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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 of 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 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.
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 claiming 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 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 police man 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.