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Negligence
- failure to do something
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Malpractice-
failure to maintain accepted ethical standard.
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Plaintiff-
a person bringing a case against another in a court of law.
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Commission
— duty.
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Omission
— fail to do.
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Ethics:
Refers to the consideration of standards of conduct or the study of
philosophical ideas of right and wrong Behavior.
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Bioethics:
The branch of ethics within the field of health care —clinical settings,
clinical research, and education.
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Medico
legal problems in obstetrics practice are rising both in developed and in the
developing world. When the nurse fails to exercise the duty properly, she/he
found to be negligent. The failure to perform the proper duty to patient care
may be due to her incompetence or malpractice or mere negligence. The failure
to provide a standard care may be either by acts of omission or commission.
Adverse outcomes of medical care often due to -
(i)
System errors (inadequate staff,
physician or operating room etc.)
(ii)
Health care personnel's error.
Once the act of substandard care due to system error,
negligence, malpractice or incompetence is
proved in the court of law, the plaintiff to be compensated.
Common areas of legal threat:
l . Perinatal injury — Still birth, Neonatal death, Neonatal
injury.
2. Maternal injury —
Maternal trauma, Maternal death, forgotten packs in abdominal cavity Or with in
the vagina.
3. Both — Instrumental
delivery, operative delivery, Anaesthesia.
Measures to minimize medico legal problem
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Communication-
must be made in a clear and understandable way to the client and the relatives
about the management decision.
·
Informed
and written consent- must be taken before any agreed management decision.
·
Proper
documentation of facts in the patients file clearly and legibly in respect of
date and time.
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Strict
adherence to established management protocol (evidenced based) is essential,
when there is any deviation, it must be documented showing sufficient reasons.
·
Careful
record maintenance in institution as it may be required later on.
·
Adequate
training and supervision of juniors, especially involved in labor ward patient
care. Seniors must be available for consultation or direct involvement as and
when asked for.
·
Regular
audit and meetings - should be done to update the knowledge of all the staff
involved in patient care. Audit will help to improve the quality of care.
Ethical issues: Abortion, Maternal fetal conflict, Intra uterine fetal
surgery, Reproductive assistance, Embryonic stem cell research, Human genome
project, Cord blood banking, Makin
treatment decision for children, Terminating life sustaining treatment,
Organ transplantation issues, Adolescent pregnancies.
Abortion: Abortion is the extraction or the expulsion of products of conception
less than 20 weeks and of weight less than 500 grams from the mother.
Legal status of abortion:
Summary of the decision is as follows:
l) First trimester - Abortion decision and its implementation
should be left to the judgment of women and her physician
2) Second trimester -
state promote its interest in the health of the pregnant mother, and rnay
choose to regulate abortion in the ways that are reasonably related to health.
3) Third trimester -
crossed the viability period. The state is promoting its interest in the
potentiality of human life, but it can prescribe abortion to preserve the life
or health of pregnant women.
In India: Medical termination of pregnancy act (MTP). Abortion was legalized in
1971 and enforced on 1st April 1972.
It consisted of 3 components:
- Conditions where
the pregnancy can be terminated?
- Who can do it?
- The place where it
can be performed?
The purpose of this act was to: define the situations and
circumstances in which safe abortion could be legally performed and to empower
medical practitioners and institutions delivering this service.
Nurses ethical decision making: Nurse has the right to refuse to
assist abortion procedures. ( moral and ethical beliefs). Written agreement
during the time of entry. Ensure that someone with similar qualification is
there to care the client.
Maternal fetal conflict
Previously mother and fetus were considered as two different
unit. Both of them deserve
respect and treatment. It was designed to promote perinatal
care to bring about a healthy baby. Attempts have been made to criminalize the
behavior of women who failed to follow physicians order or advice or who engage
in behavior such as substance abuse.
Legal implications: Such cases are best resolved by internal
hospital mechanism including: Counseling, Consultation with institutional
ethical committee, Court intervention, Public awareness, mandatory
rehabilitation.
Intrauterine fetal surgery
Therapeutic procedure, opening of the uterus performing the
surgery and replace the fetus into the uterus, A multidisciplinary approach.
Legal implications: Parents should be informed about the experimental nature of
treatment, risk and alternatives, Mother has the autonomy to refuse, informed
consent.
Reproductive Assistance
Assisted reproductive technology are high technological
approaches used to treat infertility which includes: Invitro fertilization and
embryo transfer, Surrogate mothers. One third of the pregnancy that result from
ART are multiple pregnancy and à miscarriage and preterm. So American
society for reproductive medicine has issued guidelines to limit the number of
embryo transferred à ethical Issues for carrying unused
embryos.
Legal obligations: These are satisfied by informed consent by all parties
husband, wife and the donor. All of them should remain anonymous and physician
has the right to select the donor. If child is born with abnormalities, the
question of legitimacy can be solved by abortion.
Embryonic stem cell research
Stem cells can be found in embryonic tissues and in primitive
germ cell of the fetus. Research had proven that by tissue culture of these
cells can be differentiated it into other cells such as heart cells, nerve
cells and it can be used to solve the problem such as Alzheimer’s,
parkinsonism, spinal cord injury etc.
Ethical issues:
l) What moral status should be attached to the embryo?
2) How an embryo is
viewed as a full person or a cluster of undifferentiated cells?
3) What sources of
embryonic tissues are acceptable for research?
4) Is it ethical to produce embryo solely for research?
Cord blood banking
Cord blood taken from the newborns umbilical cord at birth
are stored. It has a combating role in leukemia, immune blood disorders because
of the presence of stem cells (regenerative cells)
Ethical questions:
Who owns the blood (donor, parent)?
How will the informed consent will be obtained and from whom?
How to notify the family if the blood reveals an infectious
disease or genetic disorder.
Making treatment decision for children
It is more complex because of their lack of capacity to
participate in decision making. Health care professionals need to determine
whether their responsibility is limited for the child or it includes the
interest of the parents.
Ethical obligations:
- inform the treatment modalities to the parents.
-counseling
-Institutions ethical committee.
-Court decision
l . What if parents are unavailable and a child needs medical
treatment?
2. Should children be
involved in medical decisions even though their parents have final authority to
make those decisions?
3. What happens when an
older child disagrees with her parents about a medical treatment?
4. Under what
circumstances can minors make medical decisions for themselves?
Terminating life sustaining treatment
Parents are the decision makers (social, emotional and
financial burden).
Recommendations:
·
Pain
relief is never denied
·
Never
starting is much easier than withdrawing. but there is no moral difference Autonomy of parents
Legal obligations:
Is it justifiable to withhold or withdraw care because of
costs?
Is it justifiable to withhold or withdraw food or fluids?
Justification for withholding, withdrawing and limiting therapy
includes; treatrnent has poor rate if Success, Burden of treatment outweighs
the benefit or the quality of life, The burden of disease outweigh the benefit
of the continued survival.
Organ transplantation issues:
Death of the child can benefit other child, through organ
transplantation. It will help the, survival of the child.
Ethical issues:
-Which individual on the waiting list should receive the
organ available?
-Should the families
be permitted to pay the donor families for organ?
-What are the brain
death and non heart beating criteria that enable organ collection to proceed?
Adolescent pregnancy
An adolescent can be said as a emancipated when the they are
self supporting, and living away from home, married, pregnant etc.
Legal obligations:
They have the right and responsibility to consent the health
care. Entitled to get confidentiality.
Only with her consent or agreement other adults including her
parents be included in communications.
Human genome project
Multidisciplinary approach to explore and map all human
genetic material. Bring about a safer future. It helps to detect any genetic
problem, To improve the quality of life. This information can be used in
clinical decisions about surveillance and prevention or treatment of disease.
Ethical questions:
l . Question for the payment of genetic testing?
2. Confidentiality
3. Counseling and
interventions
4. Right to refuse and
receive the information's
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