fetal Conflicts
• The Uncooperative Patient—Coercion and
Restraint
• Do-Not-Attempt-Resuscitation Orders in the
Operating Room
• Withdrawal/Withholding of Medical Therapy—
Curing versus Caring.
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33. Jehovah's Witness Patients
• The classic example of a p/t who refuses therapy in
anesthesia practice is that of Jehovah's Witnesses,
many of whom believe that accepting a blood
transfusion violates a Biblical injunction
• It is the right of any p/t to refuse blood transfusion
therapy, regardless of whether this desire is founded
in a religious preference.
• Such refusals have become more common in non–
Jehovah's Witness p/ts because blood transfusion
therapy was connected to cases of acquired (AIDS) in
the 1980s and p/ts began questioning the value and
necessity of transfusion therapy in light of its risks.
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34. Cont…
• Because beliefs differ regarding which, if any, blood
replacement therapies are acceptable, it is important
to have a thorough and detailed discussion of possible
therapies with a Jehovah's Witness p/t before surgery,
and the conclusions should be documented in the
patient's chart.
• If Anaesthetist/ Anaesthesiologists believe that they
cannot comply with an adult patient's desire to forgo
transfusion, they have the ethical obligation to find an
alternative caregiver whenever possible.
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35. Cont…
• The courts strongly support the rights of adult p/ts to
refuse blood products for themselves but have been
inconsistent and have interfered in the cases of some
pregnant p/ts.
• Transfusion of pediatric Jehovah's Witness p/ts by
court order is common at this time but may become
ethically and legally less acceptable as therapy other
than blood transfusion to maintain oxygen-carrying
capacity.
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36. The Pediatric Patient and Other Patients with
Impaired Competence
– The ethical practice of medicine weighs heavily
toward adherence to respect for autonomy in
patients who are competent to make medical
decisions.
– Children are an example of persons who may or may
not yet be autonomous.
– Laws in each state define the age at which children
become legally competent to make medical decisions
(usually age 18), but many younger children have the
mental and emotional capacity to make medical
decisions.
– Forcing such individuals to undergo treatments that
they do not want is unethical and could be illegal as
well.
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37. Do-Not-Attempt-Resuscitation Orders in the
Operating Room
• The DNAR order is, in essence, documentation of the
patient's wishes to avoid the medical interventions
associated with resuscitation.
• Because the causes and outcomes expected with
cardiac arrest in the OR are different from what may
happen elsewhere and the prognosis is much more
favorable, it is very important to reassess the patient's
desires when surgery is anticipated.
• The ASA has issued guidelines for the management of
a patient with DNAR orders and other directives
limiting medical care.
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38. Cont…
• The anesthesiologist should include in the discussion
the following steps:
1) Determine what the patient's goals are regarding
surgery and resuscitation;
2) Establish exactly what is meant by “resuscitation,”
in contrast to routine anesthetic care;
3) Educate the patient about the risks and benefits of
resuscitation in the operating room setting; and
4) Document the agreements reached with the p/t
about which interventions commonly associated
with resuscitation are acceptable to the p/t
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39. Cont…
• Finally, DNAR orders must never be construed as an
excuse to not “care” for the patient.
• A patient's decision to forgo resuscitation does not
imply a wish to avoid other beneficial interventions.
• Placement of a pulmonary artery catheter, for
example, may help ensure optimal management of a
frail patient
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40. Withdrawal/Withholding of Medical Therapy—
Curing versus Caring
• More than 80% of deaths in the US occur in health
care facilities, and the majority of deaths in ICUs take
place after an explicit decision to withdraw or
withhold treatment.
• Two common scenarios in which anesthesiologists
may be involved in withdrawal or withholding of life-
sustaining interventions are in the ICU /OR before
organ donation after cardiac death.
• In both cases, the issues and principles of
withdrawing/withholding treatment are the same.
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41. Withdrawal of life-sustaining interventions
heralds the final phase of end-of-life care
• Terminal care requires special physician knowledge
and experience such as
• To be expert
• In medically supportive therapy,
• In Problematic symptom management,
• Knowledgeable about physiologic changes in
dying patients,
• Ability to work within complex health care
teams, ability to communicate well, and
empathy.
• Anyone intimately involved in care of a dying
patient should also be intimately familiar with
the ethical and legal standards.
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42. Problems relating to professional conduct
Malpractice and negligence
Un ethical advertising
Autonomy of the patient VS paternalism
Informed conscent
Confidentiality
Research
Irrational use of drugs
Fidelity
justness
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43. Mal practice and Negligence
Medical Malpractice
• The most common cause of medical malpractice is
medical negligence.
• Negligence is breach of a duty that is the proximate
cause of a harm.
• Medical negligence occurs when a physician's failure
(breach) to meet the standard of care (duty) which
Directly leads (proximate cause) to patient injury
(harm).
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44. Fidelity
• This principle, as well as other principles, should be
honored by both provider and client.
• Strict observance of promises or duties.
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45. Justice
The principle that deals with fairness, equity and
equality and provides for an individual to claim that
to which they are entitled.
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46. Cont…
1. Comparative Justice: Making a decision based
on criteria and outcomes.
• How to determine who qualifies for one
available kidney.
• Example; 55 year old male with three children
versus a 13 old girl
2. Non comparative Justice: Making a decision
based on a method of a lottery system.
• Example Distributing needed kidneys using
lottery system
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47. • What is ethical principle of in formed consent?
• When the patient considered to be
incompetents for consent?
• what are special condition of informed
consent?
• Mention Problems relating to professional
conduct.
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48. Malpractice and Negligence
Malpractice
1. Professional misconduct
2. Failure in carrying out professional duties with care
competency and integrity in the best interests of
the patient
3. Insufficient knowledge and skills /defective
application
4. Wrong attitude
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49. Can anesthetist refuse to provide anesthesia?
• Yes the anesthetist has the right to refuse to provide
anesthesia but there are obligations to serve during
emergency.
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50. Negligence
• Performing below standard of reasonably competent at
provided level
• Failure to take all reasonable precautions
• Negligence in diagnosis administration of drugs or
procedures including anesthetic management or in
providing anesthetic care
• Medical negligence may be adjudged as criminal
medical negligence if it deviates greatly from the
standard of care, whether
• Unknowingly (criminal negligence) or
• Knowingly (criminal recklessness).
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51. Can we conclude that anesthetist is
incompetent?
• Conditionally yes!
– How to determine incompetency?
• Periodic registration
• Continuous medical education
• Periodic examination/COC
• Difficult to measure difficult characteristics
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52. Cont…
Anesthetist can be incompetent due to the
following
AGE
MENTAL ILLNESS
ADDICTION
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53. Basic law of malpractice
Legal system of civil laws are divided into
Contractual law
Tort law
A tort may be loosely defined as a civil
wrongdoing negligence is one type of tort.
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54. Malpractice suit
• To be successful in malpractice suit four
elements must be proved
 Duty –the anesthetist owed him or her a duty
 Breach of duty-anesthetist failed to fulfill his or her
duty
 Causation-close causal relation ship exists between
the acts of the anesthetist and the resultant injury
 Damages –the actual damages resulted because of
the acts of the anesthetist
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55. Anatomy of medical malpractice suit
 Service of process
 Court pleadings (filled by attorney with in 21 days)
 Discovery
 Trail
 appeal
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56. Causes of suit
• The major cause of suit against anesthetist is
patient injury
• Major types of patient injuries
Death
Nerve injury
Brain damage
Cardiac arrest
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57. Causes of major injuries
• Inadequate ventilation
• Esophageal intubation
• Positioning Regional anesthesia
• CVP placement
• Equipment malfunction
• Inadequate pre operative preparation (screening of
the patient)
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58. Why the anesthetist is liable for law suit?
The anesthetist is liable for suit due to
• Use of complex instruments (which can fail)
• Use of potent drugs(mistakes in doses and
labeling)or can lead to disastrous results
• Difficult to maintain vigilance
• Lack of supervision(doctrine of respondent superior)
• Targeted by plaintiffs attorneys
• Haphazard placement of equipments ( diversion of
attention )
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59. The Process of Being Sued
The first phase of discovery is initiation of the suit
• Some lawsuits may begin “informally” by a request
from a potential plaintiff's attorney to review records or
to discuss a case.
• An attorney should be consulted before engaging in
these actions to ensure that proper procedure is
followed.
• Lawsuits officially begin with a document called a
Summons (an order to appear in a law court) and
Complaint, which is a notification to respond to
allegations by the plaintiff.
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60. Cont…
• After initiation of the suit, the 2nd phase of
discovery begins with exchange of documents and
a deposition.
• The purpose of the deposition /a statement to be
used as evidence /is for the other side of a legal
action to obtain information or clarification
otherwise unavailable, particularly about the
reasoning underlying actions.
• At the deposition, oral testimony is taken under
oath and transcribed and may be used as evidence
at trial
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61. What to Do When Sued?
Specific actions
Don't discuss the case with any one
Never alter any records
Gather together all pertinent records
Make notes recalling all events
Cooperate fully with the attorney provided by the
insurer or other bodies.
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62. The do’s
Review record
Analyze the case
Look for other relevant documents
Review literature
Identify experts in the field /Consultants
and clinicians.
Make a list of fact witness Witnesses to the
event, or defendants documentation.
Educate your attorney
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63. The don’ts
Don’t discuss the case with any one
Don’t change the records
Don’t accept any calls from other attorneys or
patient or family members
Don’t talk to media
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64. Cont…?
• Some conversations are privileged and may not be
discovered by the plaintiff, including discussions with
attorneys, risk management personnel, insurance
company representatives, personal clinicians
Conversations with close friends are discoverable.
• The physician/ defendant should inform the attorney
about his or her relationship with the plaintiffs and
any problems that may have occurred.
• A fully informed attorney is the best advocate.
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65. Cont…
• In addition to the defendant, the defendant's
attorney, the plaintiff's attorney, and the court
reporter, the plaintiff may also be present at the
deposition.
• After the court reporter administers the oath, the
plaintiff's attorney will ask standard questions,
including education, licensing, and certification.
• The defendant's attorney will intercede as
appropriate.
• The same questions may be asked several times over.
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66. Cont…
• A goal of a plaintiff's attorney is to develop a causal
atmosphere to lower the guard of the defendant
before asking more relevant questions.
• A defendant is best served by not speculating about
factual matters that may be found in the medical
record and answering only the questions asked and
asking for clarification if unclear about the meaning of
a question.
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67. Malpractice Defense
• Physicians having their medical competence publicly
questioned may feel
• Guilt, failure,
• Anger, shame,
• Isolation, depression,
• Fatigue, denial, and physical symptoms.
• It is important to be forthright about these feelings
and to manage them, if for no other reason than to
be able to participate fully and positively in the legal
defense.
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68. Risk management
• Primary goal is prevention of patient injury
• Patient injury is inevitable in anesthesia practice if so
establish practice of defense medicine
Key factors in preventing patient injury
Vigilance
Up to date knowledge
Adequate monitoring(physiologic monitoring
and monitoring of equipment function)
Presence of qualified anesthesia personnel in
the operating room
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69. Cont’d
Use of check list prior to each case
Pre and post op rounds
Developing good patient relationship
Maintaining up to date practice habit
Good records(good defense if adequate if not
disastrous
Informed cons cent
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70. Informed cons cent
• Include risks of anesthesia
• Discussions about alternatives
• Acceptance of patient about proposed procedure
• If change of plan attach written notes
• Anesthesia record should be net and accurate
• It should be adequate before jury if not it could be
damaging
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71. Components of anesthesia record
• Vital signs
• ASA classifications
• Monitors utilized
• Fluids administered
• Dose and time of administered drugs
• Respiratory variables that are monitored
• Anesthetic personnel name
• If catastrophic incident write a separate note
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72. If anesthetic complications occurs
• Be honest with both family and patient about the
cause
• Appropriate consultation should be obtained quickly
• Notify institutional risk management group
• If permanent injury is likely notify liability insurance
carrier
• Follow patient with telephone after discharge
• Be consistent in explaining cause of damage
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73. Conclusion
• Be in continuous attendance during conduct of all
anesthesia never leave the operating room for no
urgent reason
• Review departmental standard of care criteria
anesthesia related mortality and morbidity
• Establish regular schedule of equipment
maintenance
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74. Clinical cases
case I
• Patient with uncontrolled diabetes mellitus gangrene
of foot for above knee amputation pt does not want
to live a compromised type of life so refused the
operation impending coma families want to take him
home
1- should we amputate the limb and save life
2-will not doing the operation abate to negligence or
permitting suicide?
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75. Case II
• Anesthesia for a patient under going
abortion(termination of pregnancy )
Ethical principle – it is wrong to kill
1-when does abortion become legal?
2-When does developing embryo become a person?
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76. Case III
• Transfusion of whole blood for Jehovah witness
pregnant mother with ruptured uterus HB 18%
1-what is your decision about transfusion of whole
blood?
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77. Case IV
• Blood of wrong group transfused to the patient she
developed renal failure and died
1- who is responsible for this ?
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78. Case V
• Patient suffered from intra operative cerebral
ischemia vegetative state under ventilator therapy
for 25 years families insisted for DNR
1- what is your opinion?
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79. Ethics and research
Human Subjects Research
• Ethical conduct of human subjects research follows
three principles:
1) respect for autonomy and the obligation to protect
subjects with limited autonomy;
2) beneficence, with obligations to minimize risks,
maximize benefits, and ensure that the research
design is scientifically sound; and
3) justice, the obligation to treat each person with
regard to what is morally right and to ensure fair
distribution of benefits and burdens.
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80. Cont…
• Subjects must be free to refuse or end participation at
any time without penalty.
• Situational coercion” in which subjects believe that
they are not truly free to refuse should be avoided or
mitigated.
• Examples of situational coercion include prisoners and
hospitalized patients.
• Researchers are obligated to maximize benefit and
minimize potential harm, including
–Physical,
–Psychological,
–Social,
–Legal, and financial harm.
80
Mengistu

81. Mengistu QUESTION??
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