Introduction to Medical Ethics

Overview; Definitions &Concepts of ethics & bioethics; Western approach to ethics; Islamic

approach; Tools & Frameworks

Tabuk FOM, medical students (Feb. 28, 2011)

Dr. Ghaiath M. A. HusseinAsst. Prof., Dept. of Medical EthicsKing Fahad Medical City – Faculty of MedicineKing Saud Bin Abdul-Aziz University for Health SciencesEmail: ghaiathme@gmail.comOffice: 01-2889999 Ext.7588, Mob.: 0566511653

What we will try to learn today?• Section I: Definitions & Concepts

o What is ethics?o What is bioethics?o What is medical ethics?o Development of medical ethics

• Western approaches to ethics• Islamic approaches to ethics• Tools and Frameworks to resolve ethical issues in

healthcare

Section I: Overviewof ethics & bioethics

Which one would you drink?

Less embarrassing choices…

• I need to pass the exam..cheat or not?• I need the organs of this dying patient... Let him

die fast?• I need the money of this Pharma company...

Shall I change the results of my research on their drug?

Levels of moral response

• The expressive level (unanalyzed expressions or feeling that, by themselves, don’t provide reasons or justification)

• The pre-reflective level (justification via law, religious tenets, social values, codes of ethics, etc.; accepted uncritically)

• The reflective level (reasoned ethical argument/defense based on ethical principles, rules, virtues, values to which we consciously subscribe; justification provided)

Thomas J and Waluchow W, 1998

Ethics

Ghaiath

• explicit critical reflection on moral beliefs, practices and problems

• philosophical study of morality

This is at the reflective level…

(contrast with “descriptive ethics”)

What do you think?

The Fact-Value Distinction

Ghaiath

• Fact: description of the way the world is; an actual state of affairs (“is”)

• Value: judgment about the way things should be (“ought”)o no “ought” can be deduced from an “is”

Ethical reasoning

Values and ethical principles• Value = something a person/community has

identified as important (e.g., autonomy/self-determination)

• Values by themselves don't tell us what we ought to do

• Key values in bioethics have corresponding ethical principles meant to guide action (e.g., principle of respect for autonomy)

Section II: Definitions & ConceptsWhat is ethics?What are the branches of ethics?What is bioethics?What is medical/clinical ethics?What is an ethical issue?

What is ethics?

• A system of moral principles or standards governing conduct.

• a system of principles by which human actions and proposals may be judged good or bad, right or wrong;

• A set of rules or a standard governing the conduct of a particular class of human action or profession;

• Any set of moral principles or values recognized by a particular religion, belief or philosophy;

• The principles of right conduct of an individual. (UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)

What is bioethics?• It is derived from Greek bio- life and ethicos moral. • The science/art that aims at identification, analysis,

and resolution of the ethical issues in almost any field that is related to human life and health.

• Give example of an ethical issue/problem you faced or witnessed, mentioning the following:o What was the situation?o What was your feeling towards it?o What did you do?o Do you think you did the best thing? why?o What you think you need to know more to be able to

handle similar situations in the future?

Questions answered by Bioethics

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

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

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

What is clinical/medical ethics?

• Clinical ethics is a practical discipline that provides a structured approach to assist physicians in identifying, analyzing and resolving ethical issues in clinical medicine.

• The practice of good clinical medicine requires some working knowledge about ethical issues such as informed consent, truth-telling, confidentiality, end-of-life care, pain relief, and patient rights

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

• There is an ethical issue when:o …we encounter conflicting values, beliefs, goals, or

responsibilitieso …we are concerned that persons or their rights are

not being respectedo …we are concerned about fairness and justiceo …we are unsure what we should do or why we should

do it, morally speaking

Domains of Ethics in Health Care

• Shared decision making with patients• Ethical practices in end-of-life care • Patient privacy and confidentiality• Professionalism in patient care • Ethical practices in resource allocation • Ethical practices in management • Ethical practices in research • Ethical practices in the everyday workplace

What else could it be?• Miscommunication stands for 70-80% of problems

in healthcareo E.g. Doctors don’t know to tell medical info

• Management issueo “when shall I get promoted? All my colleagues did. This

is not ethical!”• Financial issue

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

Section III: Western approach to ethics and ethical reasoning

How right and wrong are distinguished?

Ethical justificationIn ethics, the support/reasons ultimately come from moral values, principles and theories:

• “I think we should do X because A and B are really important values”

• “Y wouldn’t be appropriate because it violates principles A and B”

• “X would be the right thing to do because of our obligation to do A”

Jonathan Breslin, 2006

Ethical theories and principles as lenses

“Doing bioethics well requires appeal to the insights provided by multiple theories…the metaphor of lenses provides a more accurate and a more productive understanding of the role of theories in bioethics…”

(Sherwin, The Politics of Women’s Health, 205).

Why do we need to know about western philosophies?

• A Doctor is an international currency (you may be practicing anywhere)

• Bridging the knowledge & cultural gaps• Western literature & experience are steps ahead

of ours• Ethical concepts & tools are quite universal• No self-development with knowing others• To call for Allah on guidance تعالى الله إلى الدعوة

General characteristics of western philosophies

• Secularism: people are free to practice their religion but no particular religious guidance to right & wrong

• Individualism:It’s all about I, me and myself!o The individual and nuclear family structure are the societal

builidng block.o The indivdual’s interest is what should come first (vs. more

collective extended family ethics in our region)

• 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

• Principlism: o Autonomy: respect humans'

ability to choose,o Beneficence: Do Good for

others,o Nonmaleficence (Do No Harm),

& o Justice

Other philosophies...

• Taxonomy of ethics

Other philosophies Abrahamic Philosophies

Oriental philosophies

African, Asian, etc. Islamic Buddhist

Human Rights Jewish Conficious

Catholic Indian

Protestant Persian

Jehovah Witnesses

Section IV:Islamic approach to ethical analysis and decision making

Ethics in Islam… not a separate entity!

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

that they should worship Me (Alone). ِج�َّن�� ال �ْق�ُت� ل َخ� َو�َم�االذاريات ) �د�َوِن� �ع�ُب �َي ل �ال إ �َس� �ْن (56َو�اِإل

• Worship in Islam includes:o To follow the orders of Allah and His Prophet Mohamed

(PBUH)o “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)

• It is the methodology of o defining, analysing and resolving the ethical issues

that arise in healthcare practice, or research; o based on the Islamic moral and legislative sources

(Koran, Sunna & Ijtihad); ando aims at achieving the goals of Islamic morality (i.e.

preservation of human’s religion, soul, mind, wealth & progeny )

• Clear and fixed sources• Clear goals of morality (Maqasid Alshariya)• Its moral style endorses values of:

o Bringing hope ( تنفرَوا َوال (بشرَواo Softness ( لَينا قوال له (فْقوالo Kindness ( زاْنه اال شيء في الرفق كاِن (َماo Respect for vulnerable ( بالْقوارير َمَّن ) (رفْقا َمنا لَيَس

صغَيرْنا َويرحم كُبَيرْنا يوقر (لم

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): o Injury should be relieved; An individual should not

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

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

benefit of equal wortho - the lesser harm is committed

4. The principle of Hardship (Mashaqqat): Difficulty calls forth ease, Necessity (Dharuraat) legalizes the prohibited5. 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.

Section V: Tools & Frameworks

Box 1: Medical Indications• Medical Indications are those facts about the

patient's physiological or psychological condition that indicate which forms of diagnostic, therapeutic, or educational interventions are appropriate.

• Is the Problem Acute? Chronic? Critical? Reversible? Emergent? Terminal?

• What Are the Goals of Treatment?• InWhat Circumstances Are Medical Treatments Not

Indicated?• What Are the Probabilities of Success of Various

Treatment Options?• How Can This Patient Be Benefited by Medical and

Nursing Care, and How Can Harm Be Avoided?

Box 2: preferences of patients

• The choices that persons make when they are faced with decisions about thier health and medical treatment.

• Ethical issues included:1)respect for the autonomy of the patient; (2) the legal, clinical, and psychological significance of patient preferences; (3) informed consent; (4) decisional capacity; (5) truth telling; (6) cultural and religious beliefs; (7) refusal of treatment; (8) advance directives; (9) surrogate decisions; (10) the challenging patient; and (11) alternative medicine.

Box 3: Quality of life• refers to that degree of satisfaction that people

experience and value about their lives as a whole, and in its particular aspects, such as physical health.

• The main ethical principles involved are: Beneficence & Autonomy

Box 3: Quality of life...cont’d• Relevant ethical questions• What are the prospects, with or without treatment, for a

return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?

• Are there biases that might prejudice the provider's evaluation of the patient's quality of life?

• What ethical issues arise concerning improving or enhancing a patient's quality of life?

• Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?

• What are the plans and rationale to forgo life-sustaining treatment?

Box 4: Contextual Features• It addresses the ways in which professional,

familial, religious, financial, legal, and institutional factors influence clinical decisions

• Involved ethical principles are: beneficence, respect for autonomy and justice

• Justice refers to those moral and social theories that attempt to distribute the benefits and burdens of a social system in a fair and equitable way among all participants in the system.

CASES Approach

The CASES Approach

• The CASES approach was developed by the National Center for Ethics in Health Care

• Clarify the facts & requirements

• Assemble the relevant information

• Synthesize the information

• Explain the synthesis

• Support the ethical decision making process

Clarify the facts & requirements

• Characterize the type of problem• Obtain information about the case• Establish the goal from the ethical

analysis (consultation process)• Formulate the ethics question

o Given [uncertainty or conflict about values], what decisions or actions are ethically justifiable? or

o Given [uncertainty or conflict about values], is it ethically justifiable to [decision or action]?

Assemble the Relevant Information• Consider the types of information needed

(Medical facts, Patient’s preferences, QOL, Contextual features)

• Identify the appropriate sources of information• Gather information systematically from each

source• Summarize the information and the ethics

question

Synthesize the Information• Determine whether a formal meeting is needed• Engage in ethical analysis• Identify the ethically appropriate decision maker()• Facilitate moral deliberation about ethically

justifiable options

Explain the Synthesis• Communicate the synthesis to key participant• Provide additional resources• Document the consultation in the health record• Document the consultation in consultation service

records

Support the Consultation Process• Follow up with decisions taken• Evaluate the outcome of the decision• Adjust the consultation process• Identify underlying systems issues

Islamic Approach to Resolving Ethical Issues in Clinical Practice

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): o Injury should be relieved; An individual should not harm others or

be harmed by otherso An injury is not relieved by inflicting or causing a harm of the same

degreeo Prevention of harm has priority over pursuit of a benefit of equal

wortho The lesser harm is committed

• The principle of Hardship (Mashaqqat): Difficulty calls forth ease, Necessity (Dharuraat) legalizes the prohibited

• 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.

• Is there a previous Fatwa on the issue?• Is there a text on the issue from Koran and/or

Sunna, or secondary sources?• What are the medical/scientific facts?• What are the Sharia Goals involved?• What are applicable fiqhi principles?• Weighing of principles?• Applying the relevant secondary sources

(matching the scripts to goals and principles)

Cases for discussion & Group Work

The case of Dax Cowart

• Dax Cowart, was very badly burned and sustained a long, painful treatment and rehabilitation. He believed that his disabilities caused by the explosion—blindness, disfigurement, and crippling—would make his life intolerable and not worth living.

• He refused treatment and wished to die. • He personally assessed his future quality of life

as not worth living.

The case of Dax Cowart...cont’d

• Later, Dax revised his earlier assessment as he gradually overcame depression.

• He learned to appreciate mental activities, to enjoy social interaction, and to cope with his frustrations.

• He became a lecturer about his own story and an advocate for patients' rights and personal autonomy.

• He graduated from law school, passed the bar, and practiced law.

• Confronting death: Who chooses? Who decides? A dialogue between Dax Cowart and Robert Burt. Hastings Cent Rep. 1998;28(1):14–28.

Exercise

• Analysize Mr. “Dax” Case according to oGroup A: the 4 boxes modeloGroup B: CASES approachoGroup C: Islamic Approach

Thank You

To contact me:Office: (+966)-(1)-2889999 Ext. 7588 Email: ghussein@kfmc.med.sa Personal: 00966566511653 – email: ghaiathme@gmail.com More Resources:http://med-ethics.com/ http://omarkasule.tripod.com/http://www.islamset.com/ethics/index.html