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General Principles of Medical Ethics: National and International Perspective

Medical ethics is a field of study that deals with moral principles and values in the practice of
medicine. These principles guide healthcare professionals in making decisions that are ethical, just,
and respectful of the rights and well-being of patients. The general principles of medical ethics,
often referred to as the four pillars, provide a framework for ethical decision-making in healthcare.
These principles are autonomy, beneficence, non-maleficence, and justice.

1. Autonomy:

Autonomy is the principle that recognizes and respects an individual's right to make their own
decisions about their healthcare. It emphasizes the importance of informed consent, ensuring that
patients have the necessary information to make choices about their treatment and care. This
principle recognizes the right of individuals to accept or refuse medical interventions, even if those
decisions may not align with the healthcare provider's recommendations. Respecting autonomy
requires clear communication, providing adequate information, and involving patients in the
decision-making process.

2. Beneficence:

Beneficence is the principle that promotes actions that contribute to the well-being and best
interests of the patient. Healthcare professionals have an ethical obligation to seek the welfare of
their patients and to provide care that maximizes benefits. This involves assessing the risks and
benefits of interventions and choosing the course of action that will result in the greatest overall
good for the patient. Beneficence also extends to actions aimed at preventing harm and promoting
positive outcomes for patients. It underscores the healthcare provider's commitment to acting in
the patient's best interests.

3. Non-Maleficence:

Non-maleficence is the principle that requires healthcare professionals to do no harm. This

principle emphasizes the importance of minimizing the risks of harm to patients while pursuing
benefits. It involves a commitment to avoiding actions that may cause unnecessary suffering or
adverse effects. In the context of medical ethics, the principle of non-maleficence highlights the
need for careful consideration of potential harms associated with medical interventions and the
importance of selecting interventions with the least risk of harm. This principle reinforces the
responsibility of healthcare providers to prioritize the well-being and safety of their patients.

4. Justice:

Justice is the principle that addresses the fair and equitable distribution of healthcare resources and
access to medical care. It emphasizes the need to treat individuals fairly, without discrimination or
bias. This principle involves considerations of distributive justice, ensuring that healthcare

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resources are allocated in a manner that is just and accessible to all, regardless of factors such as
socioeconomic status, race, ethnicity, or gender. Justice also encompasses the concept of
procedural justice, which emphasizes fair decision-making processes in healthcare institutions and
the need for transparency and accountability.

These four principles often work together and may sometimes come into conflict. In such cases,
healthcare professionals must carefully balance and prioritize these principles based on the specific
context and the needs of the patient. Ethical decision-making in medicine involves thoughtful
consideration of the patient's values, cultural background, and preferences, as well as a
commitment to open communication and collaboration between healthcare providers, patients, and
their families.

In conclusion, the general principles of medical ethics—autonomy, beneficence, non-maleficence,

and justice—provide a comprehensive framework for guiding ethical decision-making in
healthcare. These principles underscore the importance of respecting patients' autonomy,
promoting their well-being, avoiding harm, and ensuring fair and equitable access to healthcare.
Adhering to these principles contributes to the delivery of ethical and compassionate healthcare
that prioritizes the interests and rights of patients.

PROFESSIONAL ACCOUNTABILITY

Liability of medical professionals falls mainly under three heads namely tortious, criminal and
contractual. The remedies can also availed under the Constitution of India or compensation can
be awarded under the Consumer Protection Act, 1986.

Tortious Liability

In tortious liability, negligence as a tort is the breach of a legal duty to take care which results in
damage, undesired by the defendant- Winfield

Therefore, the definition involves three constituents of the negligence:

 A legal duty to exercise due care on the part of the party complained of towards the party
complaining;
 Breach of said duty
 Consequential damage

A-man cannot be charged with negligence if he has no duty to exercise diligence.1 In Dr. Laxman
Balakrishna Joshi v. Dr. Trimbak Bapu Godbole2, the Supreme Court held that a person who
holds himself out ready to give medical advice and treatment impliedly undertakes that he is

1
Donoghue v. Stevenson 1932 AC 562
2
AIR 1969 SC 128

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possessed of skill and knowledge for the purpose. Such a person when consulted by a patient owes
him certain duties, that is, the duty of care in deciding whether to undertake the case, a duty of care
in deciding the treatment and a duty of care in administering the treatment. A breach of any of
these duties gives right of action for negligence.

The Indian law also recognizes the concept of vicarious liability in which the law holds one person
liable for the tortuous act of another, even if he has nothing to do with the commission of the tort.
In the case of State of Haryana v. Santra3, the Supreme Court held government hospitals
vicariously liable for the negligent acts of their employees.

Criminal Liability

For an act to amount to criminal negligence, the degree of negligence should be much higher, i.e.
Gross or of a very high degree. To prosecute a medical professional for negligence under criminal
law, it must be shown that he did something which in given facts and circumstances no medical
professional in his ordinary senses and prudence would have done or failed to do. The negligence
should be of such a nature that the injury which resulted was most likely imminent.

Res ipsa loquitur is only a rule of evidence and operates in the domain of civil law especially in
cases of torts and helps in determining the onus of proof in actions relating to negligence. It cannot
be passed in service for determining per se the liability for negligence within the domain of
criminal negligence.

In a landmark judgement of Jacob Mathew w State of Punjab4, the Supreme Court held that a
doctor cannot be prosecuted for simple lack of care and error of judgement or accident during
treatment and placed medical profession in a different pedestal.

Contractual Liability

When a patient approaches a hospital for medical care, it establishes a relationship between the
hospital and patient which is contractual in nature. The subject matter of the contract can include
good medical services, technical services including para medical staff. The contractual obligation
is also for hygiene and health care including good condition of infrastructure of equipment,
reasonable pre-operative and post-operative health care services.

Provisions under Constitution of India

The Constitution incorporates provision guaranteeing everyone's right to the highest attainable
standard of physical and mental health. In the case of Paschim Banga Khet Mazdoor Samiti w.
State of WB5, the Supreme Court held that Article 21 imposes an obligation on the State to provide

3
AIR 2000 SC 1800
4
(2005) 6 SCC 1
5
(1996) 4 SCC 37

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medical assistance to every injured person. Preservation of human life is of paramount importance.
Failure on the part of a government hospital to provide timely medical treatment to a person in
need of such treatment results in violation of his rights to life guaranteed under Article 21 of the
Constitution. The Court directed the State to pay Rs. 25,000/- to the petitioner as compensation.
In the case of Irloskar Brothers Lid. v Employees' State Insurance Corporation6, the Supreme
Court held that "right to health" is a fundamental right. The Court further held that it is a right not
only available against the State and its, instrumentalities but even private industries to ensure to
the workmen to provide facilities and opportunities for health and vigour of the workman assured
in the provision of Part IV of the Constitution which are integral part of right to equality under
Article 14 and right to invigorated life under Article 21 which are fundamental rights to the
workmen.

Remedies under The Consumer Protection Act, 1986

The Consumer Protection Act, 1986 has been designed to protect the consumer by exerting legal,
moral and economic pressure on the defaulter against inadequate or deficient services. In Ms
Cosmopolitan Hospital and Anr. V. Smt. Vasantha P. Nair7, the National Consumer Redressal
Commission upheld the inclusion of doctors under term "service".

In the case of Indian Medical Association w. V.P Shantha8, the Supreme Court held that the
medical practitioners were not immune from claim of damages on the ground of medical
negligence. It also held that it is not the medical profession alone that comes under the preview of
consumer protection act, but all the professionals.

Equality in Access to Health Care

Equality in access to health care refers to the idea that all individuals, regardless of their
background, should have equal opportunities to receive necessary and appropriate medical
services. Achieving health care equality involves addressing and eliminating barriers that may
prevent certain groups from accessing healthcare services, including economic, social, cultural,
and geographic factors. Equality in access to health care is a fundamental principle that is
recognized and protected by various international and national legal frameworks. The right to
health is enshrined in several international agreements, and many countries have incorporated
these principles into their national laws.

International Legal Perspective

1. Universal Declaration of Human Rights, 1948 (UDHR): The right to health is rooted in
the Universal Declaration of Human Rights, adopted by the United Nations General

6
(1996) 2 SCC 682
7
1992 (1) CPR 820
8
(1995) 6 SCC 651

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Assembly in 1948. Article 25 of the UDHR states that "Everyone has the right to a standard
of living adequate for the health and well-being of himself and of his family, including food,
clothing, housing, and medical care."
2. International Covenant on Economic, Social, and Cultural Rights, 1966 (ICESCR):
Article 12 of the ICESCR recognizes the right of everyone to the enjoyment of the highest
attainable standard of physical and mental health. It includes the obligation of states to take
steps to achieve the full realization of this right, including the prevention, treatment, and
control of diseases.
3. International Convention on the Elimination of All Forms of Racial Discrimination,
1965 (CERD): CERD, in Article 5(e)(iv), requires states to ensure the right to public health,
medical care, social security, and social services for all without discrimination based on race,
color, or national or ethnic origin.
4. Sustainable Development Goals (SDGs): Goal 3 of the SDGs aims to ensure healthy lives
and promote well-being for all, including universal health coverage. The emphasis is on
achieving equitable access to health services.
5. World Health Organization (WHO): The WHO Constitution recognizes the right to health
as a fundamental human right and emphasizes the importance of access to medical care
without discrimination.

Indian Legal Perspective

Equality in access to healthcare is a paramount principle in the legal framework of India, reflecting
the nation's commitment to ensuring that all its citizens have the right to the highest attainable
standard of health without discrimination. The Indian legal perspective on healthcare equality is
shaped by constitutional provisions, specific health legislation, and policies aimed at addressing
disparities and promoting universal access to medical services.

Constitutional Protections:

The Constitution of India, adopted in 1950, includes provisions that lay the foundation for
healthcare equality. The Preamble emphasizes justice, equality, and the promotion of the welfare
of the people, setting the tone for subsequent constitutional provisions.

i. Directive Principles of State Policy: Article 47 of the Constitution directs the state to
regard the improvement of public health as one of its primary duties. It specifically
highlights the need to raise the level of nutrition and the standard of living, and to improve
public health.

ii. Right to Life and Personal Liberty: The Supreme Court of India, in several landmark
judgments, has interpreted the right to life under Article 21 of the Constitution as
encompassing the right to health. The judiciary has affirmed that the right to life includes
the right to lead a healthy life and access to medical facilities.

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Health Legislation:

India has enacted specific health-related legislation to ensure the availability and accessibility of
healthcare services. The National Health Policy and various other health-related laws emphasize
the need for equality in access to healthcare.

i. National Health Policy: The National Health Policy of India outlines the government's
commitment to achieving the highest possible level of health for all citizens. It recognizes
the need to reduce disparities in healthcare access and enhance the quality of healthcare
services.

ii. Clinical Establishments (Registration and Regulation) Act, 2010: This legislation
focuses on the registration and regulation of clinical establishments to ensure that
healthcare services are provided in a manner that does not discriminate against any section
of the society.

iii. Right to Information (RTI) Act: While not specific to healthcare, the RTI Act empowers
citizens to seek information about government healthcare initiatives, expenditures, and
policies. This transparency contributes to holding authorities accountable for the equitable
distribution of healthcare resources.

Social Welfare Schemes:

The government of India has implemented various social welfare schemes to address health
disparities and promote equal access to healthcare services.

i. Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY): Launched in

2018, PMJAY is one of the world's largest health insurance schemes. It aims to provide
financial protection to over 100 million vulnerable families by offering coverage for
hospitalization and secondary and tertiary healthcare.

ii. National Rural Health Mission (NRHM) and National Urban Health Mission
(NUHM): These missions focus on addressing rural and urban health disparities,
respectively, by strengthening healthcare infrastructure, improving the availability of
healthcare personnel, and enhancing the quality of healthcare services.

Case laws:

The Supreme Court of India has played a significant role in shaping the legal framework for
providing equality in access to healthcare.

i. Consumer Education and Research Centre v. Union of India (1995): This case
recognized the right to health as a fundamental right. The court held that the government

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has a constitutional obligation to provide healthcare services and ensure that they are
accessible to all.
ii. Paschim Banga Khet Mazdoor Samity v. State of West Bengal (1996): In this case, the
court stressed the importance of providing medical facilities to laborers and workers,
especially in rural areas.
iii. Mohini Jain v. State of Karnataka (1992): This case dealt with the right to education but
also had implications for healthcare as education and healthcare are closely connected. The
court held that access to healthcare is a fundamental right.

Professional duties and Medical Ethics

The Indian Medical Council (Professional Conduct, Etiquette, and Ethics) Regulations, 2002, is a
set of guidelines that govern the professional behavior, conduct, and ethics of registered medical
practitioners in India. These regulations were established by the Medical Council of India (MCI),
the now-dissolved regulatory body for medical education and practice in the country. With the
introduction of the National Medical Commission (NMC) in 2019, the regulatory landscape has
changed, but the principles outlined in the 2002 regulations continue to influence medical ethics
and practice.

i. Introduction:

The Regulations, instituted under Section 20A read with Section 33(m) of the Indian Medical
Council Act, 1956, set forth the standards of professional conduct and etiquette expected of
medical practitioners. The overarching goal is to ensure the highest quality of medical care and to
maintain public trust in the medical profession.

ii. Preamble:

The preamble of the regulations emphasizes the noble nature of the medical profession and the
responsibilities it entails. It highlights the need for practitioners to uphold a high standard of
professional conduct, maintain confidentiality, and prioritize the well-being of patients.

iii. Principles of Professional Conduct:

a. Patient-Doctor Relationship: The regulations stress the importance of maintaining the
utmost respect and dignity in the patient-doctor relationship. Physicians are expected to
provide care without any discrimination and must not exploit the trust placed in them.
b. Confidentiality: The principle of patient confidentiality is a cornerstone. Doctors are
obligated to maintain the confidentiality of patient information and can only disclose it
in certain legally sanctioned circumstances or with the patient's explicit consent.
c. Informed Consent: The regulations mandate obtaining informed consent from patients
before undertaking any diagnostic procedure, treatment, or surgery. Patients must be
provided with comprehensive information about the nature, purpose, risks, and benefits
of the intervention.
d. Professional Competence: Medical practitioners are required to maintain a high
standard of professional competence. Continuous medical education is encouraged to
stay updated with advancements in medical science and technology.

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e. Integrity and Honesty: Honesty and integrity are emphasized, with a prohibition on
engaging in unprofessional or unethical conduct. Physicians are expected to be
transparent in their professional dealings and to act in the best interests of patients.
f. Community Health: The regulations underscore the doctor's responsibility toward
society. Physicians are encouraged to participate in community health programs,
preventive healthcare, and other initiatives that contribute to the well-being of the
community.
g. Collegiality and Collaboration: The regulations promote a spirit of collegiality among
medical professionals. Collaboration with peers and other healthcare professionals for
the betterment of patient care is encouraged.
h. Advertising and Solicitation: Advertising of medical services is strictly prohibited, and
doctors are not allowed to solicit patients directly or indirectly. This provision aims to
maintain the dignity of the medical profession and prevent undue commercialization.
i. Remuneration: Remuneration for professional services must be as per the guidelines
prescribed by the Medical Council of India. Fee splitting and other practices that
compromise professional independence are discouraged.
j. Maintaining Medical Records: The regulations outline the importance of maintaining
accurate and complete medical records for every patient. These records should be treated
with confidentiality and made available only to authorized persons.
iv. Reporting Unethical Conduct:

The regulations include a provision that encourages doctors to report any unethical conduct by
their colleagues to the appropriate authorities. This reflects the commitment to self-regulation
within the medical profession and the importance of maintaining ethical standards.

v. Amendments and Evolution:

Over the years, the regulations have been subject to amendments and updates to reflect changes in
medical practices, technological advancements, and evolving ethical considerations. This
demonstrates the adaptability of the regulatory framework to ensure its relevance in contemporary
healthcare settings.

vi. Transition to the National Medical Commission:

With the establishment of the National Medical Commission (NMC) in 2019, the regulatory
landscape for medical practitioners in India has undergone significant changes. The NMC Act and
subsequent regulations issued by the NMC have taken the place of the MCI. However, the
fundamental principles of professional conduct and ethics outlined in the 2002 regulations
continue to guide medical practitioners in India.

In conclusion, the Indian Medical Council (Professional Conduct, Etiquette, and Ethics)
Regulations, 2002, serves as a comprehensive guide for the ethical practice of medicine in India.
Its principles are designed to ensure that medical practitioners uphold the highest standards of
professionalism, integrity, and patient-centered care, reflecting the noble nature of the medical
profession. While the regulatory landscape has evolved with the establishment of the National
Medical Commission, the core principles of medical ethics persist in shaping the conduct of
healthcare professionals in the country.

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