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Presented at Kuala Belait on 22-23 February 2008 by Professor Dr Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Universiti Brunei Darussalam & Visiting Professor of Epidemiology, Universiti Malaya
GROUP #1 (CASES ON PRIVACY AND CONFIDENTIALITY)
Case #1: A patient with diastolic blood pressure of 120 mmHg failed to return to the Health Center for treatment. The nurse called the head of the village and asked him to convince the patient to come. In order to impress on him the urgency of the matter she had to explain all the details of the history and examination that had been carried out on the patient.
Case #2: A clerk in the records department casually mentioned impotence of a patient to his friends at the village restaurant. Word spread quickly around the village resulting in cancellation of the patient’s engagement.
Case #3: A neurologist informed his wife over dinner about an elderly bus school bus driver who had Parkinson disease and had to take an unusually high dose of medication to suppress the tremors but he felt sleepy all day. The wife asked for the name and realized that the patient was a driver on her company who had been coming to work late in the past 2 weeks. She dismissed him the next morning.
GROUP #2 (CASES ON DISCLOSURE)
Case #1: Midwives refuse to inform a mother and hide the congenitally malformed baby from her for a week
Case #2: The manager of a national airline writes to ask a private practitioner to provide records about treatment of a pilot for vision and psychological problems. He asks specifically for information on drug abuse.
Case #3: A medical researcher stationed at the hospital used to take an aliquot from every blood specimen to test for HBV. The hospital authorities knew what he was doing but the patients were not informed because he did not record names of patients. One day out of curiosity he tested specimen for HIV and found it positive. He was confused what to do regarding disclosure.
Case #4: A community pediatrician had reported abuse of a couple’s first child to the authorities. The authorities called in the parents to discuss the matter. The abusing father was so angry that he divorced his wife for giving information to the pediatrician. He later took the wife back under the rujuk provisions of the Law. At the next visit the pediatrician noted signs of child abuse and asked the mother. The mother confirmed the abuse but asked the pediatrician not to follow up the matter for the sake of her marriage and family. The pediatrician this time did not report to the authorities.
Case #5: A midwife who had contracted HIV due to transfusion hid her status for 5 years. She was very meticulous during deliveries observing all precautions and during that time no patient was reported to have been infected. After a family quarrel her husband revealed her status to the newspaper. The editor failed to interview her before publication of the report. The midwife refused a request by the head of obstetrics to have an HIV test. The hospital suspended her and charged her for criminal negligence in the high court.
GROUP #3 (CASES ON CONSENT TO TREATMENT)
Case #1: A bed-ridden patient with limited movements and sensation communicates by sign language and limited speech. She can recognize letters and can write sentences by nodding when the right letter is touched. She indicates that she does not want physiotherapy, wants to divorce her spouse, and wants to give the family home to the kind doctor taking care of her. She wants to disinherit her sons for not sitting around her bed and caring for her daily. She wanted to return to her home and leave the nursing home.
Case #2: A patient with a benign prostatic enlargement and mild urinary retention asked the urologist for prostatectomy. The urologist refused after examination revealed no complications and a normal PSA level. Because there was only one urologist in the government hospital, the patient sued the hospital in the High Court to force them to carry out the operation. Due to delays in scheduling a hearing the patient went overseas and had the operation done. Histological examination showed low grade prostate carcinoma confined within the prostatic capsule.
GROUP #4 (CASES ON REFUSAL OF TREATMENT)
Case #1: 40-year old theater nurse refuses to accept the diagnosis of breast cancer and refuses surgery
Case #2: 40-year old policeman refused surgery to drain a pyomyositis abscess. He still refused surgery after the abscess bursts spontaneously. The surgeons sedate him and carry out the surgery without his consent.
Case #3: A 30-year old soldier with a history of schizophrenia refuses a chest x-ray for a severe cough lasting 2 months. His commanding officer authorizes using force to take the x-ray and to treat him accordingly.
Case #4: a 42-year old actor pregnant for the first time refuses an elective caesarean section. She continued to refuse the procedure when labor became obstructed and signs of fetal distress appeared. The obstetrician went ahead to operate on the basis of consent by the husband.
Case #5: A 14-year old patient refused admission because he hated the physicians on the pediatric ward. The father agreed with the patient but the mother disagreed. Both parents agreed with the patient’s refusal of any blood transfusion which the doctors considered necessary since the hemoglobin level had fallen to a dangerous level.
Case #6: a 60-year retired nurse refused HRT after a diagnosis of osteoporosis was made. She argued that HRT was anticipating and contradicting pre-determination, takdir.
GROUP #5 (CASES ON NEGLIGENCE & MALPRACTICE)
Case #1: patient with no obvious injury after a minor accident was discharged without x-ray investigations. He develops back problems 3 months later leading to leg paralysis.
Case #2: A 45-year old mother of 5 grown up children had hysterectomy because of prolonged, heavy, and irregular menstruation. The surgeon took care to preserve the ovaries and therefore saw no need to put on her on HRT. A year later she had a hip fracture due to osteoporosis treated by hip replacement and she was started on HRT. Six months later she developed pain in the right groin and examination revealed cancer of the ovary. The cancer was too advanced for surgery and she was put on palliative radiotherapy and chemotherapy.
Case #3: An aspiring actor was advised by her media consultants to change her facial features in order to succeed in landing major and lucrative acting roles. She went to a doctor who advertised his cosmetic surgery services on the television and women’s magazines. Six months later and a series of operations she was angry. Her face was asymmetric and her eye lids drooped. She asked for his license as a plastic surgeon. He told her he was a general surgeon who had interest in plastic or cosmetic surgery. With her career ruined she decided to take him to court.
Case #4: A patient with epilepsy well controlled on drugs for the past 10 years, experienced a minor epileptic seizure. His physician increased the drug dosage and told him all would be well and that he could go back and resume driving the school bus. The patient asked for an MC to explain his day’s absence to the manager of the school bus company. The next morning the patient crushed the bus into a wall as he was driving it out of the garage. He explained that he felt sleepy at the time of the accident.
GROUP #6 (CASES ON LIFE SUPPORT IN TERMINAL ILLNESS)
Case #1: Patient with brain stem death is kept on artificial life support on the insistence of the family because announcing the death immediately will have an adverse effect on the values of the family business on the stock exchange
Case #2: The family took an unconscious man to hospital reluctantly because they believed he was dead. He was admitted to the ICU and was put on artificial life support. For a period of 4 weeks the family insisted on and the physicians refused withdrawal of life support. The patient woke up in the 5th week.
GROUP #7 (CASES ON REPRODUCTIVE ISSUES)
Case #1: a mentally retarded sexually active 14-year old teenager was taken to the family planning clinic to receive contraceptives without the knowledge of her parents. Due to irregular use of the pills she became pregnant and her aunt took her overseas for an abortion. On return she advised her parents to take her for sterilization. The parents preferred hysterectomy because in her retarded condition she could not maintain menstrual hygiene. The family gynecologist preferred depo provera.
Case #2: A couple married for 10 years without a child decided to have IVF. Before the procedure was completed, the husband died. The wife insisted on using the semen of her dead husband. The relatives of the husband objected. The first wife who had been divorced 15 years earlier with one girl also asked for the semen for an IVF procedure that she hoped would enable her have another baby to act as a bone marrow donor for her daughter who had leukemia and had failed to find a matching donor.
GROUP #8 (CASES ON ORGAN DONATION)
GROUP #9 (CASES ON DRUG ABUSE AND SUICIDE)
Case #1: A patient, whose engagement had been cancelled in the week that he failed his university entry examinations, started smoking, drinking alcohol, and using illicit drugs to forget but to no avail. He was admitted to the medical ward after suffering a nervous breakdown. He was violent and abusive on the ward and refused to take his medication. Two weeks from his admission he left the ward without telling anyone and went and killed his former fiancée at her home. He later became very agitated and depressed and within 10 hours he also committed suicide. His parents and the parents of his ex-fiancee jointly sued the hospital.
Case #2: The patient was a brooding type who was always sad. He had a mental break down when his wife had a spontaneous abortion of a 3-month pregnancy. He was taken to the hospital emergency room. The attending physician finding nothing physically wrong with him decided to discharge him. The physician ignored the repeated talk of the patient about following his dead baby into the grave and just gave him valium and sent him home. When the effect of valium wore off at home he became agitated. His wife found him 10 minutes later lying unconscious on the bed with a half-empty bottle of detergent next to him. She called an ambulance that arrived in record time. By the time he was seen by the physician in the emergency room, he had recovered some consciousness and could talk. He told the physician that he wanted to die. He categorically refused to consent to the procedure of gastric lavage to remove the detergent from his stomach. A psychiatrist called to assess his mental competence concluded that he was competent to make decisions.
GROUP #10 (CASES ON DOCTOR ETIQUETTE, adab al tabiib)
Case #1: A physician prescribed a new unlicensed drug donated to him by a pharmaceutical company. The physician had shares in the company. He had no previous personal knowledge of the drug. The patient developed an immediate allergic reaction. The physician blamed the nurse for not asking about drug allergies before injecting the drug.
Case #2: A 60-year old surgeon was known by everybody in the hospital to cause pain while examining patients without prior explanation and consent. He used to make lewd jokes about female patients. He discussed diagnoses with his drinking partners and details of many patients were known in the community. A junior doctor who complained to the hospital director was told to keep quiet. Nobody else dared complain about him because of his seniority.
Case #3: A well-known businessman was diagnosed with drug-resistant tuberculosis. He refused admission to the TB ward because of his social position. He contacted the hospital manager who was his golf partner to pressure the junior doctor to admit him to a room on a normal ward. When the junior doctor refused, he was transferred to another department and the admission went ahead.
GROUP #11 (CASES ON RESOURCES)
Case #1: A 65-year old man whose brother had just died from coronary heart disease walked into the health center and asked for examination because he was afraid that his heart may also have problems. The triage nurse asked him if he had any specific complaints. He replied that he has none and that he was in perfect health. The nurse rebuked him for wasting her time. ‘Don’t you the line of 120 really people waiting to see a doctor? How can we waste time in someone healthy like you?’. The man was admitted to the ICU 5 days later with myocardial infarction and he died after 2 days.
Case #2: The ICU staff were in a dilemma because 2 patients presented at the same time and they had only one free bed. The first patient was 90 years old and has been admitted three times before with myocardial infarction. His sons forced him to come to hospital; he had expressed preference to stay and die at home in peace. The second patient was a 30-year neurosurgeon. He was the only one in the whole country. He had been involved in a serous car accident and was in coma.
Case #3: a 37-year old mother, who had just had a normal delivery with considerable blood loss, protested at being discharged the next day. She needed rest and could not get that at home where she had 5 children to look after. The midwives told her they needed the bed for other patients. She was readmitted the next day with fatal postnatal hemorrhage.
GROUP #12 (PHYSICIANS WITH DUAL OBLIGATIONS)
Case #1: A worker sustained severe injury while at work. Under pressure from management a company physician refused to certify disability qualifying the worker for a hefty compensation. The worker sued the employer. While the case is still in court the worker died and the physician refused to certify that infection of the injured hand contributed to death):
Case #2: A national football team physician examined a player and found that he had a chromic shoulder dislocation and advised that he should not play again until it was treated. The player protested because he had always played with that condition since he was young. The team manager threatened to dismiss the physician if he did not certify the player as fit to play because that star player was the only hope of the team to win in an international match the next day.
GROUP #13 (POSTMORTEM)
Case #1: A child’s asthma progressed to respiratory failure and death because the father refused to give up smoking and the mother refused to get rid of cats to which the children are allergic. Hospital authorities request for a postmortem examination to establish the cause of death for fear that they may be charged unfairly for negligence in the death of the child. The social workers also request a postmortem because they suspect that parental negligence contributed to the death. The family rejects postmortem claiming the child died from a curse and not disease:
Case #2: A police officer died a few minutes after admission from what was suspected were injuries sustained in the course of his duty. The police department insisted on a postmortem to determine the cause of death in order to make decisions about compensation. The family was divided. Some were opposed to postmortem and others wanted to go ahead.
ADDITIONAL CASES FOR THE AFTERNOON
Case I.
16 years old single Chinese girl admitted for vomiting and pregnancy test was positive. Her father requested to know about her problem but the mother insisted that the doctor don’t tell him about the pregnancy saying that he will surely kill her daughter if he knows about it. The mother also requested that the doctor terminate the pregnancy without the father’s knowledge.
Issues:
- Confidentiality – should the doctor tell the father?
- Breaking the law – should the doctor terminate the pregnancy?
- Social values- doctors need to be aware of the social determinants that influence the health status of their patients
Case II.
A drug addict was seen in the OPD for cough. Investigations revealed that he was HIV Positive and evidence of pulmonary TB on CXR. Patient refused admission and treatment and asked that his family not to be told about his condition.
Issues:
- Refusal of treatment- when the patients be confined or treated against their will?
- Breaching confidentiality- doctor should view it with critical eye and legal requirement
- Public health- doctor responsible not just for their patients but, for others as well
Case III.
42 years old Malay man admitted in ICU in a comatose state. He was ventilated but his family wanted the life support to be disconnected when they were told of his brain death. When he died, the family also refused post mortem to determine cause of death
Issues:
1. Artificial life support – who has the right to decide initiation and discontinuation of the life support.
2. Post Mortem refusal – can the doctor override the family’s decision?
3. Resource allocation – avoiding wasteful practices.
Case IV.
A junior doctor felt frustrated that his specialist was managing with out-of-date treatment that delayed recovery for the patients. He was also concerned that the doctor was having affairs with the staff and patients.
Issues:
1. Resolution of conflict among doctors.
2. Reporting of unethical behavior
3. Senior doctors should serve as a good model in dealing with patients.
Case I.
16 years old single Chinese girl admitted for vomiting and pregnancy test was positive. Her father requested to know about her problem but the mother insisted that the doctor don’t tell him about the pregnancy saying that he will surely kill her daughter if he knows about it. The mother also requested that the doctor terminate the pregnancy without the father’s knowledge.
Issues:
- Confidentiality – should the doctor tell the father?
- Breaking the law – should the doctor terminate the pregnancy?
- Social values- doctors need to be aware of the social determinants that influence the health status of their patients
Case II.
A drug addict was seen in the OPD for cough. Investigations revealed that he was HIV Positive and evidence of pulmonary TB on CXR. Patient refused admission and treatment and asked that his family not to be told about his condition.
Issues:
- Refusal of treatment- when the patients be confined or treated against their will?
- Breaching confidentiality- doctor should view it with critical eye and legal requirement
- Public health- doctor responsible not just for their patients but, for others as well
Case III.
42 years old Malay man admitted in ICU in a comatose state. He was ventilated but his family wanted the life support to be disconnected when they were told of his brain death. When he died, the family also refused post mortem to determine cause of death
Issues:
1. Artificial life support – who has the right to decide initiation and discontinuation of the life support.
2. Post Mortem refusal – can the doctor override the family’s decision?
3. Resource allocation – avoiding wasteful practices.
Case IV.
A junior doctor felt frustrated that his specialist was managing with out-of-date treatment that delayed recovery for the patients. He was also concerned that the doctor was having affairs with the staff and patients.
Issues:
1. Resolution of conflict among doctors.
2. Reporting of unethical behavior
3. Senior doctors should serve as a good model in dealing with patients.