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Singapore

Healthcare System

Our Philosophy

The Ministry of Health believes in ensuring quality and affordable basic medical services for all.
At the same time, the Ministry promotes healthy living and preventive health programmes as well as maintains high standards of living, clean water and
hygiene to achieve better health for all.

Structure and Budget


Singapores healthcare system is designed to ensure that everyone has access to different levels of
healthcare in a timely, cost-effective and seamless manner. More
Healthcare Services and Facilities
Healthcare services are accessible through a wide network of primary, acute and step-down care
providers. More
Healthcare Regulation
The Ministry of Health and its statutory boards regulate both the public and private providers of
healthcare in Singapore. More
Quality and Innovation
To ensure that patients are treated safely with good healthcare standards, the Ministry strives to
promote better quality and innovation through various initiatives. More
Achievement and Accolades
Our healthcare model has won international praise and recognition. More
International Media Reports
Our healthcare system has been featured widely by many publications. Here are some stories we
would like to share. More
Compliments from the Public
Members of the public and patients have written in to MOH and various media forums to share their
stories. More

Singapore Healthcare Guide


Singapore has a world-class healthcare system that is being reviewed as a model by the Obama
administrations healthcare team as it explores ways to reform the US healthcare system. In 2000,
Singapores healthcare system was ranked by the World Health Organization (WHO) as the best in
Asia - ahead of Hong Kong and Japan. In 2003, the Political and Economic Risk Consultancy (PERC)
ranked Singapore healthcare as third best in the world. Currently, Singapore hosts 12 hospitals and
medical facilities that are accredited by the Joint Commission International (JCI), thus accounting
for one-third of all JCI-accredited medical institutions in Asia. In general, any type of medical
treatment that you may require is available in Singapore at a reasonable cost and very good quality of
service.
The objective of this article is to briefly introduce a newcomer to healthcare system in Singapore.
Healthcare infrastruture in Singapore consists of both public and private healthcare facilities with
both offering high quality of medical care but generally different level of service and comfort. Health
plans, insurance, and benefits vary largely and depend typically on your immigration status and the
employer. Singapore citizens and permanent residents are entitled to subsidized government
healthcare services through compulsory national savings scheme whereas foreigners holding various
work passes get the health coverage either through their employer or purchase it privately on their
own. It is not mandatory for employers in Singapore to provide health insurance benefits. As a
general rule of thumb, the larger the company, the higher the probability that the company offers
some type of health insurance benefits to its staff.

Healthcare Facilities

Government healthcare facilities

Government healthcare facilities are primarily designed to provide subsidised healthcare services to
Singaporeans. These facilities consist of a number of government hospitals for inpatient services and
numerous polyclinics offering outpatient services. Although wholly owned by the government, the
public sector hospitals are operated as private limited companies in order to compete with the
private sector on service and quality. They are a far cry from what is generally known as a
government hospital in other countries. Government healthcare facilities not only provide very
good healthcare services to masses but also handle the most complicated cases referred from other
hospitals and neighboring countries. A list of major public hospitals and centres is available at the end
of this article.
Government health system also sets the benchmark for the private sector on professional medical
standards and fees. Specifically, the government influence most long-term trends such as the supply
of hospital beds, the introduction of high-tech/high-cost medicine, and the rate of cost increases in
the public sector which sets the bench mark in terms of pricing for the private sector. Charges in
public health services are subsidised by the government while in the private hospitals and outpatient
clinics, patients pay the amount charged by the hospitals and doctors on a fee-for-service basis.

Private healthcare Facilities

Private healthcare facilities in Singapore are as good as any in the world with excellent level of
medical care and service levels. For non-Singaporeans, the difference in cost between government
and private healthcare facilities is negligible as they directly compete with each other. Since private
healthcare facilities in general offer better service level and minimum waiting times, most of the
expatriates living in Singapore (as well as medical tourists from abroad) prefer to visit a private
healthcare facility.
Private healthcare facilities consist of numerous private clinics offering outpatient services as well as
private hospitals. Majority of the private hospitals are JCI-accredited. A list of major private hospitals
and clinics is available at the end of this article.

Healthcare Coverage
Government health insurance

Singapore citizens and permanent residents are entitled to subsidized healthcare services provided
through government healthcare facilities. Depending on various factors, the amount of subsidy can
roughly range from 50% to 80%. Further help in co-paying the balance of the medical bill is
enabled through a compulsory savings scheme called Central Providence Fund (CPF). Depending on

factors such as age and income, a percentage of the monthly salary of an employee is contributed to
the CPF. Note that the CPF is not nationally redistributive in that whatever amount you contribute will
be for your own or dependents use only, it will not be used to subsidize the benefits for another
employee who may have earned less than you. Part of the CPF contributions goes towards medical
insurance schemes namely Medisave, Medishield, ElderShield and Medifund that collectively can
handle major part of the co-pay amounts.
To illustrate an example, Mr. X who is a Singapore citizen earns S$4,167 a month. He is then
hospitalised where he chooses to stay in a Class C ward. Below is a breakdown of what he can expect
to pay and what he can expect to be subsidised under two different scenarios:
Medisave Bill Subsidy (source: Ministry of Health)


To know more about subsidized healthcare system for Singaporeans, refer to Ministry of Health
website.

Private health insurance


If you are a foreigner working in Singapore, you are exempted from CPF contributions but this also
means that you do not have access to the governments subsidized health insurance scheme as
above. The good news is that day-to-day healthcare services are quite affordable in Singapore even if
you dont have any health insurance. However you must think about your health insurance options to
handle any critical illnesses for you and your family.
If your Singapore employer is a medium to large size company, its likely that the company will
provide a health insurance policy that covers you and your family. You should check health insurance
benefits with your potential employer if you are in the process of relocating to Singapore. If you have
your own business or are considering providing health benefits to your employees, you should

seriously consider taking up a private health insurance policy to cover for at least critical illnesses.
There is a variety of choices and healthy competition among internationally recognized health
insurance companies who can offer you a policy that suits your needs. Depending on your age,
lifestyle habits, and the type of policy, the monthly cost of a critical illness private health insurance
may range from S$75 to S$400 per insured. Below is a list of some of the established private insurers
in Singapore:
Allianz
Aviva
Great Eastern
Prudential
Finding the right medical insurance policy can be a very time-consuming task and prone to error as
the insurance companies usually have many exclusions and exceptions in their coverage policies. Its
very important to read the fine print to be sure you know what you are getting in the policy. A good
alternative is to engage an independent insurance broker who has in-depth knowledge of policies
from various insurance companies and can recommend you a policy thats best suited to your
particular requirements.

Major Hospitals

Government Hospitals

Public healthcare facilities are divided into 2 clusters which are the National Health Care Group (NHG)
and Singapore Health Services (SingHealth). These clusters were made to foster vertical integration of
services, enhance synergy and economies of scale in-line with the governments aim to spur
innovation and improve the quality of healthcare while keeping medical costs affordable. NHG and
SingHealth run these hospitals and specialty centres as private companies but remain wholly-owned
by the government.
Below is the breakdown of public hospitals and centres under the NHG and Singhealth:
National Health Group

SingHealth

Alexandra Hospital

Changi General Hospital

National University Hospital

KK Womens and Childrens Hospital

Tan Tock Seng Hospital

Singapore General Hospital

Institute of Mental Health/Woodbridge Hospital Polyclinics SingHealth


National Skin Centre

National Cancer Centre Singapore

NHG Polyclinics

National Dental Centre

The Cancer Institute

National Heart Centre

The Eye Institute

National Neuroscience Institute

The Heart Institute

Singapore National Eye Centre

Private Hospitals
Below is a list of major private hospitals and medical centres in Singapore:
Major Private Hospitals

Major Private Medical Centres

Mount Elizabeth Hospital

Camden Medical Centre

Gleneagles Hospital and Medical Centre

Thomson Medical Centre

Mount Alvernia Hospital and Medical Centre Novena Medical Centre


Raffles Hospital

Johns Hopkins Singapore International Medical Centre

You may also visit the MOHs hospital directory for a comprehensive list.

Healthcare cost examples

Charges listed here are for general information purposes only and perhaps more relevant to non-
insured individuals. For government subsidized as well as privately insured patients, clearly the
majority of the medical services bill will be absorbed by the third party.

Primary healthcare costs

Day-to-day healthcare services are relativey affordable in Singapore. A routine check-up with a
General Practicioner plus (generic) medicine will likely cost you around S$20-S$30 while blood-work
and x-ray will cost you around S$50-S$80. Roughly 20% of primary health care is provided through the
government polyclinics, while the remaining 80% is provided through some 2,000 private medical
clinics. Specialist consultation in a private clinic might cost you between S$75 -S$125.

Hospitalization costs

Hospitalization charges vary depending on the type of ward choosen. Wards in Singapore vary from
open wards with no air-con in place to a private medical suite that resembles a royal suite at a 5-star
hotel. Accordingly the daily charges for a ward can vary from S$30 to S$3000. Charges between
government and private hospitals for non-subsidized patients are very similar. For more details on
charges by various Singapore hospitals, refer to MOH web page.

Major surgery costs

Singapore provides a unique value-proposition for major surgeries to patients arounds the world. The
city-state is able to provide world-class healthcare service at a relatively affordable cost. The table
below provide a rough comparision chart for illustration purposes:
Medical Procedure

USA

Singapore Thailand

Heart Bypass

$140,000 $25,000

$15,000

Hip Replacement

$45,000 $13,000

$13,000

Knee Replacement $40,000 $15,000

$12,000

As is evident from the above table, the cost for most procedures in Singapore is very affordable
compared to the US.
The video below highlights the salient features of Singapores healthcare system, which is hailed as
one of the most successful in the world.

Medical Ethics

Contents

1 History
2 Values in medical ethics
o 2.1 Autonomy
o 2.2 Beneficence
o 2.3 Non-Maleficence
o 2.4 Double effect
o 2.5 Conflicts between autonomy and beneficence/non-maleficence
2.5.1 Euthanasia
3 Informed consent
4 Confidentiality
5 Criticisms of orthodox medical ethics
6 Importance of communication
7 Control and resolution
o 7.1 Guidelines
o 7.2 Ethics committees
8 Medical ethics in an online world
9 Cultural concerns
o 9.1 Truth-telling
o 9.2 Online business practices
10 Conflicts of interest
o 10.1 Referral
o 10.2 Vendor relationships
o 10.3 Treatment of family members
o 10.4 Sexual relationships
11 Futility
12 Further reading
13 See also
o 13.1 Reproductive medicine
o 13.2 Medical research
14 Sources and references
15 External links



History
See also: List of medical ethics cases

Historically, Western medical ethics may be traced to guidelines on the duty of
physicians in antiquity, such as the Hippocratic Oath, and early Christian teachings.
The first code of medical ethics, Formula Comitis Archiatrorum, was published in the
5th century, during the reign of the Ostrogothic king Theodoric the Great. In the
medieval and early modern period, the field is indebted to Muslim medicine such as
Ishaq ibn Ali al-Ruhawi (who wrote the Conduct of a Physician, the first book
dedicated to medical ethics) and Muhammad ibn Zakariya ar-Razi (known as Rhazes
in the West), Jewish thinkers such as Maimonides, Roman Catholic scholastic
thinkers such as Thomas Aquinas, and the case-oriented analysis (casuistry) of
Catholic moral theology. These intellectual traditions continue in Catholic, Islamic
and Jewish medical ethics.

By the 18th and 19th centuries, medical ethics emerged as a more self-conscious
discourse. In England, Thomas Percival, a physician and author, crafted the first

modern code of medical ethics. He drew up a pamphlet with the code in 1794 and
wrote an expanded version in 1803, in which he coined the expressions "medical
ethics" and "medical jurisprudence".[1] However, there are some who see Percival's
guidelines that relate to physician consultations as being excessively protective of
the home physician's reputation. Jeffrey Berlant is one such critic who considers
Percival's codes of physician consultations as being an early example of the anti-
competitive, "guild"-like nature of the physician community.[2][3]

In 1815, the Apothecaries Act was passed by the Parliament of the United Kingdom.
It introduced compulsory apprenticeship and formal qualifications for the
apothecaries of the day under the license of the Society of Apothecaries. This was
the beginning of regulation of the medical profession in the UK.

In 1847, the American Medical Association adopted its first code of ethics, with this
being based in large part upon Percival's work [2]. While the secularized field
borrowed largely from Catholic medical ethics, in the 20th century a distinctively
liberal Protestant approach was articulated by thinkers such as Joseph Fletcher. In
the 1960s and 1970s, building upon liberal theory and procedural justice, much of
the discourse of medical ethics went through a dramatic shift and largely
reconfigured itself into bioethics.[4]

Well-known medical ethics cases include:

Albert Kligman's dermatology experiments
Deep sleep therapy
Doctors' Trial
Henrietta Lacks
Human radiation experiments
Jesse Gelsinger
Moore v. Regents of the University of California
Surgical removal of body parts to try to improve mental health
Medical Experimentation on Black Americans
Milgram experiment
Radioactive iodine experiments
The Monster Study
Plutonium injections
The Stanford Prison Experiment
Tuskegee syphilis experiment
Willowbrook State School
Greenberg v. Miami Children's Hospital Research Institute

Since the 1970s, the growing influence of ethics in contemporary medicine can be
seen in the increasing use of Institutional Review Boards to evaluate experiments on
human subjects, the establishment of hospital ethics committees, the expansion of
the role of clinician ethicists, and the integration of ethics into many medical school
curricula.[5]
Values in medical ethics


A common framework used in the analysis of medical ethics is the "four principles"
approach postulated by Tom Beauchamp and James Childress in their textbook
Principles of biomedical ethics. It recognizes four basic moral principles, which are to
be judged and weighed against each other, with attention given to the scope of their
application. The four principles are:[6]

Respect for autonomy - the patient has the right to refuse or choose their
treatment. (Voluntas aegroti suprema lex.)
Beneficence - a practitioner should act in the best interest of the patient. (Salus
aegroti suprema lex.)
Non-maleficence - "first, do no harm" (primum non nocere).
Justice - concerns the distribution of scarce health resources, and the decision of
who gets what treatment (fairness and equality).

Other values which are sometimes discussed include:

Respect for persons - the patient (and the person treating the patient) have the
right to be treated with dignity.
Truthfulness and honesty - the concept of informed consent has increased in
importance since the historical events of the Doctors' Trial of the Nuremberg trials
and Tuskegee syphilis experiment.

Values such as these do not give answers as to how to handle a particular situation,
but provide a useful framework for understanding conflicts.

When moral values are in conflict, the result may be an ethical dilemma or crisis.
Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally,
the values of the medical community (i.e., the hospital and its staff) conflict with the
values of the individual patient, family, or larger non-medical community. Conflicts
can also arise between health care providers, or among family members. Some
argue for example, that the principles of autonomy and beneficence clash when
patients refuse blood transfusions, considering them life-saving; and truth-telling
was not emphasized to a large extent before the HIV era.
Autonomy

The principle of autonomy recognizes the rights of individuals to self-determination.
This is rooted in society's respect for individuals' ability to make informed decisions
about personal matters. Autonomy has become more important as social values
have shifted to define medical quality in terms of outcomes that are important to
the patient rather than medical professionals. The increasing importance of
autonomy can be seen as a social reaction to a "paternalistic" tradition within
healthcare.[citation needed] Some have questioned whether the backlash against
historically excessive paternalism in favor of patient autonomy has inhibited the
proper use of soft paternalism to the detriment of outcomes for some patients.[7]
Respect for autonomy is the basis for informed consent and advance directives.

Autonomy is a general indicator of health. Many diseases are characterised by loss of


autonomy, in various manners. This makes autonomy an indicator for both personal
well-being, and for the well-being of the profession. This has implications for the
consideration of medical ethics: "is the aim of health care to do good, and benefit
from it?"; or "is the aim of health care to do good to others, and have them, and
society, benefit from this?". (Ethics - by definition - tries to find a beneficial balance
between the activities of the individual and its effects on a collective.)

By considering autonomy as a gauge parameter for (self) health care, the medical
and ethical perspective both benefit from the implied reference to health.

Psychiatrists and clinical psychologists are often asked to evaluate a patient's
capacity for making life-and-death decisions at the end of life. Persons with a
psychiatric condition such as delirium or clinical depression may not have the
capacity to make end-of-life decisions. Therefore, for these persons, a request to
refuse treatment may be taken in consideration of their condition and not followed.
Unless there is a clear advance directive to the contrary, persons who lack mental
capacity are generally treated according to their best interests. On the other hand,
persons who have the mental capacity to make end-of-life decisions have the right
to refuse treatment and choose an early death if that is what they truly want. In such
cases, psychiatrists and psychologists are typically part of protecting that right.[8]
Beneficence

The term beneficence refers to actions that promote the well being of others. In the
medical context, this means taking actions that serve the best interests of patients.
However, uncertainty surrounds the precise definition of which practices do in fact
help patients.

James Childress and Tom Beauchamp in Principle of Biomedical Ethics (1978) identify
beneficence as one of the core values of health care ethics. Some scholars, such as
Edmund Pellegrino, argue that beneficence is the only fundamental principle of
medical ethics. They argue that healing should be the sole purpose of medicine, and
that endeavors like cosmetic surgery, contraception and euthanasia fall beyond its
purview.
Non-Maleficence
Main article: Primum non nocere

The concept of non-maleficence is embodied by the phrase, "first, do no harm," or
the Latin, primum non nocere. Many consider that should be the main or primary
consideration (hence primum): that it is more important not to harm your patient,
than to do them good. This is partly because enthusiastic practitioners are prone to
using treatments that they believe will do good, without first having evaluated them
adequately to ensure they do no (or only acceptable levels of) harm. Much harm has
been done to patients as a result, as in the saying, "The treatment was a success, but
the patient died." It is not only more important to do no harm than to do good; it is
also important to know how likely it is that your treatment will harm a patient. So a
physician should go further than not prescribing medications they know to be

harmful - he or she should not prescribe medications (or otherwise treat the patient)
unless s/he knows that the treatment is unlikely to be harmful; or at the very least,
that patient understands the risks and benefits, and that the likely benefits outweigh
the likely risks.

In practice, however, many treatments carry some risk of harm. In some
circumstances, e.g. in desperate situations where the outcome without treatment
will be grave, risky treatments that stand a high chance of harming the patient will
be justified, as the risk of not treating is also very likely to do harm. So the principle
of non-maleficence is not absolute, and balances against the principle of beneficence
(doing good), as the effects of the two principles together often give rise to a double
effect (further described in next section).

Depending on the cultural consensus conditioning (expressed by its religious,
political and legal social system) the legal definition of non-maleficence differs.
Violation of non-maleficence is the subject of medical malpractice litigation.
Regulations therefore differ over time, per nation.
Double effect
Main article: Principle of double effect

Double effect refers to two types of consequences which may be produced by a
single action,[9] and in medical ethics it is usually regarded as the combined effect of
beneficence and non-maleficence.[10]

A commonly cited example of this phenomenon is the use of morphine or other
analgesic in the dying patient.[11] Such use of morphine can have the beneficial
effect of easing the pain and suffering of the patient, while simultaneously having
the maleficent effect of hastening the death of the patient through suppression of
the respiratory system.
Conflicts between autonomy and beneficence/non-maleficence

Autonomy can come into conflict with beneficence when patients disagree with
recommendations that health care professionals believe are in the patient's best
interest. When the patient's interests conflict with the patient's welfare, different
societies settle the conflict in a wide range of manners. Western medicine generally
defers to the wishes of a mentally competent patient to make his own decisions,
even in cases where the medical team believes that he is not acting in his own best
interests. However, many other societies prioritize beneficence over autonomy.

Examples include when a patient does not want a treatment because of, for
example, religious or cultural views. In the case of euthanasia, the patient, or
relatives of a patient, may want to end the life of the patient. Also, the patient may
want an unnecessary treatment, as can be the case in hypochondria or with
cosmetic surgery; here, the practitioner may be required to balance the desires of
the patient for medically unnecessary potential risks against the patient's informed
autonomy in the issue. A doctor may want to prefer autonomy because refusal to
please the patient's will would harm the doctor-patient relationship.


Individuals' capacity for informed decision making may come into question during
resolution of conflicts between autonomy and beneficence. The role of surrogate
medical decision makers is an extension of the principle of autonomy.

On the other hand, autonomy and beneficence/non-maleficence may also overlap.
For example, a breach of patients' autonomy may cause decreased confidence for
medical services in the population and subsequently less willingness to seek help,
which in turn may cause inability to perform beneficence. Beneficence is a task
worthy of many to complete due to its difficulty to perform under extreme
circumstances that are not correlated directly with individuals seeking euthanasia.

The principles of autonomy and beneficence/non-maleficence may also be expanded
to include effects on the relatives of patients or even the medical practitioners, the
overall population and economic issues when making medical decisions.
Euthanasia
Main article: Euthanasia
Unbalanced scales.svg

The neutrality of this section is disputed. Please do not remove this message
until the dispute is resolved. (February 2012)

Some American physicians[who?] interpret the non-maleficence principle to exclude
the practice of euthanasia, though not all concur. Probably the most extreme
example in recent history of the violation of the non-maleficence dictum was Dr.
Jack Kevorkian, who was convicted of second-degree homicide in Michigan in 1998
after demonstrating active euthanasia on the TV news show 60 Minutes.

In some countries such as the Netherlands, euthanasia is accepted as standard
medical practice.[citation needed] Legal regulations assign this to the medical
profession. In such nations, the aim is to alleviate the suffering of patients from
diseases known to be incurable by the methods known in that culture. In that sense,
the "Primum no Nocere" is based on the belief that the inability of the medical
expert to offer help, creates a known great and ongoing suffering in the
patient.[citation needed]
Informed consent
Main article: Informed consent

Informed consent in ethics usually refers to the idea that a person must be fully
informed about and understand the potential benefits and risks of their choice of
treatment. An uninformed person is at risk of mistakenly making a choice not
reflective of his or her values or wishes. It does not specifically mean the process of
obtaining consent, nor the specific legal requirements, which vary from place to
place, for capacity to consent. Patients can elect to make their own medical
decisions, or can delegate decision-making authority to another party. If the patient
is incapacitated, laws around the world designate different processes for obtaining
informed consent, typically by having a person appointed by the patient or their next

of kin make decisions for them. The value of informed consent is closely related to
the values of autonomy and truth telling.

A correlate to "informed consent" is the concept of informed refusal.
Confidentiality
Main article: Confidentiality

Confidentiality is commonly applied to conversations between doctors and patients.
This concept is commonly known as patient-physician privilege.

Legal protections prevent physicians from revealing their discussions with patients,
even under oath in court.

Confidentiality is mandated in America by HIPAA laws, specifically the Privacy Rule,
and various state laws, some more rigorous than HIPAA. However, numerous
exceptions to the rules have been carved out over the years. For example, many
states require physicians to report gunshot wounds to the police and impaired
drivers to the Department of Motor Vehicles. Confidentiality is also challenged in
cases involving the diagnosis of a sexually transmitted disease in a patient who
refuses to reveal the diagnosis to a spouse, and in the termination of a pregnancy in
an underage patient, without the knowledge of the patient's parents. Many states in
the U.S. have laws governing parental notification in underage abortion.[12][13]

Traditionally, medical ethics has viewed the duty of confidentiality as a relatively
non-negotiable tenet of medical practice. More recently, critics like Jacob Appel have
argued for a more nuanced approach to the duty that acknowledges the need for
flexibility in many cases.[14]

Confidentiality is an important issue in primary care ethics, where physicians care for
many patients from the same family and community, and where third parties often
request information from the considerable medical database typically gathered in
primary health care.
Criticisms of orthodox medical ethics

It has been argued that mainstream medical ethics is biased by the assumption of a
framework in which individuals are not simply free to contract with one another to
provide whatever medical treatment is demanded, subject to the ability to pay.
Because a high proportion of medical care is typically provided via the welfare state,
and because there are legal restrictions on what treatment may be provided and by
whom, an automatic divergence may exist between the wishes of patients and the
preferences of medical practitioners and other parties. Tassano[15] has questioned
the idea that Beneficence might in some cases have priority over Autonomy. He
argues that violations of Autonomy more often reflect the interests of the state or of
the supplier group than those of the patient.

Routine regulatory professional bodies or the courts of law are valid social recourses.
Importance of communication


Many so-called "ethical conflicts" in medical ethics are traceable back to a lack of
communication. Communication breakdowns between patients and their healthcare
team, between family members, or between members of the medical community,
can all lead to disagreements and strong feelings. These breakdowns should be
remedied, and many apparently insurmountable "ethics" problems can be solved
with open lines of communication.[citation needed]
Control and resolution

To ensure that appropriate ethical values are being applied within hospitals,
effective hospital accreditation requires that ethical considerations are taken into
account, for example with respect to physician integrity, conflicts of interest,
research ethics and organ transplantation ethics.
Guidelines

There are various ethical guidelines. For example, the Declaration of Helsinki is
regarded as authoritative in human research ethics.[16]

In the United Kingdom, General Medical Council provides clear overall modern
guidance in the form of its 'Good Medical Practice' statement. Other organisations,
such as the Medical Protection Society and a number of university departments, are
often consulted by British doctors regarding issues relating to ethics.
Ethics committees

Often, simple communication is not enough to resolve a conflict, and a hospital
ethics committee must convene to decide a complex matter.

These bodies are composed primarily of health care professionals, but may also
include philosophers, lay people, and clergy - indeed, in many parts of the world
their presence is considered mandatory in order to provide balance.

With respect to the expected composition of such bodies in the USA, Europe and
Australia, the following applies [3].

U.S. recommendations suggest that Research and Ethical Boards (REBs) should
have five or more members, including at least one scientist, one non-scientist and
one person not affiliated with the institution. The REB should include people
knowledgeable in the law and standards of practice and professional conduct.
Special memberships are advocated for handicapped or disabled concerns, if
required by the protocol under review. The European Forum for Good Clinical
Practice (EFGCP) suggests that REBs include two practicing physicians who share
experience in biomedical research and are independent from the institution where
the research is conducted; one lay person; one lawyer; and one paramedical
professional, e.g. nurse or pharmacist. They recommend that a quorum include both
sexes from a wide age range and reflect the cultural make-up of the local
community. The 1996 Australian Health Ethics Committee recommendations were
entitled, "Membership Generally of Institutional Ethics Committees". They suggest a

chairperson be preferably someone not employed or otherwise connected with the


institution. Members should include a person with knowledge and experience in
professional care, counselling or treatment of humans; a minister of religion or
equivalent, e.g. Aboriginal elder; a layman; a laywoman; a lawyer and, in the case of
a hospital-based ethics committee, a nurse.

The assignment of philosophers or religious clerics will reflect the importance
attached by the society to the basic values involved. An example from Sweden with
Torbjrn Tnnsj on a couple of such committees indicates secular trends gaining
influence.
Medical ethics in an online world

Increasingly, medical researchers are researching activities in online environments
such as discussion boards and bulletin boards, and there is concern that the
requirements of informed consent and privacy are not as stringently applied as they
should be, although some guidelines do exist.[17]

One issue that has arisen, however, is the disclosure of information. While
researchers wish to quote from the original source in order to argue a point, this can
have repercussions. The quotations and other information about the site can be
used to identify the site, and researchers have reported cases where members of the
site, bloggers and others have used this information as 'clues' in a game in an
attempt to identify the site.[18] Some researchers have employed various methods
of "heavy disguise,"[18] including discussing a different condition from that under
study,[19][20] or even setting up bogus sites (called 'Maryut sites') to ensure that
the researched site is not discovered.[21]
Cultural concerns

Culture differences can create difficult medical ethics problems. Some cultures have
spiritual or magical theories about the origins of disease, for example, and
reconciling these beliefs with the tenets of Western medicine can be difficult.
Truth-telling

Some cultures do not place a great emphasis on informing the patient of the
diagnosis, especially when cancer is the diagnosis. American culture rarely used
truth-telling especially in medical cases, up until the 1970s. In American medicine,
the principle of informed consent now takes precedence over other ethical values,
and patients are usually at least asked whether they want to know the diagnosis.
Online business practices

The delivery of diagnosis online leads patients to believe that doctors in some parts
of the country are at the direct service of drug companies. Finding diagnosis as
convenient as what drug still has patent rights on it. Physicians and drug companies
are found to be competing for top ten search engine ranks to lower costs of selling
these drugs with little to no patient involvement.[22]
Conflicts of interest

Physicians should not allow a conflict of interest to influence medical judgment. In


some cases, conflicts are hard to avoid, and doctors have a responsibility to avoid
entering such situations. Unfortunately, research has shown that conflicts of
interests are very common among both academic physicians[23] and physicians in
practice.[24] The The Pew Charitable Trusts has announced the Prescription Project
for "academic medical centers, professional medical societies and public and private
payers to end conflicts of interest resulting from the $12 billion spent annually on
pharmaceutical marketing".
Referral

For example, doctors who receive income from referring patients for medical tests
have been shown to refer more patients for medical tests.[25] This practice is
proscribed by the American College of Physicians Ethics Manual.[26]

Fee splitting and the payments of commissions to attract referrals of patients is
considered unethical and unacceptable in most parts of the world.
Vendor relationships
See also: Pharmaceutical_marketing#To_health_care_providers

Studies show that doctors can be influenced by drug company inducements,
including gifts and food.[27] Industry-sponsored Continuing Medical Education
(CME) programs influence prescribing patterns.[28] Many patients surveyed in one
study agreed that physician gifts from drug companies influence prescribing
practices.[29] A growing movement among physicians is attempting to diminish the
influence of pharmaceutical industry marketing upon medical practice, as evidenced
by Stanford University's ban on drug company-sponsored lunches and gifts. Other
academic institutions that have banned pharmaceutical industry-sponsored gifts and
food include the Johns Hopkins Medical Institutions, University of Michigan,
University of Pennsylvania, and Yale University.[30][31]
Treatment of family members

Many doctors treat their family members. Doctors who do so must be vigilant not to
create conflicts of interest or treat inappropriately.[32][33]
Sexual relationships

Sexual relationships between doctors and patients can create ethical conflicts, since
sexual consent may conflict with the fiduciary responsibility of the physician. Doctors
who enter into sexual relationships with patients face the threats of deregistration
and prosecution. In the early 1990s, it was estimated that 2-9% of doctors had
violated this rule.[34] Sexual relationships between physicians and patients' relatives
may also be prohibited in some jurisdictions, although this prohibition is highly
controversial.[35]
Futility
Further information: Futile medical care

The concept of medical futility has been an important topic in discussions of medical
ethics. What should be done if there is no chance that a patient will survive but the

family members insist on advanced care? Previously, some articles defined futility as
the patient having less than a one percent chance of surviving. Some of these cases
wind up in the courts.

Advanced directives include living wills and durable powers of attorney for health
care. (See also Do Not Resuscitate and cardiopulmonary resuscitation) In many
cases, the "expressed wishes" of the patient are documented in these directives, and
this provides a framework to guide family members and health care professionals in
the decision making process when the patient is incapacitated. Undocumented
expressed wishes can also help guide decisions in the absence of advanced
directives, as in the Quinlan case in Missouri.

"Substituted judgment" is the concept that a family member can give consent for
treatment if the patient is unable (or unwilling) to give consent themselves. The key
question for the decision making surrogate is not, "What would you like to do?", but
instead, "What do you think the patient would want in this situation?".

Courts have supported family's arbitrary definitions of futility to include simple
biological survival, as in the Baby K case (in which the courts ordered a child born
with only a brain stem instead of a complete brain to be kept on a ventilator based
on the religious belief that all life must be preserved).

In some hospitals, medical futility is referred to as "non-beneficial care."

Baby Doe Law establishes state protection for a disabled child's right to life, ensuring
that this right is protected even over the wishes of parents or guardians in cases
where they want to withhold treatment.

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