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Lecture
for 3rd year medical students Faculty of Medicine King Fahad Medical
City on May 28, 2013 by Professor Omar Hasan Kasule Sr
·
Describe the principles of
medical ethics
·
Integrate the principles of
ethics into clinical practice relevant to cardiovascular disease
·
Define professional conduct in
the Saudi Arabian context
·
Describe the physician’s
professional responsibility
EUROPEAN ETHICAL
PRINCIPLES 4: FOUR PRINCIPLE FORMULATION
·
James F Childress and Tom L
Beauchamp drafted the main ideas of the book ‘Principles of biomedical ethics’
in 1976
·
Autonomy (respect for decision
making capacities of autonomous persons)
·
Nonmalificence (not causing harm
to others)
·
Beneficence (prevent harm,
provide benefit, balance benefits against risks and cost)
·
Justice (fair distribution of
risks, benefits, and costs).
ISLAMIC APPROACH
TO ETHICS 1: Overriding paradigms
·
Tauhid provides an
integrating paradigm that assures that an ethical problem is not considered in
isolation from other issues.
·
Shumuliyat is the
comprehensiveness of the Islamic world view that embraces everything within the
Islamic system.
·
Tawazun is a balanced
moderate approach.
·
Tadafu’u is
consideration of actions and the reactions to those actions.
ISLAMIC APPROACH
TO ETHICS 2: maqasid al shari’at as the theory of ethics
·
Protection of morality/hifdh
al ddiin
·
Protection of Life hifdh al
nafs
·
Protection of Progeny, hifdh
al nasl
·
Protection of the Mind, hifdh
al ‘aql
·
Protection of Wealth, hifdh al
maal
ISLAMIC APPROACH
TO ETHICS 3: qawa’id al fiqh as ethical principles
·
The Principle of Intention, qa’idat
al qasd
·
The Principle of Certainty, qa’idat
al yaqeen
·
The Principle of Injury: qa’idat
an dharar: (covers the 4 princples of autonomy, beneficence,
non-malefacence, and justice)
·
Principle of Hardship, qa’idat
al mashaqqat
·
The Principle of Custom or
Precedent, qa’idat al ‘aadat
PROTECTION OF
LIFE, nafs:
·
The primary purpose of medicine
is to fulfill the second purpose, the preservation of life.
·
Medicine contributes to the
preservation and continuation of life by making sure that the nutritional
functions are well maintained.
·
Medical knowledge is used in the
prevention of disease that impairs human health. Disease treatment and
rehabilitation lead to better quality health.
PROTECTION OF
PROGENY, nasl:
·
Medicine contributes to the
fulfillment of this 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.
PROTECTION OF
THE MIND, ‘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.
PROTECTION OF
WEALTH, 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 a healthy vibrant community.
·
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.
·
The question may be posed whether
the effort to protect life is worth the cost.
·
The issue of opportunity cost and
equitable resource distribution also arises.
THE PRINCIPLE OF
INTENTION, qasd:
·
The Principle of intention
comprises several sub principles. The sub principle that 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 that what
matters is the intention and not the words rejects the wrong use of data to
justify wrong or immoral actions.
·
The sub principle that means are
judged with the same criteria as the intentions implies that no useful medical
purpose should be achieved by using immoral methods.
THE
PRINCIPLE OF CERTAINTY, yaqeen:
·
Medical diagnosis cannot reach
the legal standard of certainty.
·
Treatment decisions are best on a
balance of probabilities.
·
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.
·
Established medical procedures
and protocols are treated as customs or precedents. What has been accepted as
customary over a long time is not considered harmful unless there is evidence
to the contrary.
·
All medical procedures are
considered permissible unless there is evidence to prove their prohibition.
THE PRINCIPLE OF
INJURY, dharar: 1
·
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 a harm has priority over pursuit of a benefit of equal worth. If
the benefit has far more importance and worth than the harm, 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.
THE PRINCIPLE OF
INJURY, dharar: 2
·
If confronted with 2 medical
situations both of which are harmful and there is no way but to choose one of
them, the lesser harm is committed. A lesser harm is committed in order to
prevent a bigger harm.
·
In the same way medical
interventions that in the public interest have priority over consideration of
the individual interest. The individual may have to sustain a harm in order to
protect public interest.
·
In the course of combating
communicable diseases, the state cannot infringe the rights of the public
unless there is a public benefit to be achieved. In many situations, the line
between benefit and injury is so fine that salat
al istikharat is needed to reach a solution since no empirical methods can
be used.
PRINCIPLE OF
HARDSHIP, mashaqqat: 1
·
Medical interventions that would
otherwise be prohibited actions are permitted under the principle of hardship
if there is a necessity.
·
Necessity legalizes the
prohibited. In the medical setting a hardship is defined as any condition that
will seriously impair physical and mental health if not relieved promptly.
Hardship mitigates easing of the sharia rules and obligations.
·
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.
PRINCIPLE OF
HARDSHIP, mashaqqat: 2
·
Necessity however does not
permanently abrogate the patient’s rights that must be restored or recompensed
in due course; necessity only legalizes temporary violation of rights. The
temporary legalization of prohibited medical action ends with the end of the
necessity that justified it in the first place.
·
This can be stated in al
alternative way if the obstacle ends, enforcement of the prohibited resumes/ It
is illegal to get out of a difficulty by delegating to someone else to
undertake a harmful act.
THE PRINCIPLE OF
CUSTOM or PRECEDENT, ‘aadat:
·
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.
CASE
ANALYSIS#1:
A
60-year old comatose accident victim suffering from severe multi-organ
traumatic injury and with a signed organ donation card was evaluated in the ER
of a remote rural hospital. Most clinical signs of brain death were positive
but two were not. The doctor at the insistence of the family declared death to
enable a teenage cousin to obtain a transplant kidney
CASE
ANALYSIS #2:
A
40-year old billionaire stage 4 cancer victim with multi organ failure in ICU
and on artificial life support was determined clinically dead on the basis of
clinical signs repeated after 6 hours. Confirmatory tests were negative. Family
members, ready to pay extra ICU costs, begged the physicians to delay death
declaration until the wife arrived from overseas
CASE
ANALYSIS #3:
A
90-year old deeply comatose man with multiple organ failure was admitted to the
last available ICU bed and was put on artificial life support minutes when the
family refused a DNR order. A few minutes later ambulances started bringing in
over 100 casualties from an air crash site. The head of the ICU carried out a
rapid assessment of the comatose man showed equivocal clinical signs of brain
death; some indicating death and others not. None of the confirmatory tests was
positive.
CASE ANALYSIS #4:
In
a measles mini-epidemic the MOH orders vaccination of all children with no
immunization records. A pediatrician living at the KSU campus with non-school
going toddlers refuses to take his children for vaccination arguing that the
risk of vaccination complications was higher for his children than the risk of
measles infection.
CASE ANALYSIS #5:
A
mentally retarded Down syndrome youth aged 15 years had been to court several
times for sexual attacks on toddlers. The judge ordered the doctors to suppress
his sexual aggression by use of hormones and if that was not effective to
remove his testes.
CASE ANALYSIS #6:
A
50-year old with 3 young wives complained of erectile dysfunction caused by his
anti-hypertensive medication. When the government hospital refused to provide
free Viagra he stopped his anti-hypertensive medication and suffered a stroke.
CASE ANALYSIS #7:
An
elderly patient with advanced esophageal cancer refused insertion of a
nasogastric feeding tube and insisted on taking sold food that he could not
swallow. He said he would prefer to die from starvation than accept the tube.
The surgeons sedated him and inserted the tube without his consent and kept him
under sedation so that he cannot complain
CASE ANALYSIS #8:
A
30 year old soldier with insulin dependent juvenile diabetes asked for free
Viagra from a government clinic before his second marriage and was denied. He
did not have enough money to buy the drug for himself. He claims that his first
marriage was destroyed by erectile dysfunction
CASE ANALYSIS #9:
In
a chemical disaster, there was limited antidote and a decision was made to give
it only to children aged below 5 years. Health workers, emergency workers, and
the police were angry at this prioritization refusing to work
CASE ANALYSIS #10:
A 90 year old 100% dependent on a respirator
with no hope of independent life asks the doctor to disconnect the machines so
that he can die in peace but the doctor refuses. He has no serious disease; he
had become dependent on the respirator during a prolonged and poorly managed
episode of pneumonia.
DEFINITION
OF PROFESSIONALISM
— No
one definition, variation by place and time
— Attitudes
— Behaviors
— Skills
— Values
and morals?
THE
AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) 6 DIMENSIONS OF GOOD PROFESSIONALISM
— Altruism
— Accountability
— Excellence
— Duty
— Honor
and integrity
— Respect
for others
THE
FORMULATION OF PROFESSIONALISM FROM AN ISLAMIC PERSPECTIVE: 7 DIMENSIONS:
— (Faith
(iman),
— Consciousness
(taqwat),
— Best
character (ahsan al akhlaq),
— Excellent
performance (itqaan al ‘amal),
— Strife
toward perfection (ihsan),
— Responsibility
(amanat),
— Self-accountability
(muhasabat al nafs).
DEVELOPMENT
OF PROFESSIONALISM
— Medicine
in the family and by religious leaders
— Trained
professionals
— Professional
organizations
— Professional
codes
TYPES
OF PROFESSIONAL ORGANIZATIONS
— Defend
the interests of physicians: British Medical Association, American Medical
Association, Canadian Medical Association
— Regulate
and discipline physicians: General Medical Council of the UK, US State
Licensing Boards, Saudi Commission for Health Specialties
— Promote
research and academic exchange: Saudi Internal Medicine Association
— Others:
Islamic Medical Association of North America, Islamic Medical Association of
KSA
TEACHING
/ LEARNING PROFESSIONALISM
— Passively
as apprenticeship:
◦ advantages
and disadvantages
◦ need
for role models
— Structured
curriculum