Methods of ethical analysis in clinical care, presented in a training for the members of the clinical ethics committee at (KAAUH) in Nov. 2021)

1. METHODS OF
ETHICAL
ANALYSIS IN
CLINICAL CARE
GHAIATH HUSSEIN, MBBS, MHSC, PHD
ASSISTANT PROFESSOR IN MEDICAL ETHICS &
LAW
TRINITY COLLEGE DUBLIN
This Photo by Unknown Author is licensed under CC BY

2. OUTLINE
Step-wise approach to ethical issue in clinical care
Theory-based ethical analysis
Principle-based ethical analysis
5 + 5 approach (an Islamic approach to ethical analysis)

3. TO TERMINATE OR NOT TO TERMINATE?
 Batoul is a 36-year-old Saudi lady. She is the mother of two children aged 8 and 10,
and is now pregnant in her 15th week of gestation with a normal and viable fetus.
Two weeks ago, a huge ovarian mass (19 × 12 cm) was discovered, and was found
to be a cystoadenocarcinoma with features of metastasis.
 Since the patient is a candidate for chemotherapy, the oncology board of the hospital
recommended the termination of pregnancy. Three consultants, including her
following obstetrician and an oncologist, approved this recommendation. However,
the patient did not accept that the pregnancy would have to be terminated.
Accordingly, the husband was approached; he approved and signed the consent on
her behalf.
 Batoul felt terribly upset about what had happened, and refused to start the
chemotherapy. The case was submitted to the ethics committee of the hospital.

4. THE THREE BASIC QUESTIONS BIOETHICS IS TRYING TO ANSWER
What?
What we
should do?
Why?
Why we
should it
(and not
something
How?
How to apply the
ethical decision?

5. HOW TO APPROACH AN ETHICAL ISSUE?

6. OVERVIEW OF ETHICAL STANDARDS (MORAL REFERENCE)
Secular
Most western philosophies
• Deontology
• Utilitarianism
• Virtue ethics
• Social contracts
• Feminism
Principlis
m
Autonomy
Beneficence
Non-maleficence
Justice
Religious
Christian ethics
Jewish ethics
Islamic ethics

7. OVERVIEW OF THE MAIN ETHICAL THEORIES
Theory Focus Key Philosophers Examples in
practice
Virtue ethics Moral character Aristotle, oriental
& religious ethics
Altruism,
dedication, patients
first
Deontology Rules and duties Immanuel Kant Duty of care
Consequentialism Consequences Bentham, JS Mill Public health
(vaccinations)
Contractarianism Legitimacy of
authority &
norms
JJ Rousseau, Hume Health laws &
policies

8. PRINCIPLE-BASED APPROACH

Principle Meaning/focus Applications in clinical care
Autonomy Respect human dignity; humans are
treated as ends not means to an end
Informed consent; protective measures in
clinical research
Beneficence Duty to do good Act in patient’s best interests; EBHC
Non-
maleficence
Duty not to harm; from Hippocrates‟ oath
(“First, do no harm” or “Primum non
nocere”
Principle of double effect (cannot
intentionally desire to cause harm in order to
do good)
Justice Prescribe actions that are fair to those
involved; duty to treat all fairly,
distributing the risks and benefits
equally.
Patients in similar situations
should be offered similar care unless
extenuating circumstances are involved,
such as for emergency cases.

9. FROM THEORY TO
APPLICATION
IN GROUPS OF 3-4 ANALYZE BATOUL’S CASE
USING A PRINCIPLES-BASED APPROACH
 WHAT ARE THE RELEVANT PRINCIPLES?
 HOW DO THEY APPLY TO THE CASE?

10. THE ‘5+5’
APPROACH TO
ETHICAL
ANALYSIS
AN ISLAMIC
APPROACH
BASED ON
HIGHER GOALS
OF SHARI’A &
MAJOR FIQHI
PRINCIPLES

11. THE FIRST 5: HIGHER GOALS OF ISLAMIC LAW
Preservation of life/body/soul
• Seeking medical advice & remedy; disease prevention
Preservation of faith/religion
• Enable patients to perform their rituals; relating spiritual care to Islamic teachings and beliefs
Preservation of mind/intellect
• Forbidding alcohol and drugs
Preservation of progeny/lineage
• Reproductive health within conventional family structure
Preservation of wealth/money
• Rational allocation of resources

12. THE SECOND 5: THE
MAJOR FIQHI PRINCIPLES
AND THEIR SUBPRINCIPLES
 Principle of Intention
 Acts are judged by
intentions
 Principle of Harm
 Relieve harm; Don’t inflict
harm
 Principle of Certainty
 Certainty cannot be
overruled by doubt
 Principle of Hardship
 Hardship brings forth ease
 Principle of Customs
 Customs are acknowledged;
or precedent has legal force

13. FIQHI PRINCIPLES
AND A SUMMARY
OF THEIR MAIN
SUB-PRINCIPLES
I. The Principle of Intention (Qaidat Al Niyyah)
Deeds are judged by intentions
What matters in contracts is the intention and not the letter of the law
Means are judged as the ends
II. The Principle of Certainty (Qaidat Al Yaqeen)
Certainty is not removed by doubt, and what is not confirmed/certain
cannot be confirmed by doubt
The rule is that people are innocent (i.e. not liable); the norm (of
Shari‘ah) is that of non-liability; the rule is freedom from accountability
What is proven by evidence is valid until denied by contrary evidence
(of same or better strength)
The rule in deeds is permission; the basic principle (status) is
permissibility
The rule in violating the five goals (of Sharia) is the restriction
The norm is that the status quo remains as it was before unless it is
proven to have changed.
Certainty is not removed (invalidated) by doubt
Existing assertions should continue in force; the ongoing (practice)
should be left as is

14. FIQHI PRINCIPLES
AND A SUMMARY
OF THEIR MAIN
SUB-PRINCIPLES
III. The Principle of Injury (Qaidat Al Dharar)
Avoiding harm takes precedence over bringing good.
Harm must be removed; An individual should not harm others or be harmed by others
Harm is prevented as much as possible
Harm cannot be removed with similar harm; A greater harm can be removed by a
lesser harm
A specific (personal) harm is accepted towards a general harm
Among evils, the lesser harm is committed
IV. Principle of Hardship (Qaidat Al Mashaqaat)
Difficulty calls forth ease; Hardship begets facility
Refer to alternatives when the required is difficult (beyond the person’s ability)
Necessity legalizes the prohibited, or “Necessity makes the unlawful lawful”
Necessities are judged by the magnitude
Law is eased in restrictive situations and restrictive in lax situations
V. The Principle of Custom or Precedent (Qaidat Al Urf)
Customs (precedents) are recognized unless contradicted specifically by text
Only the known customs, not the rare ones, are recognized; Transient customs are not
recognized
A matter established by custom is like a matter established by a legal text;
What is objectionable by custom is like what is legally objectionable

15. FROM THEORY TO
APPLICATION
IN GROUPS OF 3-4 ANALYZE BATOUL’S CASE
USING A 5+5 APPROACH
 WHAT ARE THE RELEVANT PRINCIPLES
(AND SUB-PRINCIPLES)?
 HOW DO THEY APPLY TO THE CASE?

16. TOOLS TO HELP
IN ETHICAL
ANALYSIS
CASES approach
The ‘4 boxes’
model

17. CASES
APPROACH
CLARIFY THE
CONSULTATION
REQUEST
ASSEMBLE THE
RELEVANT
INFORMATION
SYNTHESIZE THE
THE
INFORMATION
EXPLAIN THE
SYNTHESIS
SUPPORT THE
CONSULTATION
PROCESS

18. CLARIFY
CLARIFY the Consultation
Request
• Characterize the
type of consultation
request
• Obtain preliminary
information from
the requester
• Establish realistic
expectations about
the consultation
process
• Formulate the ethics
question
Assemble
Assemble the Relevant
information
• Consider the types
of information
needed
Identify the
appropriate sources
of information
• Gather information
systematically from
each source
• Summarize the
information and the
ethics question
Synthesize
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
Explain the Synthesis
• Communicate the
synthesis to key
participant
• Provide additional
resources
• Document the
consultation in
the health record
• Document the
consultation
Support
Support the consultation
Process
• Follow up with
participant
• Evaluate the
consultation
• Adjust the
consultation
process
• Identify
underlying
systems issues
CASES APPROACH TO ETHICAL CONSULTATIONS

19. MEDICAL
INDICATIONS
PATIENT AND FAMILY
PREFERENCE
CONTEXUAL
FEATURES
QUALITY OF LIFE
THE FOUR BOX MODEL

20. 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

21. 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?
 In What 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?

22. BOX 2: PREFERENCES OF PATIENTS
 The choices that persons make when they are faced with decisions about their
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.

23. 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
 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?

24. 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.

25. YOUR CASES…
SHARE ANY OF YOUR CASES TO
APPLY THE APPROACHES ON
THEM