LEGAL AND ETHICAL RESPONSIBILITIES - Principles of Health Sciences 1 – 1 - ثاني ثانوي

Link to digital lesson CHAPTER www.ien.edu.sa 5 LEGAL AND ETHICAL RESPONSIBILITIES Legal Case Study Investigation You are a doctor in your hometown main hospital. Your neighbor called you to tell you that his daughter was proposed to by one of your acquaintances. The father is asking you whether you can provide information about the health status of his daughter's possible future husband. Can you disclose this private information? What information can a doctor disclose? LEARNING OBJECTIVES After completing this chapter, you should be able to: •Provide one example of a situation that might result in legal action for each of the following: malpractice, negligence, assault and battery, invasion of privacy, false imprisonment, abuse, and defamation. • Describe how contract/consent laws affect health care. • Define privileged communications and explain how electronic health care records impact confidentiality. • State the legal regulations that apply to health care records. ⚫ List at least six basic rules of ethics for health care providers. ⚫List at least six rights of the patient who is receiving health care. • Justify at least six professional standards by explaining how they help meet legal/ethical requirements. KEY TERMS abuse patients' rights ethics assault and battery Bill of Rights and Responsibilities confidentiality contract expressed consents implied consents informed consent negligence وزارة التعليم Ministry of CHAPTER 5 2022-1444 GE44.PATHWAYS.G02 S2.HLTH.SB.indb 80 privileged communications scope of practice 14/10/2022 10:13

5:1 LEGAL RESPONSIBILITIES INTRODUCTION Legal responsibilities are those that are authorized or based on law. A law is a rule that must be followed. Laws are created and enforced by governments. Health care providers must follow laws that affect health care. In addition, health care professionals/providers are also required to know and follow laws that regulate their respective licenses or registrations and the standards for their respective professions. There are different types of laws that affect health care providers, such as criminal and civil laws. ⚫ Criminal law: deals with crimes or wrongs against a person, property, or society; examples include practicing in a health profession without having the required license, illegal possession of drugs, misuse of narcotics, theft, sexual assault, and murder. ⚫ Civil law: focuses on the legal relationships between people and the protec- tion of a person's rights; in health care, civil law usually involves torts and contracts. The penalty for criminal crimes is usually incarceration. The penalty for civil violations is usually fines, but sometimes incarceration. TORTS A tort is a civil wrong that does not involve a con- tract. A tort occurs when a person is harmed or injured because a health care provider does not meet the established or expected standards of care. These offenses may be quite complex and may lead to legal action, such as: ⚫ Malpractice: is commonly called "professional negligence." It is the failure of a professional to use the degree of skill and learning com- monly expected in that individual's profession, resulting in injury, loss, or damage to a person receiving care. For example, a nurse performing minor surgery without having any training. وزارة التعليم Minister Education 2022-1444 Negligence: Negligence is the failure to pro- vide care that is normally expected of a person in a particular position, resulting in injury to another person (Figure 5-1). Examples include falls and injuries that occur when side rails FIGURE 5-1 A health care professional could be are left down, using defective equipment, and found to be negligent if a patient is injured because he bunis caused by improper heat or radiation treatments. or she forgot to lift the protective side on the bed and the patient fell out. LEGAL AND ETHICAL RESPONSIBILITIES 81 | GE44.PATHWAYS.G02 S2.HLTH SB.indb 81 14/10/2022 10:13

وزارة التعليم Mines 82 CHAPTER 5 2022-1444 Assault and battery: Assault is a threat to injure a person, and battery is the unlawful touching of a person without consent. The terms are closely related and often used together. Examples of assault and battery include performing a procedure without the consent of a patient, threatening a patient, and rough treatment of a patient while providing care. It is important to remember that patients must give consent for any care and have the right to refuse care. Some procedures or practices require written consent from the patient. Examples include surgery, certain diagnostic tests, experimental procedures, treatment of minors without parental consent. Verbal consent is permitted in other cases, this must be "informed consent." Informed consent is permission granted voluntarily by a person who is of sound mind and who has been instructed, in terms the person can under- stand, about all the risks involved. Patients have the right to withdraw consent at any time. Therefore, all procedures must be explained to the patient, and no procedure should be performed if the patient does not give consent. ⚫ Invasion of privacy: may be physical or informational. Physical invasion of privacy includes unnecessarily exposing an individual; for example during an examination. Informational invasion of privacy refers to reveal- ing personal information about an individual without that person's con- sent; for example giving information about a patient to a friend or family member without the patient's permission. ⚫ False imprisonment: refers to restraining an individual or restricting an individual's freedom without authorization. Examples include keeping patients hospitalized against their will or applying physical restraints without proper authorization. Physical restraints, devices used to limit a patient's movements, should be used only to protect patients from harming themselves or others and when all other measures to control the situation have failed. A physician's order must be obtained before they are used, and strict guidelines must be observed while they are in use. ⚫ Abuse: Abuse includes any care that results in physical harm, pain, or mental anguish. Examples of types of abuse include: ⚫ Physical abuse: hitting, restraining a person by holding them, depriv- ing people of food or water, and not providing physical care. ⚫ Verbal abuse: speaking harshly, swearing or shouting, using inap- propriate words to describe a person's race or nationality, and writing threats or abusive statements. ⚫ Psychological abuse: threatening harm; denying rights; belittling, intim- idating, or ridiculing the person; and threatening to reveal information about a person. Patients may experience abuse before entering a health care facility. Domestic abuse occurs when an intimate partner uses threats, manipulation, aggres- sion, or violent behavior to maintain power and control over another person. GE44.PATHWAYS.G02 S2.HLTH SB.indb 82 14/10/2022 10:13

If abuse is directed toward a child, it is child abuse. If it is directed toward an older person, it is elder abuse. Health care providers must be alert to the signs and symptoms that may indicate patients in their care are victims of abuse. These may include: ⚫ Unexplained bruises, fractures, burns, or injuries. Signs of neglect such as poor personal hygiene. Irrational fears or a change in personality. Aggressive or withdrawn behavior. Patient statements that indicate abuse or neglect. The law requires that any form of abuse be reported to the proper authori- ties. Even though the signs and symptoms do not always mean a person is being abused, their presence indicates a need for further investigation. Health care providers are required to report any signs or symptoms of abuse to their immediate supervisor or person responsible for reporting suspicions to the proper authorities. ⚫ Defamation: Defamation occurs when false statements cause a person to be ridiculed or cause a person's reputation to be damaged. If the infor- mation is spoken, it is slander; if it is written, it is libel. Examples include reporting that a patient has an infectious disease to a government agency when laboratory results are inaccurate, or telling others that a person has a drug problem when actually another medical condition exists. CONTRACTS OR CONSENTS A contract is an agreement between two or more parties. Contracts usually have three parts: ⚫ Offer: a health care facility or provider offers treatment or services to a patient. ⚫ Acceptance: a patient makes an appointment with the health care facility or provider and accepts the treatment or services offered. . Consideration: the patient receives the treatment or services; the health care facility or provider receives payment from the patient. Contracts or consents in health care are implied or expressed. Implied con- sents are understood without using words to give agreement. For example, when a qualified health care provider prepares a medication and a patient takes the medication, it is implied that the patient accepts this treatment. Expressed consents are stated in distinct and clear language, either orally or in writing. An example is a surgery consent. Promises of care must be kept. Therefore, all risks associated with treatment must be explained completely to the patient (Figure 5-3). وزارة التعليم Ministry of EducxION 2022-1444 GE44.PATHWAYS.G02 S2.HLTH SB.indb 83 LEGAL AND ETHICAL RESPONSIBILITIES 83 | 14/10/2022 10:13

FIGURE 5-2 All risks of treatment must be explained to a patient before asking the patient for permission to administer treatment. All parties entering into a contract must not have legal disability. A person who has a legal disability does not have the legal capacity to form a contract. Examples of people who have legal disabilities are minors (individuals under legal age), mentally incompetent persons, individuals under the influ- ence of drugs that alter the mental state, and semi- conscious or unconscious people. In such cases, parents, guardians, or others permitted by law must form the contract for the individual. A contract requires that certain standards of care be provided by competent, qualified individ- uals. If the contract is not performed according to the agreement, the contract is breached (broken). Failure to provide care and/or giving improper care on the part of the health provider, or failure on the part of the patient to pay according to the consideration, can be considered a breach of contract and cause for legal action. A final important consideration in contract law is vicarious liability. A person who directs or controls another person, such as an employer, Comm is called the principal, and the person working under the employer is called the agent. The principal may be held vicariously liable or responsible for the actions of the agent and can be required to pay or other- wise compensate people who have been injured by the agent. For example, if a dental assistant tells a patient "your dentures will look better than your real teeth," the dentist, because of vicarious liability, may have to compensate the patient financially should this statement prove false. PRIVILEGED COMMUNICATIONS Privileged communications comprise all information given to health care personnel by a patient. By law, this information must be kept con- Comm fidential and shared only with other members of the patient's health care team. It cannot be told to anyone else without the written consent of the patient. Certain information is exempt by law and must be reported in accordance with facility policy. Examples of exempt information are births and deaths; injuries caused by violence (such as assault and battery, abuse, or stabbings) that may require police involvement; drug abuse; communicable diseases; and sexually transmitted diseases. Health care records are also considered privileged communications. Such records contain information about the care provided to the patient. Although the records belong to the health care provider (for example, the physician, dentist, hospital, or long-term care facility), the patient has a right to obtain a وزارة التعليم Minis 84 CHAPTER 5 2022 1444 GE44.PATHWAYS.G02 S2.HLTH.SB.indb 84 14/10/2022 10:13

copy of any information in the record. Health care records can be used as legal records in a court of law. Erasures are therefore not allowed on such records. Errors should be crossed out with a single line so the material is still readable. Correct information should then be inserted, initialed, and dated. If nec- essary, an explanation for the correction should also be provided. Incorrect data on an electronic health record (EHR) should be corrected by following the directions for making corrections in the particular software being used or by following agency policy. All health care records must be properly maintained, kept confidential, and retained for the amount of time required by law. When records are disposed of after the legal time for retention, they should be burned or shredded to maintain confidentiality. FIGURE 5-3 The growing use of electronic health records (EHRS) has created the need to limit access to computers to maintain confidentiality. The growing use of electronic health records (EHRs) has created a dilemma in maintaining confidentiality (Figure 5-3). In a large health EHR care facility such as a hospital, many different individuals may have access to a patient's records. For this reason, health care providers are creating safeguards to maintain computer confidentiality. Some examples include limiting the personnel who have access to such records, requiring the use of iris scans or fingerprints to access records, using codes to prevent access to certain information, requiring passwords to access specific information on records, and constantly monitoring and evaluating computer use. REGULATION OF HEALTH CARE PROVIDERS Health practice has laws, regulations, and licensing boards that govern health care providers. These regulations usually determine the scope of practice (the procedures, processes, and actions) that health care providers are legally per- mitted to perform in keeping with the terms of their professional license or registration. Each medical practitioner must understand the scope of practice that his or her license, certification, or registration falls under. Failure to abide by the regulations can result in the suspension or loss of a license, certification, or registration. The Ministry of Health and Council of Ministers of Saudi Arabia have estab- lished national standards that regulate health care. Some of the regulations are mandated by the Royal Decree. A few examples of these laws include: Health Law and its implementing Regulations. Law of Practicing Health Care Professions. ⚫ Patient-Bill-of-Rights-and-Responsibilities. Saudi Guidelines for Informed Consent. Law of Private Health Institutions. وزارة التعليم Ministry of EductION 2022 1444 GE44.PATHWAYS.G02 S2.HLTH SB.indb 85 LEGAL AND ETHICAL RESPONSIBILITIES 85 | 14/10/2022 10:13

• Pharmaceutical Companies and Products Law. ⚫ Mental Health Care Law. ⚫ Legal Regulations for Telehealth Services. In addition, most health care agencies have specific rules, regulations, and standards that determine the activities performed by individuals employed in different positions. These standards are usually in the facility's policy or procedure manual. Every health care team member should read and follow the guidelines presented in the manual. Legal standards and regulations can vary; it is important to remember that you are liable, or legally responsible, for your own actions regardless of what anyone tells you or what position you hold. Therefore, when you undertake a particular position of employment in a health care agency, it is your responsibility to learn exactly what you are legally permitted to do and to familiarize yourself with your exact responsibilities. Modern health care advances have created many medical ethical dilemmas for health care providers. Some of these dilemmas include: ⚫ When should life support be discontinued? ⚫ Can a health care facility refuse to provide expensive treatment, such as a bone marrow transplant, if a patient cannot pay for the treatment? ⚫ Who decides whether a 75-year-old patient or a 56-year-old patient gets a single kidney available for transplant? ⚫Should animals be used in medical research even if it results in the death of the animal? ⚫ Should aborted embryos be used to obtain stem cells for research, espe- cially as scientists may be able to use the stem cells to cure diseases such as diabetes, osteoporosis, and Parkinson's? checkpoint 1. List four (4) legal disabilities that would prevent a person from signing a consent form or contract. 2. Define the term tort. 3. Define privileged communications and explain how they apply to health care. وزارة التعليم Minist 86 CHAPTER 5 2022-1444 5:2 ETHICS Ethics are a set of principles relating to what is morally right or wrong. Ethics provide a standard of conduct or code of behavior. This allows a health care provider to analyze information and make decisions based on what he or she believes is right and good conduct. As medical technology advances, the implications on ethical decisions become more complex. For example, digital medicine combines information GE44.PATHWAYS.G02 S2.HLTH.SB.indb 86 14/10/2022 10:13

technology, artificial intelligence, and big data with pharmaceutical, biotech- nology, and medical device companies. An example of this is the digital pill. It combines sensor technology with a drug that is used to treat a range of serious mental illnesses. A psychiatrist who prescribes it to a patient with schizophre- nia might be better positioned to help that patient by being certain he or she is taking the medicine as prescribed. On the other hand, there is the potential for a negative effect on the doctor-patient relationship with regard to mutual trust. Another consideration is whether patients fully understand how their health information may be collected, used, stored, and shared. Ethics must keep up with the rapid pace of technology and the challenges of managing a large amount of patients' behavioral, medical, and personal information. Although there are no easy answers to any of these questions, some guidelines are provided by an ethical code. The Saudi Commission for Health Specialties Department of Medical Education and Postgraduate Studies published the Code of Ethics for Healthcare Practitioners in 2014. The aim of the Code is to enhance medical professional etiquette and to establish ethical guidelines concerning professional and personal attitudes that ought to be followed by any health care practitioner. The Code covers: Health care practitioner ethics. ⚫ Duties of the health care practitioner toward patients. The health care practitioner's duties toward the community. ⚫ The health care practitioner's duties toward professional colleagues. ⚫ The health care practitioner's duties toward him/herself. ⚫The health care practitioner's duties toward his/her profession. Observance of religious rulings. Ethics of teaching and learning on patients. Ethics of documentation and authentication. ⚫ Ethics of financial affairs in the health care field. ⚫ Ethics of conducting biomedical research. Ethics of dealing with communicable diseases. Ethics of dealing with emergency situations. Ethics of dealing with life-threatening and incurable diseases. Most of the national organizations affiliated with the different health care professions have established ethical codes for personnel in their respective occupations. Although such codes differ slightly, most contain the same basic principles: ⚫ Put the saving of life and the promotion of health above all else. ⚫ Make every effort to keep the patient as comfortable as possible and to preserve life whenever possible. وزارة التعليم Ministiger Education 2022-1444 GE44.PATHWAYS.G02 S2.HLTH.SB.indb 87 LEGAL AND ETHICAL RESPONSIBILITIES 87 | 14/10/2022 10:13

Respect the patient's choice to refuse medical intervention when all options and consequences have been explained and discussed with the patient and family. ⚫ Treat all patients equally, regardless of race, religion, social or economic status, gender, age, or nationality. Bias, prejudice, and discrimination have no place in health care.Provide care for all individuals to the best of your ability. • Maintain a competent level of skill consistent with your particular health care career. Stay informed and up to date, and pursue continuing education as necessary. Maintain confidentiality. Confidentiality means that information about the patient must remain private and can be shared only with Comm other members of the patient's health care team. A legal violation can occur if a patient suffers personal or financial damage when confidential information is shared with others, including family members. Information obtained from patients should not be repeated or used for personal gain. Gossiping about patients is ethically wrong. ⚫ Refrain from immoral, unethical, and illegal practices. If you observe others taking part in illegal actions, report such actions to the proper authorities. Failure to report these actions may result in legal actions taken against you. ⚫Show loyalty to patients, team members, and employers. Avoid negative or derogatory statements, and always express a positive attitude. ⚫ Be sincere, honest, and caring. Treat others as you want to be treated. Show respect and concern for the feelings, dignity, and rights of others. Always abide by the code of ethics of your health care career to become a competent and ethical health care provider. checkpoint What does the term confidentiality mean? وزارة التعليم Mines 88 CHAPTER 5 2022-1444 5:3 PATIENTS' RIGHTS Ministry of Health legislation requires health care agencies to have written pol- icies concerning patients' rights, for the care that patients can expect to receive. Agencies expect all personnel to respect and honor these rights. The Saudi Arabia Ministry of Health issued a Patient's Bill of Rights and Responsibilities that must be recognized and honored by health care provid- ers. This bill of rights states, in part, that patients have the right to: GE44.PATHWAYS.G02 S2.HLTH.SB.indb 88 14/10/2022 10:13

FIGURE 5-4 Patients have the right to fully participate in all decisions related to their health care. • Receive accurate, easily understood information and assistance in making informed health care decisions about their health care plans, profession- als, and facilities. . A choice of health care providers that is sufficient to ensure access to appropriate high-quality health care. ⚫ Access emergency health services when and where the need arises. • Fully participate in all decisions related to their health care (Figure 5-4). ⚫ Be represented by parents, guardians, family members, or other conserva- tors if they are unable to fully participate in treatment decisions. Considerate and respectful care. . Not be discriminated against in the delivery of health care services based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, genetic information, or source of payment. ⚫ Communicate with health care providers in confidence and have the confidentiality of their individually identifiable health care information protected. Review a copy their own medical records and request amendments to their records. وزارة التعليم Minstige Edurumon 2022 1444 GE44.PATHWAYS.G02 S2.HLTH.SB.indb 89 LEGAL AND ETHICAL RESPONSIBILITIES 89 | 14/10/2022 10:14

وزارة التعليم Mines 90 CHAPTER 5 2022-1444 GE44.PATHWAYS.G02 S2.HLTH.SB.indb 90 A fair and efficient process for resolving differences with their health care plans, health care providers, and the institutions that serve them, includ- ing a rigorous system of internal review and an independent system of external review. checkpoint What are the patient's rights if he or she is unable to make an informed consent regarding a medical intervention that they need? 5:4 PROFESSIONAL STANDARDS By following professional standards at all times, you can protect yourself, your employer, and the patient. Some of the basic standards are: . Perform only those procedures for which you have been trained and you are legally permitted to do. ⚫ Use approved, correct methods while performing any procedure. ⚫ Obtain proper authorization before performing any procedure. • Identify the patient. • Obtain the patient's consent before performing any procedure. ⚫ Observe all safety precautions. Keep all information confidential. ⚫ Treat all patients equally regardless of race, religion, social or economic status, gender, age, or nationality. .Accept no tips or bribes for the care you provide. If any error occurs or you make a mistake, report it immediately to your supervisor. ⚫ Behave professionally in dress, language, manners, and actions. Even when standards are followed, errors leading to legal action sometimes still occur. It is your responsibility to understand the legal and ethical implications of your particular health care career. Never hesitate to ask specific ques- Legal tions or to request written policies from your employer. By obtaining this information and by following the basic standards listed, you will protect yourself, your employer, and the patient to whom you provide health care. 14/10/2022 10:14

checkpoint Choose three (3) professional standards and explain how they protect yourself, your employer, and the patient. Case Study Investigation Conclusion What information can a doctor disclose about a patient? When would a doctor be allowed to break confidentiality according to the Saudi code of ethics for health care practitioners? Today's Research Tomorrow's Health Care Frozen Stem Cells That Cure Major Diseases? Stem cells are important because they can become any of the specialized cell types needed in the human body. They can turn into muscle cells in the heart, nerve cells in the brain, or cells that secrete the insulin needed by a patient with diabetes. The major sources of stem cells are a developing embryo (infant); adult tissues such as bone marrow, brain, muscle, skin, and liver; and blood from the umbilical cord of a newborn infant. When a baby is born, blood from the umbilical cord can be collected and stored in liquid nitrogen. If the child later develops a disease such as cancer and needs stem cells, the cells can be recovered and used for the transplant. The cost of this procedure still limits its widespread use. Scientists the world over are finding ways to grow stem cells and force them to generate special cells that can be used to treat injury or disease. Early research has proved it is easier to work with embryonic cells, but this has created ethical dilemmas because it means embryos are destroyed. However, if adult cells can be harvested and grown, it would be easier to use an adult's own cells because they would not be rejected by the body. Conditions such as cancer and birth defects are caused by abnormal cell division. If scientists can learn how the abnormal development occurs, they could find ways to treat and even prevent the conditions. Major research is directed toward learning what makes the cells specialize to become a specific type of cell in the body. Some of the latest research on stem cells involves treatment for heart disease. If the muscle of the heart is deprived of oxygen because of a blocked artery, the muscle cells die. Researchers are using embryonic cells, FIGURE 5-5 Stem cells are stored in liquid nitrogen. cardiac stem cells that naturally reside within the heart, myoblasts (muscle stem cells), and umbilical cord blood cells to try to repair damaged heart tissue. Most of their work has been performed on rats or larger animals, but some experiments have been performed on humans undergoing open-heart surgery. Initial studies showed that stem cells injected directly into the injured heart tissue appeared to improve cardiac function. Another major area of research is directed toward patients with type 1 or insulin-dependent diabetes, a condition in which the cells of the pancreas do not produce sufficient insulin. New studies are showing some success in directing embryonic stem cells in a cell culture to form insulin-producing cells. Intensive research is needed before this is an effective treatment for diabetes, but stem cells do offer exciting promise for future therapies. وزارة التعليم Ministry of Eduction 2022 1444) GE44.PATHWAYS.G02 S2.HLTH.SB.indb 91 LEGAL AND ETHICAL RESPONSIBILITIES 91 | 14/10/2022 10:14