MEDICAL ETHICS &

LAW

Prof. Dr. Dina Aly Shokry

2024-2025
FACULTY OF MEDICINE
MTI
 Table of content

1. Chapter 1………...……………...…… 1

2. Chapter 2 …………..……………….. 38

3. Chapter 3 ……………..…………….. 59
 Medical Ethics

Chapter (1)
Medical Ethics
Definition: Medical ethics deal with the moral principles
which should guide members of medical profession in their
dealings with one another, with their patients and with their
State.

The international codes of medical ethics.

• Declaration of Geneva in 1948 (WHO).
• Nuremberg Code (1950)
• Declaration of Helsinki (1964)
• Belmont report (1979).
These codes dictated the main ethical principles in patient care
which are:
1- Non maleficence (not to harm): This is the duty of the
physician to avoid inflicting physical or emotional harm on the
patient or increasing the risk of such harm.

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 Medical Ethics

2- Beneficence (to do good): This is the duty of the physician

to be of benefit to the patient as well as to prevent and to
remove harm from the patient.
Such harm can occur due to:
a. Negligence i.e., careless omission of what should be
done.
b. Lack of medical competence, i.e., committing something
wrong that should not have been done due to lack of
sufficient knowledge or skill.
These goals apply both to:
• Individual patients e.g., by curing their diseases
and promotion their health.
• The society or population at large, e.g., by
preventing diseases through research and
employment of vaccines.
3- Justice (to be fair):
Justice in health care is usually defined as fairness in the
distribution of medical services. Some goods and services
are in short supply, thus some fair means or criteria must be
determined for allocating limited resources (resource
allocation). For example, when available beds are limited, a
physician has to decide which patients have priority for
admission. This should be based on fair criteria, e.g.,
urgency of the condition, first comes first served … etc.
4- Respect for autonomy (free decision):
This means respecting the patients to make his autonomous
choice. The patient must indicate his approval and
willingness to accept proposed treatments.

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 Medical Ethics

This principle is the basis for the practice of “informed

consent” in the physician / patient transaction.

The core attitudes for ethics in the medical practice:

1. Honesty, integrity and trustworthiness.
2. Critical self-appraisal (including recognition of limitations
and errors)
3. Empathy and compassion
4. Respect for (the dignity of) patients as people
5. Respect for the roles of other healthcare professionals in the
care of the patient
6. Responsibilities of the medical professional towards the
local and global community
7. Responsibility and reliability
8. Commitment to clinical competence and lifelong education
The medical ethics are classified into 3 main categories:
1-The rules regulating the physician - patient relation-ship.
2-The rules regulating the physician - physician relationship.
3-The rules regulating the physician - society relationship.

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 Medical Ethics

I- Physician - patient relationship.

The doctor-patient relationship like any interhuman relation
is made of what can be said and what cannot, of words and
attitudes, but also of symptoms offered, accepted or refused,
but one thing is never modified “we and we only have the
right to unveil the other’s body, to invade the other’s mind, in
a word to home access to the other innermost privacy.
The creation of the relationship usually requires some form
of physical contact with the patient. A single telephone,
conversation, pathologists and radiologists may create it.
However, the doctor has a duty to the patient to exercise
reasonable and ordinary skill and care while rendering his
services, even though he had no personal contact with the
patient.
• Breakdown in communication between doctors and
patients lead to the combination of a bad outcome and
patient dissatisfaction that is a recipe for litigation.
When faced with a bad outcome, patients and their
families are more likely to sue a physician if they feel
that he was not caring and compassionate.
• Conversely, effective communication enhances patient
satisfaction and health outcomes.
• Proper withdrawal of the doctor –patient relationship is
accomplished when the patient is notified to have
enough time to find alternative care.
• When patients fail to follow a prescribed course of
treatment, it is permitted to the doctor to discharge him
after warning him so as not to be responsible for the
resultant complications.
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 Medical Ethics

Consent for examinations, treatment or operation:

Consent is a core ethical and legal principle in health
care. Its roots lie in the ethical principle of personal autonomy,
and it embraces the obligation of the health care professional to
respect the right of an individual to make health care decisions.
Any operation, physical examination or even a blood test
without permission or consent of the patient is considered an
assault. This rule is subject to exception in an emergency.
A consent form does not give the health care provider a
license to commit malpractice. It does not relieve the
healthcare provider from his or her duty of meeting the
standard of care associated with such treatment or procedure.
In informed consent the choice should be:
1- Intentional.
2- Free of undue or controlling outside influence.
3- Made with rational understanding.
4- The patient is not highly confused or cognitively
impaired.
Forms of consent:
1- Implied consent: Most of the medical practice conducted
under the principle of "implied consent", where the very
fact that a person has presented at doctor's clinic to be
examined, or asks the doctor to visit him, implies that he is
willing to undergo clinical examination.
Implied consent covers only basic clinical methods of
examination, such as history taking, observation, palpation
and auscultation, etc. It does not extend to intimate
examinations such as vaginal and rectal examination. Even

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 Medical Ethics

using the stethoscope on the chest or measuring the blood

pressure is usually preceded by some common courtesy of
speech, such as ‘do you mind taking off your shirt to listen
to your chest?’ which is an expressed consent.
Invasive examination such as venipuncture also necessitates
express consent.
2- Express consent: (oral or written)
Where complex medical procedures are concerned, more
specific permission (either, oral or written) must be obtained
from the patient or his guardian (if lacking decisional capacity)
after explaining what is to be done and why in terms which the
person can understand, this being called "express consent".
Express consent may often be obtained in writing, but this is
not a legal requirement and a written consent is not more valid
than verbal one. However, written consent is much easier to
prove at a later date. Ideally, oral or written consent should be
witnessed by another person (doctor's secretary or assistant, a
nurse etc.), who should also sign any document. Written
consent is necessary and should not omitted in surgical
operations, invasive diagnostic procedures, termination of
pregnancy, examination of persons in custody, at the request of
the police. A written consent must be informative including
the information necessary about the nature of the procedure
and the expected side-effects or hazards.
It must be remembered that
• Examination of a patient without his consent legally
amounts to a trespass or an assault
• The implied consent cannot be taken for granted.

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 Medical Ethics

• In any procedure affecting the rights of a spouse, e.g.,

sterilization, hysterectomy, artificial insemination, etc.,
informed consent from such spouse should also be
obtained.
• An accused can be examined by a medical practitioner at
the request of the police, even without his consent, and by
use of force, if there is reasonable ground for believing that
such examination will afford evidence, as to the
commission of an offence. The examination may include
taking of fluids in cases of intoxication. Whenever a female
is to be examined, the examination should be made only by
or under the supervision of a female registered medical
practitioner.
• All informed consent rules recognize the so-called
therapeutic exceptions e.g., the apprehensive or neurotic
patients who may be harmed by such full disclosure (either
in discarding a needed procedure with minimal risk or else
in suffering psychological harm from such disclosure or
thus becoming an increased surgical risk). In such instances,
it is advisable for the doctor to obtain informed consent
from a responsible relation, or in his absence, to obtain
medical consultation and chart the intentional omission and
the therapeutic exception-basis.
• In regard to what to tell the patient, the following
guidelines are helpful:
o “If the risk of untoward result is statistically high,
the patient should be informed regardless of the effect
on his morale. If the risk is statistically low, but the
consequences of a rare untoward occurrence may be

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 Medical Ethics

severe, the patient should likewise be informed. On

the other hand, if the statistical risk is low or the
severity of the risk is not great, the physician may
safely tailor his warning so as not to excite the
patient’s fears”.
o While some doctors make an honest effort to warn
patients about risks, they fail to disclose known
adverse effects. It is easy to assume the patient
realizes that surgery requires incisions and that
incisions lead to scars. Every facial plastic surgeon
has, nevertheless, explained to a skeptical patient that
no surgery can be performed without leaving scars
and that plastic surgery is the technique of
minimizing visible scarring. Some patients just refuse
to believe it.
o Risks that may be trivial but common and risks that
may be severe must be disclosed. A risk that is severe
but rare is the risk of death. It seems reasonable that
risk of death be disclosed in all cases. Many doctors
object to such disclosure, stating that everyone knows
that the risk of death is present. They emphasize that
the risk may interfere with the patient rapport, healing
and recovery.
o Not everyone knows that tonsillectomy may result in
death. Once informed, some patients or parents
decide to forego tonsillectomy. For them, even the
smallest risk of death is sufficient grounds to delay or
avoid elective surgery. Others proceed with surgery
acknowledging the risk.

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 Medical Ethics

• A patient warned preoperatively that the care is likely to be

permanently numb after parotidectomy may be intensely
unhappy, but will not sue as a result of the numbness.
However, if the patient is informed after surgery that the
numbness was expected and is normal, he may well react
with disbelief and a conviction that such an explanation is
offered merely as an attempt to avoid malpractice litigation.
The simple solution to this is to disclose everything
Validity of consent
To be legally valid, the consent must be informed and
intelligent, that is, the consent must be given after
understanding what it is given for and of the risks involved,
because every human being of adult years and sound mind has
a right to determine what shall be done with his own body. And
accordingly, it is imperative for the doctor to give reasonable
information to his patient about:
1. Nature of the disease and the proposed treatment or
surgery.
2. Chances of success based on medical knowledge.
3. Risks of proposed treatment or procedure.
4. Adverse effects of the proposed treatment or procedure.
5. Reasonable alternatives and their chances of success, risks
and adverse effects.
6. Consequences of deciding not to proceed with the
recommended course of treatment.
Informed refusal or discharge on request:
In case the consent is refused, the doctor should obtain an
informed refusal from the patient. Failure to inform the risks of
declining treatment renders the doctor liable to the same extent

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 Medical Ethics

as failing to disclose the risks of performing the treatment. The

patient must know the risks of leaving the disease or condition
untreated, otherwise, a truly informed decision in which the
patient can balance the risks and benefits within the patient’s
own psychological framework has not been reached.
Non-validity of blanket consent
A female patient entered the hospital for an
appendectomy; the surgeon removed the appendix and then,
while she was under general anesthesia and without her prior
consent, performed a total hysterectomy, the surgeon noticing
fibroid uterus. In holding the surgeon liable for damages
despite the blanket consent form signed by the patient, the
court observed that “the so-called authorization is so
ambiguous as to be almost worthless, and certainly so, since it
fails to designate the nature of the operation authorized and for
which consent was given. It was pointed out that though it may
be convenient for a surgeon to correct unrelated conditions
discovered during the course of the operation, in the absence of
an emergency threatening the life of a patient, the surgeon
should not attempt to extend surgery beyond the scope of the
patient’s consent”
The consent is considered illegal or invalid when:
1- It includes unlawful operation: illegal abortion or
artificial insemination heterologous or unnecessary
operation.
2- It is taken by fraud or misrepresentation of the
operation: To tell the patient that an operation is
necessary to save life or to preserve health when that is
not the case or that it will give greater relief than there

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 Medical Ethics

is any reasonable prospect of obtaining, is to perpetrate

a fraud on the patient, which vitiates his consent.
3- The consent was given by one who had no legal
capacity to give it, e.g., a minor (below the legal age
for consent, in Egypt the legal age for consent is 18
years) or mentally ill.
4- It is not an informed consent (vide supra).

Medical claims in Egypt

1- Female Circumcision
(Female Genital Mutilation, FGM)
Ritual cutting and alteration of the genitalia of female
infants, girls, and adolescents has been a tradition since
antiquity. It persists today primarily in Africa and among small
communities in the Middle East and Asia.
The spectrum of these genital procedures has been
termed female circumcision, or more frequently, female genital
mutilation (FGM) as a collective name describing several
different traditional rituals that emphasizes the physical
disfigurement associated with the practice.
Types
Type -I
• This is the partial or total removal of the clitoral glans
(the external and visible part of the clitoris, which is a
sensitive part of the female genitals), and/or the
prepuce/clitoral hood (the fold of skin surrounding the
clitoral glans).

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 Medical Ethics

Type -II
• This is the partial or total removal of the clitoral glans
and the labia minora (the inner folds of the vulva), with
or without removal of the labia majora (the outer folds of
skin of the vulva).
Type-III
• Also known as infibulation, this is the narrowing of the
vaginal opening through the creation of a covering seal.
The seal is formed by cutting and repositioning the labia
minora, or labia majora, sometimes through stitching,
with or without removal of the clitoral prepuce/clitoral
hood and glans.
Type- IV
• This includes all other harmful procedures to the female
genitalia for non-medical purposes, e.g., pricking,
piercing, incising, scraping and cauterizing the genital
area.

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 Medical Ethics

In Egypt, the most common procedure involves subtotal

clitoridectomy: the clitoris is held between the thumb and
index finger, pulled out and amputated with one stroke of a
sharp object.

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 Medical Ethics

Complications include;
▪ Hemorrhage,
▪ shock secondary to blood loss or pain,
▪ local infection and failure to heal,
▪ septicemia, tetanus,
▪ trauma to adjacent structures &
▪ urinary retention.
▪ Dyspareunia and sexual dysfunction
▪ Depression, anxiety and psychosomatic disorders
The Role of Physicians in FGM/Cutting Cases
• First aid, diagnosis and treatment
• Reporting the crime.
• Psychological rehabilitation of the girl

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 Medical Ethics

• Taking and maintaining the precaution and evidence

according to chain of custody (clothing - used
instruments)
• Documentation of body injuries and locality, date of
occurrence and the tool used.
• Writing a medical or medicolegal report
• To find out is whether there is medical indication for
surgery to state medical responsibility.
• Medical referral when indicated
• Public awareness of the complications and penalties is
important for prevention and elimination of FGM.
Legislations and banning
Although FGM was officially banned in Egypt in 1997, the
practice was still legal when deemed medically necessary by a
doctor.
On 2007-June,28, the Egyptian Health Ministry announced
that it has removed the health exception from the 1996 law i.e.,
by this date all forms of female genital tract mutilation are
considered unconditionally illegal and the doctor who perform
it even with patient’s consent is subjected for criminal
conviction.
Female Genital Mutilation (FGM)
2021 ‫ لسنة‬10 ‫قانون العقوبات المعدل بالقانون‬
:1 ‫مادة رقم‬
:‫ النصان اآلتيان‬، ‫أ) من قانون العقوبات‬/‫مكررا‬
ً 242( ‫مكررا) و‬
ً 242( ‫يُستبدل بنصي المادتين‬
:)‫مكررا‬
ً 242( ‫مـادة‬
‫يُعاقب بالسجن مدة ال تقل عن خمس سنوات كل من أجرى ختانًا ألنثى بإزالة أى جزء من‬
‫أعضائها التناسلية الخارجية بشكل جزئي‬

15
 ‫‪Medical Ethics‬‬

‫أو تام أو ألحق إصابات بتـلك األعضاء ‪ ،‬فإذا نشأ عن ذلك الفعل عاهة مستديمة تكون العقوبة‬
‫السجن المشدد مدة ال تقل عن سبع سنوات ‪ ،‬أما إذا أفضى الفعل إلى الموت تكون العقوبة السجن‬
‫المشدد لمدة ال تقل عن عشر سنوات‪.‬‬
‫وتكون العقوبة السجن المشدد لمدة ال تقل عن خمس سنوات إذا كان من أجرى الختان المشار إليه‬
‫بالفقرة السابقة طبيبً‬
‫ا أو مزاوالً لمهنة التمريض ‪ ،‬فإذا نشأ عن جريمته عاهة مستديمة تكون العقوبة السجن المشدد‬
‫لمدة ال تقل عن عشر سنوات ‪ ،‬أما إذا أفضى الفعل إلى الموت تكون العقوبة السجن المشدد لمدة‬
‫ال تقل عن خمس عشرة سنة وال تزيد على عشرين سنة‪.‬‬
‫وتقضى المحكمة فضالً عن العقوبات المتقدمة بحرمان مرتكبها ‪ ،‬من األطباء ومزاولي مهنة‬
‫التمريض ‪ ،‬من ممارسة المهنة مدة ال تقل عن ثالث سنوات وال تزيد على خمس سنوات تبدأ بعد‬
‫انتهاء مدة تنفيذ العقوبة ‪ ،‬وغلق المنشأة الخاصة التي‬
‫أجري فيها الختان ‪ ،‬وإذا كانت مرخصة تكون مدة الغلق مساوية لمدة المنع من ممارسة المهنة‬
‫مع نزع لوحاتها والفتاتها ‪ ،‬سواء أكانت مملوكة للطبيب مرتكب الجريمة ‪ ،‬أم كان مديرها الفعلي‬
‫عال ًما بارتكابها ‪ ،‬وذلك بما ال يخل بحقوق الغير حسن النية ‪ ،‬ونشر الحكم في جريدتين يوميتين‬
‫واسعتي االنتشار وبالمواقع اإللكترونية التي يُعينها الحكم عل نفقة المحكوم عليه‪.‬‬
‫مكررا‪/‬أ)‪:‬‬
‫ً‬ ‫مـادة (‪242‬‬
‫يُعاقب بالسجن كل من طلب ختان أنثى وتم ختانها بنا ًء على طلبه على النحو المنصوص عليه‬
‫مكررا من هذا القانون‪.‬‬
‫ً‬ ‫بالمادة (‪)242‬‬
‫كما يُعاقب بالحبس كل من روج ‪ ،‬أو شجع ‪ ،‬أو دعا بإحدى الطرق المبينة بالمادة (‪ )171‬من هذا‬
‫القانون الرتكاب جريمة ختان أنثى ولو لم يترتب على فعله أثر‬
‫‪.‬‬
‫‪Despite strengthening the penalties, practice of the FGM/C in‬‬
‫‪Egypt constituted 86%-92% according to Egyptian‬‬
‫‪Demographic and health survey (EDHS), 2021. EDHS‬‬
‫‪revealed also that 74% of the cases of FGM/C were done by‬‬
‫‪hands of physicians.‬‬
‫‪2- Organ transplantation‬‬
‫‪Organ transplantation can allow patients with end‬‬
‫‪stage disease to return to active lives, organ donations‬‬
‫‪interventions are performed on one person in order to benefit‬‬
‫‪another person.‬‬

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 Medical Ethics

Ethical concerns about cadaveric donation:

Organ and tissue donation in Egypt whether from living or
cadaveric donors is regulated and controlled by law no. 5
/2010.
Organ donation raises at least two juridical-theological post
mortem problems;
1- Muslim law prescribes burial of the deceased as soon as
possible and prohibits cremation and any mutilation of the
corpse.
2- The creator is the sole owner of everything including the
human body, man merely exercises a sort of trusteeship on
the latter, the most explicit support for this is that expressed
by the popular Egyptian preacher (the mufti Al-sha’rawi)
in (1987) against every type of transplant as:
• Explanation from a corpse is the equivalent of mutilation
therefore it is prohibited by the sharia.
• Explanation from a living individual still harms the
donor.

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 Medical Ethics

• The body is the property of God.

The current system for cadaveric donation.
The United States has a voluntary system for organ
donation, The uniform anatomical gift allows people to use an
organ donor card to grant permission to use their organs for
transplantation after death.
In Egypt, finally the parliament has accepted a law that
regulates diagnosis of brain stem death to be equivalent to
death in 2010.
The core regulations are the creation of national committee for
approving diagnosis of brain stem death performed via hospital
committees that are located in medical centers chosen by
Ministry of health, and the doctor who violate this rule and
diagnose brain death is subjected to legal penalties that reach
execution and civil compensation up to 500,000 Egyptian
pounds.
Ethical concerns about living donation:
A-Harm to donors:
Surgeons might violate the guidelines of “do no harm”
when they perform an operation on a healthy person for
another person’s benefit. To limit risks person may not serve as
living donors if they have medical conditions that significantly
increase operative risk.
The donation of an organ has to be the effect of a free
and voluntary act that can be performed when the donor does
not run any risk for his life whilst the harm suffered is minimal.
B-Motives of donors:
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 Medical Ethics

Donation to relatives and friends is understandable

because people are expected to help and care for others with
whom they have close relationships.
Organs from living non related donors (LNRD) are often
sold so, due to the serious ethical problems related to the trade
in organ transplants from LNRD it is generally hindered in
Muslim countries.
C-Consent from donors:
Because alive donor undergoes a serious risk in order
to benefit another person, it is essential that the decision to
donate to be free and informed.
 In Egypt, ethical frame for living donation include
the following:
 The donor should be medically fit for donation
for instance, absence of kidney function
compromise in case of renal transplantation.
 The donor should be a relative to the recipient up
to fourth degree.
 Egyptians shouldn’t donate their organs to non-
Egyptians except between partners after 3 years
of marriage.
 A letter of acceptance from Egyptian syndicate
should be included before transplantation
operation.
 Informed consent from the donor.
 Selling of organs is prohibited by Egyptian law.

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 Medical Ethics

3-Assisted reproduction
The term Assisted Reproductive Technologies (ARTs) or
Medically Assisted Conception (MAC) describes all treatment
procedures which include more than the natural intercourse to
conceive.
The three main types of ARTs are
• In Vitro Fertilization (IVF),
• Intra Cytoplasmic Sperm Injection (ICSI) [i.e., injection
of a single sperm directly into the cytoplasm of the egg].
• Intra Uterine Insemination (IUI).

Pre implantation genetic diagnosis (PGD):

 PGD has been available since 1990 for testing of
aneuploidy in low prognosis infertility patients, and for
single gene and X-linked diseases in at-risk couples.
 PGD provides an alternative to current post-conception
diagnostic procedures, i.e., amniocentesis or chorionic

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 Medical Ethics

villus sampling, which are frequently followed by

pregnancy termination if results are unfavorable.

Ethical implications in AR:

The rapid evolution and progress of various techniques of AR
has opened a Pandora's Box of ethical issues that must be
urgently addressed.
-There major ethical viewpoint in pre-embryo moral status is
that the pre-embryo has the “Full Status of a Human Being”
from the moment of fertilization forward. Accordingly, any
research or other manipulation that may damage a pre-embryo
is ethically unacceptable.
-In cases where semen obtained from a donor it is against
religious and the resulting child is illegal and may also cause
social problems increasing the possibility of incest.
-The use of PGD for mere sex selection without medical
indication ex. Sex-linked diseases, is prohibited in Egypt and
most of the Islamic countries moreover parties from developed
countries object this process totally because of the following:
1. The danger of sex discrimination either by
allowing more males to be produced or by
encouraging parents to pay great attention to
gender itself.
2. The violation of the welfare of the children born
as a result of gender selection, who may expect to
act in certain gender specific ways when the
technique succeeds and who may disappoint
parents when it fails.

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 Medical Ethics

3. Sex ratio imbalance.

-The use of PGD to avoid the birth of children who are healthy
at birth but face a higher-than-average risk of having cancer or
some other serious disease is encourage
- Informed consent should be obtained from both partners.
-The doctor should not use patient’s embryos for any reason.
- Surrogacy is not allowed by the Egyptian medical law.
-It is not permitted for any medical institution to have gamete
(sperm or ovum) or embryo- banks.
-Only specialised centres in assisted reproduction technology,
that must be well equipped and licensed by ministry of health
are permitted to practice such speciality.
-Each licensed reproductive centre should keep detailed
records of the cases for ten years and these records should
include partners’ informed consent.

-The practice of cloning (i.e., any embryo produced by a

process other than fertilization, which is implanted into a

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 Medical Ethics

human body, with the intention of replicating an existing

individual, alive or dead), unlike many other areas of
reproductive technology, has been universally condemned by
the scientific, medical, ethical, and general communities.
-The use of Embryonic Stem cells (i.e., immortal, self-
renewing, undifferentiated cell types that may be produced in
culture from the inner cell mass of blastocyst-stage human
embryos) should be very heavily limited:
1-Only allow isolation of ES from frozen embryos that were
created for the purpose of IVF and would otherwise have been
destroyed.
2- Obtain full consent from the donors.
3-Provide safeguards against monetary compensation to
embryo donors and against the creation of embryos in excess of
what is required for IVF.
4-Encourage further research on the use of adult stem cells, to
the point where it will be unnecessary to use embryos for this
purpose. Specifically, we should find better ways to isolate

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 Medical Ethics

existing stem cells in the human body.

N.B. Stem cell therapy is not yet approved by the national

committee for control of the emerging treatment. It is in the
phase of clinical trials and any practice outside this frame is
considered illegal.
4-Illegal abortion
A pan-Islamic conference in Cairo in 1965 approved
the use of birth control for economic reasons, it is defined as
inability to support additional off springs, Islam permits birth
control to space births, forbids sterilization and abortion unless
the woman's life is in danger.
In 1992 in a meeting on unsafe abortion and sexual
health in the Arab world, the participants agreed that "unsafe
abortion was a major public health problem in almost all
countries.
A fatwa in 1991 in Saudi Arabia allowed for abortion
in the first 120 days after conception in the case of fetal

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 Medical Ethics

impairment. In Iran both the grand mufti and The Ayatollah Ali
Khamenei issued two fatwa in 2005 allowing for abortion
under certain circumstances the one provided for abortion in
the first trimester as in cases of genetic disorder, or if a
woman's health and life were at risk.
In Egyptian law, Article 61 stipulates "a person shall not be
punished for a crime which is in self-defense or for defending
someone else against serious danger ". This is used to condone
abortion when the woman's health or life is at risk, i.e.,
abortion is legal only when continuation of pregnancy
endangers mother's life.

To perform legal or therapeutic abortion the following

conditions should be fulfilled by law or otherwise the operation
became illegal:
*Consultation of 2 specialists indicating that abortion is
mandatory to save mother's life and stating the health condition
that necessitate this procedure.
*Informed consent from husband and wife.

25
 Medical Ethics

*Therapeutic abortion should be done in a well-equipped and

licensed hospital.
Abortion not to save mother's life is illegal or criminal by
Egyptian law no matter the reason for that.
5- Gender correction:

It is not permitted by law to change gender but

correction of sex is allowed under the following
conditions:
o Genetic counselling revealed that chromosomal
study is that of the new sex.
o Hormonal and psychiatric treatment should be
accomplished for two years.
o Consultation report for each case.

26
 Medical Ethics

Medical certificates and reports:

They may be given only to the patient or his guardian
upon his request. It should include true and correct data.
Writing false data or taking fees in return are considered
malpractice. In case of age estimation certificate, a photo and
fingerprints of the examined person should be obtained to
avoid impersonation.
The following is taken into account in the preparation of
medical reports:
First - the medical reports issued in criminal cases:
These reports are subject to the rules and procedures the
following:
1) for primary medical reports:
A- The medical examination of the patient should base on the
referral letter issued by the police, and includes all of his data.
B- The patient is displayed injured after making sure of his
personality and examined by the specialist or assistant
specialist to prove his injuries, and determine the time required
for treatment, the report is signed by the specialist or assistant
specialist and the causality manager.
C- The duration of treatment is issued , but if disability
occurs: the period of treatment shall be determined and the
percentage of disability caused by it according to the final
medical report.
2) For the final medical reports:
A- will be issued after it was decided to discharge the injured
patient permanently from the hospital, and the medical data is
taken from his medical record.
B- The final report should be signed by specialist or assistant
specialist , head of the department and the manager of the
27
 Medical Ethics

hospital after reviewing his medical record of the patient and

using all the means of diagnosis.
C- The final report should be written in a clear language and
good quality writing, and includes a statement of injuries and
final diagnosis and duration of treatment and disability or
impairment – if any- and the necessary recommendation, to be
the final ruling by the forensic physician, and sends to the
Attorney, upon request, after the authorized representative
received the final report and a formal letter to do so.
Second - the medical reports prepared for the medical
conditions:
1) These reports shouldn't be issue except if there is an official
letter or at the request of the applicant by a letter signed by
him and addressed to the director of the hospital.
2) These reports should be issued by a committee includes; the
specialist or assistant specialist , head of the department and
the manager of the hospital, and includes: date of admission
and discharge, diagnosis, medical recommendation , and after
the use of clinical examination and different diagnostic tools.
Third: The registry and reports delivered to the stakeholders:
• A special register of medical reports both the final and the
primary ones should be established in all hospitals and
health facilities, this registry should include all the
information and data and was taken by the responsibility of
a competent employee, and he hospital manager should sign
the registered records on daily bases.
• It is not permitted to deal directly with lawyers or people in
concern in the cases of misdemeanors and felonies, except
after prosecutor's documented permission, and in all cases a

28
 Medical Ethics

receipt should be signed and thumb print by the recipient

after taking all his contact information

Medical confidentiality:
Much of the close confidence between a medical man
and his patient arises from the feeling that anything found on
examination will remain secret. Any information learnt during
attending the patient should not be disclosed except after his
permission. Not only medical men but also all personnel
involved in the medical practice are not allowed to divulge
(disclose) the professional secrets. (e.g., nurses, pharmacists,
technicians, and medical students). Hospital papers,
prescriptions, and laboratory repots must be also kept away
from non-responsible persons. Publication of patient’s name or
photograph in scientific journals is considered a disclosure of
professional secrecy.
A breach of confidentiality is a disclosure to a third
party, without patient consent or court order, of private
information that the physician has learned within the patient-
physician relationship. Disclosure can be oral or written, by
telephone or fax, or electronically (via e-mail or health
information networks) however,
The healthcare information may only be disclosed in the
following situations:
1- With the consent of the patient: if he asks for a
certificate.
The general rule is that information contained in a patient's
medical record may be released to third parties only if the
patient has consented to such disclosure. The patient's

29
 Medical Ethics

authorization is required before the medical records can be

released to the following parties: patient's attorney or
insurance company, patient's employer (unless a worker's
compensation claim is involved), member of the patient's
family, government agencies, and other third parties. Some
countries allow disclosure to any person upon consent of
the patient; others permit disclosure only to specified
classes of persons.
Information may be released if the consent is written
and contains the following elements: -
a) The name of the person to make the disclosure.
b) The name or title of the person or organization to
receive the information.
c) The name of the patient.
d) The purpose of the disclosure.
e) How much and what kind of information is to be
disclosed.
f) The patient's signature.
g) The date of signature.
h) A statement that the consent may be revoked.
i) The date when the consent will automatically
expire
2- For the sake of the patient: In most circumstances, close
relatives are told the nature of the patient's illness,
especially if they live together and have to care for the
patient at home. However, this disclosure is by no
means automatic, and if the patient’s request that a
relative not be told, then the doctor must abide by that
wish, unless he is convinced that some over-riding
medical reason exists (such as the need for domiciliary

30
 Medical Ethics

care). Particular caution is required over the disclosure

of sexual matters, such as pregnancy, abortion or
venereal diseases, as it might cause severe conflict
between close relatives, such as husband and wife.
3- For the sake of the public: to protect the community
from dangerous disease or crimes. e.g.:
• Infections and quarantinable diseases should be
notified to the proper authorities. (Health office
and Ministry of Health).
• If the doctor learns of a serious crime (e.g., by
treating wounds of an assailant that he knows
must have originated in the serious assault or rape,
or in cases of illegal abortion etc.).
4- For the sake of the physician: if he is accused of
malpractice, he may explain to the court the nature of
the disease and the procedure he adopted. This may be
written as a report and given to the court to avoid
disclosure.
5- If the physician is called by the court as an expert
witness. He must tell the court all information revealed
on examination of the person who was already
consenting: e.g.: a prisoner.
6- To other doctors: It is naturally permissible, on the
ground of added benefit to the patient, that a doctor can
disclose the medical facts of a case with other doctors,
and indeed, non-medical health staff, such as
physiotherapists, radiologists, nurses, etc. It is assumed
that patients have given implied consent for the sharing
of their health information on a' need to know' basis with

31
 Medical Ethics

other healthcare professionals, who should be under the

same obligation of secrecy as the doctor.
Breach of Confidentiality
The most common bases of recovery for breach of
confidentiality are breach of contract, invasion of privacy,
negligent infliction of mental distress, and loss of
employment. Recovery for invasion of privacy generally
requires a public disclosure of a private fact, not a disclosure
to an individual or small group such as spouse or family.
Recovery in breach of contract suits is limited to economic
losses that were a direct result of the breach and does not
include losses from subsequent mental suffering or loss of
employment.
Defenses for breach of confidentiality are dependent on valid
consent for the release of information. To be valid, the
consent must be knowing and voluntary. It is prudent to have
patients sign release forms or document their oral consent in
progress notes. Physicians should consider having patients
sign progress notes where the consent to release information is
documented.
N.B. Doctors should be careful while dealing with the
following conditions:

The police

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 Medical Ethics

In most countries, like Egypt, police have no power or

authority to demand the disclosure of medical information by a
doctor, or anyone else, but they often use their status to bluff
doctors into thinking that they have the right to do so.
However, in most instances, where police require information
concerning assault on a patient who is likely to have been the
victim. This patient is usually too willing to give permission
for disclosure that may help to convict his assailant. Where
assaults occur within a family, such as between husband and
wife or close relatives, they may not wish to bring criminal
charges, so the doctor must not automatically assume that
consent for disclosure would have been given.
Lawyers

33
 Medical Ethics

As with the police, lawyers have no automatic right to

obtain medical information without the patient consent.
They must first apply to the court for disclosure. When a
doctor is asked by lawyers for a medical report, he should
know if permission has been granted and it is better to insist
on a written permission.
II-Physician - physician relationship:
1- This should acquire sufficient degree of mutual respect a
physician should not criticize his college or replace him
in treatment of patients or professional jobs.
2- A physician should not refuse treating colleagues on
their relatives or accept fees except for needed
investigations.
3- Asking for percentage of fees for referral to other
colleagues is misconduct (Dichotomy).
II- Physician - Society relationship:
1- Registration (License to practice): The Syndicate's
duty is to protect the public by keeping a Medical
Register for qualified men. So, the register of the
Ministry of Health and the membership of the syndicate
of medical practice before practicing medicine is a must.
2- Disbarring from medical Syndicate register is
possible in the following conditions.
• Refraining of paying the annual subscriptions.
• Discontinuity of practicing medicine or death.
• Conviction of misconduct, malpractice or criminal
offence by the disciplinary committees of the
syndicate.
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 Medical Ethics

Restoration of registration is possible after 2 years

at least.
3- The medical practitioner is not allowed to:
• Use intermediaries in the practice of the medical
profession whether it is paid or unpaid
• Allow the use of his name in the promotion of
medicines or drugs, or various types of treatment or for
commercial purposes.
• Give patients' consultation or medical certificate or
report away from his specialty or in contradiction with
what the examination and diagnosis revealed.
• Take a commission for referral of patients to certain
pharmacy, hospital, laboratory or radiology centers.
• Prescribe drugs or make consultations via
telecommunications
• Sell any drugs or prescriptions or medical supplies and
instruments in his or her clinic.
• To apply a new method for diagnosis or treatment
except after complete testing and passing all phases of
clinical trial and approved by the committee for Control
• of emerging treatment systems in the Egyptian Ministry
of health.

35
 Medical Ethics

-Allege any scientific discovery he was not a part of it or

taking the advantage to himself only while there were other
authors.
-Make any form of publicity for himself through press,
radio, television or through the means of the Internet or any
other form of advertising methods.
- Use false data in his title; in prescription forms or name
plate.
Legal frame for press advertisement:

36
 Medical Ethics

• It is permissible for a doctor to announce when he

opens a clinic or transferred in the newspapers for
three time in the same newspaper or once in three
different newspapers, and upon his leave for more
than two weeks he can make it the same way one by
his absence and the second after his return.
• When addressing the public in the medical programs
through the media, the doctor should stick to the
following rules:
1- Avoid referring to his place of work and ways to
contact him and over praise himself or his scientific
achievements, and it suffice to mention only his
professional field of specialization.
2- To be as simple as possible in his conversation to
fit a non-specialist listener or viewer.
3 - Avoid mentioning scientific consensus which is
not yet confirmed , or to address the disputed issues,
which will be discussed only in the scientific
sessions not directed to the public.

37
 Medical Malpractice

Chapter (2)
Medical malpractice crisis
Definition of malpractice
Malpractice is a term of broad significance. It may be defined
as ‘any professional misconduct or any unreasonable lack of
skill in the performance of professional duties. It has also been
defined as improper treatment through carelessness, ignorance
or intentional negligence.
Because of the dynamic development of medical and biological
sciences as well as techniques which are
the causes of progress in medicine but
they also give rise to the increase of
hazards or abuses in medical therapy.
A medical professional may be a doctor,
a nurse, a medical technician or other
health care provider. In the case of a
doctor who is a medical specialist, the
standard of care is determined by the standard of good medical
practice in that specialty. The term medical practice involves
hospitals, clinics, doctors, nurse, nursing homes, and virtually
every other type of health care provider and facility. Bad
outcome does not always mean that medical malpractice has
occurred.

According to Egyptian laws the duty of a medical professional

is not always the duty to cure or to guarantee a good outcome

38
 Medical Malpractice

from treatment. Except for some specialties e.g., Laboratory

medicine and aesthetic plastic surgery.

There are differences between complications and medical

errors, so you have to include all expected adverse effects from
the intervention in the patients’ consent.

Doctors should have some knowledge of juridical

mechanisms in lawsuits and ethical procedures, but should not
take defense initiatives without prior consultation of an
attorney.
A doctor is expected by law and public to have two
attributes in his practice: -
(a) Possession of a reasonable degree of proficiency.
(b) Application of that proficiency with a reasonable
degree of diligence (standard of care).

A-Professionalism
It is manifested through a commitment to carrying
out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population. It is
defined as "residents must demonstrate behaviors that reflect
a commitment to ethical practice, an understanding and
sensitivity to diversity and a responsibility attitude toward
their patient and their profession".

39
 Medical Malpractice

B-The standard of medical care

The term "standard of care" connects an action or
treatment that would be expected by a Conesus of the medical
community in a given situation, or how physicians’ colleagues
would act in a certain circumstance. It is defined as " that
degree of care which a reasonably prudent person should
exercise under same or similar circumstances, if a person
conduct falls below such a standard, he may be liable in
damages of injuries or damages resulting from his conduct".
Also, it refers to reasonable and ordinary care, skill, and
diligence as physicians and surgeons in good standing in the
same neighborhood, in the same general time of practice,
ordinarily have and exercise in like cases.
The duty of a medical professional is not always the duty
to cure or to guarantee a good outcome from treatment. The
duty is to provide medical care according to accepted standards
in the community or, in the case of a specialist, accepted
standards in that medical specialty. Since a medical
professional may have a different duty of care if a specific
guarantee of a particular result is given to the patient, doctors
require a written consent to surgery or other invasive
procedures.

40
 Medical Malpractice

Medical malpractice may arise from failure to provide

adequate medical care, the failure to properly diagnose a
medical condition or the failure to properly treat a medical
condition. Examples include failure to properly diagnose a
patient’s disease or injury resulting in improper or delayed
treatment, improperly prescribing a drug, failing to inform the
patient of available treatments, continuing a treatment that has
been shown to be ineffective or failing to provide material
information to a patient. Some types of injuries are considered
‘negligence per se’ because the particular type of injury could
not have occurred without the negligence of someone involved
in the patient’s treatment. For example, if a medical instrument
is left inside the patient’s body following an operation,
negligence usually may be assumed without further proof.
Medical malpractice frequently goes undetected or at least
overlooked. Different studies concluded that about 90% of
medical negligence escapes lawsuits.

History of malpractice
The concept that every person who enters into a
learned profession should practice in a reasonable degree of
care and skill dates back to the laws of ancient Rome and
England.

41
 Medical Malpractice

Medical responsibility can be traced back to 2030 BC when

the code of Hammurabi provided that "if the doctor has
treated a gentleman with a lancet of bronze and has caused the
gentleman to die or has opened an abscess of the eye for a
gentleman with a bronze lancet and has caused the loss of the
gentleman's eye, one shall cut off his hands.
The Egyptians described remedies and spells to almost all
known diseases. They had excellent reputation in the arts of
chemistry and pharmacology. The 6 royal books of medicine
were a part of 42 royal books of ‘Tut the King of Wisdom’ in
which they regulated the practice of medicine Egypt.

42
 Medical Malpractice

In Egypt in 1851, Abbas Basha was the 1st to issue the laws
of medical service, where he organized the jobs of doctors,
barbers and midwives. In 1852 barbers were prohibited of
practicing medicine and surgery. In 1877 the health council
(Known now as the Ministry of Health) made lists of those
barbers allowed to do circumcisions, and in 1860 Saiid Basha
issued a law preventing pharmacies from giving medications
without prescriptions.
In the United States medical malpractice suits first appeared
with regularity beginning in the 1800s. However, before the
1960, legal claims for medical malpractice were rare and had
little impact on the practice of medicine. Since the 1960 the
frequency of medical malpractice claims has increased and
today, lawsuits filed by aggrieved patients alleging malpractice
by a physician are relatively common.

43
 Medical Malpractice

The Islamic legal point view:

1- Anyone who practices a job or a science that he
knows is responsible for the injury that
happens to others as a result of his practice.
2- Anyone who practices medicine without
enough knowledge and kills someone or harms
him is responsible for his deeds and should be
punished for it (Islamic Medical Conference,
1991).
3- In managing a medical case the doctor should
do his best. If he does without negligence,
taking full measures and precautions, expected
from his equals, then he is not to blame or be
punished even if the results were not
satisfactory (Dar Al Eftaa, 1945).
Damage due to malpractice
There are 2 types of damages available in a medical
malpractice case: actual and punitive damages.
▪ Actual damage includes the cost of additional medical
treatment, lost wages, lost future earning capacity, pain
and suffering caused by the injury.
▪ Punitive damage is available if the person who caused
the harm acted intentionally, willfully or recklessly in
causing the harm.
 Iatrogenic illness is defined as any illness that results from

44
 Medical Malpractice

a diagnostic procedure or therapy, so called physicians as a

cause of illness. Rooting the review of medical literature
suggests that up to 14% of patients experience iatrogenic
neurologic complications as example, which is reflected in
morbidity, mortality and increased health care costs. From a
legal perspective, these events and hazards of medical care
are called a tort.

Types of medical malpractice

▪ Professional negligence (substandard care)
▪ Professional misconduct i.e., personal professional
behavior falls below that which is expected of a doctor.

1-Medical Negligence
The standard medical care given to patient is considered
to be inadequate. To prove negligence it must show that:
A- The doctor has a duty of care towards the patient.
B- Failure to conform that duty.
C-Resulting physical or mental damage.
D- Sufficient causal connection between the damage and the
breach.
In professional negligence cases a defendant physician
may be liable for actions where there was a duty to provide
care, a care standard was breached and as a result of that
breach a damage or injury was done to another, each of these
elements must be present and proven by a preponderance of
evidence for a finding of medical liability.
Financial, educational, cultural, religious, political and

45
 Medical Malpractice

historical factors all play a crucial role in the provision of

health care so there are differences between negligence and
patients’ expectation breach. Societal values are reflected in
patients’ expectations regarding acceptable professional
performance and the liability of doctor for medical negligence.

A- Duty
It refers to the existence of the physician’s responsibility
to the plaintiff and is usually based on the existence of the
physician – patient relationship.
Physician legal duty of care to a patient depends on the
existence of a physician – patient relationship at least in theory
this concept is straight forward: if a physician enters into a
professional relationship with a patient, the physician assumes
a legal duty to act with a reasonable care and skills in his or her
professional interactions with patients, failure to adhere to this
reasonability standard, leave a physician liable for any
resulting damage to the patient. In practice, it is not always
easy to determine that a physician – patient relationship has
been formed.

B-Proximal cause
It means that there must be a causal connection between
the violation of the standard of care and the alleged harm.
Negligence that does not result in harm cannot be deemed
malpractice, nor can injury that does not arise from non-
negligent acts.

C- Damages
They are monetary awards given by a court or jury as

46
 Medical Malpractice

compensation for a tort or breach of contract and if the

threshold legal finding of duty is made, the inquiry logically
turns to the scope of that duty in law. In case of no harm by the
physician's error, the patient cannot recover damages as the
result of the error. But, if harm was proven, this will support a
malpractice action.
In negligence malpractice there are "signs of omission" and
"sings of commission":
1. Signs of omission which includes:
(A) No informed consent.
(B) Omission of necessary investigations or
treatment.
(A) No informed consent
Consent is an absolute requirement before a doctor
approaches the patient. [For details refer to page:5]
(B)Omission of necessary investigations or
treatment
For example, it is usual to take an X-ray of the
skull in a case of suspected fracture. it is also standard
practice in dental surgery to take a radiograph of a mis-
placed tooth. If an X-ray is not undertaken, patients may
contemplate an action for professional negligence.

2. Signs of Commission which includes:

(A) Unnecessary treatment.
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 Medical Malpractice

(B) Abandon ment .

(C) Assault and battery.
(A) Unnecessary treatment.
This applies especially to surgical treatment {this
is considered violation to beneficence ethical principle}
(B) Abandonment.
Is defined as the improper unilateral termination of the
relationship. Doctor is called specially and only for one
occasion owes no duty to repeat his visits or continue
his treatment. A surgeon, however, must provide post-
operative care unless his services have been restricted to
the performance of the operation. A physician who
leaves a patient at a critical stage of disease without
reason or sufficient notice to enable the patient to
procure the services of another competent physician is
negligent.
Acts of abandonment include:
- Leaving the patient during or immediately after surgery.
- Not giving proper discharge instructions.
- Premature patient discharge.
Proper withdrawal of the doctor is an absolute defense to
abandonment. The patient should be notified to have enough
time to find alternative care.
When patients fail to follow a prescribed course of
treatment, the doctor has the right to terminate relationship
after warning the patient and this act is not considered
abandonment.
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 Medical Malpractice

(c) Assault and battery .

Assault and battery are wrongful, harmful or
offensive contact with another's body or putting the
other person in fear of such an attack. Most cases involve
errors of judgment involving a failure to obtain the
patient's informed consent to treatment.
However, a suit is occasionally brought by a patient
against a doctor for deliberate physical attack or sexual
assault for example, a woman went to a psychiatrist for
treatment of sexual difficulties. The psychiatrist had an
affair with her. She subsequently sued him for
malpractice and assault.

2-Professional misconduct
Personal professional behavior falls below that which is
expected of a doctor, the personal or professional conduct of a
doctor is seriously criticized, this aspect is not dealt with under
the law of negligence but by various tribunals, which examine
his fitness to remain an accredited physician. The doctor
professional career is dependent upon remaining registered or
licensed until retirement or death, misconduct makes him
vulnerable to losing his license.
The regulatory system for professional conduct varies
greatly from place to place. In most countries, it is
governmentally regulated where doctors are registered,
licensed and it is the main organization responsible for
discussing professional misconduct allegations against
doctors.
It may include one of the following:
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 Medical Malpractice

1-Being convicted of a crime.

2-Practicing fraudulently.
3-Practicing beyond the scope of the practice permitted by
law.
4-Practicing while the ability to practice is impaired.
5-Immoral conduct in the practice of the profession.
6-Refusing a client or patient’s service because of creed, color
or national origin.
7-Permitting or aiding an unlicensed person to perform
activities without a license.
8-Being habitually drunk, being dependent on or a habitual
user of narcotics or other drugs with similar effects.
If a practitioner is guilty of dishonorable or disgraceful
conduct, the medical council takes a disciplinary action
against him according to the gravity of the offence:
• (1) Alarm ‫التنبيه‬

• (2) Warning ‫االنذار‬

• (3) Blame-‫اللوم‬
• (4) Temporary revocation of his name from the
health registry- ‫الشطب‬

2016 ‫ لسنة‬81 ‫قانون الخدمة المدنية رقم‬

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 Medical Malpractice

Medical liability
Medical liability is one of the most important parts of
law that regulates health services. It will arise if actions of
physician are not conducted legerities or in a breach of the duty
of care. Although there are different types of liability in the
field of medicine criminal responsibility, disciplinary
proceedings, civil law liability holds central position because
of the number of cases in comparison to the criminal
responsibility and impact of the consequences in comparison to
the disciplinary proceedings.
In law, the primary liability is on the tortfeasor- the man
who performs the wrongful act, If the act is performed under
the directions of another, however, the other will be also liable.

Because medicine is such a complex field, there are many

different types of medical malpractice that health care
providers can perform. The following healthcare-related

51
 Medical Malpractice

mistakes result in approximately 195,000 deaths every year in

USA:

• Wrong Diagnosis
• Delayed Diagnosis
• Improper Treatment
• Surgical Errors
• Emergency Room Errors
• Pharmaceutical Errors
• Birth Injuries
• Hospital Negligence
• Nursing Home Abuse/Neglect
• Lack of Informed Consent
• Wrongful Death

Malpractice, unfortunately, affects both patients and their

families. It can cause a great amount of physical pain,
emotional stress, and financial strain. Families that must cover
high medical bills, especially when their main wage-earner is
the one in the hospital, are placed in very difficult situations.
Fortunately, however, these victims do have the right to
recover compensation for their losses.

Civil medical liability

Civil legal actions are private actions brought by
plaintiffs in their individual, private capacities against
defendants.
The three legal criteria that must be satisfied for the
plaintiff to be awarded damages are:
1- The patient must have suffered compensable injuries or
52
 Medical Malpractice

death.
2- These injuries were the direct result of the defendant
physician’s treatment or failure to treat.
3- In the provision of therapy, the physician did not meet his or
her contractual professional responsibility.
Compensation and damages
Negligence is the act that causes a decrease in the injured
plaintiffs’ prospects of recovering from a serious illness or
injury. If a plaintiff is successful, damages will be paid. The
largest part of damages is calculated on the loss of earning after
the incident.
This award of money is to try to restore the patient to the
state he was in before the incident, in financial terms and to
compensate for pain, suffering and loss of quality of life.
Where death has been caused, the dependent relatives will
receive compensation for loss of salary of the family
breadwinner.
In Egypt, the civil liability is due to Egyptian Civil Law
(131/ 1948) Article No.163
"‫ كل من ارتكب خطأ سبب ضررا للغير يلتزم بدفع التعويض‬163 - ‫ماده‬

Criminal medical liability

Criminal legal actions are public legal actions, from a
criminal law perspective a crime is principally an offense
against society. In most countries, redness for injured patients
during the course of medical treatment has been sought in civil
court, a plaintiff in a medical malpractice action must satisfy
53
 Medical Malpractice

four elements: duty, breach, causation and damage in order

to prevail.
In a negligence case, the wrongdoer’s action is compared to
what would be expected of a reasonable and prudent person the
same or similar circumstance.
In criminal liability the purposes include:
 Specific (of the offender) and general (of the others)
deterrence of future misconduct
 Rehabilitation
 Retribution
 Isolation of dangerous offender.
Criminal prosecution of health care providers for
medical errors is not novel to most juries’ prudence. Courts in
Japan, New Zealand, Saudi Arabia, and India also see their
health care providers on trial as criminal defendants for
medical acts. Culture and lack of alternative forms of redness
probably have a hand on the wheel. For instance, Japan relies
heavily on criminal prosecution to carry out the social function
of public accountability for medical mistakes.
Nonetheless, criminal prosecution for medical acts is
on the rise, in Taiwan, the judges, are using criminal law in
79% of the medical disputes, punish physicians in addition to
the money damages. Thus, Taiwan might be the only one
country of the civilized world that routinely punishes doctors
by the criminal law.
Supporters of criminal prosecution to medical
malpractice believe criminal sanctions are appropriate when

54
 Medical Malpractice

punishing negligent conduct because prosecution encourages

all individuals to conduct themselves with more caution and
the threat of criminal sanctions would force physicians to
monitor their own practices.
In Egypt, there is a growing rise in criminal prosecution to
medical malpractice and lately it is not uncommon to see
doctors in jail. As we do not have medical responsibility law,
the physicians are punished by state laws mainly penal code
(law 58/1937)

Medical Error
Medical error is defined as an injury or illness caused by
medical management, rather than by the underlying disease or
a condition of the patient.

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The classifications of medical error:

A number of classifications have been used, according to
the interaction between actors (i.e., those performing a task)
and circumstances.
The common medical errors are due to:
• Medication error
• Failure to follow standards
• Mis or delayed diagnosis., Delaying patient care
• Incorrectly performing a procedure, or trying to
perform a procedure without training
• Documentation error
• Failure to get informed patient consent.
• Disclose of patient’s information outside what
permitted by law.

Errors may occur: -

• Due to the actor’s

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– Misperception: Information is incorrectly perceived, such

that an incorrect intention is formed, and a wrong action
performed. The intended action would have been correctly
performed had the information been correctly perceived.
For example, unintentional overdose may be caused by
misreading the dose of an ampoule of adrenaline as 1:
1000, rather than 1: 100,000.

– Mistake: Information is correctly perceived, but an

incorrect intention is formed, and a wrong action is
performed. The intended action should have been correctly
performed, given that the information was correctly
perceived.
For example, the ampoule of adrenaline was correctly
read as 1: 1000, but administered to a patient with
malignant hypertension, resulting in a cerebrovascular
accident.
– Slip: Information is correctly perceived, the correct
intention is formed, but the wrong action is performed. The
action is not what was intended.
For example, the adrenaline is administered via an
epidural catheter port, which is in close proximity to a
central venous line port.

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• Due to circumstances:
–Exogenous error: that is error caused by factors other than
the actor, relating to, for example, product and systems
design. If we accept that ‘to err is human’, then redesign
of exogenous factors may be the best way of reducing
error.

Examples of Negligence:
 Blood transfusion without matching.
 Removal of a healthy organ leaving a diseased one.
 Unclear medical report or wrong description or
prescription (overdosing, dangerous interactions, etc.).
 Explosion of theater.
 Forgetting a foreign body or dressing during
operation in patient’s cavities.
 Doing an operation without free written consent from
the patient himself or his father if he is underage, in
coma or in emergency.
 Doing operations in non-equipped hospitals or
clinics.
 Lack of perfect sterilization for the operating tools
and room.
 Negligence in preoperative examination, investigation
or preparation.

Examples of Lack of Reasonable Degree of Skills:

Harm is done to the patient due to:
 Doing major operation by general practitioner or
non-qualified surgeon for such operation.
 To anaesthetize the patient by unqualified

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practitioner.
 Lack of skill or attention expected from the doctor’s
qualifications.
 The doctor is responsible if one of his assistants is
unqualified e.g., nurses, technicians, etc.
Common malpractice suits
Common malpractice claims may include:
• Error in diagnosis including failure to advice.
• Misuse of drugs.
• No informed consent.
• Neglected medical instruments inside the patient
after surgery.
• Sexual relation with the patient.
Malpractice litigation
There are several reasons related to patients’
decisions to bring malpractice claims including patient
dissatisfaction, doctors’ communication and interpersonal
skills. After patients decide to sue, their attorneys determine
the volume and type of malpractice lawsuits.
Because lawyers who prosecute legal claims against
doctors are compensated by means of a contingent fee based on
a percentage of whatever amount may be collected, that exists
a large financial incentive for attorneys to pursue even the most
questionable claim.
There are three main goals of malpractice litigation
including:

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1- To deter unsafe practices,

2- To compensate persons injured through negligence
and
3- To exact corrective justice.
Medical Custom is determined through the testimony of
experts in the same field as the defendant, it is the standard
used to evaluate whether the breach in question rises to the
level of negligence or not.

Expert testimony
Types of witness that are required for clinical legal cases
Medical witnesses can be either ‘professional’ or ‘expert’.

• Professional witnesses.
• professional witness will normally have provided
medical care to the patient in the past
• give evidence on the facts, based on their
knowledge of the circumstances.
• Expert witness is asked to:
• give an opinion on the facts presented
• comment or advise as appropriate,
• provide assistance on matters that are outside the
knowledge of the court.
• For example, giving an opinion on whether
treatment was appropriate and/or whether an
injury had been caused.

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Any doctor has the potential to be an expert witness, although

in reality it is likely that only recognized specialists will be
asked to be expert witnesses.

Civil cases- these form the great majority of legal cases

Witness statements in civil cases:

• Doctor can be professional witnesses to report on

a patient’s clinical condition.
• The doctor prepares a witness statement. This is
the only evidence that will be given in court by the
doctor.
• The statement is written by the doctors in their
own words and should contain the following
information:
• The doctor’s name
• Practice address
• Position in the practice
• Duration in the practice

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• Clinical experience
• An indication of which parts of the
statement are from another source.
• The statement should follow the events in
chronological order
• Each paragraph is numbered and should
refer to a separate matter
• The following declaration must be
included at the end of the statement:
• “I believe that the facts stated in this
witness statement are true”
• »‫«أثبت أنا بالذمة واألمانه‬
• The doctor must sign below the declaration

Witness in criminal cases:

• Specialist knowledge is required to help interpret

evidence in a criminal case.

• A doctor may be asked to appear as a witness:

✓ For the prosecution, where one of your
patients has sustained injuries,
✓ For the defense, where the defendant
happens to be one of your patients.
• Evidence in criminal cases often concerns injury or
attacks of some kind
• Patients usually request the majority of reports.
• All notes must be very well prepared (e.g., legible,
accurate and complete) and kept securely along with any
radiographs (or results of other investigations) taken in
connection with the report.

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• If there is need for an examination of the patient it is

essential that:

o The date and time of the examination is indicated

together with details of anyone else that was
present
o The patient’s description of the incident and
damage allegedly sustained must be fully
recorded (as expected) the clinical examination
and investigations should be undertaken
appropriately
o Any treatment that was provided should be
detailed, together with who provided this and
what the outcomes were.

How to avoid malpractice litigation

In any situation where a patient is treated, injury may
occur, there are some steps that can be taken to minimize risk
and potential litigation after an injury.
First: Is to establish communication that allows for open and
free exchange of information, patients have the right to
determine the care that they are given and providing
assistance in understanding the possibilities for that
care is the physician responsibility, patients are less
likely to sue a physician when they view the physician
as a compassionate, caring doctor who is an ally, not an
adversary office staff and nurses are a representative of
you and your care they should convey your message
that the patient is important.

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Second: Physicians should know the limits of their ability and

training, that is to take on only the duty for which they
have been trained and in which they can support their
expertise.
Third: Document all aspects of care. The written record is the
admissible information regarding what was said and
done to the patient, it cannot be altered in any way after
a motion for suit is filed, and corrections after the fact
are likely to be viewed as an attempt to cover up poor
medical care "if it is not documented, it did not occur"
is an excellent role of thumb.
Finally: Understands the process of informed consent, it is
an agreement between the patient and the physician to
perform some action or procedure.
Properly documenting care in a patient's medical records is
essential and, in the event of a lawsuit, it provides evidence
that the care that was provided met professional standards.
Even nurses who meet the standards of care must document
that carefully and accurately to avoid being vulnerable to
accusations of malpractice that may result in costly jury
verdicts and court decisions.

In Case of Malpractice Claim you have to follow those tips:

• Write 2 reports in Arabic and in English
• Stick to the reliable medical information
• Add references
• Do not use hostile words

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• Do not rationalize.
• Do not accuse colleagues
• Tell the truth
What you have to do (Do’s)
• Preparation –familiarity with the facts of the case
possession of the relevant documents before.
• Clear exposition – the ability to express things lucidly
and briefly in simple words
• Tolerance and courtesy.
What you don’t have to do (Don’ts)
• Providing opinions which are at the edge of or
beyond the expertise
• Providing opinions that are based on false
assumptions or incomplete facts
• Being impulsive or aggressive

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 E-Health Ethics

Chapter (3)
E-Health Ethics
Prof. Dr. Dina Shokry & Dr. Doaa Tawfik

Medical Internet Ethics is the field existing at the intersection

of medicine, ethics, and computers, but is conducted in the new
arena of the Internet. Therefore, a definition can be stated as:
Medical Internet Ethics is an emerging interdisciplinary field
that considers the implications of medical knowledge utilized
via the Internet, and attempts to determine the ethical
guidelines under which ethical participants will practice online
medicine or therapy, conduct online research, engage in
medical e-commerce, and contribute to medical website.

Telemedicine or e-health reduces the burden of travel, thus

reducing stress on the individual by being monitored and
receiving care at home. However, the user/patient must take
charge of his own health care to a greater extent, which may
adversely affect his psychological well-being.

Technology downplays the human factor in any personal

relationship, including that between the doctor and patient.
Virtual visits threaten to turn physicians and nurses into distant
medical technicians, cutting off the close contact between
recipient and provider and the trust such contact provides.

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 E-Health Ethics

Ethics and Self-regulation versus the Law and Enforced

regulation

When considering ethics, one must also distinguish

between what is considered "ethical" and what is considered
"the law," since in many instances there is a fine line separating
the two. Legal principles are often derived from ethical ones.

Ethics attempt to determine what is good and which

behaviors are desirable or correct in accordance with higher
principles. It offers conceptual tools for evaluating and guiding
moral decision-making.

By comparison, laws instruct people directly on how to

behave (or not to behave) under various specific circumstances.
Furthermore, there are prescribed remedies or punishments for
individuals who do not comply with the law.

Self-regulation relies upon professionals upholding their

personal and professional code of ethics; there are limited
means of enforcing the ethical guidelines. During the early
days of the Internet, there were few real standards of
accountability and ethical behavior for medicine and healthcare
on the Internet. Websites and the organizations supporting
them were left to regulate their own ethical behavior. In many
instances, esteemed medical leaders, professional
organizations, and medical institutions proved to be less than
exemplary ethical role models.

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Major Areas of Medical Internet Ethics

In this emerging field of Medical/Healthcare Internet

Ethics, there are at least 6 identified areas that will require
codes of ethical conduct to be established.

• Doctor-patient, provider-patient, therapist-client

relationships
• Online medicine, online therapy
• Online research
• Quality of information on medical and healthcare
Web sites
• Ethical conduct of medical and healthcare Web sites
• Privacy and security

Legal and Ethical Issues in E-Health

Organizational, legal, functional, social, ethical, and

technical requirements must be met to establishing an E-health
environment.

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E-health also raises issues about the recognition of

credentials and licensure; legal liability and malpractice
considerations, including provider insurance coverage;
provider remuneration; patient privacy and confidentiality; the
existence of enabling infrastructure and compatibility of
standards in areas such as data, images, and medical records;
infrastructure and future operating costs; and the quality and
appropriateness of care.

The quality and appropriateness of care is particularly of

potential concern for clinical care, which could become more
fragmented and disintegrated and thus, although perhaps
cheaper or quicker, could result in poorer care from the patient
and provider perspectives. International trade in E-health
increases the complexity of such issues, making their
resolution more difficult.

Legal issues

Citizens should be protected from the possibility of

malpractice. Policy makers should enact laws to:

(1) ensure that citizens have a high quality of care, and

(2) anticipate the legal conflicts that could arise between

recipients and providers of remote care. For example, long-
distance medical personnel might be held accountable for
misinterpreting the client's vital signs and symptoms. If a client
in country B is examined by a medical worker in country A,
what would happen in the case of an incorrect diagnosis?
Which jurisdiction should be applied? Should the doctor be

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judged in A or B, if the patient lives in B and the doctor

violates the laws of B? The courts lack legal precedent to
respond to malpractice claims in the telemedicine domain.

Providers of telemedicine in USA are limiting their

liability by clarifying doctor licensure issues, revising doctor
credentialing procedures, establishing standards, safeguarding
computerized medical data, and videotaping telemedical
procedures.

Practicing medicine without a license in the patient's

state in USA is currently prohibited, whether the physician is
treating the patient in person or from a distant location.
Furthermore, the patient may run high risks since anyone can
pose as a doctor over the Internet.

All health care poses risks to patients, whether

traditional or through telemedicine. Telemedicine has many
similarities to locum medical practice and its patients need
equal protection. The UK's General Medical Council imposed a
limitation of practice for 9 months on a British doctor who
prescribed via the internet because of patients' safety issues.
The sanction was only possible because the doctor practiced
within the UK.

Another important issue concerns the relationship

established between physician and patient in the cyber world.
Their interactions are limited by a computer screen. According
to the following problems are important to consider:

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 E-Health Ethics

• The physician's liability in case of malpractice needs to be

clarified in terms of civil law. The patient has to be protected,
and cyber physicians must be able to quantify their risk.

• The relationship between physicians and insurance companies

may need to be modified.

• Should the physician by judged in their state of residence, or

by other states in which they operate?

• Privacy laws should be adapted to face the challenge of

ensuring the privacy and security of patient data.

• The roles of electronic decision support systems, medical

software, and data collection systems in determining
responsibility need to be clarified.

Patient medical records contain all the information a

thief needs to steal someone's identity and may include Social
Security numbers, driver's license numbers, phone numbers,
addresses, even checking account and credit card information.
Fines under the Health Insurance Portability and
Accountability Act (HIPAA) for unlawfully disclosing patient
data can be as high as $250,000 and, if convicted, a person
could face 10 years in prison.

Ethical issues
1. Privacy and Data Security
The user's private life must be protected, but his
habitation is made porous and public so, it is important to
verify that the lines of communication are safe and secure, that
they ensure perfect confidentiality, and that it is impossible for
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a third party to intercept the data on purpose or by accident.

Furthermore, the transmitted data must be flawless and
uncorrupted to ensure its correct interpretation and high-quality
care.

On the provider side, medical confidentiality must be

maintained. Procedures and processes must be in place to
ensure that patient data can only be accessed by those
authorized to view it. The main concern is the unauthorized
access or interception of the medical data during transmission
by malicious actors. This can lead to breaches of patient
confidentiality and compromise their sensitive medical
information. Various measures should be put in place to
mitigate these risks to protect patient privacy in telemedicine.
Therefore, encryption is a fundamental security measure used
to safeguard patient data. This automatic encryption should be
mandatory for any transmission of identified patient
information. Web-based security systems must be implemented
if patient data are to be transmitted via the Web.

Compliance with the data protection regulations is vital

in telemedicine. Hospitals, healthcare providers, and
telemedicine platforms must adhere to all relevant data
protection laws, e.g., the General Data Protection Regulation
(GDPR) in the European Union or the HIPAA in the United
States. These regulations outline requirements for collecting,
storing, and transferring patient data. They also place measures
to ensure obtaining accurate patient consent, maintaining data
accuracy, and data security. This compliance with regulations
is essential to respect patient autonomy and maintain trust in
telemedicine.
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Building trust and rapport with patients in telemedicine

requires extra effort to establish a connection. Physicians
should focus on active listening, empathy, and maintaining a
patient-centered approach. Additionally, healthcare providers
must create a supportive environment that encourages open
dialogue, values patient input, respects patient autonomy and
avoid any change to the power dynamics in remote
consultations. In a remote setting, patients may feel more
vulnerable or hesitant to assert their preferences or question
healthcare providers' recommendations.

2. Informed Consent and Patient Autonomy

In in-person interactions, healthcare providers can use

non-verbal cues and visual aids to enhance understanding,
however, in telemedicine, these elements may be limited.
Healthcare providers must ensure that patients are adequately
informed about the benefits, limitations, and potential risks of
remote or virtual consultations or monitoring to protect patient
autonomy and facilitate adequate informed decision-making.

3. Equity and Access to Care

Another ethical concern related to telemedicine is equitable

access to care which will disproportionately affect
marginalized populations. These disparities can be solved as
follows:

a) Invest in infrastructure development to improve

internet access in underserved areas.

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b) Donations or subsidies for internet connectivity

and access could be offered to ensure
affordability.
c) Educational programs could be implemented to
improve digital literacy among marginalized
populations.
d) Policymakers can enact policies and regulations to
prioritize equitable access to telemedicine. These
policies should also include protections regarding
reimbursement parity for telemedicine visits,
promoting telehealth in underserved areas.

Telemedicine in Egypt:

The first conference of the Egyptian Medical Syndicate

"Telemedicine" was held in 2022. Several recommendations
were agreed upon at the end of this conference:

a. Telemedicine is not a replacement of traditional in-

person medicine, but it is complementary and coherent
with traditional methods of diagnosis and treatment.
b. It is left to university departments and specialized
associations to determine whether or not to provide
telehealth services, each in his specialization.
c. The need to form a "higher committee for telemedicine"
that includes representatives of the concerned
authorities to regulate, approve, monitor, and guarantee
the rights of all parties.

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d. Telemedicine could only be provided through approved

platforms and applications and by licensed individuals
in accordance with the controls, regulations, and
governing laws.
e. The need to involve and educate the patient so that they
are qualified to give informed consent to the healthcare
services.
f. Making the necessary amendments to the Medical
Ethics Regulations, Articles 8 and 15 thereof.
g. The need to prepare, qualify, and train all healthcare
providers who will be licensed to provide this service.
h. The need to submit the draft law regarding telemedicine
for further discussions and dialogues to reach the
desired formula that guarantees all parties their rights,
obliges them to their duties and controls any violation.
i. The need to teach telemedicine or digital health to
students in universities within the curricula of the
colleges concerned.
j. The Medical Liability Law should be issued quickly and
it should include telemedicine services.

Future prospects: Virtual clinics and the Metaverse

The ethical considerations regarding the virtual clinics in the

Metaverse are generally similar to those of telemedicine
especially when using virtual reality “VR” or augmented
reality “AR” glasses. Otherwise, in the metaverse, both the
doctor and the patient are represented in avatars and the
credentials are hard to authenticate. In these settings,
physicians should always act in a manner that would be
deemed proper by medical professionals.
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Furthermore, Health-related wearable devices and their

apps have shown significant regulatory and data privacy
challenges, and only a small number of the marketed apps or
wearables have received any accreditation or governmental
official reviews.

Moreover, reliance on private entities that own the

Metaverse to provide private virtual care powered by Artificial
Intelligence (AI) technology can overtake the powers of both
doctors and patients and the quality of their relationships.
Additionally, AI-driven Metaverse carries the risk of sharing
inaccurate information that could be harmful. The future
necessitates new and up-to-date governance arrangements and
scientific oversight at an international level that requires the
creation of virtual ethics committees.

In Conclusion, the benefits of remote monitoring must

be carefully evaluated against respect for privacy,
confidentiality, and security. Moral and human ethical issues
and well-being of a patient being treated at home rather than in
a hospital or some other institution should be added to these
concerns. A physician or caregiver practicing telemedicine
must ensure that his patient is aware of the proposed
relationship, and obtain consent from the patient to participate
in any telemedicine study.

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