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Presentation at the Ethics Workshop held at Jizan University on
April 10, 2014 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard),
DrPH (Harvard)
WHAT IS NEEDED?
·
Working in
groups, discuss and understands the circumstances of the case
·
Make
assumptions about essential information not given in the write up
·
Identify the
problem and define it in ethical terminology/concepts
·
Provide
solution alternatives stating the underlying ethical principle(s).
GROUP
#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. There was no other plausible cause of reversible coma or of brain
death.
·
Clinically: no
pupillary reflexes, fixedly-dilated pupils, no corneal reflex, no eye
movements, no blink reflex, no vestibule-ocular reflex, no cranial reflexes,
and no gag reflex. Findings were equivocal regarding the apnea test, cephalic
reflexes, and motor response to pain.
·
Investigations:
jugular vein partial oxygen pressure could not be determined. The EEG was
isoelectric. Bedside trans-cranial Doppler showed no cerebral circulation.
·
Family members
with the exception of the mother were certain of death and asked the physician
not to institute any life support and to call the organ harvesting team. The
doctor was not sure what to do he however convinced the family to start life
support to keep the organs viable until the transplant team arrived by
helicopter.
·
While walking
along the corridor, a nurse overheard members of the family talking about a
15-year old cousin of the victim lying in a hospital in the capital waiting for
a kidney transplant.
GROUP
#2:
·
A 40-year old
billionaire stage 4 cancer victim with multi organ failure in ICU and on
artificial life support
·
Determined
clinically dead on the basis of clinical signs repeated after 6 hours
(pupillary reflexes –ve, fixedly-dilated pupils, corneal reflex –ve, eye
movements –ve, blink reflex –ve, cold water test –ve, cranial reflexes –ve,
apnea test –ve, cephalic reflexes –ve, motor response to pain –ve, gag reflex
–ve).
·
All
confirmatory tests were also negative (jugular oxygen partial pressure -ve,
EEG=0, CT angiography).
·
Family members
begged the physicians not to withdraw life support and not declare death until
his beloved last daughter arrives from London. She might die from shock if she
does not see him alive before death. They were willing to pay for the extra
days of ICU stay.
GROUP
#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.
GROUP #4: Case
studies on DS
·
Case #1:a
38-year old mother with one live delivery of a Down syndrome baby is pregnant
for the second time. The husband insists on a pre-natal diagnosis but she
refuses.
·
Case #2:A
40-year old gynecologist recently married and became pregnant. Her husband
insists on prenatal diagnosis but she refuses
·
Case #3:
35-year old mother of 2 previous normal children asks for amniocentesis to
discover if the baby is normal. The director of the health clinic refuses
fearing she may consider abortion
·
Case #4: Down
syndrome society petitioned the Ministry of Health to make down syndrome
screening mandatory for pregnant women aged 30 and above
·
Case #5: A
doctor obtained consent to do Down screening in a 45-year old pregnant woman.
When she came for the results he refused to disclose because nurses had told
him she had talked about aborting abnormal fetii while in the waiting room.
GROUP #5: Case
studies on Thalassemia
·
Case #1: two
first cousins wanted to marry. The geneticist told them that they were both
carriers and 1 in every 4 children would get the disease. They went ahead and
married because a proportion of 25% was too low a risk
·
Case #2: a
4-year old child had repeated episodes of anemia that responded to transfusion.
The doctors without getting parental permission carried out and found a
positive test for thalassemia disease. Problems occurred in the family because
both parents had results of pre-marital testing that showed that neither was a
carrier of thalassemia
GROUP #6: Miscellaneous cases
1.
In a measles mini-epidemic in the South of
Riyadh, 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.
2.
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.
3.
A urologist with 20 years’ experience in renal
transplant refused to donate one of his kidneys to his identical twin brother
who had found no other matching kidney. The Saudi Council for Health
Specialties started de-registration proceedings for failure to give benefit
obligatory on all physicians
4.
A new company in Riyadh advertised on TV and
newspapers offering direct genetic testing services. Consumers would pay for a
kit using a credit card and they would use the kit to collect a sample of blood
by finger prick and send it back by mail. Results would be sent back after a
week.
5.
In a bird flu epidemic, all citizens were
advised to go during working hours to three immunization centers set up at the
three university centers in the city: KSU, KSUHS, and Imam Muhammad
Universities.it was made clear that the vaccination was not compulsory.
GROUP #7: Miscellaneous cases
1.
A nurse manager has just discovered that his
colleague, a surgeon, is HIV+ve, but has kept the information secret and
continued operating on patients taking infection control precautions. An
emergency case requiring immediate surgery is wheeled into the emergency room
at midnight and there is no other surgeon available.
2.
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.
3.
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
4.
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
5.
A 20 year old drug addict in and out of
rehabilitation centers for the past 5 years with no improvement asked for
marijuana or any drug that would satisfy his craving to be given within the
hospital so that he would not have to commit crimes on the streets to feed his
addiction