REGULATION, GUIDELINES AND RULES OF PROCEDURE
In the Maldives, the first law in the health fields was passed in 1978, fully 46 years after the promulgation of the first constitution in 1932. A few years later in the 1980 the Citizen’s Majlis adopted a law regulating traditional medicine and circumcision. This particular law or any that followed did not refer to regulation of medical practice.
Maldivians had depended on traditional systems of medicine before 1960, when modern medicine was widely introduced to the country. Private practice in medicine started in an informal manner in the 70s. There was no attempt by the Government to regulate practice until 1988, when the Ministry of health issued regulations on private practice. The regulations stipulated standards for clinics. Regulation was also required for practitioners. These regulations did not apply to doctors in the Government services. In 1999, the Ministry introduced new regulations requiring all doctors including those in the Government as well as the private sector be registered in the Ministry. Under these regulations, since March 1999, all doctors practicing in Maldives require registration. After September 1999, when the Maldives Medical Council was established, it has taken over the regulatory functions.
In the most countries the world over, the practice of medicine is regulated through legislative acts. For example, in India there is The Indian Medical Council Act of 1956. Similarly in the United Kingdom, the Medical act 1969 gives statutory powers to the General Medical Council. Up to the present time, there is no law regulating medical practice in the Maldives.
Disciplinary action forms a large part of the responsibility of medical council. In England, the General Medical Council through its Medical Disciplinary Committee acts as a court of medical discipline and conduct. What constitutes the disgraceful dishonorable conduct has often been a controversial point in a Court of law. Sir Donald Mac Alistair in 1892 defined it as follows: ‘If it is shown that a medical man, in pursuit of his professional, has done something with regard to which it would be reasonably regarded as disgraceful or dishonorable by his professional brethren of good repute and competency, then it is open to the Council to say that he has been guilty of infamous conduct in a professional respect.’ The Medical Act of 1969 gives to the Disciplinary Committee of the General Medical Council the power to order suspension not exceeding 12 months in addition to that of erasure. Newer concepts professional offences are being introduced. Greater concern is being given to the offences of doctors who disregard their personal responsibilities to patients, and abuse the professional confidence. This is considered serous professional misconduct, deserving disciplinary proceedings. So also is the offence of improper conduct or association with a patient or his family member and adultery. Advertising is considered as something that is capable of being a source of danger to the public as well as being incompatible with the principles that should govern relation between members of a profession. Medical Council have also prescribed standards of professional conduct and etiquette and a code of ethics for medical practitioners violations thereof constitutes infamous conduct on any professional respect.
In September 1999, a Presidential Decree established the Maldives Medical council. The Council is vested with the power to regulate medical practice in the Maldives in order to maintain professional and ethical standards. It functions under the Ministry of Health.
At the time of established of the Council, its basic regulation were promulgated. The following section gives an English translation of the original regulations in Dhivehi.
REGULATIONS OF THE MALDIVES MEDICAL COUNCIL
The mission of the Maldives Medical Council is to maintain professional and service standards for medical care, enforce ethical codes, authorize medical practice and register practitioners.
Members of the Council are appointed by the President of Maldives from the following sectors in the numbers indicated:
- 3 (three) medical practitioners appointed from medical practitioners practicing in the Maldives;
- A dental practitioner appointed from dental practitioners practicing in the Maldives;
- A person appointed by the Minister;
- A health care skilled professionals who is neither a medical practitioner nor a dental practitioner;
- A trainer trained in the field of medical or dental profession, who is working in a health care profession training center with a minimum of 5 (five) years of experience in training;
- A practicing lawyer with a minimum of 5 (five) years of experience in Maldives;
- A member of a civil society working in health profession.
The secretariat of the Council will be located in the Ministry of Health.
4. OFFICE BEARERS AND COMMITTEES
- The Council meetings shall be chaired by the President of the Council. In the absence of the President, Vice-President of the council shall preside over sittings of the meetings. If neither is present, a person to preside over the sitting shall be elected by the members present at that meeting.
- The council will have a Registrar.
- The council may appoint standing committees and ad hoc committees from among the members to advise it on various matters.
- MEETINGS OF THE COUNCIL
1. As a minimum requirement, 1 (one) council shall be held every month.
2. The minimum quorum for a council meeting is 50% of the members
3. A majority vote of the members is required to pass a motion in the council.
6. REGISTERS MAINTAINED BY THE COUNCIL
1. The Registrar of the Council will maintain a register of doctors qualified abroad or locally and practicing medicine in the Maldives.
2. Normally, only Maldivians and those foreigners who are trained in the Maldives may be permanently enrolled in the register mentioned in clause 6.1.
3. Foreigners who are educated or trained abroad may be temporarily registered for a limited for the duration of employment in clause in the Maldives.
4. Only those who are duly enrolled in the register mentioned in clause 6.1 may practice medicine in the Maldives.
5. The Council may temporarily or permanently erase form the register the name a doctor against whom, a charge of professional misconduct has been proved.
7. EDUCATION QUALIFICATIONS RECOGNIZED BY THE COUNCIL.
Minimum qualification required to practice medicine in the Maldives will be determined by the Council. Minimum standards of education and training required for the same will also be determined by the Council.
The Registrar will maintain a list of degrees, diplomas and certificates recognized by the Council to satisfy the requirement in clause 7.1.
The Registrar will maintain a list of institutes in the Maldives and abroad, that have been recognized by the council to conform to the standards of training and education referred to in clause 7.1.
The Council is authorized to negotiate with medical councils or other similar bodies vested with similar regulatory authority in their respective countries, for mutual recognition of each other’s training institutes and qualifications.
8. INFORMATIONAL REGARDING TRAINING COURSES AND EXAMINATIONS.
Institutes conducting training in the Maldives in the medical field shall provide information regarding their courses, training methods and examination to the councils as and when required.
9. PROFESSIONAL ETHICS
If a charge of violating professional ethics is raised against a medical practitioner, the council shall inquire and determine whether the allegation is true or false and the magnitude of the offence if any.
Having inquired as in clause 9.1 and if professional misconduct is proved, the council may, depending on the magnitude of the infringement, erase temporarily or permanently, the name of the practitioner from the Register.
The registrar shall maintain records of inquires conducts as per clause 9.1 and action taken as per clause 9.2.
10. REGULATION MADE BY THE COUNCIL
To accomplish the mission of the Council as given in clause 1, the council is empowered, with the advice of the Minister of Health, to make regulations, guidelines, ethical codes and rules of procedure. The following is an indicative list of areas in which the Council may exercise this power:
Policy on medical services development. Approving the curriculum and syllabus of medical courses in the Maldives. Entry qualification for courses mentioned in clause 10.2.Determining the standards of examinations conducted in the Maldives to awards medical degrees, diplomas and certificates.To lay down rules pf procedure and responsibilities of committees established under this regulation.To determine ethical standards for medical practice in the Maldives, make a code of ethics and maintain it. Determine guidelines and regulations on medical research in the Maldives.
11. ENFORCMENT OF THIS REGULATION.
These regulations will come into force from the date of formation of the Council. However, the Ministry of Health may, at his discretion, allow a reasonable period of time for existing institution in the country and existing practitioners to comply with the regulations.
The above an English translation of the original regulations promulgated at the time of established of the Council in September 1999
RULES OF PROCEDURE OF THE MALDIVES MEDICAL COUNCIL
These rules of procedure were adopted by the Maldives Medical Council under the powers vested in it through clause 10 of its basic regulation.
2. FUNCTION OF THE COUNCIL.
The council shall:
2.1 Lay down minimum criteria required for practicing medicine in the Maldives.
2.2 Maintain in the prescribed manner a register of medical practitioners to be known as the National register of Medical Practitioners.
2.3 Lay down minimum qualification and experience required to practice medicine as a specialist.
2.4 Maintain a register of Additional Medical Qualifications.
2.5 Maintain a list of basic medical qualification recognized by the council.
2.6 Maintain a list of additional and higher medical qualifications recognized by the council.
2.7 Maintain a list of educational institutions recognized by the council.
2.8 Lay down criteria for recognition of medical courses and institutions.
2.9 Lay down and enforce a Code of Medical Ethics.
3. PRESIDENT OF THE COUNCIL
The duties and responsibilities of the President are as follows:
3.1 Holding meeting of the Council as and when required.
3.2 President over the meeting of the council.
3.3 Keeping records of the proceeding and conclusions of the meeting of the Council.
3.4 General administration of the Council
3.5 Representing the Council in its dealings with other organizations both within and outside the Maldives.
4. REGISTRAR OF THE COUNCIL.
The responsibilities and functions of the registrar are follows:
4.1 Registering eligible persons in the National Register of Medical Practitioners.
4.2 Registering additional qualification acquired by medical practitioners.
4.3 Maintaining lists of qualification recognized by the council.
4.4 Maintaining lists of training institutions inquiries conducted and action taken by the Council.
4.5. Maintaining records of disciplinary inquiries conducted and action taken by the Council.
5. RECOGNITION OF MEDICAL QUALIFICATIONS MEDICAL TRAINING INSTITUTIONS.
5.1 The basic qualification recognized by the Medical Council as sufficient qualification for enrolment in the National Medical Register is the MBBS degree or its equivalent as described in clause 5.2, obtained from an institution recognized by the Council, after undergoing a minimum training period of 4 years, followed by a minimum internship period of one year.
5.2 The Medical Council recognized those medical qualification that are granted by medical institutions and which are includes in the first schedule of this regulation as equivalent to MBBS degree and considers them as sufficient qualification for enrolment in the National Register of Medical Practitioners.
5.3 The Medical Council recognized three grades of specialization in medicine, namely diploma level, master’s degree level, and postmaster’s degree level.
5.3.1 The minimum qualification required to be recognized as a diploma level specialist is postgraduate diploma included in the second schedule of this rules of procedure, and which are awarded after a minimum training period of 2 years, relaxable to 1 year at the Council discretion.
5.3.2 The minimum qualification required to be recognized as a postgraduate degree level specialist is a degree or equivalent certificate included in the third schedule of this rules of procedure, and which are awarded after minimum training period of 3 years, relaxable to 2 year at the Councils discretion.
5.3.3 The minimum qualification required to be recognized as a post masters specialist is DM (doctor of medicine), or MCh (Master in Chirurgie) certificate or their equivalent included in the fourth schedule of this rules of procedure, and which are awarded after a minimum period of 2 years of post masters training.
5.4. While the Council does not recognize diplomas and certificates awarded after less than one academic year of training, as sufficient qualification for recognition as a specialist, it may in selected cases, which are included in the fifth schedule of this rules of procedure, recognized such certificates as additional qualification.
5.5 The Council shall issue detailed criteria for recognizing and grading qualifications mentioned in clauses 5.1, 5.2, 5.3 and 5.4.
5.6. Medical Council is authorized to inspect, without interfering with the conduct of any training or examination, any place where the training or examination is being given or held, for the purpose of recognition by the Government of medical qualifications given by the medical institution.
5.7. The Medical Council is authorized to prescribe standards for post-graduate medical education for the guidance of training institutions and may advise institutions in maintaining standards for post-graduate medical education.
6. Disciplinary Control
6.1 Medical practitioners in the Maldives are required to conform to the guidelines and code of ethics by the Maldives Medical Council and those issued by the World Medical Association that have been endorsed by the Maldives Medical Council.
6.2 At the time of registration, medical practitioners shall be required to sign and acknowledge the Geneva Declaration as amended by the World Medical Association in 1968.
6.3 The Council will establish a four member disciplinary committee under the powers vested in it by clause 4.3 of the basic regulations.
6.4. The disciplinary committee will inquire into allegations of unethical conduct and malpractice raised against medical practitioners and report to the Council.
6.5 The Maldives Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period from the Register the name of any registered practitioner who has been convicted of any such offences as implies in the opinion of the Maldives Medical Council, a defect of character or who after an enquiry at which opportunity has been given to such registered practitioner to be heard in person or by pleader, has been held to have been guilty of serious professional misconduct. The Maldives Medical Council may also direct that any name so removed shall be restored.
1. Character Of The Physican:
The prime object of the medical profession is to render services to humanity; reward of financial gain is a subordinate consideration. Whosoever chooses this profession assumes the obligation to conduct himself in accord with its ideals. A physician should be an upright man, instructed in the “art of healing”. He must keep himself pure in character and be diligent in caring for the sick. He should be modest, sober, patient, prompt to do his whole duty without anxiety; pious without going so far as superstition, conducting himself with propriety in his profession and in all the actions of his life.
2. The Physician’s responsibility:
The principle objective of the medical profession is to render service to humanity with full respect for the dignity of man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. Physicians should try continuously to improve medical knowledge and skill and should make available to their patients and colleagues the benefits of their professional attainments. The physician should practice methods of healing founded on scientific basis and should not associate professionally with anyone who violates this principle. The honored ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also to society.
Soliciting of patients directly or indirectly, by a physician, by groups of physicians or by institutions or organizations is unethical. A physician shall not make use of or aid or permit others to make use of him (or his name) as subject of any form or manner of advertising or publicity through lay channels either alone or in conjunction with others which shall be of such a character as to invite attention to him or to his professional position, skill, qualification, achievements, attainments. Specialities, association, affiliations or honors and or of such character as would ordinarily result in his self-aggrandizement nor shall he give to any person whosever, whether for compensation or otherwise, any approval, recommendation, endorsement, certificate report or statement with respect of any drug, medicine, remedy, surgical or therapeutic article, apparatus or appliance or any commercial product or article with respect of any property, quality or use thereof or any test, demonstration or trial thereof, for use in connection with his name, signature, or photograph in any form or manner of advertising through lay channels nor shall he boast of cases, operations, curse or remedies or permit the publication of report thereof through lay channels. A medical practitioner is permitted to give announcement in press regarding the following:-
(1) On starting practice.
(2) On change of type of practice.
(3) On changing address.
(4) On temporary absence from duty.
(5) On resumption of practice.
(6) On succeeding to another practice.
4. Payment for professional services:
The ethical physician, engaged in the practice of medicine, limits the sources of his income received from professional activities to services rendered to the patient. Remunerations received for such services should be in the form and amount specifically announced to the patient at the time the service is rendered. It is unethical to enter into a contract of “no cure no payment”
5. Patient and copy rights:
A physician may patent surgical instruments, appliances and medicine or copyright publications methods and procedure. The use of such patients or copy right or the receipt of remuneration from them which retards or inhibits research or restrict the benefits derivable there form are un – ethical.
6. Running an open shop (Dispensing of drugs and appliances by physician)
A physician should not run an open shop for sale of medicine, for dispensing prescriptions prescribed by doctors other than him or for sale of medical or surgical appliances. It is not unethical for a physician to prescribe or supply drugs, remedies or appliances so long as there is no exploitation of the patient.
7. Rebates and commission:
A physician shall not give, solicit, or receive nor shall he offer to give, solicit or receive, any gifts, gratuity, commission or bonus in consideration of or in return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or by any subterfuge participate in or be a party to the act of division, transference, assignment, subordination, rebating splitting or refunding of any fee of medical, surgical or other treatment.
The provision of this paragraph shall apply with equal to the referring, recommending or procuring by a physician or any, person, specimen or material diagnostic, or other study or work. Nothing in this section, however, shall prohibit payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision.
8. Secret remedies:
The prescription or dispensing by a physician of secret medicine or otter secret remedial agents of which he does not know the composition, or the manufacture or promotion of their use is unethical.
9. Evasion of legal restriction:
The physician will observe the laws of the country in regulating the practice of medicine and will not assist others to evade such laws. He should be co-operative in observance and enforcement of laws and regulation in the interest of public health. A physician should comply with the provisions of the state Acts, Rules, Regulations made by the Government for protection and promotion of public health.
DUTIES OF PHYSICIANS TO PATIENTS
1. Obligations to the sick:
Though a physician is not bound to treat each and every one asking his services except in emergencies for the sake of humanity and the noble traditions of the profession, he should not only, be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission and the responsibility he incurs in the discharge of his professional duties. In his ministrations, he should never forget that the health and lives at those entrusted to his care depends on his skill and attention. A physician should endeavor to add to the comfort of the sick by making his visit at the hour indicated to the patients.
2. Patience, delicacy and secrecy:
Patience and delicacy should characterize the physician. Confidences concerning individual or domestic life entrusted by patients to a Physican and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the state. Sometime, however, a physician must deter mine whether his duty to society requires him to employ knowledge, obtained through confidence to him as a physician, to protect a healthy person against a communicable diseases to which he is about to be exposed. In such instance, the physician should act, as he would desire another to act towards one of his own family in like circumstances.
The physician should neither exaggerate nor minimize the of a patient’s condition. He would assure himself that the patient, his or his responsible friends have such knowledge of the patient’s condition as will serve the best interests of the patient and the family.
4. The patient must not be neglected:
A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency or whenever temperate public opinion expects the service. Once having undertaken a case, the physician should not neglect the patient, his relatives or his responsible friends sufficiently long in advance of, his withdrawal to allow them to secure another medical attendant. No provisionally or fully registered medical practitioner shall willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.
DUTIES OF THE PHYSICIAN TO THE PROFESSION AT LARGE
1. Upholding the honor of the profession:
A physician is expected to up-hold the dignity and honor of his profession.
2. Membership in medical society:
For the advancement of his profession, a physician should affiliate with medical societies and contribute of his time, energy and means so that these societies may represent the ideals of the profession.
3. Safeguarding the profession:
Every physician should aid in safeguarding the profession against admission to it of those who are deficient character or education. Physician should not employ in connection with his professional practice any attendant who is nether registered nor enlisted under the Medical Acts in force and should not permit such persons to attend, treat or perform operations upon patients in respect of matters regarding professional discretion or skill as it is dangerous to public health.
4. Exposure of unethical conduct:
A physician should expose, without fear or favor, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession. Questions of such conduct should be considered, first before proper medical tribunals in executive sessions or by special or duly appointed committees on ethical relations, provided such a course is possible and provided also, that the law is not hampered thereby. If doubt should arise as to the legality of the physician’s conduct, the situation under investigation may be placed before officers of the law, and the physician investigators may take the necessary steps to enlist the interest of the proper authority.
PROFESSIONAL SERVICES OF PHYSICIANS TO EACH OTHER
1. Dependence of Physicians on each other:
There is no rule that a physician should not charge another physician for his services but a physician should cheer fully and without recompense give his professional services to physicians or his dependents it they are in his vicinity.
2. Compensation for Services:
A physician should consider it as a pleasure and privilege to render gratuitous service to all physicians and their immediate family dependents. When a physician is called from a distance to attend or advice another physician or his dependents reimbursement should however be made for traveling and other incidental expenses.
DUTIES OF PHYSICIAN IN CONSULTATION
1.Consultation should be encouraged:
In case of serious illness, especially in doubtful or difficult conditions the physician should request consultations.
2.Consultation for patients’ benefit:
In every consultation, the benefit to the patient is of first importance. All physicians interested in the case should be candid with the patient, a member of his family or responsible friend.
3.Punctuality in consultation:
Utmost punctuality should be observed by a physician in meeting for consultation.
4.Conduct in consultation:
In consultations, no insincerity, rivalry or envy should be indulged in. all due respect should be observed towards the physician in charge of the case and no statement or remark be made, which would impair the confidence reposed in him. For this purpose, no discussion should be carried on in the presence of the patient or his representatives.
5.Statement to patient after consultation:-
(a) All statements of the case to the patient or his representatives should take place in the presence of all the physicians consulting, except as otherwise agreed; the announcement of the opinion to the patient or his relations or friends shall reset with the medical attendant.
(b) Differences of opinion should not be divulged unnecessarily but when there is an irreconcilable difference of opinion the circumstances should be frankly and impartially explained to the patient or his friend. It would be open to them to seek further advice should they so desire.
6.Treatment after consultation:
No decision should restrain the attending physician from making such subsequent variations of the treatment as any unexpected change may require, but at the next consultation, reasons for the variations should be stated. The same privilege, with its obligations, belongs to the consultant when sent for in an emergency during the absence of attending physician. The attending physicians may prescribe at any time for patient the consultation only in case of emergency.
7.Consultant not to take charge of the case:
When a physician has been called as a consultant, none but the rarest and most exceptional circumstances would justify that consultant taking charge of the case. He must not do so merely on the solicitation of the patient or friends.
8.Patients referred to specialists:
When a patient is referred to a specialist by the attending physician a statement of the case should be given to the specialist who should communicate his opinion in writing in a closed direct to the attending physician.
DUTIES OF PHYSICIAN IN CASES OF NTERFERENCE
1. Appointment of a substitute:
Whenever a physician requests another physician to attend his patients during his temporary absence from his practice professional courtesy requires the acceptance of such appointment is consistent with his other duties. The physician acting under such an appointment should give the utmost consideration to the interests and reputation of the absent physician. All such patients should be restored to the care of the latter upon his return.
2. Visiting another physician’s case:
A physician called to visit a patient who has recently been under the care of another physician in the same illness, should not take charge of, nor prescribe for such patient except in a case of emergency when he should communicate to the former explaining the circumstances under which the patient was seen and treatment given, or when the physician has relinquished his services. When it becomes the duty of a physician occupying an official position to se and report upon an illness or injury, he should communicate to the physician in attendance so as to give him an option of being present. The medical officer should avoid remarks upon the diagnosis or the treatment that has been adopted.
3.Engagement for an obstetric case:
In a physician agrees to attend a woman during her confinement, he/she must do so. Inability to do so for reasons of any other engagement is not tenable except when such other engagement is a more serious case. When a physician who has been engaged to attend an obstetric case is compelled to be absent, he/she must make alternate arrangements for another physician to be present.
DUTIES OF PHYSICIAN TO THE PUBLIC
1.Physicians as citizens:
Physicians, as good citizens, possessed of training, should advise concerning the health of the community where in they should bear their part in enforcing the laws of the community and in such institutions that advance the interests of humanity. They should operate especially with the proper authorities in the administration of sanitary and regulations.
Physicians, especially those engaged in nubile health work, should enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and communicable diseases. At all times the physician should notify the constituted public health authorities of every case of communicable disease under his care. In accordance with the laws, rules and regulations of the health authorities. When an epidemic prevails, a physician must continue his labors without regard to the risk to his own health.
Physician should recognize and promote the practice of pharmacy as a profession and should recognize the role of the pharmacist in education of the public concerning the practice of ethical and scientific medicine.
LIST OF INFAMOUS ACTS THAT MAY BE PUNISHED BY ERASURE FROM THE NATIONAL REGISTER OF MEDICAL PRACTITIONERS
- Adultery or improper conduct or association with a patient: Any medical practitioner who abuses his professional position by committing adultery or improper conduct with a patient or by maintaining an improper association with a patient is liable for disciplinary action.
- Conviction by court of law for offences involving moral turpitude.
- Signing or giving under one’s name and authority certificates, notifications, reports or documents of a character which is untrue, misleading or improper.
- Contravening the provision of the Law on Narcotics and regulations made under that law.
- Performing or enabling an unqualified person to perform an abortion or any illegal operation.
- Issuing of certificates of proficiency in modern medicine to unqualified or non-medical persons.
Note: – The foregoing does not apply so as to restrict the proper training and instruction of bona fide students, nurses, midwives, and paramedical workers under the personal supervision of physicians.
- Advertising to the lay press or soliciting practice: Physicians should not advertise in any form. It is improper for a physician to use an unusually large signboard or write on it anything other than his name, qualifications obtained from a university or a statutory body, titles and name of his specialty. The same should also be the contents of his prescription papers. It is improper to affix a signboard on a chemist shop or in places where he does not reside or work.
- Disclosing the secrets of a patient that have been learnt in the exercise of the profession: Those may be disclosed only in a Court of Law under order from the presiding judge. A physician is bound by law to disclose to the proper authorities information regarding acts of a criminal nature committed by the patient.
- Publishing photographs or case reports of patients without their permission in a manner by which their identity could be disclosed should the identity be not disclosed consent is not needed.
- Using touts or agents for procuring patients.
DUTIES OF A PHYSICIAN
In addition to the guidance given in the code of ethics the following duties of a physician should also be remembered-
- A physician shall use the necessary skill, care, judgment and attention in the treatment of patients. While there is considerable scope for exercising one’s judgment and discretion, a reasonable degree of proficiency must maintained.
- As soon as a registered medical practitioner agrees to treat a patient, a doctor-patient relationship is legally established, it neither guarantees a cure nor an assured improvement for the treatment given by the doctor. A medical practitioner is entitled to receive and recover in due course of law reasonable remuneration for any professional service rendered except in a case where there is a definite understanding that the services shall be gratuitous. Whether the treatment is gratuitous or not, the same amount of skill and care must be exercised, because a doctor owes a duty of care to every patient whom he undertakes to treat. It is the physician’s duty to obey a summons for attendance from a private patient as long as physician-patient relationship exists. There is a common belief among the public that a medical practitioner is at the beck and call of anyone who chooses to send for, him, but it must be remembered that there can be no legal duty on any medical man to examine, treat or give aid to a stranger, whether in an emergency such as a road accident or otherwise. Therefore, he cannot be held liable in law of refusing or failing to treat or arrange for treatment of a person with whom he is not and never has been in any kind of professional relationship. Nevertheless, it is necessary to remember that a medical practitioner should not hesitate to render medical or surgical assistance in an emergency, especially in a locality where is no other suitable medical aid; refusal in such a case would be considered a gross breach of his ethical obligation. A medical practitioner serving on the staff of a charitable hospital is bound to; render professional service to every patient attending the institution. 2. A medical practitioner should use clean and instruments and appliance.
- A physician should legibly write prescriptions, using such abbreviations as are usually employed and mentioning full and detailed instruction in a language that the chemist or pharmacist dispensing prescriptions can readily understand. He is held responsible for any damage in health, temporary or permanent, caused to the patient as a result of his wrong or un-understandable instructions mentioned in the prescription.
- A physician should give in simple language full directions to his patients or their attendants concerning the administration of remedial measures including the articles of diet. Exact quantities and precise times for the administration of medicines should be specifically mentioned.
- A physician should keep confidential, the secrets of his patients communicated to him by them or discovered by him at the time-of medical examination. The Hippocratic Oath enjoins on every medical practitioner not to divulge ‘the things he sees or hears in the exercise, in his intercourse with men and to keep silent regarding them as Inviolable secrets.’
Concept of professional secrecy does not involve contract. It is an ethical obligation on the part of the doctor. Violation of secrets would amount to professional misconduct but not breach of contract. In France and Germany exposure of medical secrets is regarded as a criminal offence. It must, however, be remembered that a medical witness is bound to reveal them in a judicial proceeding, if ordered by the court. A medical practitioner should not answer inquiries addressed to him by an insurance company regarding a person who may have consulted him without having obtained the patient’s consent, which, if possible should be in writing. However, if he is a medical examiner he must furnish all the information acquired by him without reservation, even though it may be detrimental to the interests of his client. Any information required by an insurance company regarding a deceased person from a doctor may be given only after obtaining written authority from the nearest competent relative, so also in cases of divorce and nullity no information should be given without getting the consent of the person concerned or in case of insanity to his guardian ad litem. A medical practitioner should not inform the relatives or even parents of the results of examination of his patient who has attained the age of majority unless he gives his written consent. A medical practitioner must remember that he is not entitled to examine, a person without his consent, as rarely examination without consent may legally become an assault and a trespass upon the person of the patient.
- A medical practitioner should have consent for all procedures performed on the patient. Generally, when a patient consults a doctor, consent for examination and ordinary therapeutics is presumed as granted; this is known as implied consent. However, the patient must be properly informed regarding the proposed treatment of his illness and its risks and consequences to avoid any action later on. In addition, it must not be forgotten that for all medical tests, procedures etc; an express consent is necessary, it may be oral in the presence of a witness or written depending on the circumstances of each case. Except in life saving circumstances consent of the patient or the guardian for an injection must be obtained. Legally an injection becomes an assault on the person by the doctor if not given properly and justifiably. Operative procedures and anesthesia require a special written consent and also blood transfusion. For operations, which are, illegal there cannot be any valid consent. In children under the age of 16, and an insane person, only guardian’s consent or anyone having full charge of the person is valid. Even in medico-legal cases, consent of victim is essential for examination. Consent given under fear, fraud or misrepresentation of facts or by a person who is ignorant of the implications of his consent, or who is under 16 years of age, is invalid. Absence of legally effective consent is given application of force will not be unlawful. Even a demand for discharge from a hospital against medical advice should be in writing and duly signed, as it is unlawful to detain an adult patient against his will in a hospital.
It is now recognized that the patient has the right to full information in layman’s terms, concerning his diagnosis, treatment, and prognosis. He should also be informed abut alternative treatments and possible complications. Informed consent means the consent of a patient to the performance of health care services by a registered medical practitioner provided, that prior to the consent having been given, the medical practitioner has informed the patient of the nature of the proposed procedure or treatment, of the risks involved and alternatives that a reasonable patient would consider material to the decision whether or not to undergo treatment or diagnosis. The Physician’s duty to disclosure is subject to 2 exceptions: (i) No disclosure is required if the patient indicates a preference not to be informed or (ii) If the Physician/Surgeon believes, in the exercise of sound medical judgment, that the patient is so anxiety prone or disturbed that the information would not be processed rationally or that it would probably cause significant psychological harm. The latter exception to the duty of disclosure is referred to as “therapeutic Privilege”. As to the latter exception, consultation with another physician familiar with the patient (family doctor), with a close relative or friend, or both, is advisable.
- The World Medical Association in October 1975 adopted a declaration that specifically prohibits physicians from participating in forced feeding of prisoners who have formed a rational judgment to refuse nourishment.
- The practice of euthanasia-the deliberate termination of life of a person suffering from a distressing and irremediable disease is contrary to the ethics and traditions of medicine; it is repugnant and destructive of the trust that people response in their doctors.
- Privileged Communications: A medical practitioner cannot withhold professional secrets in those cases where he has a statutory duty to notify births, deaths, infectious diseases, etc., to the public authorities. On certain occasions, he has a moral duty to protect the interests of his community or the public and in doing so, if he divulges the secrets of patient obtained in the course of his professional examination and treatment; he will be absolved from legal liabilities. For instance, a medical practitioner has a privilege to inform the warden of a hostel, if any boarder is suffering from a venereal disease. He has privilege to inform the railway authorities, if he finds that a particular engine driver is colorblind and that he does not wish to change his employment although he is persuaded to do so. In such cases the communication, if made bona fide and without malice, will be deemed to be privileged by the occasion, however it should be made only to persons directly concerned otherwise, he may be penalized. A privileged communication is, therefore, defined as a statement made by a person, who has an interest to protect, or a legal, social or moral duty to perform, to another having a corresponding interest or duty for the purpose of protecting his interest or performing his duty, even though such communication may, under normal conditions, amount to defamation or slander.
- As responsible citizens, doctors are legally bound to communicate to the policy any information about a criminal act that might have come to his knowledge in his professional work. However, in performing this obligation, he should not play the part of a detective, but use his own discretion. For instance, he should hand over to the police, a man, whom, from the nature of his injury, he may suspect to be an assailant in a murder case. In minor offences, there is no need to report one’s suspicions as legally one is bound to report only knowledge of a crime, not suspicion. In such cases, there is no need to try to obtain a confession, which is the work of the police.
DUTIES OF A PATIENT
When a patient employs a medical practitioner for the treatment of his ailment, he may reasonably be expected to supply his doctor with complete information concerning the facts and circumstances of the case, to allow him full opportunity for a diagnosis, to obey his instructions and, carry out his directions to the very letter as regards his diet, medicine, mode of life, and to pay him a reasonable fee for his services. Failure on the part of the patient to do his duty will enable the doctor to terminate the patient-physician relationship and that would free him from his legal responsibilities.
MALDIVES MEDICAL COUNCIL GUIDELINES ON PROFESSIONAL NEGLIGENCE (MALPRACTICE)
Professional Negligence or medical negligence may be defined as want of reasonable degree of care and skill or willful negligence on the part of a medical practitioner in the treatment of a patient with whom a relationship of professional attendant is established, so as to lead to his bodily injury or to the loss of his life. Modern tort law differentiates between injuries that are a result of intentional conduct and those resulting from negligence. In a civil action, the plaintiff has to prove that:
(a) His recognized legal right had been infringed,
(b) That there was a duty of care which was breached by the defendant i.e. the doctor and that
(c) This breach was the cause of injury to him,
(d) The results of this injury such as the loss of income, extra expenses and mental suffering and pain could be equated in terms of money for the purpose of compensation.
To put simply negligence involves not “neglect” or “carelessness” but failure to take such care as the circumstances demand. Therefore, there are two essential elements (a) A legal duty to exercise proper care, and (b) Failure to take such care. As a rule, a doctor cannot be found to be negligent simply because one of the risks inherent in an operation actually took place or because in a matter of opinion he made an error of judgment. He should only be found guilty when he had fallen short of the standards of reasonable medical care. It would be doing a disservice to the community at large, if we were to impose liability for everything that happens to go wrong. We must insist on due care of the patient at every point but we must not condemn as negligence that which is only a misadventure.
For the convenience of description, professional negligence is classified as a civil or criminal negligence. Civil Negligence is a form of negligence in which a patient brings an action for damages in civil court against his medical attendant, who owed him a duty in tort of care, if he had suffered injury in consequences of negligence or unskilled treatment. The liability of the medical attendant is not decreased by the fact that he treated his patient gratuitously in a charitable hospital, but the burden of proving negligence to establish his case rests always on the plaintiff. The amount of damage done is a measure of the extent of liability. The law in most countries presumes that a person who enters the medical profession undertakes to use a reasonable degree of skill, care, knowledge and prudence in the treatment of his patient to the best of his judgment, but he is not liable for an error of judgment or of diagnosis. A general medical practitioner is expected to use only the ordinary degree of skill and knowledge in the treatment of his patients. On the other hand, a specialist is expected to possess and exercise it degree of skill and learning in his special line than a general practitioner, and is judged by comparison with other specialists in the same line. As a precautionary measure against a charge of negligence a medical practitioner should, consult, or suggest the consultation of, a brother medical practitioner or a specialist in a case, where he has some doubt about the diagnosis or treatment, and he should examine, or suggest the examination of, an alleged fractured or dislocated limb or head injury by X-ray, but he should not adopt any new treatment in the form of an experiment without the consent of the patient or his guardian if he happens to be a minor.
The question of criminal negligence may arise in a criminal court, when the defense counsel may attribute the death of an assaulted person to the negligence or undue interference of the medical attendant in the treatment of the deceased. For criminal negligence medical practitioner, whether qualified or unqualified, may be prosecuted by the police and charged in a criminal court with having caused the death of his patient by doing a rash or negligent act not among to culpable homicide, if the death was the result of gross carelessness, gross negligence or gross ignorance displayed by him during the administration of an anesthetic, performance of an operation or any other treatment. In such a case, there is a presumption of the absence of intention to cause death, and of the want of knowledge that the act done will most probably result in death. Before a medical practitioner can be held criminally responsible for the death of his patient, the prosecution must prove all matters necessary to establish civil responsibility except pecuniary loss, and in addition must prove negligence or incompetence on his part which went beyond mere matter of compensation between subjects and showed such disregard for the life and safety of others as to amount to a crime against the state. This also draws attention to the fact that there exists civil liability for lesser degrees of negligence and that criminal liability should be reserved for gross aberrations. A careful medical man will, in most cases, not be exposed to any legal action and also prove that reasonable care and diligence and necessary professional skill had been exercised in the course of treatment, if he observes the following rules:
- Never criticize another colleague.
- Always confirm your diagnosis with generally approved methods such as laboratory tests and in bone or joint injuries always insist on X-rays and see that the plaster is not too tight.
- Advise immunization whenever there is danger of infection-particularly against tetanus.
- In diagnosing cancer ask for a biopsy, X-ray etc., without any delay as loss of time may mean life or death.
- Always make sure of the preparation before you giving an injection.
- It is the duty of every doctor to be well informed of developments in medical practice.
- The administration of an enthusiastic or the performance of operation should not be undertaken without the consent of the patient, or guardian, if he is minor or unconscious, after the nature and consequences of the operation have been explained to them. However, in cases of accident or other emergency wherein operation may be performed without the consent, if it is done in good faith to save life and if waiting for consent is likely to be life threatening. In doubtful cases, a second opinion should be obtained before operation. Proper precautions should be taken to avoid operating on a wrong patient or the wrong part of a patient.
- Post-operative care of an operated patient is the surgeon’s legal responsibility. If a circumstance arises wherein such care cannot be given, proper care by another consultant colleague must be arranged.
- An anesthetist should always administer a generally accepted anesthetic, after he has examined the patient and done relevant investigations.
- In the case of death from anesthesia the surgeon or anesthetist should at once report the matter to the authorities for holding an enquiry. A medical practitioner may be held responsible civilly, but not criminally, for a negligent act of some third party such as a nurse, attendant, student or assistant employed to carry out nursing and medical duties of his patients if the act was committed in his presence and to which he acquiesced. This is known as vicarious responsibility. The principle of respondent superior is that “as a general rule a man is responsible for any wrongful act done by his agent or subordinate provided such act is within the reasonable scope of their employment. “However, he is not held responsible, if the negligent act was done in his absence and the nurse, student or assistant was considered quite competent to perform the act and had traversed beyond his instructions in committing it. In a case where a swab, sponge, instrument or some other foreign object is left in the patient’s body after an operation the surgeon renders himself liable for damage, even thought it is the theatre sister’s responsibility to count all the swabs, sponges and instruments used during the operation, inasmuch as the theatre sister and other assistant were acting under the direct and immediate supervision of the surgeon so long as the operation lasted in the practice of the institution as to what comes within, the scope of a nurse’s duties and to limit the surgeon’s liability for those matters over which he has direct personal control. Hospital mangers may be held responsible for the mistakes of house physician and surgeons or resident medical officers, who are their employees.
Resolutions on “Medical Secrecy” and on “Computers in Medicine” adopted by the World Medical Association in 1973
“WHEREAS the privacy of the individual is highly prized in most societies and widely accepted as a civil right and;
WHEREAS the confidential nature of the patient-doctor relationship is regarded by most doctors as extremely important and is taken for granted by the patient and;
WHEREAS there is an increasing tendency towards an intrusion on medical secrecy;
THEREFORE BE IT RESOLVED that the 27th World Medical Assembly reaffirm the vital importance of maintaining medical secrecy not as a privilege for the doctor, but to protect the privacy of the individual as the basis for the confidential relation between the patient and his doctor; and ask the United Nations, representing the people of the world, to give to the medical profession the needed help and to show ways for securing this fundamental right for the individual human being.”
Computers in Medicine
‘BE IT RESOLVED that the 27th World Medical Assembly-
(1) Draws the attention of the peoples of the world to the great advances and advantages resulting from the use of the computers and electronic data processing in the field of health, especially in patient care and epidemiology;
(2) Requests all national medical associations to take all possible steps in 0their countries to assure that medical secrecy, for the sake of the patient, will be guaranteed to the same degree in the future as in the past;
(3) Requests member countries of WMA to reject all attempts at having as a goal legislation authorizing any procedures to electronic data processing, which could endanger or undermine the right of the patient for medical secrecy;
(4) Express the strong opinion that medical data banks should be available only to the medical profession and should not, therefore, be linked to other central data banks and;
(5) Requests Council to prepare documents about the existing possibilities of safeguarding legally and technically the confidential nature of stored medical data.
The Declaration of Geneva (as amended by the 22nd World Medical Assembly, Sydney, Australia, in August 1968)
At the time of being admitted as a Member of the Medical Profession, one should take the following oath:
‘I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honor and the noble traditions of the medical profession;
My colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patients;
I will maintain the utmost respect for human life from the time of conception;
Even under threat, I will not use my medical knowledge contrary to the laws of humanity;
I make these promises solemnly, free and upon my honor.
THE INTERNATIONAL CODE OF MEDICAL ETHICS
DUTIES OF DOCTORS IN GENERAL
A DOCTOR SHALL always maintain the highest standards of professional conduct.
A DOCTOR SHALL not permits motives of profit to influence the free and independent exercise of professional judgment on behalf of patients.
A DOCTOR SHALL, in all types of medical practice, be dedicated to providing competent medical service in full technical and moral independence, with compassion and respect for human dignity.
A DOCTOR SHALL deal honestly with patients and colleagues, and strive to expose those doctors deficient in character or competence, or who engage in fraud or deception. The following practices are deemed to be unethical conduct:-
(a) Self-advertising by doctors, unless permitted by the laws of the country and the Code of Ethics of the National Medical Association
(b) Paying or receiving any fee or any other consideration solely to procure the referral of patient or for prescribing or referring a patient to any source.
A DOCTOR SHALL respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences.
A DOCTOR SHALL act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient.
A DOCTOR SHALL use great caution in divulging discoveries of new techniques or treatment through non-professional channels.
A DOCTOR SHALL certify only that which he has personally verified.
DUTIES OF DOCTORS TO THE SICK
A DOCTOR SHALL always bear in mind the obligation of preserving human life.
A DOCTOR SHALL owe his patients complete loyalty and all the resources of his science.
Whenever an examination or treatment is beyond the doctor’s capacity he should summon another doctor who has the necessary ability.
A DOCTOR SHALL preserve absolute confidentiality except where others are endangered on all he knows about his patient even after the patient has died.
A DOCTOR SHALL give emergency cares as a humanitarian duty unless he is assured that others are willing and able to give such care.
DUTIES OF DOCTORS TO EACH OTHER
A DOCTOR SHALL behave towards his colleagues as he would have them behave towards him.
A DOCTOR SHALL NOT entice patients from his colleagues.
Adopted by the 3rd General assembly of the World Medical Association.
England, October 1949, amended by the 22nd World Medical Assembly,
Australia, August 1968, and the 35th World Medical
Assembly, Venice, Italy, October 1983
In addition to the international code of ethics, a doctor must also observe the principles of “The Declaration of Geneva” approved by the World Medical Association. The Declaration of Geneva, states, inter alia, that, ‘I (a medical practitioner) will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient’. The 27th Meeting of the World Medical Association (WMA) held in Munich in 1973 resolved, therefore, that the ‘WMA vehemently condemns color, political and religious discrimination of any form in the training of medical practitioners and in the practice of medicine and in the provision of health services for the peoples of the world.’
Maldives Medical Council Guidelines on Doctor and the Media
Increasing public interest in health matters has brought doctors more and more into contact with the media. The Registered Medical Practitioners should be aware of the ethics involved in dealing with the media. The British Medical Association in its “Handbook of Medical Ethics” (1981) suggests the following guidelines: Those doctors able to comment authoritatively on medical subjects should be prepared to do so in order that the public may be informed. Those doctors able to help the public with information should regard talking to the media as an extension of their medical practice. A doctor has the responsibility to ensure that when a subject under discussion is controversial within the medical profession, the producer or editor of a program is made aware of that fact. It is unacceptable for the doctor’s identity to be revealed in the following circumstances: – when it does not add to his professional status; when it is in the public interest; when he is speaking on behalf of an identifiable section of the profession; and when using media primarily aimed at doctors. A doctor my use his own name in connection with subjects other than when discussing a medical subject. He may be named only in passing or in general terms, avoiding discussion of individual cases. In the field of general health education the name and relevant qualifications of the doctor may be given to lend added authority. Doctors making statements on behalf of known organizations may be named when this is in the public interest. However, a doctor must not exploit the media to promote any organization in which he has a financial interest. No doctor should enter into correspondence with an individual member of the lay public as a result or any publicity gained by the doctor.
Maldives Medical Council Guidelines on Human Experimentation
In 1964, the World Market Association drew up a code of ethics on human experimentation. This code, known as the Declaration of Helsinki, was revised in 1975 as follows: ‘It is the mission of the medical doctor to safeguard the health of the people. His or her knowledge and conscience are dedicated to the fulfillment of this mission.’ The declaration of Geneva of the World Medical Association binds the doctor with the words, “The Health of my patient will be my first consideration”, and the International Code of Medical Ethics declares that “Any act or advice which could weaken physical or mental resistance of a human being may be used only in his interest.” The purpose of biochemical research involving human subjects must be to improve diagnostic, therapeutic and prophylactic procedures and the understanding of the etiology and pathogenesis of disease. In current medical practice most diagnostic, therapeutic or prophylactic procedures involve hazards. This applies a fortiori to bio-chemical research. Medical progress is based on research, which ultimately must rest in part on experimentation involving human subjects. In the field of biochemical research in which the aim is essentially diagnostic or therapeutic for a patient, and medical research, the essential object of which is purely scientific and without direct diagnosis or therapeutic value to the person subjected to the research. Special caution must be exercised in the conduct of research, which may affect the environment, and the welfare of animals used for research must be respected. Because it is essential that the results of laboratory experiments be applied to human beings to further scientific knowledge and to help suffering humanity, the World Medical Association has prepared the following recommendations as a guide to every doctor in biomedical research involving human subjects. They should be kept under review in the future. It must be stressed that the standards as drafted are only a guide to physicians all over the world. Doctors are not relieved from criminal, civil and ethical responsibilities under the laws of their own countries.
(1) Biomedical research involving human subjects must conform to generally accepted scientific principles and should be based on adequately performed laboratory and animal experimentation and, on a through knowledge o the scientific literature.
(2) The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol, which should be transmitted to a specially appointed independent committee for consideration, comment and guidance.
(3) Biomedical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with the medically qualified person and never rest on the subject of the research, even though the subject has given his or her consent.
(4) Biomedical research involving human subjects cannot legitimately be carried out unless the importance of the objective is in proportion to the inherent risk to the subject.
(5) Every biomedical research project involving human subjects should be preceded by careful assessment of predictable risks in comparison with foreseeable benefits to the subject or to others. Concern for the interests of the subject must always prevail over the interests of science and society.
(6) The right of the research subject to safeguard his or her integrity must always be respected. Every precaution should be taken to respect the privacy of the subject and to minimize the impact of the study on the subject’s physical and integrity and on the personality of the