Questionnaire study

This study is part of a WHO-SEARO funded project on "Teaching and application of health ethics in South East Asia". The results will be used to develop a teaching module in medical ethics for the region. The study is carried out in Bangladesh, India, Indonesia, Nepal, Myanmar and Sri Lanka. The principal investigator in Country is PI, Title, Address.

The questionnaire has two parts. The first part concerns ethical issues arising in the physician-patient relationship. The second part concerns ethical issues related to health policy. The questions have previously been used in questionnaires in other countries.

We really appreciate that you take the time to complete this questionnaire! On the last page there is space for comments on the questionnaire, or for any other comments that you wish to make with regard to the teaching of medical ethics.

PART I: ETHICAL ISSUES IN THE PHYSICIAN PATIENT RELATIONSHIP

CASE A

A barium enema reveals a stricture of the sigmoid colon in one of your patients. The diagnosis of sigmoid carcinoma is confirmed by microscopic examination of biopsies. Further investigations show no signs of metastases in the liver or elsewhere. You are the physician in charge of treating his patient, and you decide that it will be necessary to do a resection of the colon.

Please answer all questions with a yes or a no; please circle as appropriate.

I-A1: Would you tell this patient that he/she has a cancer, if he/she asks no questions?

Yes No

You then meet the patient's wife or husband (in the patient's absence). The wife/husband asks to be told the diagnosis.

I-A2: Would you tell the wife/husband that the patient has cancer?

Yes No

I-A3: Would you tell the patient described above that he/she has a cancer if he/she directly asks you to disclose the diagnosis?

Yes No

Please answer the following question only if you answered no to question I-A3:

I-A4: Would you tell the patient described above that he/she has cancer if she/he says: Please tell me whether I have cancer. My daughter plans to get married, and if I have cancer we will schedule the wedding sooner. I have always wanted to be present at my daughter's wedding.

Yes No

I-A5: Would you tell the patient described above that he/she has a cancer if he/she before the examination directly asks you not to disclose the diagnosis?

Yes No

I-A6: Would you tell the patient described above that he/she has a cancer if the wife/husband says that the spouse should not be told?

Yes No

The partial colectomy is successful, but during the operation the surgeon notices several small metastases in both liver lobes (which were not seen during the preoperative investigations).

I-A7: Would you tell the patient about this finding (supposing that the patient asks to be told the result of the operation).

Yes No

I-A8: Would you tell the patient that the condition is incurable?

Yes No

After this, you are approached by the patient's wife or husband (in the patient's absence). The wife/husband asks to be told the result of the operation.

I-A9: Would you tell the wife/husband that the operation revealed metastases?

Yes No

I-A10: Would you tell the wife/husband that the condition is incurable?

Yes No

Question 1

In your opinion, should the following information routinely be provided to patients

(please answer yes or no, please circle as appropriate):

I-1-1) Nature of illness Yes No

I-1-2) Cause of illness Yes No

I-1-3) Complications of illness Yes No

I-1-4) Possible side effects/complications of treatment Yes No

I-1-5) Other available treatment options Yes No

I-1-6) Nature of investigation Yes No

I-1-7) Duration of treatment and follow up Yes No

I-1-8) Approximate cost of investigation/treatment Yes No

I-1-9) Prognosis Yes No

Question 2

I-2) I treat cancer patients Yes No

Please answer the following two questions only if you answered yes to question I-2:

Question 2-1

Which of the following two statements do you agree with (please circle only one answer

alternative):

I-2-1-1) It is my usual policy to tell cancer patients that they have cancer

I-2-1-2) It is my usual policy not to tell cancer patient that they have cancer

Question 2-2

How often do you make exceptions to your general policy of telling/not telling cancer

patients that they have cancer (please circle only one answer alternative):

I-2-2-1) Often (between 25% and 50% of the cases)

I-2-2-2) Occasionally (between 10% and 25% of the cases)

I-2-2-3) Very rarely (less than 10% of the cases)

I-2-2-4) Never

CASE B

A woman who is 8 months pregnant is brought to the emergency room because of vaginal bleeding. The physician who sees her suspects an impending abortion. He explains to her that it is necessary to do a physical examination. The woman refuses, however, to be examined by a male physician. There is no female physician available in the area. The physician explains to her that both she and her foetus may die if she is not examined. She still refuses to be examined by the male doctor, and also refuses to be examined in the presence of a female attendant. She does not seem to be confused, and she seems to understand the seriousness of the condition. What should the doctor do?

(Please circle only one answer)

I-B1) Tell her that if she does not want to be examined by him, he can take no responsibility for her. She should therefore leave the hospital.

I-B2) Tell her that he will not examine her right now, but should an immediate life-threatening condition arise, he will have to examine and treat her. She can stay in the hospital if she wants to, but she is also free to leave.

I-B3) Tell her that he will not examine her right now, but should an immediate life-threatening condition arise, he will have to examine and treat her. She will have to stay in the hospital, and would not be free to leave.

I-B4) Admit her against her wishes to the hospital and examine her without waiting to see how the condition develops.

1-B5) Ask her husbands'or other responsible attendents'permission and then proceed to examine her, even if she objects.

CASE C

The vaccination programme against measles in your village where you are the Medical Officer has set a target for the village health nurse. If she does not achieve this target the District Health Officer will take her to task. In the meantime there is an epidemic

of measles in the neighbouring village. You are asked to ensure that the children in your whole village are immediately immunised, and you pass on the necessary instructions to the village health nurse. However while she goes about her task a family with three children refuses to accept the vaccination fearing the possible side effects of the vaccine. What would you do?

(please circle only one answer)

I-C1) Vaccinate the children.

1-C2) Educate the parents and then let them decide.

1-C3) Educate the parents and then insist on vaccinating the children.

1-C4) Have the village leaders educate the family and proceed with vaccination.

1-C5) Give the vaccination by force with the help of the village leaders.

1-C6) Let the parents decide and not vaccinate the child.

If the parents tell you that they do not want the children vaccinated because if they are vaccinated they would be harmed by an angry God, what would you do?

(please circle only one answer alternative)

1-C7) Vaccinate the children.

1-C8) Educate the parents and then let them decide.

1-C9) Educate the parents and then insist on vaccinating the children.

1-C10)Have the village leaders educate the family and proceed with vaccination.

1-C11)Give the vaccination by force with the help of the village leaders.

1-C12)Let the parents decide and not vaccinate the child.

CASE D

A 30 year old man presents to you with history of weight loss associated with a chronic diarrohoea and features of oral candidiasis for the past 8 months. He is recently married and has frequent intercourse with his wife as they desire to have a child You suspect an HIV infection. What would you do?

(please circle only one answer alternative)

1-D1) Inform the patient that you suspect that he may have the HIV infection and would like to take an HIV test if he gives his permission.

1-D2) Inform the patient that as you suspect he has the HIV infection you are going to take his blood for an HIV test irrespective of his giving permission.

1-D3) Not inform the patient about your suspicion of him having the HIV infection but take blood for an HIV test as one of several other blood tests without telling him.

If you answered D1) or D2) above, please answer the following question:

If the patient refuses to give permission to have the blood tested, what would you do? (please circle one answer alternative):

1-D4) Take an HIV test as one of several other blood tests without informing him.

1-D5) Not take the HIV test but treat him for his symptoms empirically.

1-D6) Not take the HIV test but refuse to treat him.

Considering that he is married, what would you do?

1-D7) Inform his wife that he may be HIV positive and having unprotected intercourse will endanger her and her children to be born.

1-D8) Not inform his wife about your suspicions and the risks thereof.

At this point he tells you that he knows that he is HIV positive.You tell him that he has to tell his wife about this and the risks involved to her and their progeny. However he refuses on the grounds that it would destroy his marriage. What would you do?

(please circle only one answer)

1-D9) Contact his wife and inform her that her husband is HIV positive and the risks to her.

1-D10)Educate him on safe sexual practice and not inform his wife about her husbands HIV status .

You find out that the wife is 3 months pregnant. What would you do?

1-D11)Contact her and inform her about her husbands HIV status.

1-D12)Contact her, inform her about the husband's status and then advise her to undergo the HIV test.

1-D13)Contact her and adivse her to undergo a blood test without informing her that it is an HIV test or informing her about her husbands status.

1-D14)Not inform her about the problems involved.

PART II: ETHICAL ISSUES IN HEALTH POLICY

In our society there is not enough money to give all patients all the health care they want or need. There is also a shortage of donor organs for patients in need of organ transplantation. In practice, this means that some patients get treated more quickly than others. It can also mean that some patients receive certain kinds of expensive treatment while others do not. In both cases we may say that some patients are given priority over others. On what basis should priority be given? This is the question we are asking you to consider in this part of the questionnaire.

Choose the one (and only one) statement in each group that best reflects your opinion.

Group A

II-A1. Among people with life threatening illnesses, younger patients should have some priority over older patients.

II-A2. People should have the same priority with respect to life saving treatment, unless they are very old.

II-A3. People should have the same priority with respect to life saving treatment, no matter what their age is.

Group B

II-B1. For medical care that improves quality of life permanently, young people should have some priority over elderly people.

II-B2. For medical care that improves quality of life permanently, elderly people should have some priority over young people.

II-B3. People should have the same priority with respect to medical care that improves quality of life permanently, no matter what their age is.

Group C

Consider a situation in which a 15 year old child and a one year old child both need the same treatment. You can only treat one of them. Which of the following do you agree with:

II-C1. The 15 year old child should be treated

II-C2. The one year old child should be treated

II-C3. No preference

Group D

II-D1. Among patients who are suffering equally, some priority should be given to those who will be helped most from treatment.

II-D2. Among patients who are suffering equally, those who can become a little better should have the same priority as those who can become much better.

Group E

II-E1. Parents with dependent children should have some priority over other adults

II-E2. For the same illness, people without children should have the same priority as people with children

Group F

Many people enjoy cigarette smoking. But cigarette smoking is also a cause of heart disease and lung cancer. Which of the following do you agree with:

II-F1. If there is not enough money to treat everybody with heart disease or lung cancer, non-smokers should have some priority over smokers.

II-F2. Smokers should have the same priority with respect to treatment for heart disease and lung cancer as everybody else.

Question G

Mr. A and Mr. B are two 45 year old clerks. Each of them suffer a life threatening injury following a road traffic accident. A major operation can make Mr. A completely healthy. An equally major operation can give Mr. B a life with moderate pain and dependency on crutches for walking. There is no question on further treatment or later medication. Both know the expected outcome of the operation and both wish to be treated. They have been admitted to the same hospital within a few hours of each other. It is uncertain whether the hospital will manage to operate both on time.

In your opinion how should the hospital prioritize between the two (Please circle one answer alternative):

II-G1) Treat Patient A first

II-G2) Treat Patient B first

II-G3) Treat them in the order they came to the hospital, i.e. treat the one first who came first to the hospital

II-G4) Draw lots

II-G5) Other, or do not know

If the case of A's condition was attempted suicide, but apart from that, the situations are the same. Would this change your decision? Please circle one answer alternative:

II-G6) Yes No

If B is a friend of yours, would that change your decision? Please circle one answer alternative:

II-G7) Yes No

We would like to know a few things about yourself:

III-1) What is your specialty?

III-2) How many years have you worked in your area of specialty?

III-3) What is your age?

III-4) Have you had any formal training in medical ethics?

Yes No

Please write any comments that you may have concerning this questionnaire or concerning teaching of medical ethics below. Continue on the back of this page if necessary. Thank you very much for your participation!