15-minute reading · Slides (PDF) · Български
How to work
Read the preparation text first, then work in groups of three or four. The reading takes 15 minutes and the tasks 75 minutes, one 90-minute class in total. Choose a discussion lead, a note-taker and a spokesperson, and rotate the roles between tasks. Open a model answer only after you have written down your own reasoning.
All people, events and circumstances are fictional and do not describe a real patient. The cases are adapted from the course case bank. Work with the information given and say what else you would want to know. The cases train ethical and legal judgement; they do not replace advice from the head of the establishment, the ethics committee or a lawyer in a real case.
Hand in one group answer with the corrected statements, the analysis of the four cases and the liability table. Each student completes the individual task at the end. Marks go to accurate use of the models, a clear line between collegiality and cover-up, and correct legal grounds for each kind of liability.
Task 1. True or false — 10 minutes
Rewrite each statement in one or two sentences. Explain what is wrong and name the rule or concept that applies.
- “The patient doesn’t take his medication because he is undisciplined.”
- “Since the patient is on haemodialysis, the relatives decide for him.”
- “The paternalistic model is always wrong.”
- “Collegiality forbids me to criticise a colleague.”
- “If the physician is acquitted in the criminal case, they cannot be liable for damages in a civil claim.”
- “The patient always sues the physician personally.”
Non-adherence may be unintentional (forgetting, a complex regimen, cost) or intentional (side effects, fear, a different view of benefit); look for the cause first. Dependence on a machine does not remove autonomy: a capable patient decides, and relatives take part as far as the patient wishes. Activity–passivity and weak paternalism are justified when the patient cannot take part, as in resuscitation, and last only while that ground exists.
The Code forbids discrediting colleagues and public polemics (Arts. 41, 42), but collegiality is observed “while respecting the interests of the patient” (Art. 40); reasoned criticism through the proper channel is allowed and sometimes required. The kinds of liability are independent (Professional Organisations Act, Art. 42(1)); civil liability has its own conditions, and in tort fault is presumed (Obligations and Contracts Act, Art. 45). The injured patient usually claims from the healthcare establishment as principal (Art. 49), not only from the physician.
Task 2. The chronic patient and the prescription — 15 minutes
Case A: “I lost my medication”
An internist follows a patient with diabetes and painful peripheral neuropathy. Over the past year diabetes control has worsened: he has gained weight and started smoking again. More and more often he comes without an appointment, says he has lost his painkiller and demands a new prescription at once. There is no firm evidence whether he takes higher doses, shares or sells the drug, or simply cannot organise his treatment.
- Which coping mechanisms and which causes of non-adherence may lie behind his behaviour? Give at least three.
- Is the physician justified in refusing a new prescription on the spot? Under what conditions would refusal be justified?
- Propose an agreed plan for the next three months: who is responsible for what, and how it will be followed up.
Possible explanations: hopelessness and emotion-focused coping through smoking and food; uncontrolled pain; cognitive or organisational difficulties; financial problems; risky use of the drug. The physician must not present suspicion as fact. Labels such as “manipulative” destroy trust and close the conversation.
Refusing on the spot without assessment abandons a patient in pain; prescribing unconditionally may harm him. It is reasonable to reassess the pain, ask without blame what is happening to the medication, and check that the regimen is understood. If there are serious signs of risky use, the physician may limit the quantity or change the treatment, explaining this openly and recording it.
An agreed plan includes small quantities on set dates from one pharmacy, regular reviews of pain and diabetes, support to stop smoking, and a concrete goal that matters to the patient, such as walking to the shop without pain. It also states what happens if the medication is “lost” again. This is mutual participation: the physician is responsible for a safe, clear plan and the patient for honest feedback.
Task 3. “Doctor, you decide” — 15 minutes
Case B: a delegated choice
A 64-year-old woman with gallstones must choose between two surgical options with different benefits and risks. After a detailed explanation she says: “Doctor, you know better — do what you think is right.” She understands the basic information and has capacity, but the medical details frighten her.
- Which relationship model does she prefer in Emanuel and Emanuel’s terms and in Szasz and Hollender’s?
- Can the physician accept the delegation without the encounter becoming paternalistic? What minimum participation must be kept?
- Write the recommendation the physician would say to her, in two or three sentences.
She wants the physician to take a larger role: elements of the paternalistic model in Emanuel’s terms, or guidance–cooperation in Szasz and Hollender’s. Her choice, however, is voluntary and informed. Wanting a recommendation is not a waiver of autonomy.
The physician may accept the delegation after checking that it is free, while keeping a minimum of participation: she knows what the operation is, its main risks and what it means for her life, and she can change her mind. The physician asks what matters most to her, for example a quick recovery, a lower risk of a second operation, or avoiding a longer anaesthetic, and links the medical facts to those values. This is closer to the interpretive model than to paternalism.
A possible wording: “Both operations are medically acceptable. Since you want to get back to looking after your granddaughter quickly, I would recommend the first option. If you agree, we will schedule it, and you can still change your mind up to the day of surgery.”
Task 4. Collegiality and safety — 15 minutes
Case C: the senior physician
A physician with more than fifty years of practice is loved by his patients. Colleagues notice that he often omits necessary treatment, forgets important tests and repeats the same questions. He rejects hints that he should rest. A nurse has noticed that two of his orders this week conflict with allergies recorded in the chart. She is unsure whether to carry them out and whether to tell anyone.
- What should the nurse do with today’s orders?
- How can colleagues check their observations fairly, without age itself becoming the reason?
- Which articles of the Code of Professional Ethics apply, and how do they fit together?
The nurse does not silently carry out an order that conflicts with a documented allergy, nor “correct” it in secret. She stops and clarifies with the physician, and if he is unavailable or insists, with the head of department, and she records what she found. This is the functional hierarchy of the team: anyone may stop a procedure when safety is at risk.
Colleagues record specific, dated observations (missed orders, wrong doses, repeated questions), not rumour or general impressions about age. Next come a private conversation and referral for independent assessment; if there is immediate risk, temporary limits on duties through the established procedure. The assessment is individual and proportionate. Neither cover-up nor automatic exclusion is professional conduct.
Art. 40 requires collegiality “while respecting the interests of the patient”. Arts. 41 and 42 forbid slander and public discrediting, not a reasoned report through the proper channel. Art. 46 sends ethical disputes to the ethics committees. Art. 49 requires help for a colleague who is ill. The physician’s dignity is protected by keeping the conversation and the assessment confidential.
Task 5. Who is liable for what — 15 minutes
Case D: a handover without the new symptom
At the end of his shift on 24 December a physician waits almost an hour for a late colleague. A nurse reports chest pain in a patient with pneumonia. The physician orders an ECG, expecting the next doctor on duty to read it. In the rushed handover he forgets to mention the symptom and leaves. The ECG is not read in time. Later the patient dies of acute myocardial infarction. The family seeks compensation and complains to the Bulgarian Medical Association and the prosecutor.
- Fill in a table with six rows, one per kind of liability: legal basis, who decides, possible outcome.
- What must be established for criminal liability, and what for civil liability?
- What share belongs to the organisation and to the late colleague?
| Type | Legal basis | Who decides | Possible outcome |
|---|---|---|---|
| Professional | Professional Organisations Act, Art. 37(1); Code, Art. 24 | Ethics committee of the Bulgarian Medical Association | Reprimand, fine, removal from the register (Art. 38) |
| Administrative | Health Act, Arts. 221, 229 | Inspection bodies | Fine; sanction on the establishment |
| Civil: tort | Obligations and Contracts Act, Arts. 45, 49, 52 | Court, on the heirs’ claim | Damages from the hospital, including non-pecuniary |
| Civil: contract | Obligations and Contracts Act, Arts. 79, 82 | Court, where there is a contract | Damages for improper performance |
| Criminal | Penal Code, Art. 123(1) | Prosecutor and court | Imprisonment |
| Employment | Labour Code, Arts. 186–188, 203, 206 | Employer; court | Disciplinary penalty; limited recourse |
Criminal liability requires proof of negligent practice of the occupation, a causal link between the omission and the death, and fault in the form of negligence (Penal Code, Art. 11). It must be shown whether an ECG read in time and treatment would have prevented the death. In civil tort, fault is presumed (Obligations and Contracts Act, Art. 45); the hospital is liable for damage caused by its physician at work (Art. 49) without proof of its own fault, and after paying it has limited recourse against him (Labour Code, Art. 206(3)).
The organisation bears a share: no structured handover, a late arrival tolerated without cover, pending tests not flagged. The late colleague may face disciplinary liability for lateness. The kinds of liability do not exclude each other (Professional Organisations Act, Art. 42(1); Labour Code, Art. 186).
Individual closing task — 5 minutes
Answer briefly without opening the model answers:
- Write one question you will ask every chronically ill patient before adding a new drug.
- Name a situation in which activity–passivity is justified, and say when it must end.
- Explain in one sentence why an injured patient usually claims from the healthcare establishment rather than only from the physician.
Feedback criteria
A complete answer looks for the cause of non-adherence before judging the patient and proposes an agreed plan that can be followed up. In Case B it separates a delegated choice from paternalism. In Case C it separates immediate safety from a fair assessment of the colleague. In Case D it distinguishes the six kinds of liability and names causation and fault as conditions for criminal liability. Listing models and articles without applying them to the facts does not complete the task.