The Pakistan Medical and Dental Council
Where the information in question is in the nature of a complaint by a person or body charging the practitioner with infamous conduct in any professional respect or professional negligence, such complaint shall be made in writing on a stamp paper attested by a magistrate addressed to the registrar, and shall contain that grounds of complaint and shall preferably be accompanied by one or more declarations of witnesses as to the facts of the case. Only the condition of magisterial attestation shall be exempted in case of a Government department. Complaint can also be sent through ethical committee of Pakistan Medical Association (PMA) and PM&DC Fax No:9266427

PART V
COMPLAINT AGAINST MEDICAL OR DENTAL PRACTITIONER AND ACTION THEREON.
  1. Whenever information is received that a registered practitioner has been guilty of any act or conduct, which prima facie constitutes of infamous conduct in any professional respect or professional negligence, the registrar shall make an abstract of such information and of such further information as he may have subsequently obtained.

  2. Where the information in question is in the nature of a complaint by a person or body charging the practitioner with infamous conduct in any professional respect or professional negligence, such complaint shall be made in writing on a stamp paper attested by a magistrate addressed to the registrar, and shall contain that grounds of complaint and shall preferably be accompanied by one or more declarations of witnesses as to the facts of the case. Only the condition of magisterial attestation shall be exempted in case of a Government department.

  3. Every declaration must state the description and true place of abode of the declarant and, where the fact stated in a declaration is not within the personal knowledge of the declarant, the source of the information and grounds for the belief of the declarant in its truth must be accurately and fully stated.

  4. (1) The abstract and all other documents bearing on the case together with all annexures in a paperbook form (ten in number ) with any complaint that may have been lodged shall be submitted to the registrar, who shall, if he thinks fit, ask the practitioner, by means of a registered letter, for an explanation within such time as may be fixed by him. After the expiry of that time, the documents with the explanation, if any, shall be referred for consideration to the Disciplinary Committee appointed by the Council to deal with fitness to practice issues and such complaints. The Disciplinary Committee shall have power to cause further investigations to be made and further evidence to be taken, and, if necessary, obtain further legal or other advice. If the Disciplinary Committee decides that the enquiry ought to be held to protect the interest of the public , the registrar shall issue a notice in writing to the practitioner and complainant concerned.
    (2) The notice under sub-regulation (1) shall-
              (i) annexe with it the complaint and the response from the respondant if any.
             (ii) appoint the day on which the Disciplinary Committee intends to deal with the case; and call upon the practitioner to appear before the Disciplinary Committee on the appointed day. Notice to medical or dental practitioner to attend proceedings in connection with the enquiry under Section 31 of the Ordinance shall be as below.
    Sir,
         On behalf of the Pakistan Medical and Dental Council, I give you notice that information and evidence have been received, by which the complainants have made charges against you as per the complaint annexed and that in relation thereto you have been alleged to have been guilty of infamous conduct in a professional respect.
        And I am directed further to give you notice that on the ---------------------of ---------------, a meeting of the Disciplinary committee of the Council will be held at ---------------
    O'clock in the --------------------------to consider the above-mentioned charges against you and decide whether or not they should direct that your name be removed from the Register/List of Registered Medical /Dental Practitioners pursuant to Section 31 of the Pakistan Medical and Dental Council Ordinance, 1962. You are invited and required to answer and appear before the Disciplinary committee of the Council in the above named place and time to establish any denial or defense that you may have to make to the above-mentioned charges, and you are hereby informed that if you do not attend as required, the Disciplinary committee may proceed to hear and to decide upon the said charges in your absence.
         Any answer or other communication or application which you may desire to make regarding the said charges or your defense thereto, must be addressed to the Registrar of the Pakistan Medical and Dental Council and transmitted so as to reach him no less that twelve days before the day appointed for the hearing of the case by the Disciplinary committee of the Council. You are required to be present on the date of hearing so communicated and if you choose to absent yourself, your name shall be removed from the Register of practitioners and you shall no longer remain eligible for the privileges of a registered practitioner.
        A coy of the Medical and Dental Council Ordinance, 1962 and of the Regulations to regulate the procedure for conducting enquiry referred to in the Ordinance is enclosed herewith for your information.
Registrar.

  1. The notice shall be sent at least twelve days before the date of the enquiry by the Disciplinary committee of the Council and shall be accompanied by a copy of the Ordinance and these regulations. A copy of the notice shall, at the same time, be sent to the complainant.
  2. The complainant, if any, and the practitioner charged shall, upon request in writing for that purpose signed by him or his legal representative, be entitled to be supplied by the registrar with a copy of any declaration, explanation answer or other document given or sent to the Disciplinary Committee by or on behalf of the other party. Both parties may bring in original, any proof to use at the hearing as evidence in support of, or in answer to, the charge specified in the notice of enquiry.
  3. Any application made by the practitioner between the date of issue of the notice and the day appointed for the hearing of the charge shall be dealt with by the Disciplinary Committee in such manner as it may think fit
  4. All material documents that are to be laid before the Disciplinary Committee as evidence in regard to the case shall be printed and a copy thereof shall be furnished to each member of the Disciplinary Committee before the hearing of the case.
  5. At the hearing of the case by the Disciplinary Committee, the complainant and the practitioner charged shall have to be present in person and can be assisted by a legal representative.
  6. The order of procedure at the inquiry shall be as follows:-
  7.      (a) The registrar will read to the Disciplinary Committee the notice of the inquiry addressed to the practitioner.
         (b) The complainant will then be invited to state his case himself or through his legal representative, and to produce his evidence in support of it. At the conclusion of the complainant's evidence, his case will be closed.
         (c) The practitioner will then be invited to state his case himself or through his legal representative and to produce his evidence in support of it. He may address the Disciplinary Committee only once either before or at the conclusion of his evidence.
         (d) At the conclusion of the practitioner's case, the Disciplinary Committee will, if the practitioner has produced evidence, hear the complainant in reply on the case generally, but will hear no further evidence, except in any special case in which the Disciplinary Committee may think it right to receive such further evidence. If the practitioner produces no evidence, the complainant will not be heard in reply, except by special leave of the Disciplinary Committee
         (e) Where any party produces a witness before the Disciplinary Committee, he will first be examined by the party producing him, and then cross-examined by the other party, and then re-examined, if so desired by the party producing him. The Disciplinary Committee may refuse to admit in evidence any declaration where the declarant is not present or declines to submit to cross-examination.
  8. Where there is no complainant, or no complainant appears, the order of procedure shall be as follows: -
  9.      (a) The Registrar will read to the Disciplinary Committee the notice of inquiry addressed to the practitioner and will state the facts of the case and produce before the Disciplinary Committee the evidence by which it is supported.
         (b) The Practitioner will then be invited to state his case himself or through his legal representative and to produce his evidence in support of it. He may address the Disciplinary Committee only once either before or at the conclusion of his evidence.
  10. (1) Upon the conclusion of the case, the Disciplinary Committee shall deliberate thereon in private, and the conclusion of the deliberation, the Chairman of the Disciplinary Committee shall call upon the Disciplinary Committee to vote on the question whether the practitioner charged is guilty of infamous conduct in any professional respect or professional negligence.
    (2) If the Disciplinary Committee by a majority of two-thirds of the members present and voting at the meeting, find the practitioner guilty of infamous conduct in any professional respect or professional negligence, the Disciplinary Committee shall recommend to the Council to remove his name from the appropriate register altogether or for a specified period or to warn or to censure him.
  11. When on the decision of the Council the name of any registered practitioner is removed from the register in accordance with the provisions of the preceding regulations, the registrar shall forthwith send notice of such removal of the practitioner by a registered letter addressed to the practitioner's last known address. The registrar shall also send, forthwith intimation of any such removal to the University, Licensing Body or concerned bodies from whom the said practitioner received his qualification or qualifications and shall request them not to admit him without previous reference to the Council to any examination for any new qualification, which is registerable in the registers. To give effect to the decision of the Council, the report of these proceedings and the decision shall be sent to the law enforcing authorities and all the medical regulatory authorities of the world having information-sharing scheme with the Council so that the practitioner can be stopped from practice in their areas of authority and vice versa.
  12. (1) Any person whose name has been removed from the register may apply to the Council for the restoration of the name, if he thinks that circumstances under which the name was removed from the register no longer remain and the period of punishment has passed.
  13.   (2) Every application under sub-regulation (1) shall be accompanied by:-
         (a) a declaration affirming that the applicant is the person whose name was originally registered;
         (b) a statement of the circumstances in which the name of the applicant had been removed from the register;
         (c) a statement giving the grounds on which the restoration of the name of the applicant to the register is sought; and
         (d) Any one or more of the following documents:-
              (i). applicant's degree/diploma.
              (ii). applicant's PM&DC Registration Certificate in original.
              (iii). a certificate from two medical or dental practitioners registered under the Ordinance as to his identity and
              (iv). copy of applicant's computerized national identity card.
  14. Where the Council is satisfied that the circumstances in which the name of a person was removed from the register no longer exist, and approves of the restoration of the name to the register, the registrar shall restore the name and inform the practitioner and the concerned authorities.

Code of Ethics for Medical and Dental Practitioners


Made in exercise of the powers conferred by Section 33 of Pakistan Medical & Dental Council Ordinance, 1962 and approved by the Council in its meeting held on 11th July, 1968 at Karachi, and revised by the Council in its 48th session held on 6thand 7thDecember 1974 at Lahore; and revised in its 97th session held on 29th and 30th December 2001 at Islamabad.

Code of Ethics  -  2001

Introduction

The Medical and Dental Council of Pakistan exists to maintain the register of Medical and Dental practitioners, regulate the standards of medical practice, protect the interests of the patients, supervise medical education, and give guidelines on ethical issues.

The medical profession is best regulated internally by the doctors themselves. With this privilege comes the responsibility, that doctors regulate their professional affairs through the Pakistan Medical and Dental Council, in the most effective way.

Both doctors and their patients have the right for making independent decisions. However, the code of ethics provides a set of principles prescribed by the Pakistan Medical and Dental Council, which doctors can use as guidelines in the varying situations, in line with their judgment, experience, knowledge and skills. Whilst the principles guiding medical practice rarely change, application of these principles to new situations will require frequent revision and publication.

This revised Code of Ethics have been prepared by the active participation of the honourable members of the Council. The assistance provided by Prof. Syed M. Awais and Prof. Jamsheer Talati during all stages of preparation of this document is highly appreciated.

The draft was approved by the Council in its 97th session held on 29th and 30th December 2001 at Islamabad, with the recommendation that draft will be circulated among the members of the Council and any recommendations received within one month will be included. Most of the recommendations received from the members have been incorporated in the draft. The final draft was approved by Executive Committee during its meeting on 15th August, 2002.

Prof. Muhammad Hayat Zafar

President,

Pakistan Medical and Dental Council
 
Contents   
 
1.0 Preamble
2.0 Jurisdiction of the Pakistan Medical and Dental Council
3.0 Purpose
4.0 Applicability
5.0 Oath of Medical and Dental Practitioners
6.0 Duties of Medical and Dental Practitioners
7.0 Medical Ethics in Islam
8.0 The Teaching of Medical Ethics
9.0 Expectations 
10.0 Fundamental Elements of Patient – Physician Relationship
11.0 Ethical Standards of Professional Competence, Care and Conduct.
12.0 Confidentiality
13.0 Conflict of interest
14.0 Truth Telling
15.0 Advertising
16.0 Certificates, Reports and other documents
17.0 Business and contractual obligations
18.0 Consent
19.0 Teaching Photography and Consent
20.0 Research Ethics and Consent
21.0 Organ Transplantation and Consent
22.0 Adoption
23.0 Resource Allocation
24.0 End-of-Life Care
25.0 Genetics in Medicine
26.0 Procedures for Review of the Code
27.0 Procedure for Enforcement of Code
28.0 Glossary.

 
The abbreviation; “RMDP” will be used to indicate Registered Medical and Dental Practitioner (s), throughout the document.
 
1.0-Preamble
 
History and legal framework
 
The Pakistan Medical and Dental Council (PMDC) Code of Ethics outlines the ethical principles and standards which determine the responsibilities and conduct of Medical and Dental professionals registered with the PMDC.

This Code of Ethics made in exercise of the powers conferred by Section 33 of Pakistan Medical & Dental Council Ordinance, 1962, is a revision of the code of ethics approved by the Council in its meeting held on 11th July, 1968 at Karachi, and subsequently revised by the Council in its 48th session held on 6th – 7th December 1974 at Lahore. This revision has been approved by the Council in the 97th session held on    29th and 30th December 2001 at Islamabad.
 
2.0- Jurisdiction of the Pakistan Medical and Dental Council (PMDC)
 
The Pakistan Medical and Dental Council was duly constituted under the Medical & Dental Council Ordinance No. XXXII, 1962, in June 1964 and is empowered to:
  1. Look after Public interest – by maintaining proper medical/dental standards.
  2. Supervise Medical/Dental Education in the country.
  3. Maintain a register of qualified doctors and dentists, qualifying from duly recognized institutions.
  4. Take such disciplinary actions, which may be required for criminal convictions or serious professional misconduct of a doctor. The Council is not an Association or a Union for protecting professional interests.
3.0-Purpose
  3.1   
The code is intended to provide guiding principles for use in every day practice for the Registered Medical and Dental Practitioners (RMDP) in their roles in regard to patients, students, community, colleagues, researchers and citizens (people).
  3.2  
The Code of Ethics is a public document which endeavours to educate its members and the public on professional ethics. It is intended for the welfare and protection of the individuals and societies with which the profession interacts.  It states the responsibility of professionals to society and individuals; and the rights of an individual. It serves public interest.
  3.3   
When a Registered Medical or Dental practitioner’s conduct or practice and consequently registration, are questioned, these are the principles and standards against which s/he will be judged.
   
The Code of Ethics provides general guidelines, and any disciplinary committee designated by the PMDC will judge each case on its merits.  This is not a comprehensive document and interpretation will depend upon circumstances.  The Registered Medical and Dental Practitioner will be given opportunity to justify their actions to a Disciplinary Committee.
 
4.0- Applicability
 
This Code is applicable to all registered Medical and Dental Practitioners.
 
5.0- Oath Of Medical And Dental Practitioners
 
Adapted from the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948; and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968; and the 35th World Medical Assembly, Venice, Italy, October 1983; and the 46th World Medical Association General Assembly, Stockholm, Sweden, September 1994. and the Islamic Medical Association Oath for Muslim Doctors.]

At the time of being admitted as a member of the medical profession:
I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets which are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;
My colleagues will be my sisters and brothers; and I will pay due respect and honour to them.
I will not permit considerations of age, disease or disability, creed, ethic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient;
I will protect human life in all stages and under all circumstances, doing my utmost to rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of Allah’s mercy, extending medical care to near and far, virtuous and sinner and friend and enemy.”
I make these promises solemnly, freely and upon my honour
 
 
Drawing on the Declaration of Geneva, the WMA formulated a more detailed code of ethics which was approved by the 3rd Assembly of the WMA meeting in London in 1949. The International Code of Medical Ethics was subsequently amended in 1968 by the 22nd Assembly of the WMA in Sydney and again in 1983 by the 35th Assembly held in Venice. The text, as amended, reads as follows:

Duties of Physicians in General

A physician shall always maintain the highest standards of professional conduct and should actively participated in continuous Medical Education .
A physician shall not permit motives of profit to influence the free and independent exercise of professional judgement on behalf of patients.
A physician shall, in all type of medical practice, be dedicated to providing competent medical services in full technical and moral independence, with compassion and respect for human dignity.
A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.
The following practices are deemed to be unethical conduct:
  1. Self advertising by physicians, unless permitted by the laws of the country and the Code of Ethics of the Pakistan Medical Association.
  2. Paying or receiving any fee or any other consideration solely to procure the referral of a patient or for prescribing or referring a patient to any source.
A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences.
A physician shall act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient.
A physician shall use great caution in divulging discoveries or new techniques or treatment through non-professional channels.
A physician shall certify only that which he has personally verified.

Duties of Physicians to the Sick

A physician shall always bear in mind the obligation of preserving human life.
A physician shall owe his patients complete loyalty and all the resources of his science.
When ever an examination or treatment is beyond the physician’s capacity he should summon another physician who has the necessary ability.
A physician shall preserve absolute confidentiality on all he knows about his patient even after the patient has died.
A physician shall give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.

Duties of Physicians to each other

A physician shall behave towards his colleagues as he would have them behave towards him.
A physician shall not entice patients from his colleagues.
A physician shall observe the principles of the “Declaration of Geneva” approved by the World Medical Association.
 

In Islam, human beings are the crown of creation and are Allah’s viceregents on earth. They are endowed with reason, choice and responsibilities, including stewardship of other creatures, the environment and their own health. Muslims are expected to be moderate and balanced in all matters, including health. Illness may be seen as a trial or even as a cleansing ordeal, but it is not viewed as a curse or punishment or an expression of Allah’s wrath. Hence, the patient is obliged to seek treatment and to avoid being fatalistic.

Islamic bioethics is intimately linked to the broad ethical teachings of the Holy Qur’an and the tradition of the Prophet Muhammad (Peace be upon him), and thus to the interpretation of Islamic law. Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, the material and spiritual realms and between ethics and jurisprudence. The Qur’an and the traditions of the Prophet Muhammad (Peace be upon him) have laid down detailed and specific ethical guidelines regarding various medical issues. The Qur’an itself has a surprising amount of an accurate detail regarding human embryological development, which informs discourse on the ethical and legal status of the embryo and fetus before birth.

Islamic bioethics emphasizes the importance of preventing illness, but when prevention fails, it provides guidance not only to the practicing physician but also to the patient. The physician understands the duty to strive to heal, acknowledging Allah as the ultimate healer. Islamic bioethics teaches that the patient must be treated with respect and compassion and that the physical, mental and spiritual dimensions of the illness experience be taken into account.

The main principles of the Hippocratic oath are, although acknowledged in Islamic bioethics, but the invocation of multiple gods in the original (Greek) version, and the exclusion of any god in later (Western) versions, have led Muslims to adopt the Oath of the Muslim Doctor, which invokes the name of Allah. It appears in the 1981 Islamic Code of Medical Ethics, which deals with many modern biomedical issues such as organ transplantation and assisted reproduction. In Islam, life is sacred: every moment of life has great value, even it is of poor quality. The saving of life is a duty, and the unwarranted taking of life a grave sin. The Qur’an affirms the reverence for human life in reference to a similar commandment given to other monotheistic peoples: “On that account We decreed for the Children of Israel that whosoever killed a human being… it shall be as if he had killed all humankind, and whosoever save the life of one, it shall be as if he saved the life of all humankind.” This passage legitimizes medical advances in saving human lives and justifies the prohibition against both suicide and euthanasia.

The Oath of the Muslims Doctor includes an undertaking “to protect human life in all stages and under all circumstances, doing [one’s] utmost to rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of Allah’s mercy, extending … medical care to near and far, virtuous and sinner and friend and enemy.”

Islamic bioethics is an extension of Shariah (Islamic Law), which is itself based on 2 foundations: the Qur’an, whose basic impulse is to release the greatest amount possible of the creative moral impulse and is itself “ a healing and a mercy to those who believe” and the Sunna (the aspects of Islamic Law based on the Prophet Muhammad’s (Peace be upon him) words of acts).

To respond to new medical technology, Islamic jurists, informed by technical experts, have regular conferences at which emerging issues are explored and consensus is sought. Thus, over the past few years, these conferences have dealt with such issues as organ transplantation, brain death, assisted conception, technology in the intensive care unit and even futuristic issues such as testicular and ovarian grafts.

If secular Western bioethics can be described as rights-based, with a strong emphasis on individual rights, Islamic bioethics is based on duties and obligations (e.g. to preserve life, seek treatment), although rights (of Allah, the community and the individual) do feature in bioethics, as does a call to virtue (Ihsan).  

 
8.0    The Teaching of Medical Ethics

The Curriculum Committee of the PMDC will ensure that adequate information on the Code of Ethics is included in the undergraduate medical college curriculum; and that case studies have been prepared and disseminated to provide guidance to practitioners.

  8.1
The goal of teaching medical ethics is to improve the quality of patient care by enhancing professional performance through a consideration of the clinician’s values, beliefs, knowledge of ethical and legal construct, ability to recognize and analyse ethical problems, and interpersonal and communication skills; and consideration of the patient. Students should be able to identify, analyse and should attempt to resolve common ethical problems of medical and clinical nature.
  8.2 
All medical and dental colleges running MBBS and BDS Courses, College of Physician and Surgeons of Pakistan and Universities running the Postgraduate Medical Courses in Pakistan are advised to incorporate medical ethics into their curriculum.
  8.3
Relevant books and journals should be made available in the central and departmental Libraries of the medical institutions, and publication of papers on issue related to medical ethics must be encouraged.
  8.4
The PMDC exhorts its members to develop strategies for dissemination of information about ethics and ethical issues to their colleagues and students, public and patients; and specifically when teaching medical students.
 
 
The PMDC expects each practitioner to:
 
  9.1
Ppromote the fundamental principle of responsibility of physicians to the right of individuals and societies to stated standards of professional competence, appropriate care, conduct  and integrity of Medical and Dental Practitioners;
  9.2 
Uphold the ethical principles of medical practice i.e. autonomy, beneficence, non-maleficience, and justice;
  9.3
Ensure the protection of individuals (patients) against harassment, discrimination and exploitation;
  9.4
Take their responsibilities as a teacher seriously.
  9.5
Be responsive to cultural and religious sensitivities; and
  9.6
Declare in a transparent manner, any potential conflict of interest.
  9.7
Inculcate these values in students, through instruction and role modeling.
  9.8
Promote the education of the public on (a) health issues and (b) their rights to quality care.
  9.9
Ensure continuation of practice only when in normal physical and mental health
  9.10
 Bring colleagues to comply with these generally accepted norms of practice and expose  physicians and dentists deficient in competence, care and conduct
 
 
Patients share with physicians the responsibility for their own health care.
 
  10.1
The patient has the right to receive information from physicians and to discuss the benefits, risks, costs of appropriate treatment alternatives, and optimal course of action. Patients are also entitled to obtain copies or summaries of their medical records, to have their questions answered, and to receive independent additional professional opinions.
  10.2 
The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients (or next of kin) may accept or refuse any recommended medical treatment in writing. 
  10.3
The patient has the right to courtesy, respect, dignity, and timely responsiveness to his or her “health needs”. 
  10.4
The patient has the right to confidentiality.  
  10.5
The patient has the right to continuity of health care. The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient.
 
 
  11.1
Conduct of Medical practitioner:

In all dealings with patients, it is expected that the interest of the patient and the advantage to the patient’s health will be the major consideration to influence the practitioners’ conduct (defined as character and behaviour as a citizen and professiona)  towards them.  The physician patient relationship should be developed as one of trust
    11.1.1 A Professional shall always maintain and demonstrate a high standard of professional conduct by:
  • Being in conformity with the principles of honesty and justice..
  • Not permitting motives of profit to influence (free and independent exercise of) professional judgment
  • Working with colleagues in ways that best serve patient’s interests.
  • Not paying or receiving any fee or any other consideration solely to procure the referral of a patient or for prescribing or referring a patient to any source.
  • Maintaining the honourable tradition by which the physician is regarded as a friend to all persons of any class, caste, colour, religion, sex, ethnicity, occupation, creed, religion and social status.
  • Being honest, factual, objective, unbiased as a reviewer for scientific material for publication; for funding purposes; and when providing reference, ensuring that comments are honest, justifiable, unbiased, and contain evidence on the subject’s competence, performance, reliability, and conduct, taking steps to ensure the accuracy of any public communications including the communication of degrees, institutional affiliation, extent of services offered, and credentials.
    11.1.2
The RMDP will not assist an unregistered person to practice / teach medicine or dentistry, or associate professionally with such a person performing the functions of a practitioner. which knowingly will make a registered practitioner liable to disciplinary action.  This does not preclude a medical practitioner from imparting proper training to medical students, nurses, midwives and other paramedical personnel, provided the doctors concerned keep a strict supervision over such individuals when treating patients.
    11.1.3
The RMDP will not knowingly make false, misleading or deceptive statements.
    11.1.4
The RMDP will deal honestly with colleagues, respecting their rights and privileges and that of other health professionals.
    11.1.5
Forgery, theft, fraud, indecent behavior or any other offence liable to be seen as moral turpitude is liable to disciplinary action.
    11.1.6
The RMDP shall use great caution in divulging discoveries or new techniques or treatment through non-professional channels.
    11.1.7
A physician shall owe his patients complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond the physician’s capacity he should consult another physician who has the necessary ability.
    11.1.8
Prisoners who are ill must be treated in the same manner as other sick people.  However, doctors have a right to take appropriate precautions if they think there is a possibility of physical violence by the patient.

Where a suspect refuses consent to a medical examination, the doctor unless directed to the contrary by a court of Law, should refuse to make any statement based on his observation of the suspect other than to advise the police whether or not the suspect appears to require immediate treatment or removal to hospital.

This does not of course, preclude the doctor from making a statement in Court based on such observation in circumstances where the accused later gives his consent to disclosure.

    11.1.9
Doctors should normally ask permission from a patient before making a physical examination.  In the case of minors, the child’s guardian should be present or give permission for the examination. For any intimate examination the patient irrespective of age, is entitled to ask for a attendant to be present.  Such requests should be acceded to whenever possible.
    11.1.10
Personal relationships:  Any form of sexual advance to a patient with whom there exists a professional relationship is professional misconduct.  A RMDP’s professional position must never be used to pursue a relationship of an emotional or sexual nature with a patient, the patient’s spouse, or a near relative of a patient. 
     
11.1.10.1
Sexual misconduct: Sexual contact with patient or patient’s spouses, partners, parents, guardians, or other individuals involved in the care of the patient is liable to lead to exclusion from the register.
    11.1.11
RMDP will ensure that they do not engage in harassment of any person, including employees, patients, students, research assistants and supervisees.  [The following constitute harassment: when single, multiple, or  persistent acts of abusive verbal language, demeaning speech, insult in front of juniors, sexual innuendoes, sexual solicitation, physical advance, throwing objects, and other threatening unacceptable gestures.].  Physicians should not use language that will interfere with the work of others.
    11.1.12
Abuse of professional knowledge, skills and privileges is unacceptable conduct:  Any registered medical/dental practitioner found guilty of causing an illegal abortion or prescribing drugs in violation of the Dangerous Drugs Act, or who becomes addicted to a drug, or is convicted of driving under the influence of alcohol or any other drug, is liable to be suspended or have his/her name removed from the Register.
    11.1.13
No RMDP should accept illegal gratification.
  11.2 Care:

The patient-physician or patient-dental practitioner relationship constitutes a fiduciary obligation, requiring physicians to be responsible to serve the interests of patients above their own financial or other interests.
    11.2.1
The practitioner is expected to provide a quality of care for a patient which is timely, compassionate and respects human privacy and dignity, is non-discriminating and does not exploit vulnerable situations. Gross negligence in respect of professional duties may justify suspension or removal from the Register.
    11.2.2
The RMDP will bear in mind the obligation of preserving life and will not discriminate on the basis of age, sex, gender, class, race, ethnicity, national origin, religion, sexual orientation, disability, health conditions, marital discord, domestic or parental status, criminal record, or any other applicable bias as proscribed by law, and ensure that personal beliefs do not prejudice patient care.
    11.2.3
The RMDP should not exploit persons over whom they have direct or indirect supervisory, evaluative, management  or other authority,  such as students and patients, supervisees, employees or research participants; whether for personal, professional or economic reasons.
    11.2.4
The RMDP should delegate to a student or other physician, only those responsibilities that such persons, based on their education, training and experience, can reasonably be expected to perform either independently or with the level of supervision provided.
    11.2.5 The RMDP shall additionally:
  • Identify themselves to patients whom they are treating
  • Treat all patients with dignity and respect,
  • Listen to patients and respect their views,
  • Give patients (and provided patient agrees, family members) information (about their illness) in a way that they can understand,
  • Respect the rights of patients to be involved fully in decisions about their care,
  • Ensure that conflict of interest does not prevent them from performing their professional work in an unbiased manner,
  • Adhere to veracity (truth telling) as judged in the patient’s interest.
    11.2.6
Details of Information:  Patients do not always fully understand the information and advice given to them by doctors.  They should be encouraged to ask questions. These should be answered carefully in non-technical terms if necessary with or without information leaflets.  The aim is to promote understanding and to encourage compliance with recommended therapy.  The doctor should keep a note of such explanation and it is felt that the patient still does not understand, it may be advisable to ask the patients permission to speak to a relative.
    11.2.7
Maternity care:  Registered medical practitioners who agree to undertake the antenatal and delivery care of a woman should clearly inform her, in advance, the arrangements for delivery.  In Pakistan, according to law a pregnancy can be terminated only if there lies a serious risk to the life of the pregnant women.
    11.2.8
Procedures:  Patients undergoing procedures or treatment of any sort have the right to be informed as to which doctor or doctors are to be involved.
    11.2.9
Fees:  Doctors fees should be appropriate to the service provided.  Patients are entitled to ask how much a doctor is going to charge.
    11.2.10
Second Opinion:  Patients are entitled to a second or further medical opinion about their illness. If requested, RMDP must either initiate or facilitate a request for this and provide the information necessary for satisfactory referral.
    11.2.11
Communication with Patients:  Many complaints to the council refer to lack of communication, or discourtesy, on the part of the doctor.  Where differences have arisen between the doctor and the patient or the patients relatives there is much to be gained and rarely anything to be lost by the expression of regret by the doctor.  Feeling that any such expression would amount o an admission of liability may have inhibited doctors. This is not necessarily so.
  11.3      Competence

The RMDP will attempt to maintain the highest levels of competence in their work more specifically the skill in diagnosing, clinical decision-making, planning, implementation, monitoring and evaluation of intervention and teaching; and will accept responsibility for their actions. 

They will therefore:

    11.3.1
Only undertake tasks for which they are qualified by virtue of education, training or experience; and know their limitations.
    11.3.2
Keep abreast of latest information about their subject through continuing education;
    11.3.3
Ensure that their approach to patient management is consistent with current research, literature and practice;
    11.3.4
Have an approach that favours competent clinical care through a careful assessment of the patient's problem, based on elicitation and analysis of the patient's history and physical examination; careful decisions on need for further investigation and request for additional consultation, appropriate management and prompt action where indicated, an approach that shuns internet prescribing or telephonic prescribing except when the physician is cognizant of the individuals past medical history
    11.3.5  
Acquire the knowledge and skills to provide proper training and supervision to their students so that such persons perform services responsibly, competently and ethically; and will be honest and objective in the assessment and certification of performance of students supervised;   
    11.3.6
Monitor and maintain an awareness of the quality of the care provided by himself/ herself through a review of carefully recorded data; and respond constructively to assessments by self and peers which identify need for further training or education;
    11.3.7  
Recognise the realistic efficacy of investigation and medication and use technology and medicine only where appropriate;
    11.3.8
Restrict prescription of drugs, appliances or treatments to only those that are beneficial to the patient.
    11.3.9
Treatment without direct patient contact.: Prescribing of medications by practitioners requires that the physician should demonstrate that a documented history and physical examination and drug reaction history are available; that there has been a sufficient dialogue between the patient and the doctor on options in management, and a review of the course of the illness and side effects of the drug.
    11.3.10
The PMDC accepts that in an emergency, during on call or cover call, or when in a partnership the case records are available, a physician may prescribe a new prescription without seeing the patient.
 
12.0-Confidentiality

The physician has a right to and should withhold disclosure of information received in a confidential context, whether this be from a patient, or as a result of being involved in the management of the patient, or review of a paper, except in certain specific circumstances where s/he may carefully and selectively disclose information where health, safety and life of other individual/s may be involved.
 
  12.1
The practitioner cannot seek to gain from information received in a confidential context (such as a paper sent for review) until that information is publicly available.
  12.2
There is no legal compulsion on a doctor to provide information concerning a criminal abortion, venereal disease, attempted suicide, or concealed birth regarding his patients to any other individual or organization.  When in doubt concerning matters, which have a legal implication, the practitioner may consult his/her legal adviser
  12.3
The professional medical record of a patient should not be handed over to any person without the consent of the patient or his/her legal representative.  Generally speaking, the state has no right to demand information from the doctor about his patient, save when some notification is required by statute such as in the case of communicable diseases. When in doubt, a legal advisor should be consulted.
  12.4
A presiding judge, may, despite the physician claiming the knowledge and communication is confidential overrule this contention and order or direct the witness to supply the required information.  The doctor has no option but to comply unless willing to accept imprisonment for contempt of court.
 
13.0-Conflicts of interest

A conflict of interest “is a set of conditions in which professional judgement concerning a primary interest tends to be unduly influenced by a secondary interest.” In the clinical context the primary obligation of physicians is to their patients, whereas in the research context scientific knowledge may be the primary interest. A secondary interest may be of a financial nature, but it may also consist of personal prestige or academic recognition and promotion. In research involving patients, the research interests, although often in concordance with patients’ interests, are secondary to clinical care and may conflict with it. A typical example of conflict of interest related to personal gain in physician self-referral. In above mentioned definition the reference to “a set of conditions” is important – having a conflict of interest is an objective situation and does not depend on underlying motives. Stating that someone has a conflict of interest does not imply a moral condemnation per se. It is the person’s action in the context of a particular situation or a lack of transparency that may be a cause for concern.
 
  13.1
The practitioner must act in patient’s best interests when making referrals and providing or arranging treatment or care.  No inducement, gift or hospitality which may affect or be seen to affect judgment may be accepted.  Neither will a practitioner offer such inducements to colleagues.
  13.2
Financial or commercial interests in organizations providing health care or in pharmaceutical or other biomedical companies, must not affect the way that patients are prescribed, treated or referred.
  13.3
Financial or commercial interest in an organization to which a patient is to be referred for treatment or investigation must be declared to the patient
  13.4
Before taking part in discussions about buying goods or services, any relevant financial or commercial interest which the practitioner or the practitioner’s family might have in the purchases, must be declared.
 
14.0-Truth Telling

In the practice of medicine, truth telling involves the provision of information not simply to enable patients to make informed choices about health care and other aspects of their lives but also to inform them about their situation. Patients may have an interest in medical information regardless of whether that information is required to make a decision about medical treatment.

The physicians should strive to create a “true impression” in the mind of the patient. Thus, truth telling requires that information be presented in such a way that it can be understood and applied. By contrast, deception involves intentionally leading another to adopt a belief that one holds to be untrue.

Patients should be told the truth because of the respect due to them as persons. Patients have a right to be told important information that physicians have about them.

 
15.0-Advertising
 
  15.1 
When publishing or broadcasting information the practitioner must not make claims about the quality of services nor compare services with those provided by colleagues.  Announcements must not, in any way, offer guarantees of cures, nor exploit patients’ vulnerability or lack of medical knowledge.
  15.2  
Published information about services must not put pressure on people to use a service, for example by arousing ill-founded fear for their future health.  Similarly, services must not be advertised by visiting or telephoning prospective patients, either in person or through a deputy
  15.3  
Practitioners may announce any change of address or hours of practice in the local press either once in three papers or three times in the same paper, on three consecutive days, and the announcement should be made in a normal manner and not unduly prominently as by big advertisements.
  15.4  
Nameplates may be fixed at the residence and on the premises where the medical/dental practitioner practices and at his residence.  The nameplate should not be ostentatious. 
 
16.0-Certificates, Reports and other documents

When RMDP are requested for certificates, medical reports birth or death certificates and any other documents, such documents should be factual to the best of their knowledge.  Due care should be taken in regard to stating the date on which the patient has been examined.

 
17.0-Business and contractual obligations

Physicians and dentists must ensure that they do not engage in any behaviour that negatively impacts directly or indirectly on patient care.  Business and contractual obligations must never interfere with clinical decisions or negatively impact on patient care in any way.  Physicians are discouraged from entering into business or other arrangements that include financial incentives; sharing of fees including refund based on successful outcomes and payments for referral of patients for laboratory investigations or other procedures except when a partnership is publicly known to exist.  

 
18.0-Consent

Consent is the “autonomous authorization of a medical intervention by individual patients.” Patients are entitled to make decisions about their medical care and have the right to be given all available information relevant to such decisions. Patients have the right to refuse treatment and to be given all available information relevant to the refusal.

Consent may be explicit or implied. Explicit consent can be given orally or in writing. Consent is implied when the patient indicates a willingness to undergo a certain procedure or treatment by his or her behaviour. For example, consent for venipuncture is implied by the action of rolling up one’s sleeve and presenting one’s arm. For treatments that entail risk or involve more than mild discomfort, it is expected that the physician will obtain explicit rather than implied consent.

Signed consent forms document but cannot replace the consent process. There are no fixed rules as to when a signed consent form is required. Some hospitals require that a consent form be signed by the patient for surgical procedures but not for certain equally risky interventions. If a signed consent form is not required, and the treatment carries risk, clinicians should seriously consider writing a note in the patient’s chart to document that the consent process has occurred.

When taking consent the physician should consider issues of adequate disclosure, the patients capacity, and the degree of voluntariness.

In the context of patient consent, “disclosure” refers to the provision of relevant information by the clinician and its comprehension by the patient. Disclosure should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment and how the  proposed treatment (and other options) might affect the patient’s employment, finances, family life and other personal concerns.

“Waiver” refers to a patient’s voluntary request to forego one or more elements of disclosure. For example, a patient may not wish to know about a serious prognosis (e.g., cancer) or about the risk of treatment.

“Capacity” refers to the patient’s ability to understand information relevant to a treatment decision and consequences of a complying or not complying with a treatment decision. A person may be “capable” ( have adequate capacity) with respect to one decision but not with respect to another. When any doubt exists,  a clinical capacity assessment by a third party may be required. In addition to assessing general cognitive ability, specific capacity assessment, determines the patient’s ability to appreciate information and implications of action.

Voluntariness” refers to a patient’s right to make health care choices free of any undue influence. However, a patient’s freedom to make choices can be compromised by internal factors such as pain and by external factors such as force, coercion and manipulation. In exceptional circumstances -- for example, involuntary admission to hospital -- patients may be denied their freedom of choice; in such circumstances the least restrictive means possible of managing the patient should always be preferred. Clinicians can minimize the impact of controlling factors on patients’ decisions by promoting awareness of available choices, inviting questions and ensuring that decisions are based on an adequate, unbiased disclosure of the relevant information.

Special circumstances affecting the consent process are listed below

 
  18.1    The Unconscious Patient

Consent may be implied or assumed on the grounds that if the patient were conscious they would consent to their life being saved.

  18.2     The Violent Patient

A doctor asked to examine a violent patient is under no obligation to put him/herself in danger but should attempt to persuade the person concerned to permit an assessment as to whether any therapy is required.

  18.3    The Mentally ill

The Mentally ill Of the doctor is in any doubt as to the patient’s capacity to consent it is advisable to seek specialist opinion as well as discussing the matter with parents, guardians, or relatives.

  18.4   The Mentally Handicapped

The Mentally Handicapped The doctor should attempt to obtain consent but, depending on the degree of handicap, may have to consult with the patient’s parents or guardians, and, in  particularly difficult cases to obtain a second opinion.

  18.5    Children

Children are entitled to considerate and careful medical care as are adults. If the doctor feels that a child will understand a proposed medical procedure, information or advice, this should be explained fully to the child. Where the consent of parents or guardians is normally required in respect of a child for whom they are responsible, due regard must be given to the wishes of the child. Also, the doctor must never assume that it is safe to ignore the parental/guardian interest.

 
19.0-Teaching Photography and Consent
 
  19.1   
Medical and dental students must identify themselves by name and must obtain permission from patients before examining them. It is advisable to limit the number of students examining any one patient.
  19.2    
The taking of photographs or videos for instructional purposes also requires permission. As far as possible these photographs and videos should be done in such a manner that a third party cannot identify the patient concerned. If the patient is identifiable, he or she should be informed about the security, storage, and eventual destruction of the record.
 
20.0-Research Ethics and Consent

When conducting medical research involving human subjects, investigators should remember their obligations with respect to  individual patients. Ethical conduct of research requires that a human subject must participate willingly, having been adequately informed about the research and given consent; that there is a favourable balance between the potential benefit and harm of participation; and that protection of vulnerable people is ensured.  The validity of findings must address questions of sufficient importance to justify any risks to participants. In any clinical trial there must be genuine uncertainty as to which treatment arm offers the most benefit, and placebo controls should not be used if equally effective standard therapies exist. When doubt exists, researchers should consult the existing literature and seek the advice of experts in research ethics.

 
  20.1  
All research projects involving human subjects, whether as individuals or communities, or the use of fetal material, embryos and tissues from the recently dead, should be reviewed and approved by an Ethical Review Committee of the institution before the study begins.
  20.2
It is essential that written consent be obtained if patients are to be involved in clinical trials. The aims and methods of the proposed research, together with any potential hazards or discomfort, should be explained to the patient.  The Consent document must be clearly written using non-technical language as to be understandable to subjects and use local language in addition wherever applicable.
  20.3
In situations where study subjects are too young or too incapacitated, as well as the mentally ill or unconscious person, consent to take part in research may be unobtainable. Research is best avoided unless it can be shown to be relevant and potentially beneficial to the patient and there is no objection from parents or relatives.
  20.4
Medical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person.
  20.5
The right of research subjects to safeguard their integrity must always be respected.  Every precaution should be taken to respect the privacy of the subject, and the confidentiality of the patient’s information.
   
20.5.1
Research results must always preserve patient anonymity unless permission has been given by the patient to use his or her name.
  20.6
Volunteers and patients may be paid for inconvenience and time spent, but such payment should not be so large as to be an inducement.
  20.7
Refusal to participate in research must not influence the care of a patient in any way.
  20.8
Declaration of Helsinki The PMDC supports the resolutions and draws attention to the Declaration of Helsinki adopted by the 18th World Medical Assembly and revised by the 48th World Medical Assembly.
 
21.0-Organ Transplantation and Consent
 
  21.1
A doctor involved in organ transplantation has duties towards both donors and   recipients.
  21.2
Prior to considering transplant from the dead donor, brain death should be diagnosed, using currently accepted criteria, by at least two independent and appropriately qualified clinicians, who are also independent of the transplant team. If family of the dead donor cannot take care of the funeral of donors body, then the transplant doctor involved in organ transplantation shall take car of transplantation and funeral.
  21.3
Living donors should be counseled as to the hazards and problems involved in the proposed procedures, preferably by an independent physician.
 
22.0-Adoption

Doctors should remember that in cases of proposed adoption there are several parties involved all of whom need continued support and counseling. Pregnant women who are considering giving up their babies for adoption should be helped to approach advisory bodies / attorneys as the circumstances may be.

23.0-Resource Allocation

All resource allocation decisions must be transparent and defensible. Questions of resource allocation are difficult and can pose practical and ethical dilemmas for clinicians. The unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit. To what extent the physician’s fiduciary duty toward a patient should supersede the interests of other patients and society as a whole is also a matter of controversy. However, the allocation of resources on the basis of clinically irrelevant factors such as religion or gender is prohibited. 

24.0-End-of-Life Care

End-of-life care requires control of pain and other symptoms, decisions on the use of life-sustaining treatment, and support of dying patients and their families.

 
  24.1
Futile treatment need neither be offered to patients nor be provided if demanded. A treatment is qualitatively futile if it “merely preserves permanent unconsciousness or fails to end total dependence on intensive medical care or when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of reported empiric date) that a medical treatment has been useless.
  24.2 The physician is not compelled to accede to demands by patients or their families for treatment thought to be inappropriate by health care providers.
 
25.0-Genetics in Medicine

Molecular genetics is concerned with the process by which the coding sequences of DNA are transcribed into proteins that control cell reproduction, specialization, maintenance and responses. Inherited or acquired biologic factors that result in an error in this molecular information processing can contribute to the development of a disease. Medical genetics involves the application of genetic knowledge and technology to specific clinical and epidemiologic concerns. Although many common diseases are suspected of having a genetic component, few are purely genetic in the sense that the genetic anomaly is adequate to give rise to the disease. In most cases, genetic risk factors must be augmented by other genetic or environmental factors for the disease to be expressed. Moreover, the detection of a genetic anomaly not help us to predict the severity with which the syndrome will expressed.

Certain ethical and legal responsibilities accompany the flood of genetic knowledge into the current practice of medicine. This is because of 3 general characteristics of genetic information: the implications of genetic information are simultaneously individual and familial; genetic information is often relevant to future disease; and genetic testing often identifies disorders for which there are not effective treatments or preventive measures.

26.0- Procedures for Review of the Code

The Code will be reviewed every five years by a committee set up by the PMDC.

27.0-Procedure for Enforcement of the Code

The PMDC may take disciplinary action (on the basis of recommendations of a disciplinary committee) against members who violate the code.

 
  27.1 Process for initiating complaints
    27.1.1 The Secretary will take note of complaints received from lay public or fellow-practitioners, mentioning the details of complainant.
    27.1.2
Process for addressing complaints:  Complaints will be examined and investigated by the standing Disciplinary Committee of the PMDC which will forward its recommendations to the Executive Council.  The Disciplinary Committee will investigate possible infractions, and will seek relevant information from persons and records, in order to reach a decision on whether the code has been violated. If disciplinary action is requested, the case will be referred to the Executive Committee.
    27.1.3
The Executive Committee will recommend to the Council prescriptive action in disciplining the member. The Executive Committee will review and endorse the Disciplinary Committee actions if it agrees, or ask for a further review of the case by another or the same or expanded Disciplinary Committee or disagree or modify the recommendations on the basis of available information. It will then pronounce the disciplinary decision.
    27.1.4 The Full Council will be informed of the decision in the next Full Council meeting. The PMDC ratifies the decision.
    27.1.5
The matter will be referred to the Court if needed.
    27.1.6  
Disciplinary action:  The disciplinary action may either be an admonition, a temporary suspension for a specified period or life long expulsion from membership of the PMDC.  The PMDC will when making the latter decision will consider whether it is in public interest to retain the name of the practitioner on the Register The PMDC expects that every member will report infringement of the code by a fellow member in the interest of patient. In minor infractions, it is expected that members will advise the individual on a one on one basis. If this fails to bring about corrective behaviour the matter should be brought to the attention of the PMDC.
  27.2
Constitution of the Disciplinary Committee The Disciplinary Committee should be constituted as per regulations for Registration of Medical & Dental practitioners.
  27.3
A claim of ignorance cannot be made as the PMDC regulations will be sent to every Registered Medical or Dental Practitioners and will be available on the website. 
  27.4
Publication The name of individuals, who have been expelled from the register of the PMDC, will be displayed in the PMDC Gazette and regional health authorities will be informed.
     
28.-Glossary
 

Competence

Ability and skill in diagnosing, clinical decision-making and management.

Care

The quality of interaction with a patient.

Conduct

Character and behavior as a citizen and professional

Veracity

Accuracy of statement

Fiduciary

Held or given in trust

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