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Presentation at The Nursing Leadership Training
program at King Fahad Medical City Riyadh on April 28, 2015 by Professor Dr.
Omar Hasan Kasule, Sr. MB ChB (MUK).MPH (Harvard), DrPH (Harvard) Chairman of
the Ethics Committee King Fahad Medical City
What is an
Ethical Dilemma?
·
A problem with two or more
competing solutions
·
No fixed or unanimous rules and
regulations
·
Whatever solution is adopted has
practical, ethical, and legal implications
Ask Your Heart?
·
Humans were created with the
innate ability to feel ‘right’ from ‘wrong’ – ask your heart first
·
In most cases the rational = the
moral
·
In a few cases human rationality
fails and a higher moral guidance needs to be invoked
Authoritative Sources: At the National
/ International Levels
·
The Mufti of the Kingdom of Saudi
Arabia
·
The Grand Ulama Authority
·
The Fiqh Academy of the Organization of the Islamic Conference
·
The Fiqh Academy of the World Muslim League
Authoritative Sources: Local
Level
·
Ethics Committee in the Hospital
·
Local Scholar
Existing Laws and
Regulations
·
Code of Medical Ethics by the Saudi Council for Health Specialties
·
Health Professions Practice Regulations by the Saudi Council for Health
Specialties
Solution Using
the 4 Ethical Principles
·
Patient autonomy = patient decides
·
Beneficence = bring benefit
·
Nonmalefacence = cause no harm
·
Justice = treat all with equity
Solutions Using Maqasid
Al Shari'at
·
Protection of ddiin (morality)
·
Protection of life (life and health), hifdh al nafs
·
Protection of progeny (family and procreation), hifdh al nasl
·
Protection of the mind (psyche) hifdh al ‘aql
·
Protection of wealth (resources), hifdh al mal
Solutions from
Principles of the Law, Qawaid Al Fiqh
·
The Principle of Intention, qa’idat al qasd: we consider the underlying intentions
·
The Principle of Certainty, qaidat al yaqeen: evidence based decisions
·
The Principle of Injury,
qaidat al dharar: cause no harm; balance benefit vs injury
·
The Principle of Hardship,
qaidat al mashaqqat: exceptions in cases of necessity
·
The Principle of Custom or
Precedent, qaidat al urf: follow the procedures
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 woman 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.