170411P - HOW TO RESOLVE ETHICAL ISSUES IN PRACTICE

Presentation at a Grand Round, King Abdullah Medical City held at Makkah AlMukarramah, Saudi Arabia on 11 April 2017 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 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 to 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 a 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 with multiple sclerosis who 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 on 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.