5. Doctor-patient relationship: legal values. Patient rights.

GeorgeCristianCurcaMD,Ph.D.Prof.demedicina legala sieticamedicala

Discipl.Medicina legala siBioetica,FacultateaMedicinaUMFCD

LEGALELEMENTSOFDOCTOR-PATIENTRELATIONSHIP

• EthicaltheoryofrightshasbeensettledbyJ.Locke(1632-1704).Heconsidered thatahumanmayactmorallyonlyifhepreservesothersrights.There,wheretherightsarerespected,good isaccomplished; therewheretherightsarebroken,good (moral) islost.Preserving rightsistoactethically.

• Humanshavefundamental rights.Fundamental rightssetoutminimum standardstoensure thataperson istreatedwithdignity.

• Afundamental rightsis:– natural(preexistourbirth)– equal(foreveryhuman)– inalienable(nochange initsvalueorcontentinourlifespan)– universal(everywherearound theglobe)

• Ethicaltheoryofrights isincludedatheoryofgoodwithin thenormativeethic:lawsarethenormativeregulations topreservetherightactiontodo.

• Ifeveryonerespectsotherhumanrightsthanherespectshisownrights.Preserving rights isaduty(amoraldutytoaccomplishgood).

• Ourrightsmaynotoverpassotherhumanrights, thereforeourrightsextendonly tillthemeetingofotherhumanrights.

• Negativerights (requirenoactiontofulfil) /positive rights(requireactionstofulfil: rightscorrelativityistheduty toactinorder topreserveotherhumanrights.

• Correlativityofrightsrequireactivemeasurestopreservefundamental rightsbecausetheyareinborn (natural)andthereforemaynotbepreservedwithoutoneactivemeasure.

• Apersonentitledtohavearight,anactiveright,doesnothaveanobligationtothanksocietyforallowingtohavethatrightbecauseallothershaveanobligationtopreservethatright(asamoralandlegalduty).

• Corollary:whenoneactiverightisbrokenallthoseaskedtoprotectthatright,areguiltyoflackofactiveaction(onepresumesthatwithoutanactiveactionthedutywouldbeincompleteorinconsistentortheresults/consequencesunfilfilled)

• Ifthedutyofhealthcareisafundamentalrightthanbycorrelativityitcreatesalegalandmoralbondforeveryonetokeepthatpersonaliveandhealthy

Respect of the dignity of the patient (respect of the humanity / human being)

• Respectofthehumanbeing isbasedon:– Respectofthehumanity (moralbond)– Respectofhumanlegalrights(legalbond)

o Fundamental rights(life, liberty,information)o Constitutional rights(intimatelife,healthcare,etc.)

• Respectofthepatientisbasedatleaston:o Respectofthehumanity(moralbonds):

o Thepatientisahumanbeing(moralandlegalbond);o Thepatientisapersoninpain:heisinsufferance(moraldutytorepairhissufferance,moraldutyfor

actionsuchasbeneficence)o Thepatientisapersonwithalteredhealthstatusinneedforhealthcareandhere liesthescopeof

themedicalprofession(,demandforbeneficence asavirtueandbeneficence asadutyextendedwithnon-maleficence-providingcompetenthealthcareaccordingtosomeprofessionalrules-)

o Respectofthehumanlegalrights(legalbonds):o Thepatienthasfullrightsevenhedoesnotclaims theserights.He isentitledasallcitizen tofull

extendofhisrightsbutaboveallheisentitled togetprofessionalhelp(healthcarerightapositiverightaskingforactions-correlativity)becausehishealthand/orhislifemaybeindanger(solidarityasafundamentalmoralprincipleofsocietal cohesion).

o Thepatientisavulnerablepersonbecausehissufferanceandhisdisease(vulnerabilities: age–veryyoung/old-,sex,sexorientedgroup,generaldisease,mentaldisorder,pregnancy,ethnicgroup,loweconomical status,etc.)

Professionalandmoralguidelines

• WorldMedicalAssociation.Sinceitwasfoundedin1947,acentralobjectiveoftheWMAhasbeentoestablishandpromotethehighestpossiblestandardsofethicalbehaviourandcarebyphysicians:

• DeclarationofGeneva,• InternationalCodeofMedicalEthics• DeclarationofHelsinkionEthicalPrinciplesforMedicalResearch

InvolvingHumanSubjects,• DeclarationofTokyo.GuidelinesforPhysiciansConcerningTorture,• DeclarationofLisbontheRightsofthePatient,• DeclarationofOttawaonChildHealth,• DeclarationofMaltaonHungerStrikers• Declarationoneuthanasia• Etc.

WorldMedicalAssociation(WMA)- DeclarationontheRightsofthePatient

34thWorldMedicalAssembly, Lisbon,Portugal, Sept/Oct1981;amendedbythe47thWMAGeneralAssembly, Bali,Indonesia, September1995,revisedinOct.2005,Chile

PREAMBLETherelationshipbetweenphysicians,theirpatientsandbroadersocietyhasundergonesignificantchangesinrecenttimes.Whileaphysicianshouldalwaysactaccordingtohis/herconscience,andalwaysinthebestinterestsofthepatient,equaleffortmustbemadetoguaranteepatientautonomyandjustice.ThefollowingDeclarationrepresentssomeoftheprincipalrightsofthepatientthatthemedicalprofessionendorsesandpromotes.

Physiciansandotherpersonsorbodiesinvolvedintheprovisionofhealthcarehaveajointresponsibilitytorecognizeandupholdtheserights.Wheneverlegislation,governmentactionoranyotheradministrationorinstitutiondeniespatientstheserights,physiciansshouldpursueappropriatemeanstoassureortorestorethem.

1.Righttogoodqualitymedicalcare

a.Everyperson isentitledwithoutdiscrimination toappropriatemedicalcare.b.Everypatienthastherighttobecaredforbyaphysicianwhomhe/sheknowstobefreetomakeclinicalandethicaljudgements withoutanyoutsideinterference.c.Thepatientshallalwaysbetreatedinaccordancewithhis/herbestinterests.Thetreatmentappliedshallbeinaccordancewithgenerallyapprovedmedicalprinciples.d.Qualityassuranceshouldalwaysbeapartofhealthcare.Physicians,inparticular, shouldacceptresponsibility forbeingguardiansof thequalityofmedicalservices.e.Incircumstanceswhereachoicemustbemadebetweenpotentialpatientsforaparticulartreatmentthatisinlimitedsupply,allsuch patientsareentitled toafairselectionprocedure forthattreatment.Thatchoicemustbebasedonmedicalcriteriaandmadewithoutdiscrimination.f.Thepatienthastherighttocontinuityofhealthcare.Thephysicianhasanobligation tocooperateinthecoordination ofmedicallyindicatedcarewithotherhealthcareproviders treatingthepatient.Thephysicianmaynotdiscontinue treatmentofapatientaslongasfurther treatmentismedicallyindicated,withoutgiving thepatientreasonableassistanceandsufficientopportunity tomakealternativearrangementsforcare.

2.Righttofreedomofchoicea.Thepatienthastherighttochoosefreelyandchangehis/herphysicianandhospitalorhealthserviceinstitution,regardlessofwhethertheyarebasedintheprivateorpublicsector.b.Thepatienthastherighttoaskfortheopinionofanother physicianatanystage.

3.Righttoself-determinationa.Thepatienthastherighttoself-determination,tomake freedecisionsregardinghimself/herself.Thephysicianwillinformthepatientoftheconsequencesofhis/herdecisions.b.Amentallycompetentadultpatienthastherighttogive orwithholdconsenttoanydiagnosticprocedureortherapy.Thepatienthastherighttotheinformationnecessarytomakehis/herdecisions.Thepatientshouldunderstandclearlywhatisthepurposeofanytestortreatment,whattheresultswouldimply,andwhatwouldbetheimplicationsofwithholdingconsent.c.Thepatienthastherighttorefusetoparticipateinresearchortheteachingofmedicine.

7.Righttoinformationa.Thepatienthastherighttoreceiveinformationabouthimself/herselfrecordedinanyofhis/hermedicalrecords,andtobefullyinformedabouthis/herhealthstatusincludingthemedicalfactsabouthis/hercondition.However,confidentialinformationinthepatient'srecordsaboutathirdpartyshouldnotbegiventothepatientwithouttheconsentofthatthirdparty.b.Exceptionally,informationmaybewithheldfromthepatientwhenthereisgoodreasontobelievethatthisinformationwouldcreateaserioushazardtohis/herlifeorhealth.c.Informationshouldbegiveninawayappropriatetothe patient'scultureandinsuchawaythatthepatientcanunderstand.d.Thepatienthastherightnottobeinformedonhis/herexplicitrequest,unlessrequiredfortheprotectionofanotherperson'slife.e.Thepatienthastherighttochoosewho,ifanyone,should beinformedonhis/herbehalf.

8.Righttoconfidentialitya.Allidentifiableinformationaboutapatient'shealthstatus,medicalcondition,diagnosis,prognosisandtreatmentandallotherinformationofapersonalkindmustbekeptconfidential,evenafterdeath.Exceptionally,descendantsmayhavearightofaccesstoinformationthatwouldinformthemoftheirhealthrisks.b.Confidentialinformationcanonlybedisclosedifthepatientgivesexplicitconsentorifexpresslyprovidedforinthelaw.Informationcanbedisclosedtootherhealthcareprovidersonlyonastrictly"needtoknow"basisunlessthepatienthasgivenexplicitconsent.c.Allidentifiablepatientdatamustbeprotected.Theprotectionofthedatamustbeappropriatetothemannerofitsstorage.Humansubstancesfromwhichidentifiabledatacanbederivedmustbelikewiseprotected.

9.RighttoHealthEducationEverypersonhastherighttohealtheducationthatwill assisthim/herinmakinginformedchoicesaboutpersonalhealthandabouttheavailablehealthservices.Theeducationshouldincludeinformationabouthealthylifestylesandaboutmethodsofpreventionandearlydetectionofillnesses.Thepersonalresponsibilityofeverybodyforhis/herownhealthshouldbestressed.Physicianshaveanobligationtoparticipateactivelyineducationalefforts.10.Righttodignitya.Thepatient'sdignityandrighttoprivacyshallberespectedatalltimesinmedicalcareandteaching,asshallhis/hercultureand values.b.Thepatientisentitledtoreliefofhis/hersufferingaccordingtothecurrentstateofknowledge.c.Thepatientisentitledtohumaneterminalcareandto beprovidedwithallavailableassistanceinmakingdyingasdignifiedandcomfortableaspossible.11.RighttoreligiousassistanceThepatienthastherighttoreceiveortodeclinespiritualandmoralcomfortincludingthehelpofaministerofhis/herchosenreligion.

Therighttoinformation• Posible conflicts:

– informationvs.dataprotection(professionalsecret)– informationastruthvs.noninformationasprotection(therapeuticprivilege)

• Liberty as a fundamental right > The right to information as a liberty expression> Self determination as a liberty expression > protecting himself (his best interest) including own health as a property

• Information become an expression of liberty and vice-versa a condition of liberty if provided and according with the truth

Autonomy Beneficence Truth Lie

Acceptableethicaldillemma Unacceptableethicaldillemma

Right to truth. Veracity(moral duty to hold the truth)

• Possible conflicts : – To tell the truth vs. to hide the truth– Not telling the truth vs. lye– All truth vs. less truth (how less?)– truth by all means vs. therapeutic privilege

• The right for truth derives from the right to liberty. One may not be free without the knowledge that empower him to make free choices in his best interest (autonomy).

• What is truth? The facts that express reality• Transmitting information according to reality, truth telling, express respect, loyalty,

fidelity and sustain the trust of the patient, secure doctor-patient relationship (duty to communicate medical error).

Trust LoyaltyFidelity(virtue)RespectDuty(moralobligation)

Acceptableethicaldillemma

Dutytotellthetruthasamoralduty:•towardthetruth(obstructing reality)•towardthepatient(not tolie,patientrights,limiting therighttoliberty),•towardourselves(not tolie–integrity,conscience-)

• Not telling the truth vs. lying: • Not telling the truth:

• knowing the truth and not telling it; it manifest the intention to retain the hole truth or parts of the truth; it is still a lie though a diminished lie.

• not knowing the truth and telling what is believed to be the truth (i.e. by lack of knowledge); without intention

• Lying:• knowing the truth (real image) and presenting a different reality

(virtual image); with intention; false reality• Motivations (all immoral): to protect his interests (if so it is a possible conflict of

interest); disrespect for the interests of the others (egoism); intention to deceive; intention to do bad (maleficence); revenge; taking control/power over the others

Therapeuticprivilege,TPThepatientisautonomous,howeverhedoesnotreceivethetruthabouthismedical

conditionItismandatorythatthetruthabouthismedicalconditiontobecommunicatetohis

representatives

Criteria tobe taken into account whenusing TPinorder tooffer asolidmotivation (legally andmorally):1. Natureofpathology (potentially

lethal)2. Badprognosis (certitudeforafatal

prognosis)3. Patientpersonality (negative,non-

fighter, abandonship)4. Psychological condition:depression,

emptiness,exhausted5. Iminent risks:suicide,abandonof

thetreatment(Beneficence vs.maleficence;Geneve Declaration:«Thehealthofmypatientwillbemyfirstconsideration”

TPcannotbeusedwhen:1. Patientisaskingforthetruthofhismedical

condition2. Patientwillundergo anothermedical

procedureaskingforaspecificmedicalconsentwhichcannotbefuuly understandifnotknowing theinitialtruth

Strength

Right to intimacy•Possible conflicts:

–Right to intimacy vs. right to free access to information–Right to professional secrecy vs. right to disclose critical information in respect of the public good

LibertyrightPropertyrightSelfdeterminationright

HealthrightLiferight Publicgood,

publichealthLoyalty,fidelity

Legalvalues Moralvalues

• Mrs.V,29,isinherfamilydoctorevidence.Sheisapparentlyhealthy,divorced,shehasa6yearsolddaughterandaprofessionalcareerasapianoteacher.Thedoctorexpressadmirationforherbeingabletotakecareofherbeautifulgirlandherowncareer.Heasksherhowshemanagetodosuchstrenuousactivities.Sheanswerbyself-determination,sleepinglessandhavingadriverlicenseandacarthatenablehertobeintimeanywhereneeded,i.e.herprivatelessons,herdaughterschool,supermarket,etc.

• After1monthofabsence,theladyapparentlynotfeelingwell,beingpale,paysavisittoherdoctormentioningthatshewasill,hospitalizedandsufferingfromepilepsy.Sheisundertreatment.

• Thefamilydoctorthinkthatifhecommunicatetothepolicehermedicalconditionshewillloseherdriverlicenseandmostprobablyshewillhavealotofproblemstocompetewithhertaskswithoutadriverlicense.Howeverifhedoesnotcommunicatethereisariskthattheladycouldhaveadrivingaccidentwhileaconvulsivestatusandshemaykillherself,herdaughterandmoreinnocentpeople.

• Whathashetodo?1. Tocommunicatetothepolicehermedicalcondition2. Nottocommunicatetothepolicehermedicalcondition

Righttoselfdetermination.Autonomy.Moraldeliberation

• The right to self determination flows from the right to liberty and the right to life.

• By self determination every person legally competent may take in his best interests his own decisions to administrate his life, his health.

• The doctor must check that the person wants to self determine, is able to self determine and then to be let to self determine (negative duty - not to interfere)

Righttomedicalcare(fromWMADeclarationofpatientrights)

a.Everyperson isentitledwithoutdiscrimination toappropriatemedicalcare.b.Everypatienthastherighttobecaredforbyaphysicianwhomhe/sheknowstobefreetomakeclinicalandethicaljudgments withoutanyoutsideinterference.c.Thepatientshallalwaysbetreatedinaccordancewithhis/herbestinterests.Thetreatmentappliedshallbeinaccordancewithgenerallyapprovedmedicalprinciples.d.Qualityassuranceshouldalwaysbeapartofhealthcare.Physicians,inparticular, shouldacceptresponsibility forbeingguardiansof thequalityofmedicalservices.e.Incircumstanceswhereachoicemustbemadebetweenpotentialpatientsforaparticulartreatmentthatisinlimitedsupply,allsuchpatientsareentitledtoafairselectionprocedure forthattreatment.Thatchoicemustbebasedonmedicalcriteriaandmadewithoutdiscrimination.f.Thepatienthastherighttocontinuityofhealthcare.Thephysicianhasanobligation tocooperateinthecoordination ofmedicallyindicatedcarewithotherhealthcareproviders treatingthepatient.Thephysicianmaynotdiscontinue treatmentofapatientaslongasfurther treatmentismedicallyindicated,withoutgiving thepatientreasonableassistanceandsufficientopportunity tomakealternativearrangementsforcare.

• UNIVERSALDECLARATIONONBIOETHICSANDHUMANRIGHTS,UNESCO,2005http://portal.unesco.org/en/ev.php-

URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html• Art.14,al.22.Takingintoaccountthattheenjoymentofthehighestattainablestandardof

healthisoneofthefundamental rightsofeveryhumanbeingwithoutdistinctionofrace,religion, politicalbelief,economicorsocialcondition, progress inscienceandtechnologyshouldadvance:(a)accesstoqualityhealthcareandessentialmedicines,especiallyforthehealthofwomenandchildren,becausehealthisessentialtolifeitselfandmustbeconsideredtobeasocialandhumangood;(b)accesstoadequatenutritionandwater;(c)improvementoflivingconditionsandtheenvironment;

• CHARTEROFFUNDAMENTALRIGHTSOFTHEEUROPEANUNION (2010/C83/02)http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2010:083:0389:0403:en:PDF• Article35Healthcare.Everyonehastherightofaccesstopreventivehealthcareandthe

righttobenefitfrommedicaltreatmentundertheconditionsestablishedbynationallawsandpractices.Ahigh levelofhumanhealthprotectionshallbeensuredinthedefinitionandimplementationofalltheUnion'spoliciesandactivities.

• Article36Accesstoservicesofgeneraleconomic interest.TheUnionrecognizesandrespectsaccesstoservicesofgeneraleconomicinterestasprovided forinnationallawsandpractices,inaccordancewiththeTreaties,inordertopromote thesocialandterritorialcohesionoftheUnion.

• CONSTITUTIONOFTHEWORLDHEALTHORGANIZATION,TheConstitutionwasadoptedbytheInternationalHealthConferenceheldinNewYorkfrom19June

• to22July1946,signedon22July1946bytherepresentativesof61States(Off.Rec.WldHlthOrg.,2,100),andenteredintoforceon7April1948.

• AmendmentsadoptedbytheTwenty-sixth,Twenty-ninth,Thirty-ninthandFifty-firstWorldHealthAssemblies(resolutionsWHA26.37,WHA29.38,WHA39.6and

• WHA51.23)cameintoforceon3February1977,20January1984,11July1994and15September2005

• http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf

• “Healthisastateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity.

• Theenjoyment ofthehighestattainablestandardofhealthisoneofthefundamentalrightsofeveryhumanbeing withoutdistinctionofrace,religion,politicalbelief,economicorsocialcondition.

• Thehealthofallpeoples isfundamental totheattainmentofpeaceandsecurityandisdependentupon thefullestco-operationof individualsandStates.

• TheachievementofanyStateinthepromotion andprotectionofhealthisofvaluetoall.”

• CONSTITUTIONOFROMANIA• Art.34.“Therighttomedicalcare,al.1“Therighttomedicalcareisguaranteed”.

• Mr.BU,85yearsold,hasAlzheimerfor10yearsandisinanadvancedstage.Hisclinicalstateisprofounddeteriorateinthelatetime.Hecannotcontrolhismouthmovements:hereceivedanasalgastrictubebutheremovesitrepeteadly.Asurgicaltubeisreccomended.

• Hisfamilyisformedbyonedaughterwhodedicatedhislast10yearstothehealthcareofhisfather,theeldersonwhichsupportedeconomicallythemedicalcareofhisfatherandother3brotherswhichhasnotbeeninvolvedintheirfatherhealthcaretillnow.

• Thedaughterasksthedoctortoperformwhatevernecessaryfortheirfathertoliveon.

• Theeldersonasksthedoctortogiveuptothetreatementandlettheirfatherdodiewithdignitybystopingthefood.

• The3brothersconsiderthattheyarenotentitledtomakeamoralchoicebecausetheyhavenotbeeninvolvedtillnowintheordeilofthemedicalcare.

• Whathavethedoctortodo?