Lecture 16 introduction to clinical ethics consultations-resolution(14.12.2016)

Introduction to clinical ethics & Clinical Ethics Consultation

(FMC, 14.12.16)

Dr Ghaiath Hussein, MBBS, MHSc. (Bioethics)

Outline How to resolve an ethical issue in

clinical practice? Tools for ethical analysis and decision

making Islamic approach to ethical decision

making

Do you remember?

He Killed Her!!

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 principlesFacts: 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)

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).

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

How to approach an ethical issue in clinical practice?

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

How to approach an ethical issue?

Set of ethical

standards

Proper case

analysis

Modality of

decision making

Follow-up of the

decision

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 (Abrahami

c)

Jewish ethics

Christian ethics

Islamic ethics

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?)

Who (& what) affects ethical decision making?

Context (country/region)

Regulations

Laws

Hospital

Policies

Guidelines

Admin. & financial

PatientFamily Clinicians

Tools & frameworks for ethical analysis

The Four Boxes ModelMedical Indications: 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?

Patient Preferences: 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?

Quality of Life: 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?"

Contextual Features: 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

Box 1: Medical IndicationsMedical 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’dRelevant 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

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]?

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

CLEO ApproachLegal: Clinical:Legally 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: 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

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

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

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

What is Islamic Bioethics?

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 )

Ethics in Islam… not a separate entity!

Law

Ethics

Religious Practice

Economy

Social Relations

Sources of Islamic Morality (& laws)

2 Main sources: Koran and Sunna

Secondary sources (Ijtihad)Unanimous agreement of Islamic jurists (Ijmaa) Acceptance by the majority of trusted scholars

(Rayul Jomhour) Measurement/Analogy (Qiyas), Remediation (Maslaha), (Istishab)

How do Muslims tell right from wrong?

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

Goals of Islamic Regulations The five purposes of Sharia are to

preserve person’s:1. Religion;2. Soul;3. Mind;4. Wealth; &5. Progeny.

All Islamic legislations came to achieve these goals.

The Major Islamic Ruling Principles

• 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

ىبر

لكةا

هيفق

العد

والق

ا

Islamic Principles & Maxims Applicable in Medicine

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

Islamic Principles & Maxims ...cont.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.

An Islamic approach to ethical analysis 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?

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?

د ص

قام

يعشر

الة

د اع

قوال

ة هي

فقال

ىبر

لكا

اعقو

الد

عيفر

الة

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(

Good to do

‘Mustahab

’

Should do

‘Wajib’Must do ‘Fardh’

Should not do

‘Makrouh

’

Must not do ‘Haram’

Maj

or S

ins

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.

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.

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.

Thank YouQUESTIONS AND ANSWERS

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