220127P - MEDICAL ETHICS-THEORIES, PRINCIPLES, AND DILEMMAS

Presentation at the Ethics Training for Hospital Staff, King Abdullah bin Abdulaziz University Hospital held via Zoom Platform, Riyadh on 25-27 January 2022. By Prof. Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard) DrPH (Harvard) Professor of Epidemiology and Bioethics - KFMC

WORDS, MEANINGS, AND TERMINOLOGIES

• Ethics: a branch of philosophy that studies what is right and wrong.
• Akhlaqiyyat is not an Arabic translation for ethics; the difference between ethics and law.
• Western perspective ethics is not always legal and vice versa.
• Islamic perspective ethics = law. Haram = unethical and halal is ethical.

ETHICS FOR SOLVING DILEMMAS IN THE GREY ZONE

• The absolute vs the relative: (makruuh and mustahabb).
• Avoiding semantic problems by looking at ethics as the science of resolving dilemmas (2 or more solutions each with benefits and potential harm).
• Most dilemmas can be resolved by asking you to hear but a few require theories and principles to guide us.

DILEMMA OF THE PROSTATE-DO YOU TELL?

• A 45-year-old man getting married in a few days goes to the urologist for a routine examination. He has symptoms that prompt the urologist to make further examinations and leads to a prostate cancer diagnosis.
• Prostate cancer is low grade, does not spread and most people die with it but from other conditions.
• Do you hide the diagnosis from him so that he can get happily married?

DILEMMA OF THE PROSTATE-DO YOU OPERATE?

• The man is very obese, has hypertension, high cholesterol, does not exercise, and smokes 10 packs of cigarettes a day. These are likely to kill him before the prostate cancer metastasizes if at all.
• After getting married, the man asks your advice: should he consent to radical prostatectomy or not? The operation will interfere with his marital and reproductive functions but will get rid of the cancer completely.
• If no operation the chance of the cancer growing and metastasizing is very low, he may die of other competing causes of death.

THE HIPPOCRATIC OATH - 12^th BYZANTINE MANUSCRIPT AS A CROSS B. 460 BC D. 370 BC

THE HIPPOCRATIC OATH OLD ENGLISH VERSION

THE OATH OF A MUSLIM PHYSICIAN – MODERN FORMULATION

MALAYSIAN MEDICAL GRADUATES TAKING THE OATH OF THE MUSLIM PHYSICIAN

EUROPEAN THEORIES OF ETHICS

Theories explain why things are right or wrong:

• Kantian (deontological) ethics by Immanuel Kant (1724-1804). Ethics are based on rules, logic, and religion with no emotion or consideration of consequences. The same rules are true in all places and times. It is a moral duty to follow those rules.
• Utilitarianism theory of Jeremy Bentham and John Stuart Mill. What is moral is what brings maximum happiness or good consequences without regard to intentions.

KANTIAN OR UTILITARIAN?

• The Ministry of Health wants to import a new flu vaccine found to be more effective overseas but wants to test it locally to make sure it is safe.
• Negative press coverage discourages the public from volunteering for testing.
• The Ministry decided to force its staff aged 50 years and above to take part in the trial.
• What do you think?

OTHER EUROPEAN THEORIES OF ETHICS

• Right = majority community opinion.
• Right = respect for individual rights.
• Right = maintaining the best physician-patient relations.
• Case by case.

4 EUROPEAN PRINCIPLES OF ETHICS

• Autonomy = the patient decides.
• Beneficence = assure benefits.
• Non-maleficence = avoid harm.
• Justice.

ETHICS THEORY BASED ON PURPOSES, Maqasid Al Shari’at

• Protection of morality, hifdh al ddiin.
• Protection of life and health, hifdh al nafs.
• Protection of the family and procreation, hifdh al nasl.
• Protection of the intellect/mind, hifdh al aql.
• Protection of resources, hifdh al maal.

ETHICAL PRINCIPLES DERIVED FROM THE MAXIMS OF THE LAW

• Principle of intention, qaidat al qasd (actions are judged by the underlying intention).
• Principle of certainty, qaidat al yaqeen (evidence-based decisions).
• Principle of harm, qaidat al dharar (balance of harm vs benefit).
• Principle of hardship, qa’idat al mashaqqat (rules suspended in difficult situations to save a life).
• Principle of custom, qaidat al urf (customary practices/guidelines are respected).

DERIVED ETHICAL PRINCIPLES

• Privacy and confidentiality.
• Disclosure.
• Fidelity.

HISTORY OF RESEARCH ETHICS

• Nuremberg Declaration - 1946.
• Declaration of Helsinki - 1964 and 2013.
• UNESCO Universal Declaration on Bioethics and Human Rights - 2005.
• The Tuskegee Syphilis Study - 1932-1972.
• The Belmont Report - 1972.
• Implementing Regulations of the Law of Ethics of Research on Living Creatures - 2010.

NUREMBERG DECLARATION 1946

DECLARATION OF HELSINKI 1964 AND 2013

THE TUSKEGEE SYPHILIS STUDY 1932 - 1972

THE BELMONT REPORT 1972

IMPLEMENTING REGULATIONS OF THE LAW OF ETHICS OF RESEARCH ON LIVING CREATURES

 

HISTORY OF GENERAL BIOETHICS

• UNESCO Universal Declaration on Bioethics and Human Rights 2005.
• Code of Ethics for Medical Practitioners.
• Professionalism and Ethics.
• CPP Human and Medical Ethics Committee.
• CPP Procedures of clinical ethical consultations.
• CPP Procedures of non-clinical ethical Consultations.
• Book of medical jurisprudence.

UNESCO UNIVERSAL DECLARATION ON BIOETHICS AND HUMAN RIGHTS 2005

CODE OF ETHICS FOR MEDICAL PRACTITIONERS

 

PROFESSIONALISM AND ETHICS

 

CPP HUMAN AND MEDICAL ETHICS COMMITTEE

 

CPP PROCEDURES OF CLINICAL ETHICAL CONSULTATIONS

 

CPP PROCEDURES OF NON-CLINICAL ETHICAL CONSULTATIONS

 

BOOK OF MEDICAL JURISPRUDENCE

 

AUTONOMY AND DISCLOSURE: Our Local Experience

• The Family tells the doctor not to tell the patient the diagnosis.
• The patient tells the doctor not to tell the family.
• Consent process for clinical trials.