Journal of Clinical Research & Bioethics

Dilemmas of Medical Ethics: Overcoming of Authorities and Negligence of Moralities

Shaheen Nazakat^* and Muhmmad Sajid ¹Department of Cardiology, University of Lahore, Lahore, Pakistan
²Department of Cardiology, Faislabad Institute of Cardiology, Lahore, Pakistan
^*Correspondence: Shaheen Nazakat, Department of Cardiology, University of Lahore, Lahore, Pakistan, Email:

Received: 09-Nov-2021 Published: 30-Nov-2021

Introduction

This memoir based on an incident that happened at about midnight (12:30 a.m.), when a house officer was supervising as a senior officer in the emergency ward of tertiary care hospital Faisalabad, Pakistan. A lady having age about 36 years was brought to the emergency ward. She was suffering from retrosternal burning and abdominal discomfort. She was feeling severe heartburn and acidity. The previous history of that lady depicted that she was suffering from duodenum ulcer and abdominal pain. The H.O examine her and diagnose that she was suffering from abdominal pain due to having appendicitis, so he decided to operate the lady immediately in the absence of a senior surgeon and without prior-permission of a senior surgeon of tertiary care hospital Faisalabad, Pakistan. After his imprudent operation, he found that the patient’s appendix was normal size and have no inflammation. But to protect himself he removed the normal-sized appendix and stitches her. After a few hours, the patient’s situation became worse than before. H.O put the patient on bag-mask ventilation which appeared to be ineffective. Despite all the efforts of medical staff, after five hours of the operation, the lady made a blood vomit and after half an hour she was expired.

The wrong perception of the H.O creates a question on the competencies of the senior doctors of ward and hospital staff. When the matter was discussed, the H.O was considered as responsible for this mishap. This case puts the attention on the fact that organizational and ethical values are not considering while making decisions. The medical staff confines to do certain jobs but due to their behavior, they commit such kind of unforgettable mistakes. They don’t follow the hierarchy of the system. The seniors were absent from duty. They don’t supervise the juniors properly. The patient was expiring due to high negligence and over confidence of junior and senior doctors. They don’t follow the proper test regarding the diagnosis of test. The house officer took personal decision without informing the senior colleagues. He took independent decision without proper follow the guidelines. The attendant of patient was not properly consulted about the diagnosis of patient. Senior doctors were sleeping on their official duty time. The H.O took the foolish decision without taking proper consent.

The question arises here, who will be the responsible and what was the mistake of their attendants. This situation had alarmed society about the Holy profession. After hearing the bad news the patient attendants shouted and show the aggressive behavior.

The Mortality inquiry held after the application given by attendants, during inquiry the perforation of duodenal ulcer had been established. This is high of negligence. But the interference of some colleagues this actual situation has been hiding out and responsible doctors and staff has safe from any kind of punishment. This was the height of favoritism and negligence. This is the difficult situation for society to decide how to punish the actual accused persons.

A care provider is considered to be the person who is equipped with the necessary knowledge and professional moralities [1]. The health care provider as an individual is a key component of the whole wellbeing organization (Hospital or any other type of health care system). As a health care providing person, besides authorities, he/she has some responsibilities. The implication of these moralities and conciseness of a person with certain limitations is the responsivity of the health care providing organization. Hospitals offer services like 24/7 health care providing a center for community members. Several hospitals in Pakistan have managed their medical staff in three shifts.

Usually due to having fewer patient junior medical staff (generally young doctors) appointed as house officers. Their duties are to work in coordination with senior staff but due to the absence of these staff, these inexperienced doctors bypass their limits and making decisions that become fatal for the patient.

Medical young doctors are considered an important part of any health providing organization and they assist the hospital staff.

However, any medical staff should follow the legal requirements with emergency arrangements as explained by Regulation 6 of the Confined Space Regulations 2001.

A health care responsible shall not enter a confined space unless there is a suitable emergency arrangement that has been made which is appropriate to the confined space in question.

The emergency arrangements that explained in regulation 6 include:

All practical measures necessary to ensure the health and safety of those taking part in the case.

The provision of a suitable and reliable means of raising the alarm in the event of an emergency.

Having all essential rescue tools nearby and in a well sustained, good condition.

The facilitation of information, coaching, and training to all involved in rescue actions.

The provision of equipment and training for revival procedures if there is an estimative risk (Health and Saftey Authority).

1^st Position (From the Organizational Point of View)

Health care providing organizations always tried to maximize the patient’s care measures. The management authorities prefer to assign authorities of emergency supervisor or house officer to the experienced medical staff [2]. There is a proper systematic framework developed by PMDC and PHC that should be implemented by the healthcare organization. The policies and protocols of any hospital are designed using a patient-centered management domain.

The death of a patient due to medical staff negligence arises a big question for the whole of administrational and sub ordinal staff. These kinds of medical uncertainties led to legislation and inquiries.

In this scenario, although policies and protocols for supervisors or house officers were existing there it was depicted that organizational policies are not well implemented and the whistleblowing or consultation mindset was not developed in the above-said hospital. The house officer appointed that time was making his half-witted experiments while he was not demanding any kind of permission from consulting medical staff. Moreover, the test reports and medical history were not considered while making a decision. Furthermore, after the operation, no senior doctor visited the patient even after five hours of this incident.

The patient was expired due to the wrong prescription of house officers and improper treatment in the emergency ward. Considering this situation I was thinking about the previous history when the same house officer was appointed as supervisor. The above-stated incident is alarming to me about the happenings that had happened before or may happen due to such kind of irresponsible behavior of medical staff in the hospital.

To minimize such kind of mishaps health care providing organizations and even medical staff should not compromise on the set standards formulated by PHC. Medical ethical and international standards should maintain and persons involved in such a mishap should strictly inquire. An organization should ensure the presence of senior consultants in the emergency ward. No operation should be done neglecting the clinical history of the patient.

Kumar and Batool [3] reported that Medical errors most of the time remains disclosed due to the repute of an organization. It is essential to uphold the standards of practice, information and error to be revealed to the responsible person and if it is not so it is against the professional practice, and authority has to feel physician guilty for negligent expose. In future serious actions should be taken to avoid such kinds of uncertainties.

2^nd Position (As per Healthcare Provider Point of View)

Medical ethical and authority hierarchy is established keeping under consideration some important health care principals. As healthcare responsible for a person who attends and predicts the person is considered to be following all the necessary parameters necessary for the life of a patient [4].

Ethics is not based on someone’s wishes, but it reasonably weighs up the risks and benefits to deal [3]. With the problem, moreover, implementation of ethics and medical protocols are indicators to the repute of health care providers as well as hospital [5].

The ethical limitations attached to a health provider after taking an oath to protect the life of the patient using all his knowledge and without the consideration of self-ego were violated.

In the present situation despite clear medical history and selfexplanation of the patient were ignored. Above all the health care provider violates Article 4 and Article 14 of rights to the patient and others stated in Charter of Rights and Responsibilities of Patient Careers and others (PHC 2019).

Article 4 stated as: Be attended to, treated and cared for with due skills, and in a professional manner for the accepted standard of health in complete consonance with the principle of medical ethics.

Article 14 has explained patients’ right as: If a healthcare provider receives emergency healthcare unconditionally. However, once the emergency has been dealt with, he may be discharged or refer to another health care establishment.

In this situation the decision made by the hair health care provider was totally irrelevant as before making a decision he should consult with the colleagues at least he should inform senior staff telephonically about the patients’ situation. Before operation he should demand some test reports and should be well aware of medical history of the patient.

Justification of My Position

My point of view in this situation is totally against the actions made by appointed H.O. He should carefully observe the patient history and then treat her accordingly. The proper tests were not made to justify either which curative mechanism should follow.

Furthermore, he violated the protocols and medical ethics, before making any operation consensus should be made with attendants and senior doctors have to supervise the H.O during operation.

Either the H.O was not intended to harm the patient but incorrect observation and ignorance with the medical history resulted in patient death. This matter should be inquired and responsible authorities should punish for this offense.

Possible Consequences

Policies without implementation are not more than printed papers. Inscribed policies and protocols are confided for the health care of the patient [6]. The violation of the serious law (to consult with a senior surgeon before operation) can lead to fatal results. In the present scenario, the dilemma occurs on behalf of organizational and H.O. House officer may be intended not to harm the patient’s life. He might be intended to cure him but without the consultations of seniors was a violation Furthermore, the attendant’s consensus should also be obtained but it was missing in the present situation.

Pledging medical inattention and breaching the principle of non-maleficence can lead to tolerating penalties and medical grievances. While actions are taken based on principles of practice, then it takes this dilemma away and eventually makes organizations more ethically justifiable.

If no punishment made than in the future it may expect to continue this kind of foolish experiment on living bodies and ultimately it can be harmful to organizational repute and competency questions for all the medical staff.

Conclusion

Misuse of authorities and medical negligence is being reported on daily basis. Comparatively being as a doctor or medical in charge, one has some responsibilities that must be fulfilled. Consultation with senior medical staff or with experienced nurses is necessary for life of a patient. In the above-explained incidence, wrong perception without the consultation of senior doctors was made. This negligence led towards the death of a patient and organizational repute was challenged. Organizational policies and medical staff coordination were weak in this situation. Capacity building of medical staff and accountability mechanisms should empower. Health care providing organizations should consider their responsibilities as health providers, not as a profit earning institution.

Recommendations

Keeping in view the present situation it is recommended that capacity building of medical supervisory staff should conduct to eradicate psychological and moral incompetency if exist in any medical staff. As a health care responsible each medical staff should realize his/her role and responsibilities. The ethical hierarchy for the better health of patient should develop by each health providing organization and organization should maximum perform its role in the implementation of these policies. There should be a proper surveillance of medical staff especially in emergency wards and they should perform any serious action with consultations of senior doctors.

There should be an accountability system for the responsible authorities. The person involved in such mishaps should present publically so that in future no one dare to do violation of medical ethics.

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