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there are different schemes of subsiriesone of which is transport subsidyHome Programmes and Schemes Himalayan North Eastern Transport Subsidy SchemeTransport Subsidy SchemeBrief about the SchemeGovernment of India had introduced Transport Subsidy Scheme (TSS) on 23.7.1971 to develop industrialization in the remote, hilly and inaccessible areas. The scheme was applicable to all industrial units (barring plantations, refineries and power generating units both in public and private sectors irrespective of their size). Under the scheme, subsidy on the transport cost for transportation of raw material and finished goods to and from the location of the unit and the designated rail-head was reimbursed for a period of 5 years from the date of commencement of commercial production. For North Eastern states, subsidy is 90%. However, for the movement of goods within NER, the subsidy is 50% on finished goods and 90% on raw material. TSS was modified and notified as “Freight Subsidy Scheme (FSS) – 2013, w.e.f. 22.1.2013 for a period of five years. The Scheme has been discontinued with effect from 22.11.2016. However, industrial units registered under the scheme prior to the date of issue of DIPP’s notification dated 22.11.2016 will be eligible for the benefits of the residual period under the scheme.more...North East Industrial Development Scheme (NEIDS), 2017 (843.4 KB)Transport Subsidy scheme (178.96 KB)Checklist for scrutiny of claims under Transport Subsidy Scheme (TSS), 1971 / Freight Subsidy Scheme (FSS), 2013 - Simplificatio (1.49 MB)Transport Subsidy Scheme (TSS), 1971 - applicability to North Eastern Region (NER) (1.17 MB)Checklist for scrutiny of claims under Transport Subsidy Scheme (TSS), 1971 / Freight Subsidy Scheme (FSS), 2013 - Simplificatio (958.43 KB)Checklist for scrutiny of claims under Transport Subsidy Scheme (TSS), 1971 / Freight Subsidy Scheme (FSS), 2013 - Simplificatio (583.97 KB)One year time limitation for submission of claims under TSS, 1971 / FSS, 2013 - clarification regarding (798.88 KB)Transport Subsidy Scheme 2009-10 - 15th September, 2009 (2.72 MB)Transport Subsidy Scheme 2009-10 - 23rd February, 2010 (7.3 MB)Revised checklist under Transport Subsidy Scheme 1971 (388.52 KB)Chesklist for scrutiny of claims under TSS/FSS - clarification (388.52 KB)One year time limitation for submission of claims under TSS/FSS - clarification (400.84 KB)Freight Subsidy Scheme (FSS), 2013 - amendment (172.99 KB)One year time limitation for submission of claims under TSS, 1971 / FSS, 2013 - clarification (117.12 KB)Clarification in respect of scrutiny of claims under FSS, 2013 (201.2 KB)Home Programmes and Schemes Industrial Promotion Startup IndiaStartup IndiaBrief about the SchemeStartup India is a flagship initiative of the Government of India (launched January 2016), intended to build a strong eco-system for nurturing innovation and Startups in the country that will drive sustainable economic growth and generate large scale employment opportunities. The Government through this initiative aims to empower Startups to grow through innovation and design. In order to meet the objectives of the initiative, Government of India announced Startup India Action Plan that addresses all aspects of the Startup ecosystem. With this Action Plan the Government hopes to accelerate spreading of the Startup movement: The Action Plan is divided across the following areas:Simplification and HandholdingFunding Support and IncentivesIndustry-Academia Partnership and IncubationDetailed Write-upScheme Objectives: The Action Plan is based on three pillars – Simplification and handholding, funding support and incentives, industry-academia partnership and incubation. Following are the 19 Action Points under the Startup India initiative: Simplification and handholding Compliance Regime based on Self-certification Startup India Hub Rolling out of Mobile App and Portal Legal Support and Fast-tracking Patent Examination at Lower Costs Relaxed Norms of Public Procurement for Startups Faster Exit for Startups Funding support and incentives Providing Funding Support through a Fund of Funds with a Corpus of INR 10,000 crore Credit Guarantee Fund for Startups Tax Exemption on Capital Gains Tax Exemption to Startups for 3 years Tax Exemption on Investments above Fair Market Value Organizing Startup Fests for Showcasing Innovation and Providing a Collaboration Platform Industry-academia partnership and incubation Launch of Atal Innovation Mission (AIM) with Self-Employment and Talent Utilization (SETU) Program Harnessing Private Sector Expertise for Incubator Setup Building Innovation Centres at National Institutes Setting up of 7 New Research Parks Modeled on the Research Park Setup at IIT Madras Promoting Startups in the Biotechnology Sector Launching of Innovation Focused Programs for Students Annual Incubator Grand ChallengeCoverage & Eligibility: For coverage and eligibility under the scheme, an entity shall be considered as a ‘Startup’ - Up to five years from the date of its incorporation/registration, If its turnover for any of the financial years has not exceeded Rupees 25 crore, and It is working towards innovation, development, deployment or commercialization of new products, processes or services driven by technology or intellectual property.Budget Availability / Utilization since last 5 years*Physical Progress against milestones till the end of previous year (i.e. cumulative till 2015-16) and during the year 2016-17: Please find enclosed at Annexure ISalient Features in Bullet Form: Easier access to funds for Startups Easier compliance norms for Startups Simpler regulations to help Startups register and stay in India Easier access to infrastructure and mentorship through wider industry-academia collaborationImplementing Agency: Department of Industrial Policy and PromotionMonitoring and Review Mechanism: A Monitoring Committee meeting is conducted every month with all relevant stakeholders, including Department of Bio Technology, Department of Science & Technology, Ministry of Human Resource Development and NITI Aayog among others to review the progress of the Startup India initiative. Regular meetings with all concerned Departments/Ministries are also organized as and when required.Findings of Evaluation, if any No evaluation has been undertaken so far.Scheme Guidelines (in searchable PDF / DOC) as amended up to 31.12.2016: Action Plan is availableCirculars / Notifications / Orders with file name indicating subject line in a self-explanatory manner: All circulars/notifications/orders are availableAbout UsRole and Functions Citizen's charter Minister of Commerce and Industry Who's Who Organization StructureAttached & Subordinate Offices Autonomous Institutions Statutory Bodies Divisions Work allocationProgrammes and SchemesHimalayan and North Eastern StatesTransport Subsidy Scheme Package-II for Special Category States Package-III for Special Category States Intellectual Property Rights(IPR)Modernisation and Strengthening of Intellectual Property Office (MSIPO) Scheme for Strengthening of Intellectual Property Appellate Board (IPAB) Industrial StatisticsScheme for Strengthening of Industrial Statistics Industrial PromotionMake in India Startup India Manufacturing & Industrial PolicyScheme for implementation of National Manufacturing Policy (NMP) InfrastructureIndustrial Corridors Modified Industrial Infrastructure Upgradation Scheme (MIIUS) Indian Footwear Leather and Accessories Development Programme OthersProject Based Support to Autonomous Institutions-National Productivity Council Project Based Support to Autonomous Institutions- Quality Council of India Petroleum & Explosives Safety Organisation (PESO) Productivity & Quality Improvement in Cement & Construction Sector Central Pulp and Paper Research Institute Scheme for Salt Worker- Training for Technology upgradation Scheme for grant of rewards to the children of salt labourersPolicies, Rules and Acts +Acts Rules PoliciesForeign Direct Investment Policy Industrial Policy National Design Policy National IPR Policy National Manufacturing Policy North East Industrial & Investment Promotion Policy (NEIIPP) Budgetary Support under GST Regime Government DecisionsOrders Notification Press Notes/FDI CircularInternational Co-OperationMOUs High Level DelegationsJapan Visit High Level Delegation Allied OrganisationsUNIDO World Intellectual Property Organization Asian Productivity Organization World BankFor InvestorsInvestor Guidance Forms Application Status-SIA eBiz Project Country DesksFDIF D I Policy Foreign Exchange Management Act Foreign Investment Facilitation Portal FDI Policy Clarifications FDI PublicationsPublicationsAnnual Reports Budget Departmental Terminology Recruitment Rules FDI Newsletter (erstwhile SIA Newsletter) FDI Statistics SIA Statistics Compendium of Plan Schemes Jobs Parliament Q & A Press Release Reports Tender/RFPRTI +RTI Act, 2005 RTI Mandatory Information Notifications on RTI How to Apply Designated Officers under RTIHome Programmes and Schemes Industrial Promotion Make in IndiaMake in IndiaBrief about the Scheme​Department of Industrial Policy and Promotion (DIPP) is entrusted with the task of formulation of Foreign Direct Investment (FDI) policy, monitoring of Ease of Doing Business reforms and Investment Promotion and Facilitation activities. Investment Promotion is being carried out as an activity.Investment promotion is a multidimensional and complex process which requires continuous efforts to be channelized around Ease of Doing Business, FDI reforms, skill development, infrastructure creation and fiscal incentives. All these activities have been brought into focus after launch of Make in India initiative by the Government in September, 2014 to make India the most preferred investment destination. The Government has put in place a comprehensive FDI policy regime by bringing more activities under the automatic route, increasing sectoral caps and easing conditionalties. In addition to this, a number of measures have been undertaken to ease the business environment of the country. Various State and Central Government services are being integrated on a single window e-biz portal.Scheme Objectives:-The Government has been taking various initiatives to promote manufacturing with the key objective of improving competitiveness of the private and public sector firms operating in the country, facilitating their integration into the global value chains and enabling them to better compete in global markets. The various objectives of the scheme include:Investor Facilitation : Invest IndiaThe objective of Invest India is to act as the first reference point for target investors and provide sector-and state-specific inputs, and hand-holding support to investors through the entire investment cycle, from pre-investment decision-making to after-care. The cabinet in its meeting held on 28th August, 2009 approved the proposal of Department of Industrial Policy & Promotion, Ministry of Commerce & Industry, for the formation of a company, Invest India, under Section 25 of the Companies Act 1956, for promotion of foreign investments. This was in line with the practices followed globally, where every country has a set up a dedicated national level investment promotion agency.Ease of Doing BusinessThe objective of this initiative is to speed up implementation of reforms to bring improvement in the business environment of the country. Department/Ministry wise action to be taken under each of the parameters has been identified and nodal Departments/Ministries have been assigned for each parameter. Inter- Departmental reviews are convened at regular intervals to ensure implementation of Action Points. On the front of State-level initiatives of business reforms, efforts are being taken to engage those States which due to historical reasons do not have enough incentives to undertake business reforms.In this regard, the best practices followed by various States Governments are being shared with States as guidance for undertaking reforms. Further, workshops are being organized with officials of States sensitize them towards reforms and make them understand the processes involved in simplification, digitization etc. States which have implemented more than 90% of reforms have also been requested to handhold the States with less than 40% implementation of reforms.Financial assistance to the following activities is provided to continue implementing the Ease of Doing Business initiatives:Continuous engagement with various stakeholders and State Governments. This involves study of best practices followed by the States, study of specific initiatives in other countries and their implementation in India, undertaking study tours and organizing seminars and workshops to disseminate best practices etc.Improvement of the regulatory environment in States/UTs and ranking them. The implementation of State Business Reforms Plan involves visiting States for conducting validation studies and for implementation of proposed reforms including activities related to seminars and study tours for this purpose.Preparation of Assessment Report on implementation of State Business Reforms Plan, State ranking and dissemination of these plans/reports through printing including distribution.Support for workshops/seminars/conferences/roadshows etc. being organized by State Governments, Industry Associations and NGOs in creating awareness of the initiatives undertaken by themselves and Central Governments on Ease of Doing Business.Engagement of agencies for assistance in activities related to Ease of Doing Business initiativeSupport for all financial implications related to setting up and continuation of E-Biz project. This project involves establishment of G2B portal that addresses needs of business and industry through creation of a one stop-shop for convenient and efficient services to all investors.CEO Forums and Joint Commission MeetingsSupport is provided to organize focused Joint Commission meetings at the level of G to G, CEO’s Forum at the level of B to B. including all such similar bilateral/multilateral mechanisms also. The support would also include all financial implication towards visits for such meetings.International Investment Outreach and its amplificationThe scheme provides support for organizing international outreach activities (including networking sessions, road shows, exhibitions, one to one meetings,) in collaboration with Indian missions and Industry associations to leverage established connects with investors in a targeted manner. Various outreach platforms for engagements will be explored in priority regions based on analysis in this regard.Support is provided for amplification of investment outreach activities through specific business events/ sector specific business events/ investments meetings organized by Industry chambers. Support will also be provided for outreach activities and its amplification at the sidelines of important global summits like G20, World Economic forum etc.Support is provided for outreach activities in potential regions/cities at a sub-sector level for investment promotion and execution of Market entry support programs. The activities related to participation in key International events based on a prior assessment by developing an event calendar to make such visit maximize investment outreach objectives would also be supported. The level of participation would range from “Partner Country” to small yet effective partnerships with industry CEO’s and media houses at international events, including sector specific events. Identified industry associations would facilitate participation in such events.The assistance is made available for organizing customized Make in India Events to undertake investment outreach and its amplification at identified strategic locations in partnership with Indian Missions, Industry Associations, Invest India and the concerned sectoral ministry. Such activities are being started alongside VVIP visits to focus countries to leverage planned VVIP visits and summits.The scheme provides support related to expenses to implement above mentioned activities including all financial implication towards involving an India/Foreign agency with proven records for conceptualization and execution of such activities overseas.Support to Indian Missions in focus countriesIndian missions in focus countries act as the key facilitator for envisaged engagements in the form of participative and owned events, bilateral meetings, summit, VVIP visits etc. Provision is made to provide financial assistance to Indian missions abroad to engage their commercial wings in investment outreach activities and information dissemination about Make in India Initiative and policy initiatives, achievements, sector strengths and improvements in ease of doing business including any other similar showcasing activities.Foreign TravelThe component on foreign travel will include deputation of official delegations aboard in connection with undertaking various investment outreach and amplification activities.Domestic Investment Outreach and amplificationThe assistance is made available for organizing and participating in key sectoral and investment outreach and amplification activities in the country in association with National level industry associations.Overall Amplification of Investment promotion and outreachFocused and extensive deployment of the right media tools is seen as a powerful way to maintain recall of the target audience. Keeping this in mind, provision is made for executing a comprehensive amplification plan with a focus to maintain recall of the Make in India Initiative through extensive usage of digital, social, electronic, outdoor and print media. It will also be an opportunity to communicate to the global business community the achievements of the Indian economy and, in particular, Make in India focus sectors, its positive strides in ease of doing business, developments under Make in India Initiatives. The Department will engage Indian/Foreign creative and media amplification agencies with proven records to formulate a brand strategy and creative vision for the amplification activities including to assist in implementation of envisaged strategy and vision. The Department will undertake production of outreach and amplification material for use in various activities. These may include high quality videos, audios, brochures, business pen drives and other customized items for various outreach activities.Project Management, Capacity Building, Monitoring and EvaluationTo enable effective management of the scheme, assistance is made available for project management support with concurrent evaluation including capacity building by undertaking industry/sector related reports, preparation of concept paper for innovative projects for attracting investments.ii. The support is provided for Provision for Program Monitoring Cell (PMC) to monitor the progress of various Action Plans developed from time to time to ensure implementation of Make in India initiatives.Home Programmes and Schemes Manufacturing Industrial Policy Scheme for implementation of National Manufacturing Policy (NMP)Scheme for implementation of National Manufacturing Policy (NMP)Brief about the SchemeThe Scheme covers the components of National Manufacturing Policy. These components are (i) Cost of Master Planning of NIMZ and (ii) Technology Acquisition and Development Fund (TADF). However, the scheme component TADF has been transferred to M/o Micro, Small and Medium Enterprises (MSME) on 16thSeptember, 2016 and is now being implemented by the Ministry.Scheme Objectives : To provide the Cost of Master Planning of National Investment & Manufacturing Zones (NIMZs) being established in the various States.Coverage & Eligibility : The Cost of Master Planning of the NIMZ will be granted to the State Government/SPV of the concerned NIMZ, which is finally approved by the Central Government.Budget Availability/Utilization since last 5 years* : As below.Physical Progress against milestone till the end of previous year (i.e. cumulative till 2015-16) and during the year 2016-17 : So far Government has granted in-principle approval to the 14 NIMZs outside the DMIC region. Out of which 3 NIMZs have been granted final approval. Under the TADF Scheme, 18 projects have been approved by the Green Manufacturing Committee (GMAC) constituted under NMP, till 16th September, 2016. However, the TADF scheme has been transferred to M/o Micro, Small and Medium Enterprises (MSME) on 16th September, 2016 and is now being implemented by the MinistrySalient Features in Bullet FormImplementing Agency : N.AMonitoring and Review Mechanism : N.AFunding of Evaluation, if any : -Scheme Guidelines (in searchable PDF/DOC) as amended upto 31.12.2016 : N.ACirculars/Notifications/Orders with file name indicating subject line in a self-explanatory manner: : Annexure-I & II.

Medical Ethics Problems Can Be ChallengingMedical ethics involves examining a specific problem, usually a clinical case, and using values, facts, and logic to decide the best course of action.Some ethical problems are relatively straightforward, such as determining right from wrong. But others can also be more perplexing, such as deciding between two "rights"—two values that conflict with each other—or choosing between two different value systems, such as the patients versus the doctors.Doctors may deal with a great variety of perplexing ethical problems even in a small medical practice. Here are some common problems identified in a 2016 Medscape survey, where at least some physicians held different opinions [1] :Withholding treatment to meet an organization's budget, or because of insurance policies;Accepting money from pharmaceutical or device manufacturers;Upcoding to get treatment covered;Getting romantically involved with a patient or family member;Covering up a mistake;Reporting an impaired colleague;Cherry-picking patients;Prescribing a placebo;Practicing defensive medicine to avoid malpractice lawsuits;Dropping insurers; andThey were breaching patient confidentiality owing to a health risk.Professional standards are a way to provide some guidance on ethical problems. Still, they cannot address every issue, and they may not address troubling nuances, such as reconciling two conflicting values.Critical Values for Deciding Ethical IssuesMany professional ethicists recommend using four fundamental values, or principles, to decide ethical issues:Autonomy: Patients have the right to determine their healthcare.Justice: Distributing the benefits and burdens of care across society.Beneficence: Doing good for the patient.Nonmalfeasance: Making sure you are not harming the patient.However, ethical values are not limited to just these four principles. Other important matters to consider include truth-telling, transparency, respect for patients and families, and respect for patients' values.Besides, medical ethics is not just a thought process. It also involves people skills, such as gathering the facts needed to make a decision and presenting your decision in a way that wins overall parties' confidence.Ethics is often seen as a prescriptive activity—telling you what you cannot do. But in many cases, it can be very freeing. It can affirm that you are doing the right thing.Listening skills are an essential part of medical ethics. Quite often, ethical disputes result from not knowing all the facts or providing all the facts to patients. Tactfulness and respect are also important. A well-constructed ethical decision could be ignored if you have not won the patient's confidence.Ethics is often seen as a prescriptive activity—telling you what you cannot do. But in many cases, it can be very freeing. It can affirm that you are doing the right thing. If you go through the proper ethical thought process, you'll have greater certainty that what you're doing is the right thing. Relieved of nagging doubts, you will be able to proceed more directly and vigorously with your care plan.As the health system evolves, ethical decisions could become more challenging. For example, mounting difficulties in finding affordable insurance prompt patients to forgo the care they need, which affects the clinician's care plan.Practical Implications of Medical EthicsSome doctors think of medical ethics as a very esoteric field, removed from clinical practice's practical considerations. Indeed, medical ethics is first and foremost a matter of conscience, but it also has some efficient implications and applications.Physicians who can describe their ethical concerns and use negotiating skills may change the organizational policies that produce burnout.Here are some reasons to take medical ethics seriously:To help resolve disputes between family, patients, physicians, or other parties. Often, the parties involved are operating strictly on emotion, making it difficult to come to a logical and fair decision. Ethics adds another dimension to help make decisions.To maintain a clear conscience. All doctors want to be sure they have done the right thing. Being an ethical physician is more important than making money or seeing as many patients as possible.To not make yourself look uninformed. Physicians sometimes stumble onto poor decisions because they did not understand their role and had not bothered to identify an ethical challenge or thought the situation through to its logical conclusion.To maintain the respect of your patients. Ethical missteps can destroy the bond between doctor and patient. Patients often implicitly trust their doctors, but once that trust has been breached, it is difficult to repair.To maintain respectful relationships with other clinicians. Your colleagues often have very definite opinions about what is ethical, often enshrined in various codes of ethics of the profession or learned from mentors. Those codes and ethics role-modeling are created by people who practice some form of ethical decision-making.To maintain some efficiency. Although ethical decision-making often requires extra time, it also can save time by anticipating disagreements that can slow down the care process. If you aren't honest, patients or other caregivers who are upset with your decisions can seriously impede your work.To reduce burnout. One cause of burnout is incongruence between physicians' values and those of their organization. Physicians who can describe their ethical concerns and use negotiating skills may change the organizational policies that produce burnout.Does Being Ethical Take More Time?Ethical decisions require a more deliberative style than many physicians are used to outside of clinical decision-making. Doctors have to collect information, explore ethical issues, and ask more questions if need be.To have the time to take these actions, you can't be continuously overwhelmed with work. As an ethical physician, you need to schedule your time, be efficient in obtaining medical information, and pass some responsibilities to other qualified caregivers.You also have the option of sharing your decisions with colleagues. And once you have worked through an ethical issue, it will be much easier to deal with it the next time it comes up. You will have developed a primary strategy.Getting to a useful, ethical conclusion about a specific problem means starting with solid values that most people can accept, such as upholding patients' health, telling patients the truth, and giving people a choice about being in a medical experiment. These fundamental values are rarely in dispute.Many other values are also widely accepted, such as patient autonomy. The same applies to being fair with your patients, meaning that all patients are essentially treated alike regarding critical healthcare decisions.But it's not always so easy. These widely accepted values often conflict with each other. For example, when patients refuse a treatment that could help them, the physician faces a conflict between respecting patient autonomy and doing what's best for them.Closing off your practice to new patients is another example of an ethical dilemma. Physicians are fully justified in not accepting every patient who comes through the door. Assuming every patient may or may not be a right business decision. However, rejecting a patient may mean that patient does not get the needed care. Many physicians struggled with this ethical decision.After working through this dilemma, you may still decide to close off your practice, but you will have thought the issue through. You will be aware that the people you are turning away even need a doctor. Some physicians might decide to find a way to help such people without burning themselves out, such as volunteering in a free clinic occasionally.Ethics, Morality, and ReligionMedical ethics differs from morality. Ethics is based on values and reasoning, and it uses persuasion to get its message across, whereas character involves adhering to a specific belief system or code of conduct.Morality relies on authority, such as the Bible, to justify its message. Character does not just involve religion. It can be political or personal, such as having a fascist or communist point of view, grounded in faith or tradition rather than facts or arguments.In contrast, medical ethics has a flexible set of solutions. It is based on facts and logic and not religious doctrine. You can still have political opinions and religious faith. Nevertheless, you will need to set them aside when forming and offering an ethical view to those who do not follow your personal morality.Some people view medicine almost as the new religion. People often come to the doctor with the same hopes they bring to a minister: "Save me, prepare me, redeem me." Of course, science cannot redeem anyone, but it does need to have a heart.A pure scientist, simply observing medical phenomena, would have a pragmatic attitude about life, sickness, and death. Science needs an ethical framework to make it humane.Ethical decisions should respect the values and attitudes of patients. If patients oppose vaccinations or blood transfusions for their child, their beliefs must be taken into account, even if you, the doctor, will not ultimately follow their requests.Respecting the patient's wishes has a practical consequence: Doctors who overrule the patient often end up seeing their treatments fail because patients will probably be fighting them the whole way. Patients who are overruled do not tell the truth. But patients in dialogue and negotiation with their doctors are more likely to come to a reasonable compromise—even if it's one the doctor doesn't entirely endorse.When Patients or Families Disagree With the DoctorSometimes when patients or their families disagree with the doctor, the obvious ethical decision isn't the right one. Here's an example that actually occurred.A child from southeast Asia had an easily treatable clubfoot, but the parents wouldn't allow treatment, evidently because they believed God had ordained clubfeet.The caregivers rightly put the child's health first, so they went to court and obtained an order for the operation. But the outcome was appalling. The family felt that the child had lost favor with God and abandoned the child. The child, in effect, became an orphan. The caregivers had won the battle but lost the war.Although physicians need to respect patients' values, physicians' own values should not sway their decisions. Conscience and the physician's religious faith should not automatically overrule the patient's need to get the best treatment possible.For example, let's say an emergency physician refuses to give a patient a morning-after pill based on the physician's own values, even though the drug has been clinically proven to work.The patient's needs, however, should come before the doctors' principles. Caregivers are expected to set their beliefs aside and focus on the best interests of the patient. If you cannot bring yourself to treat a patient, you must find another doctor who will.How Medical Values DevelopedValues are not set in stone. They evolve as the attitudes of society change. Half a century ago, when societal norms and educational standards were changing, the medical profession shifted from paternalism (the doctor knows best) to individual autonomy (patients must be consulted).Medical values tend to be loosely based on what a majority of the public holds to be true. However, ethical decisions cannot be based on public opinion because the people may not heed the values of minorities or those with views outside of the mainstream. The bottom line is that no one would want their own care decided by a bunch of inattentive and ill-informed people taking a 2-minute survey.So when you make an ethical decision in a coherent, thoughtful way, you may well diverge from current public opinion, but your values would still be sensitive to what the mainstream accepts.Who Decides Medical Ethics?Unlike religious matters, there is no ultimate arbiter of medical ethics, and ethicists intentionally do not have a set ethical code that the profession upholds.Physicians often consult their professional organizations' ethical codes, such as the American Medical Association (AMA). [2] These codes cannot take ethical decisions in situations in which a variety of competing factors are involved, but they can provide direction for decision-makers. Professional codes by doctors' own organizations can also help convince them that a particular ethical decision makes sense.Doctors may also look to their hospitals' ethics committees for answers, but these committees aren't intended to be the final medical ethics authorities. These committees are educators and work in an advisory capacity. Their role is to develop specific hospital policies, educate staff about clinical ethics, and oversee ethical consultants.So who is the ultimate arbiter of clinical medical ethics? It is the individual caregiver working in concert with the patient. Caregivers' ethical decisions go hand-in-hand with their clinical and technical decisions. Getting the ethics right depends on the integrity of the caregiver.Can Ethical Decisions on the Same Problem Differ?Because there is no preordained answer to most ethical dilemmas, even trained ethicists may disagree on solutions to the same moral problem. Although they tend to hold the same core values and use the same logic, they may not have gathered the same set of facts.Ethical decisions cannot be avoided. Whenever doctors make a clinical decision, they are almost always making a moral decision, consciously or not.Ethical decisions can change over time. The values that inform a particular ethical decision may change, or the implications of a particular decision may sink in. For example, as the public has become more comfortable with physician-assisted dying, some ethicists who once opposed it has come around to supporting it.Ethical decisions cannot be avoided. Whenever doctors make a clinical decision, they are almost always making a moral decision, consciously or not. Rather than not thinking about your care's ethical dimension, it makes more sense to be aware of it and make sure it is sound.Is It Ethical to Refrain From Judging Colleagues' Behavior?Administrative doctors clearly cannot overlook the behavior of doctors whom they oversee. It's part of their job title. But even doctors who don't have a supervisory role over colleagues have an implicit responsibility.Doctors are expected to uphold the well-being of patients in general, not just their own patients. This means they have a duty to report a doctor who abuses drugs or molesting patients, for example.Indeed, the AMA Code of Medical Ethics states that physicians should report colleagues' behavior "in the first instance so that the possible impact on patient welfare can be assessed and remedial action taken." [3]Medical Ethics and the LawMedical ethics may have different standards from the law. The law is created by judges or legislators and may not share ethical physicians' values and reasoning.For example, Baby Doe laws require doctors to treat premature babies even when they are severely disabled, but some doctors have concluded that preemies who are too sick to survive should not be treated.Physicians who disobey the Baby Doe laws (also referred to as "regulations") are rarely prosecuted. In many cases, prosecutors are reluctant to take action against doctors who violate such laws out of respect for their clinical judgment.With most malpractice cases, courts examine clinical standards of care and determine whether the defendant's doctor has met them. In many cases, unethical conduct does not rise to the level of medical malpractice.For example, a few years ago, a patient recorded a gastroenterologist making disparaging remarks about him under sedation. The gastroenterologist was clearly unethical in that he was not showing respect to the patient, but the patient did not file a malpractice lawsuit and instead filed a defamation lawsuit. (The patient lost the case because defamation must involve transmitting remarks to a third party.) [4]On the other hand, not getting a patient's informed consent for a procedure, another clearly ethical problem, is also an important element in a malpractice complaint. Physicians who do not obtain informed consent can be liable for malpractice, even if the procedure meets all clinical care standards. [5]Unethical Behavior and Medical BoardsMedical malpractice cases require some evidence of harm, but this is not the standard for reporting physicians' conduct to medical licensing boards. Medical boards can and do take action against many behaviors that are widely considered unethical even when no harm takes place.The definition of unprofessional conduct promulgated by the Federation of State Medical Boards, the trade group for state boards, includes "patient abuse" and "dishonesty." (The exact wording may vary from state to state.) [6About 20 years ago, I had a bicycle accident where I went over the handlebars and largely landed on my upper chest as a first contact point. I walked away from it without a major problem other than being pissed off at the car that had rapidly pulled up past me and turned into my “lane,” causing me to “emergency hit” the brakes, snap the rear brake cable, and thus stop with and fly over my nicely functioning front wheel and its efficient brake.A bit bruised and pissed off, but no biggie.Until a few weeks later, when I was taking a relaxing hot shower and SUDDENLY feel an extremely sharp, very small, and slightly burning point of pain around the base of the right side of my neck, the pain raced down the forward/inner part of my arm in the space of a second or so and then disappeared just around the inner skin surface of the crook of my arm, just around the elbow area.My first thought was that it was either my curlicue spinal column “pinching a nerve” or that it was a heart attack. There was no chest discomfort or “pain under my jaw, and a glance at this pic from several years earlier will give you an idea why I was considering the “nerve pinch” theory so seriously:Nonetheless, I immediately stepped out of the shower to evaluate things and to reduce the chances of passing out and hitting my head in the tub if indeed my heart had stopped!I stepped out and took my pulse in my left wrist (where I normally took it if I was trying to get a count or was worried about arrhythmia (which I’d had a short intermittent bout with several years earlier — which had seemed largely due to a lack of potassium in my diet.) Pulse was slightly raised (obviously to be expected since I had some worries that I might be about to visit St. Peter’s Permanent Vacation Resort) but strong and steady. My nerves were on edge, but I didn’t feel faint or anything. There was no chest discomfort or pressure. And no further pains.OK! So, Instant Infant Internet Self-Diagnosis: NBD (No Big Deal), and I went about my business for a couple of days. But then… about two or three days “post-pain,” I was rechecking my pulse and decided to try the right wrist for a change.Hmmm….No pulse.Tried the left wrist.Nice strong pulse.I shook the right arm a bit, tried again…No pulse.But I felt fine!It was the middle of the night, and there were NO other symptoms of anything, so I decided I’d call my doc in the morning on the assumption that maybe my spine or muscle tightness or somesuch had merely temporarily crimped the little pulse vessel in my arm or something minor like that (LOL! OK, so, CLEARLY NOT a doctor here, as I often remind folks in my postings!)I hit the sack, had a good night/morning’s sleep with my usual erratic schedule at the time, woke up, had some breakfast, and called the doc’s office in the early afternoon. I asked if I could have an appointment because I didn’t seem to have a pulse but otherwise felt fine. They set me up for early the next morning since it was the tail end of the afternoon, all their regular appointment slots full, and I was feeling okay — and since they probably thought I was either nuts or a very calm hypochondriac.I went in and had some fun with a nurse when I insisted she take my blood pressure in my right arm (or maybe just offered my right arm… don’t really remember) and had fun watching her as she discovered that I seemed to be sitting there smiling at her with zero blood pressure. I reassured her that I was fine but just missing a pulse.She wasn’t very reassured and probably worried that I was about to go glassy-eyed and try to eat her brains. She asked me to sit still and flew out the door of the examining room. About sixty seconds later, my doc walks in, looking a bit annoyed/amused, and asked me what I was doing to upset his nurse so much. I asked him to take my BP and gave him my right arm.He quickly noticed the lack of pulse and, after I reassured him that I wasn’t just playing some trick, he set me up for an angiography early the next morning. I bicycled down to the local hospital for the angiography. I proceeded to enjoy the Star Trek type experience of watching my circulatory system at work on the TV!I enjoyed it until it got up to where my neck met my shoulder, and we saw what pretty clearly looked like a massive clot up around the top of my right subclavian artery, bouncing around with every heartbeat and looking like it was about to break off and vacation in my brain.After asking me to relax and stay still, the angiographer did not look happy and went flying out of the room to grab a surgeon who had just arrived for the day and was still neatly dressed in a business suit. He came in, looked at Mikey’s Pulsey Show on the TV screen, and asked how I felt. I smiled and said, “I feel fine, but I don’t have a pulse in my right arm, and that TV image doesn’t look perfect.” He agreed and said he COULD do some more examinations and try giving me clot busters or somesuch. What he REALLY wanted to do was immediately wheel me right into the operating room and fix what looked like a severe problem.I agreed, and some assistants carefully transferred me to a gurney(?) and wheeled me away to an OR where I met a friendly anesthetist and counted down to 98 for him.I blinked my eyes and found myself looking up into the face of my very concerned younger brother… six hours later! It turned out that I was now the proud owner of the equivalent of a plastic McDonald’s soda straw replacing a massive internally directed and clotted right subclavian artery that had evidently been injured in that earlier bicycle accident a few weeks earlier!All has been well ever since. But it could EASILY have been the opposite!I’m just lucky I didn’t try the “home remedy” I’d considered: asking a friend known for giving “deep muscle massages” to visit and work on my shoulder that previous evening to see if maybe the artery had just gotten crimped by the weird twists and turns of my upper bone structure and could be uncrimped with a good massage!Soooo…. that’s my small thing, just a slightly annoying missing pulse that COULD rapidly have turned into a Mike The Brain Dead Vegetable thing or a Mike The Worm Food Guy thing or a Mike The West Philly Zombie thing. Thanks to an excellent surgeon who must have destroyed his day’s schedule on a moment’s notice to save me, I’m here today to entertain and annoy folks on Al Gore’s Internet!MJM, who’ll now take a break and eat some tuna fish (I hear it’s good brain food!) and who feels VERY badly about somehow, somewhere along the line, having lost that excellent surgeon’s name. If/when I get it in the future, I’ll stop back to add it here!