Response to the Irish Medical Council's consultation on Ethical Guidance

MPS believe that the 6th edition of the Guide to Ethical Conduct and Behaviour is a helpful document.  We welcome the opportunity to contribute to this consultation and feel that this offers a valuable opportunity to clarify specific issues in the Guide.

Specific Comments

Section B – Doctors and Patients

Paragraph 3.3 – Information for Patients
We are concerned that the use of the words "…and compliance with…" could be interpreted as implying that it is appropriate to subject a patient to pressure to accept a suggested treatment, rather than to ensure that the patient is in a position to make an informed choice.

Paragraph 3.8 – Physical Examination
With regards to minors, it would be helpful to clarify the appropriateness of examination in an emergency if it was in the patient’s best interests and if the parent or guardian was unavailable. 

Paragraph 3.9 – Intimate Examination
We believe that this section could be expanded upon, for example, to clarify the nature of the explanation to the patient and could also include advice with respect to a patient's withdrawal of consent.

We feel that the guidance could include advice that it would be helpful to document, for example, the identity of the chaperone or that an offer of a chaperone was declined.

Paragraph 3.10 – Communication with Patients
We feel that the guidance should make clear that an expression of regret and an explanation will often be of benefit, and that an apology is not an admission of liability.

Section C – Professional Responsibilities

It would be appropriate for this section to include some general advice for doctors who perform a management function, and also advice directed at those doctors who have responsibility for leading teams.

Paragraph 4.1 – Denigration of a Colleague
We feel that the first sentence of the guidance under this heading is open to misinterpretation.  A cross reference to paragraph 4.3 could clarify responsibilities where concerns about a colleague are raised.

Paragraph 4.3 – A Colleague’s Conduct and Competence
We feel that the guidance in this section could be expanded upon. This is because it may be inappropriate for a doctor to tackle a colleague directly due to the nature or seriousness of their concerns or because the doctor does not feel empowered to do so.  There should be systems in place to allow the reporting of concerns to be dealt with locally through a structured process, with the Medical Council reserved for cases where those processes fail or are unsuitable.

Paragraph 4.7 – References 
We feel that this section should also state that references should not be misleading.

Paragraph 4.10 – Medical Records
We feel that the guidance in this section could be expanded upon to clarify that notes should be clear, accurate and contemporaneous.  It would be helpful to include advice on how to act when a non-contemporaneous record might be contemplated.

We believe that it would be useful to have more detailed guidance on retention periods and disposal of records. 

It is important to note that many doctors in private practice hold their own records and it would therefore be helpful for guidance as to their responsibilities.

Paragraph 4.11 – CME and Competence Assurance
We believe that this section will require expansion to reflect the requirements of the Medical Practitioners Act.

Paragraph 4.12 – Healthcare Resources
We believe that the current guidance could be clarified to emphasise that a doctor’s first priority should be his patient.

Paragraph 4.13 – Drug Trials
The guidance in this paragraph should cross refer to the guidance contained in Section 4.14 which may apply equally to drug trials.

Paragraph 4.14 – Research
The guidance should be expanded to included circumstances where it may not be appropriate for a patient/participant to continue in a study.

Section 5 – Health Problems

We feel that the advice under this heading could be reorganised to give priority to the guidance under 5.4 – General Healthcare.  The recognition that doctors can themselves suffer ill health and how to deal with this is the springboard for the rest of the advice contained in this section.

Paragraph 5.1 – Alcohol and Drugs / 5.3 – Doctors with Communicable Diseases
The guidance should take into account that if a risk to patients or others arises, it is possible that this may be dealt with locally, however where local intervention fails there should be referral to the Medical Committee.

Paragraph 5.5 – Doctors’ Families
We recognise that it is often difficult to be objective when dealing with the healthcare of those close to you; doctors can also be put under pressure to go against their better judgement in these situations. 

We recommend that the council considers advice as to the appropriateness or otherwise of doctors registering their family members with them as patients.

Section D – Doctors in Practice

Paragraph 10.1 – Prescribing
Guidance on the use of unlicensed medication would be helpful in this section.

Paragraph 12.6 – Consultant Referral
It would be helpful to clarify the advice in this section because a requirement to refer at the insistence of a patient may not always be in the best interests of the patient, may be a waste of limited resources and may compromise a doctor’s clinical judgement. 

Section E – Confidentiality and Consent

Paragraph 16.3 – Exceptions to Confidentiality
The advice in this paragraph could be expanded to include:  

• consent should always be sought in the first incidence, where practicable;
• where consent is withheld but a disclosure is necessary/justified, the patient should be advised of the intention to disclose, where possible/practicable;
• any disclosure without consent should be kept to the minimum amount necessary.

Paragraph 16.8 – The Deceased Patient
We find that the current guidance is confined to the release of information for insurance purposes and this section could be expanded generally.

Paragraph 16.9 – Communicable Diseases
The guidance could be expanded to include the scenarios of:

• testing for communicable disease in the unconscious patient;
• managing an injury (eg, needlestick) to a healthcare worker.  

Paragraph 17.1 – Informed Consent
We feel that the guidance in this section is brief and would benefit from expansion – several subsections could be included, dealing with, inter alia:

• the types of consent,
• what is meant by informed consent,
• the provision of adequate information,
• capacity and its determination,
• decision making for those who lack capacity,
• consent in relation to children,
• advance directives.

Paragraph 20 – Research and Consent
We feel that the advice and guidance under these sections should be referred to in Section 4.14, which should provide a more detailed version.

Paragraph 21 – Organ Transplantation
We believe that this paragraph should also address potential commercial dealing in organs.