150406P - WORKSHOP 1: CASE DISCUSSIONS

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.

SCENARIO 1:

• An 80-year fully conscious and competent old man with advanced incurable cancer needed palliative chemotherapy.
• The family objected when the doctor wanted to obtain informed consent from the patient because that would involve disclosing the diagnosis which would make the patient very sad and depressed.
• The family wanted to make the decision without informing the patient.
• What should the doctor do? Provide your moral reasoning.

SCENARIO 2:

• A 30-year old man presented with classical signs of acute appendicitis.
• He consented to an operation to open the abdomen and remove the inflamed appendix.
• The surgeon found a previously undiagnosed ovarian cyst and decided to remove it.
• The removal was a simple and safe procedure that would not increase the duration of the operation.
• The head nurse refused because the patient had not given consent.
• What should the surgeon do? Provide your moral reasoning.

SCENARIO 3:

• A 90-year old in ICU with stage 4 widely metastasized cancer and multi-organ failure was told by the doctors that there was nothing they could do to reverse the course of the disease and that they could only provide symptomatic treatment.
• He asked to be discharged to die at home. His children objected saying that he needed complex nursing that they could not provide at home.
• What should the healthcare workers do? Provide your moral reasoning

SCENARIO 4:

• The thoracic surgeon wanted to carry out a de-bulking operation to decrease lung cancer mass to enable the patient breathe easier and he told the patient of the high risk of death from hemorrhage.
• The patient 85-year old patient was drowsy because of medication and was suspected of suffering from dementia.
• The doctor was not sure whether the patient was capable of understanding the explanations given and making serious decisions about the operation and he had no relatives nearby.
• What should the doctor do? Provide your moral reasoning.

SCENARIO 5:

• A patient presented to the clinic with vague complaints in the abdomen and worries about cancer.
• Physical examination and investigations revealed no pathology.
• The doctor was angry with the patient for wasting clinic time when he was in good health. 
• As the patient was leaving he told the doctor that his uncle had died the week before of stomach cancer. The doctor did not respond.
• What should the doctor have done? Provide your moral reasoning.

SCENARIO 6:

• A young man sent for pre-employment examination filled out a health questionnaire and mentioned no health problems at all.
• Physical examination revealed a severely dislocated shoulder and an unhealed acromial fracture.
• When asked about them he admitted that they caused him pain from time to time but that he was patient and did not care much about them.
• What should the examining doctor report? Provide your moral reasoning.

SCENARIO 7:

• An 80-year old diabetic man, whose son had died last year from transfusion of mismatched blood, was admitted to the same hospital for observation after falling at home.
• He insisted that no procedure be done without written approval by his physician son whom he wanted to sit by his bedside all the time.
• Nurses were inconvenienced by having to get written permission for routine monitoring of vital signs and insulin injections.
• The nurses refused to comply to his wishes and he refused to cooperate leading to a stand-off.
• What should the doctor in charge do? Provide your moral reasoning.

SCENARIO 8: 

• A young neurosurgeon planned to operate on a patient with lumbar spinal injury that had a 5-10% chance of success.
• He was perplexed about taking informed consent.
• If he informed the patient that the operation could go wrong and result in paraplegia with a 90% chance the patient would refuse the operation.
• If the operation was not carried out there was a 95% chance of further deterioration leading to paraplegia after a few months.
• What should the neurosurgeon do? Provide your moral reasoning.

SCENARIO 9:

• A 30-year old patient of multiple sclerosis had 5 years while in good health designated her husband as the decision maker.
• When she lost consciousness the doctors needed a decision whether to put her on life support.
• The husband who had by that remarried and lived in a separate house decided against life support because it would prolong her suffering.
• Her father intervened and decided for life support because that would be in her best interests.
• What should the healthcare workers do? Provide your moral reasoning.

SCENARIO 10:

• A university professor with previous episodes of transient stroke had written a directive and had it witnessed that if he lost consciousness he would not like to be resuscitated.
• Years later he was brought to the hospital unconscious from head injuries sustained in a car accident.
• The doctors reading his directive in his shirt pocket decided not to resuscitate him but his wife insisted that he be resuscitated.
• What is the right course of action by the doctors? Provide your moral reasoning.