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Presentation at the first workshop of Research Ethics Program - Clinical Ethics: Principle and Methods held at Princess Nourah bint Abdulrahman University, Riyadh on 30 October 2019. By Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City
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1. In a measles mini epidemic in the South of Riyadh, the MOH orders vaccination of all children with no immunization records. A pediatrician living at the KSU campus with non-school-going toddlers refuses to take his children for vaccination arguing that the risk of vaccination complications was higher for his children than the risk of measles infection.
2. A mentally retarded Down syndrome youth aged 15 years had been to court several times for sexual attacks on toddlers. The judge ordered the doctors to suppress his sexual aggression by use of hormones and if that was not effective to remove his testes.
3. A urologist with 20 years of experience in renal transplant refused to donate one of his kidneys to his identical twin brother who had found no other matching kidney. The Saudi Council for Health Specialties started de-registration proceedings for failure to give benefits obligatory on all physicians.
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4. A new company in Riyadh advertised on TV and newspapers offering direct genetic testing services. Consumers would pay for a kit using a credit card and they would use the kit to collect a sample of blood by finger prick and send it back by mail. Results would be sent back after a week.
5. In a bird flu epidemic, all citizens were advised to go during working hours to three immunization centers set up at the three university centers in the city: KSU, KSUHS, and Imam Muhammad Universities. It was made clear that vaccination was not compulsory.
6. A nurse manager has just discovered that his colleague, a surgeon, is HIV+ve, but has kept the information secret and continued operating on patients taking infection control precautions. An emergency case requiring immediate surgery is wheeled into the emergency room at midnight and there is no other surgeon available.
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7. An elderly patient with advanced esophageal cancer refused insertion of a nasogastric feeding tube and insisted on taking sold food that he could not swallow. He said he would prefer to die from starvation than accept the tube. The surgeons sedated him and inserted the tube without his consent and kept him under sedation so that he cannot complain.
8. A 20-year-old drug addict in and out of rehabilitation centers for the past 5 years with no improvement asked for marijuana or any drug that would satisfy his craving to be given within the hospital so that he would not have to commit crimes on the streets to feed his addiction.
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9. Wealthy and well-connected parents of children with congenital anomalies mostly cleft lip and cleft palate approached the Ministry of Health and agreed to open a cosmetic surgery unit at a remote rural hospital. The natives of the area protested saying that the hospital did not have basic services like vaccination or ante-natal care.
10. The National transplantation center set up criteria for distributing scarce organs that included Saudi citizenship, level of education, age, gender, disease severity, and potential survival. There were so many complaints and the center did not know how to set criteria that the public would accept. Eventually they settled for a first come first served basis.
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11. In a chemical disaster, there was a limited antidote, and a decision was made to give it only to children aged below 5 years. Health workers, emergency workers, and the police were angry at this prioritization refusing to work.
12. A 90-year-old 100% dependent on a respirator with no hope of independent life asks the doctor to disconnect the machines so that he can die in peace but the doctor refuses. He has no serious disease; he had become dependent on the respirator during a prolonged and poorly managed episode of pneumonia.
13. A socially respected elderly businessman with frequent travel overseas is in terminal illness due to sexually acquired HIV. On discharge from the hospital, he asks the doctors not to disclose his status to his family because of the shame involved but the doctor refuses.
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14. A child is seriously ill and requiring immediate blood transfusion and surgery but both parents refuse any intervention saying they know the child is going to die and that is the will of Allah. The doctor decides to respect the parents’ wishes.
15. A woman fully competent in slow labor with no impending fetal distress refuses cesarean section but the doctor insists because of fear for his reputation if the delivery gets complicated. He forces the woman to accept a Cesarean section immediately.
16. A 90-year-old with advanced cancer and in severe pain was not given adequate pain relief because the doctors feared addiction to opiates and respiratory depression.
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17. An elderly paternalistic doctor refused to listen to the views of the patient arguing that his duty was more to protect the patient's health than to protect patient autonomy.
18. In order to save a life, a senior medical officer allowed surgery under unclean conditions at the site of a major natural disaster with too many patients who could not be transported to the hospital in a reasonable time.
19. The MOH imposed a fee on the circumcision of boys in all its hospitals. Parents complained of the grounds that circumcision was a medical and not a religious necessity.