CASE 1
Almaz is a severely retarded 13-year old with an IQ of about 25 - 30 (the equivalent of a mental age of 1 to 2 years), blind and with pronounced neurological problems. She was born a normal child. At the age of five months she was severely injured in an automobile accident, which caused brain damage and temporary paralysis. Unable to cope with the event, Almaz's mother took her to live with her grandmother, who is 51 years old. Almaz, her two sisters, and her aunt have been living with her grandmother, ever since. Almaz regularly attends a special school but has missed many sessions lately because of her physical problems. Almaz has reached puberty and is experiencing pain connected with menstruation. She is unable to care for her most basic hygienic needs and is irritable and disoriented during the menstruation process.
Her grandmother, wanting to free Almaz from her pain and disorientation during her periods, as well as to protect her from the consequences of rape, seeks to have a hysterectomy performed, which would both terminate Almaz's menstrual cycle and sterilize her. The general practitioner who examined Almaz at the OPD was not able to reach a conclusion as he is a fresh graduate and never saw such a case. Therefore he consulted with the senior gynecologist who is in charge of the department of Gynecology and Obstetrics. After thinking about it, he advised the grandmother to apply to the Court and to bring a legal paper from the Court. As it was not a tradition to uncover such secrets in the society, the grandmother believed that it was not right to report it to court, in order not to have this case publicized. She believes that the physician knows many more facts about the child than the Court does. Refusing to report to the Court, the grandmother insisted that the Gynecologist perform the procedure. But he refuses to perform the hysterectomy on Almaz. Is the correction taken by the physician correct? Why or why not?
Case prepared by Tsigeweini Tessema, Ethiopia
CASE 2
A Tamil lady consults a doctor at a peripheral unit for her 8th pregnancy. The doctor having seen her advises her that her chances of developing post partum bleeding after delivery is very high, as it is usually so with these patients and advised her to plan to have her delivery at a general hospital where she can receive better emergency care. However, the patient vehemently refuses to go to the general hospital for delivery claiming that all her previous pregnancies took place at the peripheral unit and were event less. At delivery, however, she arrived at this peripheral hospital and insisted that she is admitted. The doctor, upon her request, admitted her, but the patient developed severe post partum hemorrhage after delivery. The patient was then transferred to the General Hospital by private transport as there was no ambulance available, but was found dead on admission at the General Hospital.
1. What do you think of the action of the doctor?
2. At an inquiry into the death of this patient, what factors would you consider for and against what the doctor did?
Prepared by the Medical Education Unit, University of Peradeniya, Sri Lanka
CASE 3
A young illiterate village woman 25 years old was referred to a general hospital by a medical officer working at a peripheral unit for investigation of a lump in her breast. The surgeon who examines her suspects breast cancer, a firm diagnosis of which could only be made at surgery when immediate histological examination of breast tissue can also be done. The surgeon then explains to the patient that, unless she agrees to surgical removal of her breast, upon confirmation of the diagnosis at surgery, that he cannot perform an investigative surgery to confirm the diagnosis. The patient refuses to give consent to mastectomy (removal of the breast) proposed by the surgeon, but agrees to the investigative surgery.
If you are the surgeon,
1. What would you do?
2. Would you change your mind to do an investigative exploration of the breast lump even when the patient has disagreed to a mastectomy?
Prepared by the Medical Education Unit, University of Peradeniya, Sri Lanka
CASE 4
A 30 year old lady presented with lower abdominal discomfort. A diagnosis of fibroids was made and the gynecologist informed her that she will have to undergo surgery to remove her lump. On admission the nurse requested the patient to sign giving consent for the operation. As often happens the patient signed and did not ask any questions. As is the usual practice details of the surgical procedure and possible complications were not disclosed. During the operation, extensive adenomyosis (a benign condition) was observed and the surgeon removed the womb as he felt this was in the best interests of the patient.
The lady who has only one child became very distressed after surgery when she got to know that her womb was removed and she could not conceive again.
1) Should the patient have been given more information prior to surgery even though she did not request further information?
2) Assume that the patient had a massive hemorrhage during surgery which resulted in the removal of her womb. Then would the information she was given prior to the surgery be adequate?
3) Should you disclose rare but serious complications to patients?
4) What are the possible consequences of the current practice regarding consent prior to surgery?
Prepared by Department of Psychological Medicine, University of Colombo, Sri Lanka.
CASE 5
Mr. R. is a clerk at a municipal council and is 40 years old, married with four children. His wife is a teacher and the age of their youngest child is just 8 months while the oldest is 8 years old. Mr. R. has been taking private treatment from a consultant physician for upper abdominal pain and loss of appetite for a duration of one year. This physician has clinically diagnosed peptic ulcer and had been treating him with a drug known as cimetidine which reduces gastric acid secretion. When Mr. R. turned up repeatedly for treatment, the physician changed the drug to omeprazole which is a second line drug (a drug used to treat patients with peptic ulcer when the condition does not respond to a drug such as commodation). Although this physician has seen this patient several times during that time in his private clinic, he has not requested an endoscopy (an investigation where a fibre optic device is used to look at the wall of the stomach).
Later, Mr.R. decided to see another doctor who is a consultative surgeon. This second doctor, having listened to the patient's history decided that Mr. R. needs an endoscopic examination. The endoscopic examination revealed an extensive gastric cancer with possible secondaries in other parts of the body. The surgeon then decided that the patient's condition is fatal although surgery may bring him some temporary relief.
If you are the surgeon:
1. Would you tell the patient that he has an extensive cancer?
2. Would you tell the patient what the first physician has done to him?
3. Would you contact the first physician to tell him what you have found?
4. Would you complain about the practice of the first physician to the Medical Council?
Prepared by the Medical Education Unit, University of Peradeniya, Sri Lanka
CASE 6
A 30 year old Muslim female patient who is married and has a child of two years, consults a general practitioner for skin patches that she has developed on her face and on the back of her chest. Her husband is a rich merchant. The general practitioner having examined her refers the patient to the Anti Leprosy Campaign clinic at Kandy. At the ALC clinic she was diagnosed with a case of lepromatous leprosy (which is an infective type of leprosy with prolonged contact). The patient was also told by the ALC officials that she need to take treatment (pills) for two years continuously. She returns to their family physician along with a letter from the ALC clinic indicating the diagnosis and pleads with her doctor not to reveal the diagnosis of her illness to her husband who is also very well known to this physician.
If you are their family physician,
1. What advice would you give to this patient?
2. Would you tell her husband about her illness in spite of the request?
Prepared by the Medical Education Unit, University of Peradeniya, Sri Lanka
CASE 7
A 30 year old physician was admitted with symptoms suggestive of AIDS. The consultant requested an HIV test. The patient agreed to testing, but wished his identity and personal details were not disclosed. The STD clinic at the General Hospital refused to carry out the test without the above details as they required the information for 'epidemiological purposes'. The test was done in the Faculty of Medicine as they agreed to test it anonymously.
1) Does the patient have a right to refuse disclosing personal details?
2) Can a public facility refuse to carry out a medically indicated test if the personal details are not revealed?
3) Is there a Government policy on confidentiality/disclosure of information?
The general procedure is to draw blood without informing the patient that it is for HIV testing.
4) Is this procedure acceptable?
Prepared by Department of Psychological Medicine, University of Colombo, Sri Lanka.
CASE 8
At a hospital in Uganda a patient was admitted in the emergency department with a bleeding gastric ulcer. He was a 38 year old man, married with three children. On assessment it was found that he required immediate surgery. He signed his consent but while being anaesthetized pleaded that he not be given blood in case it was required. The operation was performed and the surgeon in charge ignored the request as the patient had lost too much blood, and infused him with two pints of unscreened blood. Later on screening in the blood bank it was found that at least 10% of the blood was HIV positive.
1. Was the surgeon's action ethical?
2. If the patient did get AIDS from the physician do you blame the doctor (he actually did).
Prepared by Margaret Wander, Uganda
CASE 9
A 32 year old lady was admitted to the Obstetrics ward because of severe hypertension. She was 28 weeks pregnant. This was her third pregnancy. Emergency caesarian section was decided because of the failure to control the hypertension by medication. When the baby was delivered he had to be rescucitated because he could not breathe on his own. He weighed very little and developed many complications, such as hypoglycaemia, convulsions, hypoalbuminaemia etc. He was put in an incubator and on a respirator. The child did not develop spontaneous reflexes and did not improve after some days. His father was a Pediatrician and was aware of the fact that if the child would survive, he would have severe brain damage. He told the doctors not to do vigorous attempts of rescucitation in case of emergency, such as heart failure, convulsions etc. In case of a need for rescucitation, what should the doctor do? Should he/she do as advised by the father or go ahead with the rescucitation?
Case prepared by Tehmina Mustafa, Pakistan
CASE 10
Suppose you are working as a doctor in one of the refugee- camps where social and economic problems are rampant. You are a very religious person. You work there as a doctor because to save lives is the most noble thing you can do in your life. The refugees in this camp receive food rations and clothes occasionally from assistance agencies. They get medical care from your organization. A few of the refugees who have relatives in other countries might receive money from them.
One day a 15 year old girl is brought to see you by the social counselor. According to the social counselor, the girl was a friend of one person who was killed during a camp riot. According to the social counselor, the girl has symptoms of pregnancy. You examine her and find that she is 2 months into pregnancy. The girl is desperate and she says that she does not want to carry a baby. She has no relatives neither in the camp nor abroad to support her socially and economically. Nobody knows the fortunes of this refugee's life.
You have conflicting thoughts. You do not want a 15-16 year old girl to carry a heavy burden because of your refusal to help her. At the same time you are very reluctant to break your religious vow. The girl demands that you perform an abortion.
1. If you were in this doctor's place what would you decide?
2. Is it fair to let her go without intervening, if you are a very religious person?
Case prepared by Sabah Phyu, Burma
CASE 11
A researcher has arrived from USA to conduct a project in Sri Lanka. The project consists of
1) obtaining blood samples for analyzing a genetic imprint which is indicative of an incurable nervous disorder and
2) taking a detailed history and family history from the subjects. The project has not been approved in the USA because of the sensitive nature of the data and its implications to prospective employment and insurance coverage.
The project is submitted to a Research Ethics Committee for approval.
a) If you are a member of this ethics committee, what ethical issues would you consider in this case?
b) What are your recommendations?
c) What appropriate mechanisms would you recommend for the review of research on human subjects?
Prepared by the Department of Psychological Medicine, University of Colombo, Sri Lanka
CASE 12
A male patient of 26 years was admitted to the hospital in the surgical ward having sustained a compound (open) fracture of his left leg in a football match. In addition to surgical treatment, the doctor had prescribed anti-tetanus therapy and antibiotics. Unfortunately, none of the drugs were available in the hospital, so the doctor advised the relatives to purchase them from the local pharmacy. The patient and relatives refused to purchase the drugs. Instead they insisted that the patient be discharged so that they could take him to another hospital. When the doctor tried to persuade them otherwise, a row ensued. The doctor gave in, but before she discharged the patient, the doctor asked them to sign a statement that "the patient is discharged against the doctor's advice". The patient was brought back 3 days later with tetanus and died in the intensive care unit the following day. A professional inquiry was set up to investigate the case while at the same time the relatives of the deceased took the case to court to sue the hospital and the doctor for negligence.
CASE 13
Peradeniya teaching hospital is permitted to send only one patient a week for CT scanning to the General Hospital in Colombo, where this facility is available. However, CT scan service is freely available in the private sector for about Rps. 5000. The medical unit at the Peradeniya medical hospital has the following patients, who, according to the consultants, need immediate CT scanning:
1) A school girl 12 years old, only child of a farmer from Mahiyangana who is suspected of having an extradural hematoma following an injury to the head which she has suffered while doing sports at school. Doctors also found that her level of consciousness is slowly deteriorating.
2) A just retired school principal of a leading school who has been admitted to the ward unconscious and doctors having examined him thought that there could be an intracranial hematoma which could be surgically evacuated. This principal is married with 3 children, two of the are still in school. His wife is not employed.
If you are in charge of the medical unit at Peradeniya
1. Which of the above two patients would you send to Colombo for CT scanning?
2. What is the basis for your selection?
Prepared by the Medical Education Unit, University of Peradeniya, Sri Lanka.
CASE 14
Dr. X was allowed by his Government and Ethics committee to do a prevalence study in a certain village which was reputed to have had many people who suffered from sexually transmitted diseases (STDs), including HIV. He promised his clients that the whole exercise will be highly confidential, that everybody had the freedom to choose if she/he wanted the results of the investigations or not, and their decisions would be respected.
Mr Y, a 38 year old man, was celebrating one year of marriage with his third wife. He was a strict Muslim, in fact his father had had seven wives. The man was rich, respected and therefore very influential in the village. He looked very cooperative and positive towards the whole program, and indeed his contribution to the success of the program was phenomenal.
In the day of his examination, he was the first to report with his two wives and all of his five children; the eldest being 16. The missing wife had traveled to visit her parents who lived far away from the village. Everybody was handled individually with total confidentiality, except for the children whose consent came from the parents. All of them wanted to know the outcome of the investigations except Mr Y and the latest (third) married wife.
The results revealed that the youngest wife was positive for syphilis and HIV. Mr Y had a weak positive reaction for syphilis and a negative test for HIV (confirmed with several other tests). The rest screened negative to all the tests performed. Brief history revealed that the third wife was a bar maid, a profession she had just given up after marriage. The 1st wife had this to say: "I have hardly been together with my man for the past one year, but this does not worry me because I know he is just fascinated with the new young blood. He will come to me again very soon".
1. How should Dr. X handle the innocent 1st wife when she comes for the test results?
2. How will Dr. X manage the man, who perhaps shows early signs of syphilis and also is in critical danger of contracting HIV, if he is not in the window period?
3. How should Dr. X handle the 3rd wife who is both positive for syphilis and HIV?
4. Should Dr. X get concerned with the 2nd wife who had traveled and was not available for investigation?
5. Should Dr. X be concerned with the children?
Prepared by E. J. Masenga, Tanzania