1. Physician Issues Chapter Ten Module 9

2. The Hippocratic Oath Medical Students swear to this oath when they graduate. The oath has been reworded over time The following slides contain several versions of the oath There is debate whether or not the modern version have watered down the original intent of the oath. Has it become a meaningless relic? “Primum non nocere”

3. Hippocratic Oath -- Classical Version I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about. If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot. Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

4. Hippocratic Oath (Modern Version) You do solemnly swear, each man by whatever he holds most sacred That you will be loyal to the Profession of Medicine and just and generous to its members That you will lead your lives and practice your art in uprightness and honor That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it That whatsoever you shall see or hear of the lives of men which is not fitting to be spoken, you will keep inviolably secret These things do you swear. Let each man bow the head in sign of acquiescence And now, if you will be true to this, your oath, may prosperity and good repute be ever yours; the opposite, if you shall prove yourselves forsworn. Approved by the American Medical Association

5. Hippocratic Oath -- Modern Version I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today

6. "The 1995 Restatement of The Oath of Hippocrates circa 400 B.C." as introduced by The Value of Life Committee, Inc., June, 1995. I swear in the presence of the Almighty and before my family, my teachers and my peers that according to my ability and judgment I will keep this oath and stipulation: To reckon all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient. I will follow that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous. I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform act or omission with direct intent deliberately to end a human life. I will maintain the utmost respect for every human life from fertilization to natural death and reject abortion that deliberately takes a unique human life. With purity, holiness and beneficence, I will pass my life and practice my art. Except for the prudent correction of imminent danger, I will neither treat any patient nor carry out any research on any human being without the valid informed consent of the subject or the appropriate legal protector thereof, understanding that research must have as its purpose the furtherance of the health of that individual. Into whatever patient setting I enter, I will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and also from the seduction of any patient. Whenever in connection with my professional practice or not in connection with it I may see or hear in the lives of my patients which ought not be spoken abroad I will not divulge, reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art and science of medicine with the blessing of the Almighty and respected by my peers and society, but should I trespass and violate this Oath, may the reverse be my lot. Copyright held by The National Catholic Center, Boston, MA 02135

7. Code of Ethics ©2001 American Medical Association I.A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. II.A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. III.A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. IV.A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy with in the constraints of the law. V.A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated. VI.A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. VII.A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. VIII.A physician shall, while caring for a patient, regard responsibility to the patient as paramount. IX.A physician shall support access to medical care for all people.

8. The Credentialing Process There is a distinction between credentials and privileges. Credentials are the documents that verify a professional provider’s education, training and experience (e.g. licenses, diplomas, certification, references, etc.) Privileges authorize a credentialed professional to perform specific services and procedures.

9. Credentialing is critical The credentialing process is designed to ensure a competent qualified is permitted to practice within a facility. Hospital’s have a duty to ensure the competency of it professionals. Insinga v. LaBella, Patient died under the care of an individual fraudulently masquerading as a physician. Camden v. Abraham K. Asante, Asante lied on his job application as sole anesthesiologist Walson Army Hospital. Czechoslovkian Medical diploma was a forgery. Patient Joseph Brand, died three years after surgery in an irreversible coma because Asante was not competent to operate anesthesia equipment.

10. Darling v. Charleston Community Memorial Hospital Landmark case Governing body has a duty to –Evaluate –Counsel –Take action when necessary against unreasonable risk 18 year old was improperly casted for leg fracture The staff did little to intervene in a minor patient’s complaints of leg pain after the leg was cast at the hospital and the patient was admitted. Calls to the physician were not returned Nurses failed to seek help from other sources (e.g., administrator, another physician). Patient’s leg had to be amputated 8 inches below the knee. The following link is to a copy of the case at the LSU Law Center –http://biotech.law.lsu.edu/cases/Medmal/darling.htmhttp://biotech.law.lsu.edu/cases/Medmal/darling.htm

11. Medical Staff Responsibility to monitor and supervise Medical staff is responsible to Governing Board. Usually accomplished through a peer review system. Governing board has the right to dismiss disruptive physicians subject to medical staff recommendation. (Ladenheim v. Union County Hospital District, Huffaker v. Bailey)

12. Patient Autonomy Where there are two or more medically acceptable approaches to a problem a competent patient has the right to choose one or refuse both. The physician must have the patient’s informed consent to proceed.

13. “every human being of adult years and sound mind has a right to determine what shall be done with his own body…” 1914 Judge Benjamin Cardozo

14. Informed consent/alternative Procedures Stover v. Surgeons, 635 A.2d 1047 (Pa. Super. Ct. 1993 Pt. w/damage to heart valves as result of childhood rheumatic fever. Pt alleges she was only told that mechanical valves outlasted natural tissue valves and was never informed about the risks associated with installing mechanical valves. After surgery the Pt. suffered severe, permanent brain damage from multiple episodes of thromboemboli directly caused by the valve implantation. She sued for lack of informed consent.

15. Abandonment Physician is liable if: –Medical care was unreasonably discontinued –The discontinuance of medical care was against the patient’s will –The physician failed to arrange for care by another physician. –Foresight indicated that discontinuance might result in physical harm. –Actual harm was suffered by the patient.

16. Falsification of Records Intentional alteration Falsification Destruction of medical records Is presumed as evidence of actual malice and justify punitive damages. “a physician’s duty to a patient cannot but encompass his affirmative obligation to maintain the integrity, accuracy, truth and reliability of the patient’s medical record…” Matter of Jascalevich

17. No’ no’s for Physicians Failure to: –Respond: Emergency Dept. call –Provide Informed Consent –Read Nurses’ Notes –Seek Consultation –Obtain Adequate History and Physical