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Presentation at a City Grand Round at the King Fahd Medical Center in Riyadh Saudi Arabia on Monday 13th October 2008 at 08.00 am - 09.00 am by Dr Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology Institute of Medicine, University of Brunei Darussalam & Visiting Professor of Epidemiology University of Malaya. WEB: http://omarkasule.tripod.com.
1.0 OVERVIEW
The Grand Round will consist of a presentation lasting 25-35 minutes followed by discussion of practical clinical cases with ethico-legal dilemmas. The presentation will cover the ethical theory and principles used in training programs by the speaker as well as his experience of teaching and assessing medical ethico-legal knowledge and practice in 3 continents and 11 countries over a 3-year period, 2005-2008.
The training programs conducted by the speaker consisted of 3 phases. The first phase was presentation of the basic ethico-legal theory and principles. The second phase was small group discussions of cases with illustrative ethico-legal problems. The third phase was a plenary session at the end that provided an opportunity for discussing outstanding issues.
The training programs used a theory of ethics derived from the Higher Purposes of the Law as well as the Major Principles of the Law. Medical procedures deemed ethical promote and do not violate the 5 purposes of preserving religion, life, progeny, intellect, and resources. The 5 legal principles / legal axioms (intention, certainty, injury, difficulty, and custom) aid in legal reasoning of complicated ethico-legal issues.
Physicians, nurses, nurses, and medical students who participated in the training programs completed pre- and post- training questionnaires that challenged them to identify and resolve ethico-legal violations and dilemmas in various clinical case scenarios. Questionnaire data was analyzed to describe variations of ethical knowledge by country and by professional status as well as determining the impact of training on the participants.
2.0 THE ETHICS TRAINING PROGRAM
2.1 COUNTRIES COVERED (2005-2008 N)
- SOUTH-EAST ASIA: Malaysia (many), Brunei (many), Indonesia (many)
- SOUTH ASIA: India (4), Bangladesh (4), Pakistan (1)
- WEST ASIA: Turkey (1) and Yaman (1)
- EUROPE: UK (6 programs)
- AFRICA: South Africa (2), Nigeria (8), Kenya (2)
2.2 THE CURRICULUM OUTLINE
2.2.1 Theories and principles of medical ethics
v Purposes and Principles of Medicine and ethics, maqasid wa qawa’id al tibaabat
v Regulations of Medical Procedures, dhawaabit al tatbiib
v Regulations of Research Procedures, dhawaabit al bahath
v Regulations of Physician Conduct, dhawaabit al tabiib
v Regulations about Professional Misconduct, dhawaabit al inhiraaf al mihani
2.2.2 The etiquette of the physician, adab al tabiib
v Etiquette with Patients and Families, adab al tabiib ma’a al mariidh
v Etiquette with the Dying, adab al tabiib ma’a al muhtadhir
v Etiquette with the Health Care Team, adab fariiq al tibb
v Etiquette of Research on Humans, adab al bahth al ‘ilmi
2.2.3 Issues in disease conditions, fiqh al amraadh
v Uro-Genital System, jihaaz bawli & jihaaz tanaasuli
v Cardio-Respiratory System, qalb & jihaaz al tanaffus
v Connective Tissue System,
v Alimentary System, jihaaz al ma idat
v Sensory Systems, al hawaas
v Patho-physiological Disturbances
v General Systemic Conditions
v Psychiatric conditions, amraadh nafsiyyat
v Neurological conditions, amraadh al a’asaab
v Age-Related Conditions, amraadh al ‘umr
2.2.4 Issues in modern medicine fiqh mustajiddaat al tibb
v Assisted Reproduction, taqniyat al injaab
v Contraception, mani’u al haml
v Reproductive Cloning, al istinsaakh
v Abortion, isqaat al haml
v Genetic Technology, taqniyat wiraathiyyat
v Artificial Life Support, ajhizat al in’aash
v Euthanasia, qatl al rahmat
v Solid Organ Transplantation, naql al a’adha
v Stem Cell Transplantation, naql al khalaayat
v Change of Fitra, taghyiir al fitrat
2.3 METHODOLOGY OF TRAINING
2.3.1 Closing the gap: The ethico-legal training program starts from the premise that there is a gap between what is and what ought to be and that this gap can be closed by training.
2.3.3 Practical on-the-job training: Training is learning on the job and is therefore very practical in nature. The trainers do not give lectures but rather facilitate discussion and interaction among participants that leads to learning. The training is based entirely on study and discussion of cases of actual ethical problems that are encountered in hospital practice. Source material is provided in advance of any workshops. As far as possible training is brought to each health center of hospital in order to reach as many professionals as possible.
2.3.4 Details of the training workshop: A total of 5 workshops each lasting 2-3 hours is needed to cover the curriculum. So far one round of introductory workshops has been done in each of the countries. Later workshops will cover other aspects of the curriculum. Workshop participants receive the training material at least a month in advance. Each workshop is opened by a short introduction from the workshop facilitator. Then the participants are divided into discussion groups each dealing with a group of related cases. Groups present their findings in the plenary session followed by a general discussion. The facilitator summarizes the principles learned as well as correct any misunderstandings.
3.0 ETHICAL THEORIES and PRINCIPLES
3.1 EVOLUTION OF MEDICAL JURISPRUDENCE, tatawwur al fiqh al tibbi
3.1.1 First period (0 to circa 1370H)
There are three stages in the evolution of fiqh tibbi. In the first period (0 to circa 1370H) it was derived directly from the Qur’an and sunnat.
3.1.2 The second period (1370-1420H)
In the second period (1370-1420) rulings on the many novel problems arising from drastic changes in medical technology were derived from secondary sources of the Law either transmitted (such as analogy, qiyaas, or scholarly consensus, ijma) or rational (such as istishaab, istihsaan, and istirsaal).
3.1.3 The modern period (1420-present)
The failure of the tools of qiyaas to deal with many new problems led to the modern era (1420H onwards) characterized by use of the Theory of Purposes of the Law, maqasid al shari’at, to derive robust and consistent rulings. Ijtihad maqasidi is becoming popular and will be more popular in the foreseeable future.
3.1.4 The Purposes of the Law, maqasid al shari’at
The theory of maqasid al shari’at is not new but many people had not heard about it because its time had not yet come. By the 5-6th centuries of hijra the basic work on the closed part of the Law derived directly from primary sources was complete. Any further developments in the law required opening up new the flexible part of the law which necessitated discussion of the purposes of the law. It was at this time that Abu Hamid al Ghazali (d. 505H) and his teacher Imaam al Haramain al Juwayni introduced the ideas that underlie the concept of maqasid al shari’at. Other pioneers of the theory of maqasid al shari’at were Sheikh al Islam Ahmad Ibn Taymiyyah (d. 728H) and his student Ibn al Qayyim al Jawziyyat (d. 751H). The field of the purposes of the law witnessed little development until revived by the Abdalusian Maliki scholar Imaam Abu Ishaq al Shatibi in the 8th century H who elaborated Ghazzali's theory. Our subsequent discussion of the purposes of the law is from al Shatibi's book al muwafaqaat fi usuul al shariat
3.2 DERIVATION OF MEDICAL ETHICS FROM THE LAW
3.2.1 Relation between law and ethics
The Law is comprehensive being a combination of moral and positive laws. It can easily resolve ethical problems that secularized law, lacking a moral religious component, cannot solve. Many contemporary ethical issues in medicine are moral in nature and require moral guidance that can be provided only from religion. The Law is the expression and practical manifestation of morality. It automatically bans all immoral actions as haram and automatically permits all what is moral or is not specifically defined as haram.
3.2.2 The fixed and the variable
The approach to ethics is a mixture of the fixed absolute and the variable. The fixed and absolute sets parameters of what is moral. Within these parameters, consensus can be reached on specific moral issues. Ethical theories and principles are derived from the basic Law but the detailed applications require further ijtihad by physicians.
3.2.3 The ethical theory based on the Purposes of the Law
There is a parsimonious and rigorously defined ethical theory based on the 5 purposes of the Law, maqasid al shari’at. The five purposes are preservation of ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical. Legal axioms or principles, qawa’id al shari’at, guide reasoning about specific ethico-legal issues and are listed as intention, qasd; certainty, yaqiin; injury, dharar; hardship, mashaqqat; and custom or precedent, ‘urf or ‘aadat.
3.3 THE 5 PURPOSES OF THE LAW IN MEDICINE, maqasid al shari’at fi al tibb
3.3.1 Protection of ddiin, hifdh al ddiin, essentially involves ‘ibadat in the wide sense that every human endeavor is a form of ‘ibadat. Thus medical treatment makes a direct contribution to ‘ibadat by protecting and promoting good health so that the worshipper will have the energy to undertake all the responsibilities of ‘ibadat. A sick or a weak body cannot perform physical ‘ibadat properly. Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate true ‘aqidat.
3.3.2 Protection of life, hifdh al nafs: The primary purpose of medicine is to fulfill the second purpose of the Law, the preservation of life, hifdh al nafs. Medicine cannot prevent or postpone death since such matters are in the hands of Allah alone. It however tries to maintain as high a quality of life until the appointed time of death arrives. Medicine contributes to the preservation and continuation of life by making sure that physiological functions are maintained. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.
3.3.3 Protection of progeny, hifdh al nasl: Medicine contributes to the fulfillment of the progeny function by making sure that children are cared for well so that they grow into healthy adults who can bear children. Treatment of infertility ensures successful child bearing. The care for the pregnant woman, peri-natal medicine, and pediatric medicine all ensure that children are born and grow healthy. Intra-partum care, infant and child care ensure survival of healthy children.
3.3.4 Protection of the mind, hifdh al ‘aql: Medical treatment plays a very important role in protection of the mind. Treatment of physical illnesses removes stress that affects the mental state. Treatment of neuroses and psychoses restores intellectual and emotional functions. Medical treatment of alcohol and drug abuse prevents deterioration of the intellect.
3.3.5 Protection of wealth, hifdh al mal: The wealth of any community depends on the productive activities of its healthy citizens. Medicine contributes to wealth generation by prevention of disease, promotion of health, and treatment of any diseases and their sequelae. Communities with general poor health are less productive than healthy vibrant communities. The principles of protection of life and protection of wealth may conflict in cases of terminal illness. Care for the terminally ill consumes a lot of resources that could have been used to treat other persons with treatable conditions.
3.4 THE 5 PRINCIPLES OF THE LAW IN MEDICINE, qawa’id al fiqh fi al tibb
3.4.1 Overview: The principles of the Law are legal axioms that make reasoning about ethical issues quicker and more consistent. They also help provide logical resolution in issues in which the purposes of the Law may be in apparent contradiction. For example for a long-staying intensive care patient on artificial life support, the purpose of life may appear to contradict that of resources. The principle of certainty can help resolve this issue by ascertaining whether the patient is certainly alive or dead so that a decision can be made about withdrawing or continuing life support.
3.4.2 The principle of intention, qa’idat al qasd: The Principle of intention comprises several sub principles. The sub principle ‘each action is judged by the intention behind it’ calls upon the physician to consult his inner conscience and make sure that his actions, seen or not seen, are based on good intentions. The sub principle ‘what matters is the intention and not the letter of the law’ rejects the wrong use of data to justify wrong or immoral actions. The sub principle ‘means are judged with the same criteria as the intentions’ implies that no useful medical purpose should be achieved by using immoral methods.
3.4.3 The principle of certainty, qa’idat al yaqeen: Medical diagnosis cannot reach the legal standard of absolute certainty, yaqeen. Decisions are made at the level of ghalabat al dhann but not at levels of dhann or shakk. Treatment decisions are based on a balance of probabilities. The most probable diagnosis is treated as the working while those with lower probabilities are kept in mind as alternatives. Each diagnosis is treated as a working diagnosis that is changed and refined as new information emerges. This provides for stability and a situation of quasi-certainty without which practical procedures will be taken reluctantly and inefficiently. The principle of certainty asserts that uncertainty cannot abrogate an existing certainty. Existing assertions should continue in force until there is compelling evidence to change them. All medical procedures are considered permissible unless there is evidence to prove their prohibition.
3.4.4 The principle of injury, qa’idat al dharar: Medical intervention is justified on the basic principle is that injury, if it occurs, should be relieved. An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect. In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of an injury has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the injury, then the pursuit of the benefit has priority. Physicians sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made. If confronted with 2 medical situations both of which are injurious and there is no way but to choose one of them, the lesser injury is committed. A lesser injury is committed in order to prevent a bigger injury. In the same way medical interventions that are in the public interest have priority over consideration of individual interest. The individual may have to sustain an injury in order to protect public interest. In many situations, the line between benefit and injury is very fine.
3.4.5 The principle of hardship, qaidat al mashaqqat: Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessities legalize the prohibited, al daruuraat tubiihu al mahdhuuraat, and mitigate easing of legal rules and obligations. In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the purpose of the Law that is the basis for the legalization. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place.
3.4.6 The principle of custom or precedent, qaidat al urf: The standard of medical care is defined by custom. The basic principle is that custom or precedent has legal force. What is considered customary is what is uniform, widespread, and predominant and not rare. The customary must also be old and not a recent phenomenon to give chance for a medical consensus to be formed.
3.5 SUB-PRINCIPLES DERIVED FROM THE PRINCIPLE OF INJURY
3.5.1 Overview: The principle of injury is perhaps the most important in medical ethics because it has such a wide scope. It is the basis for the 4 ethical principles of Beauchamp and Childress (autonomy, beneficence, non-malefacence, and justice) as well as sub-principles that ensure protection of patient interests and rights (privacy, confidentiality, and fidelity). All these sub principles ensure that the patient’s best interests are not harmed in the course of medical intervention. Autonomy is essentially that decisions must be made by the patient himself or her self because of all involved in the medical scenario the patient has the purest intentions. The principle of injury promotes benefit (maslahat or beneficence) and makes sure that harm as a side effect (mafsadat) is minimized or prevented (non-malefacence). Ensuring privacy and confidentiality protects the patient from the harm of disclosure of private information. Fidelity by ensuring a relationship of professional physician-patient trust protects the patient’s best interests.
3.5.2 The sub-principle of autonomy: No medical procedures can be carried out without informed consent of the patient except in cases when the patient lacks legal incompetence / legal capacity, ahliyyat. The patient is free to make decisions regarding the choice of physicians and treatments. The patient must be free and capable of giving informed consent. Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient, explanation of all alternatives, recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. Consent is limited to what was explained to the patient except in an emergency. Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life. Advance directives, proxy informed consent by the family are made for the unconscious terminal patient on withholding or withdrawal of treatment.
Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the other one disagrees. Parental choice takes precedence over the child’s choice. The courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children. Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order. Suicidal patients tend to refuse treatment because they want to die. For patients in coma, proxy consent by family members can be resorted to. If no family members are available, the physician does what he as a professional thinks is in the best interest of the patient. Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.
3.5.3 The sub-principles of privacy and confidentiality are often confused. Privacy is the right to make decisions about personal or private matters and blocking access to private information. The patient voluntarily allows the physician access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines of the Law even after death of the patient. Confidentiality falls under the teaching of the prophet about keeping secrets. In routine hospital practice, many persons have access to confidential information but all are enjoined to keep such information confidential. Confidentiality includes medical records of any form. The patient should not make unnecessary revelation of negative things about himself or herself. The physician can not disclose confidential information to a third party without the consent of the patient. Information can be released without the consent of the patient for purposes of medical care, for criminal investigations, and in the public interest. Release is not justified without patient consent for the following purposes: education, research, medical audit, employment or insurance.
4.0 CASES FOR ETHICO-LEGAL TRAINING PROGRAMS
4.1 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 press 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. The fiancée sued in court and the patient committed suicide. The clerk felt no remorse. He argued that he was doing a public duty by stopping a potentially unhappy marriage.
Case #3: A neurologist informed his wife over dinner about an elderly school bus driver who had Parkinson disease and had to take an unusually high dose of medication to suppress the tremors. The medication made the patient sleepy all day. The wife asked for the name and realized that the patient was a driver for her school transport company who had been coming to work late in the past 2 weeks. She dismissed him the next morning.
4.2 GROUP #2 (CASES ON DISCLOSURE)
Case #4: The manager of a national airline was worried about the erratic behavior and mistakes of one of the senior pilots. He asked around and found out the name and address of the pilot’s family doctor who was in private practice. He wrote to the private practitioner to provide records about treatment of the pilot for vision and psychological problems. He asked specifically for information on drug abuse. The private practitioner called and gave the information but told the manager that he could not put it down in writing since he had not discussed the matter with the patient.
Case #5: 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 a specimen for HIV and found it positive. He was confused what to do regarding disclosure. He called a meeting of the senior staff in the hospital to discuss the matter. He also included a respected lawyer from the town to provide a non-medical perspective.
Case #6: 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.
4.3 GROUP #3 (CASES ON CONSENT TO TREATMENT)
Case #7: A bed-ridden patient with limited movements and sensation communicated by sign language and limited speech. She could recognize letters and could write sentences by nodding when the right letter was touched. She indicated that she did not want physiotherapy, wanted to divorce her spouse, and wanted to give the family home to the kind doctor taking care of her. She wanted 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 #8: 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.
Case #9: A patient was brought to the emergency room by the police after attempting to kill himself by hanging. He was unconscious when first brought in and had a signed suicide note in his shirt pocket saying that he wanted to die. The doctors ignored the note and started resuscitation measures. The patient became conscious after 30 minutes and protested at the medical treatment arguing that he wanted to die. The doctor was thinking of stopping resuscitation measures when the patient’s father and wife arrived and instructed the doctor to continue resuscitation.
4.4 GROUP #4 (CASES ON REFUSAL OF TREATMENT)
Case #10: A 40-year old policeman refused surgery to drain a pyomyositis abscess. He still refused surgery after the abscess burst spontaneously. The surgeons sedated him and carried out the surgery without his consent.
Case #11: A 30-year old soldier with a history of schizophrenia refused a chest X-ray for a severe cough lasting 2 months. His commanding officer authorized using force to take the X-ray and to treat him accordingly. The army doctors were not sure what to do but being army officers they obeyed orders of the commanding officer.
Case #12: A 42-year old actress pregnant for the first time refused 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. The baby was delivered alive and well.
4.5 GROUP #5 (CASES ON NEGLIGENCE & MALPRACTICE)
Case #13: A patient with no obvious injury after a minor accident was discharged without X-ray investigations. He developed back problems 3 months later leading to leg paralysis. He sued the hospital for negligence.
Case #14: 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 her on HRT. Three years 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 investigations revealed cancer of the ovary which had to be removed. Her daughter who was a nurse in the hospital argued her to sue the hospital for malpractice but she herself was not very sure of what had gone wrong.
Case #15: 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 medical certification of illness 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.
4.6 GROUP #6 (CASES ON LIFE SUPPORT IN TERMINAL ILLNESS)
Case #16: 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 withdrawal of life support because they would be ruined financially by the high ICU costs. The physicians refused withdrawal of life support because his brain stem was functional. The patient woke up in the 5th week.
Case #17: A patient is brought to the emergency room after a car accident. The examining doctor found some signs of life but refused to institute life support because he was convinced it was futile. The patient died a few minutes later. The accompanying family members were furious and accused the doctor of negligence. They threatened to sue. The doctor advised them to wait for results of the postmortem examination that would show that death was inevitable. They refused to have any postmortem because it was against their religious beliefs.
Case #18: A patient admitted to the ICU after a car accident was confirmed by 3 specialist surgeons to be in a persistent vegetative state. The doctors wanted to discontinue life support but the family refused because there were signs of life like reflex flexion of joints and blinking of the eyes. The hospital decided to seek a court injunction after keeping the patient in the ICU for 6 months without any obvious improvement.
4.7 GROUP #7 (CASES ON REPRODUCTIVE ISSUES)
Case #19: 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 stored 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.
Case #20: A married woman with 6 young children came to the hospital asking for an abortion because she had become pregnant while her husband was half-way through a 4-year prison sentence for violent behavior. She was afraid for her life. She had just discovered a secret about her husband from a police officer that the husband has killed his first wife 20 years earlier because of a jealous rage and had escaped the gallows on a legal technicality because of police incompetence in investigating the case.
Case #21: A 40-year old housewife with 8 living children is brought reluctantly to the contraceptive clinic by the husband. The husband asks for tubal ligation because he cannot afford to look after more children. The wife insists that Allah will provide for all the children irrespective of the husband’s financial situation.
4.8 GROUP #8 (CASES ON ORGAN DONATION)
Case #22: A leading politician with end-stage kidney failure presented at the transplant clinic with a distant cousin who is an impoverished farmer from the countryside. He says that the relative has agreed to be a live donor for him. The cousin stated that he will donate the kidney but on further questioning he does not seem to know what a kidney is and where it is found in the body. The transplant team seemed reluctant to go ahead with the procedure. The politician gets angry and gets them reprimanded by the Minister of Health. They resign en masse and sue the politician and the Ministry of Health for unjustified interference in their work.
Case #23: A doctor in end-stage renal failure brings over 50 relatives for blood group testing and tissue matching for kidney for live kidney donation. Only one relative was a suitable donor on the basis of tissue and blood group matching but he refused to be a donor unless a new house was built for him and he was given a big amount of money. One other relative was not a tissue match but matched for blood group and was willing to donate the kidney for free.
Case #24: A patient of terminal renal disease received a cadaveric transplant and recovered well. Two years after the operation he received a note from a stranger demanding payment of a large sum of money. The stranger claimed to be the son of the kidney donor who had died during surgery for intestinal obstruction. The stranger claimed that a source within the hospital had informed him that the deceased’s kidney has been removed without the knowledge and permission of the family.
4.9 GROUP #9 (CASES ON DRUG ABUSE AND SUICIDE)
Case #25: A patient, whose engagement had been called off in the week that he failed his university entry examinations, started smoking, drinking alcohol, and using illicit drugs to forget his problems 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 #26: 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.
4.10 GROUP #10 (CASES ON DOCTOR ETIQUETTE, adab al tabiib)
Case #27: 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 #28: 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 to complain about him because of his seniority.
Case #29: 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.
4.11 GROUP #11 (CASES ON RESOURCES)
Case #30: 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 see line of 120 really ill people waiting to see a doctor? How can we waste time in someone healthy like you?’. The man left but was admitted to the ICU 5 days later with myocardial infarction and he died after 2 days.
Case #31: 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 serious car accident and was in coma.
Case #32: 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.
4.12 GROUP #12 (PHYSICIANS WITH DUAL OBLIGATIONS)
Case #33: A worker sustained severe injury while at work. Under pressure from the 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 gangrene of the injured hand contributed to his death.
Case #34: A national football team physician examined a player and found that he had a chronic 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.
4.13 GROUP #13 (POSTMORTEM)
Case #35: A child’s asthma progressed to respiratory failure and death. The father refused tom give up his heavy smoking and the mother refused to get rid of their cats to which the child is 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 #36: A police officer died a few minutes after admission from what was suspected 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.
5.0 ASSESSMENT OF BASELINE KNOWLEDGE OF ETHICS AMONG PARTICIPANTS IN AN ETHICS TRAINING PROGRAM: PRE-WORKSHOP QUESTIONNAIRE
Appendix #1 shows a summary of responses to a pre-questionnaire by participants attending ethics training programs in various parts of the world. Preliminary analysis focused on selecting the alternative response with the highest frequency in each city (modal response). The total number of questions was 40. All 7 cities concurred on 23 questions (Q2, Q6, Q7, Q9, Q10, Q11, Q12, Q14, Q17, Q18, Q20, Q22, Q24, Q25, Q26, Q27, Q29, Q34, Q36, Q37, Q39, and Q40). Six cities concurred on 4 questions (Q1, Q3, Q4, and Q28). Five cities concurred on 10 questions (Q5, Q15, Q16, Q19, Q21, Q23, Q31, Q32, Q33, and Q38). Four cities concurred on 3 questions (Q13, Q30, Q35). It is remarkable that people from different backgrounds tend to agree on so many questions. Detailed and more sophisticated analysis of the data will be carried out to explore this observation.
6.0 ASSESSMENT OF THE IMPACT OF THE TRAINING PROGRAM ON THE KNOWLEDGE OF ETHICS AMONG PARTICIPANTS IN AN ETHICS TRAINING PROGRAM: POST-WORKSHOP QUESTIONNAIRE
6.1 NURSES AT KUALA BELAIT HOSPITAL
The participants were asked to complete the same questionnaire within 1 month of the ethics workshop. To make sure that responders gave honest answers, no personal identifiers were included on the questionnaires. Data was key-punched and analyzed using the SPSS program. Data analysis focused on estimating the proportion of participants who changed responses to the scenarios after the ethics training workshop. There was no interest in studying whether the responses were correct or not. Pre- and post intervention responses were compared and coded as ‘change’ or ‘no change’. The frequencies, proportions (percentages), and binomial 95% confidence intervals were calculated using Stata/IC 10.0. The degree of change for each question was graded as ‘little’ for changes in <10% of respondents, ‘some’ for 10 to <30%, ‘moderate’ for 30 to <50% and ‘great’ for 50% and above. Eighty two out of the 83 nurses who attended the workshop returned both the pre- and post-intervention questionnaires. The percentage of respondents who changed their responses to questions after the intervention ranged from 15.5% to 56.5%. On average of 37.4% and 29.2% of respondents changed in Islamic questions and general questions respectively. The most changed five questions are Islamic questions in the aspects of ‘animal research’ (56.5%), ‘life support’ (43.2%), ‘euthanasia’ (42.2%), ‘halal medicine’ (40%), and ‘needles to addicts’ (39.1%). The conclusion from the study is that there were considerable changes in response to questions after the intervention and greater changes were observed in the Islamic questions than in the general questions. It is recommended, after further studies to corroborate this finding, that teaching of medical ethics should consider the religious medium because it seems to have a bigger impact on the trainees.
6.2 DOCTORS AT KUALA BELAIT HOSPITAL
Percentage of respondents who changed their responses to questions after the intervention ranged from 2.3% to 38.1%. In average of 20.1% and 15.2% of respondents changed in Islamic questions and general questions respectively. There were four questions with moderate changes and all of them were Islamic questions such as Q38 (38.1%), Q28 (31.7%), Q23 (31.0%), and Q21 (31.0%). All the rest questions were graded some (<30%) or little (<10%) changes.