Ethics Of Medical Practice

Ethics of Medical Practice INTRODUCTION Ethics is a science of moral values or principles. Medical ethics is thus described as moral principles (code of conduct), which should guide the members of medical profession in their dealings with the patients, their relatives, community, and with other colleagues in profession. The principle objective of the medical profession is to render service to humanity with full respect for dignity of human beings. Every doctor, whatever is his/her speciality, has to discharge medicolegal responsibilities and to solve medicolegal problems from the very first day of his/her medical practice. Almost everything a doctor does in practice of medicine is in some manner or the other is governed by the legal system. Quite often, a doctor victimizes himself/herself to the litigious tactics of the public, irrespective of whether they are actual causative factors or not. The major reasons for this are, firstly ignorance about medical law and ethics by the young medicos, leading to the consequences of negligent behaviours/failure to discharge compulsory duties towards the patient and the state, amounting to either infamous conduct or negligence charges. Secondly, members of the general public are becoming increasingly aware of their rights due from a doctor, questioning the legality of issues. Hence, it is absolutely essential that every member of medi- cal profession clearly knows what exactly are their compulsory duties and proper behaviour towards their patients. They should also know who are the authorities proposing these rules and what penalties one is likely to be punished with in the event of breach of them. Origin of Medical Ethics is as old as the origin of Medicine. To the earliest man, medicine was known in the form of magic, witchcraft, worship and various objects of nature. To protect themselves from their charlatan effect, ancient men framed set of regulations to control these medical men, this may be marked as the earliest code of ethics. About the medical ethics in India, details mentioned have been noticed in the first treatise on Indian medicine, i.e. Agnivesa Charaka Samhita: Charaka’s Oath, supposed to be composed in about 7th century BC. It is said that specific codes regarding the training, duties, privileges and social status of the physicians were mentioned in it.3,4 CHARAKA’S OATH According to this, the teacher instructed the disciples, in presence of sacred fire, Brahmans and Physicians thus: Thou shalt be free from envy, not cause other’s death, and pray for the welfare of all creatures. Day and night, thou shalt be engaged in the relief of patients, thou shalt not desert a patient, not commit adultery, be modest in the attire and appearance, not be drunkard or sinful, nor associate with abettors of crimes. A person known to the patient shalt while entering a patient’s house, accompany you. The peculiar customs of the patient’s household shall not be made public. Arthashastra of Kautilya of 3rd-5th centuries BC is considered to be further improvised code of ethics. Here, physi- cians were required to have taken a written permission from the ruler (king) to practice medicine, their practice being regula- rised from time to time and they were punished for negligence.3 Sushruta, the Father of Indian Surgery was another famous authority in Indian system of medicine, which composed Sushruta Samhita (200-300 AD) and defined clearly the qualities, responsibilities and duties of physicians. They were so carefully written that they are in no way inferior to the modern concepts of medical law and ethics.

However, the Medical Council of India (founded in 1933) formulates the modern code of medical law and ethics in India. It is framed and worded on the same line as in the Declaration of Geneva by the World Medical Association, which again is a restated modern version of the oldest code of medical ethics, the Hippocratic oath: held in high esteem by every medical professional. CODES OF MODERN MEDICAL ETHICS Modern code of medical ethics is basically developed from several ethical principles put forth by noble men and organisations in medical profession from the historical period of medical practice such as Hippocratic oath, Declaration of Geneva and International Code of Medical Ethics, etc. Although these are apparently three separate codes, they are framed well dependent on each other, more so with Hippocratic oath. Added to this are Declaration of Sydney, Declaration of Tokyo, etc. which are recent in origin. Hippocratic oath is the oldest code of medical ethics, which is 25 centuries old now; its basic tenets remain as valid as ever. However, the historical attractiveness of archaic language and formulations, which became anachronistic, led to the restate- ment of the same in the Declaration of Geneva. New doctors at convocation ceremonies formerly pledged Hippocratic oath, though this is rare now. An English translation of this oath is given below: • I swear by Apollo the physician, and Aesculapius and Health, and All-heal, and all the Gods and Goddesses, that according to my ability and judgement • I will keep this oath and this stipulation—to reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. • I will follow the system of regimen, which, according to my ability and judgement, I consider for the benefit of my patients, and abstain, from whatever is deleterious and mischievous. • I will give no deadly medicine to anyone if asked, or suggest any such counsel, and in like manner I will not give to a woman a pessary to produce abortion. • With purity and holiness, I will pass my life and practice my art. • I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. • Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and further, from the seduction of females or males, of freemen or slaves. • Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as 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, respected by all men, in all times. But should I trespass and violate this oath, may the reverse be my lot. Declaration of Geneva Following the gross transgression of medical ethics during Second World War, the World Medical Association restated the Hippocratic oath in a modern style, and called it as Declaration of Geneva, as given below: • I solemnly pledge myself to concesrate my life to the service of humanity.

• I will give to my teachers the respect and gratitude that is their due. • I will practice my profession with conscience and dignity. • The health of my patient will be my first consideration. • I will respect the secrets, which are confided in me. • I will maintain by all means, in my power, the honor and the noble traditions of the medical profession. • My colleagues will be my brothers. • I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. • I will maintain the utmost respect for human life from the time of conception. • Even under threat, I will not use my medical knowledge con- trary to the laws of humanity. Declaration of Sydney This was the first published to guide to determine the time of death of comatose donor in brain death. The patient is not dead until the life support has been withdrawn. This was first adopted by the 22nd World Medical Assembly, Sydney, Australia, August 1968, and amended by the 35th World Medical Assembly, Venice, Italy, October 1983, and the WMA General Assembly, Pilanesberg, South Africa, October 2006. Following is the text of this declaration released on June 14, 2006. • Determination of death can be made on the basis of the irreversible cessation of all functions of the entire brain, including the brainstem, or the irreversible cessation of circulatory and respiratory functions. This determination will be based on clinical judgment according to accepted criteria supplemented, if necessary, by standard diagnostic procedures and made by a physician. • Even without intervention, cell, organ and tissue activity in the body may continue temporarily after a determination of death. Cessation of all life at the cellular level is not a necessary criterion for determination of death. • The use of deceased donor organs for transplantation has made it important for physicians to be able to determine when mechanically-supported patients have died. • After death has occurred, it may be possible to maintain circulation to the organs and tissues of the body mechanically. This may be done to preserve organs and tissues for transplantation. • Prior to postmortem transplantation, the determination that death has occurred shall be made by a physician who is in no way immediately involved in the transplantation procedure. • Following determination of death, all treatment and resuscitation attempts may be ceased and donor organs may be recovered, provided that prevailing requirements of consent and other relevant ethical and legal requirements have been fulfilled. Declaration of Tokyo This was first published in 1975. Declaration of Tokyo gives the guidelines for medical doctors concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. This was adopted by the 29th World Medical Assembly, Tokyo, Japan, in October 1975. It is the privilege of the medical doctor to practice medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use made of any

medical knowledge contrary to the laws of humanity. For the purpose of this declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. Following is the text of this declaration released:7 • The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedure is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including armed conflict and civil strife. • The doctor shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment. • The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment are used or threatened. • A doctor must have complete clinical independence in deciding upon the care of a person for whom he/she is medically responsible. The doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose. • Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgement concerning the consequences of such voluntary refusal of nourishment, he/she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgement should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner. • The World Medical Association will support, and should encourage the international community, the national medical associations and fellow doctors to support the doctor and his/her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment. INTERNATIONAL CODE OF MEDICAL ETHICS This was first adopted by the Third General Assembly of the World Medical Association at London in October 1949.8 International code of medical ethics is again solely based on Declaration of Geneva and framed as sets of duties of doctor in general, to the sick and to each other. The English text of this code is as follows: Duties of Doctors in General • A doctor must always maintain the highest standards of professional conduct. • A doctor must practice his profession uninfluenced by motives of profit. • Following practices are deemed unethical: – Any self-advertisement except such as is expressly author- ised by the national code of medical ethics. – Collaboration in any form of medical service in which the doctor does not have professional independence. – Receiving any money in connection with services rendered to a patient other than a proper professional fee, even with the knowledge of the patient. • Any act or advice, which could weaken physical or mental resistance of a human being, may be used only in his/her interest.

• A doctor is advised to use great caution in divulging discov- eries or new techniques on treatment. • A doctor should certify or testify only to that which he/she has personally verified. Duties of Doctors to the Sick • A doctor must always bear in mind the obligation of preserving human life. • A doctor owes to his or her patient complete loyalty and all the resources of his/her science. Whenever an examination or treatment is beyond his/her capacity, he/she should summon another doctor who has the necessary ability. • A doctor shall preserve absolute secrecy on all he/she knows about his/her patient because of the confidence entrusted in him. • A doctor must give emergency care as a humanitarian duty unless he/she is assured that others are willing and would be able to give such care. Duties of Doctors to Each Other (Medical Etiquette) The terminology is used to indicate the conventional law of courtesy to be observed among the members of medical profession. It is the rules of conduct growing the relationship in the medical profession and includes the following: • A doctor ought to behave to his/her colleagues, as he/she would have them behave to him/her. • A doctor must not entice patients from his/her colleagues. • A doctor must observe the principles of “The Declaration of Geneva approved by the World Medical Association”. Declaration of Helsinki This code of conduct for doctors emerged during 1964, introduced by the World Medical Association. It was revised in Tokyo in 1975, and governs medical research.9 This was intended purely to embark upon any experimental scheme of treatment or whenever clinical trials for a new drug were proposed on human beings as an experiment. Such experimentations upon human beings were more common during the Second World War, involving most of the war prisoners, as experimental subjects, for a new drug or other novel methods of treatment in medicine. CODES OF MEDICAL ETHICS IN INDIA The Medical Law and Ethical Codes for the medical professionals in India are prescribed by the Indian Medical Council, under the section 20-A of Indian Medical Council Act of 1956 and Amendment Act No: 24 of 1964. The text of the code is actually prescribed in two parts: The Declaration and the Code Proper. The Declaration This is based on Declaration of Geneva. At the time of registration as registered medical practitioner each applicant shall be given a copy of the declaration by the Registrar of concerned State Medical Council and shall be made to read and agree to abide by the same. The actual text of declaration of the code is provided by the Medical Council of India, is medical ethics in India, may be presented as follows: Declaration of Code of Medical Ethics in India • I solemnly pledge myself to consecrate my life to the service of humanity. • Even under threat, I will not use my medical knowledge contrary, to the laws of humanity. • I will maintain the utmost respect for human life from time of conception. • I will not permit consideration of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. • I will practice my profession with conscience and dignities.

• The health of my patient will be my first consideration. • I will respect the secrets, which are confided in me. • I will give to my teachers the respect and gratitude that is their due. • I will maintain by all means, in my power, the honour and noble traditions of the medical profession. • I will treat my colleagues with all respects and dignity. • I shall abide by the code of medical ethics as enunciated in the medical council regulations, 2002 (Professional Conduct Etiquette and Ethics) • I make these promises, solemnly truly and upon my honour. Place Signature Date Name Address Proper Code of Medical Ethics and other laws prescribed by the Indian Medical Council is dealt with in detail under separate side headings below, namely: Indian Medical Council and State Medical Council, Registered Medical Practitioner, Professional Misconduct, Professional Secrecy, Consent, Medical negligence. INDIAN MEDICAL COUNCIL (IMC) The Indian Legislative Assembly, in the year 1933, passed an Act, The Indian Medical Council Act, 1933 (Act No: XXVII of 1933). With this the Indian Medical Council was created. This Act, however, now got amended by the Indian Medical Council Act, 1956, and the Indian Medical Council (Amendment) Act, 1964, which extend to the whole of India.1,10-12 The medical profession in India is thus brought under the control of Indian Medical Council, by maintaining a register, entering the names of all Medical Practitioners of the country in it, before being allowed to practice the art of medicine. It lays down actual code of conduct (ethical codes) for the medical profession in India based on Geneva Declaration, which each qualified Medical Practitioner has to agree to and abide by, at the time of getting his/her name registered in the register of the council (through State Medical Council). Codes of Medical Ethics Prescribed Though the Indian Medical Council prescribes the ethical codes, their enforcement rests with the State Medical Councils and various aspects of the same will be discussed under State Medical Council separately. Functions of Indian Medical Council : Maintenance of Medical Register An officer by name Registrar is appointed by the Council, who will maintain a register called Indian Medical Register. This contains the names of all medical persons who are enrolled on any of the State Medical Register and who possess a recognised medical qualification. A name once entered is erased normally on death of the doctor or as a disciplinary action. Names may also be erased temporarily and then reentered, depending on the time and condition of disciplinary actions taken. Maintenance of Medical Education Postgraduate education: It prescribes standards of postgraduate medical education for the universities and would also offer advice to universities so as to maintain uniformity all over the country. Undergraduate education: It maintains standards at under- graduate medical education by appointing inspectors who inspect the facilities and examinations held by universities/medical institutions is in India, the purpose being to recommend recognition of the qualification to Central Government. Indications for Inspection

MCI may arrange for an inspection of a medical college under following circumstances: • For every medical qualification when it is newly introduced. • For every five years routinely, to determine the standards, equipments, training, staff pattern and other facilities. If the inspection result is unsatisfactory, the inspectors concerned can make recommendation to the Medical Council of India for withdrawing recognition accorded earlier. Recognition of Foreign Medical Degrees Two important sections of Indian Medical Council Act 1956, govern this and they are: Section 12, empowers the council to recognize medical qualifications granted by institutions outside India and to enter in a scheme of reciprocity with Medical Councils of Foreign Countries in the matter of mutual recognition of medical qualifications between the two countries. Section 13(4) of the same Act, gives authorisation to the council to recognize foreign medical qualifications which are not included in the schedule (II), based on reciprocal recognition. Procedure: A person with such qualification should first send an application through Central Government. The full literature regarding the course of study, syllabi, duration of the course, etc. may also be required to be furnished. The council may con- sult directory of medical institutions published by WHO. Appeal against Disciplinary Action The Indian Medical Council can give advice to the Central Government (Health Ministry) regarding appeals preferred by a medical practitioner against the decisions taken by the State Medical Council on disciplinary matters. Procedure of Appeal The medical practitioner, against whom the State Medical Council has taken disciplinary action, may appeal to the Central Government in writing stating the grounds of the appeal and be accompanied by all relevant documents including a receipt for paying the nominal fees (Rs. 20/-) to Central Government. The appeal should be filed within 30 days from the date of decision appealed against. The Final Decision The final decision of the Central Government, which is given after consulting Indian Medical Council, is final and binding on the State Government and the State Medical Council. Warning Notices Indian Medical Council may issue warning notice to every doctor at the time of getting enrolled as Registered Medical Practitioner. This comprises of information about certain unethical practices known as infamous conduct in a professional respect.10,15,16 Explanation Warning notice hence implies that whenever a Registered Medical Practitioner commits professional misconduct, they are self- warned about the offence and the consequences of disciplinary action by the State Medical Council. Thus, warning notice is not a written letter or notice or any document by State Medical Council or Indian Medical Council through post or a messenger to the offending Registered Medical Practitioner. The council usually appoints a secretary for its day-to-day work. The secretary is the executive officer of the council. He/ she shall maintain the Indian Medical Registrar and is to update it periodically by erasing the names of practitioners who have: • Died • Convicted by criminal court • Guilty of professional misconduct He shall also restore the names of those doctors whose period of temporary erasure expires. STATE MEDICAL COUNCIL (SMC) After the Indian Medical Council Act 1933, 1956 and the Amendment Act of 1964, several State Governments have created State Medical Councils bypassing the State Medical Acts, to keep a control over the medical profession at a State Level. Disciplinary functions of State Medical Council :

State Medical Council Maintenance of Medical Register. The State Medical Council also maintains a State Medical Register. This Register will contain the name, address, qualifications and date of qualification of every person who is registered under this Act on paying a prescribed fee. On registration a number is allotted to each person with a certificate, enabling him/her to be considered as Registered Medical Practitioner. Display of this certificate in the place of his/her practice helps the lay public to distinguish a qualified doctor from the unqualified. It is the duty of the Registrar to inform Indian Medical Council, from time-to-time, about the additions and deletions from the State Medical Register regularly. Disciplinary Control Though the other functions mentioned above form the bulk of the Council’s workload, it is the disciplinary function which is most controversial and receives maximum attention from the medical profession, public and the press. The State Medical Council Acts empower the respective council to erase the name of any doctor from the Register, when convicted of any felony, misdemeanor, crime or offence, or judged after due enquiry by the council to have been guilty of infamous conduct in a professional respect (Professional Misconduct). This power of the councils is intended to protect the public and not to be a punitive measure against attending practitioners, though the deterrent value is admitted. As erasure or suspension is the most serious professional disaster, which can overtake the doctor, the disciplinary machinery of the Medical Councils should be fully understood by every practitioner. Disciplinary Enquiry Disciplinary enquiry may arise usually from two sources. • Accusations of professional misconduct either from a member of the public or a professional colleague or a certain public officer. • A statutory notification from the court officials where a doctor is convicted for any criminal offence. Procedure On receipt of such a notification or accusation of professional misconduct, the Registrar of State Medical Council submits it to the President and on scrutinising the same one of the following is opted. • Rejection of the case: Obviously false, malicious or otherwise unfounded trivialities are rejected at this stage (acquittal if no prima facie case existing). • Submission to special committee: The cases, which cannot be rejected, shall be referred to a special committee of the President and a few other members, one of whom is a nonmedical man of good repute. The committee will examine the facts of the case and on giving an opportunity to the accused doctor to defend, refers the case to the disciplinary committee, who decides the punishment under disciplinary action. The disciplinary committee is the definitive body of the State Medical Council, which hears cases of serious nature or offences, which have been repeated after previous warnings by subcommittees. The committee has to decide the disciplinary actions enumerated below: – Acquittals: The case may be dismissed if no prima facie evidence against the accused. – Warning: If it is a case of first offense, doctor may be sent back merely with warning not to repeat the same. – Suspension: It is the eraser of the name of the doctor from the register for a specific period considering the gravity of offense, to be reinstalled at the end of the period of suspension. Penal Erasure (Professional Death Sentence) This means erasure of the name of the doctor from the register permanently when the offense is confirmed beyond doubt allowing not to practise the profession. When a practitioner’s name has been erased from the register,

he/she may apply for restoration at various fixed intervals. He/she may also appeal to the Central Health Ministry against the decision of the State Medical Council. REGISTERED MEDICAL PRACTITIONER Definition A Registered Medical Practitioner is a qualified doctor who has been registered in State/Indian Medical Councils. Procedure of Getting Registered After passing qualifying examinations (MBBS) one has to undergo a period of compulsory training of internship (House Surgeonship) for a period of minimum one year in an insti- tution approved by the Indian Medical Council. On completion of this training he/she will have to fill in certain application forms and pay the nominal fee to the State Medical Council. The office which will then scrutinize the contents in the application and if approved, enters the name of the doctor in the register, and provides him a Registration Certificate and a code number by which he/she may be referred for all further communications. Declaration At the time of registration, the Registrar of State Medical Council will provide a declaration form, which contains all the medical law and ethical codes. The doctors has to sign this and get attested by Registrar/a Registered Medical Practitioner and return it to the Registrar, will have to be abide by the same, breach of which will lead him to the charges of professional misconduct, which leads to the punishment of either warning or penal erasure. Merits of Registration as Registered Medical Practitioner On getting registered a doctor has certain merits such as achieving some special rights and privileges. He/she also have to perform certain duties towards the patients and the state. Both of these are discussed below. Rights and Privileges of Registered Medical Practitioner • He/she is legally recognised as medical man and is entitled to possess/dispense, to prescribe medicines listed in dangerous drug act. • He/she can set up medical practice anywhere in India. • He/she is enabled to hold official and semi-official (government) appointments at public hospitals. • He/she is entitled to sign statutory medical certificates, such as for birth, death, mental illness, etc. • He/she is entitled to sue for recovery of his or her fees in court of law. However, gratuitous service may be rendered to a deserving poor patient, as well as to all other physicians and his/her dependent family members. • He/she is entitled to perform medicolegal autopsies. • He or she is entitled to give evidence at any inquest or in any court of law as an expert. • He/she is exempted from serving on a jury and at an inquest. • He/she can choose his/her patient. • He/she can add title, description, etc. to his or her name. Duties of Registered Medical Practitioner • To exercise a reasonable degree of skill and knowledge in treating a patient. • To attend and examine a patient as long as there is a need after commencing the treatment. However, he/she can terminate his/her services, when another physician attends his patient or the patient starts using remedies other than those prescribed by him/her. • To provide proper and suitable medicine to the patient either directly or by a prescription.

• To give proper instructions to the patient or relative of the patient regarding the use of medicine, dosage schedule, diet, etc. and warn the dangers if not used properly. • To appoint a substitute doctor during temporary absence, with the consent of patient, especially in obstetrics and gynecology cases. • To warn the possibilities of cross-infecting the others, in case the patient is suffering from communicable disease. • To take proper care of children and adult patients, who are unable to take care of themselves. • To inform all the risks involved in treatment plan. However, under the Doctrine of therapeutic privileges doctor need not disclose everything. • To handle poisons carefully and give proper treatment to a poisoning case and also cooperate with law enforcement authorities in deciding whether the case is a suicide, homicide or accident. • To inform health authorities of a communicable disease reported under the Doctrine of privileged communication forgoing the professional secrecy principles of ethical code. • To exercise all duties with regard to surgery, i.e. taking consent, operating under proper anesthesia, aseptic measures, pre- and postoperative care, etc. • To treat war prisoners, civilians of any country, etc. under the duties proposed in Geneva Convention. • To refer a patient to specialist/consultant as and when needed on taking prior consent. • To take an X-ray of injured part (unless trivial) for ruling out fractures. • To maintain a perfect professional secrecy. PROFESSIONAL MISCONDUCT (Synonyms: Infamous Conduct) Definition Professional misconduct can be defined as something done by a doctor in profession, which is considered as disgraceful and dishonourable by his or her professional brethren of good repute and competence, after the enquiry by the State Medical Council. Punishments Under disciplinary control the State/Indian Medical Council decides this and depending on the type of misconduct punishment can be: • Warning • Suspension • Penal erasure (professional death sentence). Examples The potential reasons for penal erasure or suspension from the register are limitless. However, a few examples are enumerated below. Each of these is also called as ingredients of professional misconduct and listed under 6 A’s. • Association with unqualified persons • Advertising • Adultery • Abortion (illegal) • Addiction • Alcohol. Apart from these, the councils can also consider any other form of alleged infamous conduct, which is not in the above list for deciding the punishment. Association with Unqualified Persons Following may be considered as suitable examples: • Employing unqualified or unregistered assistants. • Assisting an unqualified person for some purpose. – Ghost surgery: Here a qualified surgeon performs a surgery on a patient on behalf of an unqualified, who enters the

operation theater after the patient is anesthetised and leaves prior to returning to consciousness. Covering of unqualified persons: Here a qualified doctor covers unqualified persons as to enable them to practice midwifery by issuing a certificate to them, which enables them to conduct such practice. However, this is not applicable where in proper training is offered to bonafide medical students/dispensers/surgery attendants and skilled technical assistants, under the supervision of qualified and registered medical practitioners. Conversely, the said registered medical practitioner is held responsible for all. - Illustration of a doctor’s name plate/signboard (Unusually large measuring 20’ × 5’) with consultancy rates and cost of various tests and medicine given etc displayed in the heart of the city in a prominent area. Note: It shows no address. - Another signboard hanging from the roof at the entrance of the clinic : Notification in the lay press (A model) mistakes committed by these trainees/students (vicarious liability). Advertising Includes three modes, namely direct advertisement, indirect advertisement and canvassing: Direct Advertising • An unusually big name plate or signboard announcing the structure of fees collected from the patient, any concession, etc. • Inserting name in a telephone directory in a special place, in bold type prints, etc. • A prescription paper containing appointments held. • Notification in the lay press of his/her addresses or telephone number/consulting hours unless he/she has: – Started practice afresh – Change of practicing place – Resumed practice after a temporary absence from duty, such as on returning from a short vacation or visit abroad – Changed the type of his practice. Note: In each of these instances the advertisement should not appear more than twice, in two newspapers.Indirect Advertisement • Contributing articles to lay press (except on public health and allied matters). • Appearance, frequently in broadcasting media such as radios, television, etc. which have the effect of advertising. • Allowing the use of his/her name on price list of publicity materials, handbills, etc. Canvassing - includes use of touts or agents for procuring patients. Adultery - A medical man should maintain the highest professional standard and should not abuse his/her position to seduce a female patient or some other member of patient’s family. Abortion - Abortion includes procuring, assisting or attempting to procure a criminal abortion. Addiction - Supplying or selling addiction forming drugs to a person for other than medical Grounds. Alcohol - Attending patients while under the effect of alcohol. PROFESSIONAL SECRECY Definition : Professional secrets are the ones, which a doctor comes to know about his/her patient in his professional capacity as a physician/ doctor.