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150514P - START OF LIFE ISSUES

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Presentation at a medical ethics course held at the Security Forces Hospital Riyadh May 14, 2015 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.


Reproductive issues
·        Assisted reproduction
·        Contraception
·        The permissible reversible contraceptive methods for males
·        Permissible reversible contraceptive methods for females
·        Abortion
·        Gender selection
·        Gender correction / change operations
·        Menopause
·        Onco-fertility

Case Scenario - 1
An infertile couple was in the midst of an IVF procedure when the husband died soon after his semen was frozen. The wife wanted to obtain the semen and have a baby by a surrogate mother. A former wife also wanted the semen because she had a girl with leukemia who needed a compatible bone marrow donor, preferably a sister.

Case Scenario - 2
A recently married woman continued taking oral contraceptives prescribed for menstrual irregularities. Her husband wanted his wife to discontinue her contraception because he wanted to start a family immediately, but the wife refused.

Case Scenario - 3
A 14 year-old girl was admitted to the hospital for an abortion. She was two months pregnant from what she claimed was rape. The family was distraught and wanted the doctors to carry out the abortion immediately. The physicians were reluctant because there was no medical reason.

Case Scenario - 4
A couple who had eight girls in successive pregnancies desperately wished a boy. They decided to try IVF with selection of male gametes. The obstetricians refused because there was no medical indication since the couple had no problem in conceiving.

Case Scenario - 5
A child whose external appearance was female and had been brought up as a girl was taken to the hospital at 14 years of age because of delayed menstruation. The internal gonads and chromosomal patterns were male. The parents wanted a gender reassignment operation to conform to the genetic profile. The child refused to change from her familiar female identity.

Case Scenario - 6
A middle-aged woman without any medical condition asked her physician for hormonal treatment to appear younger. The physician refused because he judged the risk of cardiovascular and cancer complications to be more than the benefits.

Case Scenario - 7
A 14 year-old girl with cancer requiring chemotherapy was advised to have her ova removed and put in cold storage for the duration of the treatment. Her parents refused the procedure because they did not believe in IVF and she was not yet married.

Ethical issues in artificial reproduction -1
·        In vivo insemination
·        In vitro fertilization
·        Disputes about parenthood
·        Frozen sperms, ova, and embryos
·        Masturbation
·        Pre-implantation genetic diagnosis
·        Selective fetal reduction

Ethical issues in artificial reproduction -2
·        Embryo splitting
·        Developing embryos for non-IVF purposes
·        Using embryos for cloning
·        Mixing of gametes or embryos
·        Commercial trading in sperms, gametes, or embryos
·        Use of gametes from cadavers or post-mortem insemination or IVF

Confidentiality issues in teenagers
·        Confidentiality - the importance of confidentiality to adolescent patients, the practicalities of offering and maintaining confidentiality, and the consequences of failure to do so.
·        Doctor-patient relationship - the ethics of the patient-doctor relationship, boundaries and strategies for susceptible situations.
·        Gillick competence: the child could consent to contraceptives if she understood the medical treatment involved (test of Gillick competence) and that the parents could not veto her decision. A child who is Gillick competent can prevent parents viewing her medical records without her consent.

Confidentiality issues in teenagers… con’t.
·        Fraser criteria: the young person cannot be persuaded to inform their parents. The young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment. Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer. The young person's best interests require them to receive contraceptive advice or treatment with or without parental consent.

Case Scenario - 1
A 14-year old school girl with painful and irregular menstrual periods saw a school physician who prescribed oral contraceptives to regularize the period. She refused saying that if her parents found out they would suspect that she was engaged in illicit sexual relations. She only agreed to take the treatment when the physician promised that he would not disclose the information to school authorities or parents without the patient's permission.

Case Scenario - 2
A 15-year old girl asked a private gynecologist for an abortion after missing her period following a rape by a person close to her family. She asked the gynecologist to keep it a secret from the parents because if they knew they could kill her or kill the rapist.

Case Scenario - 3
A 13-year old teenager with a foul smelling vaginal discharge went for treatment at the school clinic and asked the nurses not to disclose the condition to her parents because they would suspect her of having sexually transmitted infections.