How to approach a

moral dilemma in clinical practice?

(FMC , 26.02.2017)

Dr Ghaiath Hussein, MBBS, MHSc. (Bioethics)

How to resolve an ethical issue in clinical practice?Tools for ethical analysis and ethical recommendationsIslamic approach to ethical analysis and decision making

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 13th week of gestation with a normal and viable fetus طبيعية حالة في .جنين

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 ألن .chemotherapyمرشحةThus, the oncology board األورام of theقسمhospital recommended أوصىthe 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 amid

fear of being an illegal (haram) act. Accordingly, the husband was approached, he approved and signed the consent on her behalf عنها بالنيابة الموافقة . وقع

Batoul felt terribly upset from what happened, and refused to start the chemotherapy. The case was submitted الحالة رفع لجنة to the ethics committeeتم.of the hospital in which you are a memberاألخالقيات

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

Use one of the case analysis tools and the Islamic approach to analyse the case and come with conclusions

Do you remember?

He Killed Her!!

○ 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).

Who (& what) affects ethical decision making?

Context (country/region)

Regulations

Laws

Hospital

Policies

Guidelines

Admin. & financial

PatientFamily Clinicians

How to approach an ethical issue?

Moral reference (philosophy,

religion)Proper case

analysisModality of

decision makingFollow-up of the recommendatio

n

I- Set of Ethical standards (Moral references) المرجعيات من أمثلة Secularاألخالقيةphilosophie

sMost western philosophies• Utilitarianism• Deontology• Virtue Ethics• Principlism (4

principles)

Oriental ‘Religions/

philosophies

Buddhism

Confucian ethics

Daoist ethics

Hindu ethics

Religious (Abrahamic)

Jewish ethics

Christian ethics

Islamic ethics

II- Tools for Ethical Analysis

Why do we need tools for ethical analysis? لماذااألخالقي للتحليل أدوات نحتاج

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? كيفاألخالقي التحليل أدوات تساعدنا أن يمكن

Tools that helps us have information about all those involved in the decision

Who is involved in ethical decision? (what do you think?)

Tools & frameworks for ethical analysis

The Four Boxes Model األربعة الصناديق نموذجMedical Indications: المعلومات الطبية- Simple medical facts- age, sex, current condition, treatment

options- Avoid vague or subjective terms like ‘hard’,

‘hopeless’, ‘advanced’- Use clear and specific terms e.g., Cancer of

X, in stage Y

Patient Preferences: يريد ماذاالمريضAddress 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: الحياة كفاءةالمتوقعةOverall assessment of the patient’s prognosis with each of the treatment options;What are the advantages and disadvantages of each treatment option?

تتوفر أن يمكن حياة نوعية أفضل هي ماللمريض؟

Contextual Features: العوامل المحيطةSocial, legal, economic, and institutional circumstances in the case that can: influence the decision be influenced by the decision

) الشرعية ) والقانونية االجتماعية الجوانبسياسات ) تسمح هل والمؤسسية والمالية،

) المقترح؟ بالعالج المستشفى

CLEO ApproachLegal: القانونية الجوانب Clinical: الطبية الجوانبLegally 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:المؤسسية Ethical: األخالقية الجوانبAny 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 األخالقية اللجان دور

Collect information• Medical• Non-

medical

Meet involved parties• Doctors• Nurses• Patient

(& family)

Ethical Analysis• Weighing

collected info. vs. ethical principles (& laws)

Decision Making• Single

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

اتخاذ وليس بتوصية التوجيه هو األخالقية اللجان دورالطبي الفريق عن بالنيابة القرارات

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

للتحليل اإلسالمية المقاربةاألخالقي

An Islamic approach to ethical analysis إسالمية مقاربة

األخالقي للتحليل What are the facts (medical/scientific)? الحقائق هي ما

والطبية العلمية Is there a text on the issue from Koran and/or Sunna?

المسألة؟ في واضح نص السنة أو القرآن في هل Which Sharia Goals are involved? الشريعة مقاصد هي ما

الصلة؟ ذات Which fiqhi principles are applicable? القواعد من أي

الحالة؟ في تطبيقه يمكن الفقهية Weighing of goals & principles? والقواعد المقاصد موازنة Is there a previous Fatwa on similar issue? ذات الفتاوى

الصلة

Summary of Islamic Analysis

ال -1 حفظ عالقة؟ له الشريعة مقاصد من ...أي

النف الدينس العقل المال النسل

تطبيقه؟ -2 يمكن الفقهية القواعد من أي

القصد-النية المشقة الضرر اليقين العرف

تطبيقه؟ -3 يمكن الفرعية الفقهية القواعد من أي

د ص

قام

يعشر

الة

د اع

قوال

ة هي

فقال

ىبر

لكا

اعقو

الد

عيفر

الة

Back to the 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 13th week of gestation with a normal and viable fetus طبيعية حالة في .جنين

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 ألن .chemotherapyمرشحةThus, the oncology board األورام of theقسمhospital recommended أوصىthe 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 amid

fear of being an illegal (haram) act. Accordingly, the husband was approached, he approved and signed the consent on her behalf عنها بالنيابة الموافقة . وقع

Batoul felt terribly upset from what happened, and refused to start the chemotherapy. The case was submitted الحالة رفع لجنة to the ethics committeeتم.of the hospital in which you are a memberاألخالقيات

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

Use one of the case analysis tools and the Islamic approach to analyse the case and come with conclusions

Questions for Discussion : 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.

Example of analysis The 4-boxes model

Medical Indications: المعلومات الطبية- Saudi woman, 36, has children (alive and

well),- Ovarian cancer with features of metasis

Patient Preferences: يريد ماذاالمريض• The patient refused the abortion• She believes abortion is haram (other

possible causes, see box 4)• She feels upset from ignoring her and

having her husband’s consent instead

Quality of Life: الحياة كفاءةالمتوقعةpt’s prognosis with each of the treatment options;

Contextual Features: العوامل المحيطةSocial, legal, economic, and institutional circumstances in the case that can: influence the decision be influenced by the decision

) الشرعية ) والقانونية االجتماعية الجوانبسياسات ) تسمح هل والمؤسسية والمالية،

) المقترح؟ بالعالج المستشفىWill be discussed within the Islamic

Approach االسالمية المقاربة مع الحقا تناقش

Option + -ve

Chemo + abortion

Stop/delay? Metasais

Loss of fetus

Chemo + no abortion

Stop/delay? Metasis

Congenital?

Example of analysis Example for listing of the ethical issues?

Ethical issues Points of ethical consideration

Abortion Is it ethical to terminate pregnancy at this stage?Does the fetus have any rights (needs protection) at this stage?If it has rights; what if its rights conflict with the mother’s right to live, survive, keep her health?The Islamic legality of termination of pregnancy in this condition

Refusal of treatment Does she have the right to refuse? When?…

Example of using philosophical schools By using Principle-based ethics (principlism)

Ethical principle

Points of ethical consideration

Autonomy Does the woman have the right to decide on her own?

Does she has the capacity to decide?

Does the husband should/must have a role in the decision?

Beneficence … good for… pt.’s best interests المريض مصلحةNon-maleficence

…avoid doing harm for…

Justice Not directly relevant ؟

Example of using the Islamic Approach By using Goals of Shariya ( الشريعة (مقاصدShariya Goal المقصد

Relevance to the case

Preservation of soul ( النفس (حفظ

The soul of the mother could be endangered if not treated soon يجب األم نفس على للحفاظ

العالج في اإلسراعDoes the fetus has a soul that needs protection?

الحفظ تستوجب نفس للجنين هلWhat is there is conflict between the two souls ماذا

النفسين؟ حفظ بين التعارض حدث لوPreservation of faith ( الدين (حفظ

…

Preservation of progeny ( النسل (حفظ

…

Example of using the Islamic Approach By using Fiqhi Maxims ( الفقهية (القواعدFiqhi Maxim القاعدة Relevance to the case

Intention ( النية (القصد What is the intention of considering abortion? اإلجهاض؟ من النية هي ما

Principle of Harm (الضرر)Principle of Hardship (المشقة)Principle of Custom ( محكمة- العادة (العsرف

…

…

Steps to be taken after analysis Seek answers to the questions raised in

the boxes Formulate a proper argument (why do

you accept or reject a certain treatment option?)

Make a recommendation (or recommendations), e.g. It is ethically and Islamically acceptable to

terminate this pregnancy based on the resources and the arguments discussed above

Steps to be taken after analysis

Make a plan for implementation, e.g. Meet the patient (why?)Meet the husband (why?)Meet the treating doctors/teamWhat needs to be done if the pt. accepts

the recommendation? What needs to be done if the pt. refuses

the recommendation?

Thank You

QUESTIONS AND ANSWERS

Download more lectures from: http://ghaiathme.wix.com/mep-couse More Resources:http://med-ethics.com/ http://omarkasule.tripod.com/http://www.islamset.com/ethics/index.html