Lecture Week 7 Patients Rights

NRS2301 Health Law and Ethics
PATIENT’S RIGHTS IN AND TO HEALTH CARE
Week 7, Sem 2
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Hand Hygiene
Lecture Outcomes:
By the completion of this lecture, tutorials, and self directed learning,
the students are expected to:
1. Discuss the right to health care and the 3 senses in which the right to
health care can be claimed.
2. Explain why an economic approach is inadequate for deciding on

health care issues.
3. Explain informed consent and its components.
4. Recognize the notion of competency and implications for patients

with impaired decision making capacity.
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© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org
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Lecture Outcomes
By the completion of this lecture, tutorials, and self directed learning, the
student is expected to:
5. Outline the moral basis of confidentiality.
6. Discuss conditions under which demands to keep information

confidential may be justly overridden.
7. Identify the right to dignity and dying with dignity.
8. Examine the right to be treated with respect.
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Introduction
In North America in 1996, a patient who had
amyotrophic lateral sclerosis sued his doctor for
keeping him alive against his expressed wishes. This
was the first case of its kind (Reed 1996 as cited in
Johnstone 2004, p. 126 ).
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Introduction
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In Australia in 2002, it was reported that an elderly

woman in the care of a government run facility was
assaulted several times by another resident, smeared
with excrement and had many falls. The daughter
described broken toilets and call bells, and reported
rats in the facility (Miller 2002 as cited in Johnstone
2004, p. 126).
Stories of substandard care and violations of patient

rights do occur in health care and are being made more
public in recent decades.
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Introduction
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In 1970, Hospital in UAE started provide services with

international-standard.
2011, HAAD and Dubai Health Authority
(DHA) mandate all hospital to provide the Patient's Charter of Rights
& Responsibilities to all patients
2017, new law gives patients right to die.
Use health regulators agencies as Heath care Authorities Dubai
Health Authority (DHA), the Dubai Healthcare City Authority
(DHCR) and the Health Authority – Abu Dhabi (HAAD) decision
regarding malpractice or negligence cases.
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What are Patient Hand Hygiene
Rights?
Patient rights are those “claims that need to be protected as
specifically applied in a health care context” (Johnstone 2004, p.
129).
Examples of patient rights:
• Right to health care
• Right to be informed and given
informed consent
• Right to refuse consent
• Right to a second opinion
• Right to have access to an interpreter
• Right to be treated with respect, dignity & confidentiality
• Right to know the name, status and practice experience
of the attending health professional.
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Categories of Hand Hygiene
Rights
This lecture will focus on 5 broad categories of patient rights:
1. Right to health care
2. Right to informed consent
3. Right to confidentiality
4. Right to dignity and dying with dignity
5. Right to be treated with respect
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1. Right to Hand Hygiene
Health Care
1948 United Nations Declaration of Human
Rights acknowledged people’s entitlement
to health care by stating:
“Everyone has the right to a standard of
living adequate for the health and well-being
of self and family, including food, clothing,
housing, and medical care and necessary
social services and the right to security in the
event of unemployment, sickness, disability,
widowhood, old age ... or circumstances
beyond his control”.
(Johnstone 2004, p. 130)
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Right to Health Hand Hygiene
Care
• Claiming a Right to Health Care?
Johnstone (2009, p. 130) examines the nature of a claim to health

care by looking at what he calls 4 senses:
aspect
(a.) Right to equal access to health care

(b.) Right to appropriate care
(c.) Right to quality of care
(d.) Right to safe care)
mcq
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Care
a. Right to Equal Access:
All people has equal access to
health care and can get the
services they need & require without discrimination
The argument to this right to health care concerns

resource allocation (distributive justice).
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a. Right to Equal Access:
• The argument goes - there are not enough health care
resources to go around, it is not possible to satisfy
everyone’s needs, therefore, choices have to be made
regarding what services are made available and who
gets them.
• Others say no; we should not accept this economic

rationalisation approach to the right to health care. To
do so is to reduce human life to something with a price
tag attached which is an unjust moral action.
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Care
b. Right to Appropriate Care
Concerns care that is appropriate to the person’s
health beliefs, values, and practices.
Failing to be culturally sensitive to the values,
beliefs and practices of the patient when giving care
and making moral decisions can have harmful
consequences to the patient. (clinically, legally and
morally).
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Care
b. Right to Appropriate Care
“Appropriate care” also means patients are entitled
to choose alternative or ‘scientifically unproven’
therapies instead of traditional approaches to
disease and to engage lay folk or professionals
other than the medical doctor in their care.
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Care
c. Right to Quality of Care
Concerns the standard of care being
delivered and the competency, accountability,
& responsibility of health care providers.
Health care professionals must agree to
and have in place standards of practice,
codes of conduct, processes of quality assurance,
formal measures of patient outcomes,
and so on to ensure that members who fail to
provide quality care can be appropriately censored .
liabel
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Care
Implications for Nurses
Johnstone (2004) asserts that nurses have a moral

obligation to respond to violations of a person’s right to
health care.
Nurses need to participate in the debate about health

care rights, be active in decisions about resource
allocation, health care policy, and the restructuring of
health care delivery systems.
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Care
Implications for Nurses
Nurses need to manage their own profession in terms of

standards of care, conduct, and mechanisms for dealing
with poor practice.
Nurses need to provide members with sound education

responsive to the changing needs of society. Nurses need
to help the public become informed of their entitlements to
health care.
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Questions:
1- Nurses ought to protect patients from violations to the right to health

care by:
A. Participating actively in decisions affecting the delivery of health

care
B. Allowing the government to decide about their scope of practice and
standards of nursing care
C. Using caution when talking about observations of unsafe
occupational and patient hazards in the workplace
D. Explaining to the public that speaking out about poor health care is
useless
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2. Right to Informed Hand Hygiene
Consent
What is Informed Consent?
It is a legal document derived from the doctor’s duty
to tell the patient information about care and treatment that will
assist the patient to make a rational and informed choice about
undergoing such care.
It protects the public from harm, fraud, and stress which occur
when information is not disclosed.
Informed consent also has a serious moral dimension which
involves the principle of a patient’s autonomy to make a choice.
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Right to Informed Hand Hygiene
Consent
The moral justification of the right to informed
consent involves:
A. Sovereignty of the Individual
self determination - autounomy
Informed consent embraces the view that the individual
has soul guardianship of his/her own interests and is the
ultimate decision-maker, thus the term, “sovereignty of the
individual” (Kuczewski 1996). Furthermore, it implies that
the individual competent in making decisions, and that
outside interferences are not welcome.
mental capacity to make decision
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Consent
Informed consent and Sovereignty of the Individual
Culturally, some individuals must have family involvement in decisions
of health care. In the palliative care, it is recognized that illness can
impede the patient’s capacity to judge what is in their best interests.
‫تعيق‬
It can be argued that family members and care givers have a vital
role to play in the consent process because they know the patient
intimately, they can help their loved one deliberate about care
choices, and can provide meaningful feedback about how those
choices are reached. This process of involving family can strengthen
family bonds. Kuczewski (1996) believes informed consent is a
shared process rather than an individual one.
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Consent
B. Informed Consent and Ethical Principlism
The significant underlying moral principles of informed consent
include:
Autonomy – demands that patients are self-determining
choosers.
Non-maleficence – demands that patients be protected from
harms (battery, assault, exploitation) that may result from
inadequate or inappropriate consent practices.
Beneficence – demands the maximization of patient’s wellbeing
via the consent process.
Justice – demands fairness and that patient’s not be unduly or
intolerably burdened by consent practices (Johnstone, 2004, p. 141)
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Consent
How is Consent “Informed”? short answer
Beauchamp & Childress (2001) say that for consent to be

considered “informed”, a number of components must be
satisfied: what are the components for the informed consent?
• The giving of all relevant information by the health professional
• Understanding by the patient of the information given; in addition
knowing that consent is about giving permission to the health
professional to proceed with an intervention or treatment
• Voluntariness in which the patient is not forced or manipulated
into giving consent
• Competence in which the patient is lucid and rational to give
consent. clear
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Consent
Kanitsaki (1992) reported a case where a doctor placed a pen
in a woman’s hand and guided her to make an X on a
surgical consent. The woman spoke little English, had not
been informed of the surgery, but the doctor was too busy to
wait and get an interpreter. (Johnstone 2004, p. 137)
While health professionals have been willing to share

information about care and treatments with their patients, the
practices of obtaining consent are still problematic. (Johnstone
2004, Kanitsaki 1992; Faden & Beauchamp 1986).
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Consent
Why is gaining consent problematic for some health professionals?
The reasons used by health professionals are:
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1. the process is too time consuming.
2. patients forget the information anyway.
3. patients don’t want to know all the details of care and
treatment, risks and benefits.
4. patients really don’t understand the information well enough to
be informed
5. giving information on risks is frightening and may cause refusal
of treatment that could harm the patient
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Consent
Are these reasons valid?
It is true that gaining consent is time
consuming. However, this is not a morally
acceptable excuse. If health professionals are
truly interested in the well-being of their
patients, they ought to spend whatever time it
takes to inform, answer a question, or allay a
worry.
Patients must make the right choices for

themselves in an unhurried and reflective
manner.
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Consent
Faden & Beachamp (1986) suggest a few strategies
that might resolve the issue of time constraints. One
strategy is to use nurses to meet patients’
information needs. While nurses can and do help
the patient understand their illness or care, they do
not have the legitimate authority to give information
about medical treatments. Nurses take a
professional and legal risk by doing so.
nurse not scope of practice to explain the informed consent
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Consent
How Can Health Professionals Facilitate Informed Consent?
1. Make consent forms available in the language spoken by the
patient.
2. Involve a trained interpreter, not the cleaning person or kitchen
worker, these people do not have the medical terminology to
translate, may seriously misinterpret the information, and
because they do not have a relationship with the patient, may
not appreciate the need to be confidential with the information.
3. Revisit the original consent to ensure it is still valid. This is
particularly important in situations where the condition of the
patient has changed or life saving therapies are refused.
4. Recognize factors that affect patient decision on consenting.
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Consent
Health professionals must recognize that many factors
can affect the patient exercising informed and
voluntary choices such as:
1. Fear of refusal that if they refuse a certain
procedure they may be denied other treatments.
2. Fear of the unknown.
3. Disagreement or cultural conflict or clashes with
the suggested treatment options
4. Pain or grief states can impede decision making
5. lack of communication: have poor interpersonal
skills, are rushed or intimidating, or lack the
information necessary for the patient
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Consent
The Problem of Competency
One of the requirements of informed consent: is the
person’s competency to decide.
Competency is a complicated issue because there is no
general agreement on the characteristics of a
“competent” person and no legal measures of it.
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Consent
Example: Consider the elderly lady who is demented. She may be

deemed competent to eat her meal alone, but not competent to
refuse treatment to a broken arm sustained in a fall.
As shown in the example, competence is always “task specific,

where the task may be physical or mental” (Gert et al 1997
as cited Johnstone 2004, p. 147).
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Consent
Consider the case of John McKewan, a ventilated quadraplegic. He had
been an outstanding Australian water skiing champion, but had an
unfortunate accident in which he broke his neck. Frustrated with his helpless
condition, John expressed a wish to die many times during his hospitalization.
He even went on a hunger strike and instructed his lawyer to compose a
“living will” to not revive him when he went into a coma. This action initiated
an assessment by a psychiatrist who deemed him incompetent and he was
force fed against his wishes. So he ended his hunger strike and agreed to
anti-depressants. A year later he went home and was cared for 24 hours a
day by his family and hired nursing help. He continued to express his desire
to die and even commented that he was going to hire someone to help him
die he was so frustrated by his quality of life. Early one morning the nursing
assistant found John had died; he was off his ventilator.
Would you say John was incompetent in his decision to want to die? Was
he being irrational in his thinking?
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Consent
Judgement about a person’s competency

to make a choice becomes problematic when:
1. There is disagreement between the patient and the health
professional about the course of care, where treatments that
seem rational accept are refused by the patient.
2. In cases where the patient is cognitively impaired or mentally ill
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2. Right to Informed Consent
Measuring Competency and its Difficulties
(No single standards of competence is adequate for)

all decision.
In measuring competency, Grisso & Appelbaum (1998)

propose to assess a patient’s ability to:
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Topic – Patient's Rights-
In and To Health Care

Measure: Difficulty:
don’t study it
1. Evidencing a choice: A comatose patient would be unable to

express a choice; a semi-comatose
patient may be able to squeeze a hand
or blink to indicate understanding. The
question then becomes is the action of
squeezing or blinking truly
understanding or a reflex action.
2. Reasonable outcome of a Spending a life’s savings on shark fin

choice: therapy in hopes of curing cancer may
be a reasonable outcome to one person
but may be rejected by another.
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Topic – Patient's Rights-
In and To Health Care

Measure: Difficulty:
3. Choices based on Suicide may not always be connected to

rational reasons: mental illness or depression. It could be
a reasonable and rational solution to a
life of severe abuse or intolerable pain.
• A psychiatric patient who was informed

4. Ability to understand: there was a 1 in 3000 chance of dying
from electric shock therapy replied
happily that she hoped she was the one.
• How will the patient has actually

5. Actual understanding: understood information which has been
disclosed.
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• While this framework of determining competency is useful, how do
health professionals decide when it is right to accept or reject a
person’s ability to choose and decide on treatment options, and
when and how to override a patient’s preferences?
• To help us, Buchanan and Brock (1989) suggest health professionals

ask themselves:
1. Is the person a danger to him/herself?
2. Does the person need care?
3. Is the person a danger to others?
The decision is based on the extent of “risk of harm”.
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2. Right to Informed Consent: Example

To illustrate, consider the young male teenager who refuses to take
his psychotropic medication because of “awful” side effects. He has
been trying to cope with the side effects for some time, but can’t
any longer. He claims he would rather deal with his mental illness; he
knows what will happen to his mental state as he has not complied
with taking other psychotropic drugs in the past.
What do the health professionals do? Do they intervene by forcibly

giving the patient the drug by injection against his will, preventing
even greater harm of a mental crisis that is sure to follow? Or let
the patient stop his medication and deal with the mental breakdown
when it happens
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Is the patient is competent and able to make an informed
choice, do they?
If they go against the patient’s will and give the drug forcibly,
perhaps the greater harm is the patient’s increasing distrust of
health professionals and even less co-operation with taking
needed medications.
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Nurses and Informed Consent
It is important for the nurses to know the elements of and issues,
ethical principles and moral values underlying consent practices since
they are advocates for patients.
Nurses are encouraged to take time to inform their patients of what

planned nursing care and procedures, ensure patient’s understand the
information and provide voluntary permission.
Nurses must ensure that the patient has the capacity to make
informed choices about such care, and if not, include a surrogate
decision maker to do so. power interner
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3. Right to Confidentiality
In 1904, a doctor writes of his refusal to warn (inform) a woman

that her future husband had syphilis, thus risking her and her
offspring of being exposed to the disease (Bok 1980).
Such was the strength of the principle of confidentiality. The notion

that whatever is revealed in the patient-professional relationship
is to be kept secret even if might cause harm.
Is this morally correct?
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People who are HIV positive have been dismissed from

their jobs, evicted from their accommodation, and
discriminated against, because of breaches of
confidentiality.
Today it is recognized that when an innocent people

stand to be harmed by failure to disclose, the demand
to breach confidentiality becomes morally convincing.
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In 1974, in California, U.S.A., a university student named Mr.
Poddar, fell in love with a young lady, Miss Tarasoff.
Unfortunately the lady did not have the same feelings and so
told Poddar. Poddar became depressed, sought psychiatric
help at the university hospital, and revealed during his sessions
that he intended to kill Tarasoff. The psychiatrist informed the
university police that Poddar might be a danger to himself and
an unnamed girl who had rejected his advances. The police
detained Poddar for some time, but released him when he
appeared rational and promised to stay away from the girl.
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The psychiatrist was advised by his superior to do no more in
the situation and to destroy the patient’s files for confidentiality
reasons. Two months later, Poddar killed Tarasoff. The
psychiatrist never warned the girl or her parents of the threat
by Poddar.
Based on this case, the Supreme Court of the United States ruled a
new law that doctors must warn potential victims of harm.
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The demand to keep information disclosed in a patient-
professional relationship secret comes from the moral principles
of autonomy, non-maleficience, justice, and fidelity.
Autonomy:
Patients can choose who should have access to information about
themselves as well as what information is shared, if any. Patients
have the right to privacy of personal information which health
professional ought to respect.
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Non-maleficence:
People are entitled to be protected from harm that might come
from disclosure. If the consequence of keeping a secret causes or
fails to prevent an avoidable harm, then confidentiality must be
overridden.
Justice:
If the consequence of keeping a secret results in an unequal
distribution of harm over benefit, then confidentiality must be
overridden ( a person whom private information is known,
deserves to be treated fairly).
Fidelity:
keeping promises, is a rule that guides human conduct and has
some binding power, but is not justified where an avoidable harm
occurs as a result
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Confidentiality is an important ethical requirement of any
patient-professional relationship & is a principle that ought to be
respected.
Confidentiality must not be upheld in instances where avoidable

and unnecessary harm to innocent others is a serious consequence.
As in any ethically troubling situation, nurses must make

decisions to disclose or not to disclose patient information on
sound moral reasoning and decision making processes.
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4. Right to Dignity and Dying with Dignity

What does it mean - the right to dignity and to die with dignity?
Some of the most revealing definitions come from first year

nursing students who finished their clinical placement in a
residential care home for the elderly:
“Dignity is feeling good about yourself”
“Dignity and dying with dignity is being happy with oneself and
what one has achieved in life”
“Dying with dignity is having no pain, no fear, feeling valued”
“Dignity is concerned with self-respect”
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4. Right to Dignity and Dying with Dignity
People ought to be supported in attempts to maintain their

self-respect and self-esteem, and in making autonomous
choices.
The challenge for nurses is to find out what the patient considers
as being dignity and/or dying with dignity, and then to uphold
those terms. Even if they don’t agree with the patient’s views,
nurses must be careful not to impose their own opinions of what is
dignity and dying with dignity onto the patient.
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5. Right to Be Treated with Respect
people ought to be treated with respect (regardless of gender,

religion, culture or social standing) is foundational to the
relationship developed between patients and health care
professionals.
In nursing, respect is often key to professional codes of ethics.

The International Council of Nurses (2000) states: “inherent in
nursing is respect for human rights, including the right to life ... and ... in
providing care, the nurse promotes an environment in which the human
rights, values, customs, and spiritual beliefs of the individual, family,
and community are respected.”
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What meaning is assigned to respect?
• Every culture has ways of being that are termed “respectful”.
• The demand to treat people with respect is linked with
acknowledging people for who they are and responding to
them in ways that preserve their integrity and self-identity. To
show admiration, esteem, and kind consideration of others is
to treat them “good”.
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5. Right to Be Treated with

Respect
Disrespect is to deprive people of
their human worth. Those who are
dominant in a culture may
randomly attribute certain
characteristics as personally, socially,
or morally aggressive.
Examples of disrespect: discriminating in giving quality care

because the patient is old, disabled, mentally ill, or from a
different culture.
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The ingredients for respectful interactions with
patients include:
1. Respect human beings as worthy
2. Value them for who they are
3. Focus on the person and be present when interacting with
them
4. listen and take seriously what they say
5. Support actions that promote the patient’s well-being
6. keep the relationship open and positive
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Summary
Understanding the issues of patient’s rights to and in
health care is an important one for health professionals.
Violations of patient rights occur in health care and
nurses have a role in promoting and protecting these
rights.
Health professionals must not treat patients as passive
recipients of health care, but as active negotiators in
their health care.
Respect will help to ensure that the rights of patients in
health care are protected.
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Required Reading:
Johnstone, M. (2016). Bioethics: a nursing perspective. 6th Edition.

Australia: Churchill Livingstone. Chapter 7 & 8.
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NRS2301 Health Law and Ethics

PATIENT’S RIGHTS IN AND TO HEALTH CARE

2. Explain why an economic approach is inadequate for deciding on

3. Explain informed consent and its components.

4. Recognize the notion of competency and implications for patients

5. Outline the moral basis of confidentiality.

6. Discuss conditions under which demands to keep information

7. Identify the right to dignity and dying with dignity.

8. Examine the right to be treated with respect.

In Australia in 2002, it was reported that an elderly

Stories of substandard care and violations of patient

In 1970, Hospital in UAE started provide services with

1. Right to health care

2. Right to informed consent

4. Right to dignity and dying with dignity

5. Right to be treated with respect

Johnstone (2009, p. 130) examines the nature of a claim to health

(a.) Right to equal access to health care

The argument to this right to health care concerns

• Others say no; we should not accept this economic

Johnstone (2004) asserts that nurses have a moral

Nurses need to participate in the debate about health

Nurses need to manage their own profession in terms of

Nurses need to provide members with sound education

1- Nurses ought to protect patients from violations to the right to health

A. Participating actively in decisions affecting the delivery of health

Beauchamp & Childress (2001) say that for consent to be

While health professionals have been willing to share

Patients must make the right choices for

Example: Consider the elderly lady who is demented. She may be

As shown in the example, competence is always “task specific,

Judgement about a person’s competency

2. In cases where the patient is cognitively impaired or mentally ill

2. Right to Informed Consent

Measuring Competency and its Difficulties

(No single standards of competence is adequate for)

In measuring competency, Grisso & Appelbaum (1998)

Measuring Competency and its Difficulties

1. Evidencing a choice: A comatose patient would be unable to

2. Reasonable outcome of a Spending a life’s savings on shark fin

Measuring Competency and its Difficulties

3. Choices based on Suicide may not always be connected to

• A psychiatric patient who was informed

• How will the patient has actually

2. Right to Informed Consent

• To help us, Buchanan and Brock (1989) suggest health professionals

2. Right to Informed Consent: Example

What do the health professionals do? Do they intervene by forcibly

2. Right to Informed Consent

2. Right to Informed Consent

Nurses are encouraged to take time to inform their patients of what

In 1904, a doctor writes of his refusal to warn (inform) a woman

Such was the strength of the principle of confidentiality. The notion

People who are HIV positive have been dismissed from

Today it is recognized that when an innocent people

Confidentiality must not be upheld in instances where avoidable

As in any ethically troubling situation, nurses must make

4. Right to Dignity and Dying with Dignity

Some of the most revealing definitions come from first year

4. Right to Dignity and Dying with Dignity

People ought to be supported in attempts to maintain their

5. Right to Be Treated with Respect

people ought to be treated with respect (regardless of gender,