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Presentation at the P&O Diploma Program Female in King Fahad Medical City, Riyadh on 08 April 2019; by Prof. Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard) DrPH (Harvard) Chairman, Institutional Review Board - KFMC
WHAT is ETHICS?
• Telling right (moral or ethical) from wrong (immoral or unethical).
• Ethical may/may not be the same as legal.
Knowing what is ethical or unethical is natural in most cases: ask your heart.
• Healthcare practitioners face ethical dilemmas (2 choices each with advantages, disadvantages, and risks).
• Sources of solutions for dilemmas: medical fatwa from the high ulama authority, hospital religious guide, hospital committee, use of ethical theories and principles.
HIGHER PURPOSES 4
• Protect morality, hifdh al ddiin.
• Protect life and health, hifdh al nafs.
• Protect procreation and the family, hifdh al nasl.
• Protect the human intellect, hifdh al aql.
• Protect resources, hifdh al maal.
4 MAIN ETHICAL PRINCIPLES
• Autonomy (patient decides).
• Beneficence (do what brings benefit).
• Non-maleficence (avoid what brings harm).
• Justice (treat all equally).
FIGURE OF THE CODE OF ETHICS FOR HEALTH PRACTITIONERS
Code of Ethics for Health Practitioners
 |
http://www.scfhs.org.sa/en/registration/ClassAndRegister/Reregister/Documents/Ethics%20for%20Health%20Practitioners.pdf |
AUTONOMY (Basis of Informed Consent)
• Autonomy is the innate human right of a patient to control access to his body and what is done to him or her. Autonomy is the right to choose who treats him, where he is treated, and what treatment to use.
• Autonomy = initial consent + authorization of treatment.
• Paternalism (doctor knows and decides all) is a violation of the patient’s autonomy rights.
INFORMED CONSENT
• Informed consent or refusal of must be free, voluntary and follows full disclosure of the procedure in non-technical language, benefits, side effects, alternatives, and cost).
• Competent adults consent for themselves. Legal guardian consents for incompetent adults (e.g. mental patients, patients in coma) and children.
• In life-saving situations 3 consultants can sign consent if no legal guardian is available.
• Consent can be by the advance directive (living will).
• Procedures are limited to what the patient consented to.
• Consent does not legalize illegal procedures such as abortion or assisted suicide.
CASE SCENARIO on CONSENT #1
• A 40-year old driver refused surgery to drain a pyomyositis abscess. He still refused surgery after the abscess burst spontaneously.
• The surgeons sedated him and carried out the surgery without his consent.
CASE SCENARIO on CONSENT #2 (For Children)
• A 14-year old patient refused admission because he hated the physicians on the pediatric ward. The father agreed with the patient but the mother disagreed.
• Both parents agreed with the patient’s refusal of any blood transfusion which the doctors considered necessary since the hemoglobin level had fallen to a dangerous level.
DISCLOSURE and TRUTHFULNESS
• Obligation to Tell the Truth (doctors should not lie to patients).
• What is Disclosed (full disclosure unless there is a valid reason).
• Partial Disclosure and White or Technical Lies.
• Disclosures to Others about the Patient (not generally allowed without patient consent).
• Giving Bad News.
CASE SCENARIO on DISCLOSURE #1
• A conscious and competent patient told nurses on admission to the ICU that he did not want his family to be told anything about his condition. When his condition deteriorated the physicians wanted to consult his family about end-of-life decisions but he refused to give up his right to confidentiality.
CASE SCENARIO on DISCLOSURE #2
• A pediatrician examined a child with multiple trauma wounds and suspected that the father was responsible. He was reluctant to report because the father would be imprisoned and the family would lose its breadwinner. What do you think is the correct approach?
PRIVACY and CONFIDENTIALITY
• Privacy.
• Confidentiality.
• Medical Records.
• Release of Confidential Information.
CASE SCENARIO on CONFIDENTIALITY
• A neurologist informed his wife over dinner about an elderly school bus driver who had Parkinson's disease and had to take an unusually high dose of medication to suppress the tremors. The medication made the patient sleepy all day.
• The wife asked for the name and realized that the patient was a driver for her school transport company who had been coming to work late in the past 2 weeks. She dismissed him the next morning.
FIDELITY
• Definition of Fidelity.
• Conflicts Regarding Fidelity.
DIMENSIONS of PROFESSIONALISM
• 6 dimensions of professionalism – by ABIM (American board of internal medicine): altruism, accountability, excellence, duty, honor and integrity, respect for others.
• Negative ‘dimensions’ of professionalism – by ABIM: abuse of power and sexual harassment, conflicts of interest, professional arrogance, physician impairment, fraud in research.
• Proposed 7 dimensions of professionalism: faith (iman), consciousness (taqwat), best character (ahsan al akhlaq), excellent performance (itqaan al ‘amal), strife toward perfection (ihsan), responsibility (amanat), self-accountability (muhasabat al nafs).
DEALING with PHARMACEUTICAL COMPANIES
• Do drug company representatives give drug information? Accurate? Biased?
• Should a healthcare worker accept the following gifts from pharmaceutical companies?
• Free drug samples YES/NO
Free gifts of pens, calendars, writing pads? YES/NO
• Expenses for attending conferences YES/NO
• Payments as consultants YES/NO
• Payments for giving lectures YES/NO
CASE SCENARIO on PROFESSIONALISM #1
• Hospital director wanted to discipline a doctor who refused to treat a patient with chronic bronchitis and had refused to give up smoking with the result that he had to come to the emergency room 2 or 3 times a week.
CASE SCENARIO #1 on PROFESSIONALISM #2
• A hospital director refused to employ a newly graduated resident with good recommendations and high grades because he remembered him as a very unprofessional and dishonest student.
CASE SCENARIO #2 on PROFESSIONALISM #3
• The hospital director was planning to terminate the contract of the best cardiovascular surgeon in the hospital because of immoral behaviors outside work. In 10 years of working at the hospital no ethical or professional infraction was reported on him.
CASE SCENARIO #3 on PROFESSIONALISM #4
• The hospital manager disciplined a physician who was 2 hours late for his cardiac follow-up clinic because he was in a community program on the prevention of cardiovascular disease. What do you think about this? What principles will you use?
START of LIFE ISSUES
• Assisted reproduction.
• Contraception.
• Abortion.
• Gender selection.
• Gender selection/correction.
• Menopause.
• Oncofertility.
CASE SCENARIO on START of life ISSUES #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 on START of life ISSUES #2
• 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 on START of life ISSUES #3
• 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.
END of LIFE ETHICS
• Definition of death: brain death, cardiorespiratory death.
• Palliative care.
• Do Not Resuscitate (DNR).
• Decisions for the terminally ill: withholding of life support, withdrawal of life support, nutrition, hydration.
• Euthanasia assisted suicide.
CASE SCENARIO on END of LIFE #1
• 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 on END of LIFE #2
• A 30-year-old patient of 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.
MEDICAL MALPRACTICE and MEDICAL ERRORS
• Malpractice = not following guidelines.
• Negligence = not following guidelines + residual harm to the patient.
CASE SCENARIO on MEDICAL ERROR #1
• A patient suffered brain damage because the doctor failed to intubate in a home setting. The family took the doctor to court.
CASE SCENARIO on MEDICAL ERROR #2
• A medical officer pierced the eardrum of a patient who protested loudly about the pain and eventually became deaf in that ear. A consultant who was standing by did not say anything. The patient sued both the medical officer and the consultant.
CASE SCENARIO on MEDICAL ERROR #3
• A medical officer by chance at the site of an accident tried resuscitation and failed. He was sued by the victim’s family.
RESEARCH ETHICS
• No Research without informed consent.
• No conflict of interest: financial and non-financial.
• No plagiarism.
• No gift authorship.
CASE SCENARIO on RESEARCH ETHICS
• A researcher was offered a fully paid conference package with his family when he published a paper favorable to the drug being introduced by the pharmaceutical company.
• The next year he published an unfavorable report about another drug of the company. No conference package was offered, and his wife was asking him why they did not go overseas this year. Explain.
ORGAN HARVESTING and TRANSPLANTATION
• Free voluntary donor consent.
• No selling organs.
• Preference for relative donors.
• Everything handled by SCOT (Saudi Center for Organ Transplantation).
CASE SCENARIO on ORGAN TRANSPLANTATION
• An ICU 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.