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Presented to Surgical Department
Residents on December 14, 2015 by Professor Omar Hasan Kasule Sr. MB ChB (MUK),
MPH (Harvard), DrPH (Harvard)
Case
Scenario 1 (Autonomy as the basis of informed consent)
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 (Scope and limitations of consent)
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.
Case
Scenario 3 (Consent and protection of the patient)
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.
Case
Scenario 4 (Consent and the protection of the physician)
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.
Case
Scenario 5: (The process of informed consent)
A
complex brain operation had a 3-page risk disclosure sheet. The surgeon
determined that his poorly educated patient could not understand the
information even with the best of translations and may even refuse the
life-saving operation. The operation was necessary to release a hematoma and a
fractured bone fragment putting pressure on the cerebrum and would soon lead to
loss of consciousness due to increased intracranial pressure. He gave the
patient simple information that the operation would help him recover from the
effects of trauma and that it had some risks that he did not mention. What
should the surgeon do? Provide your moral reasoning.
Case
Scenario 6: (Capacity/competence to consent)
A
university professor admitted for stroke refused life-saving treatment even
after thorough explanation by his son who was a neurosurgeon. While in the
hospital he seemed to forget essential information about his illness, forgot
his age and his wife’s name, and was confused about the day of the week. He
however was in continuous telephone contact with his laboratory at the
university guiding the young researchers. What should the doctor do? Provide
your moral reasoning.
Case
Scenario 7: (Proxy consent / substitute decision maker)
A
30-year old victim of a road traffic accident was in deep coma with some signs
of brain stem function was put in life support in the ICU. He had told his wife
before the accident that he would like to be left to die in dignity rather than
live with the aid of machines. He also had authorized his wife in writing to
make decisions about his treatment if he fell unconscious. His family led by
his father refused this and insisted that life support continue until recovery.
What should the doctor do? Provide your moral reasoning.
Case
Scenario 8: (Prospective consent / advance directives)
A
40-year old victim of multiple sclerosis aware of the final stages of his
illness signed an advance directive authorizing doctors not to initiate life
support if he stopped breathing on his own. He developed acute pneumonia a
short while after writing the directive and experienced severe respiratory
distress. The doctors were not sure what to do. Members of the family were
divided in their views. What should the doctors do? Provide your moral
reasoning.
Case
Scenario 9: (Consent for children)
A
14-year old male with bone cancer confined to the tibia refused amputation that
would prevent spread of the cancer to other parts of the body. He understood
the bad consequences of his decision. His father and mother opposed his
decision and authorized the surgeons to carry out the amputation. What should
the doctor do? Provide your moral reasoning.
Case
Scenario 10: (Consent for the mentally impaired)
A
14-year old mentally impaired girl used to wander from her home and her parents
feared that she might be raped and become pregnant. They took her to the
hospital and asked the doctors to sterilize her. The doctors talked to her and
she opposed the operation vehemently. What should the doctor do? Provide your
moral reasoning.
Case
Scenario 11: (Consent for the unconscious)
A
60-year old diabetic was admitted to the hospital in coma due to diabetic
keto-acidosis and with a gangrenous foot. The doctors decided to amputate the
foot as soon as the general condition had stabilized enough to withstand
anesthesia. His sons and daughters refused the operation even after
explanations that the gangrene would spread and result in fatal septicemia.
They reasoned that it was better for him to die and be buried with all parts of
his body than to live with an amputated limb. What should the doctor do?
Provide your moral reasoning.