Step 4-professionalism

index
Ethics of truth telling in medical 2-4
practice

Ethical issues in mental illness 5-8

Ethical aspects of organ 9-11

transplantation

How to write medical/medico-legal 12-15

or reports submitted to prosecution
court

Forensic Medicine and Clinical Toxicology department

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 Ethics of truth telling in medical practice
Learning objectives:
- Identify the importance of truth telling (veracity) to patients.
- Recognize some situations where information may be withheld from patients.
- Describe SPIKES protocol for breaking bad news.

Patients normally believe their healthcare provider is telling them the truth
about a medical diagnosis, the results of a test, or treatment options.
Long time ago, physicians sometimes felt that patients couldn’t handle the
truth. If a patient was diagnosed with terminal cancer for example, the physician
sometimes thought it was best if the patient wasn’t told. Better to let the patient
enjoy their last few months happy rather than sad and depressed.
Attitudes have changed recently, but the subject of truth-telling in healthcare is
still controversial. Is it ethically permissible for a healthcare provider to purposely
hide information or deceive a patient?

Importance of truth telling to patients:

Truth-telling or veracity is seen as a basic moral principle in medical practice
for the following:
1-Respecting patient's autonomy.
Respecting patients' autonomy means allowing patients to make their own
decisions, but how a patient can be in control of his medical decisions if the
choices are being made based on incomplete or false information.
2- In terminal illness:
A patient with a terminal illness needs to know his condition to prepare for
death, deal with finances and spend time with family and beloved ones.
3-Keeping a trusting doctor-patient relationship.
4-Avoiding malpractice and medico-legal claims.
Withholding (hiding) important information would hinder obtaining a valid
informed consent, which is a legal obligation on the physician.
Truth telling principle may not be routinely applied in the following
situations:
1-According to the patient's wishes:
When the patient has previously expressed that he does not want to
know the truth if it is bad because it would be too upsetting or frightening.
The physician should ask the patient to assign a responsible guardian.
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 2-According to the patient's condition:
When revealing information would cause significantly more harm to
the patient than benefit, as the patient may become severely depressed and
can commit suicide.
So, the physician should deliver the truth gradually while providing
support to the patient.

3-According to decision making capacity:

When the patient is unable to consent to treatment being incompetent
or incapacitated and emergency treatment is required.
The physician should inform the patient's relatives if available and obtain
their consent.

Whenever a physician has to tell his patient bad information about

his illness, he should follow a guidance protocol for breaking bad news:
"SPIKES" protocol for breaking bad news:
- It has four objectives:
- Gathering information from the patient.
- Giving complete medical information to the patient.
- Providing support to the patient.
- Encouraging patient’s collaboration in developing a future strategy for
treatment.

- Components of "SPIKES" protocol:

(S) – Setting:
- Arrange for some privacy with no interruptions.
- Involve important persons.

(P) – Perception of condition/seriousness by the patient:

- Determine what the patient knows about his condition or what he suspects.
- Accept denial but do not confront at this stage.

(I) –Invitation obtained from the patient to provide information:

- Ask patient if he wishes to know the details of the medical condition and/or
treatment.
- Accept patient’s right not to know but offer to answer questions later.

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(K) – Knowledge: giving medical facts
- Use understandable language.
- Consider educational level, socio-cultural background, and emotional state.
- Give information gradually.
- Check whether the patient understood what you said.
- Respond to the patient’s reactions as they occur.
- Give any positive facts first.
e.g., Cancer has not spread to lymph nodes, highly responsive to therapy,
treatment available.
- Give accurate facts about treatment options, prognosis, costs etc.

(E) - Explore emotions and sympathize

- Give the patient time to express his feelings, then respond in an empathic way.

(S) – Strategy and summary

- Ask whether they want to clarify something else.
- Offer agenda for the next meeting.

Assessment questions:
1- MCQ:
Truth telling the patient is important due to all the following
EXCEPT:
a- For terminally ill patients.
b- Hiding medical errors.
c- Respecting autonomy.
d- Keeping mutual trust.

2- True or false:
In breaking bad news, give complete information as fast as you can so you
do not hurt the patient's feelings.

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 Ethical issues in mental illness
Learning objectives:
- Throw a light on the physician-patient relationship in mental illness.
- Describe some ethical principles concerning mentally ill patients.
- Recognize main skills of importance to the ethical practice of neurology and
psychiatry.
Mental illness is generally characterized by some combination of abnormal
thoughts, emotions, behavior, and relationships with others.
In neuropsychiatric practice, patients may suffer from significant mental and
physical symptoms. The resulting distress could make patients fragile and weak while
dealing with their physicians, thus creating an imbalance (disparity) in the physician-
patient relationship.
This disparity between physicians and mentally ill patients puts a special ethical
obligation on physicians, that they must place the unique needs of the patient above
their own professional or personal interests.
Patients may suffer from ethical problems as invalid informed consent, breaking
confidentiality, conflict of interest ‫تعارض المصالح‬, fraud ‫ خداع‬and exploitation ‫استغالل‬.
Thus, mentally ill people are considered among the vulnerable ‫ المستضعفة‬groups of
patients.
Physicians must be cautious for situations that may cause physical, sexual,
psychological, or financial harm to the patient.
Important ethical and professional practices in neuropsychiatric care:
1) Informed Consent:
Informed consent is an ethically and legally important process. Before obtaining
consent from the patients, neuropsychiatrists must be careful about the following
points:
1- Assessment of decision-making capacity of patients according to clinical and
legal standards.
2-Providing the patient with all information needed for accurate decision-making.
3- Protection of the patient from being pressured by internal or external factors (e.g.
patient’s illness, stigma, lack of resources)
A physician may be in need to modify the method of giving the patient the
information about his /her disease , if it is truly damaging to the patient, and follow
one of the protocols that help in this situation . For example, it is unacceptable to hide

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information from the patient about side effects of a medication hoping that they will
not occur.
2) Assessment of decision-making capacity:
Decision-making capacity is the ability of an individual to reach an informed,
reasoned, and free choice.
Common assessment standards which are done if the patient can:
- Understand relevant information.
- Interpret information wisely.
- Appreciate the situation and its consequences.
- Make a constant choice with reasoning ‫منطقى‬.
Assessment of decision-making capacity is required if patients:
- Exhibit cognitive impairment, ‫ عجز إدراكى‬e.g., impaired judgment.
- Manifest irrational behaviors and decisions.
Involuntary (obligatory) neuropsychiatric treatment:
Obligatory treatment against patients' wishes most commonly includes
hospitalization. It is usually indicated by patients’ imminent dangerousness to
themselves or others, or their inability to meet basic needs.
As depriving a patient of his freedom is a serious decision, involuntary treatment
should be decided according to legal rules. The patient's illness must show
dangerousness criteria, as follows:
1- The patient is suffering from a severe mental disorder.
2- As a result of this severe disorder, the person is:
a) Likely to cause harm to himself or to suffer substantial mental or physical
deterioration, or
b) Likely to cause harm to others.
3- The patient either refuses or is unable to consent to voluntary admission for
treatment.
4- The patient lacks capacity to make an informed decision concerning treatment.

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 3) Confidentiality:
Keeping medical confidentiality is an ethical and a legal patient right, especially
the mentally ill due to communication of highly personal information and the trust
and dependence created between the patient and his physician.
Important considerations guide the confidentiality in mental illness:
i. At the beginning of the physician-patient relationship, patients should be told about
the limits of confidentiality and the events that would require disclosure.
ii. Disclosure of confidential information should only occur if informed consent has
been given by the patient or to protect the patient or third parties from imminent harm.
iii. Disclosure of patient information should always be limited to the minimum
required for the situation.
iv. Psychotherapy notes involving personal information should be kept separate from
other components of the medical record.
v. electronic patient records require appropriate, additional protection.
4) Honesty and Trust:
Neurologists and psychiatrists should always keep a trusting and constructive
relationship with their patients. They must avoid any act of fraud or exploitation to
those vulnerable individuals.
Specific examples of fraud in neuropsychiatric practice:
1- Making false or intentionally misleading statements to patients.
2- Recommending unnecessary treatment or hospital admission.
3- Fabricating medical records, research results, or false bills.
4-Supporting false sick leaves from work or school.
5- Falsifying ‫ تزوير‬qualifications.
6- Practicing outside one’s area of professional competence.

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Assessment questions:
1- True or false:
Psychotherapy notes should be kept in the patient's medical record.

2 – MCQ:
• Assessment of decision-making capacity is indicated if the patient:
a- Makes a constant choice.
b- Interprets information.
c- Appreciates consequences.
d- Behaves irrationally.

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 ETHICAL ASPECTS OF ORGAN TRANSPLANTATION
Learning objectives:
- Define organ transplantation and its types.
- Recognize the ethical rules of organ donation.
- Define brain death and some of its criteria.
- Solve some medico-legal problems related to organ transplantation.

Definition:
Organ transplantation is the surgical replacement of a failing or a damaged
organ with a healthy one.
A graft is similar to a transplant. It involves tissue replacement e.g., skin,
cornea, and bone marrow.
Types of transplantation:
a- Auto transplantation: Organs and/or tissues are transplanted within the
same person's body (e.g., skin graft in plastic surgery). There are no legal or
ethical limitations as regards auto transplants.
b- Allotransplantation: Organs and/or tissues are transplanted between two
different persons which can be either from a living or dead person.

Successful transplant depends on the degree of similarity between the tissue

antigens of the donor ‫المتبرع‬and recipient ‫المستقبل‬.

Rejection remains one of the main causes of failure in organ transplantation

because it is difficult to find completely matching tissues.
Blood transfusion: is the commonest form of transplantation.
Legal rules before Blood transfusion:
• Voluntary informed consent from the patient.
• No risk to the health of the donor.
• The donor should be free from transmissible diseases.
• Donor's information should be kept confidential.
• Payment to the donor is ethically unacceptable.
A) Living organ donation:
Living people who wish to donate their organs can donate in two ways:
1. Donate one of a set of paired organs (kidney).
2. Donate a portion of an organ (a portion of the liver, a lobe of the lung).

Living donors may be:

a) Living Related Donors (LRDs): blood relatives of the recipient e.g., parents,
brothers, or sisters.

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b) Living Non-Related Donors (LNRDs): not related by blood to the recipient
e.g., a husband, wife, or a friend.
c) Living Non-directed donors (LNDDs): unknown to the recipient but make
their donation purely out of humanitarian motives.
Rules before living organ donation:
a- Voluntary informed consent should be obtained from a competent donor.
b- There should be no harm to the donor.
c- The operation should be done in a well-equipped hospital.
d- Organ donation from children and mentally disabled persons is regarded as
a violation of their body integrity, due to lack of capacity to give consent.
Living donor complications:
- Health problems: postoperative and future health complications are all
possible.
- Psychological problems: family members may feel pressured to donate
when they have a sick relative.
- No medical follow up for the donor: while patients are under the
continuous care and follow up of their transplant surgeon and medical
team, donors may be faced with a future complication with no adequate
care.
B- Cadaveric organ donation:
It is the organ donation from a dead person. This type of donation deserves
the support of medical profession, law, and public.

Ethical and legal problems of cadaveric organ donation:

1- Brain death of the person should be declared ‫ يعلن‬before organ donation.
2- The wishes of the dead person should be respected.
3- Consent of the family should be obtained.

Brain death:
It is defined as the irreversible loss of the brain function, including the brain
stem. One of the common causes of brain death in adults is traumatic brain injury .

Some criteria for diagnosis of brain death include:

• Deep uninterrupted coma with no response to verbal or painful stimuli.
• At least six hours have passed since the onset of coma.
• The cause of the coma can be confirmed by adequate diagnostic measures
(e.g., extensive damage to the brain).
• Complete absence of brain stem reflexes (e.g., pupillary, corneal, gag and
cough reflexes).
• No spontaneous respiration.

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 After confirming his death, the dead person should be maintained on
mechanical ventilation, under adequate medical care to keep his organs healthy
until the time of transplantation.

Rules before cadaveric organ donation:

a- Because of a potential conflict of interest ‫التعارض المحتمل للمصالح‬, the
transplant team should be different from the team providing care for the
potential donor.
b- No organs are removed until the donor's death has been declared by a
competent medical team other than the recipient's physician or transplant
team.
c- There should be no payment for organs, as buying and selling human
organs are unethical, and doctors involved in paid donation will be
accused of medical malpractice.
d- Once a person dies; his or her organs may be donated if the person has
consented to do so before death. If the wishes of the dead person regarding
organ donation are unknown, the hospital authority (not the transplant
team) may request from a family member to give consent to remove the
organs.

Case study:
A 30-year-old woman was admitted to the intensive care unit. She had a
massive brain hemorrhage after being involved in a car accident. The patient is
brain dead and will be removed from the ventilator. There are other patients in
the hospital waiting for available organs for transplantation. You are the treating
physician of the patient, and her family trusts you.

Could you obtain their consent for organ donation?

- A physician who is taking care of a patient should not be involved in the

process of organ donation after patient’s death, and this includes obtaining the
family consent.
- So, even if your relationship with the family of the patient is excellent, it is
against the law (as his treating physician) to obtain this consent. You should
refer the matter to the hospital authority.

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 How to write medical/medico-legal reports
submitted to prosecution or court
‫كيف تكتب التقاريرالطبية أوالطبية الشرعية المقدمة الى النيابة أوالمحكمة‬
Prof Maha Ghanem
Physicians are asked to provide medical/medico-legal reports about their
patients for a wide variety of purposes.
A medico-legal report is usually read by non-medical personnel e.g.
prosecutor or judge ‫وكيل النيابة أو القاضى‬. Once prepared, the report may be used as
an evidence in court proceedings and subjected to scrutiny (review and
analysis).
A structured, comprehensive medical/medico-legal report may minimize
the chances of having to give a testimony in court ‫ شهادة فى المحكمة‬and avoid
changing a physician's position from a witness to accused.
Parties ‫الجهات‬that may request medical/medico-legal reports
A treating doctor has a professional and ethical obligation to assist by
providing information concerning a patient’s condition or injury, at the patient’s
request, to the patient’s legal advisors or, with the patient’s consent, to other
nominated third parties.
A request for a treating doctor to prepare a report for legal purposes may be
received from:
• A patient
• A lawyer
• An insurance company
• An employer
• A legal authority e.g. prosecution, court.
In case of a complaint or accusation, a physician will be asked to present a
report about his patient's condition and management lines (in two versions;
English and Arabic).

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 Before preparing a medical/medico-legal report
Unless the report is requested by the prosecution or the court (by a written
order, you should take the permission of the patient to provide it.
You should know the nature and purpose of the report you are giving. If the
purpose of the report is not clear, you may be asked for clarification.
Use medical records to prepare the report. Do not rely on your memory or the
information provided by the requesting party ‫الطرف الطالب للتقرير‬
Format for a medical/ medico-legal report
Never write the report as a paragraph or as a story.
Divide the report into sections :
1- Name of the requesting party, date of the request and purpose of the report.
2- Data of the patient (name, age ….).
3- Date of admission or date of interviewing the patient.
4-Your credentials, including professional address, qualifications, experience,
and position at the time you were involved in the patient’s management.
5- Write the medical facts in chronological order ‫ ترتيب زمنى‬guided by
scientific literature and supported by documents.
- Clinical presentation (history and symptoms)
– Examination findings.
– Investigations
– Provisional diagnosis
– Treatment/management

6- Provide the patient's informed consent if present (a highly important

document).
7- Current patient's condition.
8- Response to requested questions (confined to facts).
9- Signature and date of the report.
10- References supporting your strategy for patient management.
Professional obligations when writing a medical report
1. Be honest and not misleading when you write reports and certificates, and
only sign documents you believe to be accurate.

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 2. Verify the content before you sign a report or certificate.
3. If you have agreed to issue a report, take a justifiable time frame.
4. No expectations should be written.
5. Do not accuse your colleague.
Tips
• Only write what you would be prepared to say under oath ‫القسم‬in court.
• Always refer to your medical records
• If you receive additional information, or you have made a mistake, provide
a supplementary report.
• Explain medical abbreviations, terms, and concepts simply.
• Avoid the use of legal terms
• Differentiate fact(s) from opinion(s).
• Beware of providing an opinion that is beyond your knowledge.
• You should not deliberately omit any relevant information.
• Avoid emotive (emotionally provoking) language.
• Seek advice from your medical defense organization if you have any
concerns, including asking to review your draft report.

Role of medical expert witness

A medical expert witness may be requested by the court or even by the
treating doctor to give opinions regarding the management of a case. He would
be expected to define the standard of care in medical negligence claims and
determine if any deviation occurred from the standard professional practice.
The medical expert witness should not be involved in the care of the patient
in question, but possess special knowledge and experience that enable him to
give opinions and conclusions relevant to the case, to be presented in a well
prepared and revised "medical expert evidence report".
To be effective, a medical expert witness needs to be trained to acquire
competence. Incompetent expert witnesses would mislead the court to
inappropriate conclusions.
The expert's evidence report is delivered to the court, with a statement
signed by the expert that the report is his and that he takes full
responsibility for it.
A Medical expert evidence report must include:
– Expert’s qualifications.
– All material facts and assumptions on which the report is based.

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– Reasons for each opinion expressed.
– Indicating if a particular question or issue falls outside the expert’s area of
expertise.
– References that support the expert opinion.
– Any examinations, tests, or other investigations the expert has relied on, and
qualifications of the persons who carried them out.
– Statement if the opinion is provisional because there is insufficient data or for
any other reason.
Further reading
1. Australian Medical Association. Ethical Guidelines for Doctors Acting as
Medical Witnesses – 2011. Canberra: AMA, 2011. Available at
[Link]
medical-witnesses-2011 [Accessed 22 September 2014].
2. Australian Health Practitioner Regulatory Agency. Medical Board of
Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia,
Section 8.8. Canberra: AHPRA, 2014. Available at
[Link]/Codes-Guidelines-Policies/[Link]
[Accessed 22 September 2014].
3. How to write a medico-legal report. Australian Family Physician vol 43,
No.11, November 2014 Pages 777-779.

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