PAKISTAN MEDICAL AND DENTAL COUNCIL

CODE OF ETHICS

OF PRACTICE FOR

MEDICAL AND DENTAL PRACTITIONERS

1. (1) These regulations may be called the Code of Ethics .of Practice for medical and dental, Regulations.

(2) They shall come into force at once.

(3) They shall extends to whole of Pakistan
 .
PART II

GENERAL

2. Declaration before registraiion.-Each applicant, at the time of making an

application for registration with. the Council, shall submit a d.eclarationthat he has
read, understood and agreed to abide by these regulations on the format set out
in the Annexure I of these regulations.

3. Duties of physicians in general.- A physician shall always maintain high-

est standards of professional conduct and shall actively participate .in continuous
medical education and as such a physician shall.- .

(a) , not permit motives of profit to influence the free and independentexer-
cise of professional judgment on behalf of patients;

(b) in all type of medical practice, be dedicated to providing competent

medical services with full technical and moral independence. with
,compassion and respect for human dignity;
. . . ..

(c) deal.honestiy with patients and colleagues and strive to expose ihose
physicians deficient in character or competence or who engage in
fraud or deceplion; . .. .. .

(d) respect the rights of patients, colleagues and of other healthprofes-

sionals and shall safeguard patient confidences; . .

(e) act only. in the patient's. interest when providing medical care which ..
might have the effect of weakening the physical and mental condition
of the patient; .

(I) use great caution in divulging discoveries or new techniques or treat-

ment through non-professional channels; and

(g) certify only that which he has persqnally verified.

4. Duties of Physicians to the Sick.- A physician .shall-

)tr'., (a) always bear in mind the obligation of preserving human life;

(b) owe his patients complete loyalty and all the resources of his science;

(c) summon another physician who has the necessar)tability when ever
an examination or treatment is beyond the former physician's
capacity;

,(d) preserve absolute confidentiality on all he knows about his patient

even after the patient has died; and

(e) give emergency care as a humanitarian duty unless he is assured that

others are willing and able to give sych care.
 5. Duties of Physicians to each other.- A physician shall-

(a) behave towards his colleagues gently;

(b) not entice patients from his colleagues; and

(c) observe the principles of the "Declaration of Geneva" approved by the

World Medical Association.

6. Medical Ethics and religion." A medical or or dental practitioner shall

respect the beliefs of the patients and shall not impose his beliefs on the patient.

7. Practice of medicine, surgery and dentistry prohibited without-

registration etc with Council.-(t) No person shall practice modern system of
medicine or surgery unless that person is a doctbrOr dentist having registered
qualification and valid registration with Pakistan Medical and Dental CounciL
(
(2) Every medical or dental practitioner has to ensure that his registration with
the Council is valid. -

8. Display of registration numbers.- (1) -Every medical or dental practitioner

shall, in his clinic or place of practice, display a copy of valid registration certifi-
cate issued to him by the Council and referhis registratiorinumber in all his pre-
-scriptions, certificates, money receipts given to his patients. .

(2) No medical or dental practitioner shall display suffixing to his name those
degrees or diplomas which have not been -registered by the Council. A medical-or
dental practitioner shall not be considered a specialist unless an -additional quali-
fication of that specialty has been registered by the Council against his name.

9. Rational use of drugs.- (1) Every Medical or dental practitioner shall adopt
practice with good and rational practices to prescribe drugs.

(2) A medical or dental practitioner shall

(a) be free to choose whom to serve, with whom to associate and lay
down the timings and place of professional service for the patients;

(b) not be bound to treat each and every'person asking his services, but
he shall not only be ever ready to respond to the calls of the sick and
the injured, if in his opinion the situation Warrants it as such, but shall
be mindful of the high character of his mission and the responsibility
he discharges in the course of his professional duties;

(c) in his treatment, never forget that the health and the lives of those
entrusted to his care depend on his skill and attention; and

(d) if not available due to any reaSOAand the patient requires continuous
monitoring or care, then the Medical or dental practitioner shall
arrange for another Medical or dental practitioner of sufficient
proficiency as an alternate and inform the patient.
(3) For. a medical or dental practitioner to advise a patient to. seek service of
another medical or dental practitioner is acceptable, however, in case of
emergency, the medical or dental practitioner must treat the patient firs\.

(4) No medical or dental practitioner shall normally refuse treatment toa patient,
however for good reason if the medical or dental practitioner thinks it would
not be appropriate to.provide hisprofessional.services toa particular patient or
when a patient is suffering from an ailment which is not within the range of
experience of the treating medical or dental practitioner, the medical or dental
practitioner may refuse treatment and refer the patient to another medical or
dental practitioner.

PART III

.TEACHING ETHICS TO STUDENTS

10. The Teaching of medicalethics.- (1)The curriculum committee of the

Council will.ensure that adequate information on this Code of Ethics is included
in the undergraduate medical college curriculum and that case studies havebeeh.
prepared and disseminated to provide g\Jidance to medical or dental practitioners.

(2) The goal of teaching medical ethics shall be to improve the quality of patient
care by enhancing professional performance through a consideration of the.
clinician's values, beliefs, knowledge of ethical and legal construct, ability to
recognize and analyze ethical problems and interpersonal and communication
skills and consideration of the patient, whereby students shall be able to identify,
analyze and attempt to resolve common ethical problems of medical and clinicaT .
nature.

(3) All medical and dental colleges running MBBS and BOS courses, College
of Physician and Surgeons of Pakistan and universities running the postgraduate
medical courses in Pakistan may incorporaterrieaical ethics into their curriculum.

(4) Relevant books and journals shall be made available in the central and
departmental libraries of the medical institutions, and publication of papers on
issue related to medical ethics.

(5) All medical or dental practitioners may develop strategies for dissemina-
tion of information about ethics and ethical issues to their colleagues and
students, public and patients; specifically when teaching medical and dental
students.
 PART IV

EXPECTATiONS

11. Council's expectations.-The Council expects each medical or dental

practitioner to-

(a) promote fundamental principle of responsibility of physicians to the

right of individuals and societies to stated standards.of professional
competence, appropriate care, conduct and integrity of medical or
dental practitioners;

(b) uphold the ethical principles of mepical practice that is to say autonomy,.
beneficence, non-nialeficience, and justice;

(c) ensure the protection of individual patients against harassment,

discrimination and exploitation;

(d) take their responsibilities as a teacher seriously;

. .

(e) be responsive to cultural and religious sensitivities;

(f) declare in a transparent manner, any potential conflict of interest;

(g) inculcate thes-e values in students, through instruction and role

modeling;

(h) promote the education of the public on (a) health issues and (b) their.
rights to quality care;

(i) ensure continuation of practice only when in normal physical and

mental health; and

(j) bring colleagues to comply with these generally accepted norms of

practice and expose physicians and dentists deficient in competence,
care and conduct

PART V

FUNDAMENTAL ELEMENTS OF PATIENT. PHYSICIAN RELATIONSHIP

12. Rights of the Patient- (1) To share with physicians the responsibility for their
own health care, the patient-

(a) has right to receive information from physicians and to discuss the
benefits, risks, costs of appropriate treatment, alternatives and optimal
course of action;
 (b) is entitled to obtain copies or summaries of their medical records, to
have their questions answered and to .receive independent additional
professional opinions;

(c) has the tight to make decisions regarding the health care that is
recommended by his physician and as such thepatients(or his next
of kin) may accept or refuse any recommended medical treatment in
writing;

(d) has the right to courtesy, respect, dignity, timely responsiveness to his
health needs, and respect of his gender and sanctity;

(e) has the right to confidentiality; and

(f) has the right to continuity of health care.

I .-

I '- (2) The physician has an obligation to cooperate in the coordination of

!
medically indicated care with other
. health care providers .treating the patient.

13. Second opinion." .Patients are entitled to a second or further medical

opinion about their illness and on request; medical or dental practitioner must
either initiate or facilitate a request for this and provide the information necessary
for satisfactory referral. .

14. Rights . of the medical or dentalpractitioner.- It is obvious that ..

patients and their attendants shall respect :the privacy of the medical or dental
practitioner. Patient shall call the medical or dental practitioner on telephone only
in a dire emergency and not otherwise and on telephone, patients shall restrict
themselves to their medical or del'ltalproblem only and not use this facility for
seeking other information.

.) PART VI

ETHICAL STANDARDS OF PROFESSIONAL COMPETENCE, CARE AND

CONDUCT

15. Conduct of medical or dental practitioner.- In all dealings with patients, it

is expected that the interest of patient and advaniage to the patient's health
will be the major consideration to influence. the medical or dental practitioners'
conduct. The physician-patienHelationship shall be developed as one of
trust. A professional shall always maintain and demonstrate a high standard of
professional conduct by.-

(a) being in conformity with the principles of honesty and justice;

(b) not permitting motives of profit to influence (free and independent

exercise of) professional judgment;
 (c) warking with calleagues in ways that best serve patient's interests;

(d) nat paying .or receiving any fee .or any ather consideratian salely ta
procure the referral .of a patient .orfor prescribing .orreferring a patient
ta any saurce;

(e) maintaining the hanarabletraditian by which the physician is regarded

as a friend ta all persans .of any class, caste, calar, religian; sex,
ethnicity, accupatian, creed, religian and sacial status; and

(f) being hanest, factual, .objective, unbiased as a reviewer far scientific

material far publicatian; far funding purpases; and when providing
reference, ensuring that camments are hanest, justifiable, unbiased
and cantain evidence an the subject'scampetence, perfarmance,
reliability and canduct, taking steps ta ensure the accuracy .of any.
I

public cammunicatians including the cammunicatian .of degrees,

I '
institulianalaffiliatian, extent .of serviCes .offered and credentials.

16. Statement to patients and their relatives or representatives,. AI.I

statem~nts ta the patients .or their representatives shall be made .only by the
can suiting medical .ordental practitianers:and nat by any assaciates .orassistants
etc.

17. Examination, consultation or procedures on a female. patient.- (1) A

female patient shall be given cansultation either by a female medical .or dental
practitianer .or shall b.eexamined in the presence afa female attendant by a
male dactar. Underna circumstances a male attendant, assistant .or husband .or
relative etc shall beallawed during a gynecalagical and obstetrical cansultatian,
examinatian .or during narmal delivery being canducted by a female medical
practitianer. Hawever in exceptianal circumsta.nces a patient may file a request--
with the medical practitianer ta allaw her husband ta witness a narmal delivery

.'i
and the medical practitianer may cansider the request and shall ensure that
sanctity .of the female patient is preserved during pracedures and cansultatian
and there is na unnecessary expasure.

18. Assistance of unregistered person prohil:iited.-(1) a medical .or dental

practitianer will nat assist an unregistered persan ta practice or teach medicine or
dentistry .or assaciate prafessianally with such a persan perfarming the functi.ons
as a medical .or dental practitianer and knawingly assisting such an individual
shall make a registered medical .ordental practitianer liable ta disciplinary actian.
This daes nat preclude a medical .or dental practitianer from imparting praper
training ta medical students, nurses, midwives and ather paramedical persannel,
provided the dactar cancerned keep a strict supervisian aver such individuals
when treating patients.

(2) A medical .or dental practitianer shall use great cautian in divulging
discaveries .or new techniques .ortreatment through nan-prafessianal channels.
(3) A medical or dental practitioner shall not allow his name to be used by any
other person or let any other person sit in his place of practice if that person is not
a registered medical or dental practitioner. . .

(4) A physician shall owe his patients all the resources of his science. Whenever
an examination or treatment is beyond the physician's capacity he shall consult
another physician who has the necessary ability.

19. Prisoners.- Prisoners who are ill must be. treated in the same manner as
other sick people. However, doctors have a right to take appropriate precautions
if they think there is a possibility of physical violence by the patient. Where a
suspect refuses consent to a medical examination, the doctor unless directed to
the contrary by a court of law, shall refuse to mak~ any statement based on his
observation of the suspect other than to advise the police whether or not the
suspect appears torequireimmediatelfeatment or removal to hospital. This does
not of course, preclude the doCtor from. making a statement in court based on
such observation in circumstances where the accused: later gives his consent to
disclosure.

20. Permission' of. patient before examination.- A doctor shall normally tC\ke
permission from. a patient before making a physical examination. In case of
minors, the child's guardian shall be present or give permission for the eXamina- .
tion. For' any intimate examination the patient, irrespective of age, patient is
entitled to ask for an attendant to be present. Such requests shall be acceded to
whenever possible.

21.Care.- (1) The patient-physician or patient dental practitionerrefationship

. constitutes a fiduciary obligation, requiring physicians to be responsible to serve
the interests of patients' above their own financial or other interests. The medical
or dental practitioner is expected to provide a quality of care for a patient which
is timely, compassionate, respecting human privacy and dignity, non-discrimi:-'
nating and does not exploit vulnerable situations. Negligence in respect of
professional duties may justify suspension or removal from the Register.

(2) The medical or dental practitioner shall bear in mind the obligation of
preserving life and will not discriminate on the basis of age, sex, gender, class,
race, ethnicity, national origin, religion, sexLJaL9rientation, disability, health
conditions, marital discord, domestic or pare"rital status, criminal record, or any
other applicable bias as proscribed by law, and ensure that personal beliefs do
not prejudice patient care.

(3) The Medical or dental practitioner shall not exploit persons over whom they
have direct or indirect supervisory, evaluative, management or other authority,
such as students and patients, supervisees, employees or research participants,
whether for personal, professional or economic reasons.

(4) The medical or dental practitioner shall delegate to a student or other

physician, only those responsibilities that such persons, based on their educa-
tion, training and experience, can reasonably be expected to perform either
independently or with the level. of supervision provided.
(5) The Medical or dental practitioner shall additionally-

(a) identify themselves to patients whom they are treating;

(b) treat all patients with dignity and respect;

(c) listen to patients and respect their views;

(d) give patients (and provided patient agrees, family members) informa-
tion (about their illness) in a way that they can understand;

(e). respect the rights of patients to 'be involved fully in decisions about
their care;

(f) ensure that conflict of interest does not prevent them from performing
their professional work in an unbiased manner; and

(g) adhereto veracity (truth telling) as judged in the patient's interest. .

22. Details of information." It is obvious that patients do not always fully

understand the information and advice given to them by doctors. They shall be
encouraged toask'questions.These shall be answered carefully innbn-technical
terms if necessary with or without information .Ieaflets, as theaini. is to promote
understanding and to encourage co.mpliar'lce with recommended therapy. The
. doctor shall keep a noteof such explanation and if it is felt that the patient still
does not understand, may be advisable to ask the patients permission to speak
to a relative, The medical or dental practitioner shall break all news to the patient
and relatives etc, hims.elf and shall not allow his coworkers to do that.

23. Maternity care.- Registered medical practitioners who agree to .undertake

the anten.atal and delivery 'care of a woman shall clearly inform her, in advance,,,:,.
the arrangements for delivery . .In Pakistan, according to law a pregnancy Can
be terminated only if there is a serious risk to the life of the pregnant women.
The choice of gender of baby by any means shall be illegal and the gender of the
foetus shall not be disclosed unless it is absolutely sure that no harm shall come
to the baby and mother as a result of this disclosure.

24. Information about doctor or dentist conducting procedures.- Patients .

. undergoing procedures or treatment of any sort have the right to be informed as
to which .doctor or doctors are to be involved and what will be nature of the
procedure with its advantages, disadvantages, risks and alternative, options.

25. Competence.- (1) A medical or dental practitioner in active clinical practice

is expected 10 continuously strive for improving his knowledge and keep abreast
with the latest advancements in the field. He shall seek out sources of such
knowledge and try to attend professional meetings or activities for advancement
of professional knowledge. He shall maintain knowledge of CME programmes by
. Council and try to participate in them to gain CME credits. CME credits !;ihall be
provided by specialist boards authorized by Council for the purpose.
(2) The medical or dental practitioners will attempt to maintain the highest
levels of competence in their work more specifically the skill in diagnosing,
clinical decision-making: planning, implementation, monitoring and evaluation of
intervention and teaching; and shall accept responsibility for their actions. They
shall therefore,-

(a) only undertake tasks for which they are qualified allowed by virtue of
education, training or experience and know their limitations;

(b) keep abreast of latest information about their subject through

continuing education;

(c) ensure that their approach to patient management is consistent with

current research, literature and practice;

,(d) have an approach that favours competent clinical care through a

careful assessment of the patient's problem, based on elicitation and
analysis of the patient's history and physical examination; careful
decisions on need for further investigation and request for additional
consultation, appropriate management and prompt action where
indicated, ariapproach that shuns internet prescribing or telephonic
prescribing except when the physician is cognizant of the individuals
. past medical history;

(e) . acquire the knowledge and skills to provide proper training and
supervision to their students so that such persons perform services
responsibly, competently and ethically; and will be honest. and
objective in the assessment and certification of performance of students
supervised;

(f). monitor and maintain an awareness of the quality of the care provided
. by himself through a review of carefully recorded data and respond
constructively to assessments by self and peers which identify need for
further training or education;

(g) recognise the realistic efficacy of Investigation and medication and use
technology and medicine only where appropriate; and

(h) restrict prescription of drugs, appliances or treatments to only those

that are beneficial to the patient.

26. Treatment without direct patient contact.- Prescribing of medications by

medical or dental practitioners requires that the physician shall demonstrate that
a documented history and physical examination and drug reaction history are
available and that there has been a sufficient dialogue between the patient and
the doctor on options in management, and a review of the course of the illness
and side effects of the drug but the Council accepts that in an emergency, during
on call or cover call, or when in a partnership the case records are available, a
physician may prescribe anew prescription without seeing the patient but only
emergency single dose shall be prescribed and the patient shall be called over.for
a checkup. Telemedicine to the extent of radiological reporting is allowed.

27. Confidentiality.- The physician has a right to and shall withhold disclosure
of information received in a confidential context, whether this is from a patient or
as a result of being involved in the management of the patient, or review of a
paper, except in the following specific circumstances where he may carefully and
selectively disclose information where health, safety and life of other individual
may be involved, namely:-

(a) The medical or dental practitioner cannot seek to gain from information
. received in a confidential context (such as a paper sent for review) until
t~at information is publicly available;

. (b) There is. no legal compulsion on a doctor to provide information

concerning a criminal abortion, venereal disease, attempted suicide,
or concealed birth regarding his patients to any other indiVidual or
organization. When in doubt concerning matters .which have a legal
implication. the medical or dental practitioner may consult his/her legal
adviser;

(c) The professional medical record ofa patient shallilot be handed over
to any person without the consent of:lhepalientor his/her legal
representative. No one. has a right to demand information from th.e
doctor about his patient, save when the notification is required under a
statutory or legal obligation and when in doubt, the medical or dental
practitioner or a dentist may consult a legal advisor;

(d) confidences concerning individual or domestic life entrusted by

patients to a medical or dental practitioner and defects in the disposi-
tion or character of patients observed during medical attendance shall
never be revealed unless their revelation is required by law;

(e) a medical or dental practitioner who gains access to medical records

or other information without consenCshali be guilty of invasion of
privacy; and

(f) the medical or dental practitioner who grants access of an information

of a patient to a third person except. Councilor law enforcing agencies,
without consent shall be guilty of breach of confidentiality, but where a
medical or dental practitioner is of the opinion to determine it his duty
to society requiring him to employ knowledge about a patient obtained
through confidence as a medical or dental practitioner, to protect a
healthy person against a communicable disease to which he is about
to be exposed, the Medical or dental practitioner shall give out
information to concerned quarters.
28. Conflicts of interest.- For guidance of medical or dental practitioner a
detail on conflict of interest is given at Annexure-II of these regulations.

29. Dealing with conflict of interest.- (1) A medical or dental practitioner must
act in patient's best interests when making referrals and providing or arranging
treatment or care and no inducement, gift or hospitality which may affect or be
seen to affect judgment may be accepted and nor shall such inducements offered
to colleagues.

(2) Financial or commercial interests in organizations providing health care or in

pharmaceutical or other biomedical companies must not affect the way that
patients are prescribed, treated or referred.

(3) Financial or commercial interest in an organization 'to which a patient is to

be referred for treatment or investigation must be declaredtothe patient

(4) . Before taking part in discussions about buying goods or services; any
.. relevantfinancial or commercial interest which the medical or dental practitioner
or the medical. or dental practitioner's family might have in the purchases, must be
declared.

30. Truth telling.- In the practice of medicine, it is obvious that truth telling
involves the provision of information not simply to enable patients to make
informed choices about health care and other aspects of their lives but also. to
inform them about their situation. Patients may have an interest in medical
information regardless of whether that information is required to make a decision.
about medical treatment.

The physicians shall strive to create a true impression in the mind of the
patient which requires that information be presented in such a way that it can be;...
understood and applied. Patients shall be told the truth because of the respect
due to them as persons as patients have a right to be told important. infOrmation
that physicians have about them.

31. Advertising.- (1)When publishing or broadcasting information the medical

or dental practitioner must not make claims about the quality of services nor com-
pare services with those provided by colieagues:"Announcements must not, in
any way, offer guarantees of cures, nor exploit patients' vulnerability or lack of
medical knowledge.

(2) Published information about services must not put pressure on peopie to
use a service, for example by arousing ill-founded fear for their future health.
Similarly, services must not be advertised by visiting or telephoning prospective
patients, either in person or through a deputy

(3) Medical or dental practitioners may announce any change <;>faddress or

hours of practice in the local press either once in three papers or three times in
the same paper, on three consecutive days, and the announcement shall be
made in a normal manner and not unduly prominently as by big advertisements.
(4) Name plates may be fixed at the residence and on the premises where the
medical or dental medical or dental practitioner practices and at his residence.
The name plate shall not be ostentatious.

32. Certificates, reports and other documents~- When medical or dental prac-
titioners are requested for certificates, medical reports birth or death certificates
and any othe(documents, such documents shall be factualto the best of their
. knowledge .. Due care shall be taken in regard to stating the date on which the
patient has been examined etc.

33. Business and contractual obligations.- Physicians and dentists must.

ensure that they do not engage in any behaviour that negatively impacts directly
or indirectly on patient care. Business and contractual obligations must never
interfere with clinical decisions or negatively impact on patient care in anyway.
Physicians are discouraged from entering into business or other arrangements
that include' financial incentives; sharing of fees including refund based on.
successful outcomes and payments for referral of patients for laboratory investi-
gationsor other procedures except when a partnership is publicly known to exist;.

34. Informed Consent.-For guidance of medical or dental practitioner a detail

on informed consent is given at Annexure-III of these regulations. . .

35. Medical and dental students., it is obvious that medical and dental
students must identify themselves by name and must obtainper)1lission from
patients before examining them. It is advisable to limit the number of students
. examining anyone patient.

36. Taking of photographs or videos for teaching purposes.- Taking of.--

patients' photographs and videos shall be done in such a manner that a third party
cannot identify the patient concerned. If the patient is identifiable, he or she shall
be informed about the security, storage and eventual destruction of the record.

37. Adoption.- Doctors shall remember tha! in.cases of proposed adoption

there are several parties involved all of whom need continued support and
counseling .. Pregnant women who are considering giving up their babies for
adoption shall be helped to approach advisory bodies or atlorneysas the circum-
stances may be.

38. Leader of the medical or dental team.- The Medical or dental practitioner
shall take his responsibilities as leader of the medical or dental team seriously as
all responsibility of the care of the patient rests on him and nolthe Paramedical
staff. The medical or dental practitioner shall not accept any paramedical staff to
be in his team if he is not comfortable with him and this opinion shall be binding
on the employer.
 PART VII

PROFESSIONAL FEE AND TIMINGS

39. Fees and other charges.-(1) The fee charged from the patientforthe treat-
ment or consultation shall be as decided by the medical or dental' practitioner. The
treatment shall commence if the fee is acceptable to the patient, medical. or den- .
tal practitioner and the hospital or clinic. if there is any disagreement the patient
may seek care elsewhere. For poor or non-affording patients, the medical or den-
tal practitioner may make a concession if he so desires, However, the medical or
dental practitioner is bound to provide first 'aid to .the patient in emergency and
only then refer him. . ,

(2) The medical or dental practitioner shall ensure that the fee is commensurate
with his qualification and level of services offered and the hour at which his time
Was spent in providing the services.

(3) A Medical or dental practitioner shall announce his fees before' rendering.
service and not after the operation or treatment is under way. Remuneration ..
received for such services shall be in the form of currency only arid its amount
specifically announced to the patient at the time the service is rendered.'

(4) The f~e shall riot be in the form of ajavour of any kind.

(5) Medical or dental practitioners rendering service on behalf of the

. Government shall refrain from anticipating or accepting ariyconsideration,

(6) A medical or dental practitioner shall clearly display his fees and other
. charges in his chamber and/or the hospitals he is visiting.' .

(7) A medical or dental practitioner can receive compensation of any medicine

dispensed by him.

(8) A medical or dental practitioner shall write or stamp his name anddesigna-
tion in full along with registration number in his prescription letter head

(9) A medical or dental practitioner shall consider it as a pleasure and privilege

to render gratuitous service to all Medical or dental practitioners and their
immediate family dependants

40. Rebates and Commission.- A medical or dental practitioner shall not give,
solicit, or receive nor shall he offer to give solicit or receive any gift; gratuity,
commission or bonus in consideration of or return for the referr,ing, recommend-
ing or procuring of any patient for medical, surgical or other treatment.
l
41. Communication with Patients.- To address many complaints to the
Council refered due to lack of communication, or discourtesy, on the part of the
doctor, where' differences have arisen between the doctor and the patient or the
patients relatives there is much to be gained and rarely anything to be lost by the
. expression of regret by the doctor and feeling that any such expression would
amount to an admission of liability may have inhibited doctors.
42. Maintenance of medical records.- Every medical or. dental practitioner
shall ensure proper documentation of hfs professional services along with
necessary reports results maintained by an easily discern able scientific method.

PART VIII

Research Ethics and Consent

43. Research Ethics and Consent.- (1) .When conducting medical research
involving human subjects, investigators shall remember their: obligations with
respect to individual patients. Ethical conduct of research requires that a human.
subject must participate willingly, having been adequately informed about the
research and given consent that there is a f.avourable. balarice between the
potential benefit and harm of participation; and that protecti9n of vulnerable.
people is ensured. The validity of findings must address questions of sufficient
importance to justify any risks to participants. In any clinical triftl there must be
genuine uncertainty as to which treatment arm offers the mo.st benefit, and
placebo controls shall notbe used if equally effective standard therapies exist.
When doubt exists, researchers shall consult the existing literature and seek the
. advice of experts in research ethics~

(2) All research projects involving human subjects, whether ;as individuals or
communities, or the use of fetal material, embryos and, tissUes from the recently
. dead, shall be reviewed and approved by an. Ethical ReviilwCommittee of the
institution before the study begins .

. (3) Written consent shall be obtained if patients are to be involved in clinical

trials. The aims and methods of the proposed research, t()gether with any
potential hazards or discomfort, shall be explained to the patient. The consent
document must be clearly written using non-technicaL language as to be under::--
standable to subjects and use local language in addition wherever applicable.

(4 )In siiuations where study subjects are too young or too incapacitated, as
well as the mentally ill or unconscious person, consent to take part in nisearch
may be unobtainable. Research is best avoided unless it can be shown to be
relevant and potentially beneficial to the patieflt-afldthere is no objection from
parents or relatives.

(5) Medical research involving human subjects shall be conducted only by

scientifically qualified persons and under the supervision of a clinically competent
medical person.

(6) The right of research subjects to safeguard their integrity must always be
respected. Every precaution shall be taken to respect the privacy of the subject,
and the confidentiality of the patient's information.

(7) Research results must always preserve patient anonymity unless permis-
sion has been given by the patient to use his or her name.
 (8) Volunteers and patients may be paid for inconvenience arid time spent,but
such payment shall not be so large as to be an'inducement.

(9) Refusal of a patienUo participate in research must.notinfluence the care of

a patient in any way. .

44, Decisions of national bio-ethic committee and declaration of Helsinki.-

The Council endorses the decisions of nationalbio-ethic committee and declara-
tion of Helsinki resolutions as adopted by the 18th World Medical Assembly and
revised by the 48th World Medical Assembly shall be binding on all medical or
dental practitioners. .

45. Organ Transplantation and Consent.- A doctor involve~ in organ trans-

plantation has duties towards both donors and recipients. Prior to considering
transplant from the dead donor, brain death. shall be diagnosed, using currently
accepted criteria, by at least. two independent and appropriately qualified
clinicians, who are also independent of the transplant team. Iff~mily' of the d.ead
donor cannot take care of the funeral of donors body, then the transplant doctor
involved in organ transplantation shall take Gar of transplantation andfurieral.
Living donors shall be counseled as to the hazards and problems involve.d in the
proposed procedures, preferably by an. independent physiciarl" All statutory
human organ transplant ruleS arid orders shall apply.

46. Resource Allocation.-' All resource allocation decisions must be

transparent and defensible. Questions of resource alloGation ar~ difficult and can
pose practical and ethical dilemmas for clinicians. The unequal allocation of a
scarce resource may be justified by morally relevant factors such as need or
likelihood of benefit. To what extent the physician's fiduciary: duty towards a
patient/shall supersede the interests of other patients and society as a whole is
also a matter of controversy. However, the allocation of resources on the basis of
clinically irrelevant factors such as religion or gender is prohibited.

PART IX

,-
\ 47. End-of-life
MISCELLANEOUS

care.- (1) End-of-Iife care requires control of pain and other

symptoms, decisions on the use of life-sustaining treatment, and support of dying
patients and their families. Futile treatment ne-eCfTleither be offered to patients
nor be provided if demanded ..A treatment is qualitatively futile if it merely
preserves permanent unconsciousness or fails to end total.dependence on
intensive medical care or when physicians conclude, either through personal
experience, experiences shared with colleagues, or consideration of reported
empiric date that a medical treatment has been useless.

(2) The physician is not compelled to accede to demands by patients or their

families for treatment thought to be inappropriate by health care providers.

48. Genetics in Med.icine.- For-guidance 6f medical or dental practitioner or a

dentist a research study of various characteristics of genetic information is given
at Annexure-V of these regulations.
 PART X

PUNISHMENT AND DISCIPLINARY ACTION

49. The following acts of misconduct commission or omission on the part of a

Medical or dental practitioner shall constitute professional misconduct rendering
him/her liable for disciplinary action, namely:- .

(a) if he/she commits any violation of these Regulations;: .

(b) .forgery, theft, fraud, plagiarism ,indecent behavior or any other

offence, liable to be seen as moral turpitude .is liable to disciplinary

action;
(c) Any form of sexual advance, to a patient or colleague or coworker.
with whom there exists a professional relationship'! is professional
misconduct. A registered medical medical or dental practitioner or
dentist's professional position must neverbe used to pursuea relation-
ship of an emotional or sexual nature witha patient, the patient's
spouse or a nearrelative.ofa patienLSexual contai;t or intent there
of with patient or patient's spouses, partners, paren.~s,guardians, or
otherindividualsinvolved in the care of thEipatiennS Hable to lead to.
exclusion from the Register; A registered medical or dental practitiOn-
me t
er ordentist will ensure that they do not engage in s8.xualharass n
of any person, including. employees; patierits,st0dents, research
assistants andsupervisees; The following constitute jharassment that.
isto say single, multiple or persistent acts of abusive. v~rballanguage
or gestures, demeaning speech. insult in front of, juniors, sexual
innuendoes, sexual solicitatiori, physical advance, throwing objects,
and other threatening unacceptable gestures and these shall render a
medical or dental practitioner liable for disciplinary actionand cancel~-
lation of registration. The administration shall also be held responsible
for any such untoward event. Physieiansshall not use language that
will interfere with the work of others;. .

(d) Abuse of professional knowledge, skills and privileges is unacceptable

conduct. Any registered medical or dental medical or dental prac'
titioner found guilty of causing an iHe-g~lX-abortionor prescribing drugs
in violation of any law or who becomes addicted to a drug or is con-
victed of driving under the influence of alcohol or any other drug, is
liable to be suspended or have his name removed from the Register;

(e) No medical or dental practitioner shall acceptillegalgratification and

such acts shall be cognizable;

(f) The following practices are deemed to be unethical conduct namely:-

(i) self advertising by physicians, unless permitted by the laws of the

country and the code of ethics of the pakistan Medical

Association; and
 (ii) paying or receiving any fee or any other consideration 'solely to
procure the referral of a patient or for prescribing or referring a .
patient to any source. -

(g) Conviction by Court of Law for offences involving moral turpitude r

Crimi mil acts

(h) _ Any substance abuse or addiction -

50. Othermisconduct.-(l) It must be clearly understood that the instances of

offences and of Professional misconduct which are given abbvedo not constitute
and are not intended to constitute-a complete list olthe infamous acts which calls
for disciplinary action, and that by issuing these regulations is the Pakistan
Medical and Dental Council is in noway precluded from considering and dealing
with any other form of professionalrnisconduct on the part ofa medical or dental
practitioner. Circumstances may and do arise fromtime to time in relation to which
there may occur questions of professional misconduct which dd not come within
any olthese categories. Every care shall be takenthatthe code-is not violated in
letter and spirit. In such instances as in all others, the Council has to consider and
decide upon the facts brought before it. -- -

(2) Professional negligence or i!"competence shall be judged by thepeergroup

known as the disciplinary committee pf the Council.

(3) It is made clear that any cornplaintWithregard to professional misconduct -

and violation _of these - regulations can be brought before the Council for
disciplinary action. Upon receipt of any complaint of professional misconduct and
violation of these rules, in the first instance, the Registrar PM&DC shall call the
practitioner over and counsel himlher. Upon non settlement and failure to comply
despite counseling, the Council would hold an enquiry and give opportunity to the.... _
registered medical or dental practitioner to be heard in person or by pleader

I.
under Council rules. If the medical or dental.practitioner is found to be guilty of
committing professional misconduct, the Council may award punishment under
the rules or as the case may be, including removal altogether or for a specified
period, from the Register of the name of the delinquent registered medical or
dental practitioner. Removal of'name from the Register shall be widely publicized
in local press including conveying to different medical associations or societies or
I
bodies internationally or nationally.

PART XI

MATTERS RELATING TO PHARMACEUTICAL INDUSTRY

51. Accepting gifts, inducements or promotional Aids (1) Registered

medical or dental practitioners shall ensure that they do not compromise their
professional autonomy or integrity once .any gift, benefit in kind or economic
advantage is offered to them as an inducementlo prescribe, supply, administer, .
recommend, buy or sell any drug or medical equipment as the case may be.
 (2) Notwithstanding anything to the contrary contained herein, registered
medical or dental practitioners may oc-Casionally accept promotional aid items
(e.g. stethoscope, BP apparatus, weight machine, tongue depressor, hand wash
etc.) from drug manufacturers or distributors as the case may be, provided that
these items are primarily for the benefit of patients

(3) In addition to items listed in sub regulation (2), registered medical or

dental practitioners may accept from drug manufacturers or distributors as the
case may be, text or reference-books, mediCal journals, CDs and:other education-
al materials if they are satisfied that these serve a genuine, demonstrable and
direct educational function.

(4) Registered medical or dental practitioners may not enter into a written or
verbal agreement of any kind, with any manufacturer or distributor of drugs or
medical equipment, for personal gain of any kind whatsoever other than
employment.

52. Drug Samples.- (1) Registered medical or dental practitioners must

appreciate that free drug samples are provided to them jor the benefit of
patients only and to raise awareness Ofthe dn.lgand that they db not accept such
. samples as an inducement to prescribingapy drugsoras reward fbr having done

so.
(2) Registered medical or dental practitioners should accept free drug samples
for patient use only and noUor th~ personal gain or re"sale.

(3) Notwithstanding anything to the contrary contained herein, registered

medical or dental practitionersmc'jy p.urchase drugs at a discount directly from
the manufacturer provided that this discoun\ is duly passed on to the patients.

53. Meetings, conferences and. hospitality.- (1) If registered medical or

dental practitioners wish to engage in or undertake any academic pursuits they
should make all possible efforts to generate their own funds either throughinsti-

tutions with which they are affiliated or from personal contributions.

(2) Since continuing medical education (CME) or scientific and educational

conferences or professional meetings contribule-tO the improvement of patient
care, registered medical or dental practitioners may accept support from manu-
facturers or distributors of drugs ormedical.equipment in this regard provided that
any financial support provided is strictly through cheque or bank draft deposited
in a duly designated account rather than in thejr personal bank accounts and shall
be disclosed to the institution and to the Council on demand.

(3) Registered medical or dental practitioners should also ensure that the pri-
mary purpose of any educational meeting is the enhancement of medical
knowledge and they should participate in these events with the objective of gain-
ing current, accurate and balanced medical education in an ethical and profes-

sional manner.
 (4) In organizing an educational meeting, congress or symposium the organiz~-
ing medical or dental practitioners should ensure that a minimum of eighty per-
cent of the time allocated for such meeting, congress or symposium is spent on
core educational activities and only a maximum of twenty percent of the total time
is devoted to recreational _activities which are in accordance with the dignity of-
the medical profession. - -

(5) Registered _medical or dental practitioners may accept an invitation and

financial - support for a domestic or international trip from manufacturers or
distributors of drugs or medical equipment subject to the following conditions,
namely:- -

(a) the trip is primarily for an academic purpose and preferably the
selected medical or dental practitioner is_presenting a paper in the
course of the trip or participating in the proceedings in a similarly

I

"
(b)
meaningful manner;_

the trip is to attend- an event of international nature featuring Pakistani

as well as non-Pakistani participants;

the invitation and financial support is for the regist-ered medical or

(c)
dental practitiorieronly and not for his or her spouse or Children;
and - '

(d) the medical or _dental practitioner shall disclose the purpose and
invitation
.. .
to the institute and
".
to. the Council.

_54. Endorsement.- (1) No registered medical or dental practitioner below the

rank of a- professor may endorse any drug or medical equipment publicly or in
the print, air or electronic media and shall make all possible efforts to ensure
that any study conducted on the efficacy or otherwise of any drug or medical~-
equipment is communicated to the' public through appropriate scientific bodies or
published in the appropriate sCientific literature.

(2) A registered medical or dental practitioner may, however participate

in celebrity based disease"awareness programs or customer driven campaigns
to create public awareness on-matters of general hygiene or measures for dis-
ease prevention. Amedical or dental practitioner may appear in any media event
or program if is so duty bound to do so.

(3) A registered medical or dental practitioner shall not promote a drug or med-
ical equipment or a manufacturer or distributor in the course of scientific piesen-
tations in any manner whatsoever, including but not limited to by.-

(a) stating the name of the drug or equipment brand in the slides; or -

(b) stating the name or logo of thedrug or equipment manufacturer or dis-

tributor in the slides; or

(c) All medical or dental practitioners shall abide the drug laws.
 (4) Any registered medical or dental practitioner presenting a paper at a con-
ference, seminar or symposium shall issue or announce a disclaimer in respect
of any personal financial rewards from interest in or association of any kind with
the manufacturer or distributor sponsoring the conference, seminar or sympo-
sium.

55. Medical Research.- (1) No registered medical or dental practitioner

may accept direct payments from any drug manufacturer or 'distributor for
conducting research studies of any nature whatsoever and all such research
funding should only be received through approved institutions in accordance with
the rules and byelaws o(such institutions.

(2) Every clinical trial conducted by a registered medical or dental practitioner

must meet the current scientific arid ethical requirements ~nd the existing
legal regulations and must conform to the internationally recognized principles
~\
,
of Good Clinical Practice,

(3) All financial sources of research shall be disclosed to the Council on

demand.

(4) Every registered medical or (jental practitioner must ensure that the funding
party does not influence the research agenda, methodology employed, participant
selection, data analysis or publicatioriof findings. All researc.h prbposalsrnust be
assessed and approved prior to initiation by the ethical review committee
(ERG) of the relevant institution.

(5) At the time of publishing any papers or making a presentation which

provides the results of any medical research the relevant registered medical or
dental practitioners shall make a declaration of any funding provided by--
manufacturers or distributors of drugs or medical equipment to carry out such
research.

(6) Registered medical or dental practitioners may accept an honorarium

from their institutions and not directly from any donors providing funding for
such research, against the. time of their involvementin a clinical trial or research
study ensuring complete- disclosure and without any conflict of interest, in the
following cases, namely:- .

(a) Industry initiated trials or studies; and

(b) Investigator or doctor initiated trials or studies.

56. Decisions regarding pharmaceutical industry and its interaction with the
medical or dental practitioners and the funding by the pharma-industry, various
guidelines and decisions including those for continuous medical education events
as developed by the National Bio Ethics Committee shall also apply.
 Part- XII

REPEAL

57. Repeal.-The Code of Ethics .made by the Council in its 98tb meeting at
Karachi on 24th and 25th August 2002 and any regulation in these matters made
earlier are hereby repealed.

[No.

Registrar
Pakistan Medical and Dental Council
 Annexure I

A.t the time of registration, each applicantshall be required to make

following declaration agreeing to abide by the same.

DECLARATION

(see regulation 2)

(a) 1 solemnly pledge myself to consecrate my life to the service of

humanity;

(b) I will give to my teachers the respect and gratitude which is their due;

(c), I will practice my profession with conscience and dignity;

(d) The health of my patient will be my first consideratio~;

(e). I will respect the secrets which are confided in me, even after the
patient has died;

(f) 'I will maintain by all the means inmy power, the honour and the noble ,',
traditions of the medical profession;' . ' .
.. '

" '

(g) My colleagues will be like my sisters and brothers and I will pay due
respect and honour to them. '

(h) I will not permit considerations of age, disease or disability, creed,ethic

origin, gender, nationality, political affiliation, race, sexual orientation;
/
or social standing to intervene between my duty and my patient;

(i) I will protecthumanlife in all stages and under all circumstances, doing
my utmost to rescue it from death, malady, pain and anxiety. To be,all
the way, an instrument of Allah's mercy, extending medical care to near
and far, virtuoUS and sinner and friend and enemy;

(j) I shall abide by the rnedical or dental practitioners of medicine and

dentistry (code of ethics) regulation,-.2011 of the Council and under-
stand that I shall be punished upon its violation by me;

(k) Imake these promises solemnly, freely and upon my honour.

Signature ,date .
Name " .
Council's Registration number .
e'mail ' .
Address Current. .
Permanent: , .
Contact number Mobile land line .
 Annexure 1\

A conflict of interest

(see regulation28):

A conflict of interest "is a set of conditions in which professional judgment

concerning a primary interest tends to be unduly influenced :by a secoridary
interest." In the clinical context the primary obligation of physic;ians sh,!lIbe to
theirpatiehts, Whereas in the research context scientific knowledge maybe the
primary interest. A secondary interest may be of a financial nature, but it may also
consist of personal prestige or academic recognition and promotion. In research
involving patients, the research interests, although often in co,!cordance with' it
and is a.,ln 'above mentioned definition the reference to ,"a set of conditions" is
important _ having a conflict of interest is an objective situation and does not
depend ciA underlying motives. Stating that someone has a c(;mfliet of interest
does not imply a moral. condemnation per sec It ,is the person's aCtjon in the cori-
text of a particuli3Jsituation or alack of transparency that may be a cause for Gon-
cern."'"

Annexure III

Informed Consent

'(see regulation 34)

(1) 'Consent is the "autonomous authorization of a medica,l intervention by

, individual patients." Patients are entitled to' make, decisions at,out theirm~djcal
care and have the right to be given all available information \relevant to such
decisions. Patients have the right to refuse treatment and tobe given all;available
information relevant to the refusal. Consent may be explicit or implied. Explicit
consent can be given orally or in writing. Consent is implied when the patient

,
indicates a willingness to undergo a certain procedure or treatment on him or
his behaviour. For example, consent for venipuncture is implied by the action of
,rolling up one's sleeve and presenting one's arm. Fqr treatments that entail risk or
involve more than mild discomfort, it is expected"that the physician will obtain
explicit rather than implied consent. Signed consent forms documentbut cannot
replace the consent process. There are no. fixed rules as to when a signed
consent form is required. Some hospitals require that a consent form b.e signed
by the patient for surgical procedures but not for certain equally risky interven-
tions. If a signed consent form is not required, and the treatment carries risk,
clinicians shall seriously consider writing a note in the patient's chart to document
that the consent process has occurred. When taking consent ttJephysician shall
consider issues of adequate disclosure, the patients capacity, and the degree of
voluntariness. In the context of patient consent, "disclosure" refers to the
, provision of relevant information by the clinician and its comprehension by the
patient. Disclosure shall inform the patient adequately about the treatment and its
expected effects, relevant alternative options and their benefits and risks, and the
consequences of declining or delaying treatment and how the proposed treatment
(and other options) might affect the patient's ,employment, finances, family life and


other personal concerns. "Waiver" refers to a patient's voluntary request to forego

one or more elements of disclosure. For example, a patient may not wish to know
about a serious prognosis (e.g., cancer) or about the risk of treatment.

(2) "Capacity" refers to the patient's ability to understand information relevant to

\
a treatment decision and consequences of a complying or not complying with a
treatment decision: A person may be "capable" (have adequate capacity) with.
respect to one decision but not with respectto another. When any doubtexists, a
clinical capacity assessment by a third party may be required. In' addition to
assessing general cognitive ability, specific capacity assessment, determines the
patient's ability to appreciate information and implications of action.
"Voluntariness" refers to a patient's right to make health care choices free of any
undue influ!,!nce. However, a patient's freedom to make choices can be com-
promised by internal factors such as pain and by external faCtors such as force,
coercion and manipulation. In exceptional circumstances -- for example, involun-
tary admissionto hospital .- patients may be denied their freedom of cho1ce; in
such circumstances the least restrictive means possible of managing it)e.patient
shall always be preferred, Cliniciims can minimize theimpa,ct of controlling fac-.
torson patients'decisions by' promoting awqreness of available choices,inviting
questions and ensuring that decisions are based on an adequate, unbiased dis.
closure of. the relevant iniormation.
'

(3) An informed -consent can be said to have been giVen based upon a Clear
appreciation .and understanding of the facts, implications, and future'conse-'
quences of .an action. In order to give informed consent,fu!lilUhelegal standard
of informed consent with a completed, dated and signed consent form. True
informed consent requires a number of elements:

(a) that the patient is competent;

(b) that appropriate information is presented to the patient by the medical

and dental practitioner; and

(c) that the patient understand the material presented by the medical and
dental practitioner;

(d) that the patient acts voluntarily (Without Goercion or under duress) and
that the patient agree to the plan presented.

(4) Special circumstances affecting the consent process are listed below:-

(a) The unconscious patient's,- consent may be implied or assumed on

the grounds that if the patient were consc.ious they would consent to
their life being saved.

(b) A doctor asked to examine a violent patient is under no obligation to

put him in danger but shall attempt to persuade the person concerned
to permit an assessment as to whether any therapy is required.
(c) The mentally ill of the doctor is in any doubt as to the patien,t's


capacity to consent it is advisable fo seek specialistopinion as well as

discussing the matter with parents, guardians or relatives.

(d) For Mentally Handicapped patients the doctor shall attempt to obtain
consent but, deQending on the degree of handicap, may have to .
consult with the patient's parents or guardians, and, in particularly
difficult cases to obtain a second opinion. .

(e) Children are entitled to considerate and careful rnedicalcare as are

adults. If the doctor feels that a child will understand a proposed
medical procedure, information or advice, this shall be explained fully
to the child. Where the consent of parents or guardians is normally
required in respect of a child for whom they are responsible, due
. regard must be given to .the wishes of the child. Also, the doctor must
never assume that it is safe to ignore the parental or guardian interest.

. Annexure V

.Genetics in medicines

(see regulation48)

Molecular genetics is concemed with the process by which the coding

sequences of DNA are transcribed into proteins that control cell reproduction,
specialization, .maintenance and responses. Inherited or acquired biologic factors
that result in an error in this molecular information processing .cancontribute to
the development of a disease. Medical genetics involves the application of genet-
ic knowledge and technology to specific clinical andepidemiologicconcems.
Although many common diseases are suspected of having a genetic component,
few are purely genetic in the sense that the genetic anomaly is .adequate to give
rise to the disease. In most cases, genetic risk factors must be augmented bto._
other genetic or environmental factors for the disease to be expressed. Moreover,
the detection of a genetic anomaly not help us to predict the severity with which
the syndrome will be expressed. Certain ethical and legalresponsibilities accom-
pany the flood of genetic knowledge into the current practice of medicine. This is
because of three general characteristics of genetic information, that is to say the
implications of genetic information are simultaneously individual and familial
genetic information is often relevant to future disease; and genetic testing often
identifies disorders for which there are not effective treatments or preventive
measures.

(No F.16-5/2010-MER)

DR. ARSHAD KARIM CHANDIO,

Deputy Director General (MER).

PRINTED BY THE MANAGER, PRINTING CORPORATION OF PAKISTAN PRESS, KARACHI

PUBLISHED BY THE DEPUTY CONTROLLER, STATIONERY & FORMS, KARACHI.