HOW TO APPROACH AN ETHICAL ISSUE IN CLINICAL PRACTICE?

4th year medical students (May 14, 2012)

Prepared and presented by:

Dr. Ghaiath Husseinghaiathme@gmail.com

A less embarrassing choice… بأذى تسببت والدها يد على المهزوز الطفل لمتالزمة صغرها في تعرضت فتاة ي

عمره   كطفل اآلن فدماغها للدماغ   ) 6شديد اآلن عمرها ( 14أشهر باإلضافة سنةعدم و الكالم و دقائق عده من ألكثر رأسها حمل و المشي على قدرتها لعدم   طفلة يبقوها أن بالتبني والداها فقرر اإلخراج بعملية التحكم أو األكل على قدرتهاالطبيبة   فقامت بالمقال ذكرت نواحي عدة من لمصلحتها ذلك أن و حياتها لبقية

و الرحم من  breast bud  باستئصال كبيرة جرعات بإعطائها قاموا ثم للطفلةإعطاء على األخالقيات لجنة موافقة بعد البلوغ عميلة لتثبيط االستروجناستئصالهم تم لهذا و المبايض و الرحم لسرطان تعرضها لخطر نظرا االستروجن

الجرعات إعطاء قبل هذه أن بالنقال ذكر ما أن 4حسب و العالم في العالج من النوع لهذا تخضع طفلة

بمقرر نأخذه عما بعيدة و علي جديدة الحالة لها األفضل أنه و ذلك قررا والداها , للطبيبة يجوز هل الطبيب منظور من الموضوع نتناول عندما طبعا األخالقياتاألهل؟ بموافقة كان إن و الجسم في مهمة عملية لمنع سليمة أعضاء استئصال ) (   و العدالة مبدأ و المريض مصلحة المنفعة مبدأ ينافي أنه نرى هذا حالتنا ففي   الجرعات تلك إعطائها يجوز هل و النسل حفظ منها و الخمسة الضروريات أيضاصحيح؟ الطبيبة تصرف هل السرطان؟ لمرض تعريضها و االستروجن من الهائلة

شديدة إعاقات من تعاني أنها و خاصة بالمريض الرحمة من كنوع يعد أنه أو

Should the surgeon perform the operation despite Um Abdallah’s objections?

Outline

What is medical ethics? What is an ethical issue? Schools of thought )Philosophies( Tools for ethical analysis and decision

making Islamic approach to ethical decision

making

What is clinical/medical ethics?

It is that branch of bioethics that is related to the identification, analysis, and resolution of moral problems that arise in the healthcare of individual patients.

Questions answered by Bioethics

○deciding what we should do )what decisions are morally right or acceptable(;

○explaining why we should do it )how do we justify our decision in moral terms(; and

○describing how we should do it )the method or manner of our response when we act on our decision(.

What is an “ethical issue” or a “moral problem”?

There is an ethical issue when:…we encounter conflicting values, beliefs,

goals, or responsibilities…we are concerned that persons or their

rights are not being respected…we are concerned about fairness and

justice…we are unsure what we should do or why

we should do it, morally speaking

What else could it be?

Miscommunication stands for 70-80% of problems in healthcareE.g. Doctors don’t know to tell medical info

Management issue“when shall I get promoted? All my

colleagues did. This is not ethical!” Financial issue

“I am underpaid for my workload. This is not ethical!”

How to approach an ethical issue in clinical practice?

Schools of thought in moral reasoning (how right and wrong are distinguished?)

How to approach an ethical issue?

Set of ethical standards

Proper case analysis

Modality of decision making

Follow-up of the decision

I- Set of Ethical standards

Secular

Most western philosophies• Utilitarianism• Ethical

Egoism• Deontology• Social

contracts• Humanism

Religious (Oriental)

Bhudism

Confucian ethics

Daoist ethics

Hindu ethics

Religious (Abrahamic)

Jewish ethics

Christian ethics

Islamic ethics

Schools of thought in moral reasoning

Utilitarianism: the value of an action is determined by its utility; all actions should be directed toward achieving the greatest happiness for the greatest number of people.

Deontology: actions are judged based upon inherent right-making characteristics or principles rather than on their consequences. Emphasis on duty, rules and regulations, principles and moral

obligations which govern ones right action

Schools of thought in moral reasoning (cont.)

Feminist ethics )Ethics of Care( commitment to correcting male biases )e.g. women’s subordination is morally wrong( and that the moral experience of women is as worthy of respect as that of men.

Casuistry: The greatest confidence in our moral judgments resides not at the level of theory, where we endlessly disagree, but rather at the level of the case, where our intuitions often

converge without the benefit of theory.

Schools of thought in moral reasoning (cont.)

Virtue ethics: It emphasizes the virtues, or moral character

A patient should not comply with a “don’t smoke” advice from a smoking doctor!

Schools of thought in moral reasoning (cont.)

Principlism: Autonomy: respect humans'

ability to choose, Beneficence: Do Good for others, Nonmaleficence )Do No Harm(, & Justice

II- Tools for Ethical Analysis Why do we need tools for ethical

analysis?To make sure we do not miss any

information or possible factor that could affect the decision we take

How do they help us reach ethical decision?Tools that helps us have information about

all those involved in the decision Who is involved in ethical decision?

)what do you think?(

Who (&what) affects ethical decision making?

Context )country/region(

Regulations

Laws

Hospital

Policies

Guidelines

Admin. & financial

PatientFamily Clinicians

Tools & frameworks for ethical analysis

The Four Boxes ModelMedical Indications: Consider each medical condition and its proposed treatment. Ask the following questions: Does it fulfil any of the goals of medicine? With what likelihood? If not, is the proposed treatment futile?

Patient Preferences: Address the following: What does the patient want? Does the patient have the capacity to decide? If not, who will decide for the patient? Do the patient's wishes reflect a process that is informed? understood? voluntary?

Quality of Life: Patient's quality of life in the patient's terms. What is the patient's subjective acceptance of likely quality of life? What are the views of the care providers about the quality of life? Is quality of life "less than minimal?"

Contextual Features: Social, legal, economic, and institutional circumstances in the case that can: influence the decision be influenced by the decision e.g., inability to pay for treatment; inadequate social support

CLEO ApproachLegal: Clinical:Legally required process for treatment decision making when a patient lacks capacity to do soFamily involvement: who to involve? when and how substitute treatment decisions are to be made?

Diagnoses: Irreversible? Progressive? Permanent? Prognoses: Disabling? Terminal?clinicians’ level of certainty?

Organizational: Ethical:Any institutional pressures to not have a bed blocked by someone whose recovery will be long and slow or the benefits seemingly small? Any other healthcare facilities better able to provide palliative/rehabilitative care for longer periods of time? Any different views as to diagnosis, prognosis, next steps among the team or other physicians

The patient’s will, desires, perception of life, relationship with their family? What cultural or religious beliefs involved? Family’s stand: why? To show their fidelity to the patient and/or deal with their individual and collective sadness/shock/grieving? No longer sure what is really going on or who to trust

III- Modalities of resolving ethical issues

Doctor-patient level

•Usually patients )& families( accept doctors decision

Ethics consultation

•Mediation•Conflict resolution

All hospitals should have an ethics expert/body to provide consultation

Legal level

•Arbitration:If family )or the doctor( is still unhappy/unsure, they can still go to court.

The roles of ethics committees

Collect information• Med

ical• Non

-medical

Meet involved parties• Doct

ors• Nur

ses• Pati

ent (& family)

Ethical Analysis• Wei

ghing collected info. vs. ethical principles (& laws)

Decision Making• Sing

le decision; or

• Provide alternatives

Follow-Up• How

decisions are implemented?

• Lessons learned

Ethics Committee’s main role is provide guidance NOT to take decisions on behalf of any party

Islamic approach to ethical analysis and decision making (Islamic Bioethics)

Ethics in Islam… not a separate entity!

Law

Ethics

Religious PracticeEconomy

Social Relations

How should Muslims decide their acts? “And I (Allâh) created not the jinn and mankind except

that they should worship Me (Alone)” (51:56). uتvقwلwخ وwمwاالذاريات ( xونuدu wعvب xي ل xال إ wَسv xن وwاإل zنxجv56ال(

Worship in Islam includes the duty to follow the orders of Allah and His Prophet Mohamed )PBUH( “And whosoever does not judge by what Allâh has revealed,

such are the Kâfirûn )i.e. disbelievers - of a lesser degree as they do not act on Allâh’s Laws” )5: 44(; “And whosoever does not judge by that which Allâh has revealed, such are the Zâlimûn )polytheists and wrong-doers - of a lesser degree(” )5: 45(; “And whosoever does not judge by what Allâh has revealed )then( such )people( are the Fâsiqûn [the rebellious i.e. disobedient )of a lesser degree(” )5: 47(; “And whatsoever the Messenger )Muhammad ) وسلم عليه الله gives you, take it; and )صلىwhatsoever he forbids you, abstain )from it(” )59:7(.

Sources of Islamic Morality (& laws)

2 Main sources: Koran and Sunna

Secondary sources (Ijtihad)Unanimous agreement of Islamic jurists (Ijmaa) Acceptance by the majority of trusted scholars

(Rayul Jomhour) Measurement/Analogy (Qiyas), Remediation )Maslaha(, (Istishab)

Goals of Islamic Regulations

The five purposes of Sharia are to preserve person’s:

1. Religion;

2. Soul;

3. Mind;

4. Wealth; &

5. Progeny.

All Islamic legislations came to achieve these goals.

What is Islamic Bioethics?

It is the methodology of defining, analysing and resolving the ethical

issues that arise in healthcare practice, or research;

based on the Islamic moral and legislative sources )Koran, Sunna & Ijtihad(; and

aims at achieving the goals of Islamic morality )i.e. preservation of human’s religion, soul, mind, wealth & progeny (

Islamic Principles & Maxims Applicable in Medicine

1. The principle of Intention (Qasd): Each action is judged by the intention behind it

2. The principle of Certainty (Yaqeen): Certainty can not be removed by doubt

3. The principle of Injury/Harm (Dharar): Injury should be relieved; An individual should not

harm others or be harmed by others- An injury is not relieved by inflicting or causing a

harm of the same degree- Prevention of harm has priority over pursuit of a

benefit of equal worth- the lesser harm is committed

Islamic Principles & Maxims ...cont.4. The principle of Hardship )Mashaqqat(:

Difficulty calls forth ease, Necessity )Dharuraat( legalizes the prohibited

5. The principle of - Custom or precedent )Urf(: Custom is recognized as a source of law on

which legal rulings are based unless contradicted specifically by text from the main legislative sources, i.e. Koran and Sunna.

An Islamic approach to ethical analysis What are the facts )medical/scientific(? Is there a text on the issue from Koran and/or

Sunna? Which Sharia Goals are involved? Which fiqhi principles are applicable? Weighing of principles? Applying the relevant secondary sources

)matching the scripts to goals and principles( Is there a previous Fatwa on similar issue?

Summary of Islamic Analysis

1- Which Sharia goal(s) is involved?

2- Which Grand Fiqhi Principle(s) involved?

Intention Hardship Harm/Injury

Certainty Custom

3- Which Fiqhi Maxims are involved?

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Case for discussion Batoul is a 36 years old Saudi lady. She is a mother

of 2 children )8 & 10 years old(, and she is now pregnant in her 15th week of gestation with a normal and viable fetus.

Two weeks ago, she was found to have a huge ovarian mass )19 X 12 cm( found to be a cystoadenocarcinoma with features of metastasis.

She is a candidate for chemotherapy. Thus, the oncology board of the hospital recommended the termination of pregnancy. Three consultants, including her following obstetrician and an oncologist, had approved this recommendation.

Case for discussion…cont.

She did not accept to terminate the pregnancy. Accordingly, the husband was approached, he approved and signed the consent on her behalf.

Batoul felt terribly upset from what happened, and refused to start the chemotherapy. The case was submitted to the ethics committee of the hospital in which you are a member.

You were delegated by the ethics committee to resolve the case.

Discussion questions: What are the ethical issues involved in this

case? Describe in details the steps you will take,

including what are the information that you will collect, who you will meet, what are the questions that you may want to ask, what are the factors (medical, ethical, religious, legal, etc.) that you will consider as you recommend a decision.

Describe briefly the modality that you will suggest to implement and follow-up the recommendation that you will come up with.

Thank YouQUESTIONS AND ANSWERS

Download more lectures from: https://sites.google.com/site/medicalethicscourse/More Resources:http://med-ethics.com/ http://omarkasule.tripod.com/http://www.islamset.com/ethics/index.html