PRESENTER : DR.

TEENU THOMAS
GUIDE : DR. DEEPAK NAIK P
CO-GUIDE : DR. SOURABH C M
 INTRODUCTION

 DOCTOR - PATIENT RELATIONSHIP

 PRINCIPLES OF ETHICS

 SURGICAL ETHICS ISSUES

 END OF LIFE ISSUES

 CONCLUSION
 CHARACTER

INTRODUCTION
 Greek healers in the 4th Century B.C., drafted the

Hippocratic Oath and pledged to –

“Prescribe regimens for the good of my patients according

to my ability and my judgment and never do harm to
anyone”

 In 1847, the American Medical Association adopted its

first code of ethics, with this being based in large part

upon Percival work.
 - Honesty and Integrity

 - Mutual respect

 - Trust

 - Empathy

 - Mutual goals
AUTONOMY
 Patient has freedom of thought, intention and action when making decisions

regarding health care procedures.

 To make a fully informed decision, she/he must understand :

 All risks and benefits of the procedure

 Likelihood of success.

 Informed clearly the consequences of surgery that may affect him

adversely
 Patients have the right to exercise choice over their surgical care and

should be allowed to refuse treatments that they do not want, even when
surgeons think that they are wrong.(Patients can refuse surgical treatment
that will save their lives, either at present or in the future. )

 In the case of a child, the principle of avoiding the harm of death, and

providing a medical benefit would be given precedence over the

autonomy of the child's parents as surrogate decision makers.
 The surgeon should act in “the best interest” of the patient - the procedure
be provided with the intent of doing good to the patient

 One should do Minimizing harm to patient (including pain control).

 Surgeons needs to develop and maintain skills and knowledge by

continually updating training and consider individual circumstances of all
patients.

 The conscientious surgeon should thus ensure that the equipment is

functioning and reliable. Faulty equipment compromises patient care and
increases the like hood of surgical complications
 “Above all, do no harm,“

 The procedure does not harm the patient or others in society.

 Ability of surgeon to exercise sound judgment and recognizing the limits

of one’s professional competence.

 Surgeon should know when and where to stop scalpel.

SOLUTION :

Research and auditing - update his knowledge.

 Disclosure and discussion of surgical complications including medical errors.

 Regular “mortality and morbidity” meetings in which surgical teams review any recent

complications.
 “Fairness and equality ”

 The burdens and benefits of new or experimental treatments must

be distributed equally among all groups in society.

 The four main areas that surgeon must consider when evaluating JUSTICE :

1. Fair distribution of scarce resources

2. Competing needs

3. Rights and obligations

4. Potential conflicts with established legislations

 DUTY OF CANDOUR

 Equal consideration should be given to disclosure of information that

was generated by the intervention, particularly where ‘something

went wrong’ that caused (or had the potential to cause) harm or
distress. The duty to disclose these matters is described as the duty
of candour.

 Failure to disclose these foreseeable complications prior to surgery

may lead to a claim that the consent was invalid.

• As Surgeon ethical issues in operation theatre

• Informed consent and difficulties

• Confidentiality

• Surgical research

• Excellent standards
 ETHICAL ISSUES IN OPERATION THEATRE
1. Exposure of Body :

 Protect privacy and dignity of patient.

 Parts of body should not be exposed to others.

 Whenever exposure is necessary, it should be limited to parts needed only in the

presence of limited number of people.

 If female patient - in the presence of female staff.

 Exceptions are allowed when necessary according to a definite need.

Examples: -

 Preparation for anesthesia

 Chest auscultation and inspection.

 Insertion of foley’s catheter.

2. OT Traffic and Noise

 In the corridors, receiving area and OT → causes inconvenience to patients and staff.

 Problem related to the behavior of staff and students and limited space in OT.

 Patients coming to OR are worried → need privacy, silence and reassurance.

 Noise should be kept to minimum.

 Discussions should be in staff rooms only, away from patients.

3.Comments And Behaviour

 No Jokes and laughing, speaking Loudly infront of

patients in a language not known to them, before

anesthesia, during procedure with local/spinal

anesthesia.

 Comments regarding disease, body shape and

weight -should not be said if patient is awake.

4.Honesty

 The answer should be honest and concentrate on:

- Concept of team work.

- Quality is assured.

- Supervised by the consultant / senior staff.

INFORMED CONSENT AND DIFFICULTIES
 Consent means voluntary agreement, compliance or permission

 To be legally valid, it must be given after understanding what it is given for and of

the risks involved

Why to obtain consent ?

To examine, treat or operate a patient without consent is an assault in law, even if it is

beneficial and done in good faith.If the doctor fails to give required information to
the patient prior to obtaining consent, he may be charged for negligence
 Components of an acceptable Informed Consent are:

1. Decision-Making Capacity

2. Complete Disclosure

3. Understanding

4. Comprehensive discussion between the patient and treating Surgeon

5. Complete documentation of the discussion in the medical record

6. Consent form is not the appropriate document to fully describe the consent process

7. Should not be delegated to most junior member of the team

 For consent to be valid, adult patients must:

 Capacity to give it – able to understand, remember information disclosed to them about

treatment choices

 Not be coerced into decisions that reflect the preferences of others

 Have been given suffcient information for these choices to be based on an accurate

understanding of reasons for and against with specific treatments.

 Surgery on patients who are temporarily incapacitated should be postponed until

their capacity is restored.

 Recommendations include all complications that may have a significant effect on

outcome and explain what treatment may be necessary.

 DO NOT ATTEMPT RESUSCITATION? Doctors must discuss it with patients or their

relatives. The reason for this is that the patient may have personal circumstances
that might influence this final decision.
 The process of informed consent is designed to ensure that the patient has a complete
understanding.

o Venue : Calm & quiet place

o Consent form : Patient’s language

(written ; with diagrams)

o Time : Patient should take time and take own decision

o Principle person : Surgeon

o Entry : Case record

o Information : accurate and reasonably complete.

ALSO…

 Avoid Technical language

 Provision of translators should be there for Clarification of doubts

 It should not be taken by a junior member of staff who has never conducted

such a procedure and thus may not have enough understanding to counsel

the patient properly.

Disclosure prior to consent must include:

i. Condition and the reasons for surgery

ii. Type of surgery proposed and how it might correct the condition

iii. Anticipated prognosis and expected /unexpected side effects of the proposed surgery.

iv. Any alternative and potentially successful

treatments other than the proposed surgery.

iv. Consequences of no treatment at all.

 Often called “decision-making capacity”.

 Patient has the ability to understand the problem, options of

treatment, and risks/benefits of each approach.

 Patient can understand and select an approach.

 Practical Difficulties

1. Refusal by patient for surgery.

2. Temporary Unconsciousness patients.

3. Children less than 18 yrs ( parents or someone with parental responsibility

are ordinarily required to provide consent on their behalf.)

If faced with a surgical emergency in a child of 15 for whom no consent is

available for life- or limb-saving treatment, and there is no time to seek
authority , the child or the court, then proceed with the operation without
consent
4. Only if it is established that such patients also (in addition to or as a consequence of

their mental illness) lack capacity to provide consent - proceed in their best interests.

OR if possible postpone treatment until patients become able either to consent or to

refuse

5. Relatives of incapacitated adult patients can sign consent forms for surgery on their

behalf if appointed as a deputy by the Court of Protection.

6. INCAPACITY IN AN EMERGENCY If an adult lacks capacity, and you are treating in

their best interests to save life and to prevent serious and permanent injury.
 Attention must be paid to:

 whether or not the patient has understood what has been stated;

 avoiding overly technical language in descriptions and explanations;

 the provision of translators for patients whose first language is not English;

asking patients if they have further questions.

 A signed consent form is not proof that valid consent has been

obtained.Even when they have provided their signature, patients can and
do deny that appropriate information has been communicated.

 Surgeons are therefore well advised to make brief notes of what they have

said to patients about their proposed treatments, especially information

about signifcant risks. These notes should be placed in the patient’s clinical
record.
 CONFIDENTIALITY
 The principle of confidentiality is that
the information a patient reveals to a
surgeon is private and has limits on how
and when it can be disclosed to a third
party.

 The patient have right to dignity.

 They undermine the trust between

surgeon and patient on which successful
surgery and the professional reputations
of surgeons depend.
 Breaking confidentiality :

A. Police : Doctors should consider disclosure if the alleged offence is

grave.Clinicians must disclose to the police any information identifying of

committing a grave offence (threat to self or others ) and even in the absence of

a police request.

B. As a result of court orders

C. To the requirements of public health legislation.

 RESEARCH
 Surgeons have responsibility to improve operative techniques through research, to

assure their patients that the care proposed is best.

 The administration of such regulation is through research ethics committees.

 Surgeons should not participate in research that has not been approved by such

bodies.
 GOOD STANDARDS
 Surgeons must only offer specialised treatment in
which they have been properly trained.

 They also have a duty to monitor the performance of

their colleagues.

 Surgical teams and the institutions in which they

function should have clear protocols for exposing
unacceptable professional performance.
 END OF LIFE –ISSUES
Surgeon need not provide treatment in situations where :

 In unusual circumstances (close to death) that no evidence shows that a specific

treatment desired by the patient will provide any benefit from any perspective.

 If there are no treatment options i.e. brain dead and the family insists on

treatment – if there is nothing that the surgeon can do.

Noted in case sheet along with senior clinician’s agreement if the law allows.
 Informed consent is an important legal document

 Exercise a reasonable degree of care

 Establish a good rapport with the patient and family

 Medical records helps a lot in defending the case in issue of claimed

professional negligence

 Conduct of ethical surgery illustrates good citizenship: protecting the

vulnerable and respecting human equality.

 Deficiencies exist in the application of some ethical standards.

 Preserve Patients’ dignity during all phases of transportation. Patients

should not be exposed unnecessarily regarding: area of exposure,

duration of exposure and number of people present during exposure.

 Good Surgical Practice states that ‘a surgeon should be courteous

when working with all members of the surgical team’.

 Bailey & Love’s Short Practice of Surgery, 28th e

 Surgical Ethics - Indian Perspective

YOU