Faculty of Medicine

King Abdulaziz University

MEDICAL ETHICS

Study Guide
Phase 2, MBBS 1430-1431 (2009-2010)

TABLE OF CONTENTS Topic

THE OUTCOMES OF THE UNDERGRADUATE CURRICULUM CURRICULUM MAP PHASE 2 STRUCTURE OF THE MODULE INTRODUCTION AIMS & OBJECTIVES TEACHERS CONTACTS ASSESSMENT ICONS TOPIC OUTLINES NO.
1 2 3 4 5 6 7 8 9

Page
4 5 6 6 7 7 8 9 11 12

LECTURES
Introduction to Medical Ethics Medical ethics Islamic perspective Autonomy and Consent Beneficence and Non-Malfeasance Confidentiality: Justice and Equity Intersex and sex correction Ethical Issues for Moslem patients Ethics of Medical Genetics

NO. 1 2 3 4 5 6 7 8 9 10

PRACTICAL
Trust vs. Confidentiality Justice and Resources Beginning of life issues (I) Beginning of life issues (II) Autonomy and self harm Maternal Fetal conflict Consent Conflict of interest Research and Ethics Medical Errors

Problem-Based Learning (PBL) Sessions

1 2 Cases

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OUTCOMES OF THE MEDICAL UNDERGRADUATE CURRICULUM

1) Knowledge Graduate should have sufficient knowledge and understanding of: a. The normal structure, function and development of the human body and interaction between body and mind b. The normal pregnancy and child birth, the principles of antenatal and postnatal care c. The aetiology, pathogenesis, clinical presentation, natural history and prognosis of common physical and mental disease, particular those which pose acute danger to function, life or the community. d. Common diagnostic tests and procedures, their uses, limitations and costs e. The management of common conditions including pharmacological, psychological, physical and nutritional therapy f. The principles of health education, disease prevention, rehabilitation and the care of the suffering and dying. g. The principles and ethics related to health care and the Islamic and legal responsibilities of the medical profession 2) Skills Graduate should acquire the skills of a. Take a tactful, accurate and organised medical history b. Perform a gentle and accurate physical and mental examination c. Integrate history and physical examination to reach a provisional diagnosis of differential diagnosis d. Select the most appropriate and cost effective diagnostic procedures e. Formulate a management plan f. Counsel patients and families clearly regarding diagnostic and therapeutic procedures before eliciting consent g. Perform common life-saving procedures h. Use information resources to obtain further knowledge and interpret medical evidence critically and scientifically i. Communicate clearly and considerately with other health professionals 3) Attitudes Graduate should have the attitude of a. Respect for every human being and abide by relevant Islamic ethics b. A desire to ease pain and suffering c. Willingness to work in a team with other health professionals d. Responsibility to remain a life-long learner and maintain the highest ethical and professional standards e. Referring patients to other health professional when needed f. A realization that it is not always in the interest of patients to pursue every diagnostic or therapeutic possibility

Phase 2
YOU ARE HERE

Medical Ethic

Faculty of Medicine

CURRICULUM MAP

Year 1 Phase I

Year 2

Year 3 Phase II

Year 4

Year 5

Year 6

Internship

Phase III

Now you are in the final year of Phase 2, having digested preclinical science and its relation to clinical illness and disease, you should have by now realised that medicine is a life long professional commitment. What makes a good doctor is not just clinical skills and knowledge, that he/she has to maintain for life, but also other important qualities that constitute what sometimes descried as Professionalism. These qualities, that makes good doctors binds together physicians of various nations and diverse background. In this course over a period of three weeks we shall discuss various issues related to professionalism. The first two days will be formal lectures but the teaching in the The

remaining two weeks or so depends very much on you input and interaction.

materials and subjects matter of this course are very stimulating and should trigger very interesting discussion. Quite often there is no right or wrong, however guidelines and general consensus has to be respected.

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Fourth Year Courses

Semester 1 Semester 2

Clinical Skill Module

Basic Imaging/ Laboratory Medicine Medical Ethics / Forensic Medicine Community Medicine SSM&Elective

Otorhinolaryngolo gy/ Opthalmology

STRUCTURE OF THE MODULE

TIMETABLED HOURS: TEACHING DEPARTMENTS: 9 lectures , 10 Problem solving and tutorials, two PBL

Obstetrics & gynaecology, Family Medicine, Medical Education, ICU, Medicine, Paediatrics, Anatomy, Physiology

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INTRODUCTION
Welcome to the Medical Ethics module. This is a relatively new module, yet we believe it is the most crucial module for making a good doctor. In simple term, Ethics is the basis of the professional contract between the medical profession and the society. It demands set of fundamental principles and definitive professional responsibilities. The most important principles are the dedication to serving the interest of patients, placing their interest above those of the physician, upholding patient autonomy through honest information and striving for justice in healthcare distribution. Professional responsibilities include commitment to lifelong learning and professional competence, honesty, maintaining confidentiality, appropriate relationships with patients and colleagues. However, the medical profession everywhere increasingly being challenged with the explosion of technology, changing market forces, problem of health care delivery and globalization. Hence, it is crucial for medical students to formally study the fundamental principles and responsibilities of professionalism and the challenges ahead. The lectures on the core principles of medical ethics are given over two days in the first week. In the remaining period, you are expected to further appreciate those principles and responsibilities, through interactive problem solving scenarios and case discussion sessions. We hope that you will find this course stimulating, educational as well as applied to your current and future practice as much as we believe it is.

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AIMS & OBJECTIVES

1) Knowledge: By the end of this course you should be able to: List the basic principles of Medical Ethics. Recognize the Islamic teaching being the basis of Medical Ethics Define the terminology used in bioethics whether in clinical or research situations. Review the scope of Professionalism in Medicine. Recognize the challenges to the principles of medical Ethics induced by technological development. Recognize the complexity of implementation of ethical issues in relation to human life and death, including the allocation of scarce medical resources. Review the national legal regulations and low in KSA that governs medical practice.

2) Skills: By the end of this course you should be able to: - Analyze ethical issues present in a given medical setting. - Generate various options of actions based on the analyze of those issues (Critical thinking) - Appraise and evaluate counter arguments to their own position. - Justify decisions and actions in terms of valid ethical arguments. - Demonstrate ability to communicated ethical issues with patients, their relatives and other healthcare professionals

3) Attitude: By the end of this course you should be able to: Demonstrate professional attitude in behaviour with patients and colleagues Uphold and attitude of not only scientific and technical expertise but also other moral dimensions which include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility Maintain and attitude of critical self-appraisal and commitment to lifelong education with relevant guidelines, law and emerging challenges to moral principles.

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TEACHERS CONTACTS

Name
Prof. Hassan Nasrat (Chairman of the Module) Professor M. Al Hadramy Professor Yasser Jamal Professor Omyma Abo Talib Professor Adel Mostafa Professor Tarik Jamal Professor Abdel Rahman Fahmhy Dr Z. Faysal Zaher Dr Jomanna Al Amma Jawaher Al Ahmady (Coordinator of the Module) Dr Sameera Albasry Dr Salih Damnan

Department
Obstetrics and Gynaecology Medicine Surgery Medical Education Anatomy ENT Physiology Paediatrics Genetics Family Medicine Obstetrics and Gynaecology ICU

E-mail
hnassrat@KAU.EDU.SA

Adelmostafa_2000@Yahoo.com

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ASSESSMENT
1. Formative:
This form of assessment is designed to give you feedback to help you to identify areas for improvement. It includes a set of MCQs, that address the fundamental principles that you have learned in the first week of the course. The Answers are presented and discussed immediately with you after the assessment. The results will be made available to you.

2. Summative
This type of assessment is used for judgment or decisions to be made about your performance. It serves as: a. Verification of achievement for the student satisfying requirement b. Motivation of the student to maintain or improve performance c. Certification of performance d. Grades

In this Course, your performance will be assessed according to the following :

1. Contribution and attendance 2. Assignment 3. MCQ (Mid course) 4. Final End of course MCQ (Two Hours)

20 Marks 20 Marks 20 Marks 40 Marks

Total = 100 Marks

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Exams: Written Exams will include multiple-choice questions (MCQs). It will cover material presented in lecture, readings, and discussion. All exams must be taken on the date scheduled. In case of an emergency, the coordinator must be notified. No make-up exams will be provided if you fail to notify and discuss your situation with the coordinator. Assignment paper: The purpose of the work is to provide you with the opportunity to express your self and views about some of the interesting areas of Medical Ethics e.g. justice in medical care, criteria for ethical medical trial, who own the geneetc . It should be written as an assay (average 200-400 ward). You will need to discuss

with your tutor the topic to be addressed. The coordinator of the course must approve the topic. Topics that have not been approved will not be accepted. The topics will be discussed in the third week of your course. All papers must referenced, all papers must be typed, double-spaced, have 1-inch margins.

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Icons
The following icons have been used to help you identify the various experiences you will be exposed to.

Learning objectives

Content of the lecture

Independent learning from textbooks

Independent learning from the CD-ROM. The computer cluster is in the 2nd floor of the medical library, building No. 7.

Independent learning from the Internet

Problem-Based Learning

Self- Assessment (the answer to self-assessment exercises will be discussed in tutorial sessions)

The main concepts 11

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Topic Outlines

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LECTURES
Lectures provide a framework to help the student organize her/ his study of the module. They are usually given by individuals with a special interest and/or expertise in the field. The lectures are not meant to be comprehensive, and should be supplemented by reading. Lectures will emphasize the most important points to be learned. Lectures are designed to build upon one another so that there is a continuity and progression to the material presented

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Lecture 1: Introduction to Medical Ethics

Student Notes: DEPARTMENT: Obstetrics and Gynaecology MALE TUTOR: Professor Hassan Nasrat FEMALE TUTOR: LOCATION: Auditorium .

At the end of this lecture you should be able to:

Describe what is medial ethics and why it became an important element in modern medical curriculum 2. Describe what is Special about Medicine? What Special About Medical Ethics? 3. Describe Who decide what is ethical 4. Describe how decisions on medical ethics are made 5. Describe the Fundamental Principles of Medical Ethics. 6. Describe the ethical responsibilities of physicians towards patients, colleagues, society, and him or her self 7. Describe changes in medical ethics and future challenges 1.

Physicians as professionals have ethical responsibilities towards their patients, colleagues, society, and their own selves in addition to the global human being. The principles of Medical Ethics: Justice, Beneficence, Non-Malfeasance, and autonomy.

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 1:
Student Notes: .

Islamic Scholars were the first to lay down basic ethical principles in practice of medicine. For Moslem doctors the Islamic principles are the main source of their ethical rules and regulation in medical practice

http://scfhs.org.sa (Saudi Commission for Medial Specialties) WWW.WMA.net (World Medial Association) WWW.EMRO.ORG (Islamic Medical Charter) WWW.Imana.org (Islamic Medial Association of North America) WWW.themwl.org (Islamic League) The National Bioethics site http://www.annals.org/

Try to write one paragraph on how do you see the difference between traditions and politeness in behaviour versus ethics rules and regulations. Give applied examples to each of the fours principles of Ethics in Medicine.

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Lecture 2: Medical Ethics-Islamic Perspective

Student Notes: DEPARTMENT: Medicine MALE TUTOR: Prof Mohamed Al Hadramy FEMALE TUTOR: LOCATION: Auditorium .

At the end of this lecture you should be able to:

1. Express Islamic approach to medicine and medical care givers in society. 2. Express the five goals of Islamic Shariah (i.e. protection and preservation of life, mind, private ownership, family and religion) as foundation for ethical principles. 3. Express the principles of Medical; autonomy, justice, beneficence, non-maleficence and distributive justice in relation to Islamic teaching. 4. Discuss how the views of Islam to illness influence patients and doctors approach to treatment (e.g. 1)Necessity overrides prohibition 2) Accept the lesser of the two harms 3) Public interest overrides the individual interest. 4) Harm has to be removed at every cost if possible ) 5. Explain similarities and differences between

medical ethics based on Islam and other Western Secular bioethics.

Medical Ethics are based on two main foundations Quran and the Sunna. However, in face of new medical technology, Islamic jurists together with technical experts have regular conferences at which major issues are explored and consensus is reached. In some issue there is diversity of views derived from the various school of jurisprudence (Islam is not monolithic). Islam upholds the principles of medical ethics. In Islam illness are viewed as cleansing ordeal or as trial but not punishment or curse. In general Patients are obliged to seek treatment and to avoid being fatalistic

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 2:
Student Notes: .

Islamic Medical Ethic is based on duties, obligations (e.g. to preserve life, seek treatment) and rights (of God, the community and the individual) and call for virtue (Ihsan)

Arabic books

www.islamset.com www.islamtopsites.com

Describes differences in the application of medical ethics between Muslim and non Muslim physicians

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Lecture 3: Autonomy and Consent

Student Notes: DEPARTMENT: Surgery / Medical Education MALE TUTOR: Dr A Makkay FEMALE TUTOR: Professor Omyma LOCATION: Auditorium .

At the end of this lecture you should be able to: 1. Discuss what is meant by patient autonomy, and its limitations. 2. Describe the principles and component of an informed consent 3. Recognize how the principles may varies in different types of informed consents: treatment, research volunteers and for genetic studies. 4. Outline circumstances that need special care for informed consent

Autonomy defined as the right of patients to make decisions about their treatment. The opposite is paternalism. However, patients autonomy may be restricted if there is harm to others (include fetus in utero?). However to be able to make a choice (to have autonomy) it is important to: have all the information and have the capability to process that information. Autonomy and consent for vulnerable population (e.g. children, institutionalized persons and minority) require special care and consideration.
(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 3:

In current practice of medicine patient autonomy not paternalism should be respected. An informed consent is the legal documentation of patient autonomy. A valid consent must be informed, competent, and without coercion. Those components should be respected even in case of special vulnerable groups

Try to give examples for: - Situations where informed consent may not be fully respected. - For limitations of patient autonomy.

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Lecture 4: Beneficence and Non-Malfeasance

Student Notes: DEPARTMENT: Paediatrics / Family Medicine MALE TUTOR: Dr Jameel Atta FEMALE TUTOR: Dr Jawaher Al Ahmady LOCATION: Auditorium .

At the end of this lecture you should be able to: 1. 2. 3. Define the meaning of Beneficence and Malfeasance. Recognize that doing good and preventing harm are the fundamental duties of a doctor. Discuss how beneficence is not absolute issue (i.e. doing what is in the best interest of someone may not be necessary right from another point of view) Recognize that variables such as physical, mental, social and spiritual all could influence the balance between the benefit and potential harm. Recognize the meaning of Euthanasia, withholding treatment and stopping treatment and the Ethical views for each Recognize the meaning of professional negligence and malpractice

4.

5.

6.

By nature of their duties doctors always aim to do good for patient; but they should realize the difference between doing whatever can be done versus what should be done when there is real chance of making patient better. Futile Treatment describes intervention that has minimal or no benefit. To do good however this requires the doctor to be competent and therefore up to date with current medical thinking. He must be able to demonstrate clinical governance. Non-malfeasance: is the basis for considerations of negligence, health and safety and risk assessment.

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 4:
Student Notes: .

The levels of beneficence my be understood in the order of: To do positive good; make sure good outweigh harm, prevent harm and finally do not directly harm. - Doctor must be up to date

How do you decide on what is in the best interest for someone who lacks the capacity to decide?

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Lecture 5: Confidentiality:
Student Notes: DEPARTMENT: Surgery &Physiology MALE TUTOR: Prof. Mohamed Bakhotma FEMALE TUTOR: Professor A Fahmy LOCATION: Auditorium .

At the end of this lecture you should be able to: 1. Recognize the importance of confidentiality in medical care and its importance in doctor/patient relationship 2. Recognize the challenges in keeping confidentiality in the age of digital medical informatics and the era of genetic testing. 3. Recognize the very limited situations where confidentiality may be breached (exception to confidentiality) and its limitation.

Although confidentiality is perhaps one of the earliest medical ethical virtue (Hippocratic low), there are many examples where it can very easily be breached in day-to-day practice. Currently patients data in most hospital are kept in digital format on mainframe computers. While this does improve service it created the challenge of how to maintain confidentiality. Unnecessary breach of confidentiality is a medico legal issue. However there are few exceptions where confidentiality may be breached. These too should have limitations.

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 5:
Student Notes: . The basis of doctor-patient relationship is trust. Patients trust their doctors with very sensitive issues, if this trust is lost, it will be impossible to provide adequate care. Only very limited situations would permit breaching of confidentiality.

illustrate some examples of situations where confidentiality may be breached: - Unintentionally. - Compulsory. - Exceptionally.

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Lecture 6: justice and equity

Student Notes: DEPARTMENT: Anatomy MALE TUTOR: Professor Adel FEMALE TUTOR: Professor Adel LOCATION: Auditorium .

At the end of this lecture you should be able to: 1. Recognize that justice and equity are important ethical principle 2. Describe situations where rationing and prioritization cannot be avoided 3. Recognize factors such as age, type of illness, merit, and demand, cost effectiveness or need that can influence rationing. 4. Recognize the potential harmful influence of privatization on justice and fairness in medical care

Justice is a fundamental principle of ethical practice. Resources sometimes make it necessary to adopt fairness in term of prioritizing health service. The factors that could influence prioritization include age, type of illness, merit (usefulness to society), effectiveness of treatment. However in all cases the evidence based principles in medical care should be applied.

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 6:

Resources sometimes make it necessary to adopt fairness (rather than justice) in term of prioritizing health service. Practice Evidence based medicine is essential in upholding the principle of justice.

Describe at global level how justice is being made or not made in term of health care. Describe how evidence based medicine can influence justice plan and implementation

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Lecture 7: Intersex and Sex correction

Student Notes: DEPARTMENT: Surgery MALE TUTOR: Professor Y Jamal FEMALE TUTOR: Professor Y Jamal LOCATION: Auditorium .

At the end of this lecture you should be able to: 1. Define what is meant by intersex and differentiate between intersex and transgender. Recognize the multiple ethical problems/implications: psychological, social, religious, legal etc. associated with intersex and its reassignment. Recognize the importance of sex of rearing Recognize the difference in ethical and psychological problems associated with the timing of presentation of intersex: at birth vs. at puberty and adulthood. Discuss the importance of multidisciplinary approach in the management of intersex. Describe the Islamic views in relation to intersex and sex correction

2.

3. 4.

5. 6.

In broad terms, the ethical issues in intersex disorders are related to each of the following issues: Assigning sex at birth: It may be easy in some cases e.g. congenital adrenal hyperplasia. In other cases like micropenis, streak gonads, it need more work up (how (Insert here handouts and additional and who decide/ consent on what gender) Telling parents (how much should the parent be tolled). Birth registration and certification: (legal issues related to timing of registration) 26
pages for notes if needed)

Phase 2 Medical Ethic Ethical psychological problems are further complicated by the timing of presentation. If noticed at birth, it is seen in the form of abnormal genitals (congenital adrenal hyperplasia, micro penis and streak gonads). If noticed at puberty, the symptoms are amenorrhoea, unexplained virilism (androgen insensitivity, 5 alpha reductase deficiency). Some ethical issues in relevant cases: o Female pseudohermaphrodites (e.g. congenital adrenal hyperplasia (CAH) commonly caused by 2-OH enzyme deficiency) should be reared up as girls, but may doctor may face resistance from the parents. o Male pseudohermaphrodites These are genetic males (46 XY). o Complete androgen insensitivity (AIS): Timing of surgery (goandectomy and vaginoplasty) and how and what to tellteh parents (their daughter is a boy). Telling the parents:How much should one tell the parents? o True hermaphrodites and mixed gonadal dysgenesis Awaiting results of tests can be very trying for the parents. It is necessary for the doctors to give the parents, some idea regarding the different possibilities. They need to be told, that regardless of the outcome of the investigations, their child will be managed in an adequate fashion. How much should a child know when he/she are grown up: is important issues that need to be considered

Faculty of Medicine

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Continue Lecture 7:

"Intersex" is a general term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy (internally, externally, or genetically) that doesn't seem to fit the typical definitions of female or male. Transgender is a term that describes having a feeling that ones identity is different from most women (or men). the importance of multidisciplinary group: medical, psychosocial, surgical, ethical in the overall management of children born with atypical genitalia intersex cannot be overemphasized.

Describe the difference between sex change and sex correction. Describe some of the causes where sex assignments could lead to intersex.

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Lecture 8: Ethical Issues for Moslem patients:

DEPARTMENT: ENT MALE TUTOR: Professor T Jamal FEMALE TUTOR: LOCATION: Auditorium

At the end of this lecture you should be able to: 1. Describe basic of Islamic teaching in relation to illness. 2. Describe the practice of Islam (Prayer, Fasting, etc) under difference circumstances of health inadequacy and illness.

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 8:

The Moslem doctor is responsible to teach and show his/her patients the means to safely maintain and practice Islam

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Lecture 9: Ethics of Genetics

DEPARTMENT: Medical Genetics MALE TUTOR: Dr Jomana Al amma FEMALE TUTOR: Dr Jomana Al amma LOCATION: Auditorium

At the end of this lecture you should be able to: 1. Describe scope of ethical issue in relation to genetics and bioethics. 2. Describe the ethical principles in genetic counseling 3. Recognize the ethical principles of genetic research 4. Describe the Islamic views in relation to genetic medical intervention

Advances in genetics (research and medicine) have created many potential ethical issues. It is essential for every institute to realise the ethical problems and set the guidelines for the application of genetics in medicine. Muslim doctors base their guidance on the principles of Islamic ethics.

(Insert here handouts and additional pages for notes if needed)

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Continue Lecture 9:

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Practical 1: Trust and Confidentiality

Student Notes: DEPARTMENT: Ob. and Gyn. MALE TUTOR: Dr Nabeel Bandogji FEMALE TUTOR: Dr Jawaher LOCATION: Auditorium Summary: Mr Abdulla a 52 years old man came to you requesting to have a blood test for HIV. He read about the disease and feel that he may have contracted the disease. After discussion with him you agreed to do the test. He however does not want his name to appear on the request form for the test. The test was performed and the result came back as positive. Mr Abdulla does want any one to know, including his wife, and promise to take all necessary precautions. .

At the end of this lecture you should be able to: A trust relationship between doctor and patient is crucial Patient autonomy may be limited by potential harm to others Confidentiality has some limitation (only the wife has to be told)

(Insert here handouts and additional pages for notes if needed)

Continue Practical 1:
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Practical 2: Justice and Resources Distribution

Student Notes: DEPARTMENT: Ob. and Gyn. MALE TUTOR: Dr Nabeel Bandogji FEMALE TUTOR: Dr Jawaher LOCATION: Auditorium
Summary: Case 2:
In a new epidemic of H1N1 Flue, a drug was available for treatment. But there was no enough medication to treat every one. What should the doctors do? And how could they prioritize patients for treatment while at the same time being fair.

Case 2:
Who should have the intensive care bed? Barry is a 32 year old man with meningitis and is brought into the A&E department of hospital A. He is unconscious with an extremely low blood pressure and evidence of renal failure. His condition is grave and without intensive care support he is almost certain to die. With intensive care support he may make a full recovery. Until this illness he has been fit and well. The Intensive Care Unit (ICU) in hospital A is full, with some patients critically ill and some in a relatively stable condition but for who optimum care would still require the facilities of an ICU. There is evidence that moving a patient from an ICU early increases their chances of complications and may increase mortality. There is an available bed in an ICU in hospital B, which is fifty miles away. The intensive care consultant on call must decide if Barry should be moved to hospital B or if a patient already in ICU should be transferred to allow Barry to be admitted. The clinical ethics committee is asked to review the case retrospectively and advise on how such cases should be approached in the future.

At the end of this lecture you should be able to:

Recognize conflicts between the physicians obligations to patients and to society and identify the reasons for conflicts Identify and deal with ethical issues involved in allocating scarce medical resources

Recognize physician responsibilities public and global health

for

(Insert here handouts and additional pages for notes if needed)

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Continue Practical 2:
Student Notes: .

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Practical 3: Beginning of life issues

Part 1(Prenatal diagnosis and Fetal right)
DEPARTMENT: Ob. and Gyn. MALE TUTOR: Professor H Nasrat FEMALE TUTOR: Professor H Nasrat LOCATION: Room 311 5th Floor
Summary: Case 1: A 35-year-old G1 P0 presents to your office for her first prenatal appointment at about 11 weeks gestation. Patient has had an unremarkable medical history. The pregnancy has been complicated by some mild nausea and vomiting in the first trimester. At her first appointment, Nuchal Translucency/First Trimester Screening counseling is done and the patient agrees to have the tests at 12 weeks gestation along with her other routine blood tests. Four weeks later the patient and her husband arrives at your office for their regular prenatal visit. The Nuchal Translucency/First Trimester Screening test returned showing an increased risk of Trisomy 21 at 1:41 Case 1 continued The couple goes on to Genetic Counselling and elects to have an amniocentesis. The amniocentesis comes back showing a normal XY fetus with no evidence of Downs Syndrome or any other abnormalities. An ultrasound is also done at 18 weeks to confirm a normal developing male fetus consistent with the dates. At their followup appointment, the couple is extremely upset that they were put through such an anxiety rattling experience and ask you as a physician how you could do that to them, knowing that the Nuchal Translucency/First Trimester Screen is only about 90% predictive. How would you address their concerns?

Student Notes:

At the end of this lecture you should be able to:

Principle of pre-counseling for genetic screening (consent for prenatal diagnosis) Understand the sometimes difficult line between professional obligations and patient (parental) decision-making Understand the responsibilities of the physicians duty to inform The fetal right and regulations for termination of pregnancy

(Insert here handouts and additional pages for notes if needed)

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Continue Practical 3:

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Practical 4: Beginning of life issues Part 2

(Assisted Reproduction and Embryo Selection): Student Notes: DEPARTMENT: Ob. and Gyn. MALE TUTOR: Professor H Nasrat FEMALE TUTOR: Professor H Nasrat LOCATION: Room 311 5th Floor .

Summary:

A 32 years old healthy patient has been married for seven years. She has two daughters the youngest is 2 years old and the eldest is 5 years old. Her husband is keen to have a boy. They decided to go for an invitro fertilization and for PGD (preimplantation genetic diagnosis) to have a baby boy.

The rules governing assisted reproduction Who should be granted such procedures? Pre-implantation genetic diagnosis for medical and non-medical indications

At the end of this lecture you should be able to:

(Insert here handouts and additional pages for notes if needed)

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Continue Practical 4:
Student Notes: .

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Practical 5: Autonomy Versus Beneficence

DEPARTMENT: Paediatrics/OB &gyn MALE TUTOR: Dr Jameel Atta FEMALE TUTOR: Dr Sameera Al Basry LOCATION: Summary: A 60 years old lady was seen in the clinic and was advised that she must have mastectomy, and the chances are fair that she will be cured. After you explained to her the details, she refuses the operation and decide she is going for traditional therapy. Case 2: Mrs. X is 35 and is in need of dialysis. She is refusing treatment because she is scared of the treatment, which she believes is invasive. She has been counselled about the nature of the treatment there are no alternatives that would be of practical benefit. She is competent to make treatment decisions. She understands that if she refuses dialysis she will die. She has a daughter of 15 years who lives at home. The clinician feels very strongly that she should receive dialysis but despite numerous attempts to persuade her she refuses

At the end of this lecture you should be able to: Understand the importance of Patient consent and informed choice Describe the role of physician in critical situation (Protecting self harm while honoring autonomy).

(Insert here handouts and additional pages for notes if needed)

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Continue Practical 5:

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Practical 6: Maternal Fetal conflict

Student Notes: DEPARTMENT: Paediatrics/OB &gyn MALE TUTOR: Dr Jameel Atta FEMALE TUTOR: Dr Sameera Al Basry LOCATION: Summary:
Mrs Khalda is a 28 year old G1P0 who presents to the labor floor at term. After being in labour for 6 hours your were called urgently because of fetal bradycardia ( 64 bpm). You inform the patient that she need an emergency Cesarean section. The patient adamantly refuses and says, "I will not have surgery under any circumstance!"

At the end of this lecture you should be able to:

To understand that the conflict between the wishes of the pregnant woman and the best interests of the fetus is a tension between autonomy and beneficence; The need for consent for intervention and the importance of considering the pregnant womans view Consider how such conflicts may be resolved and appropriately dealt with; Understand the importance of communicating medical information in language and terms that the patient can understand;

Doctors legal responsibility

Understand the scope of informed consent in maternal-fetal conflict cases

(Insert here handouts and additional pages for notes if needed)

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Medical Ethic

Faculty of Medicine Student Notes: .

Continue Practical 6:

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Phase 2

Medical Ethic

Faculty of Medicine

Practical 7: Informed Consent

Student Notes: DEPARTMENT: Anatomy MALE TUTOR: Professor Adel FEMALE TUTOR: Professor Adel LOCATION: Summary:
Case 1: A 33 years old lady admitted to the emergency room with severe vaginal bleeding. She is pregnant at 32 weeks and diagnosed to have major placenta previa. The doctor decided to perform emergency cesarean section. The husband refused to sign the consent form despite explaining to him that this operation is to save his wifes life. Case 2: During a clinic visit, Doctor tells Patient

that he wants to run some blood tests. He gives her directions to the phlebotomy lab and sends her with the appropriate paper work. She sits in the phlebotomy lab waiting her turn and watches the technician draw blood from another patient. The lab technician puts the tourniquet on her arm and sticks her with the needle repeatedly trying to find a vein. The multiple attempts to find a vein results in severe bruising and pain. She sues her doctor for assault and battery on the grounds that she did not consent to the procedure.
Case 3: During surgery to repair a vesicovaginal

fistula (a leak between the bladder and the vagina), Dr. Freeby gratuitously removed a small mole from Patient's leg. Patient sued for assault and battery for the unauthorized removal of the mole.
Case 4: A diabetic patient who had previous four

CS was having her fifth once Prior to the delivery of her baby, the patient gave her written consent for a cesarean section and a possible hysterectomy. Immediately after the delivery of her child, Doctor determined that a hysterectomy was not necessary. After delivery the Doctor performed a bilateral tubal ligation. The patient husband was upset, claiming lack of written consent for the tubal ligation, the wife was satisfied by the decision.
(Insert here handouts and additional pages for notes if needed)

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Medical Ethic

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Continue Practical 1:
Student Notes: .

At the end of this lecture you should be able to: The regulation for consent the difference between basic consent and informed consent. What is express consent compared to implied consent? Who can give informed consent? When is the patient's consent not required?

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Medical Ethic

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Practical 8: Conflict of interest

Student Notes: DEPARTMENT: Anatomy MALE TUTOR: Professor Adel FEMALE TUTOR: Professor Adel LOCATION: Summary:
Mr. Abdulla is a general manager of a major pharmaceutical drug company who had interested in conducting a trial of its new drug. His brother a physicians, share holder in the company and member in the ethical committee of the local teaching hospital. The proposal for the trial was submitted to the hospital for approval.

At the end of this lecture you should be able to: Understand conflict of interest Describe function of the ethical committee

(Insert here handouts and additional pages for notes if needed)

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Medical Ethic

Faculty of Medicine Student Notes: .

Continue Practical 8:

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Faculty of Medicine Student Notes: .

Practical 9: Research Ethics

DEPARTMENT: Anatomy MALE TUTOR: Professor Adel FEMALE TUTOR: Professor Adel LOCATION:

Summary:

Case 1: Dr. R, a general practitioner in a small rural town, is approached by a contract research organization (C.R.o.) to participate in a clinical trial of a new non-steroidal anti- inflammatory drug (nsAid) for osteoarthritis. she is offered a sum of money for each patient that she enrolls in the trial. The C.R.o. representative assures her that the trial has received all the necessary approvals, including one from an ethics review committee. Dr. R has never participated in a trial before and is pleased to have this opportunity, especially with the extra money. She accepts without inquiring further about the scientific or ethical aspects of the trial. Case 2: In a community bases study of 15,127 persons in a rural area in Uganda 5 clusters were randomly assigned to receive intervention for sexually transmitted diseases and five clusters were randomly assigned to control groups. Individuals eligible for the study were read a consent form that explained the study and its potential risks and benefits..They were informed of their rights to decline all or part of the study activities without loss of access to clinical and educational services. The subjects were encouraged to obtain the results of their HIV-status and share it with their partner

(Insert here handouts and additional pages for notes if needed)

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Medical Ethic

Faculty of Medicine Student Notes: .

Continue Practical 9:

At the end of this lecture you should be able to: Identify the main principles of research ethics Describe the important difference in the balance research and clinical care The role of research ethics committee Globalization of research and the potential problem of research in developing countries

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Medical Ethic

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Practical 10: Medical Errors

Student Notes: DEPARTMENT: Ob & Gyn MALE TUTOR: Professor H Nasrat FEMALE TUTOR: : Professor H Nasrat LOCATION: Room 311 Fifth floor
Summary: Case 1: Mrs Rola was admitted for emergency caesarean section. The operation went well and standard procedures were followed throughout the surgery. The next day the patient recovered well, but 48 hours latter she experienced abdominal discomfort, fever, nausea and vomiting. Examination and investigation revealed the possibility of intra-abdominal swab been left. The patient and her husband were told that she need to have another exploratory laparotomy to deal with some possible infection. The patient was taken to theatre and on laparotomy the the gauze swab was found and removed. The patient later recovered well, she and her husband were upset from what has happened and decided to pursue legal claim. Case 2: You are halfway through a busy clinic afternoon and seeing Mr. Osler, a middle-aged man with hypertension. His blood pressure diary indicates that he is above your therapeutic target, and you decide to add a new antihypertensive drug to his regimen. You write a prescription, the nurse faxes it to the pharmacy, and you move on to the next patient. Two days later you are called by the emergency room about Mr. Osler, who became dizzy while getting his morning paper. He fell on his porch, sustaining a forehead laceration. A careful evaluation showed only postural hypotension, and his laceration was closed. You arrive to say hello to him and see his medication bottles at the bedside. You are shocked to find that the hospital pharmacy dispensed the new drug at 10 times the dose you intended. You step out of the room to collect yourself and decide what to do

At the end of this lecture you should be able to:

The Physician patient relationship based on trust How to deal with medical errors The ethical principles of disclosure of medical errors

(Insert here handouts and additional pages for notes if needed)

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Medical Ethic

Faculty of Medicine

Continue Practical 10:

Student Notes: .

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PBL
PBL process
The clinical scenario Key information

Explore the problem What you know What you need to know Identify learning issues Self/group study Share the knowledge Solve the problem Give feedback & reflect

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Univ ersit y
The Facult y of Medici ne and Allied Scienc es

Phase 2

Professionalism

Faculty of Medicine

Further Reading

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