Weeks 7&9 - Patients' Rights

BSN502
Health Law and Ethics in the UAE

PATIENT’S RIGHTS IN AND TO HEALTH
CARE
Semester 1/2023-2024
fchs.ac.ae
Lecture Outcomes:
Hand Hygiene
By the completion of this lecture, tutorials, and self directed

learning, the students are expected to:
1. Discuss the right to health care and the 3 senses in which the
right to health care can be claimed.
2. Explain why an economic approach is inadequate for deciding
on health care issues.
3. Explain informed consent and its components.
4. Recognize the notion of competency and implications for
patients with impaired decision making capacity.
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Lecture Outcomes cont:
Hand Hygiene
5. Outline the moral basis of confidentiality.

6. Discuss conditions under which demands to keep
information confidential may be justly overridden.
7. Identify the right to dignity and dying with dignity.
8. Examine the right to be treated with respect.
Hand Hygiene
Introduction
 In North America in 1996, a patient who had
amyotrophic lateral sclerosis sued his doctor for
keeping him alive against his expressed wishes.
 This was the first case of its kind (Reed 1996 as cited
in Johnstone 2004, p. 126 ).
Introduction
Hand Hygiene
 In Australia in 2002, it was reported that an elderly

woman in the care of a government run facility was
assaulted several times by another resident, smeared
with excrement and had many falls. The daughter
described broken toilets and call bells, and reported
rats in the facility (Miller 2002 as cited in Johnstone
2004, p. 126).
Stories of substandard care and violations of patient

rights do occur in health care and are being made
more public in recent decades.
Introduction
Hand Hygiene
 In 1970, Hospitals in UAE started to provide services with

international-standard.
 2011, HAAD and Dubai Health Authority (DHA) mandate all
hospitals to provide the Patient's Charter of Rights &
Responsibilities to all patients
 2017, new law gives patients right to die.
 Use of health regulators agencies as Health care
Authorities- Dubai Health Authority (DHA), the Dubai
Healthcare City Authority (DHCR) and the Health Authority
– Abu Dhabi (HAAD) decision regarding malpractice or
negligence cases.
What are Patient Rights Hand Hygiene
cont.?
Patient rights are those “claims that need to be
protected as specifically applied in a health care context”
(Johnstone 2004, p. 129).
 Examples of patient rights:
 Right to health care
 Right to be informed and given
 informed consent
 Right to refuse consent
What are Patient Rights Hand Hygiene
cont.?
 Examples of patient rights cont:
 Right to a second opinion
 Right to have access to an interpreter
 Right to be treated with respect, dignity &
confidentiality
 Right to know the name, status and practice
experience of the attending health professional.
Categories of Rights Hand Hygiene
Five (5) broad categories of patient rights:
1. Right to health care

2. Right to informed consent
3. Right to confidentiality
4. Right to dignity and dying with dignity
5. Right to be treated with respect
1. Right to Health Care
Hand Hygiene
In 1948 United Nations Declaration of

Human Rights acknowledged people’s
entitlement to health care
It stated: “Everyone has the right to a standard of

living adequate for the health and well-being of self
and family, including food, clothing, housing, and
medical care and necessary social services and the
right to security in the event of unemployment,
sickness, disability, widowhood, old age ... or
circumstances beyond his control”.
(Johnstone 2004, p. 130)
1. Right to Health Care Hand Hygiene
Claiming a Right to Health Care?

Johnstone (2009, p. 130) examines the nature of a claim
to health care by looking at what he calls 4 senses:
(a.) Right to equal access to health care
(b.) Right to appropriate care
(c.) Right to quality of care
(d.) Right to safe care
a. Right to Equal Access:

 All people have equal access to health care and can get
the services they need & require without discrimination
 The argument to this right to health care concerns
resource allocation (distributive justice).
a. Right to Equal Access:

The argument
 there are not enough health care resources to go around,
it is not possible to satisfy everyone’s needs, therefore,
choices have to be made regarding what services are
made available and who gets them.
Others say No; we should not accept this economic

rationalisation approach to the right to health care.
 To do so is to reduce human life to something with a
price tag attached which is an unjust moral action.
b. Right to Appropriate Care

 Concerns care that is appropriate to the
person’s health beliefs, values, and
practices.
 Need to be culturally sensitive to the
values, beliefs and practices of the
patient when giving care and making
moral decisions
 Failure to do so can have harmful
consequences to the patient. (clinically,
legally and morally).
b. Right to Appropriate Care

Appropriate care” also means patients are entitled to
choose alternative or ‘scientifically unproven’ therapies
instead of traditional approaches to disease and to
engage lay folk or professionals other than the medical
doctor in their care.
c. Right to Quality of Care

Concerns the standard of care being delivered
and the competency, accountability,
& responsibility of health care providers.
 Health care professionals must agree to and have in
place standards of practice, codes of conduct,
processes of quality assurance, formal measures of
patient outcomes, and so on
 This ensures that members who fail to provide
quality care can be appropriately censored .
 Implications for Nurses
 Johnstone (2004) asserts that nurses have a moral

obligation to respond to violations of a person’s right to
health care.
 Nurses need to participate in the debate about health
care rights, be active in decisions about resource
allocation, health care policy, and the restructuring of
health care delivery systems.
Implications for Nurses
Nurses need to:

 manage their own profession in terms of standards of
care, conduct, and mechanisms for dealing with poor
practice.
 provide members with sound education responsive to
the changing needs of society.
 help the public become informed of their entitlements
to health care.
Lets Review Hand Hygiene
Nurses ought to protect patients from violations to the right to health

care by:
A. Participating actively in decisions affecting the delivery of health

care
B. Allowing the government to decide about their scope of practice
and standards of nursing care
C. Using caution when talking about observations of unsafe
occupational and patient hazards in the workplace
D. Explaining to the public that speaking out about poor health care is
useless
2. Right to Informed Consent Hand Hygiene
What is Informed Consent?

 It is a legal document derived from the doctor’s duty to
tell the patient information about care and treatment
 The information will assist the patient to make a rational
and informed choice about undergoing such care.
 It protects the public from harm, fraud, and stress which
occur when information is not disclosed.
 It has a moral dimension which involves the principle
of a patient’s autonomy to make a choice.
The moral justification of the right to

informed consent involves:
A. Sovereignty of the Individual
 It is the view that the individual has soul guardianship of

his/her own interests and is the ultimate decision-maker.
(Kuczewski 1996).
 It implies that the individual is competent in making
decisions, and that outside interferences are not
welcome.
2. Right to Informed Consent
Hand Hygiene
Informed consent and Sovereignty of the Individual

 In some cultures, some individuals must have family
involvement in decisions of health care.
 In the palliative care, illness can impede the patient’s capacity to
judge what is in their best interests.
 Informed consent is a shared process rather than an individual
one. Kuczewski (1996)
B. Informed Consent and Ethical Principlism

 The significant underlying moral principles of informed
consent include:
 Autonomy -self-determining /having a choice
 Non-maleficence- protected from harms from
inadequate or inappropriate consent practices.
 Beneficence - maximization of patient’s wellbeing via the
consent process.
 Justice –fairness - patient not unduly or intolerably
burdened by consent practices (Johnstone, 2004, p. 141)
How is Consent “Informed”?

 Components to be satisfied for consent to be considered
“informed”
• Giving all relevant information by the health professional
• Understanding by the patient of the information given;
 knowing that consent is giving permission to the health
professional to proceed with an intervention or treatment
• Voluntariness - the patient should not be forced or
manipulated into giving consent
• Competence - the patient is lucid and rational to give
consent. ”,
Beauchamp & Childress (2001)
 Practices of obtaining consent are still problematic.

(Johnstone 2004, Kanitsaki 1992; Faden & Beauchamp
1986).
Kanitsaki (1992) reported a case where a doctor placed

a pen in a woman’s hand and guided her to make an X
on a surgical consent. The woman spoke little English,
had not been informed of the surgery, but the doctor
was too busy to wait and get an interpreter (Johnstone
2004, p. 137)
Why is gaining consent problematic for some health

professionals?
The reasons used by health professionals are:
1. the process is too time consuming.
2. patients forget the information anyway.
3. patients don’t want to know all the details of care and
treatment, risks and benefits.
4. patients really don’t understand the information well
enough to be informed
5. giving information on risks is frightening and may cause
refusal of treatment that could harm the patient
Are these reasons valid?

Time consuming
 not a morally acceptable excuse.
 health professionals should to spend whatever
time it takes to inform, answer a question, or
allay a worry.
 Patients must make the right choices for themselves in

an unhurried and reflective manner
Strategies to resolve the issue of time constraints

 Use nurses to meet patients’ information needs.
 NB* nurses do not have the legitimate authority to give
information about medical treatments.
 Nurses take a professional and legal risk by doing so.
(Faden & Beachamp, 1986)
How Can Health Professionals Facilitate Informed

Consent?
1. Make consent forms available in the language spoken by
the patient.
2. Involve a trained interpreter
 Other non professional workers may not appreciate the need
to be confidential with the information.
3. Revisit the original consent to ensure it is still valid.

4. Recognize factors that affect patient decision on consenting.
Factors that can affect the patient exercising informed

and voluntary choices
1. Fear that if they refuse a certain procedure, they may be
denied other treatments.
2. Fear of the unknown.
3. Disagreement or cultural conflict or clashes with the
suggested treatment options
4. Pain or grief states can impede decision making
5. Lack of communication:
 have poor interpersonal skills,
 are rushed or intimidating,
 lack the information necessary for the patient
The Problem of Competency

 Informed consent requires the person’s
competency to decide.
 Competency is a complicated issue because there
is no general agreement on the characteristics of a
“competent” person and no legal measures of it.
Example: Consider the elderly lady who

is demented. She may be deemed
competent to eat her meal alone, but not
competent to refuse treatment to a
broken arm sustained in a fall.
Competence is always “task specific, where the task may be physical

or mental” (Gert et al 1997 as cited Johnstone 2004, p. 147).
Consider the case of John McKewan, a ventilated quadraplegic. He had

been an outstanding Australian water skiing champion, but had an
unfortunate accident in which he broke his neck. Frustrated with his helpless
condition, John expressed a wish to die many times during his
hospitalization. He even went on a hunger strike and instructed his lawyer
to compose a “living will” to not revive him when he went into a coma. This
action initiated an assessment by a psychiatrist who deemed him
incompetent and he was force fed against his wishes. So he ended his
hunger strike and agreed to anti-depressants. A year later he went home and
was cared for 24 hours a day by his family and hired nursing help. He
continued to express his desire to die and even commented that he was
going to hire someone to help him die he was so frustrated by his
quality of life. Early one morning the nursing assistant found John had died;
he was off his ventilator.
 Would you say John was incompetent in his decision to want to die?
Was he being irrational in his thinking?
Discuss in Groups
Judgement about a person’s competency to

make a choice becomes problematic when:
1. There is disagreement between the patient and the
health professional about the course of care
2. The treatments that seem rational to accept are
refused by the patient.
3. In cases where the patient is cognitively impaired or
mentally ill
Measuring Competency and its Difficulties

There is no single standards of competence is adequate for all
decision.
In measuring competency, Grisso & Appelbaum (1998)
propose to assess a patient’s ability to:
Hand Hygiene

Measure: Difficulty:
1. Evidencing a  A comatose patient would be unable to express a
choice: choice; a semi-comatose patient may be able to
squeeze a hand or blink to indicate
understanding.
 The question then becomes is the action of
squeezing or blinking truly understanding or a
reflex action.
2. Reasonable Spending a life’s savings on shark fin therapy in

outcome of a hopes of curing cancer may be a reasonable
choice: outcome to one person but may be rejected by
another.
Hand Hygiene

Measure: Difficulty:
3. Choices based  Suicide may not always be connected to
on rational mental illness or depression.
reasons:  It could be a reasonable and rational solution
to a life of severe abuse or intolerable pain.
4. Ability to A psychiatric patient who was informed there

understand: was a 1 in 3000 chance of dying from electric
shock therapy replied happily that she hoped
she was the one.
5. Actual How will the patient have actually understood

understanding: information which has been disclosed.
Questions to guide on how to decide when it is right to

accept or reject a person’s ability to choose and
decide on treatment options, and when and how to
override a patient’s preferences
1. Is the person a danger to him/herself?
2. Does the person need care?
3. Is the person a danger to others?
Buchanan and Brock (1989)
The decision is based on the extent of “risk of harm”.
Example
To illustrate, consider the young male teenager who refuses to take his
psychotropic medication because of “awful” side effects. He has been
trying to cope with the side effects for some time, but can’t any longer.
He claims he would rather deal with his mental illness; he knows what
will happen to his mental state as he has not complied with taking other
psychotropic drugs in the past.
What do the health professionals do in the above scenario?
 Do they intervene by forcibly giving the patient the drug

by injection against his will, preventing even greater harm
of a mental crisis that is sure to follow?
 Or, let the patient stop his medication and deal with the
mental breakdown when it happens
 Is the patient is competent and able to make an informed
choice, do they?
Roles of Nurses in Informed Consent

 Know the elements of and issues, ethical principles
and moral values underlying consent practices
 Take time to inform the patients of the planned
nursing care and procedures
 Ensure patient understands the information and
provide voluntary permission.
 Ensure that the patient has the capacity to make
informed choices about such care, and if not, include
a surrogate decision maker to do so.
3. Right to Confidentiality Hand Hygiene
In 1904, a doctor writes of his refusal

to warn (inform) a woman that her
future husband had syphilis, thus
risking her and her offspring of being
exposed to the disease (Bok 1980).
The notion was, whatever is revealed in the patient-professional

relationship is to be kept secret even if might cause harm.
Is this morally correct?
Discuss in groups
Problems with breaching confidentiality

People who are HIV positive have been dismissed from
their jobs, evicted from their accommodation, and
discriminated against, because of breaches of
confidentiality.
 Today it is recognized that when an innocent person

stand to be harmed by failure to disclose, the demand
to breach confidentiality becomes morally convincing.
Read the scenario and discuss

In 1974, in California, U.S.A., a university student named
Mr. Poddar, fell in love with a young lady, Miss Tarasoff.
Unfortunately the lady did not have the same feelings
and so told Poddar. Poddar became depressed, sought
psychiatric help at the university hospital, and revealed
during his sessions that he intended to kill Tarasoff. The
psychiatrist informed the university police that Poddar
might be a danger to himself and an unnamed girl who
had rejected his advances. The police detained Poddar
for some time, but released him when he appeared
rational and promised to stay away from the girl.
The psychiatrist was advised by his superior to do no

more in the situation and to destroy the patient’s files for
confidentiality reasons. Two months later, Poddar killed
Tarasoff. The psychiatrist never warned the girl or her
parents of the threat by Poddar.
Based on this case, the Supreme Court of the United

States ruled a new law that doctors must warn potential
victims of harm.
The moral principles that demand to keep information

disclosed in a patient-professional relationship secret are:
 autonomy,
 non-maleficience,
 justice,
 and fidelity
Moral Principles Hand Hygiene
and Confidentiality
Autonomy:  Patients can choose who should have access to their
information, what information is shared
 Patients have the right to privacy of personal
information.
Non-maleficence:  People should be protected from harm that might come

from disclosure.
 If keeping a secret causes or fails to prevent an avoidable
harm, then confidentiality must be overridden.
Justice: • If the consequence of keeping a secret results in an

unequal distribution of harm over benefit, then
confidentiality must be overridden
Fidelity: • Keeping promises, is a rule that guides human conduct

however, it is not justified where an avoidable harm
occurs as a result
Summary
 Confidentiality is an important ethical requirement of
any patient-professional relationship
It is a principle that ought to be respected
 Confidentiality must not be upheld in instances where
avoidable and unnecessary harm to innocent others is
a serious consequence.
 Nurses must make decisions to disclose or not to disclose
patient information on sound moral reasoning and decision
making processes.
4. Right to Dignity and Dying Hand Hygiene
with Dignity
What does it mean - the right to dignity and to die with

dignity? (responses from some year 1 students)
 “Dignity is feeling good about yourself”
 “Dignity and dying with dignity is being happy with

oneself and what one has achieved in life”
 “Dying with dignity is having no pain, no fear, feeling
valued”
 “Dignity is concerned with self-respect”
(Johnstone 2004, p. 166)
4. Right to Dignity and Dying Hand Hygiene
with Dignity
 People ought to be supported in attempts to maintain
their self-respect and self-esteem, and in making
autonomous choices.
 The challenge for nurses:
 to know what the patient considers as being dignity
and/or dying with dignity
 to uphold those terms even if they don’t agree with the
patient’s views,
 nurses must not to impose their own opinions of what is
dignity and dying with dignity onto the patient.
Hand Hygiene
5. Right to Be Treated with Respect

 People ought to be treated with respect (regardless of
gender, religion, culture or social
 In nursing, respect is key to professional codes of ethics.
The International Council of Nurses (ICN) (2000) states: “inherent

in nursing is respect for human rights, including the right to life ...
and ... in providing care, the nurse promotes an environment in
which the human rights, values, customs, and spiritual beliefs of
the individual, family, and community are respected.” (Johnstone
2004, p. 167)
5. Right to Be Treated Hand Hygiene
with Respect
What meaning is assigned to respect?
 Every culture has ways of being that are termed
“respectful”.
 Respecting people is:
 linked with acknowledging people for who they are
responding to people in ways that preserve their
integrity and self-identity.
Showing admiration, esteem, and kind
consideration of others is to treat them
“good”.
with Respect
Disrespect is to deprive people of
their human worth.
 Those who are dominant in a
culture may randomly attribute
certain characteristics as
personally, socially, or morally
aggressive.
Examples: discriminating in giving quality care because
the patient is old, disabled, mentally ill, or from a
different culture.
with Respect
The ingredients for respectful interactions
with patients include:
1. Respect human beings as worthy
2. Value them for who they are
3. Focus on the person and be present when interacting
with them
4. Listen and take seriously what they say
5. Support actions that promote the patient’s well-being
6. Keep the relationship open and positive
Hand Hygiene
Summary
 Understanding the issues of patient’s rights to and in
health care is an important one for health professionals.
 Violations of patient rights occur in health care and
nurses have a role in promoting and protecting these
rights.
 Health professionals must not treat patients as passive
recipients of health care, but as active negotiators in their
health care.
 Respect will help to ensure that the rights of patients in
health care are protected.
Hand Hygiene
References
Beauchamp, T. & Childress, J. (2009). Principles of biomedical ethics. 6th Edition.

New York: Oxford University Press.
Burkhardt, T & Nathaniel, A. (2014). Ethics and issues in

contemporary nursing. 4th edition. Canada: Delmar Cengage Learning.
Johnstone, M. (2016). Bioethics: a nursing perspective. 6th Edition.

Australia: Churchill Livingstone. Chapter 7 & 8.

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BSN502

Health Law and Ethics in the UAE

By the completion of this lecture, tutorials, and self directed

5. Outline the moral basis of confidentiality.

 In Australia in 2002, it was reported that an elderly

Stories of substandard care and violations of patient

 In 1970, Hospitals in UAE started to provide services with

Five (5) broad categories of patient rights:

1. Right to health care

In 1948 United Nations Declaration of

It stated: “Everyone has the right to a standard of

Claiming a Right to Health Care?

a. Right to Equal Access:

a. Right to Equal Access:

Others say No; we should not accept this economic

b. Right to Appropriate Care

b. Right to Appropriate Care

c. Right to Quality of Care

 Implications for Nurses

 Johnstone (2004) asserts that nurses have a moral

Implications for Nurses

Nurses need to:

Nurses ought to protect patients from violations to the right to health

A. Participating actively in decisions affecting the delivery of health

What is Informed Consent?

The moral justification of the right to

A. Sovereignty of the Individual

 It is the view that the individual has soul guardianship of

Informed consent and Sovereignty of the Individual

one. Kuczewski (1996)

B. Informed Consent and Ethical Principlism

How is Consent “Informed”?

 Practices of obtaining consent are still problematic.

Kanitsaki (1992) reported a case where a doctor placed

Why is gaining consent problematic for some health

Are these reasons valid?

 Patients must make the right choices for themselves in

Strategies to resolve the issue of time constraints

How Can Health Professionals Facilitate Informed

3. Revisit the original consent to ensure it is still valid.

Factors that can affect the patient exercising informed

The Problem of Competency

The Problem of Competency

Example: Consider the elderly lady who

Competence is always “task specific, where the task may be physical

Consider the case of John McKewan, a ventilated quadraplegic. He had

The Problem of Competency

Judgement about a person’s competency to

Measuring Competency and its Difficulties

Measuring Competency and its Difficulties

2. Reasonable Spending a life’s savings on shark fin therapy in

Measuring Competency and its Difficulties

4. Ability to A psychiatric patient who was informed there

5. Actual How will the patient have actually understood

Questions to guide on how to decide when it is right to

What do the health professionals do in the above scenario?

 Do they intervene by forcibly giving the patient the drug

Roles of Nurses in Informed Consent

In 1904, a doctor writes of his refusal