Transcript Slide 1

HUMAN RIGHTS
Medical humanities II
2012-2013
Prof. Marija Definis-Gojanović, MD, Ph.D.
Relevant Medical Ethics
Duties of the Health Professional
•
The ethical obligations of health professionals are
articulated at three levels:
a) in United Nations documents
b) in statements issued by international organizations
representing health professionals, such as the World
Medical Association, the World Psychiatric
Association and the International Council of Nurses
c) in codes of ethics issued by national medical
associations and nursing organizations
International standards
• the 1957 and 1977 United Nations Standard Minimum Rules for the
Treatment of Prisoners
• Council of Europe Standard Minimum Rules for the Treatment of
Prisoners (1973)
• the 1987 and 2006 European Prison Rules
• the United Nations 1990 Rules for the Protection of Juveniles
Deprived of their Liberty
• the 1985 United Nations Standard Minimum Rules for the
Administration of Juvenile Justice (“the Beijing Rules”);
• the 2010 United Nations Rules for the Treatment of Women
Prisoners (“the Bangkok Rules”)
UN Principles of Medical Ethics
• Adopted 1982, endorsed by American Psychiatric
and Psychological Associations
“It is a gross contravention of medical ethics, as well
as an offence against applicable international
instruments, for health personnel, particularly
physicians, to engage, actively or passively, in acts
which constitute participation in, complicity in,
incitement to, or attempts to commit torture.”
The Treatment of Prisoners and Detainees by Health
Professionals
• Detainees are entitled to same standard of health care
as general population
- includes informed consent
- no restraints unless clinician deems serious safety
risk
• The use of hoods during a medical evaluation is
absolutely unacceptable
• Neglecting detainees causes mistrust of doctors
Core Principle of Medical Ethics: Torture
“Physicians must oppose and must not
participate in torture for any reason.”
Ethical Codes of the World Medical Association
•
•
•
•
•
•
International Code of Medical Ethics
The Declaration of Geneva
The Helsinki declaration
The Declaration of Lisbon
The Declaration of Tokyo
The WMA Statement on Body Searches of
prisoners
• The Declaration of Malta
• The Declaration of Hamburg
National codes of medical ethics
• CODE OF MEDICAL ETHICS AND DEONTOLOGY,
Croatia, 2006
1. Fundamental Principles
2. Medical Doctors’ Duties to their Patients
3. Family Planning and Human Fertility
4. Dying Patients
5. Organ and Tissue Transplantation
6. Biomedical Research / Clinical Trials
7. Human Genome
8. Providing Health Care Services to Persons in Custody
9. Respect for Colleagues and Medical Profession
Principles common to all codes of health-care
ethics
• The duty to provide compassionate care
• Informed consent
• Confidentiality
Dual Obligations
• Primary duty to the patient and secondary duty to employer
and/or society
• Clinical independence is essential for both therapeutic care and
forensic documentation
• Complicity may result in criminal prosecution
• Forensic clinicians have a duty to the court and must inform
individuals of their role and any limits of confidentiality
• Consensus in international ethical precepts that legal and other
imperatives cannot oblige health professionals to act contrary to
medical ethics
Declaration of Geneva
• Forerunner of International Code
• More general, outlined a personal statement for
professionals:
• Health of my patient, first consideration
• No discrimination: age, disease, or disability, creed,
ethnic origin, gender, nationality, political affiliation,
race, sexual orientation or social standing
What are the Basic Principles of Medical
Ethics?
•
•
•
•
Autonomy
Justice
Beneficence
Non-maleficence
• Roles and duties of doctors during
extraordinary circumstances
• Local organizations must foster a
spirit of collaboration in the
response to a disaster.
• It is also the responsibility of each
agency involved in the emergency
to recognize that the primary
purpose of coordination is to
achieve maximum impact with the
given resources and to work with
one another to reach this endpoint.
Effects of disasters
Consequences of disasters on health services
􀂃 Disasters can cause serious damage to health facilities, water
supplies and sewage systems. Structural damage to facilities poses a
risk for both health care workers and patients.
􀂃 Limited road access makes it at least difficult for disaster victims to
reach health care centers.
􀂃Disrupted communication systems lead to a poor understanding of the
various receiving facilities’, military resources’ and relief
organizations' actual capacity. Consequently, the already limited
resources are not effectively utilized to meet the demands.
Consequences of disasters on health services
• Increased demands for medical attention:
􀂃 Climatic exposure because of rain or cold weather puts a particular
strain on the health system;
• 􀂃 Inadequacy of food and nutrition exposes the population to
malnutrition, particularly in the vulnerable groups such as children
and the elderly; and
• 􀂃 If there is a mass casualty incident, health systems can be quickly
overwhelmed and left unable to cope with the excessive demands.
Consequences of disasters on health services
• Population displacement:
􀂃 A mass exodus from the emergency site places additional stress and
demands on the host country, its population, facilities and health
services, particularly.
􀂃 Depending on the size of the population migration, the host facilities
may not be able to cope with the new burden, and
􀂃 Mass migration can introduce new diseases into the host community.
Consequences of disasters on health services
• Major outbreaks of communicable diseases:
􀂃 While natural disasters do not always lead to massive infectious
disease outbreaks, they do increase the risk of disease transmission.
The disruption of sanitation services and the failure to restore public
health programmes combined with the population density and
displacement, all culminate in an increased risk for disease
outbreaks.
􀂃 The incidence of endemic vector-borne diseases may increase due to
poor sanitation and the disruption of vector control activities.
Role of emergency health services in disasters
To minimize mortality and morbidity, it is also necessary to organize
the relief response according to three levels of preventive health
measures:
• Primary prevention is the ultimate goal of preventive health care. It
aims to prevent the transmission of disease to generally healthy
populations.
• Secondary prevention identifies and treats as early as possible
diseased people to prevent the infection from progressing to a more
serious complication or death.
• Tertiary prevention reduces permanent damage from disease such
as a patient being offered rehabilitative services to lower the effects
of paralysis due to polio or land mine injuries.
The role of the military in disaster response
The military’s hierarchical command structure allows it to respond to
disasters in a rapid and coordinated manner.
Military services generally have easy access to resources and are
equipped to perform vital functions in disaster response such as
resource distribution, security services, search and rescue, logistics
assistance, transportation to otherwise unreachable communities and
field hospital staffing and management.
If the political climate allows for collaboration, the host country’s
ministry of health and the lead health agency should consider
coordinating with the military in the response to a disaster as well as
in the disaster preparedness plan.
Disaster preparedness
• The health objectives of disaster preparedness are to:
􀂃 Prevent morbidity and mortality;
􀂃 Provide care for casualties;
􀂃 Manage adverse climatic and environmental conditions;
􀂃 Ensure restoration of normal health;
􀂃 Re-establish health services;
􀂃 Protect staff; and
􀂃 Protect public health and medical assets.
Policy development
• National governments must designate a branch of the ministry or
organization with the responsibility to develop, organize and manage
an emergency preparedness programme for the country.
• This group must work with central government, provincial and
community organizations and NGOs .
Vulnerability assessment
• Potential hazards for the community are identified and prioritized in
a vulnerability assessment.
• Once the vulnerabilities are identified, the assessment must also
recommend how to address each of the vulnerabilities.
Disaster planning
• A disaster’s outputs plan must provide:
􀂃 An understanding of organizational responsibilities in response and
recovery;
􀂃 Stronger emergency management networks;
􀂃 Improve community awareness and participation;
􀂃 Effective response and recovery strategies; and
􀂃 A simple and flexible written plan.
Training and education
• must provide the important skills and knowledge needed to
show an effected community how it can participate in
emergency management and also show it the appropriate and
critical actions needed in an emergency.
Monitoring and evaluation
• The objective is to measure how well the disaster
preparedness programme has been developed and is being
implemented.
• International Federation of Red Cross and Red Crescent
Societies - created preparedness and ‘press the button’
response systems with equipment ready for immediate use.
• Between disasters, the International Federation pays a lot of
attention to training volunteers in the community.
• During a disaster, the International Federation uses Regional
Disaster Response Teams (RDRT) and Field Assessment and
Coordination Teams (FACT).
Facility-based health care—key points
• All services should function effectively and be well
coordinated to achieve the following:
􀂃 Comprehensive care—looking for other conditions that a
patient may not report such as depression with persistent
headaches or abdominal pain (summarization);
􀂃 Continuity of care—following up referrals, defaulters of TB
treatment or immunization; and
􀂃 Integrated care—linking curative with preventive care at
every opportunity such as combining child immunization
with antenatal clinic days.
Mass Casualty Incident (MCI)
• is any event where the needs of a large number of victims
disrupt the normal capabilities of the local health service
• Requires:
1. the pre-establishment of basic guidelines and principles of
an Incident Command System (ICS),
2. triage and
3. patient flows according to the hospital’s plan
The incident command system
• is composed of five major components:
􀂃 Incident command;
􀂃 Operations;
􀂃 Planning;
􀂃 Logistics; and
􀂃 Finance
Triage
• In a disaster medical response, triage sorts and priorities
victims for medical attention according to the degree of
injury or illness and expectations for survival.
• Triage reduces the burden on health facilities.
• Triage categorization of patients is based on the following
criteria:
􀂃 The nature and life-threatening urgency
􀂃 The potential for survival
Triage classification system
􀂃 Immediate medical care;
􀂃 Delayed care;
􀂃 Non-urgent or minor; and
􀂃 Dead or ‘near dead.’
Medical response
• Fairness: This value requires that health care resources be
allocated fairly with a special concern that those most vulnerable
are treated fairly.
• Respect for Person: This value states that each person is a
unique individual and is to be valued despite gender, ethnicity,
age, religion, social status, economic value or any other variable.
• Solidarity: Each person makes a commitment not only to family
and loved ones but also to the community.
• Limiting Harm: Each physician and health care professional
commits to “do no harm.”
Medical response
• “Procedural Values” :
1. Reasonableness: treatment decisions are to be based on science,
evidence, practice, experience
2. Transparency/Openness: open to public discussion and scrutiny
3. Inclusiveness: any decisions are to be made explicitly with the
intent of including the views of health care workers and the public
4. Responsiveness: mechanisms to address comments,
recommendations, disputes and complaints
5. Responsibility: health care workers and the public have an
obligation to participate to the extent possible in discussions and
to offer their opinions and recommendations