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Omar Hasan Kasule, Sr1
1Institute of Medicine, Universiti Brunei Darussalam
Abstract
This papers reports results of a cross sectional self-administered questionnaire study on ethical knowledge among medical students at the Institute of Medicine of Universiti Brunei Darussalam. The primary objective of the research was to establish the general level of knowledge and understanding medical students to provide a baseline that can be used to assess student progress as they move through the medical course. The results of data analysis would be used in refining the design of the ethico-legal curriculum at the Institute of Medicine. The questionnaire had been used in a similar study at the International University Malaysia. After explaining the aims and procedures of the study as well as obtaining written consent, students were asked to complete and return the questionnaire. Students were presented with scenarios with ethico-legal issues that confronted them with making choices on issues dealing with knowledge of ethics or attitudes and practices regarding ethical issues. They were asked to choose the best of 3-4 alternative solutions for each scenario. The alternatives in knowledge scenarios sought to test the student’s knowledge and were coded as ‘do know’, ‘do not know’, ‘not sure’, or ‘avoid; the issue. The alternatives in scenarios with a legal dilemma were testing the student’s attitude and practice and were coded as ‘avoid’, ‘do something about the problem’, ‘refer or report to someone else’. Doing something about the dilemma included: ‘do what you think is right’ ‘confront wrong doer’, ‘confront the patient’, ‘disclose to patient’, disclose to family’, ‘disclose to colleagues’, ‘seek ‘advice’. Reporting or notification included: ‘notify authorities’, ‘blow the whistle’, ‘refer’, ‘notify authorities’.
with avoiding the ethical dilemma or doing something about it. Each alternative that addressed the ethical dilemma had an embedded ethical guideline. The guidelines were derived from the 5 Purposes of the Law, maqasid al shari’at which are preservation of morality, life, progeny, intellect, and resources; the 5 Principles of the Law, qawa’id al shari’at, which are intentionality, certainty, injury (including beneficence, non-malefacence, autonomy and justice), difficulty, or precedent); the principles of patient-physician interaction which are confidentiality, disclosure, and fidelity; blowing the whistle on unethical practices, confronting the wrong doers; or a relevant specific law or regulation. Data was coded and was analyzed using the SPSS and STATA packages. The data was summarized as proportions with Poisson 95% confidence intervals because of small numbers. Bivariate associations were tested using the Pearson chi square. The analysis focused on establishing whether there were relationships between responses to the various scenarios and gender, race, or religion. It also sought to establish what values, laws, and ethical principles students preferred to use in solving the dilemmas. Details of student responses to the dilemma were also discussed qualitatively. The response was 20/20 (100% ) for year 1, 11/13 for year 2 ( ), and for year 3. The age of respondents ranged 17-21 years.
Key words: ethics knowledge medical students
TABLE #1: Gender and Ethnic Distribution by Year of Study
Gender | Ethnicity | Year 1 | Year 2 | Year 3 | Total | P value | |
Male | Malay | ||||||
Chinese | |||||||
South Asian | |||||||
All male | |||||||
Female | Malay | ||||||
Chinese | |||||||
South Asian | |||||||
All female | |||||||
TABLE #2: Distribution of student responses to knowledge scenarios
Student | Do know | Do not know | Not sure | Total |
Male | ||||
Female | ||||
TABLE #3: Distribution of student responses to attitude and practice scenarios
Student | Avoid | Do something | Report | Refer | Total |
Male | |||||
Female | |||||
I- GENERAL SCENARIOS
1. (ATTITUDE & PRACTICE): You become aware, by accident, that one of the patients is secretly is HIV-positive (the laboratory report somehow became stuck to the underside of an envelope he gave to you).
a. tell his spouse about his condition and warn her to be careful? (DO SOMETHING – breach of confidentiality)
b. inform your patient that you learned about his HIV by accident, and ask him if he is seeking treatment? (DO SOMETHING – disclosure to patient)
c. make sure that when you treat him, you wear a mask and gloves, and warn other members of the health team to do the same? (DO SOMETHING- Protect yourself)
d. carries on as normal, saying nothing about it? (AVOID- do nothing)
2. (ATTITUDE & PRACTICE) You are part of a team providing general health care. In the course of this, blood is taken for tests and there is some left over. A commercial laboratory approaches you for supply of this excess blood so that it can prepare a saleable protein from it. Do you
a. send the blood to this laboratory as requested? (DO SOMETHING – comply with unethical request)
b. agree to send the blood if a fee is distributed among the health team? (DO SOMETHING – commit financial fraud)
c. revise the patients’ consent form to allow them to agree to the donation? (DO SOMETHING – documentation fraud)
d. negotiate a payment to all the patients who are prepared to consent to donating their excess blood? (DO SOMETHING- obtain patient consent for a fee)
3. (ATTITIDE & PRACTICE) A number of alternative treatments for your patient are possible. The one which promises the best outcome is also the most expensive and it also carries the most risks. In respect of a patient who is established not to be wealthy, do you
a. explain the costs but omit to emphasize the risks? (DO SOMETHING – partial disclosure to patient)
b. explain both the risks and the expenses involved? (DO SOMETHING – full disclosure to patient)
c. advise a cheaper but possibly less effective treatment? (DO SOMETHING – recommend to patient)
d. give the patient a written list of treatments and their costs and ask him to make up his own mind? (DO SOMETHING – full disclosure to patient)
4. (ATTITIDE & PRACTICE) The health team is doing blood grouping, among other tests and you become aware, from the records, that a friend of yours, also a patient, cannot be the biological father of the child he is bringing up. Do you
a. do nothing? (AVOID)
b. warn your friend about the non-paternity? (DO SOMETHING – breach confidentiality)
c. amend the records so that the truth is forever concealed? (DO SOMETHING – change records)
d. ask your supervisor what to do? (REFER – refer to higher authority)
5. (ATTITIDE & PRACTICE)While working in the clinic, it is becoming obvious to you that a number of patients are pretending to be ill, to obtain time off work. You overhear conversations in which they admit to doing second jobs during their medical leave, like driving taxis and selling insurance. Do you
a. warn the doctor concerned? (DO SOMETHING – confront colleague)
b. argue with the patients whose conversations you have overheard? (DO SOMETHING – confront patient)
c. contact the police? (REPORT – to police)
d. do nothing? (AVOID – do nothing)
6. (ATTITIDE & PRACTICE) Later in life, as an executive in a big bioengineering company, you are involved in a project which promises to bring relief to hundreds of thousands of sufferers from deafness and blindness. However in your senior position you become aware that the company is only publishing the results of trials which show a favorable outcome; many trials convincingly demonstrate that thousands of patients could be harmed, but they are suppressed. Do you
a. do nothing? (AVOID – do nothing)
b. state your concern, as a ‘whistleblower’ in an anonymous letter to the newspapers? (REPORT - blow whistle)
c. ask for a personal interview with the Minister of Health asking for investigation and complete confidentiality? (REPORT - blow whistle)
d. look for another job pending your full exposure of the malpractice? (REPORT – prepare to blow whistle)
7. (ATTITIDE & PRACTICE) A member of your team is giving powdered peach stones, free, to the patients, because he believes that this prevents cancer. You have reliable information that the peach stone powder is toxic (in fact it can generate cyanide in the stomach). You have argued with your colleague about this but he is adamant that he is only doing good. Do you
a. continue to argue with your colleague in the hope of persuading him that he is misguided? (DO SOMETHING – confront colleague)
b. report your concerns to the team leader?(REPORT - blow whisle)
c. go directly to the Ministry of Health with your concerns? (Report - blow whistle)
d. write to the New Straits Times about your concerns? (BLOW WHISTLE)
8. (NOT CLASSIFIED) Working within the Ministry of Health, you use your lunch break to design a rather clever diagnostic device, which you believe to be novel. Do you
a. provide its specifications to the Chief Medical Officer through your Head of department?
b. form a company to exploit it?
c. contact a company and offer to sell it to them?
d. apply for a patent by completing application forms from the Patent Office?
9. (ATTITIDE & PRACTICE) As part of the management team in a large city hospital, you are called to a meeting to vote on the response to the following problem. A decision must be taken with at the most four hours. It appears that a patient about to give birth would definitely die, along with her baby, if a caesarian section is not performed. (The pelvis is too narrow and in the any case the baby is in a transverse lie.) For religious reasons the patient has refused the operation. The obstetricians want to perform the caesarean but have come to the hospital management group for their decision. Do you vote for
a. applying to the High Court for permission for the hospital to conduct the operation? (DO SOMETHING – seek consent from court)
b. obtaining consent from the patient’s husband then going ahead with the caesarean? (DO SOMETHING – seek consent from family)
c. letting events merely take their course, while trying to keep the patient as comfortable as possible? (AVOID)
d. telephoning the Minister of Health for his opinion? (REFER – to Minister)
10. (KNOWLEDGE) Consider the term “patient autonomy”. Do you take it to mean that
a. each patient has individual characteristics? (DO NOT KNOW)
b. a patient’s own choice of treatments and possible outcomes must be respected? (DO KNOW)
c. patients must be regarded as valuable human beings? (NOT SURE)
d. the patient must automatically follow the best advice given to him? (DO NOT KNOW)
11. (KNOWLEDGE) In normal circumstances patients register at your reception area and are told to wait before being called in to see you. You gently move a patient’s head for a better examination but she says that you twisted her neck and complains to the police. Are you protected by the
a. fact that the police will not take up the case? (DO NOT KNOW)
b. lawyers that your clinic will hire? (DO NOT KNOW)
c. legal doctrine of implied consent? (DO KNOW)
d. the sum of money which will be given to the patient in compensation? (DO NOT KNOW)
12. (KNOWLEDGE) If for a certain procedure involving physically manipulating the patient, written consent is necessary, but you fail to obtain this and go ahead, are you legally liable in
a. battery? (DO KNOW)
b. negligence? (DO NOT KNOW)
c. recklessness? (NOT SURE)
d. carelessness? (NOT SURE)
13. (ATTITUDE AND PRACTICE) A six-year old boy is brought to your clinic for a simple procedure. However you notice multiple bruises on his back and the backs of his arms. The father who accompanies him appears have identifiable needle marks on his arms. Do you
a. demand from the father an explanation of how the bruises occurred. (DO SOMETHING – confront parent)
b. telephone the police immediately with your suspicions. (REPORT – to police)
c. immediately after the end of the consultation, telephone the Society for the Protection of Children (assuming one exists in your area). (DO SOMETHING – seek help)
d. note down the address of the family and watch the house for a few hours in the evening? (AVOID)
14. (ATTITUDE AND PRACTICE) Running your own clinic/ dispensary, you are asked for a certain treatment by a fifteen year old boy. However you aware that his parents violently disagree with the treatment, which however in your opinion will increase the boy’s ability to benefit from his schooling. Reasoning with the parents has had no effect. Do you
a. contact several colleagues in the same specialty and ask them what they would do? (DO SOMETHING - seek advice)
b. seek legal advice? (DO SOMETHING -seek advice)
c. merely proceed with the treatment? (DO WHAT YOU THINK IS RIGHT)
d. ask the boy to go elsewhere? (AVOID)
15. (ATTITUDE AND PRACTICE) A non-urgent procedure is needed for a six-year old boy. However seemingly the boy cannot sit still long enough for the treatment to proceed. Trying to settle him forcibly with the help of his parents causes him to become hysterical and to start kicking and screaming. You noticed that in the waiting room he was continually climbing over the chairs and running round the table. Do you
a. refuse to waste time with the boy? (AVOID)
b. tell the parents how to get psychiatric help? (AVOID)
c. ask the parents to restrain the boy with leather straps so that you can proceed? (DO WHAT YOU THINK IS RIGHT)
d. inform the parents that the child has attention deficit hyperactivity disorder (ADHD). (TRUTHFULNESS IN DISCLOSURE)
16. (ATTITUDE AND PRACTICE) A 16-year old girl has been your patient for some time, but has been very difficult. At this session she tells you that she is in love with you and wishes to elope with you. Do you
a. immediately send her away and refuse further treatment altogether? (AVOID)
b. call her parents and ask them to reason with her? (DISCLOSURE)
c. tell her not to be silly and ask her to sit still for the consultation? (DO WHAT YOU THINK IS RIGHT)
d. ignore her comments, call in a chaperone and proceed? (AVOID)
17. (ATTITUDE AND PRACTICE) As a health professional your relatives often seek your advice. One of your nieces is evidently undergoing precocious puberty at the age of eight (menstruation and bodily changes). She is seeing a well-respected endocrinologist who has explained that he would like to try out a new diagnostic procedure, and has explained its chances of success and its risks to the mother, your sister. She is in a dilemma about giving permission when she speaks to you. Would you
a. state bluntly that you have no experience in such matters and leave it at that? (AVOID)
b. introduce her to a female colleague who has had several daughters so that they can talk it over together? (REFER)
c. recommend some books on endocrinology? (REFER)
d. seek out the endocrinologist for an explanation of the procedure? (REFER)
18. (ATTITUDE AND PRACTICE) From his breath a patient, a middle aged man with a wife and two children aged 18 and 20, is clearly an alcoholic and he smells of tobacco smoke. There is no doubt that the treatment you are giving him is adversely affected by these habits. Do you
a. ask him next time to bring his family and recruit their support for stopping these habits? (DO WHAT YOU THINK IS RIGHT)
b. ask him to make an appointment with a psychiatrist through his family doctor? (REFER)
c. Give him personal counseling on the adverse effects of smoking and drinking? (DO WHAT YOU THINK IS RIGHT)
d. refuse to treat him further if he continues to smoke and drink? (AVOID)
19. (KNOWLEDGE) Do you believe that at present, in Malaysia, regulations allow
a. unlimited use of any kind of stem cell for any purpose? (DO NOT KNOW)
b. use of stem cells for therapeutic purposes only? (KNOW)
c. use of stem cells for reproductive cloning? (DO NOT KNOW)
d. no use of stem cells whatsoever either in research or therapy? (DO NOT KNOW)
20. (KNOWLEDGE) The ethical committee on which you sit proposes that a new treatment should be tried on inmates in an institution for the criminally insane, because the issue of informed consent can be put on one side. Do you
a. agree that this is a good idea? (DO NOT KNOW)
b. dismiss the idea from the start unless number of factors relating to medical ethics are properly considered? (DO KNOW)
c. ask about physical protection for the investigators? (AVOID)
d. point out that when the results are published the subjects must be anonymised? (DO KNOW)
II- ISLAMIC MEDICAL JURISPRUDENCE
21. A female Muslim patient preparing for a chest X-ray becomes very uncomfortable and adamantly refuses to be touched by one of the only two male radiographers attached to the hospital. Do you
a. advise the patient that this is acceptable for the sake of health? (DO KNOW)
b. call your superior, to have him explain the procedure to the patient? (AVOID)
c. call for a chaperone? (DO KNOW)
d. have the hospital call a female radiographer from a nearby hospital? (DO KNOW)
22. The parents of a young Muslim patient in a coma but not brain dead have mentioned to you, that they will seek a court order to have their daughter’s life support removed as specialists have told them the chance of recovery is small and it has been two years since her devastating accident. Another reason is the rising hospital bills. Do you
a. inform the hospital director? (AVOID)
b. seek an injunction to prevent the disconnection? (DO KNOW)
c. help to secure financial assistance for the patient? (DO NOT KNOW)
d. counsel the parents on the obligations of a Muslim? (AVOID)
23. Following in vitro testing, your research supervisor has proposed that you test a new drug on cats, after which you will examine its effects on their reproductive organs. Do you
a. agree to do this as the purpose of animal research is to spare humans?
b. counter-propose the use of smaller animals, for example, rats?
c. Concur, as long as the testing will not cause suffering and pain to the animal?
d. decline as you know that the testing is not a necessity (dharuurat)?
24. A Muslim female confides to you that she feels uneasy examining the eye of a patient of the opposite sex. Do you
a. advise her to carry on as usual in a professional manner?
b. advise her to wear gloves?
c. dismiss her feelings as irrelevant?
d. discuss her concerns with your superiors?
25. In training, you witness a colleague perform a procedure which only a medical officer is allowed to do. Although there is no adverse effect on the patient, do you
a. feel obligated to report the incident to your supervisor immediately?
b. keep quiet?
c. advise your colleague on the possible implications of the actions?
d. tell your colleague what you observed and that you would keep the matter secret?
26. A Muslim female patient is worried over the reactions of her husband when he finds out that she has sought treatment without his permission. Do you
a. simply refrain from treating?
b. advise her to obtain permission from her husband?
c. carry on, as a spouse cannot overrule the choice of the patient to seek treatment?
d. ask the patient to come back with her husband so you can explain the necessity of the treatment?
27. As a researcher on ageing, you are offered a position on the research committee of a well-known international company working on an elixir claimed to guarantee a lifespan of 100 years. Do you
a. seize the opportunity to enhance your international standing?
b. turn down the offer as you believe that life and death is in the hands of Allah?
c. accept the offer for the sake of acquiring new knowledge?
d. decline as you fear criticisms from other Muslims?
28. Your sister tells you that she has been taking a natural herbal product from China which has increased her energy level. As someone who has some knowledge of the process of drug development, you are concerned about the source of the product and side effects. Do you
a. advise your sister to stop taking the product?
b. investigate whether the product is halal?
c. do nothing?
d. explore the side effects of similar products?
29. In the presence of a bed-ridden but conscious Muslim patient, when it is time to perform the obligatory prayers (solat), do you
a. ask if you could assist the patient to pray?
b. ask your supervisor for guidance?
c. decide that the patient is not fit to perform the solat?
d. do nothing?
30. When treating or giving advice to a non-Muslim patient, do you
a. continue to practice values according to the teachings of the Qur’an?
b. proceed without any reference to Islamic values?
c. perform your duties according to what you have been taught?
d. see no obligation to inculcate Islamic perspectives?
31. A married couple who rely on your advice propose to travel to Indonesia to find a surrogate mother who will have the couple fertilized ovum implanted. Your advice is that:
a. Surrogacy is not permitted in Islam.
b. This is medically justified.
c. This is allowed on the basis of an individual’s reproductive rights as its impact on society is negligible.
d. All methods of assisted reproduction can be considered provided the couple is legally married.
32. Your 45-year-old Muslim aunt with 12 children including a young baby consults you regarding permanent sterilization. You would
a. inform her that it is strictly prohibited.
b. tell her that she should opt for other types of family limitation.
c. tell her that such a decision is acceptable with her husband’s consent.
d. tell her that since she is approaching menopause contraception is not necessary.
33. A devout member of your ethics committee objects to a proposal to issue free needle to heroin addicts. Do you:
a. agree that this is wrong.
b. point out that this will only encourage drug addiction.
c. suggest more stringent prosecution of addicts.
d. point out that the principle of lesser harm may be applied.
34. The Ministry of Health is seeking individual views of euthanasia. In your response to the Ministry, do you point out that:
a. in all forms it is viewed by the Islamic Law as murder.
b. it may allowed for the purpose of easing the burden of a prolonged illness.
c. it may allowed in some circumstances based on individual human rights.
d. it may be ethical in the case of withdrawing life support from a patient in vegetative state.
35. A 40-year-old Muslim lady 12 weeks pregnant insists on having an abortion following detection of Down syndrome fetus. As a member of the ethics committee you would advise:
a. complying with her request.
b. having the prenatal test repeated to verify the result.
c. against the abortion since there is a likelihood that the result is incorrect.
d. telling her that abortion in this circumstances is not acceptable.
36. The ethics committee is reconsidering the matter of organ donation. Should it decide that:
a. organ donation from a non Muslim to a Muslim is not allowed.
b. only the living are allowed to donate.
c. an adult Muslim can sign a statement authorizing removal of his organs in case of death.
d. physicians have the authority to decide on the donation of organs of the deceased.
37. A 10-year-old boy is diagnosed to have haemophilia A. Porcine Factor VIII is available. Other options are either less effective or very costly. His parents are reluctant to agree to the treatment. As a member of the healthcare team you would:
a. suggest the less effective treatment.
b. advise treating the patient with Porcine VIII since he is bleeding but conceal this from his parents.
c. put out an appeal to the public for extra funds for the non-porcine treatment.
d. explain to the parents that the porcine source is acceptable based on the principle of dharurah.
38. A 20-year-old girl who was previously well was found dead in her girl friend’s apartment. Consent for a post-mortem examination could not be obtained. Do you consider that the best course of action is:
a. to not perform the examination and release the body.
b. to proceed with the examination since it is a medico legal autopsy which does violate the Law (Shari’at).
c. to request the police officer in-charge to obtain the court order for the examination.
d. to consult the forensic pathologist to obtain permission to perform only the external examination.
39. The parents of a newborn with a congenital defect with a poor chance of survival seek your advice with regard to a very invasive and expensive treatment, for which they can well afford. You would
a. help them look for medical institutions locally or abroad where such treatment is offered.
b. advise them against it as it is a waste of resources.
c. advise them to submit to God’s will and accept death as predestined.
d. tell them that heroic treatment of a patient with a poor prognosis is not an Islamic option.
40. You are chairing a discussion on Medical Ethics at a local conference. One of the participants poses this question to you: “Do medical ethics slow down medical research and progress? Your response is that:
a. To some extent it does, justifiably.
b. There is no justification for it doing so.
c. It legitimately safeguards and regulates medical practice.
d. Progress in medical research is independent of medical ethics.