Legal And Ethical Aspects Of Practice Of Medicine

Legal and ethical aspects of practice of medicine

• Medical service being the most humane of the services to humanity, it needs constant improvement, enrichment and application of mind ． A qualified medical practitioner, who is entrusted with the physical and mental well-being of his patient must realize his obligations to his patient.The society also has obligations to its members.

• It has to see that the man (the doctor), on whom it has vested the duty to safeguard the life and health of the members of the society, does his job with responsibility. The medical practitioner must also be aware of his responsibility to the society.

• There is ample scope for the doctor to misuse his special capacity and position in the society for his own interest at the cost of others. The society and the state cannot allow this ． Both the members of the medical profession and the society or for that purpose the state, must concurrently try to uphold the respectful position of the profession.

• Hence, the members of the profession follow certain ethics and etiquettes and the government has framed certain legislations and Acts concerning the practice of medicine. If a doctor delierately does any wrong or harm to his patient who hopefully surrenders himself to his physician for his well-being, then these Acts and legislations come to the rescue of the sufferer and the erring doctor is punished.

• Hence, it is imperative that, the new medical practitioner is well conversed with the provisions of these legislations and that he knows his own rights as well as his duties and obligations to his patient and the society.

• On the basis of the necessity narrated above, the members of the medical profession themselves follow certain ethics and etiquettes in course of their professional practice.

• ETHICS is the understanding of moral values. • The CODE OF ETHICS is the rules framed in this line and on the basis of this sense of moral values, to guide the conduct of all concerned ． • MEDICAL ETHICS means the moral principles which should guide the members of the medical profession in course of their practice of medicine and their dealings with their patients and other members of the profession.

• The term MEDICAL ETIQUETTE is essentially limited within the mutual relationship between members of the medical profession. It actually means the sense of courtesy and respect which should govern the conduct and relationship between the members of the medical profession.

• Different codes of Ethics • The history of the first use of code of ethics in the practice of medicine can be traced as back as in the 5th and 4th century B.C. (sometime between 460~377 B.C., the accepted life period of the "Father of Medicine", Hippocrates). Hippocrates recommended certain principles for those who choose to practice medicine. These principles are accepted by the new practitioner in the form of oath ．

• The Oath of Hippocrates • 1. I swear by Apollo Physician, by Asklepios, by Health, by Panacea, and by all the Gods and Goddesses, making them witnesses, that I will carry out, according to my ability and judgement, this oath and this indenture. • 2. To regard my teacher in this art as equal to my own parents ； to make him partner in my livelihood; when he is in need of money to share mine with him ； to consider his offspring as my own brother ； to teach them this art if they require to learn it, without fee or indenture.

• 3. To impart precept, oral instruction, and all other learning to my sons, to the sons of my teacher, and to pupils who have signed the indenture and sworn obedience to the physicians' law, but to none other. • 4. I will use treatment to help the sick according to my ability and judgement, but I will never use it to injure or wrong them.

• 5. I will not give poison to anyone though asked to do, nor will I suggest such a plan. • 6. Similarly, I will not give a pessary to a woman to cause abortion. But in purity and holiness I will guard my life and my art. • 7. I will not use the knife either on sufferers from stone, but I will give place to such as are craftsman therein.

• 8. Into whatsoever houses I enter, I will do so to help the sick, keeping myself free from all intentional wrong-doing and harm especially from fornication with woman or man, bond or free. • 9. Whatsoever in the course of practice I see or hear (or even outside my practice in social intercourse) that ought never to be published abroad, I will not divulge, but consider suchthings to be holy secrets.

• 10. Now, if I keep this oath and break it not, may I enjoy honour in my life and art, among all men for all time ； but if I transgress and forswear myself, may the opposite befall me.

• The Declaration of Geneva 一 1948

The World Medical Association at its third general Assembly at Geneva in September, 1948, adapted certain codes of ethics, in the form of oath to be taken by all members of the profession, at the time of entering into medical profession.

• The Declaration of Geneva is as follows ：

• 1. I solemnly pledge myself to consecrate my life to the service of humanity. • 2. I will give to my teachers, the respect and gratitude which is their due. • 3. I will practice my profession with conscience and dignity. • 4. The health of my patient will be my first consideration.

• 5. I will respect the secrets which are confided in me. • 6. I will maintain by all the means in my power, the honour and the noble traditions of the medical profession. • 7. My colleagues will be my brothers.

• 8. I will not permit considerations of religion, nationality, race, party, politics or social standing to intervene between my duty and my patient ． • 9. 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. • 10. I make these promises solemnly, freely and upon my honour.

• The Intemational Code of Medical Ethics • The World Medical Association, in its general Assembly in London in October, 1949, adapted the following code of ethics, popular as International Code of Medical Ethics. This dictates the different duties of the doctors considered from different angles. The duties laid down in the International Code of Medical Ethics are as follows ：

• 1. Doctors' duty to the sick － • (a) A doctor must always keep in mind the importance of preserving human life from the day of conception until death. • (b) A doctor owes to his patient complete loyalty and all the resources of his science. When some examinations and treatments are beyond his capacity, he should summon another doctor who has the necessary ability.

• (c) A doctor owes to his patient absolute secrecy regarding that which has been confided to him or what he knows by virtue of the patient's confidence on him. • (d) A doctor must give necessary treatment in emergency circumstances, unless he is certain that it can and will be given by others.

• 2. Doctors duty to another doctor • (a) A doctor should behave towards his colleagues in a way which he will like to have from them. • (b) A doctor must not entice away patients from his colleagues.

• 3. Duties of a doctor in general • (a) A doctor must always maintain the highest standards of professional conduct. • (b) A doctor must not allow himself to be influenced merely by motives of profit. • (c) A doctor should consider the following practices unethical 一

• i) Any self-advertisement except such as is expressly authorised by the national code of medical ethics. • ii) Participation in any health care system in which the doctor will not have professional independence.

• iii ） Receiving money for the service to his patient other than acceptance of proper professional fee or payment of money in such circumstances, without the knowledge of the patient. • (d) A doctor is hot-permitted to do anything which can weaken the physical or mental resistance of a human being, without strict therapeutic or prophylactic indication, in the interest of the patient ．

• (e) A doctor should be very careful in publishing his discoveries, particularly in respect of a method of treatment which is not recognised by the professional men. • (f) In case of issuance of a certificate and when required to give evidence he should only mention of what he can verify or prove.

• Rights and privileges enjoyed by a registered medical practitioner: A registered medical practitioner enjoys certain rights and privileges which an unregistered medical practitioner, though qualified with a medical degree which may even be a recognised one, does not enjoy. These rights and privileges can be enumerated as follows ：

• 1. Right to choose his patient 一 A registered medical practitioner is free to choose his patient. On this basis he may refuse a patient without showing any reason. He however cannot refuse to treat a patient whom he has accepted to treat, if there is no valid ground for such refusal. A registered medical practitioner SHOULD NOT REFUSE EMERGENCY treatment required by a patient.

• While refusing to treat a patient, the practitioner should remember that it is not in conformity with the ethics of his profession that he refuses relief to a sick person on flimsy ground or in a partisan manner.

• 2. Right to use title and description of the qualification which he actually possesses, which is recognised by law or by any State Medical Council or the Medical Council of India. • 3. Appointment in public and local hospitals— The Central Government and different State Governments provide that an unregistered medical practitioner cannot be appointed in public and local hospitals.

• 4. Right to prescribe and or dispense medicine to his patient 一 A registered medical practitioner can prescribe medicine for the use of his patient. He may also prepare and dispense medicine to his own patient. He should not ordinarily and as a routine serve the prescription of another doctor if it is not an emergency and unavoidable on the ground of safety of the patient.

• 5. Right to realize fee and other expenses, for attending his patient 一 If a registered medical practitioner has treated his patient with the prevailing standard of knowledge and reasonable degree of care and skill then he earns the right to realize fee against his service, irrespective of whether the patient is cured or not. He is also entitled for any other such amount actually spent by him towards his journey to the patient's residence and towards the medicine he gave to his patient.

• If the patient or his guardian does not pay the justified claim of the doctor then he may take the help of a court of law for realisation of the same. The amount of fee of a practitioner is more a matter of convention of the area and depends on his qualification and experience and the doctor should not claim disproportionately high fee from his patient.

• 6. Right to issue medical certificates and medicolegal reports 一 These certificates and reports should be prepared true to the findings maintaining all formalities. • 7. Right to give evidence in a court of law, as an expert witness 一 Only registered medical practitioners are accepted as expert witnesses in the Courts of law.

• 8. Right to be exempted from acting as a juror in course of holding an inquest 一 This is applicable for practitioners within the jurisdiction of Coroner's Court of Bombay. System of Jury does not exist in any form in any other part of the country. If a registered medical practitioner so desires he may be exempted from acting as a juror during an inquest.

• 9. Removal of eyes from a dead body for transplantation purposes. - A registered medical practitioner, maintaining all legal and other relevant formalities in this regard, can remove eyes from a dead body, if he is working in and for a centre approved for this purpose.

• 10. Right to use the red cross emblem － Nobody including the registered medical practitioners except the members of the medical service of the army of a country and except the red cross societies during war and during their exercise of humanitarian in peace, can use the red cross.

MALPRACTICE AND NEGLIGENCE IN MEDICAL PRACTICE • Definition of malpractice • In medical profession, malpractice may be defined as absence of reasonable care and skill in a doctor in course of treating his patient or his wilful negligence in the treatment of a patient, causing some damage, bodily injury or death of the patient ．

• Definition of negligence • Negligence in medical practice may be defined as the omission to do something which a reasonably competent medical practitioner, guided by the prevailing standard of medical knowledge and practice and such other considerations, which ordinarily should regulate the conduct of a medical man, would do, or doing something which such a reasonably competent medical man would not do, leading to some harm or damage to the patient.

• Medical malpractice may be (a) criminal, (b) civil or (c) ethical. • Criminal Malpractice 一 As in other criminal

cages, in criminal malpractice by a doctor, he is prosecuted by the State for commission of some wrong which comes under the purview of the criminal procedure code ． The wrong deed of the doctor is considered as an offence against the community or the State and liable to be punished by a law court according to some provisions of the penal codes.

• The wrong deeds of a doctor which amounts to criminal malpractice are contravention of the provisions of the Drug Act, wilful manipulation of the medical records, performing criminal abortion, wilful issuance of a death certificate in a wrong way, covering a criminal act in course of his practice, gross and wilful negligence of a patient resulting in his death or such bodily injury which cannot be compensated by money.

• Criminal negligence 一 • Criminal negligence is a sort of criminal malpractice where the gross careless or negligent act of the doctor causes serious bodily harm or death of the patient. These are such acts of the doctor which show that the doctor is least concerned about the welfare or safety of his patient.

• As the criminal law does not approve and allow any act of a person which may be dangerous and harmful to another, these types of gross negligent acts on the part of the doctor, resulting in irrepairable bodily harm or death of the patient are counted as criminal negligence, and the erring doctor is liable to be punished.

• Civil Malpractice or Civil Negligence 一

These two terms are synonymous. Civil Malpractice or Civil Negligence indicates such act of negligence (see definition of negligence given above), on the part of the treating physician which causes some suffering, harm or damage to the patient which can be compensated by paying money and does not come under the purview of the Cr. P.C. and I.P.C. and does riot demand legal punishment of the doctor.

• Ethical malpractice 一 • This neither amounts to criminal nor to civil negligence. The patient is not directly affected in ethical malpractice. These are those acts of breach of ethics of medical practice which, though do not or may not amount to negligence, may lead to debar the physician from medical practice, on the decision of a State Medical Council.

• The burden of proof and the Ingredient of negligence-The burden of proof of negligence of the doctor lies on the plaintiff i.e., the complainant.To prove negligence on the part of the doctor the following ingredients must be present.

• 1. That, the doctor was duty-bound to treat the patient and attend him regularly. Here it may be repeated again that treatment given to a patient in an emergency circumstance does not make the doctor duty-bound to treat the patient, because doctor patient relationship is not established on the basis of treatment, given on emergency requirement alone.

• Secondly, even if the relationship has already been established after the doctor has accepted the patient for treatment, he may not subsequently attend the patient on some valid ground.

• 2. That,the doctor did not do his duty to treat the patient properly as is expected from a reasonably competent doctor, though the doctorpatient relationship was already established and the doctor thus had a duty to the patient. Thus, there has been dereliction of duty on the part of the doctor. Here also, dereliction of duty should not be inferred only because the patient could not be cured or because the patient suffered much or for a long period ．

• To decide on this point, it must be shown by the plaintiff that the doctor did not execute his duty in accordance with the prevailing standard of knowledge, care and skill and did not attend the patient or act in the expected manner.

• 3. Actual damage or harm of the patient is another essential ingredient of negligence on the part of the doctor which must have resulted from dereliction of his duty.

• It may be marked that neither the damage alone, nor the dereliction of duty alone can be accepted as proof of negligence on the part of the doctor. Firstly, treatment of a patient by a doctor does not guarantee a cure and harm from a disease may be a natural consequence.

• Secondly, the doctor is the best judge to decide what extent of attention should be paid to which patient. So, in absence of any of the two factors, negligence on the part of the doctor cannot be established. And question of dereliction of duty cannot arise if there was no duty for the doctor to attend the patient.

• Defences of a doctor against charges of negligence. • When charged for negligence, a doctor may plead any or many of the following arguments as his defence. • 1. That, he had no duty to the patient. • 2. That, he discharged his duties in accordance with the prevailing standard of medical practice.

• 3. That, the damage caused to the patient is not due to his negligence but could be due to the act of any other person who also was concerned with his treatment ． • 4. That, the damage was the result of a third party who interfered in the treatment without his knowledge or consent. • 5. That, the patient did not follow his advice properly or it was a case of contributory negligence.

• 6. That, the damage complained of is an expected outcome for the particular type of the disease the patient suffered from. • 7. That, it was a case of reasonable error of judgement. • 8. That, it was a case of therapeutic or diagnostic misadventure (see page 35). • 9. That, it is a case of medical maloccurrence

• 10. That, the complain should not be entertained because it has already been tried once by a court of law (Res judicata). • 11. That, the dame was the result of taking some unavoidable risk which was taken in good faith in the interest of the patient with his or his guardian’s consent.

• 12. That, the patient persistently insisted on the specific line of treatment which has caused the damage inspite of the doctor's warning about the risk involved in that method of treatment. • 13. That, the time limit allowed by the law for lodging such a complaint is over and the complaint may not be entertained now. Complaints of negligence should be lodged within two years, counting from the alleged date of causation of the damage.

• It should be remembered that free treatment of a patient does not absolve a doctor from his responsibility towards his patient and does not give him immunity against a negligence charge.

• Procedure to initiate a charge of negligence against a doctor 一 The charge of criminal negligence against the doctor is lodged by the public prosecutor. The charge of civil negligence may be lodged by the sufferer patient or it may come up when the doctor sues the patient for non-payment of his fees and the patient argues that, there was no question of paying the doctor's fees as because the treatment of the doctor did not benefit him, rather caused some damage to him.

• IATROGENIC DISEASES or CONDMONS • These are diseases or conditions arising out of medicinal or therapeutic sources or uses. Two different types of circumstances are recognised, e.g., (a) Medical Maloccurrence, (b) Therapeutic Misadventure.

• (a) Medical Maloccurrence • Not in all diseases or in all persons, one medicine gives the same or the expected result. Bio-physiological actions and reactions to different drugs are different and are extremely variable. Thus, individuals may react differently to the same drug, in the same dose and same mode of application. Also, it is to our knowledge that some individuals may be quite tolerant to some drugs due to which the usual dose of the drug may not give the desired effect.

• On the other hand some individuals may be idio-syncratic to some drugs while others are not. These are medical maloccurences, which may cause extra suffering to the patient and the doctor is not actually responsible in these cases, as the doctor is not negligent in his act. However, the issue should not be considered so simply.

• An experienced medical practitioner having standard knowledge should be aware of the usual unexpected and unexplained reactions with different drugs in different individuals. He should be acquainted with the latrogenic effects, side-effects and contraindica- tions of different drugs, at least of those used by him. Medical maloccurrence is thus not a blank cheque to be used by the doctor against whom a charge of negligence has come up.

• (b) Therapeutic Misadventure • (1) Therapeutic misadventure may be truly due to the therapeutic reasons when no action or an adverse reaction to a drug is there or when the doctor knows that the drug may cause some untoward reaction, or its prolonged use may cause some harm to the patient, but finding no other way he uses the drug. This condition, to a great extent, is similar to medical maloccurrence.

• It may also be (2) an instance of diagnostic misadventure, where some diagnostic procedure may bring hazard to the patient, as in case of injection of some radio-opaque dye in some special radiological investigation; laryngoscopy, bronchoscopy or ex-plorative laparotomy.

• It may be (3) experimental misadventure, where a person might have been subjected to,use of some drug or undergo certain operative procedure on experimental basis.

• In case of therapeutic and diagnostic misadventure, the defence of the doctor stands only if he can show that, (i) the steps he took was quite justified,(ii) the hazard was quite unexpected and is not known to occur, (iii) he took reasonable precaution against the possible hazard as its possibility was known to him or (iv) he had no other way but to take the risk of the hazard,though he knew its possibility.

• In case of experimental misadventure, if the doctor wants to use this point as a defence against a charge of negligence he must justify the reason for his experimentation and must show that he got a valid consent from the patient or his guardian, after duly explaining him the merits and demerits of the experiment and the risk involved in the act.

• Corporate Negligence • The question of corporate negligence arises in hospitals or nursing homes, where more than one individuals at more than one levels remain responsible for the well-being of the patient on the basis and terms of their service. Thus, not only the treating doctor of the patient but also the hospital administration and some other categories of the hospital staff related with treatment of the patient may be charged for negligence due to the damage suffered by the patient.

• A doctor may be charged for negligence in his part of duty, a nurse may be charged if she does not take care of the patient according to the direction of the doctor and the hospital superintendent may be charged if he does not take steps to make the drugs necessary for the patient, available in time. The superintendent will not only be responsible for posting of persons with desirable qualification and experience for a specific post but he will alsobe obliged to see that every employee perform his part of duty to the patient.

• Calculated Risk • In some cases acceptance of some degree risk may be inevitable. If in such cases proper care is taken against the risk then a charge of negligence will not stand against the doctor, even though the patient might have suffered some damage out of the act involving the risk. The justification of the step involving the risk and the precautions taken to overcome the risk will act as good defence for the doctor who is charged for negligence.

• Common Knowledge • The doctor may be charged for a negligent act not involving his technical or specialized knowledge and experience, but some act involving application of common sense only. Necessity of fluid therapy for a dehydrated patient suffering from gastro-enteritis, is a matter of common sense or common knowledge.

• If a doctor fails to do the needful in such a case, he is negligent and to prove this the plaintiff need not show that the doctor did not show reasonable degree of scientific knowledge and care and skill as it is a common knowledge that such a patient requires fluid therapy for which the doctor did not take proper step.

• Novus Actus Intervenins • A doctor will not be responsible for any harm caused to the patient due to interference or intervention during the course of treatment of the patient, by any person who is not related with the treatment of that person. In some circumstances, it happens the other way.

• For example, if the victim of an assault suffers some harm due to negligence of the doctor during the course of treatment, which the original assault was not likely to cause, then the assailant will not be fully responsible for the total harm. The doctor will be held responsible for his negligent act which caused the ultimate harm.

• Duties of a Patient • The doctor-patient relationship is not a one way traffic. In connection with his treatment the patient also has certain duties to do. These are: • 1. The patient should inform the doctor everything about his illness and should not keep the doctor ignorant of anything related with his illness. • 2. He should properly follow the advice of the doctor.

• 3. He should not do anything which the doctor prohibits as a part of the treatment. • 4. He should not follow the advice of any other doctor without the knowledge and consent of the doctor in his charge (he can, of course, do so if the doctor in charge of the patient relinquishes the charge or if the patient decides not to continue under the treatment of the first doctor) ．

• 5. The patient should pay the due fees to the doctor. When a charge of negligence is brought against a doctor, he may plead not responsible, for reasons of failure on the part of the patient to do any or more of the above-noted duties of the patient.

• Contributory Negligence • Sometime the alleged damage suffered by the patient or the negligent act of the treating physician is related to some undesirable or negligent act of the patient himself. If the patient would have acted in the way as is expected or desirable from a patient, the doctor either would have not committed the mistake or the damage would have not been caused to the patient. This is contributory negligence.

• Hence in contributory negligence, there is at least some contribution by the patient, to the damage suffered by him. Accordingly, in these circumstances, the doctor will either be not held responsible at all if the negligent act of the patient is solely responsible for the damage he complains or the doctor will be held partly responsible if the damage complained of is partly due to his negligence and partly due to the act of the patient.

• Contributory negligence is thus a good defence for the doctor, but only in civil cases and not in criminal negligence cases. In criminal negligence cases the charge framed against the doctor is as per the criminal laws of the country, when the act of the doctor amounts to some codified crime of the country.

• Contributory negligence is thus a good defence for the doctor, but only in civil cases and not in criminal negligence cases. In criminal negligence cases the charge framed against the doctor is as per the criminal laws of the country, when the act of the doctor amounts to some codified crime of the country.

• If the doctor has committed any offence, then he will be charged upto the extent of his offensive act. In criminal negligence, the negligence is gross and the resultant damage is also gross. While prescribing a very dangerous drug to his patient the doctor must give detail instructions about the method of its use and warning against its danger.

• If he fails to give proper instruction leading to severe harm to the patient,then he alone is responsible for the harm caused. If he gives proper instruction which the patient does not follow and suffers the harm, then the patient alone is responsible and not the doctor.

• In connection with contributory negligence two special circumstances need mention. • 1 ． If after the negligent act of the patient himself, the doctor gets time but fails to take precautionary step against the possible damage and if damage occurs consequently, then the doctor cannot take the plea of contributory negligence to defend himself in the face of charge of negligence, because, after the act of the patient he got clear time and scope to avert the "possible" damage which he did not do. This is termed as "the last clear chance doctrine" which limits the scope of use of contributory negligence as defence by the doctor.

• 2. In some other circumstances, it is seen that the patient was negligent only after the damage was caused by the negligence of the doctor. The negligence of the patient might aggravate the damage which could be avoided by the patient. However as the negligence of the doctor is responsible for the damage complained of, he cannot take the plea of the patient's subsequent negligence to defend himself, though further damage might have not occurred if the patient was not negligent. This provision is termed "the avoidable consequence rule".

• Product Liability • This means liability of producer, agent or seller of medicine, instrument or appliance, the use of which has caused some damage or harm to the patient. The burden to prove this lie on the plaintiff.

• Vicarious Responsibility • This means liability of a person due to the act of another. In medical practice, this means responsibility of a superior medical or paramedical employee for the negligent act of his subordinate employees or persons under training who are expected to work under the guidance of the superior. This working relationship is also termed "'respondent superior", because a superior has to answer for the fault of his subordinate.

• Thus, an intern doctor, though qualified, is under practical training under the guidance of the unit head of the department and if he commits some negligent acts which cause some damage to a patient, then for his act the unit-in-charge will be answerable and responsible. However this will not be so, if the negligence complained of, comes under the purview of Doctrine of Common Knowledge.

• However, to be totally out of danger arising from the complaint, the intern doctor may have to prove that he has not acted against the advice of the unit-incharge, or his acts in relation to the treatment of the patient were known to the unit-in-charge, or that the unit-in-charge got time to rectify his mistake.

• Some precautionary steps recommended for registered medical practitioners to avoid acharge of negligence 一 • 1. The registered medical practitioner must not guarantee cure of his patient. • 2. He should keep his professional knowledge uptodate. • 3. He should apply due care and skill for the treatment of the patient.

• 4. He should take written informed consent in ail steps or treatment if these involve any risk or if they are beyond what are routinely followed. • 5. It is advisable that consent should be taken from both husband and wife if either of them is going to have a treatment which may cause sterility or impotence.

• 6. Laboratory investigations should be advised whenever necessary to come to a diagnosis or to confirm a clinical diagnosis. • 7. Condition of the patient and the treatment are to be regularly recorded in detail. • 8. He should consult a professional colleague whenever necessary .

• 9. The condition of the instruments or equipments must be checked before use. • 10. Particular attention to be paid on the labelof a medicine while giving it to a patient for internal use. Special attention should be paid towards the expiry date of the medicine, crack in an ampoule or break of the seal of the container.

• 11 ． Sensitivity test should be pertormed petore injecting a drug whici is known to cause allergic reaction or anaphylaxis or it the patient is Known to be hypersensitive to a drug of the group to be used ． • 12. Whenever necessary, the patient should be immunised against a disease.

• 13. Injury due to assault and poisoning cases should be specially dealt with. • 14. No method should be tried beyond the skill or field of specialisation of the doctor concerned. • 15. Experimental treatment should be generally avoided. But if it is necessary then it should be done only with the written consent of the patient or the guardian of the patient.

• 16. The prescription must contain clear instructions to the patient. • 17. Post-operativecare should be optimum. 18. No advice should be given over telephone. • 19. Anaesthesia should be administered by a qualified and experienced doctor. • 20. Necessary clinical check up, laboratory investigations and premedication as are required should be done before administration of anaesthesia ．

• 21 ． Anaesthetist should not leave the patient before his recovery from anaesthesia. • 22. In case of death of the patient under anesthesia or on the operation table, an inquest should be recommended. • 23. Due care must be exercised while chosing an assistant during an operation or otherwise.

• 24 ． Irrespective of whether the patient responds to the treatment or not, the treatment should not be given up unless the patient desires it or agrees to it. • 25. During any emergency, the patient should not be left unattended except when there is more emergency of another patient.

• 26. The capacity of a professional colleague and his efficiency should not be publicly criticised ． • 27. If the doctor is unable to attend the patient due to any cause, then the patient should be informed of the same, well in advance with advice to arrange for a substitute.

• 28. Whenever necessary, the patient should be referred to another centre with availability of better facilities. • 29. Female patients should not be examined without the presence of another female.

• 30. Provisions of the M.T.P.(medical termination of pregnancy) Act should be strictly followed ． • 31 ． Death certificateand other medical certificates should be issued with care.

• Malingering • Malingering in medical practice means feigning or pretending some illness or injury with some motive. The motives are divergent in nature. It may be with the intention to avoid duty, take premature retirement from the service, to bring a false charge of assault or poisoning against somebody, to avoid a business contract, to extract compensation, to avoid attendance in a court or to establish a defence (on the ground) of self-protection, when charged for causing assault or injury to another person.

• To establish his case the malingerer may inflict certain minor injuries on his body or may take some drug to alter the functions of the body system e.g. to alter the body temperature, pulse rate, heart function etc. In case of any doubt about the illness of the person concerned, thorough clinical examination, necessary laboratory investigations and constant watch by admitting him in a hospital may be needed before giving him any treatment or issuing a certificate in his favour.

• Euthanasia or Mercy Killing • Euthanasia or mercy killing is the practice of killing a person for giving relief from incurable pain or suffering or allowing or causing painless death when life has become meaningless and dis-agreeable. In India, like almost in all other countries of the world, euthanasia has no legal status.

• On the other hand, as the law stands, the practice of euthanasia is a clear act of offence, either a suicide and assistance to commit suicide or a murder. It is a case of suicide and assistance to commit suicide when a person terminates his life with the assistance of another, usually a doctor; it is a case of murdet when it is practised without the available consent from the person so killed.

• When a doctor kills such a patient according to the desire of the patient, a double legal position exists. From the point of view of the patient concerned it is a case of suicide but the legal position of the doctor concerned is like that of a murderer. Uruguay is the only country where practice of euthanasia has legal approval.

• In U.S.A. its practice is a clear offence theoretically, but in practice the judgements of different courts during trial of euthanasia cases seem to be liberal. • Though not approved, the legal position of euthanasia in Germany, Switzerland, Poland are comparatively liberal. • Hitler's Germany made it compulsory for them whose life ceased to be useful, often deliberately selecting wrong persons.

• Ethical contradiction 一 • The Hippocratic oath and international code of medical ethics pose ethical contradiction for the doctors. According to the oath and the ethics, the doctor is to relieve the pain of his patient in one hand and protect and prolong his life on the other. The first can be used in favour of the doctrine of euthanasia but the second counters the doctrine.

• Religious and Philosophical background 一 No religion approves euthanasia. Philosophers like Aristotle, Plato and Pythagorus favoured euthanasia. Different organisations have moved from time to time to form public opinion in favour of euthanasia and legalise it.

• Methods of Practice • Active euthanasia 一 Morphine is the drug of choice which is administered in multiple of a lethal dose to terminate the life of the person concerned. • Passive euthanasia 一 Artificial lifesustaining aids are withdrawn to precipitate death.

• Voluntary and involuntary euthanasia 一 When euthanasia is practised with the expressed desire and consent of the person concerned, it is called voluntary euthanasia. When it is practised without the scope to make the desire of the subject available (as in case of unconscious subjects), it is called involuntary euthanasia.