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Presentation at a workshop on Ethical Problems in Medicine at the Sulaymaniyah Health Center Riyadh on 13 December 2022 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics
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 and the Grand Ulama Authority
- The Fiqh Academy of the Organization of the Islamic Conference
- The Fiqh Academy of the World Muslim League
- Other Fiqh Academies
Authoritative Sources: Local Level
- Ethics Committee in the Hospital
- Local Scholar or religious guide
Existing Laws and Regulations
- Code of Medical Ethics by the Saudi Council for Health Specialties
- Health Professions Practice Regulations by the Ministry of Health
Code of Ethics for Health Practitioners
European Ethical Principles (Beauchamp and Childress 1994)
- Autonomy (patient decides)
- Beneficence (bring benefit)
- Non-maleficence (do no harm)
- Justice (equity vs equality)
Alternative Ethical Theory (Purposes of Medicine)
- 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
Autonomy and Consent to Treatment
- The Patient's Autonomous Right to Consent
- Conditions of Informed Consent
- Refusal of Consent/withdrawal of consent
- Proxy Consent by the guardian
o
Consent for older children
o
Consent for younger Children
o
Consent for Mental Patients
o
Consent for the Unconscious
Informed Consent
- General consent on admission
- Procedural consent eg blood transfusion
- No need for additional consent eg blood pressure determination
- Anesthesia consent is separate
- Duration of consent
Obligation to Tell the Truth
- As part of the professional contract between the physician and the patient, the physician must tell the whole truth.
- Veracity is based on respect for autonomy, fidelity, and confidentiality.
- Patients have the right to know the risks and benefits of medical procedures in order for them to make autonomous informed consent.
- Deception violates fidelity.
What is Disclosed?
- Disclosure of some forms of information may constitute malefacence.
- There is no obligation to disclose information that the patient does not request or does not want.
- Some patients may prefer not to know the truth.
- There is no obligation to disclose unwanted information.
- Patients should be told only what they need to know or what they want to know.
Partial Disclosure and White
or Technical Lies
·
Partial disclosure can be considered a half truth and
therefore a form of lying.
·
Technical lies are statements that are apparently true
and whose truth can be defended using data and reasoning but they contain an
element of untruth that any person privy to the whole information will be able
to discern.
·
The physician may consider telling ‘white lies’ for
the sake of the patient welfare.
·
The physician should be guided in his communication by
the background and understanding of a patient. Some patients can be given a lot
of information and they do not get disturbed. Some types of information agitate
patients. The prophet taught talking to each person according to his ability to
understand.
Disclosures to Others
about the Patient
·
It may be necessary that the physician shares some
confidential information with members of the family in order to get involve
them in patient care.
·
This may take the form of getting more information
about the patient, consultation about the best care or trying to interpret and
understand the patient’s choices and decisions.
·
In general divulging unsolicited information to
governmental or other authorities is frowned upon.
Giving Bad News - 1
·
Bad news is common in medicine. The patient may have
to be told about a diagnostic result that indicates a more serious disease than
had been anticipated. The prognosis may be bad or the treatment may fail.
·
In general it is better to keep quiet than to
pronounce anything that is uncomfortable. However the obligation of veracity
and transparency force the physician to give bad news to the patient and the
family.
·
Telling the patient half truths or white technical
lies may be a way out of the dilemma of giving bad news but it destroys the
confidence and trust that patients put in doctors.
·
Telling a straight lie is forbidden.
·
Each case should be evaluated on its own merits by
balancing benefits and injuries. In the end it may be better to be straight in
dealing with the patient and warn them before giving bad news. Their permission
could also be asked. Some may prefer that they be not told the whole truth
because that would distress and disturb them.
Giving Bad News - 2
·
Some bad news is better given to the relatives. They
can find a way of conveying the information in a gentler way that minimizes the
mental injury to the patient. They may also make a better judgment of what to
tell and what not to tell the patient.
·
Some bad news may be given to authorities in the form
of medical certification for temporary or permanent disability, sick leave, and
return to work.
·
Physicians should be careful about their body
language. It is very difficult to hide feelings inside. The patient will read
the body language and will believe it more than verbal language. A verbal
reassurance of the patient that he will so well can be contradicted by show of
worry and agitation on the face of the physician. This is perhaps one argument
for telling the whole truth to the patient whatever the consequence because
they can read it for themselves from the physician’s body language.
Privacy and
Confidentiality
·
Privacy
·
Confidentiality
·
Medical Records
·
Release of Confidential Information
Fidelity
·
Definition of Fidelity
·
Conflicts Regarding Fidelity
Scenario #1 - (DNR)
·
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.
Scenario #2 - Autonomy
·
A urologist with 20 years’ 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 benefit
obligatory on all physicians.
Scenario #3 - Autonomy
and informed consent
·
A 30-year old woman presented with classical signs of
acute appendicitis.
·
She 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 as well
·
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 #4 - autonomy
·
The thoracic surgeon wanted to carry out a de-bulking
operation to decrease lung cancer mass to enable the patient 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 - benefit
vs injury
·
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.
Scenario #6 - benefit
vs injury
·
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 #7 - benefit
vs risk
·
A middle-aged woman without any medical condition
asked her physician for hormonal treatment to appear younger. The physician
refused because he judged the risk of cardiovascular and cancer complications
to be more than the benefits.
Scenario #8 –
euthanasia
·
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.
Scenario #9 - abortion
·
A 14 year-old girl was admitted to the hospital for an
abortion. She was two months pregnant from what she claimed was rape. The
family was distraught and wanted the doctors to carry out the abortion
immediately. The physicians were reluctant because there was no medical reason.
Scenario #10 - sex
change
·
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.
Scenario #11 - disease
screening
·
A 4-year old child had repeated episodes of anemia
that responded to transfusion. The doctors without getting parental permission
carried out and found a positive test for thalassemia disease. Problems
occurred in the family because both parents had results of pre-marital testing
that showed that neither was a carrier of thalassemia.
Scenario #12 -
disclosure
·
A 90-year old with multi organ failure and clinical
signs of brain stem death was on life support was occupying the last available
bed in the ICU 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.