Home 
Contact 
Profile 
Videos 
Presentation at a Clinical Ethics Course held at Princess Nourah bint Abdulrahman University, Riyadh on 10 November 2019. 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
} No maleficence =
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.