ETHICS IN HEALTH CARE Submitted by: Group 5 Franklin Aloysius (11078) Annie Jenifer (11067) Priyanka Shukla (11098 ) Swarupa Rani Sahu (11116 ) Tejas Savani (11118) [Pick the date]
INTRODUCTION Patients, families and healthcare professionals sometimes face difficult decisions aboutmedical treatments. These decisions may conflict with a patient and/or familys morals, religiousbeliefs or healthcare guidelines. Healthcare ethics is a thoughtful review of how to act in the bestinterest of patients and their family. It is also about making good choices based on beliefs and valuesregarding life, health, suffering and death. The ethical and/or moral premises of healthcare are complex and intricate. To consolidatesuch a large segment of moral philosophy, it becomes important to focus on what separateshealthcare ethics from other forms of morality. And on the whole, it can be said that healthcare itselfis a "special" institution within society. With that said, healthcare ought to "be treated differentlyfrom other social goods" in a society. It is an institution of which we are all a part whether we like itor not. At some point in every persons life, a decision has to be made regarding ones healthcare. Canhe/she afford it? Does he/she deserve it? Does he/she need it? Where should he/she go to get it? Doeshe/she even want it? And it is this last question which poses the biggest dilemma facing a person.After weighing all of the costs and benefits of her healthcare situation, the person has to decide if thecosts of healthcare outweigh the benefits. More than basic economic issues are at stake in thisconundrum. In fact, a person must decide whether or not his/her life is ending or if it is worthsalvaging. Of course, in instances where the patient is unable to decide due to medical complications,like Acoma, then the decision must come from elsewhere. And defining that "elsewhere" has provento be a very difficult endeavour in healthcare philosophy. Whereas bioethics tends to deal with more broadly-based issues like the consecrated nature ofthe human body and the roles of science and technology in healthcare, medical ethics is specificallyfocused on applying ethical principles to the field of medicine. It is a large and relatively new area ofstudy in ethics. And one of the major premises of medical ethics surrounds "the development ofvaluation measures of outcomes of health care treatments and programs. Termslike beneficence and non-maleficence are vital to the overall understanding of medical ethics.Therefore, it becomes important to acquire a basic grasp of the varying dynamics that go into adoctor-patient relationship.Six of the values that commonly apply to medical ethics discussions are: Autonomy - the patient has the right to refuse or choose their treatment. Beneficence - a practitioner should act in the best interest of the patient. Non-maleficence - "first, do no harm". Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment. Dignity - the patient (and the person treating the patient) have the right to be treated with dignity. Truthfulness and honesty
CASE1: Myers Squibb Co. bribed doctors to prescribe its drugs. It is one of the largest health carefraud case ever handled by US. The suit claims company salespeople plied physicians with speakingfees, expensive meals, gifts and trips to induce or reward them for prescribing large amounts of itsdrugs, which were billed to private insurers. Doctors were offered golf outings, basketball camps,samba lessons and luxury suites. Low-prescribing doctors were threatened with loss of perks. Merck, a US based pharmaceutical company, agreed to pay $950 million and has pleadedguilty to a criminal charge over the marketing and sales of the painkiller “Vioxx”. Thepharmaceutical giant copped to a misdemeanour, urging MDs to prescribe Vioxx for RheumatoidArthritis. The FDA had initially approved Vioxx in May, 1999 to treat osteoarthritis, acute pain, andmenstrual cramps. By September 30, 2004, when Merck announced its “voluntary recall,” some 25million Americans had been prescribed the widely hyped drug. Evidence suggest that using Vioxxdoubled the patient‟s risk of suffering a heart attack or stroke ,based on a review of 1.4 millionpatients‟ records. 55,000 people died, and many more were permanently disabled. The Merckexecutives‟ real crime was conspiracy to commit murder. The murders perpetrated by Merckexecutives were intentional. An early clinical trial had alerted them to the fact that Vioxx causedcoronary damage. Once Vioxx was approved, Merck spent more than $100 million a yearadvertising it. Merck execs continued to ignore and suppress indications that their new blockbusterwas causing strokes and heart attacks. Sales hit $2.5 billion in 2003. If these MDs had declared theirconflicts of interest, Vioxx would have been pulled from the market before , Merck made an extrabillion or two, and killed 6,000 more Americans. The corporate boo-boo in this instance involved pay-offs to doctors who purchase drugs forstate-owned institutions overseas. Johnson & Johnson recently settled a similar bribery case. Merck,AstraZeneca, Bristol-Myers Squibb, and GlaxoSmithKline are all in settlement negotiations with thegovernment. On the home front, Pfizer has paid $2.3 billion for violating the federal False Claims Act andbribing institutional purchasers in connection with Bextra, Lipitor, Viagra, Zithromax, Norvasc,Lyrica, Relpax, Celebrex, and Depo-provera. The systemic corruption is getting worse. In the 15 years between 1991 and 2005, accordingto Public Citizen, drug companies paid the government $5 billion in penalties and settlements inconnection with kickbacks and false claims.
CASE 2 Since many people can benefit greatly in terms of length and quality of life from organ andtissue transplants, the demand usually exceeds the supply. The costs related to some organ transplantsare very high as well. Therefore, many questions are raised today regarding how best to procure moreorgans, how to fairly distribute limited resources, and whether all transplants should be covered bypublic funds. The multi-billion rupee Gurgaon kidney scandal came to light in January 2008 when policearrested several people for running a kidney transplant racket in Gurgaon, Harayna. Kidneys frommost of the victims, who were the poor hailing from the nearby western Uttar Pradesh,weretransplanted into clients from United States, United Kingdom, Canada, Saudi Arabia and Greece. Thepolice raid was prompted by complaints by the locals from Moradabad about illegal kidney sales. Theman accused of the scandal, Amit Kumar, was arrested in Nepal on 7 February 2008. Dr.Amit Kumarand his accomplices had performed 600 kidney transplants in the past decade 6 yearsMedical Errors It is not expected that medicine can cure everyone; it might be expected that it makes no oneworse than he or she was before. Patient safety has always been an important principle in the practiceof medicine. The Institute of Medicine reports, To Err is Human and Crossing the QualityChasm, have increased awareness of patient safety issues both within the health care professions andin the mind of the public. Even more well-known is the principle "first, do no harm," which is anessential feature of the foundation of the practice of medicine since Hippocratic times. In fact theHippocratic writings consider avoiding harm to be a moral imperative of physician behaviour. No maleficence, the contemporary articulation of the obligation to avoid causing harm, is notrestricted to deliberate harm. Harm committed with the intent of healing is no less prohibited by thisprinciple than malicious harm, and every physician must assume the duty of preventing all harm.Harm from errors, system flaws, accidents, complications, and known risks are all consequences thatmust be avoided wherever possible. This is an aspirational goal, meaning medicine should strive toeliminate all potential harm from health care, but reality dictates that we will never fully succeed. Thefact that there will always be ways to improve patient safety is the main reason that it always hasbeen and always should be such a prominent feature of medical practice and medical ethics. Injury due to error is especially destructive to the patient-physician relationship because itlowers expectations of high quality care and dedication from physicians and other health careprofessionals. Errors seem to imply lack of concern and dereliction of duty, when in fact; many errorsare the result of poor systems and inadequate infrastructure. Several articles in this issue addressthese concerns.
If we take a broad look at a variety of approaches to reducing medical errors and improvingpatient safety.In doing so we hope to create the foundation for physician activism in this arena as wellas to promote attitudes of personal responsibility for preventing errors and minimizing the impact oferrors that occur. There are a number of ways physicians can be active in protecting patients andreducing error. Preventing harm is one of the most basic duties of a physician. Therefore physiciansat all levels of training should devise multiple mechanisms to prevent error and improve outcomes. By not disclosing a medical error, the doctor conspicuously places his own interests abovethat of the patient to the detriment of the patient, thereby violating a patient-centred ethic. Moralcourage is therefore needed if doctors are to do the right thing when medical errors occur. This moralcourage can be facilitated by institutions having policies and guidelines on disclosure of errors inplace, training doctors and other hospital staff on how to disclose medical errors and providingemotional support for doctors who make mistakes in their efforts to treat patients and save lives.Medical waste dischargeIndiscriminate disposal of infected and hazardous waste from hospitals, nursing homes andpathological laboratories has led to significant degradation of the environment, leading to spread ofdiseases and putting the people to great risk from certain highly contagious and transmission pronedisease vectors. This has given rise to considerable environmental concern. The first standard on thesubject to be brought out in India was by the Bureau of Indian Standards (BIS), IS 12625 : 1989,entitled „Solid Wastes- Hospitals-Guidelines for Management‟ but it was unable to bring anyimprovement in the situation. In this scenario, the notification of the „Biomedicalwaste (Management& Handling) Rules, 1998‟ assumes great significance. According to these rules, it shall be the duty ofevery occupier of an institution generating bio-medical waste, which includes hospitals, nursinghomes, clinics, dispensaries, veterinary institution, animal houses, pathology laboratories, bloodbanks etc., to take all steps to ensure that such wastes are handled without any adverse effect tohuman health and the environment.Euthanasia In some countrieseuthanasia is accepted as standard medical practice. Legal regulationsassign this to the medical profession. In such nations, the aim is to alleviate the suffering of patientsfrom diseases known to be incurable by the methods known in that culture. In that sense, the "Primumno Nocere" is based on the belief that the inability of the medical expert to offer help, creates a knowngreat and ongoing suffering in the patient.
Ultrasound testing Foetal ultrasound screening has become routine practice in many western countries. Duringthe last decade, such screening has led to frequent situations characterised by clinical uncertainty dueto the disclosure of soft markers in the unborn child. Soft markers are minor anatomical variationsindicating a somewhat increased likelihood that the foetus has a chromosomal aberration, mostfrequently trisomy 21 (Down syndrome). This paper presents the results of a comprehensive literaturesearch of the National Library of Medicine with emphasis on the chronological development ofscientific knowledge in relation to soft markers and the link between advancing imaging technologyand clinical counselling dilemmas. An analysis of the literature makes evident that many ultrasoundexaminers have counselled individual pregnant women on the basis of insufficient data. Moraldilemmas have thus emerged as a direct result of advancing medical technology, and healthy foetallives prove to have been lost due to invasive diagnostic testing aimed at resolving clinicaluncertainty. Ultrasound examiners have warned against a policy of disclosing all findings of softmarkers to expectant parents, but no exploration of experiential aspects linked to the disclosure offoetal soft markers has yet been published in the medical literature. The emotional reactions ofmothers are important to consider given their potential impact on the biological development of thefoetus.Right to health In cases were patient needs emergency treatment, the role of medical institutions becomesimportant, as the first few moments after the accident, i.e., the Golden Hour, are very precious andcrucial . Many lives can be saved and disabilities can be prevented by providing timely proper care,that is, by providing immediate treatment to the victims of accidents. But unfortunately, in India,emergency care is the most neglected area of health care today. According to a leading daily, over30% of the emergency patients in the country die before they reach the hospital. Over 80% of theaccident and emergency victims never get quality medical care during the Golden Hour. One major reason for which hospital/ clinics /doctors refuse to treat accident cases is thepotential medico-legal complications associated with such patients. In other cases, the victim isrefused either due to want of bed or other necessary medical equipment/systems. PrithvirajBiswas, a student of the National Institute of Design, died in a tragic hit-and runaccident hospital, but the staff there refused to treat him. His classmates strongly believe that Biswascould have been saved, if the doctors at V.S. Hospital had attended to his injuries, instead of refusingto treat him and referring him to the civil Hospital at the other end of the City, where he was declared“dead on arrival.
Although a doctor is free to choose whom he will serve, his liberty does not extend toaccident, injury and emergency cases. As per law, hospitals, nursing homes and clinics of doctors, thatdeclare, or profess, in writing that they provide emergency sevices/24 hour services are legally boundto attend all the cases. Failure to have the requisite equipment in working order and non-availability ofcompetent staff within reasonable time would be inferred as medical negligence. In many cases it has been observed that doctors wait for the arrival of the police beforeattending accident victims, especially with head and burn injuries. In such cases, the Supreme Courtdirectives are very clear: There are no provisions in the IPC or CPC, which prevents doctors from promptly attendingto seriously, injured persons and accident cases before the arrival of the police.The treatment of the patient should not wait for the arrival of the police or completing legalformalities. All government hospital and medical institutions should be asked to provide immediatemedical aid to all the cases, whether medico-legal or not. The Supreme Court further observed that Article 21 of the Constitution imposes an obligationon the State of safeguard the “Right to Life” of every person. Preservation of human life is, thus, ofparamount importance. The government hospitals run by a state and the medical officers employedtherein are duty-bound to extend medical assistance for preserving human life. Failure on the part of agovernment hospital to provide timely medical treatment to a person in need of such treatment resultsin violation of his ”Right to Life”, guaranteed under Article 21.Can doctors resort to strikes? Resident physicians in several hospitals in Jodhpur, Rajasthan started an indefinite “doctors‟strike” to protest alleged lathi-charge by the police. The regular services in government hospitals wereparalyzed bringing endless miseries for the innocent patients, mostly from the impoverished section ofthe society who cannot afford the expensive treatment in private hospitals. And after almost threedays of extreme medical muddle created by the agitating healers, the striking medicos withdrew thestrike after the government bowed down to their demands of disciplining the police but not beforedozens of the defenceless patients including many children succumbed to their illnesses as a result ofabsence of treatment in the hospitals.“Doctors‟ strike” has become a routine affair in India these days. Indian medicos frequently choose tocease work or “strike” in order to settle their scores against the government or hospital authorities. Butdo our healers have any moral, ethical or legal rights to join a “strike” that denies essential medicalservices from the ailing people? Who should be held responsible if innocent patients die withouttreatment because of a “doctors‟ strike”? In fact, the “Code of Ethics” of the Medical Council ofIndia (MCI), reads, “The prime object of the medical profession is to render service to humanity;
reward or financial gain is a subordinate consideration”. But yet it is a common knowledge thatfinancial profit is the principal motivating force for a large fraction of the medical community in Indiatoday. Mushrooming private hospitals and nursing homes on almost every street corner bearirrefutable testimony that practice of medicine has turned into a highly lucrative business in modernIndia.But the ultimate price of any “doctors‟ strike” is always paid by the defenceless patients- often withtheir lives as so many patients have already died as a result of the only 3-day “doctors‟ strike” inJodhpur. Obviously, doctors do not have a moral right to go on a “strike” at the expense of thevulnerable patients.Organizations The World Medical Association (WMA) is an international organization representingphysicians. It was founded on 17 September 1947, when physicians from 27 different countries metat the First General Assembly of the WMA in Paris. The organization was created to ensure theindependence of physicians and to work for the highest possible standards of ethical behaviour andcare by physicians, at all times. The Declarations, Resolutions and Statements cover a wide range ofsubjects, including an International Code of Medical Ethics, the rights of patients, research on humansubjects, care of the sick and wounded in times of armed conflict, torture of prisoners, the use andabuse of drugs, family planning and pollution. The Council for International Organizations of Medical Sciences (CIOMS) is aninternational, nongovernmental, not-for-profit organization established jointlyby WHO and UNESCO in 1949. CIOMS serves the scientific interests of the internationalbiomedical community in general and has been active in promulgating guidelines for the ethicalconduct of research, among other activities.
CONCLUSIONMost people have gotten a doctors prescription at some point in their lives for a medicine they haveneeded. Some people need prescription medication on a regular basis due to their medical problems.The question is, to what degree can you trust that your doctor writes a prescription based only on yourbest interests as a patient?That seems like a strange question - after all, what else would a doctor have in mind? Shouldnt thedoctors choice of medication depend solely upon what your needs are as a patient? That does soundlike the way things should be, but recent revelations suggest that something very different is going on:pharmaceuticals companies may be exercising undue and unethical influence on doctors and whatdoctors prescribe.Speak Up For Your Safety1. Speak up if you have questions about the treatment. You have a right to know!2. Pay attention to the treatment you receive3. Educate yourself about your diagnosis, and all medical tests you are undergoing4. Ask a trusted family member or friend to be your advocate5. Understand all informed consent documents or other medical forms you are asked to sign.6. Refuse a medical treatment you‟re not comfortable with other measures7. Educating health care professionals so that they understand patient‟s perspective8. Governmental Reform-enforcement of stringent rule There is a critical need for healthcare professionals who understand the importance of ethicsin health care. People worship doctors as being next to god. Medical professionals should save life.They should keep their vested interest aside. Ethical values cannot be compromised. An awareness ofthe importance of ethical values can help clinicians, educators, researchers, and leaders in healthcareto face ethical challenges and uphold ethical environments. It is important that all healthcareprofessionals value and support their peers who have the courage to stand up and speak out againstunethical behaviour even when others are silent or differ in opinion. Government should enforce stringent rules to curb unethical practices in health care. Publiccan be educated to create an awareness. People should raise their voice and stop the unethicalbehaviour of a doctors and healthcare units. It is essential that the healthcare industry developsleaders with strong ethical values, leaders who are willing to live these values with integrity andcourage, even when doing so risks their professional relationships and their position in theirorganizations.
BIBLIOGRAPHY 1. Wikipedia 2. New York times 3. Proquest Data 4. Times of India 5. CNBC news channel