Healthcare Management Quality and Technology( HMQT)

Master’s Program 2021

Course Title:
Healthcare, Law, Business & Ethics
Course Code HMQT427- 3 Credits

Presented by
Michel Daher, MD, FACS, FEBS.
Professor of Surgery- UOB
Course Director: Medical Ethics and Bioethics- UOB and SGUB
Chairman IRB/REC – UOB and SGHUMC
Secretary General National Ethics Committee
mndaher@inco.com.lb
 Course Title:
Healthcare, Law, Business & Ethics
Course Code HMQT427- 3 Credits

Ethical Dilemmas in Healthcare

Presented by
Michel Daher, MD, FACS, FEBS.
Professor of Surgery- UOB
Course Director: Medical Ethics and Bioethics- UOB and SGUB
Chairman IRB/REC – UOB and SGHUMC
Secretary General National Ethics Committee
mndaher@inco.com.lb
Sick patients ask physicians to help
them get better;

and physicians profess to be morally

committed and technically competent
to help the sick.

How to honor this contract?

Physician- Patient Relationship
It is a patient-centered action, which
means:
 Communicate with the patient before
dealing with the disease,
 Consider the whole person, and not
symptoms or organ
 Technology will help the clinical aspect
Values in the relationship
 Values are beliefs and principles founded in
health care ethics.
 They guide the daily practice and work of
all health professionals
 All agreed on the values of competence,
respect and integrity.
Problems affecting Ethics in the
practice of medicine
 Communication
 Confidentiality

 Informed consent

 Acceptance and compliance with

treatment
 Avoidance of untruth about the

prognosis
 End-of-life issues and palliative care
Ethics of Physician-Patient Relationship
Confidentiality

Michel Daher, MD, FACS

Professor of Surgery, UOB
Secretary General, National Ethics Committee ( CCNLE)
 The Case
 CASE I
A 61-year-old man is diagnosed with
metastatic cancer of the prostate. He refuses
hormonal therapy and chemotherapy. He
instructs his physician not to inform his wife
and says he does not intend to tell her
himself. The next day, the wife calls to
inquire about her husband's health.
What is the ethical issue in this case?
 The Case
 CASE II
A 32-year-old man is diagnosed
presymptomatically with Huntington disease. This
is an autosomal dominant genetic disease (50%
chance of transmitting the gene and the disease to
offspring). He tells his physician that he does not
want his wife, whom he has recently married, to
know. The physician knows that the wife is eager to
have children.

What is the ethical issue in this case?

 The Case

 CASE III

A 27-year-old gay man is diagnosed as

HIV positive. He tells his physician that
he cannot face the prospect that his
partner will learn of the infection.

What is the ethical issue in this case?

Confidentiality
What is confidentiality?
 Physicians are obliged to keep information
about their patients confidential.
 Confidentiality provides a foundation for
trust in the therapeutic relationship.
 "What I may see or hear in the course of the
treatment or even outside of the treatment in regard
to the life of men, which on no account one must
spread abroad, I will keep to myself, holding such
things shameful to be spoken about."
Hippocratic Oath
 Confidentiality
Why is confidentiality important?
Ethics
 Without an understanding that their disclosures will
be kept secret, patients may withhold personal
information.
 Competent patients have the right to control the use
of information pertaining to themselves. They have
the right to determine the time and manner in which
sensitive information is revealed to family members,
friends and others.
 Confidentiality
Why is confidentiality important ? Law
 The confidentiality of patient information is prescribed in law.
 Physicians are prohibited from providing information to third
parties regarding a patient's condition without the consent of the
patient or his or her authorized agent, unless such disclosure is
required by law.
 A breach of confidentiality that is not required by law may
prompt disciplinary action by the LOP.
 Moreover, a breach of confidentiality may result in a civil suit.
Legal requirements to reveal certain kinds of information
without the patient's consent are defined in both statutory and
common law.
 Confidentiality
Why is confidentiality important ? Policy
 The Hippocratic Oath explicitly demands confidentiality
in physicians' dealings with patients.
 The Hippocratic Oath and subsequent Codes of Ethics
admitted no exceptions to the duty of confidentiality.
However, more recent codes allow that breaches of
confidentiality may be justified or required in certain
circumstances.
 Respect the patient's right to confidentiality except when
this right conflicts with your responsibility to the law, or
when the maintenance of confidentiality would result in
a significant risk of substantial harm to others or to the
patient if the patient is incompetent.
 Confidentiality of Medical Information
 CASE I
A 61-year-old man is diagnosed with metastatic cancer of the prostate. He refuses
hormonal therapy and chemotherapy. He instructs his physician not to inform his wife
and says he does not intend to tell her himself. The next day, the wife calls to inquire
about her husband's health.

 Recommendation In Case I:
The physician should not divulge the husband's diagnosis.
Although the wife has a moral right to know of her husband's
condition, which certainly will affect her deeply, it is her
husband's obligation to inform her. The physician, while feeling
distressed about the situation, cannot justify disclosure because
his obligation to respect his patient's preferences outweighs
possible harm to the wife from not knowing her husband's
diagnosis. The physician should encourage the husband to reveal
his condition but should not himself divulge the diagnosis to his
wife. Knowing that the patient has the right to restrict
information to any party, including his spouse.
 Confidentiality of Medical Information
 CASE II
A 32-year-old man is diagnosed presymptomatically with Huntington
disease. This is an autosomal dominant genetic disease (50% chance of
transmitting the gene and the disease to offspring). He tells his physician that
he does not want his wife, whom he has recently married, to know. The
physician knows that the wife is eager to have children.
 Recommendation In Case II:
A stronger rationale is present for divulging the
diagnosis to the patient's wife, namely, the possibility
of harm to future children. However, serious efforts
should be made to convince the husband to seek
genetic counseling and to urge him to discuss the
matter with his wife. Risk of harm to future children is
high (50%), but that risk is statistical and might not
occur.
Confidentiality of Medical Information
 CASE III
A 27-year-old gay man is diagnosed as HIV positive. He tells his
physician that he cannot face the prospect that his partner will learn of
the infection.
 Recommendation In Case III:
The physician has a duty to ensure that the partner
is informed of his serious risk, first by urging the
patient to do so and, if this fails, by taking the steps
prescribed in public health law and practice
regarding contact tracing and notification.
Provisions of local law should be consulted.
 Doctor-Patient Relationship
-Confidentiality-
• Relatives
• Patients
• Non-medical
administration
• Sponsor
• Medical
Medical Ethics
• Colleagues
Authority

Code of Medical Ethics- LOP 2013

Dr. Michel Daher, Oct 2009
 OVERALL MESAGE IS
Honor

Integrity

Best interest of the patient

The ideal doctor should adapt the

Hippoctratic Oath to today’s world
Ethics of Physician-Patient Relationship
Patient Consent

Michel Daher, MD, FACS

Professor of Surgery, UOB
Secretary General, National Ethics Committee ( CCNLE)
 The Case
 Anthony, a 22-year-old Jehovah's Witness, is admitted to the
intensive care unit for gastrointestinal bleeding. His blood pressure
is 80/60 mm Hg, and in the past 4 hours his hematocrit has fallen
from 38% to 21%. The medical resident implores Anthony to accept
life-saving transfusions, but he refuses, saying that his religion
teaches him that death is preferable to receiving blood products.
When the blood pressure reaches 60/20 mm Hg, the desperate
resident decides to give the blood while Anthony is unconscious.
The attending physician vetoes the plan, saying that the patient has
the right to refuse treatment, even if an avoidable death is the
outcome.

What is the ethical issue in this case?

 Patient Consent
Respect for Patients' Health Care Decisions
 The relationship between patients and physicians have been
evolving to a more equal relationship of shared decision
making, in which physicians provide information that allows
competent adult patients to make their own choices,
referred to as "informed consent."
 Informed consent does not refer to a patient's signature on a
consent form. It is a process of continuous communication and
dialogue between the physician and the patient.
 Compliance is improved by informing patients about their
options and maintaining open and full communication with
them
 Patient Consent
What is consent?
 Consent is the "autonomous authorization of a medical intervention . . . by
individual patients.“
 Patients are entitled to make decisions about their medical care and have the
right to be given all available information relevant to such decisions.
 Obtaining consent is a process that should occur throughout the relationship
between clinician and patient.
 Although the term "consent" implies acceptance of treatment, the concept of
consent applies equally to refusal of treatment.
 Consent has three components: disclosure, capacity and voluntariness.
 "Disclosure" refers to the provision of relevant information by the

clinician and its comprehension by the patient.

 "Capacity" refers to the patient's ability to understand the relevant

information and to appreciate those consequences of his or her decision.

 "Voluntariness" refers to the patient's right to come to a decision freely,

without force, coercion or manipulation.

 Patient Consent
Why is consent important? Ethics
 The notion of consent is grounded in the ethical
principles of patient autonomy and respect for persons.
 "Autonomy" refers to the patient's right to make free
decisions about his or her health care.
 Respect for persons requires that health care
professionals refrain from carrying out unwanted
interventions and that they foster patients' control over
their own lives.
 Patient Consent
Why is consent important? Law
 Obtaining the patient's consent to medical care is a
legal requirement.
 Under common law, treating a patient without his or
her consent constitutes battery, whereas treating a
patient on the basis of inadequately informed consent
constitutes negligence.
 The elements of consent, describes how capacity
should be determined, allows patients to challenge a
finding of incapacity and defines who may give
consent on behalf of the patient
Law 2004: Patients Rights and Informed Consent
 Patient Consent
Respect for Patients' Health Care Decisions:
 Anthony, a 22-year-old Jehovah's Witness, is admitted to the intensive care unit for
gastrointestinal bleeding. His blood pressure is 80/60 mm Hg, and in the past 4
hours his hematocrit has fallen from 38% to 21%. The medical resident implores
Anthony to accept life-saving transfusions, but he refuses, saying that his religion
teaches him that death is preferable to receiving blood products. When the blood
pressure reaches 60/20 mm Hg, the desperate resident decides to give the blood
while Anthony is unconscious. The attending physician vetoes the plan, saying that
the patient has the right to refuse treatment, even if an avoidable death is the
outcome.
 In Anthony's case, the ethical dilemma is a conflict
between beneficence and autonomy. Which principle
has priority depends on the particular situation, and in
this case, autonomy supersedes beneficence. If the
patient were a child without sufficient knowledge or
reasoning capability to make an informed choice, the
physician would not be obligated to withhold
transfusions, even if the family so demanded
 OVERALL MESAGE IS
Honor

Integrity

Best interest of the patient

The ideal doctor should adapt the

Hippoctratic Oath to today’s world
Ethics of Physician-Patient Relationship
Truth Telling

Michel Daher, MD, FACS

Professor of Surgery, UOB
Secretary General, National Ethics Committee ( CCNLE)
 The Case
 CASE I
Mr. R.S., a 65-year-old man, comes to his physician with
complaints of weight loss and mild abdominal discomfort. The
patient, whom the physician knows well, has just retired from a
busy career and has made plans for a round-the-world tour with
his wife. Studies reveal mild elevation in liver functions and a
questionable mass in the tail of the pancreas. At the beginning of
his interview with his physician to discuss the test results, Mr.
R.S. remarks, "Doc, I hope you don't have any bad news for me.
We've got big plans." Ordinarily, a needle biopsy of the pancreas
to confirm pancreatic cancer would be the next step. The
physician wonders whether he should put this off until Mr. R.S.
returns from his trip. Should the physician's concern that Mr.
R.S. may have pancreatic cancer be revealed to him at this time?

What is the ethical issue in this case?

 Truth Telling
What is truth telling?
 In the practice of medicine, truth telling
involves the provision of information not
simply to enable patients to make informed
choices about health care and other aspects of
their lives but also to inform them about
their situation.
 Truth telling requires accuracy and honesty:
Thus, truth telling requires that information
be presented in such a way that it can be
understood and applied.
 Truth Telling
Why is truth telling important? Ethics
 The covenant of trust between physician and patient is central
to the practice of medicine.
 Patients should be told the truth because of the respect due to
them as persons. Patients have a right to be told important
information that physicians have about them. Not telling the
truth can harm patients in many ways.
 Patients who remain uninformed about their condition may fail
to obtain medical attention when they should. They may also
make decisions affecting their lives that they would not make if
they were aware of their condition.
 Not telling patients the truth about their condition may entail
deceiving them. Lack of candour or outright deception, even
when well intentioned, can undermine the public's confidence in
the medical profession
 Truth Telling
Why is truth telling important? Law

 There may be narrow exceptions to truth telling, for

example when the patient's emotional condition is
such that the disclosure of bad news could cause harm
 The most relevant test for nondisclosure is "whether
the disclosure would in itself cause physical and
mental harm to this patient.“
 Physicians should start from the assumption that all
patients are able to cope with the facts, and reserve
nondisclosure for cases in which more harm will
result from telling the truth than from not telling it.
Truth Telling
Why is truth telling important? Policy

 The Code of Ethics recommends that

physicians provide patients with whatever
information that will, from the patient's
perspective, have a bearing on medical
care decision-making and communicate
that information in a way that is
comprehensible to the patient
 Truth Telling
How should I approach truth telling in
practice?(1)
 Truth telling can be difficult in practice because of
medical uncertainty and the concern that bad news
might harm the patient.
 Predicting what information a patient will find
upsetting, can be difficult. Patients may indicate,
explicitly or implicitly, their desire not to know the
truth of their situation.
 It is possible to deliver the truth in a way that softens
its impact; The truth may be brutal, but "the telling of it
should not be."
 Truth Telling
How should I approach truth telling in
practice?(2)
 Patients should be explicitly offered the opportunity
to be told important information. When a patient has
a serious illness such as cancer, it may be helpful to
document his or her preferences regarding the
involvement of family members.
 Families who resist disclosure of the truth should be
counseled about the importance of truth telling
 It is important to bear in mind that substantial
variability exists within cultures and that cultural
values can change.
 Truth Telling
Recommendation of the case of Mr. R.S.(1)
Mr R.S. should be told the truth: he probably has
cancer of the pancreas. There is a strong ethical
obligation on the physician to tell the truth to
patients about their diagnosis and its treatment.
 Truth Telling
Recommendation of the case of Mr. R.S.(2)
The following considerations are relevant:
 (a) Speaking truthfully means relating the facts of the
situation. The truth may be "brutal," but the telling of it
should not be. It reinforces the patient's ability to
deliberate and choose;
 (b) It is advisable to ask about how much the patient
wishes to know and whether the patient may wish some
other person to be informed.
 (c) Truthful disclosure has implications for Mr. R.S.'s
plans. Further diagnostic studies might be done and
appropriate treatments chosen. The trip might be delayed
or canceled. Estate and advance care planning might be
considered. Mr. R.S. should have the opportunity to take
control of his future.
 OVERALL MESAGE IS
Honor

Integrity

Best interest of the patient

The ideal doctor should adapt the

Hippoctratic Oath to today’s world
Ethics of Physician-Patient Relationship
Disclosure of Medical Error

Michel Daher, MD, FACS

Professor of Surgery, UOB
Secretary General, National Ethics Committee ( CCNLE)
 The Case
 A 41-year-old woman has a breast biopsy that reveals
cancer. She is treated by modified radical mastectomy
and reconstructive breast surgery. Postoperatively, she
develops persistent swelling and drainage of the breast
and a fever consistent with a breast abscess.
 She is returned to the operating room for exploration of
the operative site. The surgeon discovers that a sponge
had been left in the surgical wound. The sponge is
removed, and the abscess is treated. The patient
recovers and is discharged.

What is the problem in this case?

 Medical Error
What is medical error?
 Medical error is a significant quality-of-care problem
 Medical errors are usually considered to be "preventable adverse
medical events."
 Patients are harmed as a consequence of either
 what is done to them — errors of commission —

 or what is not done but should have been done to prevent an

adverse outcome — errors of omission.

 Negligent actions should be distinguished from honest mistakes.
 The former are preventable,

 Negligence, can be established only in a court of law.

 Whether all errors are truly preventable can be debated.

Medical Errors
 Occur in any stage of patient care
 During diagnosis

 Treatment

 Preventive care

 Even minor errors can have psychological

devastating effects (for patient & doctor)
 Errors are not discussed openly by providers
Human Factors At Work

1.Avoid reliance on memory

2.Make things visible
3.Review and simplify processes
4.Standardize common processes and
procedures
5.Routinely use checklists
6.Decrease the reliance on vigilance
Patient Safety Facts

 Most medical errors do not result in medical

injury, though some do, and these are
termed preventable adverse events.
 Many adverse events are neither
preventable nor ameliorable.
Prevalence of Medical Errors

 8th leading cause of death in the U.S.

 Between 44,000 & 98,000 deaths/year
 About 3% of all hospitalizations
 Estimated cost of $25 billion
 Increased hospital cost of $4700 per patient
 Rates vary by specialty (highest –vascular surgery,
lowest –general medicine)
 Medication errors most common
To Err is Human, IOM report, 2000
Medication Errors

 Medication errors each year:

 7000 deaths

 95,000 hospital admissions

 700,000 emergency visits

 3,000,000 office visits

 30% more money spent on treating errors than on

medications themselves
IOM, To Err is Human, 2000
Error Disclosure
 Recommended by medical, ethics and
safety experts
 Highly desired by patients
 Sometimes promoted by legal doctrine
 But

 Inhibited by our medical culture

 Stifled by some insurance policies
Only 30% of medical errors committed on doctors are disclosed
Novack, JAMA, 1989; 261
Patient’s Desires

 Explicit statement an error has occurred

 What the error was
 Why the error happened
 How recurrences will be prevented
 An apology

Gallagher T, Levinson W, Arch Intern Med, 2005;165

Ethical Basis of Disclosure

 “Concern regarding legal liability… should not affect

the physician’s honesty…”(AMA Code of Ethics)
 Patient-centered perspective
 Patients want to know

 Want more than they receive

 Disclosure may facilitate adjustment

 Harm from error may require treatment, necessitating

informed consent
 Medical Error
Why is the disclosure of medical error
important? Ethics
 Failing to disclose errors to patients undermines public
trust in medicine because it potentially involves deception
 Disclosure of error, by contrast, is consistent with recent
ethical advances in medicine toward more openness with
patients and the involvement of patients in their care,
 Patients are also due information about errors out of
respect for them as persons.
 Finally, nondisclosure of error may also undermine efforts
to improve the safety of medical practice if the error is
not reported to the appropriate authorities.
 Medical Error
Why is the disclosure of medical
error important? Law
 The law recognizes that physicians may
make mistakes without negligence
 These decisions suggest that a doctor who
makes an error in treating a patient has a
positive legal duty to inform the patient.
 Unfortunately, the current adversarial legal
climate is perceived as a disincentive for
many physicians to be honest about error.
 Medical Error
How should I approach medical
error in practice?
 Frankly disclosing error can be challenging for
practitioners.
 Medical professionals have high expectations of
themselves and, not surprisingly, find it difficult to
acknowledge their errors openly before patients
and colleagues.
 When harm to a patient occurs because of error, it
is imperative to be sure about what happened.
 Disclosure of Medical Error
Recommendation about the case
 Disclosure is required because harm was done to this
patient by the medical error.
 Although the outcome was satisfactory, the patient
required a second operation with attendant risks; her
hospital stay, with its attendant risks, was prolonged;
chemotherapy was delayed; and costs were incurred.
 A fundamental duty of respect for persons dictates that
apology be offered the patient for harms of this sort.
The surgeon should inform and apologize to the patient
and report the error to the institutions, which also
should apologize. Appropriate compensatory measures
should be taken.
Summary: Human Factors

 Errors are inevitable -even for doctors!

 There are situations that can increase the
likelihood of error
 Recognize them for your patient’s sake

-and yours!
 Attention to human factors principles can

lead to a reduction in error or its consequences

IOM Recommendations

 Create a national Center for Patient Safety

 Increase mandatory and voluntary reporting
 Raise the standards of expectations of
payers, oversight bodies, and professionals
 Implement safety practices in all delivery
sites by changing the system of care
Conclusions (1)
 Human beings will always make errors
 Errors are common in medicine, killing tens
of thousands
 We begin to know something about the
epidemiology of error, but we need to know
much more
 Naming, blaming and shaming have no
remedial value
Conclusions (2)
 We need to design health care
systems that put safety first
(First, do no harm)
 We know a lot about how to do
that
 It’s a long, never ending job
 Never say always, never say never
Perception of doctors and
patients has changed

Paternalist approach

Friendly democratic approach

 OVERALL MESAGE IS
Honor

Integrity

Best interest of the patient

The ideal doctor should adapt the

Hippoctratic Oath to today’s world
References

 Banga J, Medical Errors and Medical Narcissism,Jones

and Bartlet Pub, Sudbury, MA, 2005
 Hilfiker D, Facing our mistakes, NEJM1984;310:118-22
 Borrell-Carrió F, Epstein RM,Preventing errors in clinical
practice: A call for self-awareness, Ann Fam Med
2004;2:310-316
 Wojcieszak D, Saxton JW, Sorry Works!, Author House,
Bloomington, 2007