Home 
Contact 
Profile 
Videos 
Presentation at a Clinical Ethics Course held Online at Princess Nourah bint Abdulrahman University, Riyadh on 20 September 2020 at 2:00 PM - 4:00 PM). By: Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.
THE LEARNING
OBJECTIVES / OUTCOMES:
} Understand
the methods and processes of clinical ethics consultation.
} Analysis
of case scenarios with ethical dilemmas.
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.
SOLUTION
USING THE 4 ETHICAL PRINCIPLES:
} Patient autonomy =
patient decides.
} Beneficence =
bring benefit.
} Nonmaleficence =
cause no harm.
} Justice = treat
all with equity.
SOLUTIONS
USING Maqasid Al Shari'at:
} Protection of ddiin
(morality).
} Protection of life
(life and health), hifdh al nafs.
} Protection of
progeny (family and procreation), hifdh al nasl.
} Protection of the
mind (psyche) hifdh al ‘aql.
} Protection of
wealth (resources), hifdh al mal.
SOLUTIONS
FROM PRINCIPLES OF THE LAW, Qawaid Al Fiqh:
} The Principle of
Intention,
qa’idat al qasd: we consider the underlying intentions.
} The Principle of
Certainty,
qaidat al yaqeen: evidence-based decisions.
} The Principle of
Injury,
qaidat al dharar: cause no harm; balance benefit vs injury.
} The Principle of
Hardship,
qaidat al mashaqqat: exceptions in cases of necessity.
} The Principle of
Custom or
Precedent, qaidat al urf: follow the procedures.
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.
SCENARIO
- 2:
} 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
- 3:
} A 90-year-old in
ICU with stage 4 widely metastasized cancer and multi-organ failure was told by
the doctors that there was nothing they could do to reverse the course of the
disease and that they could only provide symptomatic treatment.
} He asked to be
discharged to die at home. His children objected saying that he needed complex
nursing that they could not provide at home.
} What should healthcare workers do? Provide your moral reasoning.
SCENARIO
- 4:
} The thoracic
surgeon wanted to carry out a de-bulking operation to decrease lung cancer mass
to enable the patient to 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:
} A patient
presented to the clinic with vague complaints in the abdomen and worries about
cancer.
} Physical
examination and investigations revealed no pathology.
} The doctor was
angry with the patient for wasting clinic time when he was in good health.
} As the patient was
leaving he told the doctor that his uncle had died the week before of stomach
cancer. The doctor did not respond.
} What should the
doctor have done? Provide your moral reasoning.
SCENARIO
- 6:
} A young man sent
for a pre-employment examination filled out a health questionnaire and mentioned
no health problems at all.
} Physical
examination revealed a severely dislocated shoulder and an unhealed acromial
fracture.
} When asked about
them he admitted that they caused him pain from time to time but that he was
patient and did not care much about them.
} What should the
examining doctor report? Provide your moral reasoning.
SCENARIO
- 7:
} An 80-year-old
diabetic man, whose son had died last year from a transfusion of mismatched
blood, was admitted to the same hospital for observation after falling at home.
} He insisted that
no procedure be done without written approval by his physician son whom he
wanted to sit by his bedside all the time.
} Nurses were inconvenienced
by having to get written permission for routine monitoring of vital signs and
insulin injections.
} The nurses refused
to comply with his wishes and he refused to cooperate leading to a stand-off.
} What should the
doctor in charge do? Provide your moral reasoning.
SCENARIO
- 8:
} A young
neurosurgeon planned to operate on a patient with a 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
- 9:
} A 30-year-old
patient with 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 healthcare workers do? Provide your moral reasoning.
SCENARIO
- 10:
} A university
professor with previous episodes of transient stroke had written a directive
and had it witnessed that if he lost consciousness he would not like to be
resuscitated.
} Years later he was
brought to the hospital unconscious from head injuries sustained in a car
accident.
} The doctors
reading his directive in his shirt pocket decided not to resuscitate him but
his wife insisted that he be resuscitated.
} What is the right
course of action for the doctors? Provide your moral reasoning.