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REGULATIONS OFPHYSICIAN
CONDUCT
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VALUES, COMPETENCE,
AND RESPONSIBILITYThe physician-patient is based on brotherhood.
The physician must maintain the higheststandards of justice. He should also follow thefollowing guidelines : good intentions,
avoiding doubtful things, leaving alonematters that do not concern him, loving forothers, causing no harm, giving sincereadvice, avoiding the prohibited, doing the
enjoined acts, renouncing greed, avoidingsterile arguments, respect for life, basingdecisions and actions on evidence, followingthe dictates of conscience, righteous acts,
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quality work, guarding the tongue, avoidinganger and rage, humane limits, consciousnessof God in all circumstances, performing goodacts to wipe out bad ones, treating people
with the best of manners, restraint andmodesty, maintaining objectivity, seekinghelp from God, and avoiding oppression ortransgression against others. The physician
should be professionally competent , balanced, have responsibility and accountability .
He must work for the benefit of the patients andthe community.
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MEDICAL DECISIONSNo medical procedures can be carried out
without informed consent of the patientexcept in cases of legal incompetence. Thepatient has the purest intentions in decisionsin the best interests of his or her life. Others
may have bias their decision-making. Thepatient must be free and capable of givinginformed consent. Informed consent requiresdisclosure by the physician, understanding by
the patient, voluntariness of the decision,legal competence of the patient,recommendation of the physician on the bestcourse of action, decision by the patient, andauthorization by the patient to carry out theprocedures.
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The patient is free to male decisions
regarding choice of physicians and
choice of treatments. Consent can be by
proxy in the form of the patientdelegating decision making or by means
of a living will.
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Valid consent must be voluntary, informed, andby a person with capacity to consent. Itinvolves explaining the procedurecontemplated, making sure the patient
understands, and offering the patient achoice.
Consent is limited to what was explained to thepatient except in an emergency. Refusal to
consent must be an informed refusal (patientunderstands what he is doing). Refusal toconsent by a competent adult even ifirrational is conclusive and treatment can
only be given by permission of the court.
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Doubts about consent are resolved in favor ofpreserving life. Spouses and family membersdo not have an automatic right to consent. Aspouse cannot overrule the patients choice.
Advance directives, proxy informed consentby the family are made for the unconsciousterminal patient on withholding orwithdrawal of treatment.
Physician assisted suicide, active euthanasia,and voluntary euthanasia are illegal. A do notresuscitate order (DNR) by a physician couldcreate legal complications.
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The living will has the following advantages:(a) reassuring the patient that terminal care
will be carried out as he or she desires
(b) providing guidance and legal protection and
thus relieving the physicians of the burdenof decision making and legal liabilities
(c) relieving the family of the mental stressinvolved in making decisions about terminal
care. The disadvantage of a living will is thatit may not anticipate all developments of thefuture thus limiting the options available tothe physicians and the family.
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The device of the power of attorney can be usedinstead of the living will or advance directive.Decision by a proxy can work in two ways:
(a) decide what the patient would have decided
if able(b) decide in the best interests of the patient.
Informed consent is still required forphysicians in special practices such as a shipsdoctor, prison doctor, doctors in armedforces. Police surgeons may have to carry outexaminations on suspects without informedconsent.
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CONSENT OF THE INCOMPETENT
Competent children can consent to treatmentbut cannot refuse treatment. The consent ofone parent is sufficient if the 2 disagree.Parental choice takes precedence over the
childs choice. Courts can overrule parents.Life-saving treatment of minors is given evenif parents refuse. Parental choice is final intherapeutic or non-therapeutic research on
children. Mental patients cannot consent totreatment, research, or sterilization becauseof their intellectual incompetence.
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They are admitted, detained, and treatedvoluntarily or involuntarily for their ownbenefit, in emergencies, for purposes ofassessment, if they are a danger to
themselves, or on a court order. Suicidalpatients tend to refuse treatment becausethey want to die. Nutrition, hydration, andtreatment can be withdrawn in a persistent
vegetative state since the chance of recoveryis low. There is no moral difference betweenwithholding and withdrawing futiletreatment.
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Labor and delivery are emergencies that
require immediate decisions but the
woman may not be competent and
proxies are used. Forced medicalintervention and cesarean section may
be ordered in the fetal interest. Birth
plans can be treated as an advancedirective.
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DISCLOSURE AND TRUTHFULNESS
As part of the professional contract between thephysician and the patient, the physician musttell the whole truth. Patients have the right toknow the risks and benefits of medicalprocedure in order for them to make anautonomous informed consent. Deceptionviolates fidelity. If disclosure will cause harmit is not obligatory. Partial disclosure andwhite or technical lies are permissible under
necessity. Disclosure to the family and otherprofessionals is allowed if it is necessary fortreatment purposes. Physicians must usetheir judgment in disclosure of bad news to
the patient.
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PRIVACY AND CONFIDENTIALITY
Privacy and confidentiality are often confused.Privacy is the right to make decisions aboutpersonal or private matters and blockingaccess to private information. The patient
voluntarily allows the physician access toprivate information in the trust that it willnot be disclosed to others. This confidentialitymust be maintained within the confines of the
Law even after death of the patient. Inroutine hospital practice many persons haveaccess to confidential information but all areenjoined to keep such information
confidential.
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Confidentiality includes medical records of anyform. The patient should not makeunnecessary revelation of negative thingsabout himself or herself. The physician can
not disclose confidential information to athird party without the consent of the patient.Information can be released without theconsent of the patient for purposes of medical
care, for criminal investigations, and in thepublic interest. Release is not justifiedwithout patient consent for the followingpurposes: education, research, medical audit,
employment or insurance.
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FIDELITY
The principle of fidelity requires thatphysicians be faithful to their patients. Itincludes: acting in faith, fulfillingagreements, maintaining relations, and
fiduciary responsibilities (trust andconfidence). It is not based on a writtencontract. Abandoning the patient at any stageof treatment without alternative
arrangements is a violation of fidelity. Thefidelity obligation may conflict with theobligation to protect third parties bydisclosing contagious disease or dangerous
behavior of the patient.
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The physician may find himself in a
situation of divided loyalty between the
interests of the patient and the interests
of the institution. The conflict may bebetween two patients of the physician
such as when maternal and fetal
interests conflict. Physicians involved inclinical trials have conflicting dual roles
of physicians and investigators.
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REGULATIONS
OF MEDICAL PROCEDURES
Dr H Tatang Kartawan2009
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EXAMINATION AND
INVESTIGATION
Patient consent is necessary for history takingotherwise it is considered trespassing onprivacy and spying. History taking providesan opportunity to discuss diseases of the
heart that underlie physical disease.
The physician is not obliged to report criminalinformation to the authorities unless there isdemonstrable immediate public interest andnecessity.
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Physical clinical examination also
requires informed consent. A patient
can only be examined against his or her
consent only if there is a necessityrelating to the life of the patient or to
public interest such as criminal
investigation.Mental patients can are not legally
competent to give consent; the
necessary consent could be obtained
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Examination by a caregiver of the
opposite gender requires special
consideration. It is always preferable
that physicians of the same gendercarry out the examination. A physician
of the opposite gender can be used only
if a situation of necessity arises. Achaperone must be present.
Examination limited to what is
necessary.
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The results of laboratory investigations havethe same requirements for confidentiality ashistory and clinical examination. The resultsof radiological investigations are confidential.
Invasive investigations carry a higher risk tothe patient; their benefits should be carefullyweighed against the benefits. Theseinvestigations should be carried out only ifthere is a clear necessity.
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MEDICAL TREATMENTMedical treatment may involve
destruction (antibiotics, cytotoxics, anti-
metabolites, antagonists, antitoxins, and
detoxification), replacement (hormones,fluids, electrolytes), biological
modification & modulation, psycho-
active therapy, and supportivetreatment (diet, rest, analgesia etc).
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SURGICAL TREATMENT
Permitted surgical procedures include
resection, restorative/reconstructive
surgery, transplantation, blood
transfusion, anesthesia, and criticalcare. Transfusion of whole blood or
blood components is widely accepted
and raises few legal or ethical issues.Blood donation is analogous to organ
donation by a living donor.
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Attempts must be made to minimize
inappropriate mixing of male and
female health care personnel in a small
confined space of the operating theater.
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In emergency treatment/critical care,
financial considerations complicate the
picture when destitute patients who
cannot pay present at the emergency
room.
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OTHER TREATMENTS
Prayers are spiritual treatments.
Immunization and other preventivemeasures are treatment before disease.
Various traditional, alternative, andcomplementary therapies are permittedif they are of benefit.
Other permitted treatment modalities areirradiation, immunotherapy, andgenetic therapy.
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