MEDICAL ETHICS
Dr. Abhishek Karn
Dept. of Forensic Medicine
& Toxicology
·
Medical service is the most humane of all the
services to humanity.
· Ethics is the understanding
of moral values.
· Medical ethics is a system of moral
principles that apply values and judgments to the practice of medicine. It deals
with the moral principles which should guide members of the medical profession
in their dealings with each other, their patients and the State.
· A common framework used in
the analysis of medical ethics is the "4 principles" approach postulated
by Tom Beauchamp and James Childress which are to be judged and weighed against
each other, with attention given to the scope of their application.
· The 4 principles are:
1.
Respect for autonomy - the patient has the right to
refuse or choose their treatment.
2.
Beneficence - a practitioner should act in the best
interest of the patient.
3.
Non-maleficence - "first, do no harm"
4. Justice - concerns the distribution of scarce health
resources, and the decision of who gets what treatment (fairness and equality).
Other values that are
sometimes discussed include:
1.
Respect for persons - the patient (and the person
treating the patient) have the right to be treated with dignity.
2.
Truthfulness and honesty - (Informed Consent--refers
to the idea that a person must be fully informed about and understand the
potential benefits and risks of their choice of treatment. An uninformed person
is at risk of mistakenly making a choice not reflective of his or her values or
wishes. It does not specifically mean the process of obtaining consent, or the
specific legal requirements, which vary from place to place, for capacity to
consent. Patients can elect to make their own medical decisions, or can
delegate decision-making authority to another party. The value of informed
consent is closely related to the values of autonomy and truth telling.
NMC -
Code of Ethics
CODE OF ETHICS---
• The code of ethics is the rules framed in this line and on the basis of this
sense of moral values to guide the conduct of all concerned.
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The Nepal
Medical Council has in accordance with the Nepal Medical Council Act 1964,
passed a medical Code of Ethics, which all doctors registered under it, are
to abide by.
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The code
is as follows:
1. DECLARATION:-
(The following
declaration should be read and agreed upon by the applicant at the time of
registration)
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I
solemnly pledge myself to dedicate my life to the service of humanity.
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Even
under threat and duress I will not use my knowledge contrary to the norms of
humanity.
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I will
maintain the utmost respect for human life right from the time of
conception as per the laws of the land.
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I will
not allow consideration of age, sex, religion, nationality, ethnicity,
politics, or social standing to intervene between my duty and my patient.
0 I will carry out my professional duties with conscience
and dignity.
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The health
of my patient will be my first consideration.
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I will
respect the secrets of my patients confided in me.
0 I will give to my teachers the respect and gratitude
that is their due.
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I will
maintain, by all means in my power, the honour and noble traditions of the
medical profession.
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I will
maintain utmost rapport with my professional colleagues.
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I make
these promises solemnly, freely and upon my honour.
2. GENERAL
PRINCIPLES OF MEDICAL ETHICS
2.1 Character
of the Physician
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A
physician should be an upright Person, instructed in the art of healing.
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S/he
should possess good character and be diligent in caring for the sick.
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S/he
should also be modest, sober, patient, alert, and prompt in action.
2.2 Responsibility
of the Physician to Medical Profession
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The main
aim of the medical profession is to render service to the cause of humanity.
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S/he
should work with full devotion and should always try to improve medical
knowledge and skill so that patients and colleagues are maximally benefited.
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The
physician should practice medicine on scientific basis and should not be
associated professionally with anyone who violates this principle.
2.3 Advertising
in Medical Practice
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2.3.1 General
Consideration
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Nepal
Medical Council (NMC) does not wish to hinder the ethical dissemination of
relevant factual information about the services available at an institution or
being provided by a physician.
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This can
help the patient to make informed choice seeking treatment and assist
physicians in advising their patients on the choice of specialist.
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The
council recognizes the duty the medical profession has in disseminating
information about advances in medical science and therapeutics, provided that
it is done in an ethical manner.
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Solicitation
of patients directly or indirectly, by a physician, by groups of physicians or
by institutions or organizations is unethical.
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Self-advertisement
is not only incompatible with the principles, which should govern relationships
between members of a profession but could be a source of danger to the public.
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A
physician successful at achieving publicity may not be the most appropriate
physician for a patient to consult and also may raise illusionary hopes of cure
in extreme cases.
A physician is
allowed to make a formal announcement of the following in the press related to
medical practice.
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On
starting practice.
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On change
of type of practice.
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On change
of address.
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On
temporary absence from duty.
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On
resumption of another practice.
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On
succeeding to another practice.
2.3.2 Privacy,
Security and Confidentiality of Information of the Patients
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It is not
a breach of confidentiality to release or transfer confidential health care
information required for the purpose of conducting scientific research,
management audits, financial audits, programme evaluations, or similar studies
provided the information released dose not identify directly or indirectly
any individual patient in any report of such research audit or evaluation
or otherwise disclose patient's identity in any manner.
2.4 Terms of
Payment of Professional Services
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Fee for
professional services provided to the patient should be clarified at the time
of the service given.
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It is
unethical to enter into a contract of – ‘no cure no payment’.
2.5 Running
or Opening a Medical Shop
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A
physician should not run a shop for dispensing prescriptions prescribed by
physician other than himself or sale of the medical or surgical appliances.
2.6 Secret
Remedies
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It is
unethical to prescribe drugs or formulations about which the physician has no
knowledge about its composition and pharmacological action.
2.7 Commission
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It is
unethical to receive or offer any gift, gratuity, commission, or bonus in
consideration of or in return for referring, recommending, or procuring of
patient for prescribing medical and surgical treatment, investigation and
consultation.
2.8 Legal
Restrictions
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A
physician should always follow the Nepal Medical Council rules and regulation,
which regulate the practice of medicine.
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S/he
should also abide by other laws enforced in the country.
3. DUTIES OF
PHYSICIANS TO THEIR PATIENTS
3.1 Obligation
to the Patient
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A
physician is not bound to treat each and every patient asking for his services except
in emergencies, but s/he should be ready to respond to the calls of the
sick and injured in conformity with the high character of medical profession.
3.2 Patient's
Secrecy
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Patient's
confidence concerning individual or domestic life entrusted by the patient to a
physician and observed during medical attendance should never be divulged
unless the laws of the country require its revelation.
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Even in
such circumstances it should only be made after formal protest.
3.3 Prognosis of
the Disease
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A
physician should explain the nature of the illness to the patient.
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S/he
should neither exaggerate nor minimize the gravity of a patient's condition but
should always be sympathetic to the patient and his/her family.
3.4 Service to
the Patients
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A
physician is free to choose whom to serve except in emergency cases.
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But once
s/he undertakes a patient for treatment s/he should not reject the patient
without giving reasonable time or information in advance to the patient and
his/her relatives.
3.5 Consent
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A
physician must seek an informed written consent prior to performing a
diagnostic or treatment procedure.
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Consent
should be taken from the patient if s/he is above sixteen years, but in the
case of minors or unconscious patients, consent from guardian can be taken.
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If there
is an emergency and nobody is available to sign consent on behalf of patient,
it is the responsibility of the physician to start the treatment.
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It is
obligatory for the physician to explain the nature of the procedure and the
expected result.
3.6 Attendant
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A
physician should keep in all instances an attendant before examining a patient
of the opposite sex.
3.7 Continuity
of Treatment
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A
physician should not discontinue the treatment except in the following
conditions:
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Refusal
to pay the fee for service.
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Non-compliance
with the recommended treatment.
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Exerting
undue pressure to prescribe unnecessary drugs.
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Forcing
to do an immoral act in his/her favour.
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When
physician himself is unwell.
4. DUTIES OF THE
PHYSICIAN TO THE MEDICAL PROFESSION
4.1 Honour of
the Profession
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A
physician should uphold the dignity and honour of medical profession to the
highest standard.
4.2 Membership
in Medical Societies
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For the
advancement of profession, a physician is encouraged to affiliate with medical
societies and contribute his time, energy and other means so that these
societies may represent the ideals of the profession.
4.3 Safeguard to
the Profession
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The
physician should not employ, in connection with his professional practice, any
physician who is neither registered nor enlisted under the Nepal Medical
Council Act in force, and should not permit such persons to attend, treat or
perform operations upon patients so as to endanger their life.
4.4 Exposure of
Unethical Conduct
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It is the
duty of the physician to report to the NMC without fear of any incompetent,
corrupt, and dishonest member or unethical conduct on the part of members of
the profession.
5. DUTIES OF
PHYSICIANS TO THE FAMILY MEMBERS OF THE PROFESSIONAL COLLEAGUES
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It is not
mandatory that a physician should not charge fee from another physician or
his/her immediate family members for rendering professional services.
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But the
physician should consider it a pleasure and privilege to render such services
to their professional colleagues and their immediate family members, free of
charge as far as possible.
6. DUTIES OF
PHYSICIAN IN CONSULTATION
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In case
of any doubt or difficulty, a physician should request consultation with other
colleagues giving priority to the patient's benefit.
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No
insincerity, rivalry, or envy should be indulged in during consultation.
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During
the temporary absence of one physician, if s/he requests another physician to
attend his/her patients, it is a professional courtesy to accept such a
request.
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Upon such
temporary appointment, the physician acting under such privilege should give
utmost consideration to the interest and representation of the absent
physician.
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A
physician should not usually take charge of or visit another physician's
patient in the same illness except in emergency.
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If s/he
does so in emergency, then it is his/her duty to explain the reason of visit
and treatment given to the patient to his/her colleague.
7. DISCIPLINARY
ACTIONS
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There are
certain kinds of professional misconduct and criminal offences, which
lead to disciplinary proceedings or which in the opinion of the Nepal Medical
Council (NMC), could give rise to a charge of serious professional misconduct.
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Any abuse
of the professional privileges accorded to him/her or restriction of
professional duty or serious breach of medical ethics may lead to charge of serious
professional misconduct.
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In
accordance with the Nepal Medical Council Act and Regulations, NMC will form professional
conduct and health committee, which will then recommend the gravity of
conviction to Nepal Medical Council.
8. PROFESSIONAL
CONDUCT AND PERSONAL BEHAVIOUR OF THE PHYSICIAN
8.1.1
Neglect or Disregard by physician of Their Professional Responsibilities to
patients for Their Care and Treatment
a. Neglect or Disregard on Medical Care:
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The Nepal
Medical Council may institute disciplinary proceedings when a physician seriously
disregards or neglects professional duties to his/her patient.
b. Improper
Delegation of Medical Duties:
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It is the
responsibility of a physician to delegate his/her responsibility of management
of the patient to his/her subordinates e.g., nurses, paramedical, medical
personnel etc.
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Therefore,
h/she should be fully satisfied that the person to whom these duties are
delegated is competent enough to carry these out.
8.1.2 Abuse of
Professional Privileges and Skills
a. Prescribing
Narcotic Drugs to Addicts:-
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All
physicians must provide standard medical care as allowed by available
resources.
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A
physician should not prescribe or supply controlled drugs to addicted persons
other than in the course of bonafide treatment.
b. Medical
Certificates:-
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Physicians
are expected to exercise care in issuing medical certificates or similar
documents.
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c. Termination
of pregnancy
The law of the country prohibits the termination of pregnancy unless medically indicated.
The law of the country prohibits the termination of pregnancy unless medically indicated.
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d. Sex
Determination
Divulging the gender of a foetus should not be done in USG or other investigation report as this may lead to subsequent termination.
Divulging the gender of a foetus should not be done in USG or other investigation report as this may lead to subsequent termination.
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e. Professional
Confidence
A physician should not disclose information, which he obtained in confidence from or about a patient except in conditions required by law. The infirmity of the patient and prognosis should not be told to others not directly concerned.
A physician should not disclose information, which he obtained in confidence from or about a patient except in conditions required by law. The infirmity of the patient and prognosis should not be told to others not directly concerned.
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f.
Improper Pressure
A physician should not exert improper pressure upon a patient to lend him money or to alter the patient's will in his favour.
A physician should not exert improper pressure upon a patient to lend him money or to alter the patient's will in his favour.
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g.
Emotional or Sexual Relationship
A physician should not enter into any emotional or sexual relationship with patient or a member of patient's family, which may disrupt the patient's life, damage, or distress the patient or his or her family.
A physician should not enter into any emotional or sexual relationship with patient or a member of patient's family, which may disrupt the patient's life, damage, or distress the patient or his or her family.
8.2 Personal
Behaviour
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To keep
up the reputation of the medical profession in the public, a physician should
maintain proper standard of personal behaviour not only in professional duties
but at other times as well.
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The following
are the three main areas of personal behaviour, which may lead to disciplinary
proceedings:
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a. Abuse
of Alcohol and Drugs
Treating the patient under the influence of alcohol or drugs is liable to disciplinary proceedings.
Treating the patient under the influence of alcohol or drugs is liable to disciplinary proceedings.
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b.
Dishonesty
Criminal deception, forgery, fraud, theft, and any other offences involving morality and honesty are liable to disciplinary action.
Criminal deception, forgery, fraud, theft, and any other offences involving morality and honesty are liable to disciplinary action.
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c.
Indecency and Violence
Indecent behaviour or violent assault on a patient would be regarded as a serious professional misconduct.
Indecent behaviour or violent assault on a patient would be regarded as a serious professional misconduct.
9. UNPROFESSIONAL ACTIONS AND MISCONDUCTS
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9.1 A
physician should use an 18x14 inch size signboard and write his name,
NMC number, qualification, titles, and name of his specialty.
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The
letters should be in blue on a white background.
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S/he
should not use the International Red Cross symbol to make known the fact of
being a physician.
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It is
improper to affix a signboard on a chemist's shop.
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9.2 A
physician should not encourage any direct or indirect advertisement in the
media, with or without photograph, of a congratulatory nature that is linked
with professional services being offered.
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9.3 A
physician should not use touts or agents for procuring patients.
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9.4 A
physician should not insult or misbehave with fellow physicians by words
or behaviour.
10. POWER OF
PROFESSIONAL CONDUCT AND HEALTH
COMMITTEE
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The
committee will initially enquire all the complaints and issues related to
professional misconduct.
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At the
conclusion of any inquiry regarding professional misconduct, the committee will
decide one of the following alternatives, according to the severity of
misconduct:
10.1 Warn and
conclude the case
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In case
the physician is found innocent, the committee will admonish and conclude the
case.
10.2 Put on
probation by postponing judgement
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The
committee can recommend Nepal Medical Council to put a physician on probation
for a specified period, and in this period, professional referees are appointed
to look after the conduct of the convicted physician.
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If
referees furnish the satisfactory report of conduct after a specified period,
then the case will be normally concluded.
10.3
Recommendation of name to be struck off the register
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In case
of unsatisfactory report of conduct from referees or if there is a serious
professional misconduct or conviction by court in criminal cases involving
moral or ethical issues, the committee may recommend erasure of physician's
registration to the Nepal Medical Council.
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If a
physician's registration is erased, s/he ceases to practice as a registered
physician; the erasure of registration, in accordance with the NMC Act, will be
for two years.
10.4 Application
for restoration of registration
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Application
for restoration of registration can be made to the Professional Conduct and
Health Committee at any time after 2 years from the date of erasure.
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The
Professional Conduct and Health Committee determine every application on its
merits any may recommend unconditional or conditional restoration or
registration or extend the period or erasure for another one year.
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In case
of unsuccessful application, a further period of at least 12 months must elapse
before a further application can be made.
11. ERASURE OF
NAME FROM MEDICAL REGISTER
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The NMC
can order the erasure of name of physician from the medical register for two
years on recommendation of the Professional Conduct and Health Committee.
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The
erasure remains effective unless the physician's application is accepted for
restoration of name to the medical register.
12. APPEAL
AGAINST ERASURE IN COURT
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If a
physician's registration is erased from the medical register for whatever
reason, s/he has got the right to appeal to the court against it.
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