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Presentation
at a training program Applying the Principles of Ethics to Clinical
Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan
Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics
Committee King Fahad Medical City.
Reproductive issues
·
Assisted
reproduction
·
Contraception
·
The permissible
reversible contraceptive methods for males
·
Permissible
reversible contraceptive methods for females
·
Abortion
·
Gender
selection
·
Gender
correction / change operations
·
Menopause
·
Onco-fertility
Case scenario #1
An infertile couple was in the midst of an IVF procedure when the
husband died soon after his semen was frozen. The wife wanted to obtain the
semen and have a baby by a surrogate mother. A former wife also wanted the
semen because she had a girl with leukemia who needed a compatible bone marrow
donor, preferably a sister.
Case scenario #2
A recently married woman continued taking oral contraceptives
prescribed for menstrual irregularities. Her husband wanted his wife to
discontinue her contraception because he wanted to start a family immediately,
but the wife refused.
Case scenario #3
A 14 year-old
girl was admitted to the hospital for an abortion. She was two months pregnant
from what she claimed was rape. The family was distraught and wanted the
doctors to carry out the abortion immediately. The physicians were reluctant
because there was no medical reason.
Case scenario #4
A couple who had eight girls in successive pregnancies desperately
wished a boy. They decided to try IVF with selection of male gametes. The
obstetricians refused because there was no medical indication since the couple
had no problem in conceiving.
Case scenario #5
A child whose external appearance was female and had been brought
up as a girl was taken to the hospital at 14 years of age because of delayed
menstruation. The internal gonads and chromosomal patterns were male. The
parents wanted a gender reassignment operation to conform to the genetic
profile. The child refused to change from her familiar female identity.
Case scenario #6
A middle-aged woman without any medical condition asked her
physician for hormonal treatment to appear younger. The physician refused
because he judged the risk of cardiovascular and cancer complications to be
more than the benefits.
Case scenario #7
A 14 year-old girl with cancer requiring chemotherapy was advised
to have her ova removed and put in cold storage for the duration of the
treatment. Her parents refused the procedure because they did not believe in
IVF and she was not yet married.
Ethical issues in artificial reproduction
·
In vivo
insemination
·
In vitro fertilization
·
Disputes about
parenthood
·
Frozen sperms, ova, and embryos
·
Masturbation
·
Pre-implantation
genetic diagnosis
·
Selective fetal
reduction
·
Embryo
splitting
·
Developing
embryos for non-IVF purposes
·
Using embryos
for cloning
·
Mixing of
gametes or embryos
·
Commercial
trading in sperms, gametes, or embryos
·
Use of gametes
from cadavers or post-mortem insemination or IVF
Confidentiality issues in teenagers
·
Confidentiality -
the importance of confidentiality to adolescent patients, the practicalities of
offering and maintaining confidentiality, and the consequences of failure to do
so.
·
Doctor-patient
relationship - the ethics of the patient-doctor relationship, boundaries and
strategies for susceptible situations.
·
Gillick
competence: the child could consent to contraceptives if she understood the
medical treatment involved (test of Gillick competence) and that the parents
could not veto her decision. A child who is Gillick competent can prevent
parents viewing her medical records without her consent.
·
Fraser criteria:
the young person cannot be persuaded to inform their parents. The young person
is likely to begin, or to continue having, sexual intercourse with or without
contraceptive treatment. Unless the young person receives contraceptive
treatment, their physical or mental health, or both, are likely to suffer. The young
person's best interests require them to receive contraceptive advice or
treatment with or without parental consent.
Case scenario 1
A 14-year old school girl with painful and irregular menstrual
periods saw a school physician who prescribed oral contraceptives to regularize
the period. She refused saying that if her parents found out they would suspect
that she was engaged in illicit sexual relations. She only agreed to take the
treatment when the physician promised that he would not disclose the
information to school authorities or parents without the patient's permission.
Case scenario 2
A 15-year old girl asked a private gynecologist for an abortion
after missing her period following a rape by a person close to her family. She
asked the gynecologist to keep it a secret from the parents because if they
knew they could kill her or kill the rapist.
Case scenario 3
A 13-year old teenager with a foul smelling vaginal discharge went
for treatment at the school clinic and asked the nurses not to disclose the
condition to her parents because they would suspect her of having sexually
transmitted infections.