CODE OF ETHICS OF PRACTICE FOR MEDICAL AND DENTAL PRACTITIONERS,
[Gazette of Pakistan, Extraordinary, Part-II, 16th July, 2011]
S.R.O. 80(KE)/2011, dated 3.6.2011.–In exercise of the powers conferred by sub-section (1) (i) of Section 33 of the Pakistan Medical and Dental Council. Ordinance, 1962 (XXXII of 1962), the Pakistan Medical and Dental Council, with the previous sanction of the Federal Government, is pleased to make the following regulations, namely:
1. Short title and commencement.–(1). These regulations may be called the Code of Ethics of Practice for Medical and Dental Practitioners, Regulations, 2011.
(2) They shall come into force at once
(3) They shall extends to whole of Pakistan
2. Declaration before registration.–Each applicant, at the time of making an application for registration with the Council, shall submit a declaration that he has read, understood and agreed to abide by these regulations on the format set out in the Annexure I of these regulations.
3. Duties of physicians in general.–A physician shall always maintain highest standards of professional conduct and shall actively participate in continuous medical education and as such a physician shall,–
(a) not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patients;
(b) in all type of medical practice, be dedicated to providing competent medical services with full technical and moral independence, with compassion and respect for human dignity;
(c) deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence or who engage in fraud or deception;
(d) respect the rights of patients, colleagues and of other health professionals and shall safeguard patient confidences;
(e) 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;
(f) use great caution in divulging discoveries or new techniques or treatment through non-professional channels; and
(g) certify only that which he has personally verified.
4. Duties of Physicians to the Sick.–A physician shall–
(a) always bear in mind the obligation of preserving human life;
(b) owe his patients complete loyalty and all the resources of his science;
(c) summon another physician who has the necessary ability when ever an examination or treatment is beyond the former physician's capacity;
(d) preserve absolute confidentiality on all he knows about his patient even after the patient has died; and
(e) give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.
5. Duties of Physicians to each other.–A physician shall–
(a) behave towards his colleagues gently;
(b) not entice patients from his colleagues; and
(c) observe the principles of the "Declaration of Geneva" approved by the World Medical Association.
6. Medical Ethics and religion.–A medical or dental practitioner shall respect the beliefs of the patients and shall not impose his beliefs on the patient.
7. Practice of medicine, surgery and dentistry prohibited without registration etc. with Council.–(1) No person shall practice modern system of medicine or surgery unless that person is a doctor or dentist having registered qualification and valid registration with Pakistan Medical and Dental Council.
(2) Every medical or dental practitioner has to ensure that his registration with the Council is valid.
8. Display of registration numbers.–(1) Every medical or dental practitioner shall, in his clinic or place of practice, display a copy of valid registration certificate issued to him by the Council and refer his registration number in all his prescriptions, certificates, money receipts given to his patients.
(2) No medical or dental practitioner shall display suffixing to his name those degrees or diplomas which have not been registered by the Council. A medical or dental practitioner shall not be considered a specialist unless an additional qualification of that specialty has been registered by the Council against his name.
9. Rational use of drugs.–(1) Every Medical or dental practitioner shall adopt practice with good and rational practices to prescribe drugs.
(2) A medical or dental practitioner shall:–
(a) be free to choose whom to serve, with whom to associate and lay down the timings and place of professional service for the patients;
(b) not be bound to treat each and every person asking his services, but he shall not only be ever ready to respond to the calls of the sick and the injured, if in his opinion the situation warrants it as such, but shall be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties;
(c) in his treatment, never forget that the health and the lives of those entrusted to his care depend on his skill and attention; and
(d) if not available due to any reason and the patient requires continuous monitoring or care, then the Medical or dental practitioner shall arrange for another Medical or dental practitioner of sufficient proficiency as an alternate and inform the patient.
(3) For a medical or dental practitioner to advise a patient to seek service of another medical or dental practitioner is acceptable, however, in case of emergency, the medical or dental practitioner must treat the patient first.
(4) No medical or dental practitioner shall normally refuse treatment to a patient, however for good reason if the medical or dental practitioner thinks it would not be appropriate to provide his professional services to a particular patient or when a patient is suffering from an ailment which is not within the range of experience of the treating medical or dental practitioner, the medical or dental practitioner may refuse treatment and refer the patient to another medical or dental practitioner.
TEACHING ETHICS TO STUDENTS
10. The Teaching of medical ethics.–(1) The curriculum committee of the Council will ensure that adequate information on this Code of Ethics is included in the undergraduate medical college curriculum and that case studies have been prepared and disseminated to provide guidance to medical or dental practitioners.
(2) The goal of teaching medical ethics shall be to improve the quality of patient care by enhancing professional performance through a consideration of the clinician's values, beliefs, knowledge of ethical and legal construct, ability to recognize and analyze ethical problems and interpersonal and communication skills and consideration of the patient, whereby students shall be able to identify, analyze and attempt to resolve common ethical problems of medical and clinical nature.
(3) All medical and dental colleges running MBBS and BDS courses, College of Physician and Surgeons of Pakistan and universities running the postgraduate medical courses in Pakistan may incorporate medical ethics into their curriculum.
(4) Relevant books and journals shall be made available in the central and departmental libraries of the medical institutions, and publication of papers on issue related to medical ethics.
(5) All medical or dental practitioners may develop strategies for dissemination of information about ethics and ethical issues to their colleagues and students, public and patients, specifically when teaching medical and dental students.
11. Council's expectations.–The Council expects each medical or dental practitioner to–
(a) promote fundamental principle of responsibility of physicians to the right of individuals and societies to stated standards of professional competence, appropriate care, conduct and integrity of medical or dental practitioners;
(b) uphold the ethical principles of medical practice that is to say autonomy, beneficence, non-maleficience. and justice;
(c) ensure the protection of individual patients against harassment, discrimination and exploitation;
(d) take their responsibilities as a teacher seriously;
(e) be responsive to cultural and religious sensitivities;
(f) declare in a transparent manner, any potential conflict of interest;
(g) inculcate these values in students, through instruction and role modeling;
(h) promote the education of the public on (a) health issues and (b) their rights to quality care;
(i) ensure continuation of practice only when in normal physical and mental health; and
(j) bring colleagues to comply with these generally accepted norms of practice and expose physicians and dentists deficient in competence, care and conduct.
FUNDAMENTAL ELEMENTS OF PATIENT – PHYSICIAN RELATIONSHIP
12. Rights of the Patient.–(1) To share with physicians the responsibility for their own health care, the patient:–
(a) has right to receive information from physicians and to discuss the benefits, risks, costs of appropriate treatment, alternatives and optimal course of action:
(b) is entitled to obtain copies or summaries of their medical records, to have their questions answered and to receive independent additional professional opinions;
(c) has the right to make decisions regarding the health care that is recommended by his physician and as such the patients (or his next of kin) may accept or refuse any recommended medical treatment in writing;
(d) has the right to Courtesy, respect, dignity, timely responsiveness to his health needs, and respect of his gender and sanctity;
(e) has the right to confidentiality; and
(f) has the right to continuity of health care.
(2) The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient.
13. Second opinion.–Patients are entitled to a second or further medical opinion about their illness and on request, medical or dental practitioner must either initiate or facilitate a request for this and provide the information necessary for satisfactory referral.
14. Rights of the medical or dental practitioner.–It is obvious that patients and their attendants shall respect the privacy of the medical or dental practitioner. Patient shall call the medical or dental practitioner on telephone only in a dire emergency and not otherwise and on telephone, patients shall restrict themselves to their medical or dental problem only and not use this factlity for seeking other information.
ETHICAL STANDARDS OF PROFESSIONAL COMPETENCE, CARE AND CONDUCT
15. Conduct of medical or dental practitioner.–In all dealings with patients, it is expected that the interest of patient and advantage to the patient's health will be the major consideration to influence the medical or dental practitioners' conduct. The physician-patient-relationship shall be developed as one of trust. A professional shall always maintain and demonstrate a high standard of professional conduct by,–
(a) being in conformity with the principles of honesty and justice;
(b) not permitting motives of profit to influence (free and independent exercise of professional judgment;
(c) working with colleagues in ways that best serve patient's interests;
(d) not paying or receiving any fee or any other consideration solely to procure the referral of a patient or for prescribing or referring a patient to any source:
(e) maintaining the honorable tradition by which the physician is regarded as a friend to all persons of any class, caste, color, religion, sex, ethnicity, occupation, creed, religion and social status; and
(f) being honest, factual, objective, unbiased as a reviewer for scientific material for publication; for funding purposes; and when providing reference, ensuring that comments are honest, justifiable, unbiased and contain evidence on the subject's competence, performance, reliability and conduct, taking steps to ensure the accuracy of any public communications including the communication of degrees, institutional affiliation, extent of services offered and credentials.
16. Statement to patients and their relatives or representatives.—All statements to the patients or their representatives shall be made only by the consulting medical or dental practitioners and not by any associates or assistants etc.
17. Examination, consultation or procedures on a female patient.–(1) A female patient shall be given consultation either by a female medical or dental practitioner or shall be examined in the presence of a female attendant by a male doctor. Under no circumstances a male attendant, assistant or husband or relative etc shall be allowed during a gynecological and obstetrical consultation, examination or during normal delivery being conducted by a female medical practitioner. However in exceptional circumstances a patient may file a request with the medical practitioner to allow her husband to witness a normal delivery and the medical practitioner may consider the request and shall ensure that sanctity of the female patient is preserved during procedures and consultation and there is no unnecessary exposure.
18. Assistance of unregistered person prohibited.–(1) a medical or dental practitioner will not assist an unregistered person to practice or teach medicine or dentistry or associate professionally with such a person performing the functions as a medical or dental practitioner and knowingly assisting such an individual shall make a registered medical or dental practitioner liable to disciplinary action. This does not preclude a medical or dental practitioner from imparting proper training to medical students, nurses, midwives and other paramedical personnel, provided the doctor concerned keep a strict supervision over such individuals when treating patients.
(2) A medical or dental practitioner shall use great caution in divulging discoveries or new techniques or treatment through non-professional channels.
(3) A medical or dental practitioner shall not allow his name to be used by any other person or let any other person sit in his place of practice if that person is not a registered medical or dental practitioner.
(4) A physician shall owe his patients all the resources of his science. Whenever an examination or treatment is beyond the physician's capacity he shall consult another physician who has the necessary ability.
19. Prisoners.–Prisoners who are ill must be treated in the same manner as other sick people. However, doctors have a right to take appropriate precautions if they think there is a possibility of physical violence by the patient. Where a suspect refuses consent to a medical examination, the doctor unless directed to the contrary by a Court of law, shall refuse to make any statement based on his observation of the suspect other than to advise the police whether or not the suspect appears to require immediate treatment or removal to hospital. This does not of course, preclude the doctor from making a statement in Court based on such observation in circumstances where the accused later gives his consent to disclosure.
20. Permission of patient before examination.–A doctor shall normally take permission from a patient before making a physical examination. In case of minors, the child's guardian shall be present or give permission for the examination. For any intimate examination the patient, irrespective of age, patient is entitled to ask for an attendant to be present. Such requests shall be acceded to whenever possible.
21. Care.–(1) The patient-physician or patient dental practitioner relationship constitutes a fiduciary obligation, requiring physicians to be responsible to serve the interests of patients above their own financial or other interests. The medical or dental practitioner is expected to provide a quality of care for a patient which is timely, compassionate, respecting human privacy and dignity, non-discriminating and does not exploit vulnerable situations. Negligence in respect of professional duties may justify suspension or removal from the Register.
(2) The medical or dental practitioner shall bear in mind the obligation of preserving life and will not discriminate on the basis of age, sex, gender, class, race, ethnicity, national origin, religion, sexual orientation, disability, health conditions, marital discord, domestic or parental status, criminal record, or any other applicable bias as proscribed by law, and ensure that personal beliefs do not prejudice patient care.
(3) The Medical or dental practitioner shall not exploit persons over whom they have direct or indirect supervisory, evaluative, management or other authority, such as students and patients, supervisees, employees or research participants, whether for personal, professional or economic reasons.
(4) The medical or dental practitioner shall delegate to a student or other physician, only those responsibilities that such persons, based on their education, training and experience, can reasonably be expected to perform either independently or with the level of supervision provided.
(5) The Medical or dental practitioner shall additionally–
(a) identify themselves to patients whom they are treating;
(b) treat all patients with dignity and respect;
(c) listen to patients and respect their views;
(d) give patients (and provided patient agrees, family members) information (about their illness) in a way that they can understand;
(e) respect the rights of patients to be involved fully in decisions about their care;
(f) ensure that conflict of interest does not prevent them from performing their professional work in an unbiased manner; and
(g) adhere to veracity (truth telling) as judged in the patient's interest.
22. Details, of information.–It is obvious that patients do not always fully understand the information, and advice given to them by doctors. They shall be encouraged to ask questions. These shall be answered carefully in non-technical terms if necessary with or without information leaflets, as the aim is to promote understanding and to encourage compliance with recommended therapy. The doctor shall keep a note of such explanation and if it is felt that the patient still does not understand, it may be advisable to ask the patients permission to speak to a relative. The medical or dental practitioner shall break all news to the patient and relatives etc. himself and shall not allow his coworkers to do that.
23. Maternity care.–Registered medical practitioners who agree to undertake the antenatal and delivery care of a woman shall clearly inform her, in advance, the arrangements for delivery. In Pakistan, according to law a pregnancy can be terminated only if there is a serious risk to the life of the pregnant women. The choice of gender of baby by any means shall be illegal and the gender of the foetus shall not be disclosed unless it is absolutely sure that no harm shall come to the baby and mother as a result of this disclosure.
24. Information about doctor or dentist conducting procedures.—Patients undergoing procedures or treatment of any sort have the right to be informed as to which doctor or doctors are to be involved and what will be nature of the procedure with its advantages, disadvantages, risks and alternative, Options.
25. Competence.–(1) A medical or dental practitioner in active clinical practice is expected to continuously strive for improving his knowledge and keep abreast with the latest advancements in the field. He shall seek out sources of such knowledge and try to attend professional meetings or activities for advancement of professional knowledge. He shall maintain knowledge of CME programmes by Council and try to participate in them to gain CME credits. CME credits shall be provided by specialist boards authorized by Council for the purpose.
(2) The medical or dental practitioners will attempt to maintain the highest levels of competence in their work more specifically the skill in diagnosing, clinical decision-making, planning, implementation, monitoring and evaluation of intervention and teaching; and shall accept responsibility for their actions. They shall therefore,–
(a) only undertake tasks for which they are qualified allowed by virtue of education, training or experience and know their limitations;
(b) keep abreast of latest information about their subject through continuing education;
(c) ensure that their approach to patient management is consistent with current research, literature and practice;
(d) have an approach that favours competent clinical care through a careful assessment of the patient's problem, based on elicitation and analysis of the patient's history and physical examination; careful decisions on need for further investigation and request for additional consultation, appropriate management and prompt action where indicated, an approach that shuns internet prescribing or telephonic prescribing except when the physician is cognizant of the individuals past medical history;
(e) acquire the knowledge and skills to provide proper training and supervision to their students so that such persons perform services responsibly, competently and ethically; and will be honest and objective in the assessment and certification of performance of students supervised;
(f) monitor and maintain an awareness of the quality of the care provided by himself through a review of carefully recorded data and respond constructively to assessments by self and peers which identify need for further training or education;
(g) recognise the realistic efficacy of investigation and medication and use technology and medicine only where appropriate; and
(h) restrict prescription of drugs, appliances or treatments to only those that are beneficial to the patient.
26. Treatment without direct patient contact.–Prescribing of medications by medical or dental practitioners requires that the physician shall demonstrate that a documented history and physical examination and drug reaction history are available and that there has been a sufficient dialogue between the patient and the doctor on options in management, and a review of the course of the illness and side effects of the drug but the Council accepts that in an emergency, during on call or cover call, or when in a partnership the case records are available, a physician may prescribe a new prescription without seeing the patient but only emergency single dose shall be prescribed and the patient shall be called over for a checkup. Telemedicine to the extent of radiological reporting is allowed.
27. Confidentiality.–The physician has a right to and shall withhold disclosure of information received in a confidential context, whether this is from a patient or as a result of being involved in the management of the patient, or review of a paper, except in the following specific circumstances where he may carefully and selectively disclose information where health, safety and life of other individual may be involved, namely,–
(a) The medical or dental practitioner cannot seek to gain from information received in a confidential context (such as a paper sent for review) until that information is publicly available;
(b) There is no legal compulsion on a doctor to provide information concerning a criminal abortion, venereal disease, attempted suicide, or concealed birth regarding his patients to any other individual or organization. When in doubt concerning matters, which have a legal implication, the medical or dental practitioner may consult his/her legal adviser;
(c) The professional medical record of a patient shall not be handed over to any person without the consent of the patient or his/her legal representative. No one has a right to demand information from the doctor about his patient, save when the notification is required under a statutory or legal obligation and when in doubt, the medical or dental practitioner or a dentist may consult a legal advisor;
(d) confidences concerning individual or domestic life entrusted by patients to a medical or dental practitioner and defects in the disposition or character of patients observed during medical attendance shall never be revealed unless their revelation is required by law;
(e) a medical or dental practitioner who gains access to medical records or other information without consent shall be guilty of invasion of privacy; and
(f) the medical or dental practitioner who grants access of an information of a patient to a third person except, Council or law enforcing agencies, without consent shall be guilty of breach of confidentiality, but where a medical or dental practitioner is of the opinion to determine it his duty to society requiring him to employ knowledge about a patient obtained through confidence as a medical or dental practitioner, to protect a healthy person against a communicable disease to which he is about to be exposed, the Medical or dental practitioner shall give out information to concerned quarters.
28. Conflicts of interest.–For guidance of medical or dental practitioner a detail on conflict of interest is given at Annexure-II of these regulations.
29. Dealing with conflict of interest.–(1) A medical or dental practitioner must act in patient's best interests when making referrals and providing or arranging treatment or care and no inducement, gift or hospitality which may affect or be seen to affect judgment may be accepted and nor shall such inducements offered to colleagues.
(2) Financial commercial interests in organizations providing health care or in pharmaceutical or other biomedical companies must not affect the way that patients are prescribed, treated or referred.
(3) Financial or commercial interest in an organization to which a patient is to be referred for treatment or investigation must be declared to the patient
(4) Before taking part in discussions about buying goods or services, any relevant financial or commercial interest which the medical or dental practitioner or the medical or dental practitioner's family might have in the purchases, must be declared.