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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.
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 with 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.