Negligence And Medical Ethics

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Here I am trying to explain how Medical Negligence and Medical Ethics are interlinked and why doctors must do all they can to defend our ethics. I am sharing case history, every day clinical examinations and management of common illness to explain why they are unethical medical practice. Since I published a letter in 1996, critisising the use of preprinted assessment sheet, allowing nurses to work like doctors in the NHS(UK), the number of deaths, complications and wrong doings has escalated to catastrophic proportions. Doctors who continue to work are suffering in silence. The ones who raised concern were systamatically harassed, bullied and ostracised. The institutions, associations, nursing council and the Royal Colleges and the WMA have ignored their duty to protect fellow human. I do not think we can claim to be members of a "Noble Profession" if we allow this un-ethical medical practice continues. The General Medical Has not only ignored their duty to protect fellow human but also discriminated doctors passing out from Non-European medical schools by allowing nurses to work like doctors. This institution has failed to define the word "Doctor" and has inflicted pain and suffering to doctors who defend their moral and ethical duty. Our profession and our lives are threatened by emerging and antibiotic resistant infections. We must join hands and defend our profession. By allowing nurses with no medical school training or skill to clinically examine patients to diagnose and prescribe drugs, we have failed to protect fellow human who trust our profession. This is substandard, un-ethical medical practice that has brought us shame must be stopped. Please leave your comments and criticise me if I am wrong. As a Hindu Brahmin, it is my religious duty to defend "Dharma", protect the sick and vulnerable. Please watch this presentation and ask your self have you fulfilled your promise and are you defending your faith?
  • 1. NEGLIGENCE By Dr Kadiyali M Srivatsa Ethical duty of a doctor is to protect human rights and dignity of the patient Physician’s must “Disobey Law” that demand “Un-Ethical Behavior”
  • 2. ACT OF COMMISION To Do Something Which A Prudent Man In Similar Situation “Will NOT DO” - Alderson 1843 -
  • 3. ACT OF OMISSION Not Do Something Which A Prudent Man In Similar Situation “WILL DO”
  • 4. DILIGENCE Diligent Behavior Is Indicative Of “WORK ETHICS” You must understand “Diligence” before you can understand all about ethics A Belief That “Work Is Worship” Ref: Keith E. Thurley, Sek Hong Ng (1996), "The Concept of the Work Ethic",
  • 5. DILIGENCE Steady, earnest, conscientious application of one’s energy to accomplish what have been undertaken Exercise of investing all energy to complete the assigned tasks.
  • 6. DILIGENCE Continue to work hard and vigilant Avoid errors and stay focused on the task Pays careful attention to details Dedicated to achieving quality results. Committed to transform vision into reality. Work hard towards goal. My Vision: “Bring Tears Of Happiness”
  • 7. DILIGENCE ”The Seventh Heavenly Virtues” A zealous and careful nature in one's actions and work. Decisive work ethic, steadfastness in belief, fortitude, and the capability of not giving up. Budgeting one's time Monitoring one's own activities Upholding one's convictions at all times - especially when no one else is watching “This is called Integrity”
  • 8. FACTORS THAT INFLUENCE DILIGENCE  Discipline  Motivation  Concentration  Responsibility  Devotedness Ref: H Bernard, DD Drake, JJ Pace (1996)
  • 9. DILIGENCE IN BUDDHISM  Strive on with Diligence  Diligence is an integral part of Buddhism  The Fourth of paramita (wisdom)  “Diligence is the third paramita that lead to Liberation  Diligence will bring an increases of quality Je Gampopa (1994), Gems of Dharma, Jewels of Freedom, Altea Publishing, p. 163
  • 11. DILIGENCE IN CHRISTIANITY Diligence and Faith are two sides of a mystery
  • 12. DILIGENCE IN CHRISTIANITY  Effort to do one's part  Diligence and faith are two sides of a mystery.  One doesn’t know how, despite one's effort, it all works out.  When combined with faith assures spiritual success.  One of seven virtues describes thoroughness, completeness and persistence of an action, particularly in matters of faith. 1. How do we live the Christian Life? David Sper (2002) 2. Andreas J. Kšstenberger (2011), Excellence: The Character of God and the Pursuit of Scholarly Virtue.
  • 13. DILIGENCE IN BIBLE  Show this same diligence to the very end to make your hope sure.  Do not become lazy  Imitate those who through faith and patience inherit what has been promised”. The Holy Bible: New International Version. International Bible Society, (1973), THE LETTER OF PAUL TO THE HEBREWS 6:11-12
  • 14. SEVEN HEAVENLY VIRTUES  To oppose the seven deadly sins  Psychomachia or Battle of the soul or the Battle between Good Virtues & Evil Vices  Work in middle ages helped to spread the concept in Europe.  The Virtues are chastity, temperance, charity, diligence, patience, kind ness and humanity  Practicing these seven virtues is said to protect one against temptation from seven deadly sins. Ref: Aurelius Clemens Prudentius, a Christian governor who died around 410 A.D.,
  • 16. DILIGENCE IN ISLAM That man can have nothing but what he strives for; the fruit of his striving will soon come in sight. He will he be rewarded with a reward complete. The Quran; An-Najm 53:39-41
  • 17. DILIGENCE IN HINDUISM Discover and live a “Dharmic life”. Live with right intention and diligence Have “Concern for well being of others” 1. Brian Hatcher (2008), Bourgeois Hinduism or Faith of the Modern Vedantists, Oxford University Press. 2. Hatcher, B. A. (2007). Bourgeois Vedānta: The Colonial Roots of Middle-class Hinduism. Journal of the American Academy of Religion, 75(2), 298-323.
  • 18. DUTY OF A HINDU Every Hindu Will 1.Jnana Yogi : Acquire Knowledge 2.Bhakti Yogi : Dedication 3.Karma Yogi: Work is Worship 4.Raja Yogi: Universal Self. Hindu who acquire knowledge and dedicate his life is “Karma Yogi” He will transcend the limits of the finite self will embrace universe as the King “Raja Yogi” before Mohksha
  • 19. BRAHMAN AND MAYA • Brahman is the key metaphysical concept in various schools of Hindu philosophy. • It is the theme in its diverse discussions. • METAPHYSICS: What is ultimately real, and are there principles applying to everything that is real? • Brahman is the ultimate “Eternally constant reality” • Observed “Universe is constantly changing”. • Maya pre-exists and co-exists with Brahman • Ultimate reality, Highest Universal and Cosmic Principle
  • 20. MAYA & BRAHMAN • Maya is “perceived reality”, one that does not reveal the hidden principles, the true reality is – The Brahman. • Maya is unconscious, Brahman-Atman is conscious. • Maya is the literal and the effect, Brahman – the principle and the cause. • Maya is born, changes, evolves, dies with time • Brahman-Atman is eternal, unchanging, invisible principle, unaffected absolute and resplendent consciousness. • Maya concept is "the indifferent aggregate of all the possibilities of emanatory or derived existences, pre-existing with Brahman", just like future tree pre-exists in the seed of the tree.
  • 21. HUMAN RIGHT (1948) • Started with United Nations in 1945 • The Universal Declaration of Human Rights 1948 define human rights. • Ethical duty of a doctor is to protect the human rights and dignity of the patient • Document that defines human rights has had its effect on medical ethics.
  • 22. ETHICS & MORALITY ETHICS •Ethics is the study of morality •Systemic reflection on and analysis of moral decisions and behavior whether past, present or future. MORALITY •NOUN: Rights, Responsibility, Virtues •ADJECTIVE: Good, Bad, Right, Wrong, Just & Un Just
  • 23. MEDICAL ETHICS Ethics is a Matter of KNOWING Morality is a matter of DOING Rational criteria to DECIDE or BEHAVE Higher standards of behavior than LAW Ethics Require Physicians DISOBEY LAW that demand UN-ETHICAL BEHAVIOUS
  • 24. MEDICAL ETHICS  Moral Principles that apply values and judgments to the practice of medicine.  Practical application in clinical settings as well as work on its history, philosophy, and sociology. “ If I have to or forced to “Do Something” a prudent man will not do or “Do Not Do Something” a Prudent man in similar situation “Will Do”, I feel very uncomfortable and so must be “Un-Ethical.”
  • 25. HINDU MEDICAL ETHICS (600 BC) Study of science to attaining virtue, wealth and pleasure. Help relief pain and suffering inflicted upon fellow human who walk in the path of “Righteousness”. Duty to defend & protect “Righteousness” Gain knowledge of truth, acquire spiritual merit to help humanity. “Knowledge of Health is Knowledge of Life” Ref: Medical ethics - as prescribed by Caraka, Susruta and other ancient Indian physicians. HANDBOOK ON MEDICAL ETHICS
  • 26. HINDUISM & MEDICINE Medicine is a life long study of life with no limits. Must apply thyself to it with diligence. Learn the skill of practice from another without carping. The entire world is the teacher to the intelligent and foe to the unintelligent. You should listen and act according to the words of instruction of even an unfriendly person, when they are worthy. “Good physician should always persevere to do his best in the acquisition of the true qualities of a physician so that he may be a real giver of life to people’
  • 27. ETHICS & RELEGIOUS TEACHING “Hippocratic Oath” – A Promise “Formula Comitis Archiatorum” Code of ethics 5th Century Islamic scholors wrote the Conduct of a Physician, 1st Book Of Medical Ethics. Jewish and Christian thinkers describe case-oriented analysis Catholic moral theology.
  • 28. EUROPEAN MEDICAL ETHICS 1800-1900 Moral self-conscious discourse. Thomas Percival Modern code of medical ethics in UK Pamphlet with the code in 1794 Expanded version “Medical Ethics” 1803.
  • 29. CAVEAT EMPTOR Let the buyer, purchaser or receiver (patient) make diligent survey or assessment. The duty of seller or provider of service (doctor) must be honest and share information
  • 31. NURSES FAILED BOLAM TEST Nurses I identified to have inflicted pain and suffering to fellow human failed “BolamTest”, It is “My Duty” to raise concern about wrong doings as a prudent doctor in a similar situation will do.
  • 34. NURSE ON CALL - 2006July2006
  • 35. NURSE ON CALL - 2013
  • 37. SEPTICEMIA - 37,000 DIE
  • 39. BREACH OF DUTY Nexus Between Damage & Negligence
  • 40. NEGLIGENT CARE Un-Ethical Medical Practice  Community nurses in UK were trained for six months to clinically examine patients by senior nurses  NO Formal Medical School Training or experience  7000 Independent Nurse Practitioners were employed by the NHS to work as doctors and prescribe drugs.  Nurses with no formal emergency care training diagnose, triage patients with medical emergency  The number of patients referred to A&E, specialist has doubled since 2006.  Wrong diagnosis – treatment result in delay, prolonged pain, suffering and complications.
  • 41. UNETHICAL “SUBSTANDARD CARE”  Independent Nurse Practitioners: Not trained or supervised.  Nurses are used in A&E / ER in hospitals to perform initial assessment and discharge, admit or refer to doctors  “Walk In Clinics” managed by “Nurse Practitioners since 2006.  Clinical errors, complications, deaths, hospital admissions has doubled since 2006.  Avoidable death has increased.  Majority of hospitals are bankrupted by escalating cost.  Compensation payment has increased to £1.5 Billions  The best health care system in the world is now crumbling
  • 42. BOLAM TEST  A doctor need not possess the highest expert skill.  It is sufficient if the doctor exercise the ordinary skill of a competent doctor exercising that particular art  Must use knowledge, clinical examination, diagnosis, treatment or advice as another doctors in similar situation” Will Do”
  • 44. Medical School  Year 1: Acquire in-depth knowledge of Anatomy (human body), Physiology (How body works), Biochemistry (chemical changes in body)  Year 2-3: Pathology (abnormal functions), Microbiology (bacteria and infections), Pharmacology, Forensic, Orthopedics, Ophthalmology and dermatology  Year 3-5: Clinical Skill training (How to examine patients and diagnose illness and how to treat using drugs. Pass Final Examination before they can work as doctors under supervision in hospital
  • 45. Junior Doctor In Hospital  Year 1: Pre-registration house officer (PRHO) - 1 year  Year 2: Senior house officer a minimum of 2 years  Year 4: Specialty Registrar in general practice: 3 years  Year 5: General practitioner: total time in training: 5 years  Years 6-8: General practitioner after passing Examination  Year 9: Consultant total time in training: 7-9 years After completing they are expected to pass examination to prove they are safe to work independently as a consultant and not under supervision
  • 46. Nurse Training • Theoretical and practical training to nurse • No formal training to clinically examine and diagnose • No in-depth knowledge of pathology or drugs • Learn to take care of patients personal, physical and psychological wellbeing • Trained to offer treatment as advised by doctor • Educated by senior nurses and NOT BY DOCTORS • Registration as typical nurse is four years • Specialist Nurse Prescriber: Six months course to learn what doctors spend 10-12 Years!!!
  • 47. DOCTOR & NURSE DUTY OF NURSE Nurses job is to look after people who are ill. Hospitals are full of sick people who need social care to help them get better. These sick people are called patients. Many nurses work in hospitals taking care of patients DUTY OF A DOCTOR Doctor in the hospitals find out about patients illness and then the doctor tell the nurse what to do to help the patient get better. The nurse carry out doctors order and care for the patient until they are well enough to go home
  • 48. Early Diagnosis, Treatment & Referral To Specialist Care
  • 49. 1. WEEK NURSE Initial Diagnosis and Treatment is wrong – Delay 2. WEEK DOCTOR Doctor start from assessment, investigation, diagnose and treat – Failure 3. WEEK Process to Refer to Specialist start.
  • 50. WHY DISOBEY LAW? • Antibiotics resistant bacteria is threatening our very existence. • Knowing abusing this drug by allowing people who are not trained to clinically examine, perform tests and diagnose infections is helping bacteria develop resistance • Prescribing antibiotics claiming to be based on evidence based medicine is not safe and not in the interest of our profession • Wrong dose result in helping resistant strains colonisation • Excessive use result in antibiotics pollute environment • Ignoring and allowing people in power to continue “Un-Ethical Medical Practice” is immoral and unethical • Physician’s duty is to “Disobey Law” that demand “Un-Ethical Behavior”
  • 51. STANDARD OF CARE DIFFER • Primary care physician and Consultant • Physician and Surgeon • Junior doctor and Consultant • Nurses and Doctors • Place the Treatment is given (Primary care and Hospital care) When Medical Errors Are Committed, The Court Has To Decide Whether The Injury Caused Was Accidental Or Non-Accidental Injury
  • 52. ACCIDENTAL INJURY • Accidental injury or misfortune without criminal intent is not an offence. • Accidental injury is not an offence or neglect. • Doing a lawful act in a lawful manner by lawful means with proper care and caution is not neglect
  • 53. MODE OF TREATMENT Two School of Thoughts for given situation If doctor adopts one of them, he/she is justified and Not Negligent
  • 54. ACCIDENTAL INJURY •Who did it? •Whom it was done? •Where was it done? •When was it done? •How was it done?
  • 55. ACCIDENTAL INJURY • If the answers to all the questions are satisfactory then you can plead the injury as accidental injury and not neglect • If Answers to all the questions are favorable and still something goes wrong then it can be regarded as an accident
  • 56. REO Vs. MINISTER OF HEALTH (1954)  Anesthetist used spinal anesthesia (Procaine) which was stored in a solution of phenol.  The incidence took place in a hospital in 1947.  Patient developed diplegia (paralysed below waist)  In 1951, the hospital discovered cracks in the ampules that were stored in phenol. Doctor was not found to be negligent because he had adopted standard practice recommended in 1947. The standard of practice is to be judged at the time and date of the incidence and not the date of trial.
  • 57. BOLAM Vs. FRIERN HOSPITAL (1957) Mental health patient advised ECT He was not given anesthesia Patient sustained fractured hip and claimed compensation Court Ruled sufficient skill exercised accordance with accepted practice by “Reasonable body of medical men defending”. Doctor was not negligent, because other skilled in the particular art have opinion adverse to it.
  • 58. DUTY OF CARE
  • 59. DAMAGE • When DAMAGE is not direct but REMOTE and the REMOTNESS of the consequence could be FORESEEN or PRE-RECOGNISED • The Doctors will be held RESPOSIBLE even for REMOTE CONSEQUENCE
  • 61. DOCTOR’S RESPONSABILITY • Duty of doctors is to raise concern if patients suffer pain, demeaning treatment, torture or harm inflicted by others. • If a doctors does not raise concern, he or she can be held responsible for contributing to negligent care. • Doctor or nurse performing procedure, committed error in diagnosis or prescribed a drugs that I in a similar situation would not have - Then this is Commission “Negligent care” • Doctors or nurse did not act, prescribe or refer patients to hospital when I in similar situation would have – This is Omission and so could be labeled “Medical Negligence”
  • 62. WHY NURSE FAILED BOLAM TEST Nurses Working As Doctors • Nurse need not possess the highest expert skills. • Nurse did not exercise the ordinary skill of an ordinary competent doctor exercising that particular art and so inflicted pain and suffering to fellow human.
  • 63. ACT OF COMMISION Nurses Did Something which a General Practitioner in similar situation Will Not Do. “MEDICAL NEGLIGENCE”
  • 64. ACT OF COMMISION Labeling Infections Or Illness As URTI, LRTI, Cough, Cold, GE And Antibiotic Prescribed Is An Act Of Commission Because These Are Not Accepted As Illness or Disease By Doctors All Over The World. Patients Can Take Legal Action
  • 65. ACT OF OMMISION Prescribing Antibiotic For Viral Infection Result In Patient Colonizing With Antibiotic Resistant Bacteria. If The Patient Develops Septicemia Due To Resistant Strain And Die, Relatives Can Take Legal Action Against The Doctor because “Doctors Did Not make the correct Diagnosis”
  • 66. ACT OF OMMISSION Doctor or Nurse who Does NOT DO what another doctors in similar situation “WILL DO”
  • 67. ACT OF OMMISSION Doctor or Nurse who Does NOT DO what another doctors in similar situation “WILL DO”
  • 68. ACT OF OMMISSION Doctor or Nurse who Did NOT DO what another doctors in similar situation “WILL DO” This 18 Years old girl presented with history of Anxiety and Hoarse voice Doctors and nurses failed to undress and examine Her chest for almost 2 years but refered her to Speech therepist
  • 69. ACT OF OMMISION Wrong Diagnosis And Treatment 25 years man with rash on his cheek and neck went to local walk in clinic and consulted a nurse. Diagnosis: “Shingles and advised acyclovir cream and paracetamol Two days later, he was seen by doctors in surgery Diagnosis “Septic Shock” with low Blood pressure Doctors in similar situation would have diagnosed “Imedigo” and prescribed th right Antibioitc and advised isolation. This is “Act of Omission” resulted in complication and almost death and so “Negligence”
  • 70. ACT OF OMISSION Wrong Diagnosis & Treatment resulted in spreading infection to others in the family
  • 71. ACT OF OMISSION Diagnosed But Treatment Not Given  2 years old child taken to local walk-in-clinic on Saturday. Seen by a nurse and told the child has chest infection. No treatment given but asked to consult doctor in the surgery on Monday morning. Child seen on Monday morning as an emergency. The child was unwell, grunting and breathless with mild fever. Clinically “Serious lobar pneumonia” due to delay and not offering antibiotics early. The nurse should have offered antibiotic or refer to hospital care. The nurses are not allowed to treat children less than 2 years in the walk in clinic, so the nurse did not do what a prudent doctor in a similar situation would do (Ref to refer to specialist care in a hospital). This is an “Act of Omission” and so “Medical Negligence
  • 72. ACT OF OMMISION Correct Diagnosis But Not Managed Well  District nurse visit terminally ill patient at home. He is on high dose of codeine phosphate and opioids for pain relief.  This patient complaints about pain in supra-pubic area and unable to pass urine and severe constipation.  District nurse
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