1) ACCOUNTABILITY:

Number DPP/SHRD/03 Version 1.0

Title Code of Ethics
Effective Date May 2022
Revision Dates Last May 2022 Target May 2025
Process Owner Human Resources Director of the Government Hospitals (HRD)
Authorized By Chief Executive Officer for Government Hospitals (CEO)
Location Health Policy Network (HPN)
Applicable Functions All employees at the Governmental Hospitals (GH).

2) KEY WORDS: Ethics, Profesional Conduct.

3) STATEMENT OF PURPOSE: To define the manner in which Code of Ethics policy operates in the
Government Hospitals effectively and efficiently.
 The purpose of a code of ethics is to inform those acting on behalf of the organization how they
should conduct themselves.
 A code of ethics reiterates the organization’s values and morals so that employees and third parties
understand the standards they are accountable to uphold.

4) SCOPE: This policy applies to all staff members in the Governmental Hospitals (GH). Complying
with the Code of Ethics policy, provides the most effective and efficient operation of the policy.

5) RELATED REFERENCES:
 Lundberg, George. World Medical Association International Code of Medical Ethics. MedGenMed :
Medscape general medicine. 6. 37. Accessed online [ https://www.wma.net/policies-post/wma-
international-code-of-medical-ethics/ ] on December 23rd 2021.
 Candian Medical Association. (2018). Code of ethics of the Canadian Medical Association:
adopted Sept., 1868 . [Ottawa] accessed online
[https://policybase.cma.ca/documents/policypdf/PD19-03.pdf] on December 23rd 2021
 National Health regulatory Authority of Bahrain NHRA, 2020 CODE OF PROFESSIONAL CONDUCT,
Bahrain , v2, accessed online [
https://www.nhra.bh/Departments/HCP/MediaHandler/GenericHandler/documents/departments/HCP/Polici
es/Code%20of%20Professional%20Conduct%202020%20V2.pdf ] on 23rd of December 2021.

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6) DEFENITION:
 Ethics: Also called moral philosophy, the discipline concerned with what is morally good and bad
and morally right and wrong. The term is also applied to any system or theory of moral values or
principles.
 Code of Ethics: A professional code of ethics is a set of principles designed to help a business
govern its decision-making and distinguish right from wrong. Often referred to as an ethical code,
these principles outline the mission and values of an organization, how the professionals within the
organization are supposed to approach problems and the standards to which employees are held.

7) POLICY: All staff members at the GH should comply with the Code of Ethics policy process and
procedure.
 Requires the highest standards for honest and ethical conduct, including proper procedures for
dealing with conflicts of interest between personal and professional relationships.
 Requires full, fair, accurate, timely and understandable disclosure in reports and documents,
including financial reports, medical records, other regulatory and non-regulatory records
 Requires compliance with applicable governmental laws, rules and regulations.
 Establishes accountability for adherence to the code.
 Provides for methods to communicate violations of the code.

8) RESPONSIBILTIES:
i. Signatory Authority (CEO): To authorize and sign off the DPP.
ii. Process Owner (HR Director): To maintain the DPP and to direct staff and to set policy.
iii. Chairmen of the Departments: To monitor and evaluate the implementation of the DPP.
iv. All GH staff members: To implement the DPP.

9) PROCEDURES FOR IMPLEMENTATIONS:

9.1. Providing Safe Care:
9.1.1. Always maintain the highest standard of professional conduct.
9.1.2. Always provide proven medical treatments for your patients only.
9.1.3. Do not allow personal profit and interest to influence your judgment.
9.1.4. Maintain and improve your professional knowledge, skills, and attitude through your
engagement in lifelong learning
9.1.5. Recognize and admit your limitations and seek consultation from other more experienced
colleagues.
9.1.6. Assume responsibility for any services or treatment delegated to your staff including
standards of hygiene, disinfection, sterilization, and cross-infection control.

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 9.1.7. Ensure that you keep clear, accurate, legible, and comprehensive records of patient care
including details of relevant clinical findings, decisions made, information given to
patients, and any medication prescribed or other investigations or treatments provided.
9.1.8. Ensure that all equipment you use in the care of your patients are safe, operated only by
competent trained staff, and are subject to regular quality control inspections.
9.1.9. If you develop or become aware that you have a serious condition that might be
transmitted to patients, or if the condition may impair your judgment or performance,
must stop practicing to avoid risk to patients, take advice from your treating doctor and
report immediately to your direct supervisor.

9.2. Managing adverse events:

9.2.1. Take reasonable precautions and steps to prevent harm to the patient.
9.2.2. If an adverse event occurs, act immediately to ensure the patients are protected from
harmful consequences as far as possible.
9.2.3. Acknowledge and explain clearly to patients and their families the adverse event and
offer an apology where appropriate.
9.2.4. Comply with NHRA policies and procedures about sentinel events reporting.
9.2.5. If a patient complains, offer an open, honest, constructive response to ensure that the
complaint does not adversely affect patients care.

9.3. Emergency care:

9.3.1. Give emergency care as a humanitarian duty.
9.3.2. In emergency life threatening or organ threatening situations, where consent cannot be
obtained, treatment may be provided as long as it is necessary to save the patients life

9.4. Respect for patients:

9.4.1. Do not discriminate against any patient based on age, gender, ethnic background,
physical or mental disability, political affiliation, religion, socioeconomic status, or any
other reason.
9.4.2. Always treat your patients with the respect that they deserve as human beings.
9.4.3. Practice in a manner that maintains the patients dignity.
9.4.4. Deal honestly with patients.
9.4.5. Listen to your patients, respect their views and respond to their concerns.
9.4.6. Do not use patients for your personal gain, interest or advantage.
9.4.7. Always place the well-being and best interest of the patient first.
9.4.8. Recognize and disclose conflict of interests to the patient and resolve it in the best
interest of the patient.
9.4.9. Do not enter into an inappropriate relationship with a patient.

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 9.4.10. Do not abuse or exploit your patient.
9.4.11. Having accepted professional care for a patient, continue until the service in no longer
need or the care of the patient has been transferred to another suitable physician.
9.4.12. Respect the patients right to obtain a medical report.
9.4.13. Respect your patients right to a second opinion or request for transfer of care to
another healthcare provider.
9.5. Confidentiality:
9.5.1. Avoid public discussion about patients that could potentially lead to breach of their
confidentiality and identification by others.
9.5.2. Always maintain patients, confidentiality except in cases permitted by the laws of the
Kingdom of Bahrain.
9.5.3. Ensure that confidential patient information is only disclosed to other parties with the
patients consent or in otherwise exceptional circumstances to comply with local laws
for.
9.5.4. Access information, whether electronically or in written form, relevant to your own
patients only or when requested by the treating colleague.
9.5.5. In dealing with relatives, only share medical confidential information with the patients
consent.

9.6. Patients Consent:

9.6.1. All relevant information must be provided to the patient prior to any decision being
made regarding medical service.
9.6.2. Ensure that informed voluntary consent has been given by the patient before any
medical service is carried out.
9.6.3. Respect a competent patients right to accept or refuse medical service
9.6.4. The refusal of medical service should be fully documented
9.6.5. Give the patients /gaurdiance enough information about the nature of their illness,
alternative options of medical service available, risks and benefits of each alternative,
risk of refusal of medical service, and your recommendation as a physician in order to
allow them to make an informed decision
9.6.6. It is the responsibility of the treating physician to provide the relevant information to the
patient/guardiance . The responsibility may be delegated to another physician if he/she is
suitably qualified to undertake it and has sufficient knowledge and understanding of the
medical service and the risks involved.
9.6.7. Always assess the patients level of understanding of the information provided.
9.6.8. Communicate with your patient in a way that the information being given is understood
by them.

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 9.6.9. Ask for assistance of other physicians in case of providing health services to patients
with communication difficulties such as deafness, hearing disabilities or language, etc.
9.6.10. Provide information about beneficial diagnostic and therapeutic options available.
9.6.11. Consent should not be sought when the patient is in distress or in sever pain as they will
be less likely to make a reasoned decision at such a time.

9.7. Beginning of life:

9.7.1. Abortion or termination of pregnancy is illegal in the Kingdom of Bahrain except
where there is a direct threat to the mother’s life, and even then abortion should not be
undertaken except after the approval of three obstetrics gynecology consultants, and the
approval of the mother’s guardian if she is below 21 years old.
9.7.2. Embryos created for reproductive purposes must be treated with respect.
9.7.3. Cloning for the creation of an embryo is not permitted.
9.7.4. It is obligatory to abide and respect the local laws and regulations related to ‘In vitro
fertilization’ (IVF) in the Kingdom of Bahrain and all relevant guidelines.

9.8. End of life care:

9.8.1. Respect the dignity of dying patients.
9.8.2. Ensure that decisions made in the care of a dying patient are in accordance with the
patients wishes as far as possible.
9.8.3. Communicate effectively and compassionately with patients and their families when
breaking bad news and try to ensure their understanding of the expected outcome.
9.8.4. Provide access to palliative care where available even if a cure is not possible.
9.8.5. After the death of the patient, a team member should be available to explain to the
family members, as best as possible, the circumstances of the patients death.
9.8.6. As a form of respect to the dead; it is not allowed to take any form of photoes (i.e.,
selfies, memorials, etc.) after the death of the patients and this should be communicated
to their families compassionately and respectfuly.

9.9. Care for patients with infectious disease:

9.9.1. All patients must be treated with compassion and equal respect for their dignity
irrespective of their medical condition.
9.9.2. A patient with an infectious disease deserves and needs competent treatment and should
receive treatment unless care is outside the healthcare providers competence. In such
cases, a referral should be made to another practitioner or facility equipped to provide
competent care for the patient.
9.9.3. Ensure that you protect yourself, your patients, and colleagues by adhering to universal
precautions.

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9.10. Transfer of patients:
9.10.1. Transfer of patients may be in the form of:
a. Delegation: where another healthcare provider provides care on your behalf while
you retain the overall responsibility for patient care.
b. Referral: When a patient is sent to another healthcare provider to obtain an opinion
or treatment from another healthcare provider for example in areas outside your
area of expertise.
c. Handover: where all the responsibilities for the patient is transferred to another.
9.10.2. Upon patient transfer, you have to ensure that the person to whom the patient is
transferred has the appropriate knowledge, skills and expertise to provide the required
care.
9.10.3. Patient transfer should be made where it is in the best interest of the patient and not to
serve the interest of a colleague or institution.
9.10.4. Sufficient information should be communicated to the receiving healthcare provider
about the patient through a detailed medical report to enable continuity of care.
9.10.5. When delegation takes place, the primary healthcare provider will remain responsible
and accountable for the overall management of the patient and must ensure adequate
supervision takes place.
9.10.6. The transferring physician should contact the receiving physician to provide details
about the patients condition.

9.11. Duties to colleagues:

9.11.1. Respect all members of the health care team.
9.11.2. Deal honestly with colleagues.
9.11.3. Work as a member of a team rather than individually.
9.11.4. Treat your colleagues in a manner that you would like to be treated.
9.11.5. Do not undermine other colleagues in order to attract patients.
9.11.6. Do not make derogatory comments about your colleagues or the services they provide.
9.11.7. Communicate efficiently with colleagues involved in the care of the same patient.
9.11.8. Never engage in bullying behavior, discriminatory, or harassment.
9.11.9. Recognize the value of a team approach to patient care.

9.12. Concerns about colleagues:

9.12.1. Report colleagues who have difficulties in relation to their health or are performing
poorly.
9.12.2. Report any inappropriate, unprofessional, or unethical behavior directly to the hospital
Ethical Committee.

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9.13. Duties to the profession:
9.13.1. Recognize that self-regulation of the profession is a privilege which places the
responsibility of maintaining it on each and every healthcare provider.
9.13.2. Be willing to teach and learn.
9.13.3. Be willing to participate in peer review and undergo peer review.
9.13.4. Do not withhold information from colleagues about proven therapeutic agents or
procedures that you provide.
9.13.5. Collaborate with other colleagues for the improvement of health care services.
9.13.6. Do not receive financial benefits or other incentives solely for referring patients or
prescribing a specific product.
9.13.7. Testify only to what you have personally verified.
9.13.8. Seek appropriate care when suffering from mental or physical illness.

9.14. Use of social media:

9.14.1. Be aware about the limitation of privacy online as it can be difficult to control access to
it to remove it.
9.14.2. Keep your privacy settings under regular review
9.14.3. Maintain patient privacy when using social media to post, discuss, educate public about
radiological / surgical procedures images or photos.
9.14.4. It is not permitted to all staff members, temporary employees, volunteers, trainees,
visitors, or patients to take photos or videos of any GH permisis, facilities, equipments
or other people without written approval.
9.14.5. All GH staff members must abide to the restrictions indicated by the Human Resources
(HR) Directorate.
9.14.6. Ask for written permission from HR prior appearing in media or social media, public
speaking, providing information related to your area of expertise and professionalism in
the GH.

9.15. Advertisement:
9.15.1. Comply with NHRA guidelines regarding advertisements.
9.15.2. Ensure factual, accurate, and verifiable information is used only.
9.15.3. Avoid using photographs to promote cosmetic procedures.
9.15.4. Do not make false claims or exploit patients, lack of knowledge.
9.15.5. Do not use patients information or photographs in any advertisement
9.15.6. Advertisements should ensure the maintenance of the dignity of the profession.

9.16. Prescribing:
9.16.1. Prescribe pharmaceutical agents only when the drug or treatment serves the patients

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 9.16.2. needs.
9.16.3. Ensure that the prescribed treatment, medication, or therapy is safe, evidence-based,
registered in the kingdom of Bahrain, and clinically necessary for the patient.
9.16.4. Be aware of the danger of drug dependence when prescribing benzodiazepines, opiates,
and other drugs with addictive potential.
9.16.5. Have appropriate training, facilities, and support before treating patients with drug
dependency or abuse problems.
9.16.6. Refer patient to other facilities where needed.

9.17. Duties to society:

9.17.1. Remember the professions responsibility to society through public education.
9.17.2. Promote equitable access to health care resources.
9.17.3. Use health care resources responsibly.

9.18. Duties to oneself:

9.18.1. Seek help from appropriately qualified colleagues for personal problems that might
affect your duties to your patients and the profession.
9.18.2. Practice within the limits of your knowledge and specialty.
9.18.3. Do not overwhelm yourself with responsibilities that exceed your level of expertise.
9.18.4. Seek advice of more experienced colleague when faced with a difficult situation.
9.18.5. Escalate the matter to the consultant or even chief of staff if necessary when the proper
assistance, guidance, or supervision is not provided by other members of the team.
9.18.6. Refuse to perform procedures without supervision even if requested to do so by more
senior members of the team if you are not competent to perform them.

9.19. Duties in Clinical Trials:

9.19.1. Ensure your participation in research approved by appropriate research ethics
committees only.
9.19.2. Inform the patients clearly that they are participating in research and not receiving the
standard of care or an unapproved modality of treatment.
9.19.3. Provide the potential participants with enough information about the trial to aid them in
making an informed decision about their acceptance or refusal to being enrolled into the
given trial.
9.19.4. Ensure all participants sign an informed consent form prior to being enrolled into the
trial.
9.19.5. Inform trial participants about their right to withdraw from the trial at any time without
prejudice to their ongoing health care services.

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 9.19.6. Inform trial participants about unanticipated risks that occur during the trial and access
their willingness to continue in the trial.
9.19.7. The participants best interest and well-being always precedes the interest of the trial
and the gaining of knowledge.

10) TRAINING: All Governmental Hospitals (GH) Employees must be trained to the level stated in their
job description provided by the Government Hospitals as per designated position provided with the
associated organizational chart and as mentioned in Administrative Bylaws for Government Hospitals
chapter number (7). Staff will undergo additional training as changes in services or technologies
dictate.

11) ACCESSIBILITY, DISSEMINATION, REVIEW, and REVISION & AUTHORIZATION: Please

refer to DPP/SQPS/02: Departmental policies & process (DPPs)