Seminar 1- Example of ethical case analysis (27.02.2017)

Dr Ghaiath Hussein, MBBS, MHSc. (Bioethics)
How to resolve an ethical issue in clinical practice?
Tools for ethical analysis and ethical recommendations
Islamic 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 ‫مرشحة‬ chemotherapy.
Thus, the oncology board ‫األورام‬ ‫قسم‬ of the
hospital recommended ‫أوصى‬ 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 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 ‫تم‬ to the ethics committee ‫لجنة‬
‫األخالقيات‬of the hospital in which you are a member.
 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?

How to approach an ethical
issue?

I- Set of Ethical standards
(Moral references) ‫من‬ ‫أمثلة‬
‫األخالقية‬ ‫المرجعيات‬
Secular
philosophies
Most 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? ‫لماذا‬
‫األخالقي‬ ‫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? ‫كيف‬
‫األخالقي‬ ‫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 ‫نموذج‬
‫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
‫يريد‬ ‫ماذا‬
‫المريض‬
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?
‫كفاءة‬‫الحياة‬
‫المتوقعة‬
Overall 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 ‫ما‬
‫للمريض؟‬
‫العوامل‬
‫المحيطة‬
Social, legal, economic, and institutional
circumstances in the case that can:
influence the decision
be influenced by the decision
‫والقانونية‬ ‫االجتماعية‬ ‫الجوانب‬(‫الشرعية‬)
‫والمؤسسية‬ ،‫والمالية‬(‫تسمح‬ ‫هل‬‫سياسات‬
‫المقترح؟‬ ‫بالعالج‬ ‫المستشفى‬)

CLEO Approach
Legal:‫القانونية‬ ‫الجوانب‬Clinical:‫الطبية‬ ‫الجوانب‬
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:‫المؤسسية‬Ethical:‫األخالقية‬ ‫الجوانب‬
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

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

Seminar 1- Example of ethical case analysis (27.02.2017)

 What are the facts (medical/scientific)? ‫هي‬ ‫ما‬
‫والطبية‬ ‫العلمية‬ ‫الحقائق‬
 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? ‫مقاصد‬ ‫هي‬ ‫ما‬
‫الصلة؟‬ ‫ذات‬ ‫الشريعة‬
 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? ‫الفتاوى‬
‫الصلة‬ ‫ذات‬

Summary of Islamic
Analysis
1-‫ال‬ ‫حفظ‬ ‫عالقة؟‬ ‫له‬ ‫الشريعة‬ ‫مقاصد‬ ‫من‬ ‫أي‬...
‫الدين‬ ‫النفس‬ ‫العقل‬ ‫المال‬ ‫النسل‬
2-‫تطبيقه؟‬ ‫يمكن‬ ‫الفقهية‬ ‫القواعد‬ ‫من‬ ‫أي‬
‫القصد‬-
‫النية‬
‫المشقة‬ ‫الضرر‬ ‫اليقين‬ ‫العرف‬
3-‫تطبيقه؟‬ ‫يمكن‬ ‫الفرعية‬ ‫الفقهية‬ ‫القواعد‬ ‫من‬ ‫أي‬

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 ‫مرشحة‬ chemotherapy.
Thus, the oncology board ‫األورام‬ ‫قسم‬ of the
hospital recommended ‫أوصى‬ the termination of
pregnancy. Three consultants, including her
following obstetrician and an oncologist, had
approved this recommendation.

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
‫المعلومات‬
‫الطبية‬
- Saudi woman, 36, has children (alive and
well),
- Ovarian cancer with features of metasis
‫يريد‬ ‫ماذا‬
‫المريض‬
• 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
‫كفاءة‬‫الحياة‬
‫المتوقعة‬
pt’s prognosis with each of the treatment
options;
‫العوامل‬
‫المحيطة‬
Social, legal, economic, and institutional
circumstances in the case that can:
influence the decision
be influenced by the decision
‫والقانونية‬ ‫االجتماعية‬ ‫الجوانب‬(‫الشرعية‬)
‫والمؤسسية‬ ،‫والمالية‬(‫تسمح‬ ‫هل‬‫سياسات‬
‫المقترح؟‬ ‫بالعالج‬ ‫المستشفى‬)
Will be discussed within the Islamic
Approach‫المقاربة‬ ‫مع‬ ‫الحقا‬ ‫تناقش‬
‫االسالمية‬
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 ‫مصلحة‬
Non-
maleficence
…avoid doing harm for…
Justice Not directly relevant ‫؟‬

Example of using the
Islamic Approach
 By using Goals of Shariya (‫الشريعة‬ ‫)مقاصد‬
Shariya Goal
‫المقصد‬
Relevance to the case
Preservation of soul
(‫النفس‬ ‫)حفظ‬
The soul of the mother could be endangered if not
treated soon ‫اإلسراع‬ ‫يجب‬ ‫األم‬ ‫نفس‬ ‫على‬ ‫للحفاظ‬
‫العالج‬ ‫في‬
Does the fetus has a soul that needs protection?
‫الحفظ‬ ‫تستوجب‬ ‫نفس‬ ‫للجنين‬ ‫هل‬
What is there is conflict between the two
souls‫النفسين؟‬ ‫حفظ‬ ‫بين‬ ‫التعارض‬ ‫حدث‬ ‫لو‬ ‫ماذا‬
Preservation of faith
(‫الدين‬ ‫)حفظ‬
…
Preservation of
progeny (‫النسل‬ ‫)حفظ‬
…

Example of using the
Islamic Approach
 By using Fiqhi Maxims (‫الفقهية‬ ‫)القواعد‬
Fiqhi 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
( ‫العرف‬-‫محكمة‬ ‫العادة‬ )
…
…

 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

 Make a plan for implementation, e.g.
 Meet the patient (why?)
 Meet the husband (why?)
 Meet the treating doctors/team
 What needs to be done if the pt. accepts
the recommendation?
 What needs to be done if the pt. refuses
the recommendation?

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

Seminar 1- Example of ethical case analysis (27.02.2017)

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Seminar 1- Example of ethical case analysis (27.02.2017)