Monday, March 10, 2008
Medical Ethics - Master of Hospital Administration (MHA)
Introduction to issues in medical ethics
V Raman Kutty
Professor, AMC
Medical Ethics
• Principals to guide physicians in their relationships with others
• Ethical dilemma is a predicament in which there is no clear course to resolve the problem of conflicting moral principles
• Dynamic environment/evolving field
Principles
• Autonomy
• Beneficience
• Nonmaleficence
• Justice
Autonomy
• Right to self-determination
• Requires decision making capacity
– Lack should be proven not assumed
• Competence – legal determination
•
Preservation of Autonomy
• Advance Directives
– A document in which an individual either states preferences or designates decision maker
– Living Will
• Takes effect when terminally ill and lacking decision making capacity
Preserving Autonomy
• Surrogate Decision Makers
– Represents patients interest
– Best identified before critical illness
– In absence of specific advanced directives should use substituted judgement
Preservation of Autonomy
• The primary responsibility of the physician is to serve the patients interest
The patient self determination act of 1990
• At the time of admission information re: the patients’ right to refuse care or create an advance directive must be dispensed
Informed Consent
• Requirements
– Decision making capacity
– Volutariness
– Reasonable person standard
• Present all alternatives f/b recommendation
• Respect refusal
• All surgical and experimental procedures
Implied Consent
• Invoked when true informed consent not possible
• Emergency situations when harm would result without urgently needed intervention
Disclosure
• Truth telling on part of physician is an integral part of patient autonomy
Paternalism
• Justifiable if patient at risk of significant preventable harm, paternalistic action will prevent harm, benefits outweigh risks and the least autonomy-restrictive course of action is used
Confidentiality
• Obligation of physician to maintain information in strict confidence
• Exceptions if failure to release data to data to appropriate agencies may result in greater societal harm
Futility
• Unilateral decision made on part of physician to withold or withdraw medical intervention based on predictable futile outcome
• Physiologic futility
• Medical futility – none of last 100 cases like this…
Beneficience
• Obligation to preserve life, restore health, relieve suffering and maintain function
• To do “good”
• Nonabandonment – obligation to provide ongoing care
• Conflict of interest – must not engage in activities that are not in patients best interest
Nonmaleficence
• “Do no harm, prevent harm and remove harm”
Impaired Physician
• Physicians have the obligation to report impaired behavior in colleagues
Principle of Double Effect
• Act must be morally good
• Actor intends good effect
• Good effect outweighs bad effect
• Bad effect not means to good effect
Justice
• Allocation of medical resources must be fair and according to need
• Physicians should not make decisions regarding individuals based upon societal needs
DNR
• DNR orders affect CPR only
• Other therapies should not be influenced by DNR order
• Should be reviewed frequently
• Rationale should be in medical record
Withdrawing of Support
• Brain death is not required
• Same as not initiating
• Does not conflict with basic principles
Persistent Vegetative State
• Uncnsciousness/ loss of self awareness lasting more than weeks
Death
• Irreversible cessation of circulatory and respiratory function
• Irreversible cessation of all brain function (including brainstem)
The
“The voluntary consent of the human subject is absolutely essential.”
“This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice … and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be known to him the nature, duration and purpose of the experiment; the methods and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person which may possibly come from his participation in the experiment.”
RESEARCH ETHICS CODES
DECLARATION OF
• Issues addressed include:
• Research with humans should be based on the results from laboratory and animal experimentation
• Research protocols should be reviewed by an independent committee prior to initiation
• Informed consent from research participants is necessary
• Research should be conducted by medically/scientifically qualified individuals
• Risks should not exceed benefits
ICMR guidelines
• Recently developed by ICMR (available on website)
• All medical research in
Implications
• Informed consent requirements should be carefully followed
• IRB mandatory in large institutions- otherwise, can request other institutions’ IRB to review proposals
• Collaborative research should be approved by IRBs of all institutions
Health Systems in India - an overview - Master of Hospital Administration (MHA)
Health System in India
– an overview
Dr Biju Soman MD DPH
Asst. Professor, AMCHSS, SCTIMST, Trivandrum-11
Overview
• Concept of Community Health
• Health for All (HFA) initiative
• Primary Health Care
-Principles and components
Health & Healthcare
• Health
• The ability to realize ones’ potential
• A persons sense of well-being
• Cultural understanding about ill health & well-being
• Extent of socio-economic disparities
• Reach, quality and costs of care
• Current bio-medical understanding
Is an issue of public policy in any mature society
Health ?
• WHO Def:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
and
is the ability to lead a socially and economically productive life
Determinants of Health ?
• Biological
• Behavioral
• Environmental
• Socio-economic
• Health services
• Demographic
• Inter-sectoral components
• Longevity doubled
• IMR halved
• Small pox and Guinea worm disease got eradicated
• Reduced malaria and tuberculosis cases
• But
• Contributes to a fifth of world’s ailments, one third of diarrheas, tb, resp.ailments and other infections and perinatal conditions, a quarter of maternal morbidities, a fifth of nutritional deficiencies, diabetes, CVDs, a rising number of of HIV/AIDS cases
Who are all responsible ?
• Individual
• Family
• Community
• State
• International community
• Is a Public good so should be dealt in that way
Healthcare System for safeguarding community health
• the sum total of all the organizations, institutions and resources whose primary purpose is to improve health
• staff, funds, information, supplies, transport, communications, overall guidance and direction.
• to provide services that are responsive and financially fair, while treating people decently.
Alma-Ata
• 1978 international conference on primary care reaffirmed HFA as social goal of the governments can be achieved by primary health care
HEALTH FOR ALL 2000
(WHO, 1981)
• “The main social target of governments and of WHO should be the attainment by all the people of the world by the year 2000 of a level of health which would permit them to lead a socially and economically productive life.”
PRIMARY HEALTH CARE
(WHO)
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology
made universally accessible to individuals and families in the community through their full participation and
at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination
Elements of primary health care
• Education about health problems and methods of controlling them
• Promotion of food supply and proper nutrition
• Provision of safe water supply and basic sanitation
• Maternal and child care including FP
• Immunization against major infections
• Prevention and control of locally endemic diseases
• Appropriate treatment of common diseases and injuries
• Provision of essential drugs
Principles of primary health care
• Equity of distribution
• Health services must be shared by all people
• Provide access to all people
• Community participation
• Let them promote their own health
• Intersectoral coordination
• Education, hosing, agriculture,etc
• Appropriate technology
• According to need not on demand
Appropriate technology
• Technology that is scientifically sound, adaptable to local needs and acceptable to those who apply it and those for whom it is used, and that can be maintained by the people themselves, in keeping with the principle of self reliance with the resources the community and country can afford.
Obstacles to the implementation of PHC Strategy
Misinterpretation of the PHC Concept
Misconception that PHC is a 2nd rate health care for the poor
Selective PHC Strategies
Resistance to Change
Lack of political will
Centralized Planning & Management Infrastructure
Selective Primary Health care
• UNICEF’s going back from comprehensive PHC concept in the early years itself
• Health Sector Reform report by World Bank (1993)
Levels of Primary Healthcare
• Subcentre
• Primary Health Centre
• Community Health Centre
FRUs
PPUs
Sub centres
• First level of contact of community with the Health System
• Manned by Multipurpose Health Workers (Female and Male)
• Administration by Subcentre level committee- Panchayat Ward Member as the chair person and JPHN as the convener
Subcentres
• Provision of comprehensive primary healthcare
• Implementation of National Health programmes
• Area- divided in to 20/40 day-blocks
• Each household visited by at least one worker every month and all households covered by each worker in two months
Subcentres
• Relation with ICDS- AWW
– Sectoral level meeting
– Programmes at the AW level
– Field visit with the AWW
– Consolidation and reporting of Monthly Monitoring Reports
• Other voluntary Workers
– MSS
– Health Volunteers of Kutumbasree
– Other Self Help Groups
Primary Health Centres
• One in every Grama Panchayat
• Caters to 20,000 to 40,000 population
• Comprehensive primary healthcare and minimum curative services
• Implementation of National Health Programmes
• Coordination with the LSGIs
• No IP facilities
Community Health Centres
– One in every Block Panchayat
– Minimum curative services with IP facilities for maternity services- 6 beds
– Services of a lady medical officer ( earlier)
– Coordinates the activities of PHCs in the area
Community Health Centres
• Upgraded Block Primary Health Centres
• RCH/NRHM Programmes
• Specialty Services
• Round the clock maternity services
• Emergency Obstetric and Essential Newborn Care
• Operation Theatre
Some success models
Kerala vs. rest of India
Venganoor Grama Panchayat
• Population 33,372
• Area 10.12 sq.km
• Pop Density 3298
• Wards 19
– CHC Vizhinjam
• 4 doctors
• 14 HW
• 30 beds
– 19 Anganwadis
– 273 NHG Kudumbasree units
– 14 schools
Achievements & challenges
• 1951-2001
– Life exp : 50 yrs to 64
– IMR : 147 to 67
– CDR : 26.1 to 8.7
• Far below NHP 1983 goals
• 22 lakhs children die every year
• 130,000 mothers die per year
• Growing inequities
Facts on healthcare services
• Overall spending on health sector is 6% of GDP
– But Govt. Spends only 0.9%
• Only 17 % of the health expenditure (45 % in SL)
• Only 58% goes to primary sector, that also for salaries
• Rest is spent out of pocket by people
– Individual practice to institutionalized practice
– Defensive medicine, pharma industry
– 10% of annual household consumption
– Indebtedness (>3.3% of families)
• Externally funded programs
– “the dilemmas of aid: Combodia:1992-2002, L Gollogly)
Four major criteria for ideal Healthcare
• Universal access
• To adequate level without excessive burden
• Fair distribution
• Of financial costs for access and burden in rationing care & capacity
• Training providers
• Competence, empathy and accountability
• Attention to vulnerable groups
• Children, women, disabled, aged etc
Healthcare
• Forecasting is notoriously uncertain
• Burden of Diseases DALY
• Murry and Lopez (projections for 2020)
• Diarrhea and communicable diseases
• TB, HIV , Injuries
• Non-Communicable diseases
• Incomplete base data
• Policy dilemma
• to counter upper class demands
• We should go beyond societal averages (Relative deprivation; Gwatkin et al)
Extraordinary infrastructure
• Over 5 lakhs trained doctors
• Over 7 lakhs ANMS MPW
• Rural Primary Health care
• 1.43 lakh subcentres
• 23109 PHCs
• 3222 CHCs
• 24000 doctors
• 3500 specialists
• Rs.62.5 crores
• Facility gaps, supply gaps and staff gaps demand 20 % more funds and good management
Inequities
• Urban rural
– Life exp – from childhood onwards
– Gender gap
• Rich & poor
– IMR 2.5 times in poorest 20 %
– TFR & Child mortality 2 times
– Poorest quintile has 75 % of the malnourished children
– Six times less likely to access hospitalization, antenatal care
Major public health issues
• Communicable diseases
– 60 % of morbidity; R&D not a priority
– (TB: 14 m; 1.5 % of population, 3-5 lakhs deaths
– Malaria: 2 m, Tribal malaria, limited ext. help
– HIV/AIDS: ?3.86 m, ART($10,000 per year)?
• Maternal Health Child nutrition
• Non communicable ailments
– Cancers: 1.5-2 m
– Diabetes: 8-11 %
– CVD, Renal diseases, Accidents, mental diseases
Infrastructure (public sector)
• Rural
– District Hospital
– Taluk (subdistrict) Hospitals
– Community Health Centres (1 Lakhs ppln)
– Primary Health Centres (30,000 ppln)
– Subcentres (5000 ppln)
– Anganwadis/VHGs (1000 ppln)
• Under funding, improper management
Readings
• Healthcare organization and structure (Healthcare system and Management – 1): SL Goel; Deep & Deep Publications Pvt Ltd, 2004
• Chapter 20 & 21, Park’s Textbook of Preventive and Social Medicine; Eighteenth Edition; K Park, M/s Banarsidas Bhanot publishers, 2005
• Health Sector Reforms in India; A district Medical Officers’ Manual, GOI, and UC, India Research Press, 2004
• Working Together for Health, WHR 2006, WHO
• http://www.who.int/healthsystems/en
• Thank you
Notes for the Master of Hospital Administration (MHA) program conducted by Kerala University & CDC, Medical College, Thiruvananthapuram.
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