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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
AUTONOMY AND CONSENT TO TREATMENT
• The Patient's Autonomous Right to Consent
• Conditions of Informed Consent
• Refusal of Consent
• Proxy Consent
• Consent for older children
• Consent for younger Children
• Consent for Mental Patients
• Consent for the Unconscious
CASE SCENARIO - 1
• A patient was brought to the emergency room by the police after attempting to kill himself by hanging. He was unconscious when first brought in and had a signed suicide note in his shirt pocket saying that he wanted to die. The doctors ignored the note and started resuscitation measures. The patient became conscious after 30 minutes and protested at the medical treatment arguing that he wanted to die. The doctor was thinking of stopping resuscitation measures when the patient’s father and wife arrived and instructed the doctor to continue resuscitation.
CASE SCENARIO - 2
• A 40-year-old policeman 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. He protested strongly after recovering from sedation.
CASE SCENARIO - 3
• A 42-year old actress pregnant for the first time refused an elective cesarean section because an abdominal scar would ruin her career. She continued to refuse the procedure when labor became obstructed, and signs of fetal distress appeared. The obstetrician went ahead to operate on the basis of consent by the husband. The baby was delivered alive and well.
CASE SCENARIO - 4
• 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.
PRIVACY AND CONFIDENTIALITY
• Privacy and confidentiality are often confused
• Keeping confidentiality
• Breaching confidentiality
CASE SCENARIO - 1
• 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
CASE SCENARIO - 2
• The manager of a national airline was worried about the erratic behavior and mistakes of one of the senior pilots. He asked around and found out the name and address of the pilot’s family doctor who was in private practice. He wrote to the private practitioner to provide records about the treatment of the pilot for vision and psychological problems. He asked specifically for information on drug abuse. The private practitioner called and gave the information but told the manager that he could not put it down in writing since he had not discussed the matter with the patient.
DISCLOSURE AND TRUTHFULNESS
• Obligation to tell the truth
• What is disclosed
• Partial disclosure and white or technical lies
• Disclosures to others about the patient
• Giving bad news
CASE 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.
CASE SCENARIO - 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?