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Duty of Doctors
Medico-legal Aspects
Contents
• Introduction
• Obtaining consent, Different consenting age
• suspected poisoning
• criminal abortion
• Civil and Criminal negligence
• medicolegal postmortem
• Legal problems faced related to medical practices
• Civil law: Law of contract, Law of Tort,Consumer
Protection Act,Medical Council,Other laws
• Conclusion
• Protocol for police cases & Rape/Sexual assault:
• Introduction to Rape/Sexual assault
• Interviewing the patient
• Intervention: Preparing the patient for
examination
• Physical examination
• Providing follow up services
• Obtaining laboratory Specimen
• Examination of the Victim
• Preforma for examination of the accused in a
rape case:
 Medicolegal Certificate for Male
 Medicolegal Certificate for Female
Introduction
What is Medicine ?
What is ethics ?
Medicine is about : “Can we?”
Ethics is about: “Should we?”
In a nutshell, “ethics” means doing what is right
Why conflicts ?
1. Physicians and patients relation +Public Rules
2. High technologies
3. Heavy economic burden.
4. Ethical dilemmas
i.e.;- Medicine-brain death
- Organ transplantation
- Euthanasia
- Destroying frozen embryos
- Refusal to fund marrow transplantsnew drugs
- IVF
- Abortions
5. many people value:
• Honesty
• Integrity
• Freedom
• Loyalty
• Life
• Friendship
• Family
• Timeliness
• Hard-work
• Truthfulness
• Religion
• Etc., etc., etc.
Components of Medical Ethics
• The Physician -- Patient Relationship
• The Physician -- Physician Relationship
• The relationship of the Physician to the System of Healthcare
• The Relationship of the Physician to Society
• The Relationship of the Physician to legal system
• The Declaration of Geneva of the WMA binds the
physician with the words,
"The health of my patient will be my first consideration,“
• The International Code of Medical Ethics declares that
"A physician shall act in the patient's best interest when
providing medical care”
Medical Negligence
• A doctor must posses a reasonable degree of
proficiency & apply the proficiency with a
reasonable degree of diligence
• Failure of the doctor to provide medical
services (with requisite skill & care) gives rise
to action in medical negligence under
criminal, civil or consumer court
Medical Negligence
• A doctor is negligent if he doesn't offer his services in an emergency
situation
• But In Emergencies, CONSENT can be implied in the law if immediate
treatment is necessary to avoid life- or limb-threatening condition
• Clinical management should precede the legal duties in trauma cases
brought for treatment
• A doctor breaches his duty of care when he fails to reach the
standard of proficiency expected of him
Legal concept of Negligence
• Human Behaviour towards others: failure to act reasonably &
prudently
• Failure or breach of duty owed to the patient doctor has the
obligation to perform that duty in a manner that will bring it
to a successful conclusion)
• Damage to the individual for breach of duty (there must be
some damage to the patient resulting from breach of
duty owed)
Medicalofficer/Medical practioner/physician
Every registered medical practitioner /Officer has to
perform some medico-legal duty during his/her duty.
• Duty in Emergency
• Duty in Ward
• Duty in Surgical procedure
Medico legal In the emergency room
• very important medico-legal aspect
• have to make injury report in all unnatural cases (fight, kill
attempt,sucide,harm,abuse etc)
• But if the patient is moribund, arrangement of treatment is to
be made first.
• Police case
• If not admitted , only PC (police case) is done.
• If admitted, IPC (indoor police case) is to be done.
• In both the cases government prescribed form is available.
• If the form is not available, it may be done in plain paper under seal
and signature of the duty medical officer.
• brief history of the case is necessary.
• The injuries should be mentioned one by one with their position,
approximate measurement and type of the injuries ie, abrasion,
bruise, laceration injuries etc
• Lastly, the provisional diagnosis of the case and the prognosis
of the case are to be mentioned.
• If he fails to discharge this duty he may be charged according
to the law.and the punishment may be 3 months of
imprisonment or fine upto Rs.500.00 or both( depends on the
law by the each country)
• during examination of the case a male/female attendant
should be present for a male patient and a female for a female
patient.
• Otherwise the doctor may be charged with indecent assault
and the punishment may be imprisonment with and/or fine
Medical reports & certificates
• Reports on the medical conditions of a person (victim or
accused)folowing injury
• Death certificate
• Reports for Life-insurance
• Certificate of illness
• Certificate of fitness
• All these documents must be prepared with meticulous
accuracy
Report
Incidents requiring a report to the proper official relevant
agencies while maintaining as much patient confidentiality
as possible, include:
• Drug & chemical poisoning
• Road traffic accident
• Gun-shot wounds
• Physical assault
Gunshot & Stab Wounds
•Reports of these acts of violence
are usually made to police
Dead-on-Arrival
• If the case of death is natural, death certificate & burying
license must be submitted to relatives
• Un-natural death: be reported to police for possible
investigation & for assessment of need for a referral to
forensic medicine sp.
• Initiate resuscitation unless it is clear that patient has been
dead for some time
• Mention that deceased was brought dead
• Body to be examined by a committee
• In case there is no clear cause of death, take 50 ml blood in
plain tube & send to Toxicology Centre
Cause of Death
• In case the results (from toxicology lab) are negative, the
cause of death can be mentioned as “Death possible due to
hidden disease leading to cardiopulmonary arrest”
• All dead bodies should be kept for 2 hours before
transferring to mortuary
• Patient’s belongings should be handed over to relatives, if
the cause of death is natural.
Next in the ward,
• the doctor is to examine the case very carefully and treat the
patient with a reasonable degree of skill, care and knowledge
to avoid charge of negligence.
• BHT (bed head ticket) is to be maintained properly with care
and skill.
• The doctor should give proper and suitable prescription. He
should mention the exact quantities and precise timing for
taking medicines
• Here, may have to make “dying Declaration”. It is a
statement of a person, written or oral, whois dying as a
result of some unlawful act.
• The doctor is to assess that the patient is in good mental
condition before the declaration is recorded. The
declaration is made in question and answer form.
• The declaration should be noted down in verbatim(exact
word) or the patient in presence of two reasponsible
witnesses. It should be signed by the doctor, the patient
and the witnesses.
doctorsinthe ward,
Anotherimportantmedicolegal
• is to help in the preparation of “Dying Deposition”.
• It is the statement of a dying man, before a Magistrate and
the accused or his Counsel, on Oath.
• In a ward, it is a bed side court.
• Here, the doctor has to certify the mental and physical fitness
of the patient to make such a statement.
in the operation theatre,
• the doctor in charge of the operation should be very careful
before going to operation proper.
• He should note that all the formalities have been completed.
• The written consent of the patient and the guardian should
be taken before going for operation.
• Before closing the operation, the swab count and the
instrument count should be made so that none of them
remains in the operation field.
Types of Consent
• Implied Consent: is provided by the behaviour of the patient;
e.g. patient presents at Outpatient Clinic
• Express Consent: Any thing other than implied consent. It
may be oral or written
• Informed Consent: consent must be obtained after a
reasonable explanation of the proposed procedure to
patient, so that he is enable to make informed decision
whether or not to submit
The Extension Doctrine
• Provides an exception to the general rule that a
patient’s consent is limited to those procedures
contemplated when consent is given
• If in the course of authorized medical intervention a
doctor discovers a life-threatening condition that
requires immediate treatment and the patient is
unable to consent (e.g. under anesthesia), the
doctor may extend the operation or procedure
without the patient’s express consent
• • If any one of them remains in side the operation area, the
doctor may be charged with criminal negligence under “Res
Ipsa Loquitur” which means “The thing speaks of itself”.
• The doctor may be charged with criminal negligence causing
the death of any person by doing rash and negligent act
• The punishment is imprisonment with fine or with both.
• In addition, administrative proceedings will start against the
doctor and may be dismissed from the service and his name
may be erased from the State Medical Council.
Duty totake consent inmedicalpractice:-
• Consent means voluntary agreement, compliance or
permission when a patient is coming to a doctor for
treatment, the consent is needed.
• There is no need of taking written consent. But in
some special cases written consent is required.
• In criminal cases, the victim and the accused can not
be examined without his/her written consent.
• The court also can not compel a person to get medically
examined against his/her will.
• A) In case of rape, the victim should not be examined without
her written consent.
• B) In medicolegal cases of pregnancy, delivery and abortion, the
woman should not be examined without her written consent.
• But the convicted person can be examined without his/her
consent by applying reasonable force
Different consenting age: -
• For medicolegal examination 12 years and above.
• For sexual intercourse 16 years and above.
• For operation to suffer any bodily harm 18 years
and above.
• A child under 12 years of age and an insane person
can not give valid consent.
Requirement of consent :-
• • In various field of medical practice written consent is required.
• Only some example are given here :-
• For contraceptive sterilization written consent of both the
husband and wife should be obtained.
• • For artificial insemination written consent of both
• the donor and the recipient side should be obtained.
• • For medical termination of pregnancy the written consent
should be obtained from the woman as well as from the
guardian.
For organ transplantation,
• the organ of the dead person should not be removed
without the
• consent of the person having lawful possession of the body.
• Pathological autopsy should not be conducted without the
consent of the guardian or legal heirs of the deceased.
• But for medicolegal autopsy no consent is required. Only
inquest is sufficient to hold this autopsy.
•
In case of emergency,
• no consent is required to save the life of the patient in good
faith.
If the doctor fails to follow these rules of consent,
charged with professional negligence (malpractice) both
civil and criminal negligence.
• The punishment may be
• issuing of warning notice for infamous conduct,
• erasure of names civil negligence and
• Charge of criminal negligence if dies after
operation and if the consent has not been taken.
Suspected Poisoning
• But the doctor should confirm his suspicion before
expressing an opinion. For this he must :
• (a) Collect urine, vomit and faeces and submit for analysis.
• (b) Carefully observe and record the symptoms in relation to
food.
• (c) Consult in strict confidence with senior practitioner.
• (d) Either remove the patient to hospital or engage nurses of
his confidence.
• (e) Any suspected articles of good, excreta and stomach wash
samples should be preserved.
In case of homicidal poisoning, the doctor is duty
bound to inform the police officer or the Magistrate.
• • Non-compliance is punishable under Sec…. … if it is proved
that the doctor did it with the intention of protecting the
accused..
• Should explain to investigating police officer, he is bound to
give all information regarding the case that has come to his
notice.
• If he hides the information, he is liable to be prosecuted .
• if he gives false information, he is liable to be charged with the
offence of giving false information under the law
• A medical officer is required to report to police all the cases
of suspected poisoning, whether accidental suicidal or
homicidal in nature.
• If a case of suspected poisoning dies, death certificate should
not be issued but death declaration should be made and it
should be communicated to the nearest police station.
In a case of criminalabortion:-
• • criminal abortion is the induced destruction and expulsion
of the foetus from the womb of the mother unlawfully when
there is no therapeutic indication for the operation.
• • The doctor’s duty in this case is to guard all the informations
obtained by him as a professional secrecy. He must urge the
patient to make a statement about the induction of criminal
miscarriage.
• If she refuses to make a statement, he should not pursue the
matter. He must treat her to the best of his ability. He must
consult a professional colleague.
• If the woman dies, he should not issue a death certificate, but
should inform the police for making arrangement for
postmortem examination.
• whoever voluntarily causes criminal miscarriage is liable for
imprisonment upto 3 years and or fine and if the woman is
quick with the child the imprisonment may extended upto 7
years.(IPC)
• In this case, both the person procuring the miscarriage and
the woman are liable for punishment. If this case, both the
person procuring the miscarriage and the woman are liable for
punishment.
TORT
• Civil wrong (negligence) committed by one
individual against another is known as TORT, where,
a person fails to take proper care, so that damage
results
• Civil Law deals with legal actions which seek the
redress of wrongs which are not criminal in nature
• Criminal Law involves a legal action filed by a state
government against defendants and deals with
definitions of crimes and their punishment
Negligence
• Harmful conduct that deviates from accepted standards of
duty & care
• A doctor who injures a patient by conduct that fails to meet
the legal standard of due care may be liable for negligence in
an action for malpractice
Specific elements of Negligence
In order for a complaining party to sustain an action for
negligence against a defending party, 4 elements must be
proved in the court of law:
• Existence of doctor-patient relationship giving rise to a duty
of due care
• Breach of that duty
• Proximate cause (injury): Fall from a Stretcher in ED
sustains bruises/MI after 4 months; is unlikely to rove
that the fall caused MI
• Damages
The civil negligence
• Civil negligence is absence of reasonable degree of care and
skill or willful negligence of a medical practitioner, in the
statement of patient leading bodily injury of death of the
patient.
• • question of civil negligence will come when patient is dead ,
and the relatives suit in a civil court for compensiation
• Similarly the doctor can bring a civil suit for realization of his fees
from the patient or his relatives who refused to pay the same on
the ground of professional negligence.
Examples of civil negligence
• Loss of earning of the patient due to negligent act of the
attending doctor.
• Expenses incurred eg. Hospital expenses, special
investigation, special diet, etc.
• Reduction of expectation of life of the patient due to wrong
treatment.
• Reduced enjoyment of life of the patient.
• Pain and suffering, either physical or mental.
• Loss of potency
• Death of the patient.
• A doctor is not liable for an error of judgement or of
diagnosis, if he has secured all necessary data in which
to base a sound judgement.
• Contributory negligence on the part of a patient is very
good defence for negligence.
Criminal negligence
• • Criminal negligence occurs when the physician exhibits
gross lack of competency, gross inattention, criminal
indifference to the patient’s safety during the treatment
• Negligence is so great as to go beyond matter of mere
compensation
• Not only the doctor has made wrong diagnosis and
treatment, but he/she has shown gross neglect for life
and safety of the patient
• Doctor may be prosecuted for having caused injury or
death of a patient by a rash & negligent act amounting to
culpable homicide
examples of the criminal negligence :-
• Gross mismanagement of the delivery of a woman.
• Gross incompetent administration of a general anaesthesia
• Administration of a wrong medicine in to the eye causing loss
of vision.
• Amputation of wrong finger or operation on a wrong limb.
• Leaving instruments, tubes, sponges or swab in abdomen.
• Performing criminal abortion
• A single professional act by a physician may subject him
to both civil and criminal liability, eg, if a physician
performs an unauthorized operation on a patient, he
may be sued civilly for damages and prosecuted
criminally for assault.
• The doctor may have to pay damages in terms of
monetary fine as well as convicted for criminal
negligence with imprisonment with fine or with both.
postmortem examination
• • Lastly, another very important medicolegal duty
• of the doctors to examine the victim girl and the accused
person.
• • Every doctor who has permanent registration number of
State Medical Council is entitled to do this job.
• • Although, it is the job of service doctor, the private
practitioner may be asked to do this job during National
Emergency. Hence, here is some idea about it.
Casesformedicolegalpostmortemexamination
• All unnatural death cases.
• Sudden death, where cause of death is not known.
• All cases of death due to poisoning.
• Traffic accidents death cases.
• Death occurring during operation or under anaesthesia.
• Death occurring in prison, police custody, jail custody, asylum,
Borstal school, etc. Here, postmortem examination is to be
done under Video Photography as per directive of Human
Rights Commission.
• In case of dowry deaths. Here, postmortem examination is
preferably to be conducted at least by two doctors.
• Death certified as due to postoperative shock or
haemorrhage.
• • In exhumation(buried dead) cases. Before doing
medicolegal autopsy inquest is required from the police
authority or Magistrate
LEGALPROBLEMSFACEDBYTHEDOCTORS.
• • In the past, litigations were less because people were not
aware of their rights.
• In developed countries like U.S.A. , U.K., Canada etc., there is
Medical Law specially for medical profession.
• Unfortunately, there is less number of Medical Laws
• Medical Law does not mean doctor’s negligence. It includes
doctor-patient relationship, their duties and rights,Family
Planning etc. etc.
• • When a doctor is showing absence of reasonable degree of
care and skill in treating his patient, he may be charged with
Civil negligence.
• • When a doctor is showing gross lack of competency and
gross in attention, he may be charged with Criminal
negligence.
• So the doctors should possess some legal knowledge to
protect themselves from negligence.
SOMELAWSINRELATIONTOMEDICALPRACTICE
• Criminal Law.
• Civil Law.
• • Law of Contract
• • Law of Tort.
• Consumer Protection Act.
• MTA
• Medical Councils
• Human Rights Law
• Other Laws.
Criminal Law
• Laws related as criminal cases
• Like abortion, death by false drug and miss management
Civil law- two parts
• (A) LAW OF CONTRACT
• • Here, there is a specific contract between a patient and a doctor,
which may be ORAL, WRITTEN or IMPLIED one, under which the
doctor is supposed to treat the patient and the patient is liable to
pay the specific or reasonable fees to the doctor.
• In operative cases, usually the contract is between surgeon and
patient ONLY; and anaesthesists, cardiologists, paediatricians, and
other doctors may NOT be a party.
• They have an implied contract with the surgeon only. Hence the
surgeon may be vicariously liable for his negligence
LAWOFTORT.
• • Certain duties are imposed on every person in the society
irrespective of monetary consideration. Thus a doctor is also
having certain specific duties towards his patient, paying or
complimentary.
• • “ If a doctor commits an act, which other reasonable doctor
of his standard would not commit; or a doctor OMITS to do
something which other doctor would certainly do is a
NEGLIGENT ACT” . The doctor is liable for that under Law of
Tort.
CONSUMER PROTECTION ACT :
• •This act is most hot subject in the medical world today. This act is
enacted in 1986 as a part of an international agreement seeking to
provide for better protection to the interest of consumer and to
provide speedy and simple redressal to consumer’s disputes.
• The purpose of the act :-
• To protect the interest of the consumers of different commodities
for which they pay but do not get standard quality of service.
• • Example – daily commodities of use, Banking,
• Food Transport, Electricity supply et etc.
• • Procedure of lodging complaints :-
At anycentrementionbelowwith/withoutengaging
aLawyerandpayinganominalfees.
• At District level – District Consumer Dispute Redressal Forum -
to be chaired by a District Judge and two other members.
• Compensation towards damages upto Rs.20 lakhs
• At State level – State Consumer Dispute Redressal
Commission – chaired by a High court Judge and two other
members. Compensation above Rs.20 lakhs to 1 Crore.
• At National Level – National consumer Dispute Redressal
Commission – chaired by a Judge of Supreme Court and four
other members. Compensation more than Rs.1 Crore.
Apprehensions :-
• • Bad doctor-patient relationship.
• • Tendency for extensive laboratory investigation.
• • Tendency to make different Indemnity/Insurance policy for
paying compensation.
• • The treating Physician will charge more from the general
patients.
MEDICAL COUNCIL.
• • A patient can file a complaint with the respective council for
doctor’s negligence.
• Unfortunately the council has power to punish the doctor but
does not have the power to order compensation even if the
negligence is proved.
• • The punishment which can be given to the doctor by the
Medical Council/state Medical Council –
• • Issuing a warning notice.
• • Temporary erasure of name from Medical Registrar.
• • Permanent erasure of name from Medical Registrar.
OTHER LAWS :
• Drug Act,
• Nursing Act
• Health Act
• Organ donation Act
• Blood Transfusion Act
• etc.
• patient can file a complaint to the respective authority. Here
also they do not have power to order compensation
CONCLUSION :-
• • TO AVOID ALL THE MEDICOLEGAL PROBLEMS CERTAIN
PRECAUTIONS TO BE TAKEN :-
• • Keep full and accurate Medical Records.
• • Employ standard care and skill
• • Do not fail to get written informed consent.
• • Diagnosis to be confirmed by laboratory tests.
• • Proper investigation to be advised.
• • Proper immunization schedule to be followed.
• • Sensitivity tests to be done where applicable.
• • When diagnosis is obscure consult another
senior/specialists.
• • Do not criticize another practitioner.
• • To check the condition of the equipments frequently.
• • The drug to be identified with expiry date before
introduction.
• • The patient must not be abandoned.
• • No female patient should be examined without any female
attendant.
• • Anaesthesia should be given by a qualified person.
• • NEVER GUARANTEE A CURE.
PROTOCOLFORPOLICECASES& RAPE/SEXUAL
ASSAULT.
• • A patient when comes to ER/OPD of Govt. Hospital C/O any
injury/Accidental/Self-Infected/Homicidal/Poisoning/Sex
assault/Burn injury etc. proper reporting in papers supplied
from Police Dept. – the named as indoor Police cases/outdoor
police cases where history taken and other points are written.
• • The form should be properly filled up with signature of
patient/patient party and witness should be taken marks of
identification of patient should be noted.
• • The size of injury in which part of the body the injury is
present. Age of injury, type of weapon used should be noted.
• • If there are minor injury patient should be treated properly
at ER with advice to attend SOPD/OPD next morning and or to
attend ER in necessary.
• If patient is unconscious and unknown then
• Name of persons brought the patient should be noted with full
address and their signature should be taken.
• The valuable materials with the patient should be seized. These
should be properly packed labeled and handed over to Ward
Master with records kept in the ward.
Otherspecialpointswhichshouldbedoneintheward.
• After receiving the patient in the ward the doctor and Nurse
should note for –
• –Airway – if obstruction, proper management
• – Bleeding – if present, proper management
• – Cardiac – condition of the heart should be noted with
B.P./Pulse.
• • The weapon should be seized. It should be noted that
whether the patient come alone or with some persons.
• • If police personnel brought the patient then his name should
be written in the form.
What is Rape? Sexual Assault ?
• Define as “The carnal knowledge of a female forcibly and against her will.”
• Carnal knowledge is defined as penetration of genitalia no matter how slight by the penis
occurs while the female is sleeping ,unconscious or under the influence of alcohol or drugs.
• The old definition
• Many agencies interpreted this definition as excluding a long list of sex offenses that are
criminal in most jurisdictions, such as offenses involving oral or anal penetration, penetration
with objects, and rapes of males.
• The new Summary definition of Rape is:
• “Penetration, no matter how slight, of the vagina or anus with any body part or object, or
oral penetration by a sex organ of another person, without the consent of the victim.”
• A male who is sexually assaulted is sodomized. • Sodomy is oral or anal penetration.
Alert :-
• • The management of the sexual assault is important but
immediate physical health should be ensured first.
• primary and focused assessment done for alert for signs of
internal haemorrhage, shock or respiratory distress
• Trauma victim with physical assault, should be managed in
the order of established priorities.
• Most emergency department have commercially prepared
rape evidence collection kits as well as written protocols for
the treatment of injuries, legal documentation and sexually
transmitted disease and pregnancy prevention.
Interviewing the patient :-
• • Consent should be obtained for the examination of
collecting of swab/evidence for release of information to law
enforcement agencies.
• • Record history of event in the patient’s own words.
• • Ask the patient has bathed, gargled or brushed teeth
changed clothes or urinated defaecated since attack – may
alter interpretation of subsequent findings.
• • Examine rectum for signs of trauma, blood and semen
stains.
Interviewing the patient ….
• Record time of admission, time of examination, date and time
of sexual assault and the appearance of the patient.
• Document any evidence of trauma – dislocation, bruises,
laceration, secretion, torn and bloody clothing.
• Record emotional state.
• All collected samples & records to be enveloped by sealed.
Beforephysicalexamination
• Assist the patient to undress over a sheet large piece of paper
to obtain debris.
• Protect patient against sexually transmitted diseases such as
gonorrhoea, H.I.V. etc.
• Immediately obtained (positive swab taken in the immediate
post rate period will only reflect existing disease).
• Place each item of clothing in a separate paper bag
• Label bags appropriately : give to appropriate law
enforcement authorities and has to be sealed
PhysicalExamination.
• Examine the patient ( from head to toe) for injury especially to the head,
neck, breasts, thigh, back and buttocks.
• Assess for external evidence of trauma (bruises, laceration, stab
wounds).
• Inspect fingers for broken nails and tissue and foreign materials under
nails.
• Document evidence of trauma with body diagrams or photographs.
• Assist in conducting oral examination to determine secretion status of
patient compared with that of assailant.
• obtain a saliva specimen
• take prescribed cultures of gum and tooth areas.
Providing follow-upservices.
• • Make an appointment for follow up surveillance
• for pregnancy, sexually transmitted disease and HIV
counseling.
• • The patient should be accompanied by family member or
friend when leaving the health care facility.
• • Inform the patient for counseling services to prevent long
term psychological effects. Counseling services should be
made available to the family.
Obtaining Laboratory Specimen
• Collect vaginal aspiration which is examine for presence or
absence motile/non-motile sperm.
• Use sterile swab to draw from vaginal pool for acid
phosphatase, blood group, antigen of semen and precipitation
test against human sperm and blood.
• label all specimens with name of patient, date, time of
collection, body area from which specimen was obtained and
names of personnel collecting specimens to preserve chain of
evidence, give to designated person (crime laboratory) etc.
and obtain an itemized receipt.
Examinationof theVictim:
• It must be remembered that the police or court has no power
of compelling a women to show the private parts of her
person for examination of medical practitioner, male or
female.
Conclusion :
• • Rape has been described as :-
• • “ not an act of sex but an act of violence with sex as the
primary weapon”. It may lead to a wide variety of physical and
psychological reactions.

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Duty of doctors medico legal aspects

  • 2. Contents • Introduction • Obtaining consent, Different consenting age • suspected poisoning • criminal abortion • Civil and Criminal negligence • medicolegal postmortem
  • 3. • Legal problems faced related to medical practices • Civil law: Law of contract, Law of Tort,Consumer Protection Act,Medical Council,Other laws • Conclusion • Protocol for police cases & Rape/Sexual assault: • Introduction to Rape/Sexual assault • Interviewing the patient
  • 4. • Intervention: Preparing the patient for examination • Physical examination • Providing follow up services • Obtaining laboratory Specimen • Examination of the Victim • Preforma for examination of the accused in a rape case:  Medicolegal Certificate for Male  Medicolegal Certificate for Female
  • 5. Introduction What is Medicine ? What is ethics ? Medicine is about : “Can we?” Ethics is about: “Should we?” In a nutshell, “ethics” means doing what is right
  • 6. Why conflicts ? 1. Physicians and patients relation +Public Rules 2. High technologies 3. Heavy economic burden. 4. Ethical dilemmas i.e.;- Medicine-brain death - Organ transplantation - Euthanasia - Destroying frozen embryos - Refusal to fund marrow transplantsnew drugs - IVF - Abortions
  • 7. 5. many people value: • Honesty • Integrity • Freedom • Loyalty • Life • Friendship • Family • Timeliness • Hard-work • Truthfulness • Religion • Etc., etc., etc.
  • 8. Components of Medical Ethics • The Physician -- Patient Relationship • The Physician -- Physician Relationship • The relationship of the Physician to the System of Healthcare • The Relationship of the Physician to Society • The Relationship of the Physician to legal system
  • 9. • The Declaration of Geneva of the WMA binds the physician with the words, "The health of my patient will be my first consideration,“ • The International Code of Medical Ethics declares that "A physician shall act in the patient's best interest when providing medical care”
  • 10. Medical Negligence • A doctor must posses a reasonable degree of proficiency & apply the proficiency with a reasonable degree of diligence • Failure of the doctor to provide medical services (with requisite skill & care) gives rise to action in medical negligence under criminal, civil or consumer court
  • 11. Medical Negligence • A doctor is negligent if he doesn't offer his services in an emergency situation • But In Emergencies, CONSENT can be implied in the law if immediate treatment is necessary to avoid life- or limb-threatening condition • Clinical management should precede the legal duties in trauma cases brought for treatment • A doctor breaches his duty of care when he fails to reach the standard of proficiency expected of him
  • 12. Legal concept of Negligence • Human Behaviour towards others: failure to act reasonably & prudently • Failure or breach of duty owed to the patient doctor has the obligation to perform that duty in a manner that will bring it to a successful conclusion) • Damage to the individual for breach of duty (there must be some damage to the patient resulting from breach of duty owed)
  • 13. Medicalofficer/Medical practioner/physician Every registered medical practitioner /Officer has to perform some medico-legal duty during his/her duty. • Duty in Emergency • Duty in Ward • Duty in Surgical procedure
  • 14. Medico legal In the emergency room • very important medico-legal aspect • have to make injury report in all unnatural cases (fight, kill attempt,sucide,harm,abuse etc) • But if the patient is moribund, arrangement of treatment is to be made first. • Police case • If not admitted , only PC (police case) is done. • If admitted, IPC (indoor police case) is to be done. • In both the cases government prescribed form is available. • If the form is not available, it may be done in plain paper under seal and signature of the duty medical officer.
  • 15. • brief history of the case is necessary. • The injuries should be mentioned one by one with their position, approximate measurement and type of the injuries ie, abrasion, bruise, laceration injuries etc • Lastly, the provisional diagnosis of the case and the prognosis of the case are to be mentioned. • If he fails to discharge this duty he may be charged according to the law.and the punishment may be 3 months of imprisonment or fine upto Rs.500.00 or both( depends on the law by the each country)
  • 16. • during examination of the case a male/female attendant should be present for a male patient and a female for a female patient. • Otherwise the doctor may be charged with indecent assault and the punishment may be imprisonment with and/or fine
  • 17. Medical reports & certificates • Reports on the medical conditions of a person (victim or accused)folowing injury • Death certificate • Reports for Life-insurance • Certificate of illness • Certificate of fitness • All these documents must be prepared with meticulous accuracy
  • 18. Report Incidents requiring a report to the proper official relevant agencies while maintaining as much patient confidentiality as possible, include: • Drug & chemical poisoning • Road traffic accident • Gun-shot wounds • Physical assault
  • 19. Gunshot & Stab Wounds •Reports of these acts of violence are usually made to police
  • 20. Dead-on-Arrival • If the case of death is natural, death certificate & burying license must be submitted to relatives • Un-natural death: be reported to police for possible investigation & for assessment of need for a referral to forensic medicine sp. • Initiate resuscitation unless it is clear that patient has been dead for some time • Mention that deceased was brought dead • Body to be examined by a committee • In case there is no clear cause of death, take 50 ml blood in plain tube & send to Toxicology Centre
  • 21. Cause of Death • In case the results (from toxicology lab) are negative, the cause of death can be mentioned as “Death possible due to hidden disease leading to cardiopulmonary arrest” • All dead bodies should be kept for 2 hours before transferring to mortuary • Patient’s belongings should be handed over to relatives, if the cause of death is natural.
  • 22.
  • 23. Next in the ward, • the doctor is to examine the case very carefully and treat the patient with a reasonable degree of skill, care and knowledge to avoid charge of negligence. • BHT (bed head ticket) is to be maintained properly with care and skill. • The doctor should give proper and suitable prescription. He should mention the exact quantities and precise timing for taking medicines
  • 24. • Here, may have to make “dying Declaration”. It is a statement of a person, written or oral, whois dying as a result of some unlawful act. • The doctor is to assess that the patient is in good mental condition before the declaration is recorded. The declaration is made in question and answer form. • The declaration should be noted down in verbatim(exact word) or the patient in presence of two reasponsible witnesses. It should be signed by the doctor, the patient and the witnesses.
  • 25. doctorsinthe ward, Anotherimportantmedicolegal • is to help in the preparation of “Dying Deposition”. • It is the statement of a dying man, before a Magistrate and the accused or his Counsel, on Oath. • In a ward, it is a bed side court. • Here, the doctor has to certify the mental and physical fitness of the patient to make such a statement.
  • 26. in the operation theatre, • the doctor in charge of the operation should be very careful before going to operation proper. • He should note that all the formalities have been completed. • The written consent of the patient and the guardian should be taken before going for operation. • Before closing the operation, the swab count and the instrument count should be made so that none of them remains in the operation field.
  • 27. Types of Consent • Implied Consent: is provided by the behaviour of the patient; e.g. patient presents at Outpatient Clinic • Express Consent: Any thing other than implied consent. It may be oral or written • Informed Consent: consent must be obtained after a reasonable explanation of the proposed procedure to patient, so that he is enable to make informed decision whether or not to submit
  • 28. The Extension Doctrine • Provides an exception to the general rule that a patient’s consent is limited to those procedures contemplated when consent is given • If in the course of authorized medical intervention a doctor discovers a life-threatening condition that requires immediate treatment and the patient is unable to consent (e.g. under anesthesia), the doctor may extend the operation or procedure without the patient’s express consent
  • 29. • • If any one of them remains in side the operation area, the doctor may be charged with criminal negligence under “Res Ipsa Loquitur” which means “The thing speaks of itself”. • The doctor may be charged with criminal negligence causing the death of any person by doing rash and negligent act • The punishment is imprisonment with fine or with both. • In addition, administrative proceedings will start against the doctor and may be dismissed from the service and his name may be erased from the State Medical Council.
  • 30. Duty totake consent inmedicalpractice:- • Consent means voluntary agreement, compliance or permission when a patient is coming to a doctor for treatment, the consent is needed. • There is no need of taking written consent. But in some special cases written consent is required. • In criminal cases, the victim and the accused can not be examined without his/her written consent.
  • 31. • The court also can not compel a person to get medically examined against his/her will. • A) In case of rape, the victim should not be examined without her written consent. • B) In medicolegal cases of pregnancy, delivery and abortion, the woman should not be examined without her written consent. • But the convicted person can be examined without his/her consent by applying reasonable force
  • 32. Different consenting age: - • For medicolegal examination 12 years and above. • For sexual intercourse 16 years and above. • For operation to suffer any bodily harm 18 years and above. • A child under 12 years of age and an insane person can not give valid consent.
  • 33. Requirement of consent :- • • In various field of medical practice written consent is required. • Only some example are given here :- • For contraceptive sterilization written consent of both the husband and wife should be obtained. • • For artificial insemination written consent of both • the donor and the recipient side should be obtained. • • For medical termination of pregnancy the written consent should be obtained from the woman as well as from the guardian.
  • 34. For organ transplantation, • the organ of the dead person should not be removed without the • consent of the person having lawful possession of the body. • Pathological autopsy should not be conducted without the consent of the guardian or legal heirs of the deceased. • But for medicolegal autopsy no consent is required. Only inquest is sufficient to hold this autopsy. •
  • 35. In case of emergency, • no consent is required to save the life of the patient in good faith. If the doctor fails to follow these rules of consent, charged with professional negligence (malpractice) both civil and criminal negligence. • The punishment may be • issuing of warning notice for infamous conduct, • erasure of names civil negligence and • Charge of criminal negligence if dies after operation and if the consent has not been taken.
  • 36. Suspected Poisoning • But the doctor should confirm his suspicion before expressing an opinion. For this he must : • (a) Collect urine, vomit and faeces and submit for analysis. • (b) Carefully observe and record the symptoms in relation to food. • (c) Consult in strict confidence with senior practitioner. • (d) Either remove the patient to hospital or engage nurses of his confidence. • (e) Any suspected articles of good, excreta and stomach wash samples should be preserved. In case of homicidal poisoning, the doctor is duty bound to inform the police officer or the Magistrate.
  • 37. • • Non-compliance is punishable under Sec…. … if it is proved that the doctor did it with the intention of protecting the accused.. • Should explain to investigating police officer, he is bound to give all information regarding the case that has come to his notice. • If he hides the information, he is liable to be prosecuted . • if he gives false information, he is liable to be charged with the offence of giving false information under the law
  • 38. • A medical officer is required to report to police all the cases of suspected poisoning, whether accidental suicidal or homicidal in nature. • If a case of suspected poisoning dies, death certificate should not be issued but death declaration should be made and it should be communicated to the nearest police station.
  • 39. In a case of criminalabortion:- • • criminal abortion is the induced destruction and expulsion of the foetus from the womb of the mother unlawfully when there is no therapeutic indication for the operation. • • The doctor’s duty in this case is to guard all the informations obtained by him as a professional secrecy. He must urge the patient to make a statement about the induction of criminal miscarriage. • If she refuses to make a statement, he should not pursue the matter. He must treat her to the best of his ability. He must consult a professional colleague.
  • 40. • If the woman dies, he should not issue a death certificate, but should inform the police for making arrangement for postmortem examination. • whoever voluntarily causes criminal miscarriage is liable for imprisonment upto 3 years and or fine and if the woman is quick with the child the imprisonment may extended upto 7 years.(IPC) • In this case, both the person procuring the miscarriage and the woman are liable for punishment. If this case, both the person procuring the miscarriage and the woman are liable for punishment.
  • 41. TORT • Civil wrong (negligence) committed by one individual against another is known as TORT, where, a person fails to take proper care, so that damage results • Civil Law deals with legal actions which seek the redress of wrongs which are not criminal in nature • Criminal Law involves a legal action filed by a state government against defendants and deals with definitions of crimes and their punishment
  • 42. Negligence • Harmful conduct that deviates from accepted standards of duty & care • A doctor who injures a patient by conduct that fails to meet the legal standard of due care may be liable for negligence in an action for malpractice
  • 43. Specific elements of Negligence In order for a complaining party to sustain an action for negligence against a defending party, 4 elements must be proved in the court of law: • Existence of doctor-patient relationship giving rise to a duty of due care • Breach of that duty • Proximate cause (injury): Fall from a Stretcher in ED sustains bruises/MI after 4 months; is unlikely to rove that the fall caused MI • Damages
  • 44. The civil negligence • Civil negligence is absence of reasonable degree of care and skill or willful negligence of a medical practitioner, in the statement of patient leading bodily injury of death of the patient. • • question of civil negligence will come when patient is dead , and the relatives suit in a civil court for compensiation • Similarly the doctor can bring a civil suit for realization of his fees from the patient or his relatives who refused to pay the same on the ground of professional negligence.
  • 45. Examples of civil negligence • Loss of earning of the patient due to negligent act of the attending doctor. • Expenses incurred eg. Hospital expenses, special investigation, special diet, etc. • Reduction of expectation of life of the patient due to wrong treatment. • Reduced enjoyment of life of the patient. • Pain and suffering, either physical or mental. • Loss of potency • Death of the patient.
  • 46. • A doctor is not liable for an error of judgement or of diagnosis, if he has secured all necessary data in which to base a sound judgement. • Contributory negligence on the part of a patient is very good defence for negligence.
  • 47. Criminal negligence • • Criminal negligence occurs when the physician exhibits gross lack of competency, gross inattention, criminal indifference to the patient’s safety during the treatment • Negligence is so great as to go beyond matter of mere compensation • Not only the doctor has made wrong diagnosis and treatment, but he/she has shown gross neglect for life and safety of the patient • Doctor may be prosecuted for having caused injury or death of a patient by a rash & negligent act amounting to culpable homicide
  • 48. examples of the criminal negligence :- • Gross mismanagement of the delivery of a woman. • Gross incompetent administration of a general anaesthesia • Administration of a wrong medicine in to the eye causing loss of vision. • Amputation of wrong finger or operation on a wrong limb. • Leaving instruments, tubes, sponges or swab in abdomen. • Performing criminal abortion
  • 49. • A single professional act by a physician may subject him to both civil and criminal liability, eg, if a physician performs an unauthorized operation on a patient, he may be sued civilly for damages and prosecuted criminally for assault. • The doctor may have to pay damages in terms of monetary fine as well as convicted for criminal negligence with imprisonment with fine or with both.
  • 50. postmortem examination • • Lastly, another very important medicolegal duty • of the doctors to examine the victim girl and the accused person. • • Every doctor who has permanent registration number of State Medical Council is entitled to do this job. • • Although, it is the job of service doctor, the private practitioner may be asked to do this job during National Emergency. Hence, here is some idea about it.
  • 51. Casesformedicolegalpostmortemexamination • All unnatural death cases. • Sudden death, where cause of death is not known. • All cases of death due to poisoning. • Traffic accidents death cases. • Death occurring during operation or under anaesthesia. • Death occurring in prison, police custody, jail custody, asylum, Borstal school, etc. Here, postmortem examination is to be done under Video Photography as per directive of Human Rights Commission.
  • 52. • In case of dowry deaths. Here, postmortem examination is preferably to be conducted at least by two doctors. • Death certified as due to postoperative shock or haemorrhage. • • In exhumation(buried dead) cases. Before doing medicolegal autopsy inquest is required from the police authority or Magistrate
  • 53. LEGALPROBLEMSFACEDBYTHEDOCTORS. • • In the past, litigations were less because people were not aware of their rights. • In developed countries like U.S.A. , U.K., Canada etc., there is Medical Law specially for medical profession. • Unfortunately, there is less number of Medical Laws • Medical Law does not mean doctor’s negligence. It includes doctor-patient relationship, their duties and rights,Family Planning etc. etc.
  • 54. • • When a doctor is showing absence of reasonable degree of care and skill in treating his patient, he may be charged with Civil negligence. • • When a doctor is showing gross lack of competency and gross in attention, he may be charged with Criminal negligence. • So the doctors should possess some legal knowledge to protect themselves from negligence.
  • 55. SOMELAWSINRELATIONTOMEDICALPRACTICE • Criminal Law. • Civil Law. • • Law of Contract • • Law of Tort. • Consumer Protection Act. • MTA • Medical Councils • Human Rights Law • Other Laws.
  • 56. Criminal Law • Laws related as criminal cases • Like abortion, death by false drug and miss management
  • 57. Civil law- two parts • (A) LAW OF CONTRACT • • Here, there is a specific contract between a patient and a doctor, which may be ORAL, WRITTEN or IMPLIED one, under which the doctor is supposed to treat the patient and the patient is liable to pay the specific or reasonable fees to the doctor. • In operative cases, usually the contract is between surgeon and patient ONLY; and anaesthesists, cardiologists, paediatricians, and other doctors may NOT be a party. • They have an implied contract with the surgeon only. Hence the surgeon may be vicariously liable for his negligence
  • 58. LAWOFTORT. • • Certain duties are imposed on every person in the society irrespective of monetary consideration. Thus a doctor is also having certain specific duties towards his patient, paying or complimentary. • • “ If a doctor commits an act, which other reasonable doctor of his standard would not commit; or a doctor OMITS to do something which other doctor would certainly do is a NEGLIGENT ACT” . The doctor is liable for that under Law of Tort.
  • 59. CONSUMER PROTECTION ACT : • •This act is most hot subject in the medical world today. This act is enacted in 1986 as a part of an international agreement seeking to provide for better protection to the interest of consumer and to provide speedy and simple redressal to consumer’s disputes. • The purpose of the act :- • To protect the interest of the consumers of different commodities for which they pay but do not get standard quality of service. • • Example – daily commodities of use, Banking, • Food Transport, Electricity supply et etc. • • Procedure of lodging complaints :-
  • 60. At anycentrementionbelowwith/withoutengaging aLawyerandpayinganominalfees. • At District level – District Consumer Dispute Redressal Forum - to be chaired by a District Judge and two other members. • Compensation towards damages upto Rs.20 lakhs • At State level – State Consumer Dispute Redressal Commission – chaired by a High court Judge and two other members. Compensation above Rs.20 lakhs to 1 Crore. • At National Level – National consumer Dispute Redressal Commission – chaired by a Judge of Supreme Court and four other members. Compensation more than Rs.1 Crore.
  • 61. Apprehensions :- • • Bad doctor-patient relationship. • • Tendency for extensive laboratory investigation. • • Tendency to make different Indemnity/Insurance policy for paying compensation. • • The treating Physician will charge more from the general patients.
  • 62. MEDICAL COUNCIL. • • A patient can file a complaint with the respective council for doctor’s negligence. • Unfortunately the council has power to punish the doctor but does not have the power to order compensation even if the negligence is proved. • • The punishment which can be given to the doctor by the Medical Council/state Medical Council – • • Issuing a warning notice. • • Temporary erasure of name from Medical Registrar. • • Permanent erasure of name from Medical Registrar.
  • 63. OTHER LAWS : • Drug Act, • Nursing Act • Health Act • Organ donation Act • Blood Transfusion Act • etc. • patient can file a complaint to the respective authority. Here also they do not have power to order compensation
  • 64. CONCLUSION :- • • TO AVOID ALL THE MEDICOLEGAL PROBLEMS CERTAIN PRECAUTIONS TO BE TAKEN :- • • Keep full and accurate Medical Records. • • Employ standard care and skill • • Do not fail to get written informed consent. • • Diagnosis to be confirmed by laboratory tests. • • Proper investigation to be advised. • • Proper immunization schedule to be followed.
  • 65. • • Sensitivity tests to be done where applicable. • • When diagnosis is obscure consult another senior/specialists. • • Do not criticize another practitioner. • • To check the condition of the equipments frequently. • • The drug to be identified with expiry date before introduction. • • The patient must not be abandoned. • • No female patient should be examined without any female attendant. • • Anaesthesia should be given by a qualified person. • • NEVER GUARANTEE A CURE.
  • 66. PROTOCOLFORPOLICECASES& RAPE/SEXUAL ASSAULT. • • A patient when comes to ER/OPD of Govt. Hospital C/O any injury/Accidental/Self-Infected/Homicidal/Poisoning/Sex assault/Burn injury etc. proper reporting in papers supplied from Police Dept. – the named as indoor Police cases/outdoor police cases where history taken and other points are written. • • The form should be properly filled up with signature of patient/patient party and witness should be taken marks of identification of patient should be noted. • • The size of injury in which part of the body the injury is present. Age of injury, type of weapon used should be noted. • • If there are minor injury patient should be treated properly at ER with advice to attend SOPD/OPD next morning and or to attend ER in necessary.
  • 67. • If patient is unconscious and unknown then • Name of persons brought the patient should be noted with full address and their signature should be taken. • The valuable materials with the patient should be seized. These should be properly packed labeled and handed over to Ward Master with records kept in the ward.
  • 68. Otherspecialpointswhichshouldbedoneintheward. • After receiving the patient in the ward the doctor and Nurse should note for – • –Airway – if obstruction, proper management • – Bleeding – if present, proper management • – Cardiac – condition of the heart should be noted with B.P./Pulse. • • The weapon should be seized. It should be noted that whether the patient come alone or with some persons. • • If police personnel brought the patient then his name should be written in the form.
  • 69. What is Rape? Sexual Assault ? • Define as “The carnal knowledge of a female forcibly and against her will.” • Carnal knowledge is defined as penetration of genitalia no matter how slight by the penis occurs while the female is sleeping ,unconscious or under the influence of alcohol or drugs. • The old definition • Many agencies interpreted this definition as excluding a long list of sex offenses that are criminal in most jurisdictions, such as offenses involving oral or anal penetration, penetration with objects, and rapes of males. • The new Summary definition of Rape is: • “Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.” • A male who is sexually assaulted is sodomized. • Sodomy is oral or anal penetration.
  • 70. Alert :- • • The management of the sexual assault is important but immediate physical health should be ensured first. • primary and focused assessment done for alert for signs of internal haemorrhage, shock or respiratory distress • Trauma victim with physical assault, should be managed in the order of established priorities. • Most emergency department have commercially prepared rape evidence collection kits as well as written protocols for the treatment of injuries, legal documentation and sexually transmitted disease and pregnancy prevention.
  • 71. Interviewing the patient :- • • Consent should be obtained for the examination of collecting of swab/evidence for release of information to law enforcement agencies. • • Record history of event in the patient’s own words. • • Ask the patient has bathed, gargled or brushed teeth changed clothes or urinated defaecated since attack – may alter interpretation of subsequent findings. • • Examine rectum for signs of trauma, blood and semen stains.
  • 72. Interviewing the patient …. • Record time of admission, time of examination, date and time of sexual assault and the appearance of the patient. • Document any evidence of trauma – dislocation, bruises, laceration, secretion, torn and bloody clothing. • Record emotional state. • All collected samples & records to be enveloped by sealed.
  • 73. Beforephysicalexamination • Assist the patient to undress over a sheet large piece of paper to obtain debris. • Protect patient against sexually transmitted diseases such as gonorrhoea, H.I.V. etc. • Immediately obtained (positive swab taken in the immediate post rate period will only reflect existing disease). • Place each item of clothing in a separate paper bag • Label bags appropriately : give to appropriate law enforcement authorities and has to be sealed
  • 74. PhysicalExamination. • Examine the patient ( from head to toe) for injury especially to the head, neck, breasts, thigh, back and buttocks. • Assess for external evidence of trauma (bruises, laceration, stab wounds). • Inspect fingers for broken nails and tissue and foreign materials under nails. • Document evidence of trauma with body diagrams or photographs. • Assist in conducting oral examination to determine secretion status of patient compared with that of assailant. • obtain a saliva specimen • take prescribed cultures of gum and tooth areas.
  • 75. Providing follow-upservices. • • Make an appointment for follow up surveillance • for pregnancy, sexually transmitted disease and HIV counseling. • • The patient should be accompanied by family member or friend when leaving the health care facility. • • Inform the patient for counseling services to prevent long term psychological effects. Counseling services should be made available to the family.
  • 76. Obtaining Laboratory Specimen • Collect vaginal aspiration which is examine for presence or absence motile/non-motile sperm. • Use sterile swab to draw from vaginal pool for acid phosphatase, blood group, antigen of semen and precipitation test against human sperm and blood. • label all specimens with name of patient, date, time of collection, body area from which specimen was obtained and names of personnel collecting specimens to preserve chain of evidence, give to designated person (crime laboratory) etc. and obtain an itemized receipt.
  • 77. Examinationof theVictim: • It must be remembered that the police or court has no power of compelling a women to show the private parts of her person for examination of medical practitioner, male or female. Conclusion : • • Rape has been described as :- • • “ not an act of sex but an act of violence with sex as the primary weapon”. It may lead to a wide variety of physical and psychological reactions.