Professional Ethics

Doctor-Patient Relationship: The Legal And Ethical Expectations In The Medical Practice Of Nigeria

Ajang Precious Esq Author of the article

Abstract

“Medicine is an art which magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship”[1]In order to maintain this magical and creative ability, the relationship between physicians and their patients, must always be established within the confines of the law, medical ethics and upheld with a high sense of health-based purpose, as there are defined expectations for its existence.

Introduction

The relationship that exists between doctors and patients, forms the fulcrum of health care and medical practice: it is hinged on this that diagnoses are run, medical treatment options and procedures are explored, agreed upon, and administered, prescriptions are made and health-based advice given.

A doctor-patient relationship is formed when a doctor attends to a patient’s needs and is usually through consent.[2] In order to harness the benefits of this relationship, the need for effective communication built on trust and confidence becomes unavoidable; the patient is expected to express herself in relation to her medical attendant needs, and the Physician, is bound by the Hippocratic Oath to, with his knowledge and, or experience, to proffer medical solutions in line with good conscience. Although the patient is not bound by law and ethics like the Physician,[3] he is expected to maintain good communication with the Medical Practitioner(s) and conduct himself in the best way possible for his health’s sake. This relationship springs legal responsibilities and ethical expectations.

This article will examine the key obligations and expectations, consequences if breached, the best ways of strengthening and sustaining the relationship, the importance of it in providing medically acceptable standards of health care, as well as boundary crossing and violations in medical practice.

Key obligations and consequences

Treatment of patient:

The treatment of a patient is what even makes for the relationship between a Physician and his patient[4]. It is therefore expected that the patient must be given utmost care and attention; the physician responds to the patient in such a way, as to allow him or her to express all of the patient’s reasons for seeking care, including symptoms, feelings, thoughts and expectations.[5]  The Doctor is duty-bound to use his medical skills and experience in making sure the patient’s health is improved.

Patient Confidentiality:

Confidentiality is recognized by law as privileged communication between two parties in a professional relationship[6]. This relationship in health and medical practice imposes a duty that helps build trust and makes for smooth communication and information sharing required during the course of diagnosis, treatment, etc.[7]. It is therefore expected that test results, medical records during and after treatment, should be kept private[8] and protected.[9]

This obligation has its basis in the Hippocratic Oath, which serves as an ethical code of the Medical profession; hence Doctors, Nurses, or other clinical professionals are bound by the code. The law, however, creates circumstances where the information of the patient can be made public or given to certain individuals, bodies, agencies of government, etc. These circumstances include;

  1. when the health user of patient gives his consent,[10]
  2.  where there is a Court order or when there is a legislative requirement to that effect,[11]
  3. in the case of minor, with request of parent or guardian,[12]
  4. when guardian or representative of a patient who is incapable of giving consent, gives consent,[13]
  5. where the secrecy will lead to threat of public health[14] and
  6.  where it is in the interest of the patient.[15]

Informed Consent:

It is expected that the Physician, as a matter of ethics is not supposed to take decisions without the consent of the patient. It is a process of communication between you and your health care provider that often leads to agreement or permission for care, treatment, or services.[16] The decision that is being reached in the circumstance is termed shared decision. Every patient has the right to get information and ask questions before procedures and treatments are administered.[17]

Although argued by some scholars, it is safer and legally required for the Medical Practitioner to inform his patient about the options available, the risks and benefits associated, and the consequences of a particular treatment and, or procedure.[18] It is based on the understanding given by the doctor, that enables the patient to give an informed consent. The National Industrial Court in stressing the need for obtaining informed consent in medically related decisions in labour matters held inter alia thus:

“…any employment-based medical test must respect the human rights of the employee. HIV testing without the informed consent of the employee is a serious human right violation and undermines the dignity of the employee” (per I.G. NWENEKA)[19]

Any action in terms of treatment or procedure carried out without the consent of the patient or his guardian or legal representative as in cases of children or patients of unsound mind and, or body, will amount to a breach of the patient’s right to dignity of the human person.[20] The Physician is advised that in giving the necessary information to his patient, he should inform his patient or health user in the language he understands and, in a manner, which takes into account his literacy.[21] It is no room for the Doctor to unleash his medical jargon on the patient, who is more concerned about getting well.

Where a patient claims to have a sufficient understanding of the most appropriate treatment or procedure to be administered, the medical practitioner is obligated to investigate to know if the patient actually knows the risks and benefits, and possible consequences of his decision. It is apt to note, that when the decision taken by the patient is not viewed under the lens of a reasonable man or the compass of medically correct practices, the Medical Practitioner stands the risk of being tried for negligence.

Best ways of Strengthening and Sustaining the Relationship

A Physician who truly acts in the interest of his patient should do the following, to enable a smooth relationship.

  • Build good communication with the patient: For the relationship to thrive, the Physician is expected to know how to initiate conversations with his patient to help solve his medical problems, the best ways of communicating procedures, treatments, etc., to enable the patient give an informed consent. It is usually advised that the Medical Practitioner keeps his communication simple and basic and avoid unnecessary use of medical jargons.
  • Honesty:  Covering the severity of a case from a patient or his guardian offends the Ethics of Medicine. The Physician must, and in a suitable way possible, communicate the outcome of diagnosis ran, risks and benefits of treatments of procedures outlined for consent and also the possible consequences to the patient or his guardian. Also, a patient should be honest about answers given to questions asked by the physician and should not withhold pieces of information necessary for his treatment.[22]
  • Following health care plan: A patient is advised to follow his individualized health plan to get needed results. Health care plans may range from; monitoring blood sugar, getting regular exercise, drinking plenty of water to curb dehydration, etc.[23]
  • Friendliness and politeness: Some say a friendly nurse or doctor is most likely to get the job done, and I agree. As serious as health complications can be, a good Physician should know how to make his patient trust in him. Trust is not built on a stony face with an impolite approach, but a friendly disposition spiced with politeness; it is what makes the patient knows he is in safe hands.
  • Empathy and compassion: The physician during the course of the relationship with his patient, is enjoined to have empathy enough to understanding how the patient feels and compassionate in deploying his medical expertise in trying to solve the problem.
  • Upholding the code of ethics: No matter how compassionate a Physician may be, he is not expected to lose touch of his ethics; it is his guide in navigating in the arrangement. When the Physician operates without his ethics in mind, medical violations or malpractices creep in, and defeat the essence of the relationship and in most cases, deadly outcomes. Also, knowing when a patient deviates from the object of the relationship to something sinister or the Physician going beyond the expected extent of his practice with his patient, and drawing the line will help solve cases of boundary violations and other medical offences.
  • Making the patient comfortable: Treatment is no regimented activity. A patient must be made comfortable when he approaches the Physician for advice, diagnosis, treatment, et al. Shouting and instilling fear in the mind of the patient may have adverse therapeutic effect and sometimes worsen the situation. It is apt to mention that when it is established in evidence that a doctor’s ill treatment or maltreatment of his patient worsens the patient condition or causes death, the Medical Practitioner will stand the whips of the law.
  • Bring a companion to your appointment when necessary: A Patient is advised to come along with a friend or loved one especially when he finds it difficult retaining information. A minor who might have problems in communicating their health issues is always expected to come with his guardian or parent as the case may be.
  • Understanding and treating each case with seriousness: For the relationship to be beneficial to the patient, the doctor has to understand the nature of the case and treat it with all sense of seriousness.
  • Precautionary measures: Precautionary measures for the safety of both the Physician and his patient must be employed at all times.

Importance of the Relationship in providing Medically acceptable Standards of Health Care

  1. Effective physician-patient relationship makes for positive influence health outcomes by increasing patient satisfaction.[24]
  2. Makes for better understanding of health problems and treatments available.[25]
  3.  Contribute to better adherence to treatment plans.[26]
  4. Provides support and reassurance to patients.[27]
  5. Encourages collaboration among physicians and patients in order to create shared health goals and the cultivation of a health plan to address identified problems.
  6. Enables physicians know the patient health history, which fosters good treatment.

Boundary crossing and boundary violations in a doctor-patient relationship

During the pendency of the relationship, certain practices are likely to come in which may be beneficial or harmful to the patient. These practices are boundary crossing and boundary violations.

Boundary crossing: It is a departure from commonly accepted practices that could potentially benefit the patient. An example would be taking a walk with a depressed patient to help his mood, engaging physical contacts like a hug or handshakes. It is arguable that boundary-crossing if not checked, will lead to a slippery slope and consequently, boundary violation.[28]

Boundary violation: It is an unethical act or acts that are deleterious in a therapeutic relationship or harmful to the patient. This act is usually exploitative in nature.[29] It usually results in harm to the patient.[30]Examples of this are; establishing sexual relationships with patients, receiving inappropriate or unwanted touch, extorting money, all amount to boundary violation which offends the code of ethics of medical practice and in some cases, the law. The Medical Ethics Code provides that any registered practitioner who abuses his position by getting involved in adultery or indulging in any improper conduct will have his name erased from the Register of members.[31] On a whole, the Physician has an ethical obligation to draw the line when the red flags are up.

Conclusion The doctor-patient relationship can only be best appreciated when legal and ethical standards are strictly adhered to. The essence of the relationship is to ensure collaboration for health improvement and the mark should not be missed.


[1] Ha, J. F., & Longnecker, N. (2010). Doctor-patient communication: a review. The Ochsner Journal, 10(1), 38-43., 2002(1)

[2] Patient-Physician Relationships American Medical Association. Retrieved 5 December 2020.

[3] Dwolatzky, T., Dwolatzky, Clarfield, A. M., &Clarfield. (2006). Doctor-Patient Relationships. In R. Schulz, Encyclopedia of aging (4th ed.). Springer Publishing Company. Credo Reference: https://go.openathens.net/redirector/palmbeachstate.edu? url=https%3A%2Fsearch.credorefernce.com%2Fcontent%2Fentry2Fspencage%2Fdoctor_patient_relationships%2F0%3Finstitutionld%3D6086.

[4] ibid

[5] Rosof BM, Hernandez LM, Institute of Medicine (US) Committee on Identifying Effective Treatment for Gulf War Veterans’ Health Problems; National Academic Press (US), 2001.

[6] Brodnik, M., L. Rinehart-Thompson and R. Reynolds, (2012). Fundamentals of Law for Health Informatics and Information Management Professionals. Chicago: AHIMA Press. Chapter 1.

[7] Rule 44, Code of Medical Ethics, 2004.

[8] S.26, National Health Act, 2014.

[9] S.29(1) National Health Act, 2014.

[10] S.26(a) National Health Act, 2014.

[11] Ibid (b)

[12] Ibid (C)

[13] Ibid (d)

[14] Ibid (e)

[15] S.27, National Health Act, 2014.

[16] Rule 19, Code of Medical Ethics of Nigeria i.e. Rules of Professional Conduct for Medical & Dental Practitioners,2004.

[17] What is informed consent? American Cancer Society cancer.org I1.800.227.2345

[18] S. 23(1) (C)

[19] Adewunmi Akinola v. Ocean Marine Solutions Ltd. NICN/LA/410/2019

[20] ibid

[21] S.23(2) National Act, 2014.

[22] Bethany Nock, “How Physicians can build Patient Relationship”, gauber.com. Posted on March 16, 2017.

[23] ibid

[24]Tyler Johnson, “The importance of Physician-Patient Relationships Communication and Trust in Health Care” published by: Duke Center for Personalized Health Care, posted March 1, 2019.

[25] ibid

[26] ibid

[27] ibid

[28] Sabrina Benson, ‘Managing Boundaries and Multiple Relationships’, Corey, 8e, ©2011, Books/Cole Cengage Learning Chapter 7

[29] Chris Botterill, Boundary crossing vs boundary violations: is it about sex? Pages 26-29, Published on: An International Journal for Humanistic Psychology, Volume 33, 2005-issue 1.,21 January,2015.

[30] ibid

[31] Rule 48, Code of Ethics of Nigeria,2004.

ENDNOTES

  1. Adewunmi Akinola v. Ocean Marine Solutions Ltd. NICN/LA/410/2019
  • Dwolatzky, T., Dwolatzky, Clarfield, A. M., &Clarfield. (2006). Doctor-Patient Relationships. In R. Schulz, Encyclopedia of aging (4th ed.). Springer Publishing Company. Credo Reference: https://go.openathens.net/redirector/palmbeachstate.edu? url=https%3A%2Fsearch.credorefernce.com%2Fcontent%2Fentry2Fspencage%2Fdoctor_patient_relationships%2F0%3Finstitutionld%3D6086.
  • Rosof BM, Hernandez LM, Institute of Medicine (US) Committee on Identifying Effective Treatment for Gulf War Veterans’ Health Problems; National Academic Press (US), 2001.
  • Brodnik, M., L. Rinehart-Thompson and R. Reynolds, (2012). Fundamentals of Law for Health Informatics and Information Management Professionals. Chicago: AHIMA Press. Chapter 1.
  • Chris Botterill, Boundary crossing vs boundary violations: is it about sex? Pages 26-29, Published on: An International Journal for Humanistic Psychology, Volume 33, 2005-issue 1.,21 January,2015.
  • Code of Medical Ethics of Nigeria i.e. Rules of Professional Conduct for Medical & Dental Practitioners, 2004.
  • Ha, J. F., & Longnecker, N. (2010). Doctor-patient communication: a review. The Ochsner journal, 10(1), 38-43., 2002(1)
  • National Health Act, 2014.
  • Patient-Physician Relationships American Medical Association. Retrieved 5 December 2020.
  • Sabrina Benson, ‘Managing Boundaries and Multiple Relationships’, Corey, 8e, ©2011, Books/Cole Cengage Learning Chapter 7.
  •  Tyler Johnson, “The importance of Physician-Patient Relationships Communication and Trust in Health Care” published by: Duke Center for Personalized Health Care, posted March 1, 2019.
  • What is informed consent? American Cancer Society cancer.org I1.800.227.2345.
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About Ajang Precious Esq., LL. B, BL.

Experienced Associate with a demonstrated history of working in the law practice industry. Skilled in Literature, Law, Public Speaking, Creative Writing, and Poetry. Strong professional with a Bachelor of Laws - LLB focused in LAW from the University of Calabar.