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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 ethics
committee, use of ethical theories and principles.
HIGHER
PURPOSES
} 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
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 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 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 bread winner. 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 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
§ Payments for research 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 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.
} Onco-fertility.
CASE
SCENARION 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
SCENARION 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
SCENARION 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, and 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 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 for 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 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 ear drum 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 is 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.