CRE8LEARN INSTITUTE

Health Ethics for Health Information Management

Core topics: Terminal illness, human experimentation, organ transplant, and malpractice

Extra-class tutor: Teboho Mpholo (Mr.), Cre8Learn Institute
Supports: Botho University Health Information Management programme

About this guide. An independent supplement for extra classes. It is not official Botho University material and does not replace your lecturer's notes, set texts or assessment briefs. Where this guide and your lecturer differ, follow your lecturer.

Welcome, HIM students. Ethical dilemmas are rarely solved by doctors alone. As the guardians of the medical record, you are the legal memory of the hospital. When an ethical crisis happens, lawyers, ethics committees, and courts will read the documentation you manage.

The HIM rule for ethics: If it is not documented in the record, it did not happen. Your job is to ensure the record accurately reflects the patient's wishes, the provider's actions, and the legal consent.

Contents

1. The Four Pillars of Medical Ethics
2. Terminal Illness & Euthanasia
3. Human Experimentation & Informed Consent
4. Organ Transplantation
5. Malpractice & Negligence
6. Review Quiz

1. The Four Pillars of Medical Ethics

Every ethical debate in healthcare comes back to these four principles. You will see ethics committees use these exact words when deciding a difficult case.

Principle	Meaning	HIM Application
Autonomy	The patient's right to choose or refuse treatment.	Is the informed consent form signed? Is the patient's advanced directive in the chart?
Beneficence	Acting in the best interest of the patient (doing good).	Do the clinical notes justify the treatment provided?
Non-maleficence	"First, do no harm."	Were errors documented honestly, or covered up?
Justice	Fairness and equality in healthcare distribution.	Are organ transplant waiting lists managed fairly without bias?

2. Terminal Illness & Euthanasia

A terminal illness is an incurable disease expected to result in death. Euthanasia (often called "mercy killing") is the act of deliberately ending a life to relieve suffering. It remains illegal in most countries, but ethical debates around it are constant.

Types of Euthanasia

Type	Definition	Example
Active	Administering a lethal substance to cause death.	A doctor gives a patient a lethal injection.
Passive	Withdrawing or withholding life-sustaining treatment, allowing natural death.	Turning off a ventilator or stopping dialysis.
Voluntary	The patient explicitly requests it while of sound mind.	A competent adult asks to stop chemotherapy.
Involuntary	Ending a patient's life without their consent (usually illegal and considered murder).	Family decides to end life for a competent adult against their wishes.

HIM FOCUS: ADVANCE DIRECTIVES

HIM professionals do not decide if a patient lives or dies, but they must manage the documents that state the patient's wishes:

Living Will: A legal document where a patient states what medical treatments they do or do not want if they become terminally ill or permanently unconscious.
Do Not Resuscitate (DNR) Order: A medical order telling staff not to perform CPR if the patient's heart stops. HIM alert: The DNR form must be physically signed by the doctor and easily visible on the patient's current chart.
Healthcare Proxy / Power of Attorney: A document naming a specific person to make medical decisions if the patient cannot.

CHECKPOINT QUESTION

Scenario: A patient with terminal cancer is admitted unconscious. The family tells the doctor, "She never wanted to be put on a breathing machine." There is no Living Will or Proxy form in her record. What is the ethical and HIM dilemma here?

Answer: The dilemma is autonomy vs. beneficence. Without a documented Advance Directive, the doctor cannot legally assume the family's verbal statement is the patient's true wish. Ethically, the doctor must act to save the patient (beneficence), but legally, if the family goes to court, the lack of HIM documentation (the missing form) means the hospital has no legal proof of the patient's wishes.

3. Human Experimentation & Informed Consent

Human experimentation is vital for medical progress (e.g., testing a new vaccine), but history is full of horrific abuses. The Tuskegee Syphilis Study (1932–1972) and Nazi experiments led to strict global regulations.

The Core Rule: Informed Consent

To be ethical, a patient participating in a study must give **Informed Consent**. This means they must:

Be told the purpose, risks, and benefits of the research.
Understand the alternatives available.
Give consent voluntarily without coercion, and be allowed to withdraw at any time.

HIM FOCUS: RESEARCH AND THE RECORD

Hospitals have an Institutional Review Board (IRB) or Ethics Committee that must approve all research. As an HIM professional:

You must ensure the informed consent document for the research study is scanned into the patient's chart before the experimental treatment begins.
You must protect patient privacy. Researchers cannot simply take medical records; they need ethics approval, and you must often de-identify the data (remove names and IDs) before releasing it.

CHECKPOINT QUESTION

Scenario: A doctor is testing a new drug for hypertension. He gives the drug to a patient in the clinic and writes in the chart: "Patient agreed verbally to try new drug." Why is this a violation of health ethics and HIM standards?

Answer: Verbal agreement is not sufficient Informed Consent for experimental treatments. There must be a signed, detailed consent form in the record outlining the risks and alternatives. Without the document, the hospital is vulnerable to a lawsuit for medical battery.

4. Organ Transplantation

Organ transplantation saves lives, but organs are a severely limited resource. Ethics in transplant revolves around **Justice**—how do we decide who gets an organ?

The Ethical Rules of Allocation

Medical Criteria: The sickest patients and those with the highest chance of survival should be prioritized. A patient with active cancer, for example, is usually not a candidate for a new kidney.
No Discrimination: Organs cannot be allocated based on race, religion, wealth, or social status.
The "Dead Donor" Rule: Organs cannot be harvested if it will cause the death of the donor. The donor must be declared dead (usually by brain death criteria) by doctors who are not part of the transplant team.

HIM FOCUS: REGISTRIES AND CONFIDENTIALITY

HIM professionals play a crucial role in transplants:

Accurate coding: Transplant registries require exact coding of the organ, the disease that caused the failure, and the type of procedure.
Consent: If the donor is deceased, the HIM department must confirm that organ donation consent (e.g., registered on a donor card or signed by next-of-kin) is legally documented.
Confidentiality: The identity of the donor and the recipient must be kept strictly confidential. HIM staff must never release donor records to the recipient's family without a court order.

CHECKPOINT QUESTION

Scenario: A wealthy businessman offers to pay a hospital R500,000 to move him to the top of the kidney transplant waiting list. What ethical principle does this violate, and how does the HIM department's data protect the system?

Answer: It violates the principle of Justice (fairness). HIM protects the system because the waiting list is generated by objective medical data (blood type, tissue matching, severity of illness) stored in the records, not by personal wealth.

5. Malpractice & Negligence

Medical negligence occurs when a healthcare professional fails to provide the standard of care that a competent professional would provide, resulting in harm to the patient. When a doctor commits negligence, it is called **malpractice**.

The Four Elements of Negligence (The "4 Ds")

To successfully sue a healthcare provider for malpractice, the patient (plaintiff) must prove all four of these elements in court:

Element	Meaning	Example
1. Duty	The provider had a professional obligation to care for the patient.	The doctor admitted the patient to the hospital.
2. Dereliction (Breach)	The provider failed to meet the standard of care.	The doctor prescribed the wrong dosage of insulin.
3. Direct Cause	The breach directly caused the injury.	The wrong dose caused the patient to go into a coma.
4. Damages	The patient suffered actual harm or financial loss.	The patient has permanent brain damage and heavy medical bills.

HIM FOCUS: THE MEDICAL RECORD IS THE DEFENCE

When a lawsuit is filed, lawyers will ask for the medical record. The record is the "silent witness."

Chart Falsification: If a nurse or doctor realizes they made a mistake and goes back to change a previous note to make themselves look better, this is fraud and spoliation (destruction of evidence). It is a criminal offence.
Corrections: If a mistake is made in the chart, you must never use whiteout or delete it. You draw a single line through the error, write "error," date it, and sign it. The original note must remain legible.
Missing Records: If an HIM department loses a record during a malpractice lawsuit, the court often assumes the missing record contained information that was damaging to the hospital.

CHECKPOINT QUESTION

Scenario: During a malpractice trial, the court asks for the patient's chart. The HIM clerk realizes that the record is missing the final 3 days of the patient's admission. The hospital lawyer is panicked. What is the likely legal outcome under HIM ethics?

Answer: The court may apply the "presumption of spoliation." If the hospital cannot produce a complete record, the court assumes the missing pages contained evidence of negligence. The incomplete record becomes the greatest weakness for the hospital.

6. Review Quiz

Test your understanding of the ethical and legal principles you have just studied.

QUESTION 1

What is the difference between Active and Passive Euthanasia?

Answer: Active involves administering a lethal substance to end life. Passive involves withholding or withdrawing life-sustaining treatment and letting the disease take its natural course.

QUESTION 2

If a patient has a valid DNR (Do Not Resuscitate) order, but it is missing from the front of the chart, and a nurse performs CPR, who is legally protected?

Answer: The nurse is legally protected because they acted to save a life according to the information available in the record. The hospital/HIM department may face liability for failing to ensure the critical DNR form was clearly visible.

QUESTION 3

A patient is given a new experimental drug. The doctor writes in the chart: "Informed consent obtained." However, there is no signed form. Is this acceptable in a court of law?

Answer: No. A doctor's note saying consent was obtained is not the same as a signed, detailed legal consent form. In court, the patient can easily deny this, and the hospital will struggle to prove otherwise.

QUESTION 4

List the "4 Ds" required to prove medical malpractice.

Answer: Duty, Dereliction (Breach of Duty), Direct Cause, and Damages.

QUESTION 5

A physician realizes they accidentally wrote down the wrong medication dosage yesterday. If they ask you (the HIM clerk) to delete yesterday's note and write a new one, what should you do?

Answer: You must refuse. Deleting a note is falsification of a medical record (spoliation). The correct legal procedure is to write an addendum (an addition) to the chart explaining the correction, leaving the original note intact.

A final note. Ethics is not just abstract philosophy. In the HIM world, ethics is written in ink. Your strict adherence to accurate documentation, safeguarding consent forms, and maintaining the integrity of the medical record is what protects patients and the hospital in the face of complex legal and ethical dilemmas.