Medical Ethics 5

Informed Consent ((IC=== Informed consent )) •

Legally, Medical care cannot be given to competent patients without their informed consent (IC).

•

Case 1: - Diagnosis breast cancer patient. - Treatment: Radical mastectomy. - Order: booking her in the hospital for surgery.

‫" ا !  ا ه ن وأه  ا  ت و د  ا‬#$  % ‫(' هي ا‬  )*!‫ و‬+! )*! ‫ إ!ه‬-.‫ ا  ت إ ' أ‬/‫ آ‬12‫ ه ا  ر‬4  -‫ ا‬5*%6‫ ا !  و‬56 )*!   ‫ار و ا‬8 ‫ ا‬9‫* ن ه ن أ‬.4 ' . :(. +! •

Case 2: - Diabetic Patient with amputated leg, and end-stage renal failure, not fit for kidney transplant. - Treatment: hemodialysis for the rest of his life. - Patient asked to stop this treatment and physician refused.

C‫ار‬84 4 )! 4‫ ) و‬:‫ ع أو أ‬:‫ أ‬8! E!‫ را‬A(‫ إذا ر‬، ;‫ آ‬/<=! ‫ @زم‬A! ‫  ا‬% ‫(' هي ا‬ K ; ‫ إ‬A! ‫ ر وا‬.‫ ا آ‬/J ! ‫ن‬I 1- interaction ‫ا‬H‫ه‬، ‫ ر‬.‫ أرد ; *' ا آ‬E!‫ ل را‬84‫و‬ . ' L‫ أآ‬1-+4 ‫ ر‬.‫ ا ا آ‬M ‫ و‬A! •

The importance of IC is different in these cases, and becomes more clear when IC is not obtained

'( ‫@ت‬% ‫'   ) ا‬+( ، ‫ت‬- N‫ء درا ; و(ت ا‬P‫م أ‬I‫ ر ه‬.‫ أ و ا آ‬-( I ‫ @ت آ‬L‫وآ‬ ‫ء‬:N‫ا‬، ‫ آ ي‬/I( ‫  ا وآن ه‬R S ‫ و ا‬/  9‫ وآ‬9 9( 6، ' *% ‫; ا *ك ا‬+I.< /K‫ و‬9 (‫ وا  ر‬9 (‫ ه' ر‬، ! $ R '( ‫* ن‬. @‫ ا @دة و إ‬/:K  ‫ و‬/<2 /6 ‫ ا‬.K‫ا‬ - * ‫ ا  ت‬/‫ ؟ أه آ‬W  ‫ ر‬.‫ ا آ‬/‫ه‬، ‫ ) ه ن‬96 )‫ و ت ) ه‬... ‫ ر( ا‬U!‫ا‬8 ‫ا‬ ‫م ؟؟؟؟‬.‫ ر (' إه‬- ، ! $ R '* ‫ ا @دة رح !* ن‬/:K /<2 '.  ‫إذا‬ . . '( K‫  وا‬L ‫' أ‬+( consent    M4 inform   •

In Case 1 (typical example) obtaining IC requires provider to give all the information needed - given that the patient is competent to understand the situation - thus provides an opportunity for patient to be active in the decision process about treatment.

،A(.4... 5 ' 6 ‫ ر‬.‫ ا آ‬-84 ‫ ي‬L ‫   ه ن ا‬75 ‫  ة ه‬:/L K‫ وا‬L ‫(' أ‬

4 4 9( 6 .-  ‫) وا‬8(‫ ا‬-.‫ ا  زه و‬1 ‫  ا‬.  (‫ < را‬.../ (‫' ة أ‬I6 )*! ‫ ان‬U! )* ‫ و‬4 ‫ ت‬6 ‫"ب و‬6 ‫ ال  آ ر() إ راح‬N‫ ا‬/‫ ; آ‬. ‫ف ا <ن‬I.‫!) ) اآ‬-$ ^8( _ ES ! E!‫ ر أ!  را‬.‫وا آ‬.‫  د‬1 ‫ا ا‬H‫ ه‬5 H ‫ و‬A! ‫ع ا‬K‫و  إ‬% '( U: ‫ ا‬.
• The IC doctrine plays an important role in structuring the patient-physician relationship since it requires a mutual process of informing and discussion that lead to a mutually agreed upon treatment decision. (informed consent c!6 ‫ا ه‬H‫ ف وه‬- ‫ا ه ا‬H‫)وه‬ ‫ا‬H‫ ؟ _ ه‬5:"2 c‫ آ‬.‫' ; ا واء‬:"2 ‫ ر‬.‫ ا آ‬e‫ ا وا‬K C  ‫ ! و‬A! ‫ ر ا‬84  '!* ‫ _  ك‬، 9.K‫ إ‬9‫ إ‬6 5K‫ إذا أ‬. 'K‫; أ‬. ‫ وراي‬/f‫ و‬C!‫ ي إ‬4  ‫ أ‬M4 : A! ‫ ؟ ا‬5.%" .A! ‫ ا‬8(‫ ون ا‬4 ‫اء‬g4 ‫ م‬8! ‫ أن !' دواء أو‬U: W%! @ ،/48 ‫ (' ا‬. ‫ رات‬K ‫ و ك‬/8 ‫   إ‬C ‫ و‬. 80-70 A! ‫و ا‬Cortisone ‫ ب‬h ! ‫ ض و@زم‬C  A! * ‫ع‬K‫ ) إ‬-$ ‫ ور‬4‫ و‬. ‫ج‬o ‫ ا‬A! ‫ ا‬A(‫ور‬، /‫آ‬I  /! ‫  و‬m <*! E!‫ را‬Cortisone ‫ال‬ !- ‫و(' ا‬.‫م * < م‬m ‫"ص ا‬. ‫ ا‬1 6 ‫م و اد‬m ‫ آ < م‬A! ‫ !' ا‬E!‫ ر را‬.‫ ا ا آ‬A! ‫ا‬ .  ‫ ا‬o ‫ج  ا‬o ‫ ا‬A(! A! ‫ا‬  U ‫ج ا‬o ‫ا ه ا‬H‫ ا ه‬.8 9‫ وأ‬A! 5! E!‫ ! م را‬/‫ آ‬،‫ء‬:N‫ ا‬-I! K‫ ة وا‬CH‫*ه‬ /+4 8.4 5r‫  آ‬/J 6 ;. (q ‫ا‬... ‫ ك ا واء‬4  ‫ ك ا واء‬4)  ‫"رع‬.6 ‫ وراح‬A(‫ را‬A! ‫وا‬ .)< ‫ر ا‬:‫  آ‬JR ) 10 C ‫؟‬.t ) ‫ رأي أ‬HRr ‫ر ا <) (' ل‬:‫('   آ‬:‫ل `ال‬r U *

N ‫ار‬8 ( ‫ و‬2 '( ‫ أ  إذا آن‬. ‫ر‬# ( ‫ و‬/ ‫ (' آ‬A! ‫ إذا آن ا‬،A! ‫ ; ا‬.!:‫ا  اب‬ .! ‫! ات ا‬o< ‫ (' ا‬IK! ‫ ع  ف‬S  ‫ا ا‬H‫ وه‬JR     /*(،‫ أ  (' @ت ا  ارئ‬..t )

•

In Case 2 (special example): Where patient and provider are unable to agree on the course of treatment, the competent patient has the right to refuse the treatment.

ht. ‫ ا‬6 * ‫ ك ا‬4‫ و‬+6 / %. ‫ ا‬. 9‫ إ‬، ‫ ا * ي‬/I+ ‫ ت ا‬o C  ): _ A! :‫ل‬L * . ! ‫ار‬8 ( ‫ و‬/ *4 ‫ وه‬A(‫ را‬A! ‫ ا‬M4 ': ‫ ا‬% •

Then obtaining IC affirms the right of patient to refuse treatment but not order it.

‫ة‬% ‫ (' ا‬5 6 ‫'  ف‬. ‫ ا‬K‫ ا ا‬L N‫ ) ا‬L‫ ي( (' آ‬L ‫و ;)ن ا‬N‫  ا‬% ‫ (' ا‬1*.*  /L * . ‫ا‬ •

The ongoing process of informing and discussion would be less important if patient decision could be ignored.

.A! ‫ار ا‬K ; .! informed consent ‫ ع‬S /‫؟؟ إ آ‬A! ‫ار ا‬8 ‫ إهل‬/  4 _ *

•

The right to refuse treatment would be less valuable if there were no means of ensuring the availability of information on which refusal was based.

W ‫ا‬H‫ وه‬.C‫ إ ; اد‬/"! ;. ‫ل‬r
This contradicts the traditional provision of medical care (paternal model).

، ‫ ا‬/! A! ‫ ) ا‬U ‫ ر‬.‫)!' ا آ‬. ;S ‫ رأي ا‬HRr! '‫! و  (' دا‬I: ‫ ا‬4‫   أ‬/  ‫ ر‬.‫*ا آ‬ ‫ء‬RN‫ت ا‬+ ‫؟؟؟؟( روح را‬.../‫ه‬.../‫ه‬.../‫ ؟ ه‬%100  ‫ ح ا‬:< /‫ ) ا ؟ ه‬/! 4 ‫ هك‬/‫ه‬ : ‫ ر‬.‫ ل  ا آ‬8! ‫ ح ا ؟؟‬:< 1‫ ر آ‬.‫ل ا آ‬r<4‫ ; ا  و‬A! ‫ ا‬/R 4. 1‫آ‬% ‫ وا‬t‫ (' ا ا‬: ‫ا‬ .q ‫ا‬... ‫ ر‬.‫  ; ا آ‬K (4‫ و‬A! ‫وح ا‬4.! .< ‫ه‬4  ‫ ) ا‬A! ‫ ا‬4 ،%100

•

IC doctrine established to reject this model.

•

Ethically, the values served by the doctrine of IC justify the rejection of the paternal model.

'. ‫ ا‬%" ‫

ت ا‬# ‫  ا‬% ! 4N‫ة ا‬m ‫ ا‬CH-4 ‫ت‬$ ‫ _ 'ء إذا‬PATERNAL MODEL :* . ‫ ون‬c4  / ..4 9K ‫ ا‬M+4 )* ‫ و‬A! ‫ ) ا‬4 ‫ار‬K HRr6 5‫ إ‬E%J ("‫ز‬. ") ;S - 86   ‫ ون إء أي‬4 ‫ارات‬K HRr! ‫ د إ‬. ‫ ر‬.‫ !) إ@ إذا آن ا آ‬N‫) ا‬4 ‫ون‬6 ‫إذ @ !*) أن !* ن هك‬ . COMPETENCE ) /t ‫وه‬ Therefore, the paternal model and IC cannot reject each other unless the doctor is a hypocrite (am not sure about this sentence).

Values of IC: 1. IC serves the patient, society, and the health provider.

2. Serves to: • Promote patient well-being, and )  R : ‫' ) ا ض إ أن !_ ة  ة ; ا  ى ا‬+$ A! ‫' إ ا‬6 @ well-being) (.: ‫ء ا‬RN‫ا‬ •

Respect patient self-determination (!" ‫ارات ا‬8 ‫ام رأ! (' ا‬.‫ وا‬A! ‫ام ا‬.‫'ء ا‬$ 1‫)أه‬

•

Foster public trust in medical enterprise. ‫ ا "!ا إ ن؟؟‬# ‫ر‬%‫إذا آ ن ا   ّ أ !آ‬:‫*  ل ال‬ .W(‫ ا! ا‬: ‫ ) ا‬A! ‫ ا‬N IC ‫ا‬H‫ه‬:‫ا  اب‬

‫ ر‬84  A! ‫ ا‬N ‫(؟؟‬U ( I.4 ' ‫ إ‬/‫ا‬:‫ ر‬.‫ ل  آ‬84 ' ‫;) إ‬S ‫ا ا  ع ) ا‬H‫* _ إ   ه‬ .W(‫ ر أ ا‬.‫ ا آ‬C‫ر‬8! ‫'ء‬$ ‫ أي‬،'‫'ء أ‬$ ‫ ر‬.‫  آ‬A! ‫ ا‬M! 86   ‫ه ن‬.‫ ر‬.‫_ أو !دل ا آ‬K!  ‫; إذا‬. +" |#I( ‫ع ; ا ض‬oّ@‫ وا‬education ‫  ع ) ال‬1‫!   ه‬، 'L ‫ ا‬1  ‫*(' ا‬ 6 ‫ راح‬K‫ ا ا‬L N‫ ) ا‬L‫ و(' آ‬.9.‫ ور  (' ا‬4 ‫وح و‬4،  ‫ ) ا ض أو ا‬1 C  ‫آن‬  ‫ ا‬56 '( 5

A. Patient well-being This is the ultimate goal of PPR. MD is well trained and expert. Patient is anxious and confused and • may decide on less effective treatment. • may not complete the course of treatment, or • may refuse clearly beneficial treatment. Which appear not to serve the well being value. 1.! '. ‫دو! ا‬N4 ‫( ن‬.! @ ;S ‫ ) ا‬L‫ ; أن آ‬/ ‫ا د‬H‫وه‬.‫ ا واء‬HR‫; !( ن أ‬S ‫ ) ا‬L‫*هك آ‬ !‫دو‬N‫ ا‬: ""# ‫ ت‬J '( ‫وا@ن‬.‫  ا؟؟؟؟؟ * ا)(' ب‬.4 _!‫  إ‬U..‫ت‬+I.< ‫ ا‬/:K ) -(J .‫ى‬RN‫  ) ا  اد ا‬R‫ب و‬IN‫" أدو! ) ا‬6 " ‫ب وأ!  هك‬IN‫ا " ) ا‬ '( + ‫ أ‬/:x ‫ ا‬/L ‫ب‬IN‫ ) ا‬L‫*' آ‬%4‫! ن و‬x+. ‫ ; ا‬4،  " ‫ آ ا‬،'%( * ‫أ ا‬.‫*د‬ ) 
Why patient decision serves this goal better? 1. Health is not a fully objective matter invariant between persons. It is agreed that many diseases are clearly threatening pt. well-being ; in few cases, e.g. corrective surgery, is not. There is agreement on what constitutes a threat to health. And if defining health is the only issue, then pt. participation in docision-making in order to promote patient’s health would be weak. '( C‫و‬:.6 ‫ أن‬1** g4 IC، ‫; (*ة‬.‫ار‬8 ‫ر ا‬.R‫رآ (' ا‬I A! ‫  !* ن  ا‬4 ‫م إ‬o* ‫ا ا‬H‫ (' ه‬/ ‫*ا‬ /t‫ و('  ك و‬، ‫ أة‬1m6 /6 ‫ ه‬4‫ و‬9< ‫' ا‬6  .‫ة‬N‫ ا‬1m6 '(  #.< ‫!*) أن‬:‫ل‬L .‫'ء‬$ /‫آ‬ .‫م‬.‫ ا هي ا  ت اه‬4 ' ‫  ا إ‬/K .q ‫وا‬... - ‫و ت (' ا دات ) دورة ا أة وإ!_ @ز‬

‫؟‬/% ‫

'  ا‬#.<.4 $:- r<4 ‫ ر‬.‫ ر وا آ‬.‫  ا آ‬9< ‫' ا‬6* .U :‫ا  اب‬  ‫ ب‬: ‫ي‬HR6 5!‫ إ!_ رأ‬U ‫؟؟‬U  ‫ ا‬# )!‫|؟؟و‬%+ ‫ و!) ا  ت؟؟ و!) ا‬U...'‫آ‬:‫ ر‬.‫ا آ‬ ‫؟‬/% ‫ا‬ (!!!! )! 4‫ ر )و‬.‫ ك ! دآ‬4  /L e‫وا‬:9< ‫ا‬ ‫ة ! ا‬6‫ن ا آ‬N‫ ) ا‬L‫وآ‬.<+ U: ‫) ا‬4‫ج و‬o ‫' ! وا‬8. ‫) ا‬4 :‫ آ‬GAP   !J c… * '6. Consent '( M4Informed _ ‫ا‬H‫ ' ه‬. 4‫ و‬.U ‫ أو‬Combined bills or condoms ‫ا <ء‬ R U .1: 586 ‫ ورة؟؟‬4 L‫  ك دم آ‬- r<.4.U '  ‫' أو@د‬+*4 586‫ة أو@د و‬I ‫ و ه‬9< ‫ا‬ .(!!!!-I ‫ ! م (' ا‬12-10 ‫"  ه دم  ة‬4 5 ‫)ام‬5%!‫ أر‬- U 5% .IC '( ‫  ا‬1- ‫ا‬H‫وه‬.‫ار‬8 ‫ ا‬:J '‫ آ( ا  ت وه‬-6 ‫ @زم‬9‫ة وإ‬L‫ آ‬/ ‫ ('  ا‬5 H ‫*و‬

2. Medical criteria alone usually do not fully settle which treatment to be selected. •

It takes more than medical facts alone to determine the treatment indicated for a given condition from among several acceptable methods.

‫ر  ه‬J‫ و‬، UK ‫ !" ه ن أو‬E!‫ ب را‬: ‫ت‬HR‫ ا إذا أ‬9 ‫ أو‬-%!‫ أر‬U  ‫ ا‬U‫آ‬6 /‫)ه‬ '( --‫ ا‬4 ' ‫* إ‬I ‫ ا  وهي ه' ا‬-+4  1-‫* إ‬I ‫ ا‬M4. ‫ ب‬: HRr6 ‫ ّه‬4 94‫ و‬4 # ‫ا  ت‬ .( %" ‫ ا‬x‫ا اآ‬ • ‫ث‬.g. breast cancer, disc prolepses, uterine prolepses, hernia, headache… ‫"ب‬6 )*  5  4 ‫ إذا‬: A! ‫ ل‬86 '! . ‫@ت‬% ‫ ا‬CH‫ (' ه‬/ ‫ع آ‬o‫ !* ن ; إ‬A! ‫)@زم ا‬ (..‫ ; را‬R  ‫ه‬... ‫ ي ا‬4  :A! ‫ ا‬584،/I4 ‫(' ال‬. ‫ ا  ت آ‬HRr! ‫ أ!  ا‬8‫ و‬8 ‫ا‬H‫ه‬. ‫ ا‬A(‫ ور‬/I4 ‫ إ راح !"ب‬A! 9*  * ‫ أن‬.* 5r4 1-.6‫و! و‬x. 4 1-.. ‫'ء‬$ ‫ر أي‬J ‫ إذا‬N  * ‫ ا   ا‬A! ‫ ا‬HRr! ‫ @زم‬disc prolapse 94R  /L ‫ب‬R 5.4 ‫ب‬RN e‫* وا‬% ‫' (' ا‬K@":58!‫ و‬A! ‫ ا‬5! ‫ وراح‬# ‫  ) ا‬R  ‫ا‬ ‫ <`و  أي‬/%.6  ‫ن‬I A! ‫ار‬8 ‫' ا‬R‫ ا  و‬# ‫ ا  ت و‬/‫ أ آ‬،5‫ن ه‬I .!!"'.4 . e‫ ر ا‬K @ ‫'ء‬$ •

When there are more than one acceptable treatment method then objective criteria alone will not determine which one to follow.

3. Relative importance or value of health as compared with other aspects of individual’s well-being differs for different people.

What compounds the difficulty of selection between alternative treatments is that more than health commonly is at issue. :‫ ا آ‬U‫آ‬6 /L . : ‫ أو ا  ى ا‬U!8 ‫  اء ; ا  ى ا‬A! well-being ‫ ع ال‬S ) 1*.6 9‫*  ا‬ ;+I.< ‫ ا‬/R‫ د‬1-. ) ‫( ا وا‬$ 1-N ‫ت‬+I.< ‫ ا ا‬R ! ‫ ا‬4 ‫(' س‬. +.
6 ‫ ه‬4 ;+I.< ‫ ا‬9R‫ د‬9:/L ‫) ا س‬4 /8.6 ‫ت‬+I.< ‫ ) ا‬w< ‫ ادث وا <ت ا‬% ‫ا‬. ‫ه‬4 ‫و‬ ' ‫ ا ا س إ‬4 ! ‫روا‬J‫ و‬$N‫; وآ<ت ا‬+I.< ‫ وآ<ت ا‬-. 9 K‫ و‬-:4 /+ ‫ و ت ا‬. ‫ ا‬-I 4 !!!!!5‫" ه‬4  ...1- ‫ ا‬K .‫ ع‬S  4 ‫ ا‬+*.!‫< و‬+ ‫ اض ا‬N‫ ا‬1<8  %.4..‫ ر‬%< ‫ أ‬58!‫ و‬A! 5! )*!*

Conclusion: •

The issue is not what maximize patients’ health but what promotes their overall well-being.

، ‫ رات‬m% ‫ ا‬E:6 ‫ وإن ا ورات‬5% <4 4‫ ر‬86 ".4....‫= ام‬I ‫ هي ا‬58!‫ و‬A! ‫ ا‬5! )*!* . 86 ;. C‫ ورا‬5 4‫و‬.../:8.< ‫<) (' ا‬%.! well-being ‫ ال‬/‫وإ ام ) أ‬ •

•

Sound decision-making involves more than the medical facts alone (objective) to determine which method of treatment to use, but there is also the subjective component which recognizes the differences in importance of values among different patients e.g. amputation vs. radiation; medical vs. surgical treatment. Paternal medicine failed to recognize this component.

B. Patient self-determination (SD) What is the Nature of SD •

Patient’s interest in SD emanates from patient desire to decide on his/her own life according to his/her values.

(Never ever make fun of patient value.) @ ;. ‫م؟‬o* ‫ا ا‬H-4 ) ˆ.4 56< 5‫ ل إ‬86‫  و‬#<6 @‫  و‬5% 6 @.‫ ر‬%< ‫ أ‬58!‫ و‬A! 5! /L * ‫  أو‬5% 6 ‫ ! ز أن‬o( ) 4 4J‫ و(' إ‬% '( ‫*' إ‬%4  . ‫إذا آن ا‬.ً8 /.#   *+! 6

‫و@ ! ز‬Value :.! A! ‫'ء !" ر ) ا‬$ ‫ي‬r(. ‫ج‬o ; ‫ إ‬/J 6 ;. A! ‫'  ا‬I6 ‫زم‬o(. #<6 . !#< ‫ ا‬5 ‫ ر ؟‬.‫ ا آ‬/! $ ، ‫ ر‬.‫ ; ا آ‬6 J (‫ و ر‬A! ‫ إذا ء ا‬: ‫ `ال‬9 r :  * %1 ‫ و‬1-  ; %.
• •

SD involves the ability of the individuals to form, revise, and pursue a plan for their life that appear good to them. It includes the exercise of decision and action.

Done By Moath Al-ahmad

!1‫أ‬، 89: ‫ل‬0، ‫ آا‬78 ، ‫ ا 'ل‬78 ، 4 5 ‫ ! أ‬6، 2 #‫ أ‬: # - ‫ إه!اء‬01‫أ‬ ‫م‬9 ‫ ا‬E ، 785 !? ، ‫ا‬C‫ ?! ه‬، A B ‫ أ‬#1 ، ‫ت‬08‫ ?! ه‬، 4<= ‫?د‬، 4;  ‫ا‬ . ‫?د داري‬، #‫" ر‬F ‫و م‬، ‫ ( إ م‬، -IJ ‫ا ا‬K‫ ه‬4< *8L M8<%  ‫ر و‬%‫ ا !آ‬21  -N O"%‫ أ; آ‬P ‫ ء‬Q6‫ أ‬4< ‫ إذا‬4;? ‫و‬

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