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July 29, 2016
PHYSICIAN-PATIENT RELATIONSHIP
Maria Ana B. Mariano, MD.
Department of Bioethics and Legal Medicine

TOPIC OUTLINE Requisites of the Contractual Relationship

I. Objectives 1. Consent of the Contracting Parties – usually in the form of
II. Features of the Physician-Patient Relationship written consent especially in surgery.
a. Requisites of the Contractual Relationship
b. Instances when No Relationship Exists • Implied Consent – the act of the patient consulting the
III. Right and Duty same physician for a follow-up is a form of implied
IV. Different Rights of a Patient consent.
V. Case Scenarios 2. Object – subject matter of the contract (medical service)
VI. Quiz
• Legal – except abortion; No doctor-patient relationship

with abortion because this is illegal in our country.
OBJECTIVES • Determinate – within a time period; something material
Objectives that we can see and nothing abstract. Example: patient
• Know the nature of the physician-patient relationship consults a doctor and no findings can be seen but patient
• Know the rights of the patients keeps coming back and insist that he/she is not well, then
• Discuss the ethical issues given in a specific situation the doctor must refer the patient to a specialist.
• Value the rights of patients • Within the Commerce of Man - something we can
exchange services. For example: we cannot exchange
Specific Objectives stem cell yet because we have know idea if it really works.
• State the features of a physician-patient relationship We can exchange chemotherapy because there are a lot
• Enumerate the requisites of contractual relationship of reports/researching proving its beneficial effect.
• List instances when no relationship exists 3. Cause – factor that prompted the physician to render
• State the importance of knowing the rights of the medical service; promise of a thing or service by the other
patient 4. Consideration
• Enumerate the different rights of a patient • Remuneration – with fees (The physician is still paid
even in instance of wrong diagnosis and/or treatment for
• Cite specific examples illustrating the rights of patients
the time and efforts rendered in physical examination,

history taking, etc.)
FEATURES OF THE PHYSICIAN-PATIENT
• Act of Benevolence/Liberality – medical missions
RELATIONSHIP
(Doctors must have a benevolent heart)
• Contractual – both agree to the relationship

o Physician binds himself with respect to the patient to
Instances when No Relationship Exists
give or render some service.
• Pre-employment or pre-enrollment physical exam
o Patient solicited the service of the physician and the
• Physical exam to determine fitness to be insured
latter agreed to render such service.
• Testifying in trial courts - patient’s sanity
o How do you know the patient agrees? Patient keeps • Performing an autopsy
coming back to you and does not transfer to another • Casual conversation – i.e. social gathering
doctor.
o How do you know the doctor gives his time? The doctor RIGHT AND DUTY
attends to the patient and gives time. You cannot give 1. RIGHT – A moral and inviolable power vested in a person to
service, if you cannot give time, look what 100% to your do, hold or demand something as his own.
patient and listen. 2. DUTY – A moral obligation to do or omit something in favor
o Casual conversation with doctors (example, run into the of another according to the demand of strict justice.
hallway or party), text messaging, and medical missions
are not a doctor patient relationship. There is a formal DIFFERENT RIGHTS OF A PATIENT
setting where doctors attend to their patients 1. Right to choose his physician
(clinic/hospital). 2. Right to treatment
• Fiduciary – based on mutual trust and confidence 3. Right to give consent to diagnostic and treatment
• Consensual – based on mutual consent procedures
4. Right to disclosure of information
5. Right to confidential information

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6. Right to refuse necessary treatments procedures, which he think will serve his best interest.
7. Right to religious belief • If patient does not consent, remain quiet; leave it to the
8. Right to privacy patient to decide on his/her own. Don’t persuade. Except for
9. Other rights when confined in a hospital those who are incapable to decide such as minors.

Right to Choose His/Her Physician Right to Disclosure of Information
Basis: Principle of Autonomy • “Whatever, in connection with my professional practice, or
Principle of Paternalism (from 2D 2017) not in connection with it, I may see or hear in the lives of
• The patient is free to choose the physician to serve him. men which ought not to be spoken abroad, I will not divulge
as reckoning that all should be kept secret.”
• In case of referral to specialists, usually the patient gives the
privilege of selecting specialists to the attending physician. • Don’t label patients by their diseases. Example: cancer patient.
• The patient has the right to determine who will best treat • The physician is obliged to make a full and frank disclosure
him/her. to the patient or to any person who may act on his behalf all
the pertinent facts relative to his illness.
o Nature
RIGHT TO TREATMENT
o Extent of the disease
Republic Act No. 6615: o Contemplated procedure (medical or surgical)
• All government and private hospitals or clinics duly licensed o Probable outcome or prognosis
to operate as such are hereby required to render immediate o Side effects of treatment
emergency medical assistance (prioritize airway, breathing o After effects of treatment
and circulation) and to provide facilities and medicine o Possible complications
within its capabilities to patients in emergency cases who o Emergency situations include: bleeding, shock, DOB
are in danger of dying and/or who have suffered serious with pain
physical injuries (person wounded, beaten, assaulted by o Consequences of withholding consent to treatment
another – consequences of physical injury are: are insanity,
impotence, blindness, imbecility). Examples of Violation
• Illness - or incapacity for labor for more than 30 days. 1. Failure to point out the probable or course of treatment.
• Deformity - of incapacity to perform work in which he was 2. Pretending cure or alleviate pain to exact compliance.
habitually engaged for more than 90 days. • MD gave “Melamine” to ptx. not taking into
consideration its effect (kidney failure).
Code of Ethics 3. Concealing gravity of the condition
• In cases of emergency, wherein immediate action is 4. Untimely notice of the serious tendency of the disease
necessary, a physician should administer at the least first aid • Cancer
treatment and then refer the patient to a more qualified and • Aneurysm
competent physician. • Myocardial infarction
• Caution in divulging to patients their disease. Example:
• Any person who has been deprived of his personal liberty on young patient or mother with young children with
account of infectious or mental disease has the absolute cancer. Make sure to do necessary procedures such as
right to be treated, otherwise his confinement may be mammography, MRI. Belittling the disease and not
considered to be a “cruel and unusual punishment” which is labeling it as it is. Example for aneurysm, bukol lang yan,
prohibited by the Constitution. for MI, simple chest pain only.
• Once a physician accepts a patient, he is bound to institute 5. Failure to appraise of the different approaches
the necessary management or procedure appropriate to the • Surgical vs. Chemotherapy
patient’s condition.
• Failure to do so will constitute abandonment of patient. Disclosure of Information depends on:
• Circumstances of the case
Right to Give Consent to Diagnostic and Treatment • Character of the patient
Basis: Principle of Autonomy • Health condition of the patient
• Physicians are not authorized to institute the diagnostic or • Social position of the patient
treatment procedure, which he thinks best for the patient
without the patient’s consent (Written Consent) • Intelligence of the patient
• Before treatment, the physician is obliged to inform his • Risk involved
patients of the following: • Standards of medical practice
o Diagnosis • Effects on the patient’s condition
o General nature of the contemplated procedure
o Risks involved
Delay/Deferment in Disclosure may be done if:
o Prospect of success
o Potential danger if the procedure is not applied • It will cause mental suffering
o Alternative methods of treatment • It will prevent the patient in submitting into the much
• The patient is free to give or withhold his consent to its needed treatment
application and has the right to choose alternative • It will impair the patient’s health

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• In the absence of the patient’s choice or a proxy, the
Right to Confidential Information physician should act in the best interest of the patient.
• Privileged Communication – Relates to the right of a patient
to assert the right to keep the subject matter of the 1. Terminal Illness
relationship from being testified in court • Perform needed medical treatment
• Confidential Information- Information revealed by the • Ask for Informed consent
• Alleviate pain and suffering
patient to the doctor given in confidence and it is essential
• Terminate or omit treatment – dignified death
information given to arrive at a sound diagnosis.
• A physician should not intentionally cause death
• Physician is obliged to disclose all information to the patient
about what he perceives or observes in the latter but he is 2. Terminally Ill
not authorized to divulge such information to a third party • Patient’s best interest
who has no concern with the interest and welfare of the • Consequences of extending life under humane and
patient. comfortable conditions
• For instance, Napoles’ doctor divulged that she has a mass and • Prior expressed wishes of the patient
• Attitudes of the family
bleeding on the reproductive tract without giving specific
• Attitudes of those with custody of the patient
details.
• Doctors don’t talk to media. Media can misconstrue or 3. Dying or Comatose Patient
manipulate what we say. • Patient’s best interest
• Presence of spokesperson in a hospital institution. • Prior expressed wishes of the patient
• Attitudes of the family
Exceptions (Required by law in the): • Attitudes of those with custody of the patient
1) Interest of justice • Confirmation of the accuracy of the diagnosis
• Victims of serious and less serious physical injuries. • Doctors don’t take lives; let death take its natural course.
• Victims of child abuse or maltreatment
2) Public health: Contagious communicable diseases LIFE SUPPORT – are medications, artificial respirations, and
3) Public safety: Terrorism technologically supplied nutrition and hydration that make the
• Example: treating an NPA or fugitive. Remain quiet. patient alive.

Right to Refuse Necessary Treatments ISSUES: 1) Do the benefits of treatment outweigh the burdens?
2) Does the patient have the benefit of a dignified death?
Basis: Principle of Autonomy

• In the legal sense, every human being of adult age and of
Right to Religious Belief
sound mind has the right to determine what must be done in
his own body. Two Aspects of Freedom of Religion
• A physician is morally and ethically bound to exert all effort 1. Freedom to Believe – ABSOLUTE!
within his means to persuade the patient to give consent to 2. Freedom to Act in accordance with One’s Belief – NOT
the application of a treatment procedure. Show sketches, ABSOLUTE!
AVP, explain in Filipino, if patient still does not want to
consent, leave it to the patient to decide. Freedom to Believe (ABSOLUTE)
• HIPPOCRATIC OATH: “A physician must follow that system
1) Jehovah’s Witness – transfusion is refused because they
of regiments which according to his ability and judgment is
considered to be beneficial to the patient.” believe it is a form of nourishment and no one must be fed
• A person who enters a hospital or a clinic infers a desire to with human tissue.
be treated. There is no reason for him to refuse treatment. • Example: For dengue patients, doctors can deal with this by
Example: patient left the hospital without permission (HAMA- explaining, “we will only give plasma which is a part of the
Home against medical advice), don’t run after him/her. May blood” or inform that it is the only way the patient can survive.
be reported to social workers. 2) Christian Science Church – X-rays are refused
• A patient who is mentally competent doesn’t have a 3) Roman Catholics - abortion is illicit because “direct killing”
“constitutional right to die”. Doctors are not instruments of
as a means to save a mother is illicit and every human being
death but instruments of healing.
• However, a patient or his parents, in case he is incompetent, even inside a womb must have the same right to live from
may refuse further treatment provided that the attending God. Artificial forms of contraception is illicit because it is a
physician and hospital officials agree that there is “no threat to life.
reasonable possibility” that the patient may recover.
Freedom to Act in accordance with One’s Belief
Withholding or Withdrawing Life Support (NOT ABSOLUTE)
• The choice of the patient, or his family or legal Basis: Principle of Autonomy
representative (if the patient is incompetent) should prevail.
• May be limited by the police power of the state to protect:
(Advance Directives)
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o Public health – immunization
o Safety – cults and human sacrifices 1) Should the doctor allow him to decide for himself?
o Public welfare – chest x-ray to diagnose PTB; remember 2) What right of a patient is/are involved in this case?
the duty of utilitarianism, benefit the majority
• In case of emergency and patient is conscious, the physician CASE 2: PTB/PNEUMONIA PATIENT
must still desist from applying the treatment procedure
against the patient’s will. Pulmo, 24, female, single has been coughing for the past
• If the patient requires immediate treatment and he is 7 days but dismissed her condition as asthma until she
unconscious and no is available to give consent on his experiences high grade fever with chills. CXR showed haziness at
behalf, the physician may institute the necessary treatment the lung bases with absent breath sounds. Two common
even if it is contrary to the patient’s religious belief. conditions were present in the doctor’s mind, TB and pneumonia.
A condition called thoracentesis is indicated and can only be
Right to Privacy performed once she is confined in the hospital. She declined
• Patient has the right to be left alone and free from because she was afraid to be absent from work being a new
unwarranted publicity. employee in one of the call centers for the past 6 months.
• Invasion of the patient’s right to privacy may occur in the
following ways: 1) What right of a patient is/are involved in this case?
o Intrusions to a patient’s room where examination or 2) How must the attending physician approach the patient if he
treatment is being done will get her cooperation?
o Publication of news or stories or making press releases
about the patient’s state of health or his unique ailment CASE 3: TEEN PREGNANCY
o Taking of photographs during or after treatment and its
publication in the magazine or newspaper. Neneng, 16 years old, is a senior high school in one of
the prestigious university in the city. Being an only child in a
o Taking of motion pictures or television coverage
broken family, she became infatuated with a classmate and
o Use of patients names and pictures in commercial
became pregnant. Her parents are working: fathers is a police
advertisements
officer, mother is a university professor. She prefers not to inform
• In doing physical examination, female doctor examines female
her parents because she is afraid to be reprimanded. She keeps to
patients. Male doctor examines male patients. If in the
herself the pregnancy which is 3 months old.
opposite sex, have the presence of an observer with the same

sex of the patient.
1) Which right of a patient is involved here?
• Give the same right of privacy to patients whether in a public 2) What are legal and ethical issues that concern the doctor?
or private hospital.
Case 4: RESEARCH
EXCEPTIONS
1) Invasion of privacy by order of the courts - physical Olmet is a new drug being marketed for its blood
examination in defense of an allegation pressure lowering properties. Unknown to the community, the
2) Public interest is demanded - publication of unusual cases proponents are conducting the trial to see if in a general
as case reports population there will be similar effects with a group of
3) Waiver of the right of privacy by the patient - hypertensive patients in the various hospitals in USA and Europe.
consultations/admission in a charity teaching hospital The health center doctors were asked by the medical
representatives to prescribe the drug in exchange for lunches,
Other Rights when Confined In A Hospital umbrellas, prescription pads and ballpens.
• Right to receive visitors and communicate with relatives
within the limits prescribed by the reasonable rules and 1) Which right if a patient is/are involved here?
regulations by the hospital 2) Name at least 2 ethical/legal isses that must be addressed by
• Unrestricted right of correspondence the health center doctor as he tries to protect his patients.
• Right to be free from mechanical restraints except for some
justifiable reasons CASE 5: CHRONIC ILLNESS
• Right to be released as soon as the condition which justified
his hospitalization no longer exist Cora, 26, female married with 2 girls, ages 4 and 8 years
old was diagnosed with breast cancer which is in its terminal
• Right to continuity of care
state. She needed to choose between chemotherapy or surgery or

both. Being a single mother, she was so full of problems to think
CASE SCENARIOS about like managing her business and parenting her children.
Case 1: DIABETES PATIENT Though the husband provides child support, she is with no other
person to care for her children but her husband.
Diab missed his medicines for the past 6 months. He
exhibits signs of complications manifesting as extreme thirst with 1) What right(s) of a patient is/are involved in the case?
changes in sensorium which warrants emergency confinement. 2) What steps must the doctor observe to ensure these rights
On consult at the OPD at a government hospital, he declined are protected?
admission because he does not have any companion and is so
busy working as an insurance broker.
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CASE 6: MENTALLY-ILL

Manong Gay, 75, widower has lapses of memory and his
children are concerned because he would roam the
neighborhood and not come home for 2 days only to find out that
he was sleeping in the church. He used to be the barangay
chairman, full os supporters but when he was diagnosed with
Alzheimer’s disease, he had only a few friends to talk to. His
children are all working abroad as OFW, with a son with his
family for support.

1) Which right of a patient is involved?
2) What must the attending doctor do to ensure the proper
treatment and care will be given this patient?

*If you guys listened to the reporting, you will be able to answer the
cases. J Pero we know naman na kayang-kaya niyo masagutan
tong cases hehe.:)* - Fai

QUIZ
What are the patients’ rights involved in the ff statements?

1. Most involved in doctor-patient encounters?
2. Entails thorough understanding of the treatment plan
3. Apply principle of confidentiality
4. Ensures competent attention to emergencies
5. Allows patient self-determination
6. Fosters cooperation between doctor and patient
7. Assures patient of autonomy in decision making
8. Protects general public from harm
9. Must be observed prior to any invasive procedure
10. Protects the patient’s background from public view

*Sorry guys, kahit ako hindi ko alam kung ano talaga yung
tamang sagot sa mga statements na yan. J hehe* - Fai

REFERENCES:
• 2D (2017)
• 2C (2018)
• Dr. Mariano’s ppt presentation and lecture

TRANSER’S MESSAGE

“The missing ingredient in the development of therapies is
the voice of the patient.” - Anonymous

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