1 UPJŠ Faculty of Medicine, Košice, SR

Department of Forensic Medicine

Medical Ethics
Lecture No. 3

The rights of patients.

Protection of children and persons
with mental illness.
The human as a source of social values.
Interferences to stimulate and to limit the
human reproduction.
2 The rights of patients
The history of patients’ rights began in 1948 from Universal Declaration of
Human Rights (UN Organization) ⇒ UNESCO Declaration 1997.
Main documents: 1. Declaration on the Promotion of Patients' Rights in
Europe (Amsterdam, 28-30 March 1994)
2. Convention of Human Rights and Biomedicine (Oviedo, 1997)
3. National documents of Patients’ Rights

Patients' rights vary in different countries and in different jurisdictions, often

depending upon prevailing cultural and social norms. Different models (at least four
models) of the patient–physician relationship exist all around the world:
• the paternalistic model – the interests of the patient’s treatment are valued
above the provision of medical information and decisions of the patient
• the informative model – the patient is a consumer of medical care, the doctor
is a provider of information
• the interpretive model – the physician clarifies the patient given medical
procedure including technical aspects, the patient comes to decision basing on
the patient–physician discussion.
• the deliberative model – the same as interpretive, but without patient–
physician discussion
3 The rights of patients

1. HUMAN RIGHTS AND VALUES IN HEALTH CARE

1.1. Everyone has the right to respect of his or her person as
a human being.
1.2. Everyone has the right to self-determination.
1.3. Everyone has the right to physical and mental integrity and to the
security of his or her person.
1.4. Everyone has the right to respect his or her privacy.
1.5. Everyone has the right to have his or her moral and cultural values
and religious and philosophical convictions respected.
1.6. Everyone has the right to such protection of health as is afforded
by appropriate measures for disease prevention and health care
and to the opportunity pursue his or her own highest attainable
level of health.

2. INFORMATION
2.1. Patients have the right to be fully informed about their health status.
4 The rights of patients
3. CONSENT
3.1. The informed consent of the patient is a prerequisite for any medical
intervention.
4. CONFIDENTIALITY AND PRIVACY
4.1. All information about a patient's health status, medical
condition, diagnosis, prognosis and treatment and all other
information of a personal kind must be kept confidential, even
after death.
5. CARE AND TREATMENT
5.1. Everyone has the right to receive such health care as is appropriate
to his or her health needs, including preventive care activities aimed
at health promotion
6. APPLICATION
• European Consultation on the Rights of Patients, Amsterdam –
Declaration on the Promotion of Patient's Rights, March 28 - 30, 1994
• Universal Declaration on the Human Genome and Human Rights,
UNESCO, November 11, 1997
5 Convention of Human Rights and Biomedicine (1997)
Convention for the Protection of Human Rights and Dignity of the
Human Being with regard to the Application of Biology and Medicine
(Oviedo, 4 April, 1997, Spain):
The interests and welfare of the human being shall prevail over the sole
interest of society or science.
Any intervention in the health field, including research, must be
carried out in accordance with relevant professional obligation and
standards.
An intervention in the health field may only be carried out after the
person concerned has given free and informed consent to it.
This person shall beforehand be given appropriate information as to the
purpose and nature of the intervention as well as on its consequences and
risks.
The person concerned may freely withdraw consent at any time.
Where a minor does not have the capacity to consent to an intervention,
the intervention may only be carried out with the authorisation of his or her
representative or an authority or a person or body provided for by law.
6 Convention of Human Rights and Biomedicine (1997)
Convention for the Protection of Human Rights and Dignity of the
Human Being with regard to the Application of Biology and Medicine
(Oviedo, 4 April, 1997, Spain) – continuation:
The opinion of the minor shall be taken into consideration
as an increasingly determining factor in proportion to his or her age
and degree of maturity.
When because of emergency situation the appropriate consent cannot
be obtained, any medically necessary intervention may be carried out
immediately for the benefit of the health of the individual concerned.
Everyone has the right to respect for private life in relation to
information about his or her health.
Everyone is entitled to know any information collected about his or her
health. However, the wishes of individuals not to be so informed shall be
observed.
Any form of discrimination against a person on grounds of his or her
genetic heritage is prohibited.
7 Convention of Human Rights and Biomedicine (1997)
Convention for the Protection of Human Rights and Dignity of the
Human Being with regard to the Application of Biology and Medicine
(Oviedo, 4 April, 1997, Spain) – continuation:
Tests which are predictive of genetic diseases or which serve either to
identify the subject as a carrier of a gene responsible for a disease or to
detect a genetic predisposition or susceptibility to a disease may be perfor-
med only for health purposes or for scientific research linked to health
purposes, and subject to appropriate genetic counselling.
An intervention seeking to modify the human genome may only be
undertaken for preventive, diagnostic or therapeutic purposes and only if its
aim is not to introduce any modification in the genome of any descendants.
Non-selection of sex (gender)
Protection of persons undergoing research
Protection of persons not able to consent to research
Research on embryos in vitro
Protection of persons not able to consent to organ removal
Prohibition of financial gain and disposal of a part of the human body
8 Protection of children
A child can expect…
• to receive treatment on the basis of clinical need,
• courtesy and respect for privacy and dignity,
• treatment in a children’s hospital, unit or ward that is right for their age
and medical condition, with play and education available,
• nursing care by appropriately trained children’s nurses,
• to be involved in discussions (if they are able to understand) and
consideration to be given to their wishes,
• an introduction to the staff caring for them,
• their operation to be carried out by, or under the supervision of,
a surgeon with appropriate training and experience in the care of
children,
• anaesthetic from an anaesthetist who is trained and experienced in the
care of children.
9 Protection of children
The parent or guardian of a child can expect…
• to be with the child during treatment and to stay overnight,
• to be given time to ask questions about child’s medical problems and
suggested treatment,
• to take part in all decisions about treatment and aftercare,
• to know the names, jobs and professional status of the staff involved in
child’s care,
• to be given a name and telephone number of the doctor for any questions,
• to be informed day or night of any worsening in child’s condition,
• to have all details about the child treated in confidence (except where
required by law),
• to complain if he is unhappy with the treatment,
• to be given an explanation and an apology, if things do not go as planned,
• to choose whether or not the child may be seen by medical students.
10 Responsibility of child and parent / guardian

• to treat all staff, other patients and families with courtesy and respect,
• to give the staff full information about your child’s condition and to let the
staff know if the child has any physical or learning disabilities, allergies,
sensitivities, conditions or changes in their health and of any medicines
taken,
• to tell staff if the child has been treated by other healthcare professionals
that might be relevant to present treatment,
• to tell staff if he does understand or are uncertain about any part of the
diagnosis or treatment,
• to follow the instructions on the care of the child before going into hospital
for an operation,
• to think about and be aware of what might happen if the child refuses the
recommended treatment or does not follow the doctors’ advice and
accept responsibility for those actions and the subsequent results.
11 Charter of rights of hospitalized children, UNICEF, 1988
1. Children should be admitted to a hospital only, if the required care cannot
be granted at home.
2. Children in hospital have the right to have their parents constantly with
their.
3. Accommodation ought to be offered to all parents without own financial
charge. The parents can participate on care.
4. Children and parents have the right to be informed. Undertakings for
diminishing the physical as well as emotional stress are inevitable.
5. The parents have the right to be informed about all decisions in health
care of their children. Each child should be protected from needless
treatment or research.
6. Children should be nursed together with children of similar stage of
development, not with adults
12 Charter of rights of hospitalized children, UNICEF, 1988
7. Children should have all conditions for games and relax as well as for
education suitable to their age in an appropriate and stimulating
environment.
8. The nursing staff should be educated and experienced in optimal
reactions to physical, emotional, and developmental requirements of
children and their families.
9. The hospital staff should ensure the continuity of health care.
10. Children have the right to respect their privacy and to tact and
understanding.
13 Protection of persons with mental illness

Early illustration of psychiatric treatment methods [by Serefeddin Sabuncuoglu (1385-1470)]

14 Protection of persons with mental illness
Mental (psychiatric) illness is a mental or behavioural pattern or anomaly
that causes distress or disability, and which is not developmentally or
socially normative. Mental illnesses are classified by a combination of how a
patient feels, thinks, perceives and acts. This may be associated with
particular regions or functions of the brain or rest of the nervous system, but
often in a social context.

Serious mental illness (SMI) is defined as:

All cases of schizophrenia,
Severe cases of major depression and bipolar disorder,
Severe cases of panic disorder, obsessive-compulsive disorder, and
post-traumatic stress disorder,
Severe cases of attention deficit/hyperactivity disorder,
Severe cases of anorexia nervosa.
15 Protection of persons with mental illness
1. Making Mental Health Services More Effective
Although many people receive the care they need, many others receive
care that is far from effective and cycle endlessly in and out of mental health
services that miss their mark. It is important to improve the nation's mental
health services.
2. Measuring Results
Regular use of standardized outcome measures would help transform
mental health services into an evidence-based practice and ensure that
people with mental illness can function productively in their home
communities.
3. Providing Parity in Coverage
Coverage and access to services for serious mental illness should be on
a par with coverage and service access for physical illnesses.
4. Establishing Safeguarded Outpatient Commitment (communities)
The hospitalized persons with mental illness could be given an opportunity
for early discharge on their agreement to remain in treatment in their home
community.
16 Protection of persons with mental illness
5. Requiring Parental Approval for Children's Treatment
Parents and local authorities do not always agree on how to respond to the
mental health needs of children and adolescents. Safeguarding of parental
rights towards children is needed.

6. Engaging Persons with Mental Illness into the Process of Health

Care
The patients in local community or institutions (clinics) during the treating
cycle might help and treat each other in dependence of their possibilities.
17 Mental Health Declaration of Human Rights by CCHR
www. cchr.org
President: Jan Eastgate (scientologist ???)
The Citizens Commission on Human Rights is a
nonprofit mental health watchdog, responsible for
helping to enact more than 150 laws protecting
individuals from abusive or coercive practices.
The Declaration was adopted
by the Citizens Commission on
Human Rights (CCHR)
1. No person shall be given
psychiatric or psychological
treatment against his or her will.
2. No person may be denied his
or her personal liberty by reason
of mental illness.
3. The mentally ill person has
a right to full informed consent.
4. No person shall be admitted to
a psychiatric institution because
of their political, religious or
cultural beliefs and practices.
5. Any patient has a right to freely
associate or not with any group
or person in a psychiatric
institution.
18 The human as a source of social values

• Social values guide the selection or evaluation of actions, policies,

people, and events. That is, values serve as standards or criteria.
• Social values are ordered by importance relative to one another.
People’s values form an ordered system of value priorities that
characterize them as individuals.
• Social values are a motivational construct. They refer to the desirable
goals people want (strive) to attain.
• Social values transcend specific actions and situations. They are
abstract goals.
• Social values are beliefs tied to emotion, not cold ideas.
(Shalom H. Schwartz, 2009)
19 The human as a source of social values
Ten basic social values by its central motivational goal:
1. Self-Direction. Independent thought and action; choosing, creating,
exploring.
2. Stimulation. Excitement, novelty, and challenge in life.
3. Hedonism. Pleasure and sensuous gratification for oneself.
4. Achievement. Personal success and ambition through demonstrating
competence according to social standards.
5. Power. Social status and prestige, control or dominance over people.
6. Security. Safety, harmony, and stability of self, society, relationships.
7. Conformity. Restraint of actions, inclinations, and impulses likely to
upset or harm others and violate social expectations or norms.
8. Tradition. Respect, commitment, and acceptance of the customs and
ideas that traditional culture or religion provide the self.
9. Benevolence. Preserving and enhancing the welfare of those with
whom one is in frequent personal contact.
10. Universalism. Understanding, appreciation, tolerance, and protection
for the welfare of all people and for nature.
20 The human as a source of social values
Theoretical model of relations among ten motivational types of values
(by Shalom H. Schwartz, 2009)
21 The human and social values – NHS (video)
22 Interferences to the human reproduction
Interferences to stimulate the human reproduction:
• Assisted reproduction
artificial insemination
in vitro fertilization
• Prenatal genetic screening

Interferences to limit the human reproduction:

• Abortion
• Sterilization
• Contraception
• Planned parenthood
23 Assisted reproduction
Artificial insemination
Many medico-legal and ethical problems have arisen because of the
development of methods of artificial initiating of pregnancy.
Artificial insemination is the production of pregnancy in a woman by
introducing seminal fluid directly into the cervix of uterus by means of
cannula.
There are two types of artificial insemination:
1. Artificial insemination by husband (AIH)
2. Artificial insemination by donor (AID).
While AIH has no legal or ethical problems, AID should be obtained from
a known donor who must be "unknown" the same time. If AIH has been
unsuccessful, the full written consent of AID from the man and woman (if
they are married) or from the woman (if without a partner). The donor must
not be relative, he should be over 18 years old and preferably have his own
children. Tests for absence of chronic diseases and familial abnormalities
should be carried out before donation.
Some religions (e.g. Roman Catholic Church) totally outlaw AID.
24 Assisted reproduction
In vitro fertilization
In vitro fertilization is a method which allows to fertilize in vitro ova
removed laparoscopically and to return them subsequentally to uterus. A
multiple ovulation caused by medicines has performed before the
fertilization.
There are following possibilities of such method:
• the woman's own ova to be fertilized by her husband's sperm and re-
introduced into her uterus
• the woman's own ova to be fertilized by a donor sperm and re-
introduced into her own uterus
• the woman's own ova to be fertilized by her husband’s sperm and
returned to another ("surrogate") woman's uterus
• the woman's own ova to be fertilized by donor sperm and returned to a
surrogate woman's uterus
• an infertile woman may have another woman's ova implanted to her,
fertilized either by her husband or by a male donor.
The problem of "sparing embryos" remaining after completing the
procedure is also a great medical, ethical and social problem.
25 Reproductive technologies
The in vitro embryo
has a complicated
ethical status
depended of its
viability.
26 Prenatal genetic screening
1. Screening tests show the chance that a developing baby (foetus) has
a certain genetic condition.
• If the test result is „positive“, it means that the foetus is more likely
to have that condition. So the doctor is indicated a diagnostic test
to make sure.
• If the test result is „negative“, it means that the foetus probably
doesn't have that genetic condition. But it doesn't guarantee that
the woman will have a normal pregnancy or baby.

2. Diagnostic tests show with sure, if the developing baby has a certain
genetic condition.
The diagnostic genetic testing (karyotype) can be used to examine the
size, shape, and number of chromosomes. Extra, missing, or abnormal
positions of chromosome pieces can cause problems with growth,
development, and body functions.

The prenatal genetic screening is ethically available and acceptable

27 Limiting the human reproduction
Abortion – premature expulsion of the foetus from the womb before
pregnancy reaches full term (40 weeks).

Two forms of abortion:

1) Miscarriage or spontaneous abortion: this happens naturally – up to
50% of conceptions end this way, usually in the first few months, often
without the mother knowing she was pregnant.
2) Procured (induced) abortion: deliberately ending the pregnancy; an
operation to remove the foetus from the womb.

Approximately 205 million pregnancies occur each year worldwide.

Over a third of pregnancies are unintended and about one-fifth end in
induced abortion. Most abortions result from unintended pregnancies.
There are about 42 million induced abortions per year
28 Limiting the human reproduction – abortions
29 Limiting the human reproduction – abortions, Europe
30 Limiting the human reproduction – sterilization
Sterilization – is a medical technique that intentionally leaves a person
(female or male) unable to reproduce. For other causes of sterility, see
infertility. Sterilization methods include both surgical and non-surgical.
Most female sterilizations occur in developing countries, while vasectomies
are mainly the product of industrialized countries.
Women mostly make up sterilization rates worldwide. Their motivations
behind the procedure vary depending on demographic factors. While
physical effects are the most commonly thought of, sterilization can also can
affect the psychical condition and family life of a person.
Ethical recommendations to sterilization (Am Col Obst Gyn, 2007):
Informed concent written only + time to change the mind!
The woman be interviewed without family members present.
Socialization training, sexual abuse avoidance training, family
therapy and sex education be considered as alternatives to
sterilization.
A reversible long-term form of contraception, such as the
intrauterine device (IUD) or other implants be considered as they
may be preferable to sterilization.
31 Limiting the human reproduction – contraception
Although there is increasing international recognition of a woman’s right to
control her fertility, including the prevention of unwanted pregnancies,
physicians still have to deal with difficult issues such as requests for
contraceptives from minors and explaining the risks of different methods of
contraception.

1. Hormonal contraception by combined contraceptives contain both an

estrogen and progestin, by progestogen-only contraceptives contain only
progesterone. Also marketed is ormeloxifene; while not a hormone,
ormeloxifene acts on the hormonal system to prevent pregnancy.
Risks: increasing of cholesterol, damaging of lipoproteine metabolism,
obesity, hepatopathy, tromboembolism.
The hormonal contraception as to its risks is ethically problematic but is
the most reliable (Pearl index 0,2 – 0,3).

PEARL INDEX – number of pregnancies to 100 women used the

contraception per year.
32 Limiting the human reproduction – contraception
2. Barrier (mechanical) contraception (withdrawal – coitus interruptus,
condome, vaginal and cervical pessaries, diaphragms, IUD [intrauterine
devices]) – can lead to inflammatory complications and even to perforation
of uterus – etically problematic. Mechanical barriers however are best
devices for AIDS prevention. The Pearl index is 3 – 10 for condome, 2 – 15
for pessaries,1 – 2 for IUD, 4 – 18 for coitus interruptus.

3. Chemical contraception – spermicides inserted into the vagina before

intercourse to prevent pregnancy – are ethically problematic. Can use in
combination with barrier methods. Note the toxicity a teratogenic effects of
most chemical contraceptives for the woman. The Pearl index for chemical
contraception is 2 – 10.
33 Planned parenthood
The new fan of planned parenthood – Michelle Obama – OBAMACARE

http://plannedparenthoodhealthinsurancefacts.org

Planned parenthood is a complex of contraception means including

calendary ovulation method. Ethically is the most acceptable.
34 Thanks for attention

What is the Value of Values?