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Presentation at an Ethics Program for
the Rehabilitation Hospital at King Fahad Medical City, Riyadh on April 13,
2014 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH
(Harvard) Chairman of the Ethics Committee King Fahad Medical City.
The Patient's
Autonomous Right to Consent
·
Conditions of Informed Consent
·
Refusal of Consent
·
Proxy Consent
·
Consent for Children
·
Mental Patients
·
Consent for the Unconscious
Case Scenario - 1
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.
Case Scenario - 2
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 Scenario - 3
A 42-year old
actress pregnant for the first time refused an elective caesarean section
because an abdominal scar would ruin her career. 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.
Case Scenario - 4
A conscious and
competent patient told nurses on admission to the ICU that he did not want his
family to be told anything about his condition. When his condition deteriorated
the physicians wanted to consult his family about end of life decisions but he
refused to give up his right to confidentiality.
Privacy and Confidentiality
·
Privacy and confidentiality are often confused
·
Keeping confidentiality
·
Breaching confidentiality
Case
Scenario - 1
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.
Case Scenario - 2
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.
Disclosure and
Truthfulness
·
Obligation to tell the truth
·
What is disclosed
·
Partial disclosure and white or technical lies
·
Disclosures to others about the patient
·
Giving bad news
Case
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.
Case Scenario - 2
A pediatrician
examined a child with multiple trauma wounds and suspected that the father was
responsible. He was reluctant to report because the father would be imprisoned
and the family would lose its bread winner. What do you think is the correct
approach?