Responsibilities to Profession
Fitness to Practise

If the safety of a patient is likely to be compromised by the practice of a physician with a serious communicable disease, then that physician should excuse him/herself from the care of patients.

Similarly, if a colleague is suspected of putting a patient’s care at risk because of a serious communicable disease, then the colleague must be reported to the appropriate authority for investigation and action to be taken.

Truth Telling and Documentation

A physician must:

• be honest and trustworthy when completing reports, forms and other documents;
• be truthful about his experience, qualifications and position, particularly when applying for a job;
• take reasonable steps to verify information when signing reports and not deliberately leave out relevant information;
• complete reports, sign documents or provide evidence, in a timely manner.

Keep Up-To-Date and Maintain Competence

• It is a duty of care to the patient and a responsibility of the physician to their profession to provide an acceptable standard of care that is reasonably practical .


• Physicians should ensure that they are knowledgeable with the current guidelines, procedures and laws that concern their practice of medicine and participate in activities that enhance their competence and performance.


• It is the view of the Medical Board of Trinidad and Tobago that all physicians practicing in Trinidad and Tobago should participate in an established programme of Continuing Professional Development (CPD). Such a programme should encompass a wide range of competencies including clinical, ethical, social and inter-personal skills.


• It is through such a programme that physicians can keep their knowledge and skills relevant throughout their working lives.


• It is prudent to document participation in a CPD programme as this demonstrates efforts to maintain a reasonable standard of care.

Teaching and Peer Assessment

It is the responsibility of physicians to participate in teaching and mentoring of their juniors. They must hold themselves accountable and ‘be honest and objective when appraising or assessing the performance of colleagues’.

Whistle Blowing

• Patients must be protected from a colleague whose conduct, competence or health is questionable. The concern raised should be dealt with expeditiously, and must override personal or professional loyalties.


• Where there is a suspicion that criminal activity has taken place, and in particular in cases of alleged sexual assault, a police report must be made.


• The Medical Board of Trinidad and Tobago is not a legal entity and as such cannot determine guilt nor prosecute any physician accused of a criminal act.

Specific Ethical Concerns
Research Ethics

Following on the experiments done on humans during the second world war, the War Crimes Tribunal at Nuremberg developed the first international code of research ethics; the Nuremberg Code. There have been several guidelines developed since, that deal with research on human subjects the Medical Board of Trinidad and Tobago accepts the World Medical Association (WMA) guidelines on ethical research on human subjects.

• Physicians are obligated to show respect and act in the best interests of their patients. Similarly in research involving human subjects, it is essential that the researcher demonstrates honesty and develop a relationship with their participants that are one of mutual respect and trust.

The main reasons for the development of guidance in this area are to:

• Prevent the exploitation of participants of research;



• Protect persons who belong to vulnerable populations like young children, pregnant women and prisoners;



• Facilitate the generation of new knowledge that leads to a greater understanding of disease processes and improvement in the health status of the population.

Research ethics guiding principles

• To demonstrate respect for personhood the researcher should treat each participant as an autonomous person and in so doing obtain voluntary informed consent from the participant.



• The researcher should ensure that the risks of the study are minimal (non-maleficence) and the benefits outweigh the potential risks involved (beneficence). In addition, participants should be given an equal opportunity to take part in the research process (justice).



• The participant’s agreement to take part in the research is an active continuous process which needs to be reassessed at intervals throughout the study to ensure continued agreement.



• Participants should be allowed to make their decision to participate without the researcher exercising any undue influence to participate.



• The participant should be advised about what action to take if they experience any problems during the course of the research.



• Participants should not be discriminated against because of socioeconomic status, age, sex, culture.



• Researchers should refrain from offering compensation (gifts or tokens) that is disproportionate to the subject’s level of participation. It is however, permissible to compensate the participant for time spent away from work and money spent travelling to and from the assessment site.



• The participant should also be advised on their right to withdraw from the study at any time without this action affecting ongoing care.



• Special protection must be put into place to ensure that certain vulnerable populations are not compromised or experience undue pressure to participate in research. The populations that are particularly at risk are persons with diminished autonomy , pregnant women and their foetus, prisoners and persons who are socially or educationally disadvantaged. In the case of pregnant women and their foetus, care has to be taken to ensure that involvement in research does not put the health of either or both at risk.

Medical Termination of Pregnancy

• Sections 56 and 57 of the Offences against the Persons Act Chapter 11:08 prohibit the unlawful procuring of an abortion or assisting in procuring an abortion.



• The common law doctrine of necessity, however, recognizes that an abortion can be lawfully performed by a physician, in a medically appropriate setting, if the procedure is performed in good faith to preserve the life or health (including the mental health), of the mother.



• It is advisable for the physician performing the procedure to obtain agreement in writing from at least one senior colleague that the procedure is warranted



• According to the best interpretation of the law in Trinidad and Tobago, rape, incest or severe foetal abnormality are not of themselves a good indication for an abortion unless they threaten the life or physical or mental health of the woman involved.

Human Reproductive Cloning

The Medical Board of Trinidad and Tobago endorses the viewpoint of the international community which declared human reproductive cloning to be ‘contrary to human dignity and not to be permitted’ in 1997 at the United Nations Educational, Scientific and Cultural Organization (UNESCO) General Conference.

Refusal of Blood - Faith Based Decisions

If a competent patient refuses to receive a blood transfusion on the basis of religious belief then that patient’s wishes must be respected. However if in the case of a pregnant woman, the unborn foetus’ life is thought to be at risk then a court of law can determine that the wishes of the mother may be overridden. Similarly, in the case of a minor . Under the doctrine of parens patriae the courts can overrule parent(s) refusal of blood products.

End of Life Care

Medical Futility

The determination of medical futility is a difficult one. If a treatment does not benefit a patient; causes unnecessary pain; and does not improve the patient’s quality of life; then the treatment is considered futile. The assessment of futility however should involve discussions with the patient and/or surrogate decision makers and should reflect the patient’s best interests. In many cases the physician’s clinical discretion is important and therefore, such decisions should only be made by the most senior members of the medical care team guided by the ethos of ‘do no harm’.

Even when families are adequately informed about a patient’s prognosis, futility disputes are inevitable. Every effort should be made to communicate with the patient and family members from the beginning of a critical illness, to encourage realistic expectations and dispel subjective measures of quality of life determined by religious practices or cultural beliefs.

Medical futility should not be confused with rationing where end of life decisions are made on the basis of available resources (e.g. limited Intensive Care Unit bed space, lack of blood/blood products/medications etc.).

Where public policy does not exist to address this in the institution, physicians are urged to involve hospital administration and the ethics committee to ensure a just resolution on a case-by-case basis.

Advance Directives

• An advanced directive is a legal document that specifies the kind of care a patient wants should they become unable to communicate their wishes to health care providers.



• A physician must take into account any advance directive given in writing by the compos mentis patient. The treatment decisions for patients with diminished autonomy and those who have not made an advanced directive however must be based on an assessment of the patient’s best interest.



• Although the patient’s views are important in the decision making process, other factors need to be considered when making an assessment. Where the patient’s request for example, includes life prolonging treatment and this treatment is futile, treatment can be withheld. An advanced directive is also invalid if there are reasonable grounds to suggest that a patient’s wishes written in the past has changed.

Withholding or withdrawing life sustaining interventions

Withholding or withdrawing life sustaining interventions are distinctly different from hastening the dying process or ‘physician assisted suicide’ which is illegal in Trinidad and Tobago.

Dying patients with little hope of recovery may choose to have medical interventions and resuscitation to sustain life, withheld.

If the patient is incapacitated, this decision should be undertaken by their next of kin or surrogate/care-giver. It is incumbent on the physician to reassure the caregiver that the decision to withhold/withdraw treatment will not result in the death of the dying patient - thereby diminishing feelings of culpability - but that the underlying medical condition is the ultimate cause of death.

To enable a physician to respect a patient’s choice, the physician must recognise the ethnic, religious and cultural background of the individual (as versus the next of kin/surrogate) and should endeavour to maintain the patient’s autonomy where possible.

Do Not Resuscitate (DNR) Orders

• A DNR order avoids resuscitation in the event of cardiopulmonary arrest. The order disallows advanced cardiac life support including endotracheal intubation or manual ventilation, defibrillation, chest compressions and inotropes/vasopressors (etc.)



• This is a decision that should be taken ideally after discussions with the patient particularly as the consequences of end of life decisions are greatest for the patient. The “negative right to be left alone, should rest with the patient.”

Durable Power of Attorney

A Durable Power of Attorney for Health Care (DPAHC) identifies a person specifically designated by the patient who is legally empowered to act on their behalf in making health care decisions when capacity is lost.

Transplant Medical Ethics

The purpose of guidance on transplant medical ethics is to protect the rights of both the donor and the recipient. The Medical Board of Trinidad and Tobago endorses the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation and recommends the following:

1. Cells, tissues and organs may be removed after cardiac death has been proclaimed once explicit (e.g. on a donor card) or presumed permission has been obtained from the patient. If such consent is not available, permission should be sought from a legally specified surrogate.



2. The care of the donor and recipient should be conducted by two independent physicians, This would preclude any conflict of interest. The Board acknowledges that, especially with situations of emergent organ harvesting, this may not always be possible, but at least one senior physician, not directly involved in the care of the recipient, should be consulted by the medical team before harvesting occurs.



3. In the case of ‘living donors’ they should be “genetically, legally or emotionally related to their recipients” and informed and voluntary consent must be obtained and documented.
   
4. Organ donation from minors or legally incompetent persons is prohibited except in specific situations:

a. Familial donation of regenerative cells; and
b. Kidney transplants between identical twins.

Special precautions must be taken to ensure that minors and legally incompetent persons’ are protected. An independent authority should be an advocate for the donor in this case and any objection to donation should override permission provided by parent(s) or legal guardian.


5. Purchasing of human cells, tissues or organs for transplantation is not permitted.


The Medical Board of Trinidad and Tobago concur with the findings of the WHO Sixty-third World Health Assembly meeting and the Declaration of Istanbul and condemn the buying of human body parts for organ trafficking as this violates the principles of equity, justice and respect for human dignity and agree that transplant tourism should be prohibited.


6. Altruistic donation of human cells, tissues and organs for transplantation should be encouraged.



7. Physicians are obliged to ensure that donors have not been paid, coerced or exploited, particularly in situations where live donors are not emotionally related. This should be documented on the consent form prior to donation.



8. Physicians and health care facilities should not profit from the recovery of cells, organs or tissues or implantation of transplants. Fees for these services should be justifiable.
   Ideally, these procedures should come under the purview of the National Health programme where cells, organs and tissues are considered a national resource.



9. To ensure fairness, allocation of organs, cells and tissues should be guided by clinical criteria and ethical norms which are “equitable, externally justified, and transparent”.



10. Quality systems should be put in place that ensure ongoing monitoring and evaluation of transplant programmes. These should include reporting of adverse events; outcomes for donors and recipients, nationally and for exported human products. The development of registries would support accountability and provide information concerning system capacity and demands for organs and tissues.



11. The administration and management of all transplantation activities should be transparent with respect to safety and accountability. The privacy and confidentiality of donors and their recipients however must be preserved.

Treatment of other Physicians or Family members

Given the emotional involvement and potential bias and lack of objectivity that results from dealing with those with whom you have a close personal relationship, it is generally accepted that physicians should not treat either themselves or family members, except :

• For minor conditions


• In emergency situations


• When another qualified professional is not available