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Presented at a training program in medical ethico-legal training at Mombasa on 27th September 2008 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard). Professor of Epidemiology and Islamic Medicine, Institute of Medicine, University of Brunei. WEB: http://omarkasule.tripod.com
GROUP #1 (CASES ON PRIVACY AND CONFIDENTIALITY)
Case #1: A patient with diastolic blood pressure of 120 mmHg failed to return to the Health Center for treatment. The nurse called the head of the village and asked him to convince the patient to come. In order to press on him the urgency of the matter, she had to explain all the details of the history and examination that had been carried out on the patient.
Case #2: A clerk in the records department casually mentioned impotence of a patient to his friends at the village restaurant. Word spread quickly around the village resulting in cancellation of the patient’s engagement. The fiancée sued in court and the patient committed suicide. The clerk felt no remorse. He argued that he was doing a public duty by stopping a potentially unhappy marriage.
Case #3: 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.
GROUP #2 (CASES ON DISCLOSURE)
Case #4: Midwives refused to inform a mother and hid a congenitally malformed baby from her for a week. They gave the mothers various excuses for not showing her the baby. When the mother became very angry the pediatrician came to talk to her and told her that she had an abnormal baby. He said ‘in my experience children with this type of abnormality do not survive longer than a month’. When the patient asked for the cause of the abnormality the pediatrician replied ‘It is all your fault, you should not have become pregnant above the age of 40’. The mother broke down and cried. She left the hospital 2 hours later without being formally discharged.
Case #5: 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. Two weeks later the private practitioner received an offer of a free ticket for himself and his wife to a holiday resort. The letter from the airline public relations office said that the airline was carrying out a promotion and that names of beneficiaries had been selected at random from the telephone directory. The doctor subsequently went on the trip with his wife.
Case #6: A medical researcher stationed at the hospital used to take an aliquot from every blood specimen to test for HBV. The hospital authorities knew what he was doing but the patients were not informed because he did not record names of patients. One day out of curiosity he tested a specimen for HIV and found it positive. He was confused what to do regarding disclosure. He called a meeting of the senior staff in the hospital to discuss the matter. He also included a respected lawyer from the town to provide a non-medical perspective.
Case #7: A community pediatrician had reported abuse of a couple’s first child to the authorities. The authorities called in the parents to discuss the matter. The abusing father was so angry that he divorced his wife for giving information to the pediatrician. He later took the wife back under the rujuk provisions of the Law. At the next visit the pediatrician noted signs of child abuse and asked the mother. The mother confirmed the abuse but asked the pediatrician not to follow up the matter for the sake of her marriage and family. The pediatrician this time did not report to the authorities.
Case #8: A midwife who had contracted HIV due to transfusion hid her status for 5 years. She was very meticulous during deliveries observing all precautions and during that time no patient was reported to have been infected. After a family quarrel her husband revealed her status to the newspaper. The editor failed to interview her before publication of the report. The midwife refused a request by the head of obstetrics to have an HIV test. The hospital suspended her and charged her for criminal negligence in the high court.
GROUP #3 (CASES ON CONSENT TO TREATMENT)
Case #9: A bed-ridden patient with limited movements and sensation communicated by sign language and limited speech. She could recognize letters and could write sentences by nodding when the right letter was touched. She indicated that she did not want physiotherapy, wanted to divorce her spouse, and wanted to give the family home to the kind doctor taking care of her. She wanted to disinherit her sons for not sitting around her bed and caring for her daily. She wanted to return to her home and leave the nursing home.
Case #10: A patient with a benign prostatic enlargement and mild urinary retention asked the urologist for prostatectomy. The urologist refused after examination revealed no complications and a normal PSA level. Because there was only one urologist in the government hospital, the patient sued the hospital in the High Court to force them to carry out the operation. Due to delays in scheduling a hearing the patient went overseas and had the operation done. Histological examination showed low grade prostate carcinoma confined within the prostatic capsule.
Case #11: 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.
GROUP #4 (CASES ON REFUSAL OF TREATMENT)
Case #12: A 40-year old theater nurse refused to accept the diagnosis of breast cancer and refused surgery. The tumor grew larger, broke through the skin and became foul smelling because of bacterial infection. The hospital director put her on unpaid leave.
Case #13: 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 #14: A 30-year old soldier with a history of schizophrenia refused a chest X-ray for a severe cough lasting 2 months. His commanding officer authorized using force to take the X-ray and to treat him accordingly. The army doctors were not sure what to do but being army officers they obeyed orders of the commanding officer.
Case #15: A 42-year old actress pregnant for the first time refused an elective caesarean section. 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 #16: A 14-year old patient refused admission because he hated the physicians on the pediatric ward. The father agreed with the patient but the mother disagreed. Both parents agreed with the patient’s refusal of any blood transfusion which the doctors considered necessary since the hemoglobin level had fallen to a dangerous level.
Case #17: A 60-year old retired nurse refused HRT after a diagnosis of osteoporosis was made. She argued that HRT was anticipating and contradicting Allah’s pre-determination, takdir.
GROUP #5 (CASES ON NEGLIGENCE & MALPRACTICE)
Case #18: A patient with no obvious injury after a minor accident was discharged without X-ray investigations. He developed back problems 3 months later leading to leg paralysis. He sued the hospital for negligence.
Case #19: A 45-year old mother of 5 grown up children had hysterectomy because of prolonged, heavy, and irregular menstruation. The surgeon took care to preserve the ovaries and therefore saw no need to put her on HRT. Three years later she had a hip fracture due to osteoporosis treated by hip replacement and she was started on HRT. Six months later she developed pain in the right groin and investigations revealed cancer of the ovary which had to be removed. Her daughter who was a nurse in the hospital argued her to sue the hospital for malpractice but she herself was not very sure of what had gone wrong.
Case #20: An aspiring actor was advised by her media consultants to change her facial features in order to succeed in landing major and lucrative acting roles. She went to a doctor who advertised his cosmetic surgery services on the television and women’s magazines. She signed a consent form for surgery but did not see a notation in the footnotes that the operation was entirely at her own risk. Six months later and after a series of operations she was angry. Her face was asymmetric and her eye lids drooped. She asked for his license as a plastic surgeon. He told her he was a general surgeon who had interest in plastic or cosmetic surgery. With her career ruined she decided to take him to court.
Case #21: A patient with epilepsy well controlled on drugs for the past 10 years, experienced a minor epileptic seizure. His physician increased the drug dosage and told him all would be well and that he could go back and resume driving the school bus. The patient asked for an MC to explain his day’s absence to the manager of the school bus company. The next morning the patient crushed the bus into a wall as he was driving it out of the garage. He explained that he felt sleepy at the time of the accident.
GROUP #6 (CASES ON LIFE SUPPORT IN TERMINAL ILLNESS)
Case #22: A patient with brain stem death is kept on artificial life support at the insistence of the family because announcing the death immediately will have an adverse effect on the values of the family business on the stock exchange.
Case #23: The family took an unconscious man to hospital reluctantly because they believed he was dead. He was admitted to the ICU and was put on artificial life support. For a period of 4 weeks the family insisted on withdrawal of life support because they would be ruined financially by the high ICU costs. The physicians refused withdrawal of life support because his brain stem was functional. The patient woke up in the 5th week.
Case #24: A patient is brought to the emergency room after a car accident. The examining doctor found some signs of life but refused to institute life support because he was convinced it was futile. The patient died a few minutes later. The accompanying family members were furious and accused the doctor of negligence. They threatened to sue. The doctor advised them to wait for results of the postmortem examination that would show that death was inevitable. They refused to have any postmortem because it was against their religious beliefs.
Case #25: A patient admitted to the ICU after a car accident was confirmed by 3 specialist surgeons to be in a persistent vegetative state. The doctors wanted to discontinue life support but the family refused because there were signs of life like reflex flexion of joints and blinking of the eyes. The hospital decided to seek a court injunction after keeping the patient in the ICU for 6 months without any obvious improvement.
GROUP #7 (CASES ON REPRODUCTIVE ISSUES)
Case #26: A mentally retarded sexually active 14-year old teenager was taken to the family planning clinic to receive contraceptives without the knowledge of her parents. Due to irregular use of the pills she became pregnant and her aunt took her overseas for an abortion. On return she advised her parents to take her for sterilization. The parents preferred hysterectomy because in her retarded condition she could not maintain menstrual hygiene. The family gynecologist preferred depo provera.
Case #27: A couple married for 10 years without a child decided to have IVF. Before the procedure was completed, the husband died. The wife insisted on using the stored semen of her dead husband. The relatives of the husband objected. The first wife who had been divorced 15 years earlier with one girl also asked for the semen for an IVF procedure that she hoped would enable her have another baby to act as a bone marrow donor for her daughter who had leukemia and had failed to find a matching donor.
Case #28: A 14-year old sexually active girl was treated at the outpatient clinic for sexually transmitted disease. The doctor advised her on the use of condoms to prevent disease. She asked the doctor to keep the matter a secret even from her parents. She became extremely promiscuous after that until the whole village knew about her behavior. The news deeply embarrassed the parents. They learned from a distant relative who worked at the outpatient clinic that she had been advised about the use of condoms by the doctor and that she had obtained the condoms from the family planning clinic.
Case #29: A married woman with 6 young children came to the hospital asking for an abortion because she had become pregnant while her husband was half-way through a 4-year prison sentence for violent behavior. She was afraid for her life. She had just discovered a secret about her husband from a police officer that the husband has killed his first wife 20 years earlier because of a jealous rage and had escaped the gallows on a legal technicality because of police incompetence in investigating the case.
Case #30: A 40-year old housewife with 8 living children is brought reluctantly to the contraceptive clinic by the husband. The husband asks for tubal ligation because he cannot afford to look after more children. The wife insists that Allah will provide for all the children irrespective of the husband’s financial situation.
GROUP #8 (CASES ON ORGAN DONATION)
Case #31: A leading politician with end-stage kidney failure presents at the transplant clinic with a distant cousin who is an impoverished farmer from the countryside. He says that the relative has agreed to be a live donor for him. The cousin states that he will donate the kidney but on further questioning he does not seem to know what a kidney is and where it is found in the body. The transplant team seemed reluctant to go ahead with the procedure. The politician gets angry and gets them reprimanded by the Minister of Health. They resign en masse and sue the politician and the Ministry of Health for unjustified interference in their work.
Case #32: A doctor in end-stage renal failure brings over 50 relatives for blood group testing and tissue matching for kidney for live kidney donation. Only one relative was a suitable donor on the basis of tissue and blood group matching but he refused to be a donor unless a new house was built for him and he was given a big amount of money. One other relative was not a tissue match but matched for blood group and was willing to donate the kidney for free.
Case #33: A patient of terminal renal disease received a cadaveric transplant and recovered well. Two years after the operation he received a note from a stranger demanding payment of a large sum of money. The stranger claimed to be the son of the kidney donor who had died during surgery for intestinal obstruction. The stranger claimed that a source within the hospital had informed him that the deceased’s kidney has been removed without the knowledge and permission of the family.
Case #34: A father of a child with end-stage renal disease got tired of taking her for dialysis every week. He had failed to find a live or a cadaveric donor for her in his country. He considered traveling to a nearby country where kidneys could be bought but he was not sure. He also considered marrying a young wife (his first wife had died) and hopefully produce a child who could be a donor.
GROUP #9 (CASES ON DRUG ABUSE AND SUICIDE)
Case #35: A patient, whose engagement had been called off in the week that he failed his university entry examinations, started smoking, drinking alcohol, and using illicit drugs to forget his problems but to no avail. He was admitted to the medical ward after suffering a nervous breakdown. He was violent and abusive on the ward and refused to take his medication. Two weeks from his admission he left the ward without telling anyone and went and killed his former fiancée at her home. He later became very agitated and depressed and within 10 hours he also committed suicide. His parents and the parents of his ex-fiancee jointly sued the hospital.
Case #36: The patient was a brooding type who was always sad. He had a mental break down when his wife had a spontaneous abortion of a 3-month pregnancy. He was taken to the hospital emergency room. The attending physician finding nothing physically wrong with him, decided to discharge him. The physician ignored the repeated talk of the patient about following his dead baby into the grave and just gave him valium and sent him home. When the effect of valium wore off at home he became agitated. His wife found him 10 minutes later lying unconscious on the bed with a half-empty bottle of detergent next to him. She called an ambulance that arrived in record time. By the time he was seen by the physician in the emergency room, he had recovered some consciousness and could talk. He told the physician that he wanted to die. He categorically refused to consent to the procedure of gastric lavage to remove the detergent from his stomach. A psychiatrist called to assess his mental competence concluded that he was competent to make decisions.
GROUP #10 (CASES ON DOCTOR ETIQUETTE, adab al tabiib)
Case #37: A physician prescribed a new unlicensed drug donated to him by a pharmaceutical company. The physician had shares in the company. He had no previous personal knowledge of the drug. The patient developed an immediate allergic reaction. The physician blamed the nurse for not asking about drug allergies before injecting the drug.
Case #38: A 60-year old surgeon was known by everybody in the hospital to cause pain while examining patients without prior explanation and consent. He used to make lewd jokes about female patients. He discussed diagnoses with his drinking partners and details of many patients were known in the community. A junior doctor who complained to the hospital director was told to keep quiet. Nobody else dared to complain about him because of his seniority.
Case #39: A well-known businessman was diagnosed with drug-resistant tuberculosis. He refused admission to the TB ward because of his social position. He contacted the hospital manager who was his golf partner to pressure the junior doctor to admit him to a room on a normal ward. When the junior doctor refused, he was transferred to another department and the admission went ahead.
GROUP #11 (CASES ON RESOURCES)
Case #40: A 65-year old man whose brother had just died from coronary heart disease walked into the health center and asked for examination because he was afraid that his heart may also have problems. The triage nurse asked him if he had any specific complaints. He replied that he has none and that he was in perfect health. The nurse rebuked him for wasting her time. ‘Don’t you the see line of 120 really ill people waiting to see a doctor? How can we waste time in someone healthy like you?’. The man left but was admitted to the ICU 5 days later with myocardial infarction and he died after 2 days.
Case #41: The ICU staff were in a dilemma because 2 patients presented at the same time and they had only one free bed. The first patient was 90 years old and has been admitted three times before with myocardial infarction. His sons forced him to come to hospital; he had expressed preference to stay and die at home in peace. The second patient was a 30-year neurosurgeon. He was the only one in the whole country. He had been involved in a serious car accident and was in coma.
Case #42: A 37-year old mother, who had just had a normal delivery with considerable blood loss, protested at being discharged the next day. She needed rest and could not get that at home where she had 5 children to look after. The midwives told her they needed the bed for other patients. She was readmitted the next day with fatal postnatal hemorrhage.
GROUP #12 (PHYSICIANS WITH DUAL OBLIGATIONS)
Case #43: A worker sustained severe injury while at work. Under pressure from the management, a company physician refused to certify disability qualifying the worker for a hefty compensation. The worker sued the employer. While the case is still in court the worker died and the physician refused to certify that gangrene of the injured hand contributed to his death.
Case #44: A national football team physician examined a player and found that he had a chronic shoulder dislocation and advised that he should not play again until it was treated. The player protested because he had always played with that condition since he was young. The team manager threatened to dismiss the physician if he did not certify the player as fit to play because that star player was the only hope of the team to win in an international match the next day.
GROUP #13 (POSTMORTEM)
Case #45: A child’s asthma progressed to respiratory failure and death. The father refused tom give up his heavy smoking and the mother refused to get rid of their cats to which the child is allergic. Hospital authorities request for a postmortem examination to establish the cause of death for fear that they may be charged unfairly for negligence in the death of the child. The social workers also request a postmortem because they suspect that parental negligence contributed to the death. The family rejects postmortem claiming the child died from a curse and not disease.
Case #46: A police officer died a few minutes after admission from what was suspected injuries sustained in the course of his duty. The police department insisted on a postmortem to determine the cause of death in order to make decisions about compensation. The family was divided. Some were opposed to postmortem and others wanted to go ahead.