210711P - HOW TO RESOLVE ETHICAL ISSUES IN PRACTICE

Presented at AlYamamah Hospital on 29^th July 2021 by Dr Omar Hasan Kasule Mb ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics at King Fahad Medical City R2 Cluster.

 

 

THE LEARNING OBJECTIVES / OUTCOMES:

• Understand the sources of guidance in resolving ethical issues
• 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
• National Commission on Bioethics

 

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
• Existing fatwas: gazetted and non-gazetted

 

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 the 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 healthy. 
• 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.
• 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 with 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 the 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.

 

CLINICAL ETHICAL CONSULTATION SERVICE –  DEFINITIONS - 1:

• Ethics: a methodological discipline that is concerned with the moral analysis of medical problems to reach conclusions distinguishing right from wrong decisions.
• Ethicist / Bioethicist: a medical professional with specific training and experience in the field of applied ethics/bioethics.
• Ethics Committee: a committee established to advise on ethical issues concerning individual patents
• and on ethical policies and procedures in general.
• Clinical Consultation: seeking the professional opinion of an expert or a group of experts in a medical specialty.
• Urgent Consultation: one that requires an urgent response within 24 hours.
• Ethicist-On-Duty: The Ethicist-On-Duty is an individual allocated through the ethics consultant duty schedule to provide ethics consultations.
• Staff Member: any clinical or non-clinical employee who may elevate an ethical issue to the Ethics Committee.

 

 

CLINICAL ETHICAL CONSULTATION SERVICE – DEFINITIONS - 2:

• Ethics Clinical Consultation: Ethics consultation services are a special consultation process related to ethical issues. It helps ensure the quality of ethical practices and patient care which improves health care quality.
• An Ethics Clinical Consultation is a process by which trained consultants respond to requests for help to resolve ethical conflicts, issues, or questions involving patient care.
• An Ethics Consultation is advisory. Patients, family members, and healthcare providers remain responsible for their own decisions. Clarification of the ethically accepted course of action can help the health care providers and patients navigate difficult clinical circumstances

 

CLINICAL ETHICAL CONSULTATION SERVICE – POLICIES:

• Clinical Ethics Consultation is available and is treated like any other form of clinical consultation according to hospital regulations.
• An ethical problem exists when it is not clear what the ethically sound action is or course of action or when people disagree about what is best for a patient.
• An Ethics Consultation is advisory. Ethics consultants shall act as professionals giving specialist ethical bits of advice and their role will be advisory and non-binding. All final decision-making will be by heads of department, the attending consultants, and the patients or their families.
• An ethics consultant duty schedule shall be distributed (as required). Bioethics consultants shall take turns being the consultant on duty and while on duty, will receive all urgent consultations through special email telephone with the ethicist o duty 24 hours 7 days.
• Response to ethical consultations shall be immediate for extremely urgent cases involving end-of-life decisions, within 24 hours for other urgent cases, and within 5 working days for non-urgent cases. The investigation and resolution of ethical cases shall be completed within 2 weeks.

 

CLINICAL ETHICAL CONSULTATION SERVICE – PROCEDURES 1:

• The Chair of the Ethics Committee ensures the process of ethics consultations is operating effectively. The Administration Staff ensures the Datix online reporting system, the special email address, and the mobile telephone are working for online consultations.
• Chair of the Ethics Committee OR the Ethicist-On-Duty addresses all online consultations immediately.
• The clinical Consultant consults the Ethics Committee either electronically via the Datix online reporting system or telephonically through an assigned mobile number.
• Patients and family members can directly request an Ethics Consultation by calling the hospital operator and asking for the Ethics Consultation Service. They can also tell their physician, nurse, or health care provider that they want an Ethics Consultation. The staff made aware of a patient's or family's desire for an Ethics Consultation convey the request to the Physician and the Ethics Consultation Service.

 

 

CLINICAL ETHICAL CONSULTATION SERVICE – PROCEDURES FOR URGENT CONSULTATIONS:

• The clinical Consultant/Ethicist-On-Duty notifies the Attending Physician or their designee of the request for an Ethics Consultation.
• The clinical Consultant/Ethicist-On-Duty sends a non-urgent clinical consultation to the Chair of the Ethics Committee for presentation at the next committee meeting. The Committee members review the ethical issue. The Administrative Staff member ensures documentation in the committee minutes. The Chair of the Ethics Committee /Ethicist-On-Duty writes an official response to the consultation request.
• Chair of the Ethics Committee/Clinical Consultant attends regular ward rounds and proactively discusses an ethical issue.

 

CLINICAL ETHICAL CONSULTATION SERVICE – PROCEDURES FOR URGENT CONSULTATIONS:

• The clinical Consultant formulates an urgent or emergency clinical consultation through direct consultation with the Ethicist-On-Duty and/or the Chair of the Ethics Committee. The Clinical Consultant states it is an urgent or emergency consultation.
• Chair of the Ethics Committee/Ethicist-On-Duty responds to the urgent consultation within 24 Hours and non-urgent ones within 5 working days. The investigation and resolution of ethical cases shall be completed within 2 weeks.
• Ethicist-On-Duty visits the ward, review patient charts, and talk to the physicians (if needed) and to the patients and their families (if necessary).
• The Ethicist-On-Duty gives an electronic or telephonic opinion to the consulting physician with a follow-up letter.
• Ethicist-On-Duty signs the consultation report.
• Ethicist-On-Duty consults other ethicists or the Ethics Committee before giving an opinion if the case is complicated.

 

CLINICAL ETHICAL CONSULTATION SERVICE – OTHER PROCEDURES:

• The chair of the Ethics Committee refers issues that do not concern a specific patient to the Ethics Committee.
• The chair of the Ethics Committee establishes a process for addressing ethical issues through the opportunity reporting system (ORS).
• The chair of the Ethics Committee responds to the opportunity reporting system. He delegates ethics reviews to Ethics Committee members. Ethics Committee members respond to the issue through the ORS process.