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Presented at a grand round of the Pediatric Department of King Salman Heart Center on April 11, 2016 by Prof Omar Hasan Kasule Sr. Chairman of the Ethics Committee King Fahad Medical City, Riyadh
European ethical theories
- Utilitarian consequence-based theory (balance of good and bad)
- Obligation-based theory (moral obligations)
- Rights-based theory based on respect for human rights (individual rights)
- Community-based theory (community decides)
- Relation-based theory (family and physician-patient relations)
- Case-based theory (practical case by case decision)
European ethical principles (Beauchamp and Childress 1994)
- Autonomy (patient decides)
- Beneficence (bring benefit)
- Non-maleficence (do no harm)
- Justice (equity vs equality)
Islamic ethical theory based on maqasid al shari’at
- Protection of Morality, hifdh al ddiin
- Protection of Life, hifdh al nafs
- Protection of Progeny, hifdh al nasl
- Protection of the Mind, hifdh al ‘aql
- Protection of Wealth/resources, hifdh al maal
Islamic ethical principles based on qawaid al fiqh
- The Principle of Intention (actions are judged by the intentions behind them), qasd
- The Principle of Certainty (no action is taken in extreme uncertainty), yaqiin
- The Principle of Injury (medical intervention should cause no injury), dharar
- Principle of Hardship (in case of difficulty the usual legal restrictions are relaxed), mashaqqat
- The Principle of Custom or Precedent (follow usual procedures unless there is evidence to the contrary), urf
Major Issues in Ethics
- Autonomous informed consent
- Privacy and confidentiality
- Fidelity
Case scenario #1
A 90-year old in the intensive care unit with stage 4 widely disseminated
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. He was finally admitted to a private hospice that provided
palliative care at great expense.
Case scenario #2
A 30-year old patient with multiple sclerosis had 5 years before
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 remarried and lived in a separate house
decided against life support because it would prolong her suffering. Her father
intervened and decided on life support because that would be in her best
interests.
Case scenario #3:
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.
Case scenario #4:
Doctors wrote a Do-not-resuscitate (DNR) order for an 80-year old
grandmother with disseminated untreatable ovarian cancer. Her family objected
vehemently when told of this decision and sought its reversal. Before the
dispute was resolved the patient collapsed after an episode of acute pneumonia
unrelated to her original condition. The nurses following the DNR order did not
call the resuscitation team.
Case scenario #5:
A 70-year old man with advanced cancer and severe pain not responsive to morphia
asked the doctor to kill him and save him from suffering. The doctor refused to claim that he could not commit illegal homicide. The doctor also refused to
give the patient any advice about suicide. On the patient’s insistence, the
doctor agreed to stop hydration and nutrition to enable slow death.
Hint: withholding food and hydration is passive euthanasia
Case scenario #6:
A car accident victim in severe shock was wheeled into the
emergency room with un-recordable blood pressure or pulse. The doctor did not
declare death but against the insistence of family members refused to institute
life support because he reasoned there was no hope. The patient was declared
dead 1 hour later. The family threatened to sue the doctor.
Case scenario #7:
A 90-year old with multi-organ failure and clinical signs of brain
stem death was on life support occupying the last available bed in the intensive
care unit because the doctors were afraid to disclose death to the family that
had many vocal and angry members. However, when 50 survivors from an air crash at the site were brought it, the doctors decided to withdraw life support from the old
man to free up at least one ICU bed.
Scenario #8:
A policeman died suddenly during a fight with criminals who were
later arrested. The police authorities wanted to carry out a post mortem to
determine the cause of death in order to charge and punish the criminals with
homicide. Some members of the family objected to the post mortem on the grounds
that it was against the shari’at. Other members supported the post
mortem because of insurance compensation purposes.
Case scenario #9:
An intensive care unit doctor kept a brain stem, dead patient, on
artificial life support to maintain the vitality of his organs until the arrival of the transplant team to harvest the heart and lungs donated by the
patient while still conscious in favor of his cousin who was born with severe
congenital abnormalities and would die without the transplantation.