LEGAL MEDICINE

MEDICAL ETHICS CASE

STUDIES
 IMPORTANCE OF MEDICAL ETHICS

• Medical ethics guide your decision-making and your

interactions and conduct with patients. It is an
important part of medical professionalism, which is
always expected.

• Ethics provides us a moral compass to use in

situations that may not be straightforward.
four pillars of medical ethics

• Autonomy – respect for the patient’s right to self-determination

• Beneficence – the duty to ‘do good’. It is a value in which the
provider takes action or recommends courses that are in the
patient’s best interest
• Non-Maleficence – the duty to ‘not do bad’. Nonmaleficence is
closely related to beneficence. It is abstaining from any action
that may bring harm to the patient
• Justice – to treat all people equally and equitably.
The law reflects these principles as follows:
AUTONOMY
• Consent
• Confidentiality/Privacy
• Access to Records
BENEFICENCE
• Negligence Law
NON-MALEFICENCE
• Criminal Law
• Negligence Law Regulation
JUSTICE
• Distributive justice – fair distribution of limited healthcare resources
• Rights-based justice – respect for people’s rights, such as prohibition of discrimination
CASE NUMBER 1

VITALY TARASOFF et al., Plaintiffs and Appellants, v.

THE REGENTS OF THE UNIVERSITY OF CALIFORNIA et al.,
Defendants
and Respondents.
Docket No. S.F. 23042.
Supreme Court of California.
July 1, 1976.
a case in which the Supreme Court of California held that mental health
professionals have a duty to protect individuals who are being
threatened with bodily harm by a patient.
The original 1974 decision mandated warning the threatened
individual, but a 1976 rehearing of the case by the California Supreme
Court called for a "duty to protect" the intended victim.
The professional may discharge the duty in several ways, including
notifying police, warning the intended victim, and/or taking other
reasonable steps to protect the threatened individual.
FACTS:

• On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff.

Plaintiffs, Tatiana's parents, allege that two months earlier Poddar
confided his intention to kill Tatiana to Dr. Lawrence Moore, a
psychologist employed by the Cowell Memorial Hospital at the
University of California at Berkeley. They allege that on Moore's
request, the campus police briefly detained Poddar, but released him
when he appeared rational. They further claim that Dr. Harvey
Powelson, Moore's superior, then directed that no further action be
taken to detain Poddar. No one warned plaintiffs of Tatiana's peril.
QUESTIONS FOR THE CASE
• Can the therapists escape liability merely because Tatiana herself
was not their patient?
• Will such disclosure be a Breach in Doctor-Patient Confidentiality?
• Is there a violation of the medical ethics?
• Will the disclosure be a violation of the patient’s rights to privacy?
• If you are the psychiatrist, what will be the proper course of action
to take?
Can the therapists escape liability merely because
Tatiana herself was not their patient?
• We shall explain that defendant therapists cannot escape
liability merely because Tatiana herself was not their patient.
• When a therapist determines, or pursuant to the standards of his
profession should determine, that his patient presents a serious
danger of violence to another, he incurs an obligation to use
reasonable care to protect the intended victim against such danger.
The discharge of this duty may require the therapist to take one or
more of various steps, depending upon the nature of the case. Thus
it may call for him to warn the intended victim or others likely to
apprise the victim of the danger, to notify the police, or to take
whatever other steps are reasonably necessary under the
circumstances.
Will such disclosure be a Breach in Doctor-Patient
Confidentiality?
• We realize that the open and confidential character of
psychotherapeutic dialogue encourages patients to express threats
of violence, few of which are ever executed. Certainly a therapist
should not be encouraged routinely to reveal such threats; such
disclosures could seriously disrupt the patient's relationship with his
therapist and with the persons threatened.
• To the contrary, the therapist's obligations to his patient require
that he not disclose a confidence unless such disclosure is necessary
to avert danger to others, and even then that he do so discreetly,
and in a fashion that would preserve the privacy of his patient to the
fullest extent compatible with the prevention of the threatened
danger.
Is there a violation of the medical ethics?
• The revelation of a communication under the above circumstances
is not a breach of trust or a violation of professional ethics; as stated
in the Principles of Medical Ethics of the American Medical
Association (1957), section 9: "A physician may not reveal the
confidence entrusted to him in the course of medical attendance ...
unless he is required to do so by law or unless it becomes necessary
in order to protect the welfare of the individual or of the
community.“
Is there a violation on to the patient’s rights
to privacy?
• We conclude that the public policy favoring protection of the
confidential character of patient-psychotherapist communications must
yield to the extent to which disclosure is essential to avert danger to
others. The protective privilege ends where the public peril begins.
• When a therapist determines, or pursuant to the standards of his
profession should determine, that his patient presents a serious danger of
violence to another, he incurs an obligation to use reasonable care to
protect the intended victim against such danger. The discharge of this duty
may require the therapist to take one or more of various steps. Thus, it
may call for him to warn the intended victim, to notify the police, or to
take whatever steps are reasonably necessary under the circumstances.
If you are the psychiatrist, what will be the proper
course of action to take?
• Referrals and follow-up on the patient must be made.
• It must be proper that when threats are made, it must be
taken seriously.
• Make sure that the patient has all the tools necessary to make
a decision that's in their best interest.
• The ultimate question of resolving the tension between the
conflicting interests of patient and potential victim is one of social
policy, not professional expertise. The risk that unnecessary
warnings may be given is a reasonable price to pay for the lives of
possible victims that may be saved.
• You may only disclose confidential information in the public
interest without the patient's consent, or if consent has been
withheld, where the benefits to an individual or society of
disclosing outweigh the public and patient's interest in keeping the
information confidential.
CODE OF ETHICS OF THE PHILIPPINE
MEDICAL ASSOCIATION
ARTICLE II DUTIES OF PHYSICIANS TO THEIR
PATIENTS
Section 6. The physician should hold as sacred and highly confidential
whatever may be discovered or learned pertinent to the patient
even after death, except when required in the promotion of justice,
safety and public health.
CASE NUMBER 2
• A woman enters the emergency room with stomach pain. She undergoes a
CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening
in the wall of the aorta which causes it to stretch and bulge. The physicians
inform her that the only way to fix the problem is surgically, and that the
chances of survival are about 50/50. They also inform her that time is of
the essence, and that should the aneurysm burst, she would be dead in a
few short minutes. The woman is an erotic dancer; she worries that the
surgery will leave a scar that will negatively affect her work; therefore, she
refuses any surgical treatment. Even after much pressuring from the
physicians, she adamantly refuses surgery. Feeling that the woman is not in
her correct state of mind and knowing that time is of the essence, the
surgeons decide to perform the procedure without consent. They
anesthetize her and surgically repair the aneurysm. She survives, and sues
the hospital for millions of dollars.
Questions for Case 2
• Do you believe that the physician's actions can be justified in
any way?
• Is there anything else that they could have done?
• Is it ever right to take away someone's autonomy? (Would a
court order make the physicians' decisions ethical?)
• What would you do if you were one of the health care workers?
RESPECT FOR PATIENT AUTONOMY
• Autonomy means that a patient has the ultimate decision-
making responsibility for their own treatment.
• Autonomy also means that a medical practitioner cannot impose
treatment on an individual for whatever reason – except in cases
where that individual is deemed to be unable to make
autonomous decisions
• The refusal by a person of clinically indicated treatment questions
the extent to which patient autonomy should be respected when it is
at odds with our perception of what is ‘best’ for them.
INFORMED CONSENT
• Doctors must fully inform their patients about the risks involved
in any proposed medical procedure or treatment
• A doctor must provide “informed consent” by explaining the risks
and complications that may arise during a procedure, and by
allowing the patient to ask questions about risks and complications.
• Informed consent is only given once a doctor explains what
the information on the form actually means.
• When a doctor does not receive informed consent, he or she can
be held liable for medical negligence, even if the physician
performed the procedure flawlessly.
How to obtain informed consent
• A medical provider should provide the patient with
information about:
 The patient’s condition
 The patient’s diagnosis
 The purpose and nature of the proposed medical procedure
 Potential risks of the proposed procedure, including the potential
benefit and drawbacks of the procedure, other available
treatment options, and the risk of not having the procedure
EXPRESS CONSENT
• “Express consent” is obtained by giving a patient a form.
• It is a patient’s agreeing to medical treatment. Express consent is
usually given in the form of written consent. “Treatment” includes
surgery, anesthesia, and medical procedures not requiring surgery or
anesthesia. Typically, a doctor gives a patient a form describing the
type of surgery or procedure, as well as surgery that may have to be
performed if complications arise. The patient is given the
opportunity to read over the form, and is given the opportunity to
sign the form. The patient must sign the form before treatment is
given.
VIOLATION OF PATIENT CONSENT
• a patient may allege that the patient was not given the opportunity
to give express consent. A patient may also allege that he or she gave
express consent, but that the express consent was not also informed
consent.
• An example of failure to give informed consent occurs when a
doctor gives the patient a written consent form, but fails to explain
the medical conditions or jargon the form refers to, or the risk of
complication or death from a procedure. Under the law of informed
consent, a doctor must answer patient’s concerns sufficient to allow
the patient to make an informed, knowledgeable decision about
whether to obtain treatment.
NEGLIGENCE
• The failure to obtain patient consent before treatment, is a type
of negligence, one at the core of violation of patient consent cases. If
the failure to obtain consent resulted in a patient injury, the patient
may file a lawsuit against the negligent doctor. “Injury” does not
mean only “physical” injury. It means any kind of harm to a patient,
including harm in the form of emotional distress. In violation of
patient consent cases, a patient can receive money damages for
physical and mental injury.
• If a doctor performs a procedure they were not authorized to
perform, or exceeds the scope of permission granted to the by
the patient, the doctor could be liable for medical malpractice.
Airedale National Health Service Trust v
Bland
[1993] AC 789
Facts
• Bland was injured in the Hillsborough disaster when he was
seventeen and a half years old and was left in a persistent vegetative
state. He remained in this state for over two years with no sign of
improvement, whilst being kept alive by life support machines. Bland
could breathe by himself but required feeding via a tube and
received full care. The doctors that were treating Bland were granted
approval to remove of the tube that was feeding him. This decision
was then appealed to the House of Lords by the Solicitor acting on
Bland’s behalf.
Issue
A patient that is in a persistent vegetative state cannot withhold or offer
consent for treatment. This requires the doctors to act in the best interests
of the patient, which in this case was whether the continuation of Bland
being on life support was in his best interests. It was important to
understand whether life support can ever be withdrawn from an individual
who cannot provide medical professionals with informed consent on a
specific issue.

The Court was asked whether it would amount to an unlawful killing for the
medical professionals to remove Mr. Bland’s feeding tube, given this would
inevitably lead to his death.
The withdrawal of artificial treatment would constitute murder.
HELD
• Doctors have a duty to act in the best interests of their patients but this does not
necessarily require them to prolong life. On the basis that there was no potential
for improvement, the treatment Bland was receiving was deemed not to be in
his best interests. It is not lawful to cause or accelerate death. However, in this
instance, it was lawful to withhold life-extending treatment which in this
instance was the food that Bland was being fed through a tube.
• The Court confirmed that it is not unlawful killing for medical professionals to
remove life-sustaining treatment in circumstances where the continuation of the
treatment is not in the best interests of the individual concerned. This applies to
situations where the individual patient is unable to express any wishes as to their
treatment.
• This case therefore prevents medical professionals facing murder charges when a
considered decision is made that it is in the best interests of the patient to
remove artificial life-sustaining treatment.
• Appeal dismissed
Euthanasia
Euthanasia, sometimes known as ‘mercy killing’, refers to ending a
patient’s life who is suffering from an incurable and/or painful disease,
or who is in an irreversible coma.

Two types of euthanasia you need to know about include:

• Passive euthanasia
• Active euthanasia
• Active euthanasia: when the acting person deliberately intervenes to end
someone’s life. For example – a Doctor who injects a patient with terminal
cancer an overdose of muscle relaxants to end their life would be
considered to have carried out euthanasia.
It is a crime in the Philippines
( Art. 248 murder);
(Art. 253. Giving Assistance to Suicide)
• Passive euthanasia: where a person causes death by withholding or
withdrawing treatment that is necessary to maintain life.

NATURAL DEATH ACT OF 2005

Senate Bill 1887 also known as the “Natural Death Act” filed by Santiago
provides that any person of legal age and sound mind may execute a
written instruction, “directing the witholding or withdrawal of life-sustaining
treatment in a terminal condition or permanent unconscious condition
END