Dr. Mahesh Baldwa,
M.D,D.C.H, FIAP
MBA, LL.B,LL.M , Ph. D(law)
SENIOR PEDIATRICIAN & MEDICOLEGAL ADVISOR
Formerly Assistant Professor of Pediatrics at T.N. Medical College and Nair Hospital, Mumbai-400008
Ex. Asst. Professor JJ Hosp, Grant medical college
Professor, paper setter & examiner of law to postgraduate students of University Department of Law, University of Mumbai
Baldwa Hospital, Sumer Nagar, S.V. Road, Borivali (West)Mumbai 400 092
Cell 09322990138
Medicine is about: “Can we?” Ethics is about: “Should we?”
Law is about “diligent care with caution”
Factual situation:
Pediatric intensivists in PICU work hard to support potential chance of living. Pediatric intensive care unit (PICU) has saved many lives yet death is every day affair in nicely working PICU. Sometimes life-support interventions only prolong dying process and escalate costs. Rarely patient party may grumble for two issues for their surviving patients after discharge from PICU. First one, being huge money bill and second one being some kind of physical disability due to disease process itself. Patient party initiates blame game to express their frustration. Doctors try hard to explain disability and reason for huge bill.
Frustration of patient party:
such surviving child when it grows up and taken to family functions and if people ask parents “what caused defect in your child” causes frustration in minds of parents. Now a day’s parents want only one child which should be normal. Hence, parents and relatives ask doctors often “Whether the child will be damaged if it is resuscitated and survives?” Often the concern of parents and relatives is not “whether resuscitation will be successful or not” but if child survives, “will that be severely damaged?”
Parents feel cheated and frustrated over survival of a child with defects after spending huge amount of money. Happiness of such a child surviving is short lived. Happy Emotions of patient party get muted. Enthusiasm to rear defective child not only gets damp but may surface as emotional irritation in patient party. Patient party prepares a list of allegations quoting negligence, misconduct, deficiency in medical service and unfair and deceptive trade practice. Some times may lead to litigation. Such a situation creates room for introspection and revaluation of medical, ethical, legal, economical and social issues in making such a child survive.
Major ills of PICU care:
Specialisation, super- specialization is causing depersonalisation of heath care in PICU, corporate world making commercial forays by investing in infrastructure of PICU to earn huge profits marginalizing ethical consideration of autonomy, beneficence, non misfeasance and justice to patient at large.
Changing expectations of patient party:
One can see changing expectations of better educated and better informed patient party putting across crucial medical and ethical questions to doctors. Consumer activism, civil rights, primacy of individual autonomy is limiting adventurous paternalistic attitude of medical fraternity. Lately more and more people are distrusting of medical technology failures putting patients to bear high cost of treatment without results in PICU’s. Patient party’s worst night mare could be medical errors causing death or disability. Intentions and motives are questioned even for evidence based practice of medicine. Patient party sometimes prefers peaceful dying process over prolonged, complicated and dehumanised dying in PICU or later on in life. This is creating medical, ethical and legal dilemma.
Practice of ethical principles in PICU
Autonomy means right of patients to make decisions about their medical care without their doctor trying to influence the decision. Pediatric intensivist should inform benefits and burdens of resuscitation. Pediatric intensivist should avoid invading parental authority. Pediatric intensivist should obtain a court order in absence of parental consent for any risky beneficence medical procedure or surgery.Doctor acts in best interest to maximise benefits and minimise harm. Every form of treatment in PICU should be free of Non-malfeasance which means it ought not to produce harm due to negligence and mmisconduct. Pediatric intensivist are obliged to practice ethical principles of Justice, which means, one should strive to provide minimum level of health care to all patients, regardless of ability to pay.
Legal/Ethical dilemma of resuscitation:
If pediatric intensivist does not initiate resuscitation in a critically ill child and such un-resuscitated child does not die, and survives. Child living in this manner may have worst outcome due to the consequences of hypoxic/ischaemic encephalopathy, irreversible coma, and multisystem organ injury, later Permanent vegetative state (PVS). No advanced care at a later stage can substitute for effective timely resuscitation and repair the damage due to delayed or incorrect procedures. If any dispute is raised by patient party later on pediatric intensivist may be charged of negligence/misconduct.
On the other side of scenario pediatric intensivist decides to start resuscitation and continues. This pediatric intensivist has immediate challenge of making child survive, but in long-term has to care and rehabilitate such a defective child for life.
Once begun, Withdrawing and Withholding difficult:
There are different views with respect to legal, ethical, moral, religious, social, economic and psychological barriers to withdrawinga treatment in progress and withholding it. Some medical persons and patient party have difficulty in stopping therapy once it has begun and makes situation prone to litigation.
Legal perils and solutions:
Sometimes patient party’s emotions running amok to squarely blame pediatric intensivist for morbidity of their child (under IPC section 337-338) worse for mortality (under IPC section 304A) by complaining to police. Some other times patient party may approach consumer courts (under Section 12) for such inevitable morbidity and mortality explained befittingly on the basis of medical science but failing pediatric intensivist on grounds of alleged violation of ethics, absence of consent, improper documentation and improper communication. Uncommon but not unknown and most scaring is mob violence. Therefore pediatric intensivist is advised to adhere to good doctor patient relationship, good communication with transparent documentation and obtain written informed consent.
