A lecture on clinical ethics consultations delivered to Alfarabi Medical College undergraduate medical students on 14.12.2016

1. Dr Ghaiath Hussein, MBBS, MHSc. (Bioethics)

2. Outline
 How to resolve an ethical issue in
clinical practice?
 Tools for ethical analysis and decision
making
 Islamic approach to ethical decision
making

3. Do you remember?
He Killed Her!!

4. Ethical/Moral reasoning
 It is the process we need to go through to
reach a decision about an ethical issue.
 It helps us to differentiate:
 Values and ethical principles
 Facts: description of the way the world is; an
actual state of affairs (“is”)
 Values: judgment about the way things
should be (“ought”).
 Ethical principles: they are meant to guide
actions. Key values in bioethics have
corresponding (e.g., principle of respect for
autonomy)

5. 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).

6. 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

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

8. How to approach an ethical
issue?

9. 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

10. 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?)

11. Who (& what) affects ethical
decision making?

12. Tools & frameworks for ethical
analysis
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?
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?
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?"
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

13. 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?

14. 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.

15. 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

16. 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?

17. 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.

19. 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

20. 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
 Given [uncertainty or conflict about values], what
decisions or actions are ethically justifiable? or
 Given [uncertainty or conflict about values], is it
ethically justifiable to [decision or action]?

21. 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

22. 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

23. 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

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

25. CLEO Approach
Legal:Clinical:
Legally required process for treatment
decision making when a patient lacks
capacity to do so
Family 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

26. III- Modalities of resolving ethical
issues

27. 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
alternativ
es
Follow-Up
• How
decisions
are
implement
ed?
• Lessons
learned

29.  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 )

30. Ethics in Islam… not a separate
entity!
Law
Ethics
Religious
Practice
Economy
Social
Relations

31. Koran and Sunna
 Unanimous agreement of Islamic jurists (Ijmaa)
 Acceptance by the majority of trusted scholars
(Rayul Jomhour)
 Measurement/Analogy (Qiyas),
 Remediation (Maslaha), (Istishab)

32. Main
Quran: The book divided into chapters (Surat) whose verses (Ayat) were revealed by Allah to
His prophet Mohamed by the Holy Soul
Sunna: A term that includes all what the prophet Mohamed did (not); said; ordered
to do (not); or allowed/prohibited to do explicitly or implicitly
Secondary
(Ijtihad)
Ijmaa: Unanimous agreement among trusted scholars
Rayul Jomhour: Opinion of the majority of trusted scholars
Qiyas: Measurement/Analogy of something with no Fatwa on
something that already has a religious ruling on
Maslaha Morsala: Allowing an act for the sake of public Interest that no
holy text/script (nass) prohibits it
Istishab: is continuation of an existing ruling until there is evidence to
the contrary (OHK).
Sadd al dhari'at is prohibition of an act that is otherwise mubaah
because it has a high probability of leading to haram

33.  The are to
preserve person’s:
1. Religion;
2. Soul;
3. Mind;
4. Wealth; &
5. Progeny.
All Islamic legislations came to achieve
these goals.

34. • Each action is judged by the intention behind it
The principle of Intention (Qasd):
• Certainty can not be removed by doubt
The principle of Certainty (Yaqeen):
• Injury should be relieved
The principle of Injury/Harm (Dharar):
• Difficulty calls forth ease
The principle of Hardship (Mashaqqat):
• Custom is recognized as a source of law
The principle of Custom (Urf):
Each of the main principles has a set of sub-principles

35. 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

36. 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.

37.  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?

38. Summary of Islamic
Analysis
1- Which Sharia goal(s) is involved?
Religion Soul Mind Money Progeny
2- Which Grand Fiqhi Principle(s) involved?
Intention Hardship Harm/Injury Certainty Custom
3- Which Fiqhi Maxims are involved?

39. Scale of Permissibility of
Muslim Acts
Fardh
Fardh Ain: Individual Obligation to do an act, e.g each & every Muslim should
pray 5 times/day
Fardh Kifaya: Collective obligation, if done by some won’t commit others, e.g. to learn
medicine
Permissible ‘Mubah’
(free to do or not)
MajorSins

40. 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.

41. 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.

42. 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.

43. 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