Medical Jurisprudence

Introduction

• Juris=Law
• Prudential=knowledge
• “Deals with legal aspects of medical practice”
• Examples:
• Disposal of medical wastes,
• Ethical practice, practising registration,
• Medical negligence
• Consent
• Professional misconduct etc.

Need for Medical Jurisprudence

• The medical students or professional should be aware of responsibilities and liabilities of their medical practice
• Medical practice is governed by medical ethics and laws
• To ensure practising medical profession within the legal framework

Note

• Medical practice is governed by Medical council of India
• It is called as National Medical commission
• It is under the National Medical commission act 2019 (08/08/19)
• It replaced the Indian Medical council act 1956
• Laws pertaining to medical practice are governed by various laws and acts enacted in the country

Aims of the doctors and medical practitioners

• To preserve life
• To effect the cure of the illness
• Prevention of disease
• To help in advancement of medical knowledge

Medical council of India (MCI)

• It was a statutory body in India
• Replace or repealed by National Medical commission act 2019
• Establishing and maintaining high standards of medical education and recognition
• It registers doctors to practice medicine
• Governs the ethics and conduct of medical practitioners

Functions of MCI

• Recognition of medical qualification
• Recognition of foreign medical qualification
• Maintenance of register
• Medical education
• Disciplinary control
• Appellate tribunal
• Maintenance of Indian pharmacopoeia

Indian Medical council Act 1956

The Indian Medical Council used to:

• Give recognition for the licentiate practitioners
• Provide registration of foreign medical qualification
• Formation of committee for recognizing PG medical education
• Maintain all India Medical register containing names of registered medical practitioners

Composition of NMC

The following persons shall be appointed by the central government.

• A chairperson
• 10 ex-officio members
• 22 part time members

Chairperson

• Shall be a medical professional
• Having post graduate degree
• Experience not less than 20 years
• Out of which 10 years shall be as a leader in the area of medical education.
• Holds office for 4 years and not eligible for extension
• Shall be appointment by the central government
• Salary and allowances are admissible to the chairperson

10  Ex-officio members

The term shall be as long as the member holds the office due to which he/she is the ex officio member.

1.The president of the undergraduate medical education board (UGMEB)

2.The president of the post graduate medical education board (PGMEB)

3.The president of  medical assessment and rating board (MARB)

4.The president of the ethics and medical registration board (EMRB)

5.The director general of health services, DGHS, New Delhi

6.The director general of Indian council of medical research

7.The director of any all India institute of medical sciences to be nominated by the central government

8.Two person nominated by the central government among directors of PG institute of medical education and research, Chandigarh; JIPMER, Puducherry, Tata memorial hospital, Mumbai; North eastern Indira Gandhi regional institute of health and medical sciences, Shillong, and all India institute of Hygiene and public health, Kolkata

9.One person nominated by the central govt. from ministry of health and family welfare.

Part time members

• 3 members appointed from among person who had special knowledge and professional experience in management, law, medical ethics, health research, consumer or patient advocacy, science and technology and economics
• 10 members on rotational basis from nominees of the state and UT. One member to represent each state who is vice chancellor of a health university of that state. One member to represent each UT who is vice chancellor of university of that UT and nominated by the Ministry of home affairs.
• 9 members among nominees of state and UT among elected members of the state medical council nominated by state medical council

Schedules of MCI for recognition

• I Schedule: medical qualification in India
• II schedule: medical qualification from Outside India
• III schedule:
  • Part I: Medical qualification In India not mentioned in Schedule I
  • Part II: Medical qualification outside India not mentioned in Schedule II

Meetings and Quorums

• The commission shall meet at least once every quarter
• The chairperson leads the meeting
• Total of one half of the members including the chairperson shall constitute the quorum
• Decisions at the commission shall be taken with majority and voting can also be done

Functions of NMC

• Maintain high quality and standards in medical education
• Regulate medical institutes and hospitals
• Regular medical research
• Regulate medical professional
• Frame guidelines for the determination of the fees and other charges in 50 % seats in private medical colleges and private deemed universities
• Assess the requirement of the man power and infrastructure for proper delivery of health care and develop roadmap for meeting requirement
• To ensure compliance by the state medical council for smooth implementation
• To exercise and act as an appellate jurisdiction with reference to decisions taken by various autonomous boards such as undergraduate medical education board, post graduate medical boards etc.

Various autonomous boards

The central government constitutes certain autonomous boards under NMC

• Undergraduate medical education board (UGMEB)
• Post graduate medical education board (PGMEB)
• Medical assessment and rating board (MARB)
• Ethics and medical registration board (EMRB)

Composition of the autonomous bodies:

• Consists one president and two full time and 2 part time members
• The bodies shall meet at least once a month
• Decision shall be made on basis of majority of votes
• Any person aggrieved by the decision may appeal to the NMC within 60 days of the decision

Functions of UGMEB

• To determine standards of medical education at the undergraduate level
• To develop competency based curriculum
• To frame guidelines for starting or setting up medical college
• To determine minimum standards required and standards for conducting undergraduate courses and examination
• To grant recognition to a medical qualification at the undergraduate level.

Functions of the PGMEB

• To determine standards of medical education at the post graduate level
• To develop competency based dynamic curriculum
• To frame guidelines for starting or setting up medical institutes for imparting post graduate and super specialty courses
• To determine minimum standards required and standards for conducting post graduate courses and examination
• To grant recognition to a medical qualification at the post graduate level.
• To facilitate post graduate courses in family medicine

Functions of MARB

• To determine the assessment and rating of medical colleges as per the standards laid down by undergraduate medical education board and PGMEB
• To grant permission for starting or establishing new medical college or post graduate course or to increase number of UG and PG seats
• Carry out inspection of medical colleges for assessing and rating in accordance with the standards laid down
• Maintain essential standards, the board may issue a warning notice to impose monetary penalty or give orders to stop the admissions.

Functions of EMRB

• To maintain national register of all the licensed medical practitioners
• To regulate professional conduct and promote medical ethics. It is done by state medical board
• To act as an appellate jurisdiction with respect to the actions taken by any state medical council

National medical register

• The ethics and medical registration board shall maintain a “National medical register”
• The register will contain the name, address, all recognized qualifications possessed by the licensed medical practitioner.
• The national medical register shall be public document under section 74 of IEA
• The national medical register shall be available to the public on the website of the board
• Every state medical council shall maintain the register and regularly update it
• The national medical register will be electronically synchronized with the state medical register
• A separate national register shall be maintained for the community health providers (CHP)
• Any person who qualifies the National Exit test (NExT) shall be granted a license to practice medicine and shall have his name and qualification enrolled in the national medical register or state medical register

Medical Advisory council (MAC)

• Constituted by central government
• It advices measures related to medical education
• It acts as primary platform through which state govts and UT may put their views or concerns

National examination

• National Eligibility cum entrance test
• NMC conducts the NEET
• NExT (National Exit Test) for UG to practice and for Entrance in PG courses and for students with foreign medical degree.

State medical council (SMC)

• Every state has its state medical council
• It provides registrations for the qualified professionals and deals with the related matters
• It maintains state register
• It hears and decides appeals from any decision of the registrar
• It prescribes codes of ethics for regulating professional conduct of medical practitioners
• To reprimand or suspend a medical practitioner from the register or take any disciplinary action.

Medical Ethics

• Ethics derived from Greek word, “ethikos” meaning manner and habits of man
• “Moral principles that guide members of medical profession in dealings with fellow colleagues, patient and state are called as Medical Ethics”
• Medical etiquette is defined as, “the conventional laws of courtesy observed between members of medical profession”
• Medical profession is considered as noble profession
• Require code and regulation
• Such regulations are called as “Code of Medical Practitioner”
• Hippocratic oath is one of the earliest known code
• The modern version of Hippocratic Oath is the “International Code of Medical Ethics”
• In 2002 MCI has brought out regulations for all the doctors registered with medical council of India or state medical council
• Medical Ethics differ from law
• Violation of such ethics may lead to professional misconduct
• Lead to actions like temporary or permanent stoppage of medical practice

The regulations from MCI are described under 8 chapters

1.Code of medical ethics

2.Duties of physician to their patients

3.Duties of physicians in consultation

4.Responsibilities of physician to each other

5.Duties towards the public and to para medical profession

6.Unethical acts

7.Misconduct

8.Punishments and disciplinary actions

MCI was in existence  till 25th September 2020

Replaced by National Medical commission (NMC)

Professional Misconduct

• Also called as infamous conduct
• It is considered as disgraceful or dishonorable conduct by his/her professional colleagues of good repute and competence
• The acts of commission are:
  • Abuse of professional position by committing adultery or improper conduct with a patient
  • Improper association for patient procuring
  • Conviction by court of law (offenses involving immorality)
  • Involved in sex determination test
  • Issuing false certificate
  • Contravening of the provisions of drugs and cosmetics act
  • Involved in criminal abortion
  • Advertising: big boards mentioning names of the doctors are against the medical ethics of the doctors
  • Dichotomy

The acts of commission may be 6 A’s:

1.Adultery

2.Association

3.Abortion (illegal)

4.Associated with unqualified persons

5.Alcohol

6.Advertising

Acts of Omission are:

1.Not maintaining record of IP for 3 years

2.Refusal to provide medical record of patient to the family within 72 hours

3.If doctor do not displays the registration number

The unethical acts

• Advertising
• The doctor is permitted for formal announcement in press for following:
  • On starting practice
  • On change of type of practice
  • On changing address
  • On temporary absence from duty
  • On resumption of another practice
  • On succeeding to another practice
  • Public declaration of charges

• Patent and copyrights
• Running an open shop
• Rebates and commission
• Prescribing or dispensing secret remedies
• Violating human rights
• Practising euthanasia: mercy killing
• In dealing with Pharmaceutical companies:
  • Gifts
  • Travel facilities
  • Cash or monetary grants

Punishments for Professional Misconduct

• Penalty may be imposed on the RMP for professional misconduct and unethical acts by the NMC
• Warning notice
• Penal eraser: temporary removal of name from register for a stipulated period
• Professional death sentence

Duties of Medical Practitioners

• RMPs have duties towards patients, colleagues and state

Duties and responsibilities of RMP In general (revised)

• A physician should uphold the dignity and honour of the medical profession
• To render service to humanity with full respect to the profession and patient
• Should get membership of different medical societies for advancement of his profession
• Should participate in CMEs at least 30 hours every five years
• Shall maintain record of In patient for a period of 3 years from date of start of treatment
• Shall display the registration number given by the state or national council
• Should prescribe generic name of the drug and preferably in capital letters
• Should announce fees before rendering the services
• Should observe the laws of the country.

Duties towards Patients:

• Exercise reasonable degree of skill and knowledge
• Duty to attend the patient and examine him/her
• Duty to prescribe proper medicines and inform side effects if any
• Duty to give proper instructions
• Inform risks of the procedures
• Professional secrecy
• Prognosis of the disease should be told to the patient.

Duties of physicians in consultation:

• Unnecessary consultation should be avoided
• Lab investigations are to be prescribed wisely
• Consultation for the patient’s benefit
• Punctuality in the consultation
• Statements to the patient and relatives after consultation
• Clear mention of fees and other charges of procedures
• Treatment after consultation
• Patient referral to a specialist

Duties to the Colleagues:

• Conduct in the consultation (never criticize the colleagues)
• Consultant not to take charge of the case
• Never take fees from the colleagues
• Visiting another physicians’ case (always help the colleagues)

Duties towards the state:

• Doctors should help the patients in case of mass disaster or epidemic
• Duty to notify certain diseases (for e.g. Cholera, Covid 19 etc) so that spread can be avoided
• Duties to inform vital events like birth, death etc.

Duties of the Patient

• To furnish all the documents related to health to the doctor
• To follow the instructions given by the doctor
• To pay the fees
• In case of second opinion, patient should inform the first doctor
• Should have faith in the doctor
• Should not contribute to medical negligence
• Should co-operate with necessary medical investigations

Rights and privileges of RMPs (section 27 of IMC/NMC)

• Right to practice medicine
• Right to choose patient
• Right to prescribe/dispense medicine
• Right to possess, dispense or prescribe drugs listed in the dangerous drug act
• Right to add professional titles to his/her name
• Right to perform surgical operations
• Right to issue certificates
• Rights for appointment to public hospital
• Right to give evidence as an expert witness in the court of law
• Right to claim payments of fees for professional service given

Rights and privileges of the patients

• Right to choose doctor
• Right to access health care facilities regardless of any discrimination
• Right to be treated with dignity, with care and respect
• Right to have privacy during the consultation
• Right to have confidentiality of all information furnished to the doctor
• Right to receive full information about the diagnosis, investigations and available methods of treatment
• Right to know the procedure of the treatment or operation, risks involved, alternative treatment options
• Right to demand medical record
• Right to complain and rectification of grievances
• Right to obtain compensation for medical injuries of negligence

Professional Secrecy & Confidentiality

Definition

        Professional secrets are the ones, which a doctor comes to know about his/her patient in his professional capacity as a physician/ doctor.

Explanation

• Part of the Hippocratic oath affirms: ‘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’.
• Dr. should accept it in its spirit and intention as his/her ideal standard of professional behaviour.
• This is not only a moral obligation but also a legal one, and practitioner is liable to damages if this is neglected.

Privileged Communication or exceptions to professional secrecy

(1) Infectious Diseases : If a patient suffering from an infectious disease is employed as cook or waiter in a hotel, or a food-handler with an enteric infection, or a teacher with tuberculosis or other infective disease, or as children’s nurse, etc., he should be persuaded to leave the job until he becomes non infectious. If the patient refuses to accept this advice, the doctor can inform the employer about the illness of his patient.

(2) Venereal Diseases : If a person is suffering from syphilis and is about to marry, it is the duty of the doctor to advice the patient not to marry till he is cured; if the person refuses, the doctor can disclose the syphilitic condition of the patient to the woman concerned or to her parents. Swimming pools should be prohibited to those having syphilis or gonorrhoea, but if the person refuses, the authorities can be informed. The doctor can inform the warden of a hostel, if any boarder is suffering from venereal disease.

(3) Servants and Employees : An engine driver or a bus driver or a ship’s officer may be suffering from epilepsy, high blood pressure, alcoholism, drug addiction, or colour blindness. The doctor should persuade the patient to change his employment, because of the dangers of his present occupation, both to himself and to the public. If this fails, the doctor should inform the employer, that the patient is unfit for that kind of employment.

(4) Notifiable Diseases : A medical practitioner has a statutory duty to notify births, deaths, infectious diseases, etc., to the Public Health authorities.

(5) Patient’s own Interest : The doctor may disclose the patient’s condition to some other person, so that he may be properly treated, e.g., to warn the parents or guardians of signs in the patient of melancholia, suicidal tendencies, etc. (Therapeutic Privilege)

(6) Self-interest: Both in civil and criminal suits by the patient against the doctor, evidence about the patient’s condition may be given.

(7) Suspected Crime: Every person, aware of the commission of, or of the intention of any other person to commit any offence shall immediately give information to the nearest Magistrate or police officer of such commission or intention .If the doctor learns of a serious crime, such as murder, assault, rape, etc. by treating the victim or assailant, he is bound to give information to the police. Thus, if a doctor treats a person suffering from gunshot or stab wounds due to criminal assault, he must inform the police.

(8) Negligence Suits: When a physician is employed by the opposite party to examine a patient who has filed a suit for negligence, the information thus acquired is not privileged (no physician-patient relationship), and the doctor may testify to such information.

(9) Courts of Law: In a Court of law, a doctor cannot claim privilege concerning the facts about the illness of his patient, if it is relevant to the inquiry: before the Court.

Laws & Doctors

Penal Provisions applicable to Medical Practice:

• S. 52, I.P.C. :Nothing is said to be done in good faith which is done without due care and attention.
• S. 74, I.P.C. : Nonattendance in obedience to summons from court (6 months imprisonment).
• S. 118, I.P.C. : Concealing design to commit offence punishable with death or imprisonment for life. (imprisonment for 3 months if the offence is not committed and 7 years if the offence is committed}.
• S. 175, I.P.C. : Omission to produce document to public servant by person legally bound to produce it (six months imprisonment).
• 8.176, I.P.C.: Omission to give notice or information to public servant by person legally bound to give it (imprisonment up to one month).
• S. 177, I.P.C. : Furnishing false information (imprisonment up to six months).
• S. 178, I.P.C. : Refusing oath or affirmation when duly required by public servant to make it (imprisonment up to six months).
• S. 179, I.P.C.: Refusing to answer public servant authorised to question (imprisonment up to six months).
• S. 182, I.P.C.: False information with intent to cause public servant to use his lawful power to the injury of another person (imprisonment up to six months).
• S. 191, I.P.C. : Giving false evidence.
• S. 192, I.P.C. :Fabricating false evidence.
• S. 193, I.P.C. : Punishment for false evidence (imprisonment up to seven years).
• S. 194, I.P.C. : Giving or fabricating false evidence with intent to procure conviction of capital offence (imprisonment up to ten years).
• S. 195, I.P.C. : Giving or fabricating false evidence with intent to procure conviction of offence punishable with imprisonment for life or imprisonment.
• S. 197, I.P.C. : Issuing or signing false certificate (imprisonment up to seven years).
• S. 201, I.P.C. : Causing disappearance of evidence of offence, or giving false information to screen offenders (imprisonment up to ten years).
• S. 202, I.P.C. : Intentional omission to give information of offence by person bound to inform (imprisonment up to six months).
• S. 203, I.P.C. : Giving false information respecting an offence committed (imprisonment up to two years).
• S. 204, I.P.C. :Destruction of document to prevent its production as evidence (imprisonment up to two years).
• S. 269, I.P.C.: Negligent act likely to spread infection of disease dangerous to life (imprisonment up to six months).
• S. 270, I.P.C.: Malignant act likely to spread infection of disease dangerous to life (imprisonment up to two years).

Legal Protection to RMP

There are certain laws which provides a legal protection to the doctors performing their duty with a good intent. These laws are mentioned below

• Section 87 of IPC
• Section 88 of IPC
• Section 89 of IPC
• Section 90 of IPC
• Section 92 of IPC
• Section 93 of IPC

Consent

Consent means voluntary agreement, compliance or permission. Consent signifies acceptance by a person of the consequences of an act that is being carried out. To be legally valid, it must be given after understanding what it is given for, and of risks involved.

Reasons for obtaining Consent

1. To examine, treat or operate upon a patient without consent is assault in law, even if it is beneficial and done in good faith. The patient may recover damages.
2. If a doctor fails to give the required information to patient before asking for his consent to a particular operation or treatment, he may be charged for negligence.

Types of Consent

Consent may be:

• Expressed, i.e., specifically stated by the patient
• Implied.

Expressed consent may be (a) verbal, or (b) written.

Implied Consent:

An adult patient of sound mind who;

1. Knows that he can either agree or refuse to submit to treatment or an operation.
2. Knows or has been fully or fairly informed by his doctor as to what is to be done.
3. Then cooperated with the physician, has impliedly consented in words. The fact that a patient attends the hospital or calls the doctor to his house complaining of illness, implies that he consents to a general physical examination, to determine the nature of the illness. Consent is implied when a patient holds out his arm for an injection. Such implied consent is the consent usually given in routine practice.

Examples are:

• If a patient enters in clinic it is presumed that patient has came for examination and consultation. Thus, the conduct of patient suggests the willingness to undergo for medical examination.
• The consent is not written but legally it is effective.
• The consent is provided for medical examination such as inspection, palpation & auscultation .
• And not Examination of:
  • Private parts
  • Vein puncture or injection
  • Major intervention or operation.

Expressed Consent

• Anything other than the implied consent described above is expressed consent.
• It is one which is stated in distinct and explicit language.
• This may be of two types: oral and written consents.

Oral (Verbal) Consent:

• For majority of relatively minor examinations or therapeutic procedures, oral expressed consent is employed, but this consent should be obtained in the presence of a disinterested third party. Usually presences of a receptionist or a ward sister/ nurse, etc. any one of the following suffice the purpose. However, a person closely related/associated with the patient is not ideal for the purpose. Oral consent, when properly witnessed, is of equal validity to written consent, but the latter has the advantage of easy proof in permanent form or document which avoids further disputes in any subsequent litigation.