Emergency Care and Medical Ethics-Slide Show

Seminar on Ethical Standard in Private Health
Practice Organised By PHIRU; Facilitated By

Green Horizon Limited
EMERGENCY CARE AND MEDICAL ETHICS:

THE DILEMMA OF MEDICAL PRACTITIONERS
Amana Mohammed Yusuf
Faculty of Law, Bayero University Kano
presented at
1-Day Seminar on Ethical Standard in Private Practice for Health

Practitioners in Kano State
Organised By PHIRU and Facilitated By Green Horizon Ltd
April 22, 2014
1
Seminar on Ethical Standard in Private
Health Practice Organised By PHIRU;
Facilitateed By Green Horizon Limited
INTRODUCTION
 Deaths resulting from failure of emergency care/response in our

hospitals (private and public) in Nigeria is fast assuming a worrisome
dimension. deaths include but not limited to: roads, domestic and
industrial accidents, violent assaults, violent crime injuries and gunshot
wounds, civil and political unrest sustained injuries, as well as women
under labour etc.
 Victims of these accidents die at the scene on the spot, on the way to
the hospital, while the other deaths results from the refusal of hospitals
or doctors (particularly) and other medical workers to attend to these
victims in that extreme hour of need often time referred to as the
“golden hour”.
 In emergency medicine, the golden hour (also known as golden time)
refers to a time period lasting from a few minutes to several hours
following traumatic injury being sustained by a casualty, during which
there is the highest likelihood that prompt medical treatment will
prevent death. 2
INTRODUCTION…CONT
 Emergency in-hospital, care often time are denied by hospitals and doctors to the
victims on two grounds; inability of the victims, their family members or good
Samaritan who accompanied them to pay deposit fees demanded by the hospitals or
the doctors and the demand for the presence of a policeman or production of police
report.
 Suffice it to say that, some of the deaths under the circumstances of emergency
care it is argued are preventable were the victims given adequate emergency care at
that hours of need.
The concern of this paper is NOT pre-hospital emergency care but the denial of “in-
hospital” emergency care/response by the hospitals and doctors to these victims
when they are successfully brought to the door step of the hospital (public or private)
by either members of their family, Good Samaritan or the police and sometimes
their employers as the case may be.
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THE MEANING OF EMERGENCY CARE

 According to the Indian Supreme Court in the case of Paramanand Katara Vs Union of Indian,
AIR 1989 Sc 2039: (1989) 4 SCC 286: 1990 CrilJ 671, Emergency care may be viewed as that
instantaneous medical aid given to an injured victim to save life.
 It is prompt response to acute illnesses and injuries in order to prevent or minimize pain and
suffering, loss of function and loss of life.
 The most comprehensive definition is that propounded by the law commission of Indian in the
draft model law, where it was defined as:
the action that is required to be taken, after screening of a person injured in an accident or
who is in an emergency medical condition, as to the stabilization of the person and the
rendering of such further treatment as may, in the opinion of the hospital or medical
practitioner be necessary for the purpose of preventing aggravation of the medical condition of
the person or his death and in the case of a pregnant woman, for the purpose of a safe
delivery and safeguarding the life of the woman and the child.
 Thus, from the definitions above, emergency care is that urgent medical attention required by a
victim for the purpose of saving his life.
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THE MEANING OF EMERGENCY CARE… CONT.

 The benefits of providing emergency medical treatment to the injured
as soon as possible were first recognized about 200 years ago during
wars in Europe when ‘flying ambulance” or light horse-drawn
carriages were introduced to carry the wounded from the battle field.
Since that time, there has been steady increase in the sophistication
of emergency medical services. Thus early treatment and
stabilization of accident injuries can enhance a patient’s timely and
full recovery. Delay or well intentioned but inappropriate first aid can
result in death or permanent disability. Medical experience around
the world has demonstrated that stabilization to a specialist center,
within what they describe as the “golden hour” increases the
patient’s potential for survival and full recovery. The obligation to
render this immediate medical attention to save life is founded on
moral, ethics and law.
5
THE DILEMA OF MEDICAL PRACTIONERS IN

SITUATION OF EMERGENCY CARE
 SERVICE TO HUMANITY
 FINANCIAL CONSIDERATION
 MISINFORMED INTERPRETATION TO THE

PROVISIONS OF SECTION 4 OF THE ROBBERY
AND FIREARMS SPECIAL PROVISION ACT
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MORALITY AND ETHICS IN MEDCINE

 Morality refers to social norms that distinguish between right and wrong in
human conduct, i.e. the social life of humankind. In other words, it relates to
issues involving right and wrong and how individual people should behave. It is
derived from what ones personal conscience suggests is right or wrong, rather
than on what rule or the law says should be done.
 Ethics on the hand has been defined as the moral reasoning of actions.
According to Nixon and Forman, it refers to a professional moral conduct. While
according to Adekilekun, it means something in conformity with moral norms or
standard of professional conduct.
 Ethics, particularly professional ethics, describes the moral actions based on

professional character and ethical principles in each profession.
 Ethics is an intrinsic part of medical practice and require the physician to do

what is best for the patient and place the patient's interests before the interests
of the physician. Above all, the purpose of medical ethics is to protect and
defend human dignity and patients’ rights. Medical ethics thus, is a set of
norms, values and principles. These norms, values and principles are intended
to govern medical ethical conduct.
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MORALITY AND ETHICS IN MEDCINE… CONT

 Elsayed et al. submitted that the global medical profession has
maintained simple ethical and moral standards for more than 4,000
years. For example, the Hippocratic Oath, the prayer of Moses
Maimonides, the Bible, the Holy Koran, and the Islamic legacy, as well
as cultures, traditions, and social morality have shaped and guided the
development of ethical standards in the medical profession. The
majority of these historical documents focus on “avoiding harm to
patients”. The aforementioned traditional origins of morality and ethics
often motivate health professionals, particularly the Medical Doctor.
 Ernest, maintains that many decisions within medical practice,

particularly by medical doctors are ethical decisions requiring ethical
justifications. He posits that, there are three competing and partially
overlapping ethical rules that helps medical practitioners make ethical
decisions, rather than relying on strong feelings, flipping coins or other
unreliable equally capricious mystical methods. In order to understand
the doctors/hospital obligation in cases of emergency care, these
ethical rules ought to be understood.
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 Principle-based/Traditional approach of making

ethical decision
It is the most popular and theoretically the least sophisticated of the three
rules. It comprises of four major prima facie principles: i) autonomy, ii)
beneficence, iii) non-maleficence, and iv) justice. This rule owe it root from
the physicians’ declaration and oath made before provisional registration.
Arising from the physician oath are the following undertakings:
 I shall exercise the several part of my profession to the best of my
knowledge and ability for the good safety and welfare of all persons
committing themselves to my care and attention.
 I solemnly pledge to consecrate my life to the service of humanity.
 I will practice my profession with conscience and dignity; the health of my
patient will be my first consideration.
 I will not permit consideration of religion, nationality, race, party politics or
social standing to intervene between my duty and my patients.
 Even under threat I will not use my medical knowledge contrary to the laws
of humanity.
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PRINCIPLE-BASED/TRADITIONAL APPROACH OF
MAKING ETHICAL DECISION…CONT
 The moral center and defining elements of ethics in emergency care arising from the
physicians’ oath and the rule of professional conducts flow from these principles:
 AUTONOMY
Autonomy remained a gauge parameter for medical care and decision making by a medical
doctor. This is however subject to a patient's capacity for making life-and-death decisions. While
medical attention by a doctor/hospital to persons of full capacity is subject to his or her
consent, Persons with medical conditions such as delirium or clinical depression or trauma
resulting from accidents may not have the capacity to make life and death decisions. Therefore,
these persons, unless there is a clear advance directive to the contrary, lack the mental
capacity to make informed decisions and are generally treated according to their best interests.
It is this “best interest” principle that imposes on the doctors/hospital in emergency
circumstances the obligation to do what is reasonably right to save life. Refusal to treat
therefore becomes a deviation from the undertaking to protect life in all circumstances.
 BENEFICENCE:
The term beneficence refers to actions that promote the well being of others. In the medical
context, this means taking actions that serve the best interests of patients. It is a fundamental
duty imposed on doctors to serve the best interest of their patients by treating or preventing
disease or injuring or save life. Thus in cases of emergency, doctors are required to respond
promptly to acute illnesses and injuries in order to prevent or minimize pain and suffering, loss
of function and loss of life. In pursuing these goals, the doctors serve the principle of
beneficence, that is, they act for the benefit of their patients.
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 NONMALEFICENCE
At least, as fundamental as the duty to benefit patients is, the corresponding duty is
to refrain from inflicting harm. This duty, called the duty of nonmaleficence, is central
to maintaining emergency care. In contemporary emergency medical care, the
potential for significant patient benefit is often inescapably linked with the potential
for significant complications, side effects, or other harms. The principle of
nonmaleficence is aimed at always to maximize the benefit of treatment and to
minimize the risk of harm.
 JUSTICE
In a broad sense, acting justly can be understood as acting with impartiality
or fairness. In this sense, doctors have a duty to provide emergency care to
patients regardless of race, color, creed, gender and nationality. This duty
indirectly ascribe to doctors and hospitals in emergency situations a social
responsibility to provide necessary care to all victims in emergency
condition, regardless of ability to pay and regardless of conditions
stipulated under any law.
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 THE CONSEQUENCE BASED ETHICAL DECISION
The utilitarian/consequence based theory, is to the effect that the rightness or wrongness of a certain
action is exclusively judged by its consequences. Under this theory, “foreseeable consequence” is the
guiding principle when it comes to decision making by the doctor/hospital in emergency situation. The
theory is rooted from the utilitarian public policy of maximizing the greater satisfaction ands happiness
of the society. The criteria for determining obligation are: acts / omissions and intention / foresight.
 ACTS AND OMMISSION

This doctrine holds that in certain contexts, failure to perform an act, with certain foreseen bad
consequences of that failure, is morally less bad than to perform a different act which has the identical
foreseen bad consequences; though there is a moral difference, between acts and omissions, both of
them seems to generate the same harmful by-products. It is therefore argued that doctors have the
same greater degree of moral responsibility for the consequences of their acts as they do for the
consequences of their omissions. This underscores the intersection between clinical ethics and the
medico-legal standpoint.
 INTENTION AND FORESIGHTS

The morality of actions can be affected by whether certain consequences can be foreseen but not
intended. For instance, the death of a terminally ill patient may be foreseen by the doctor as a result of
the administration of overdose, without intending the death of his patient. The genuine intention may
well have been to relieve suffering, without wanting to terminate the patient’s life yet the patient’s
death was a foreseen consequence of the action. The net outcome of both actions and omission are
identical. Hence, the moral question is whether the fact that one merely foresees a certain outcome 12
but does not in
 Deontological bioethics duty based approach
to emergency care
 The word deontological is derived from deon the Latin root for duty or
obligation.
 The core ethical foundation of medicine from historic past is “avoiding
harm to patients”. This core ethical foundation imposes a duty on the
doctor to save life and not to see it being taken away.
 It has been argued that the health care professional-patient relationship
suggest the existence of contractual relationship like that between a
customer and a professional selling professional services to create a
duty to act. It is submitted that while this is the general position for the
purpose of creating obligation arising from the breach of the contract,
emergency situation and incompetent patients constitute notable
exceptions. The foremost ethical consideration as it relates to this
exception is “save life first”. This incorporates the traditional overriding
obligation on the doctor to treat their patients to the best of their ability.
Hence, the claims of patients rights to medical care and doctors
corresponding obligations to respect these rights.
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WHY THE APPLICATION OF MORAL AND ETHICAL
STANDARDS IN EMERGENCY HEALTH AND MEDICAL CARE
 Elsyaed et al. submitted that the application of moral and ethical standards in
health and medical care, particularly in cases of emergency has the following
potential benefits.
1. First, ethical standards promote the aim of medical care: to alleviate suffering.
2. Second, it promotes the values that are essential to good communication, such
as trust, accountability, mutual respect and fair medical care.
3. Third, it helps to build public support for medical care.
4. Fourth, it ensures that medical professionals whether in public or private
hospitals perform their duties in respectful and professional manner.
5. Fifth, it promotes other important moral and social values such as social
responsibility, human rights, patients’ welfare, compliance with the law,
regulations, and patients’ safety.
Adherence to ethical standards significantly facilitate a pleasant environment for
both patients and medical doctor in cases of emergency.
Thus, medical ethics is concerned with promoting health and medicine and
clarifying norms for improving relationships between patients and physicians.
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WHY THE APPLICATION OF MORAL AND ETHICAL

STANDARDS IN EMERGENCY HEALTH AND MEDICAL
CARE…CONT
 Therefore the obligation to save life by doctors has both moral and ethical
consideration and is traced to his professional oaths and code of ethics as well
as religions, socio-cultural dictates and moral values. He is thus in cases of
emergency required to respond promptly and expertly, without prejudice or
partiality to the need for emergency care, this is particularly so because victims
requiring emergency care are the most vulnerable and thus unable to make
treatment choice due to diminished decision making capacity.
 Doctors/Hospitals are expected to always maintain the highest standards of
professional conduct;
 not permit motives of profit to influence the free and independent exercises of
professional judgment on behalf of patients;
 always bear in mind the obligation of preserving human life;
 always give emergency care as a humanitarian duty unless assured that others
are willing and able to render such care.
 The principal objective of emergency medical care, should be the promotion of
the health of the patient and in doing so, the doctors/hospitals should be
concerned with the common good of the patient while at the same time
according full respect to the human dignity of the individual
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JUSTIFICATION FOR REFUSAL OF EMERGENCY
CARE BY MEDICAL PRACTITIONERS IN NIGERIA
 Under international law and from the rules of ethics and morality of medical practice, there is no
justification, be it in law or in fact to justify the lack of protection of vulnerable members of the society
from health-related discrimination.
 In Nigeria however, hospitals and medical doctors refuse or omit to render emergency care on the two
principal grounds of the inability of the victims or their relatives to pay the requisite deposit for such
emergency care or inability to produce a policeman or police report on demand. Hospitals and doctors
place reliance on section 4 of the Robbery and Firearms special provision Act cap 398 LFN 1990 as
justification for refusal to treat victims of accidents and more particularly victims of gunshot injuries.
The section provides thus:
4(1) It shall be an offence punishable under this act for any person to knowingly house, shelter or
give quarters to any person who has committed an offence under this section (1) & (2) of this act.
(2) It shall be the duty of any person, hospital or clinic that admits, treats or administers drug to any
person suspected of having bullet wounds to immediately report the matter to the police.
(3) Any person who; or Hospital or clinic which fails to report as stipulated in subsection (2) of this
section shall be guilty of an offence under this act.
(4) Any person convicted of an offence under subsection (1) (3) this section shall be liable in the case
f an individual to imprisonment to a term not exceeding 5 years or in the case of hospital or clinic to a
fine of ten thousand naira and in addition, the hospital or clinic shall he closedown.
 A clear reading of the above provision will show that there is nothing in the said provision that prohibit
the rending of emergency care to victims. The provision merely requires hospitals, doctors or clinics as
the case may be to report such treatment after it has been commenced.
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CONSEQUENCES OF REFUSAL OF
EMERGENCY CARE
 PATIENT
 DEATH
 PARMANENT INCAPACITY OR DISABILITY
 UNFOUNDED CONVICTION WITHOUT TRIAL
 MEDICAL PRACTITIONER
 PROFESSIONAL MISCONDUCT (RULES 28 OF THE RULES OF
PROFESSIONAL CONDUCT FOR MEDICAL AND DENTAL
PRACTITIONERS IN NIGERIA)
 CIVIL OR CRIMINAL ACTION FOR NEGLIGENCE
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Facilitated By Green Horizon Limited
LEGAL FRAMEWORK FOR EMERGENCY CARE

INItNIGERIA
 appears there is no legal framework at the moment. However the National
Assembly through the Senate and the House of Representative have two pending
bills seeking to address the problem albeit inadequate.
 THE BILL ON TREATMENT AND CARE FOR VICTIMS OF GUNSHOT
 SECTION 1
 As from the commencement of this Act every hospital in Nigeria whether public or
private shall accept a received for immediate and adequate treatment with or
without police clearance any person with a gunshot worlds.
SECTION 3: Accordingly
 No person with gunshot wound shall be refused immediate and adequate treatment
by any hospital in Nigeria whether or not initial monetary deposit is paid.
 No person with a bullet wound shall be subjected to in human and degrading
treatment or future by any person or authority including the police or other security
agencies
SECTION 13
 Any person or authority including any police officer or other security agents or
hospital who stand by or omit to do his bit which results in the unnecessary death of
any person and shall on conviction be liable to 5 years imprisonment a fire N50,000
or both.
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LEGAL FRAMEWORK FOR EMERGENCY CARE IN

NIGERIA..CONT
 The need for legislation on emergency care and other critical aspect of
health is long overdue. It is therefore recommended that appropriate
steps should be taken to domesticate those international human rights
laws that have direct bearing on emergency care in Nigeria. It is also
recommended that the National Assembly should hasten the process of
passing the bills on treatment and care for victims of gunshot and the
National Health bills without any further delay.
 NATIONAL HEALTH BILL

section 20 which provide thus:
 Sub. (1) A health care provider, health worker or health
establishment shall not refuse a person emergency medical treatment
for any reason.
 Sub (2) Any person who contrivances this section is guilty of an
offence and is liable on conviction to a fine of N10,000 or to
imprisonment for a period not exceeding three months or both fire and
imprisonment.
19
LESSONS FROM OTHER COUNTRIES

 The United State of America and Indian have been able to address the problem
of emergency care through legislative framework and judicial activism based
approach
 THE UNITED STATES OF AMERICA
 EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOUR ACT) 1986
 COBRA (CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT) 1985
 INDIAN
THROUGH DECIDED CASES, INDIAN COURTS HAS BEEN ABLE TO GIVE AN
EXPANCIVE DEFINATION TO THE RIGHT TO LIFE TO INCLUDE THE RIGHT TO
HEALTH AND ALSO MAKE A CASE FOR COMPULSORY AND COMPREHENSIVE
HEALTH INSURANCE POLICY.
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CONCLUSION
 There can be no second opinion that preservation of human life is of paramount

importance. This is so on account of the fact that once life is lost, the status quo
ante cannot be restored, as resurrection is beyond the capacity of man.
 Denial of emergency care by hospitals and doctors for any reason; be it on

ground of law or on the basis of social standing is outright discriminatory and
against morality, the physician oath and the ethics of the medical profession.
The duty to protect life by doctors and hospitals is not only moral but ethical.
 The principle rights of the patients in state of emergency includes but not
limited to: the Right to health care, irrespective of any other considerations;
Right to be treated with respect, care, compassion, attention and dignity without
any discrimination; Right to get treatment in case of emergency.
 Emergency care by hospital and medical doctors has not been given the
attention that it deserved. Substantial number of deaths from accidents; road,
domestic and industrial, gunshots and women under labour are linked to the
absence of or inadequate emergency care. In the same vain, there has been
inadequacy or absence of express legislation on emergency care.
21
END
 Thank you for listening
22

Emergency Care and Medical Ethics-Slide Show

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Seminar on Ethical Standard in Private Health

Practice Organised By PHIRU; Facilitated By

EMERGENCY CARE AND MEDICAL ETHICS:

1-Day Seminar on Ethical Standard in Private Practice for Health

 Deaths resulting from failure of emergency care/response in our

THE MEANING OF EMERGENCY CARE

THE MEANING OF EMERGENCY CARE… CONT.

THE DILEMA OF MEDICAL PRACTIONERS IN

 MISINFORMED INTERPRETATION TO THE

MORALITY AND ETHICS IN MEDCINE

 Ethics, particularly professional ethics, describes the moral actions based on

 Ethics is an intrinsic part of medical practice and require the physician to do

MORALITY AND ETHICS IN MEDCINE… CONT

 Ernest, maintains that many decisions within medical practice,

 Principle-based/Traditional approach of making

 ACTS AND OMMISSION

 INTENTION AND FORESIGHTS

WHY THE APPLICATION OF MORAL AND ETHICAL

LEGAL FRAMEWORK FOR EMERGENCY CARE

LEGAL FRAMEWORK FOR EMERGENCY CARE IN

 NATIONAL HEALTH BILL

LESSONS FROM OTHER COUNTRIES

 There can be no second opinion that preservation of human life is of paramount

 Denial of emergency care by hospitals and doctors for any reason; be it on

 Thank you for listening

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