PART III

G. Special Areas

24.  Fitness to practise

24.1  Medical practitioners whose mental or physical health are such that patients would be put at risk if they continue with their normal practice should either wholly or partially alter or withhold their practice and undergo treatment and rehabilitation where appropriate.
24.2  In 1996 provisions were introduced into the Medical Registration Ordinance giving powers to the Medical Council to take action in relation to a registered medical practitioner who, by reason of health, is physically or mentally unfit to practise medicine, surgery or midwifery. The Council takes action both in response to information from concerned colleagues and also where, during disciplinary proceedings, it appears that an illness may be the underlying cause. Section 21A of the Medical Registration Ordinance sets out the powers of the Medical Council in relation to a doctor's fitness to practise; Part V of the Medical Practitioners (Registration and Disciplinary Proceedings) Regulation sets out the procedures of the Health Committee.
 
25.  Religion

25.1  All religions should be respected in all respects.
25.2  The patient's clinical benefit is of the utmost importance. If a medical practitioner, because of his own religious belief, should have any objection to a procedure which is beneficial to the patient, he should give a full explanation to the patient and ask the patient to seek advice from another qualified medical practitioner.
25.3  Special demands from religious groups concerning medical treatment should be seriously considered.
 
26.  Care for the terminally ill

26.1  Where death is imminent, it is the doctor's responsibility to take care that a patient dies with dignity and with as little suffering as possible. The rights of the terminally ill patients for adequate symptom control should be respected. This includes problems arising from physical, emotional, social and spiritual aspects.
26.2  Euthanasia is defined as "direct intentional killing of a person as part of the medical care being offered". The Council does not support this practice which is illegal and unethical.
26.3  The withholding or withdrawing of artificial life support procedures for a terminally ill patient is not euthanasia. Withholding/withdrawing life sustaining treatment taking into account the patient's benefits, wish of the patient and family, when based upon the principle of the futility of treatment for a terminal patient, is legally acceptable and appropriate.
26.4  It is important that the right of the terminally ill patient be respected. The views of his relatives should be solicited where it is impossible to ascertain the views of the patient. The decision of withholding or withdrawing life support should have sufficient participation of the patient himself, if possible, and his immediate family, who should be provided with full information relating to the circumstances and the doctor's recommendation. In case of conflict, a patient's right of self-determination should prevail over the wishes of his relatives. A doctor's decision should always be guided by the best interest of the patient.
26.5  Doctors should exercise careful clinical judgement and whenever there is disagreement between doctor and patient or between doctor and relatives, the matter should be referred to the ethics committee of the hospital concerned or relevant authority for advice. In case of further doubt, direction from the court may be sought, as necessary.
26.6  Doctors may seek further reference from the Hospital Authority, the Hong Kong Medical Association and the relevant colleges of the Hong Kong Academy of Medicine.
 
27.  Organ transplant and organ donation

27.1  Doctors should observe the following principles and familiarise themselves with the provisions of the Human Organ Transplant Ordinance (Cap. 465) particularly section 4 of the Ordinance which is reprinted at Appendix D. Commercial dealings in human organs are prohibited, both inside and outside the HKSAR.
27.2  The benefit and welfare of every individual donor, irrespective of whether he is genetically related to the recipient, should be respected and protected in organ transplantation.
27.3  Consent must be given freely and voluntarily by any donor. If there is doubt as to whether the consent is given freely or voluntarily by the donor, the doctor should reject the proposed donation.
27.4  In the case of a referral for an organ transplant outside the HKSAR from any donor, a doctor would be acting unethically if he made the referral without ascertaining the status of the donor or following these principles.
 
28.  Pre-natal diagnosis, intrauterine intervention, scientifically assisted reproduction and related technology

28.1  When there is any commercial arrangement, a doctor must not be involved in any way with scientifically assisted reproduction and its related technology, including sex selection and surrogacy. A non-commercial arrangement may be acceptable if there is strict control and monitoring which ensures due respect for human life and the welfare of all parties concerned.
28.2  Prenatal diagnosis is done for diagnosis, treatment, and detection of disease. The procedures must be safe. The result must be reliable and the result has to be discussed with relevant colleagues and the parents concerned.
28.3  Prenatal treatment has to balance the risk of intervention and the consequence of not having such intervention.
28.4  Care for the pregnant woman and the foetus are equally important.
28.5  Procedures of prenatal intervention are well documented. The matter is whether the medical condition justifies intervention.
28.6  In certain western countries, prenatal screening is conducted on the basis of family history and known incidents of certain disease in the community. In Hong Kong, prenatal screening is done mainly on index patients, i.e. those who have family history of the disease, or pregnant women above a certain age.
28.7  Sex selection for social/cultural or other non-medical reasons is not supported. Sex selection may be indicated in cases when it is known that there is a high probability that a specific disease will affect the male foetus more than a female foetus.
28.8  The advice for termination of pregnancy would be given in a case where the foetus is liable to or has a seriously handicapping disease.
28.9  Where a foetus has defects but is in the group of normal survival recommendation for termination of pregnancy should not normally be given.
28.10  If, after having discussed with colleagues, the existence of the disease in the foetus of the index patient is confirmed, discussion with the pregnant woman concerned should then be conducted; and termination of pregnancy would proceed with the pregnant woman's consent.
28.11  Hence, prenatal diagnosis and subsequent intervention can be justified if the following important steps or factors are thoroughly examined :-
  1. indications;
  2. nature of the disease;
  3. reliability of the diagnosis;
  4. risk of the procedure;
  5. result and discussion with the parents concerned.
28.12  Prenatal diagnosis do not necessarily end in termination of pregnancy. Sometimes the known disease of the foetus can be managed by treatment such as prenatal transfusion of blood.
28.13  Medical practitioners performing termination of pregnancy must observe the principles laid down in the laws of Hong Kong governing this aspect, particularly those relevant provisions in the Offences Against the Persons Ordinance (Cap. 212).
28.14  The decision as to whether the pregnancy should be terminated is medical decision or medical judgement; the matter is also protected under the law, but the decision to do prenatal diagnosis is separate issue which should be governed by other considerations as mentioned above.
28.15  Medical practitioner may refer a patient to another colleague for advice or decision on termination of pregnancy as he considers appropriate.
28.16  Prenatal diagnosis is done not for determination of the status of the foetus, but for health care. Informed consent from the pregnant woman concerned is important in the decision of prenatal diagnosis. Likewise, the pregnant woman has the right to decline prenatal screening.
28.17  Specific advice or views from the College of Obstetricians and Gynaecologists and the College of Paediatricians should also be sought regarding the subjects under consideration.
28.18  Counselling is considered necessary and the following points should be noted :-
  1. Termination of pregnancy after prenatal diagnosis should be available as a choice. Proper counselling should be offered to the pregnant women and families to prepare them for possible physical and psychological sequelae.
  2. Pre and post tests counselling should be an integral part of the procedure.
  3. Full information should be disclosed at all stages of counselling. Such information should include facts about the foetal condition and the risks, limitations and accuracy of the proposed procedure.
  4. Parents should be fully respected in their perception and judgement of the severity of the foetal disorders, and a decision on further management of pregnancy should be made by the parents. The final decision should be that of the pregnant woman. The medical professionals are, however, under no obligation to perform termination of pregnancy against their own beliefs or if their views on the severity of the foetal disorder differ from those of the parents.
 
29.  Serious contagious/infectious diseases

29.1  All patients, including those with serious contagious/infectious diseases, are entitled to timely and appropriate investigations and treatment. A patient should not be denied of care even if his own actions and lifestyle may have contributed to the disease condition.
29.2  In any given case when it appears that others - spouses, those close to the patient, other doctors and health care workers - may be at risk if not informed that a patient has a serious infection, the doctor should discuss the situation fully and completely with the patient laying particular stress, in the case of other medical or allied health staff, on the need for them to know the situation so that they may, if required, be able to treat and support the patient. In the case of spouses, or other partners, similar considerations will apply, and the doctor should endeavour here also to obtain the patient's permission for the disclosure of the facts to those at risk.
29.3  Difficulties may clearly arise if the patient, after full discussion and consideration, refuses to consent to disclosure. If mutual trust between doctor and patient has been established such a case will, hopefully, be rare. In this case, it is covered by the general ethical standards of the profession and should be respected. Should permission be refused, however, the doctor will have to decide how to proceed, in the knowledge that the decision reached, may have to be justified subsequently. Should it appear that the welfare of other health workers may be properly considered to be endangered, the Council would not consider it to be unethical if those who might be at risk of infection, whilst treating the patient, were to be informed of the risk to themselves. They in their turn would, of course, be bound by the general rules of confidentiality.
29.4  In the exceptional circumstances of spouses or other partners being at risk, the need to disclose the position to them might be more pressing, but here again the doctor should urgently seek the patient's consent to disclosure. If this is refused, the doctor may, given the circumstances of the case, consider it a duty to inform the spouse or other partner.
29.5  Doctors involved in the diagnosis and treatment of HIV infection or AIDS must endeavour to ensure that all allied health and ancillary staff, e.g. in laboratories, fully understand their obligations to maintain confidentiality at all times.
 
30.  Doctors with serious contagious/infectious diseases

30.1  Responsibilities and rights of medical practitioners infected with serious contagious /infectious diseases.

30.1.1  Responsibilities

Medical practitioners should consider receiving counselling and testing if they have reason to suspect that they have been infected.

An infected medical practitioner should seek appropriate counselling and to act upon it when given. It is unethical if one fails to do so as patients are put at risk. The doctor who has counselled an infected colleague on general management and job modification and who is aware that the advice is not being followed and patients are put at risk has a duty to inform the Medical Council for appropriate action.
30.1.2  Expert advice and counselling

Information and counselling should be made easily available for medical practitioners who may have been exposed to serious contagious diseases through risk behaviour, exposure to contaminated blood/blood products or occupational accidents. The importance of voluntary, confidential and anonymous counselling and testing should be underlined.
30.1.3  Confidentiality

In general, medical practitioners are not required to disclose their serious contagious diseases to their employers or clients. HIV infection and AIDS are not notifiable diseases by law in Hong Kong, and reporting is on a voluntary basis. There are, however, occasions where the serious contagious disease has to be made known on a need-to- know basis, and this will normally be with the consent of the infected practitioner. For example, doctors or specialists involved in evaluating an infected medical practitioner may need to know his serious contagious disease. In exceptional circumstances, breach of confidentiality may be warranted, for instance, when an infected medical practitioner refuses to observe the restrictions and patients have been put at risk.

Maintaining confidentiality is essential in encouraging the medical practitioners to receive proper counselling and management.
30.1.4  Right to work

The status and rights of an infected medical practitioner as an employee should be safeguarded. If work restriction is required, employers should make arrangement for alternative work, with provision for retraining and redeployment.

Restriction or modification, if any, should be determined on a case-by-case basis.


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