Week 4 Ethics Decision Making

King Faisal University
College of Applied Medical Sciences
Nursing Department
health
CCR
care 3101301
ethics
3rd year,
3 Credits 1st
semester
Healthcare Ethics
Lecture 4
ETHICAL DECISION MAKING
Objectives
• Encourage , inspire , motivate you to think about ethical
decision you make
• Provide a systematic way of making ethical decisions

• Be familiar with the Islamic principle-based approach to
medically relevant Fatwas
• Utilize at least one of the approaches to identify, analyze, and
present an approach to the ethical issues encountered during
clinical practice
Ethical Dilemma
• Ethical dilemma: is a situation with uncertainty

about what is right to do from a moral or ethical
perspective.
• For example, the manager of a company may be
put in a position in which he must choose
between the interests of his employees and his
investors. Give more profits or increase the
salary?
Examples of Nurses’ Obligations in Ethical
Decision Making
• Maximize the client’s well-being.
• Balance the client’s need for autonomy with family
members’ responsibilities for the client’s well-being.
• Support each family member and enhance the family
support system.
• Carry out hospital policies.
• Protect other clients’ well-being.
• Protect the nurse’s own standards of care.
Strategies to Enhance Ethical Decisions
and Practice
• Become aware of your own values and the ethical aspects of nursing.
• Be familiar with nursing codes of ethics.
• Seek continuing education opportunities to stay knowledgeable about ethical issues in nursing.
• Respect the values, opinions, and responsibilities of other health care professionals that may be
different from your own.
• Participate in or establish ethics rounds. Ethics rounds use hypothetical or real cases that focus on
the ethical dimensions of client care rather than the client’s clinical diagnosis and treatment.
• Serve on institutional ethics committees.
• Strive for collaborative practice in which nurses function effectively in cooperation with other
health care professionals.
Clinical Ethics Committees (CECs)
• These are committees formed of clinical and non-clinical
personnel to discuss ethical issues that staff faces
during their practice.
• These issues may relate to their interaction and inter-
team disagreements or, more often, disagreements
between the team and the patient and/or his/her
family.
Factors affecting ethical decision making cont.
• Protection of faith: prayer (salat), fasting (siyaam),
(Zakaat)1, and pilgrimage (hajj). A sick or weak body
cannot perform any of them properly.
• Protection of life, hifdh al nafs (‫)حفظ النفس‬: Disease
treatment and rehabilitation lead to better quality
health
• Protection of progeny, hifdh al nasl (‫)حفظ النسل‬:Intra-
partum care, and infant and childcare ensure the
survival of healthy children.
• Protection of the mind, hifdh al „aql (‫)حفظ العقل‬:Medical
treatment of alcohol and drug abuse prevents
deterioration of the intellect.
• Protection of wealth, hifdh al mal (‫)حفظ المال‬: In cases
of terminal illness, the principles of protection of life
and protection of wealth may conflict. Care for the
terminally ill consumes a lot of resources that could be
used to treat other persons with treatable conditions.
• The principle of intention: “Each action is judged by
the intention behind it”
• The principle of certainty, qaidat al yaqeen ( ‫قاعدة‬
‫)اليقين‬:All medical procedures are considered permissible
unless there is evidence to prove their prohibition.
• The principle of injury, qaidat al dharar (‫) قاعدة الضرر‬:
If confronted with two medical situations, both of
which are harmful, and there is no way to choose among
them, the lesser harm is committed. A lesser harm is
committed in order to prevent a bigger harm.
Principle of hardship, qaidat al mashaqqat (‫)اقاعدة المشقة‬:
Necessity legalizes the prohibited. In a medical setting, a hardship

is defined as any condition that will seriously impair physical and
mental health if not relieved promptly. Hardship mitigates easing of
the Sharia rules and obligations.
The principle of custom or precedent, qaidat al urf( ‫قاعدة العرف‬

):custom or precedent has legal force
Authoritative sources
• At the national/international levels
• The Mufti of the Kingdom of Saudi Arabia (‫)مفتى المملكة‬
• The Grand Ulama Authority (‫)هيئة كبار العلماء‬
• The Fiqh Academy of the Organization of the Islamic
Cooperation (‫)االكاديمبة الفقهية لمنظمة التعاون االسالمى‬
• The Fiqh Academy of the World Muslim League
(‫)االكاديمبة الفقهية لرابطة العالم االسالمى‬
Authoritative sources cont.
Local level
• Ethics Committee in the Hospital
• Local Scholar
Existing laws and regulations
• Code of Medical Ethics by the Saudi Commission for
Health Specialties
• Health Professions Practice Regulations by the Saudi
Commission for Health Specialties
• You are on a sinking ship and there is only ONE
lifeboat available. Posted on the side of the lifeboat is
a sign which reads, “Maximum Occupancy” - 8
persons…this boat will sink if over occupied.” Standing
on the deck and waiting on board the lifeboat are nine
adults and one child. You must decide who dies. Be
prepared to defend your decision.
40
Persons on a sinking ship
 You
A middle aged
school
teacher and A member of
Her husband, the clergy
a banker
A 17 year old,
9 months
pregnant girl
was raped
A 75 year old retired A young mother and

emergency room A professional
athlete has AIDS her infant son
physician & His 68 41
year old wife

Case study
• 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 cystoadeno carcinoma 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.
Case discussion using
Islamic approach
(framework)
Conclusion
• From the above analysis, which may seem complicated, we
arrive at the conclusion that terminating the pregnancy at
this gestational age is permissible.
• The patient's refusal is most probably due to the way in

which the decision was taken, rather than the decision
itself.
• Sometimes doctors lack the necessary communication skills

to convey treatment choices to their patients.
Conclusion
• Since the patient is competent to take the decision, bypassing her to seek her
husband's approval is ethically and professionally unacceptable. Moreover, it
may be legally troublesome.
• The husband may have other reasons to terminate this pregnancy other than
seeking his wife's cure. Thus, we need to be careful, patient (endurance), and
seek proper help if we feel we are failing to communicate with the patient.
A 47-year-old woman with poorly controlled diabetes, who previously lived alone in a
second floor apartment, is admitted to the hospital with a nonhealing foot infection. She
is diagnosed with osteomyelitis and undergoes a left below-the-knee amputation. Her
pain is well controlled postoperatively and when she is medically ready for discharge she
refuses several choices of skilled nursing facilities that would care for her incision site
and provide rehabilitation therapy to help her become mobile again. The best discharge
plan for her at this time is:
A. To offer to have an ambulance bring her to her apartment
B. To keep her in the hospital until she agrees to go to a skilled nursing facility
C. To determine why she is not willing to go to the facilities offered, and what she would like
to do instead
D. To call her relatives, explain her medical situation and have them convince her to go to a
skilled nursing facility
Question
In the Laotian culture, pain may be severe before relief is requested.
Traditionally, the oldest male makes health care decisions and may
answer questions for female clients. A nurse is caring for a female
Laotian client who is in severe pain, rating an 8 on a scale of 0 to 10.
Her spouse will not allow the nurse to give any analgesics. What is the
nurse’s best course of action?
1. Administer the analgesic when the client’s spouse leaves the room.
2. Educate the client’s spouse on the reason for the pain and the action
of analgesics.
3. Respect the Laotian culture and do not administer the analgesic.
4. Report the issue to the supervisor.
Question
A nurse gives a medication without checking the medication
administration record (MAR). When the nurse documents the
medication given, the nurse notices that the medication was also given
15 minutes earlier by another nurse, resulting in the client receiving a
double dose. The nurse notifies a supervisor and a physician of the
event.
 What is your evaluation on this behavior of both first nurse and
second nurse according to the duties of the health practitioner and
the ethics of the profession?
 Based on the above situation which health care practitioner duties
were supported / or violated .
A 32-year-old female is admitted to the hospital for gastroenteritis and volume depletion.
After receiving intravenous fluids and medication to relieve her symptoms, she is able to
eat a full meal without difficulty, and her abdominal cramping is only minimal. Her serum
laboratory values are all within normal limits and her physician wants to discharge her. The
patient requests to stay “one more night” in the hospital in case her symptoms return or
pain becomes worse again. The best thing for her physician to do is:
A. To honor her request and discharge her the next day
B. To honor her request, but tell her that the extra day of hospitalization will likely not be
covered by her insurance
C. To not honor her request and discharge her immediately with plenty of pain medication in
case her symptoms return
D. To not honor her request and discharge her immediately, but arrange an outpatient follow-up
appointment for her and formulate a plan of action in case her symptoms recur at home
Home work for next class discussion
Please assume that a patient in a hospital’s emergency
department will die if she does not receive a blood transfusion,
but the patient refuses to accept a blood transfusion on religious
grounds. The physician and other hospital personnel want to
administer a blood transfusion over the patient’s objections, in
order to save her life.
• what ethical issues raised by these conditions. Also, how would
a healthcare provider resolve these ethical issues?
References
- Professionalism and Ethics Handbook for Residents:2015, Module 15
- Berman, A., Snyder, S., Kozier, B., & Erb, G. (2012). Kozier & Erb’s
Fundamentals of Nursing, Concepts, Process, and Practice. (9th
Edition). Upper Saddle River, ISBN 13: 978-0138024611. ch. 5

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King Faisal University

College of Applied Medical Sciences

• Provide a systematic way of making ethical decisions

• Ethical dilemma: is a situation with uncertainty

Necessity legalizes the prohibited. In a medical setting, a hardship

The principle of custom or precedent, qaidat al urf( ‫قاعدة العرف‬

A 75 year old retired A young mother and

year old wife

• The patient's refusal is most probably due to the way in

• Sometimes doctors lack the necessary communication skills

husband's approval is ethically and professionally unacceptable. Moreover, it

may be legally troublesome.

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