Journal of Epidemiology and Global Health

Volume 10, Issue 2, June 2020, Pages 143 - 152

Top Ethical Issues Concerning Healthcare Providers Working in Saudi Arabia

Authors
Amar Mansour Almoallem1, Mohammed Abdulaziz Almudayfir1, Yassar H. Al-Jahdail1, Anwar E. Ahmed2, 5, Adnan Al-Shaikh1, 3, 5, Salim Baharoon1, 4, 5, Abdullah AlHarbi1, 4, 5, Hamdan Al-Jahdali1, 4, 5, *
1College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
2College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh
3Department of Pediatrics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah
4Department of Medicine, King Abulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh
5College of Medicine, King Abdullah International Medical Research Center (KAIMRC), Riyadh
*Corresponding author. Email: Jahdalih@gmail.com
Corresponding Author
Hamdan Al-Jahdali
Received 30 May 2019, Accepted 20 October 2019, Available Online 13 January 2020.
DOI
10.2991/jegh.k.191211.001How to use a DOI?
Keywords
Ethics; bioethics; ethical issues; ethical dilemma; health care; health care professionals; Saudi Arabia
Abstract

Background: Healthcare providers working in Saudi Arabia come from various nationalities, cultures, and training backgrounds. This study aimed to assess the perceptions of healthcare providers working in Riyadh hospitals about ethical dilemmas and solutions.

Methods: This is a cross-sectional study among physicians working in Riyadh’s private and governmental hospitals between June and December 2017. The study collected information on demographics, knowledge about medical ethics, the sources of such knowledge, and common ethical issues in general and the top ethical issues and dilemmas encountered in their daily practice.

Results: A total of 455 physicians from government and private hospitals were enrolled in the study. The mean age of the participants was 34.29 ± 10.5 years, females were 29.7% and mean years of practice was 13.0 ± 11.5. The top ethical issues identified by the participants were “disagreement with the patients’ relatives about treatment” (91%), patient disagreement with decisions made by professionals (84%), treating the incompetent patient (79%), conflict with administration policy and procedures (77%), scarcity of resources (72%), and making decision about do-not-resuscitate or life-sustaining treatment (68%). There were significant differences in dealing with ethical issues in relation to gender, confidence about ethical knowledge, nationality, seniority, training site, and private or government hospitals academic and nonacademic.

Conclusion: Healthcare providers in Riyadh hospitals face multiple ethical challenges. In addition to improvement in ethics knowledge through educational program among healthcare professional, there is a valid need for healthcare professionals and other sectors within society to engage in serious and continuous dialogue to address these issues and propose recommendations.

Copyright
© 2020 Atlantis Press International B.V.
Open Access
This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).

1. INTRODUCTION

Healthcare professionals frequently encounter moral dilemmas during their daily practice [1,2]. Previous studies have explored major ethical dilemmas faced by healthcare professionals in different cultures and countries [38]. For example, the top three ethical issues for Canadian healthcare professionals were disagreement between patients/families and healthcare workers regarding treatment decisions, waiting lists, and access to needed resources, whereas impaired capacity for decision making, caregiver’s disagreement, and end-of-life treatment limitation were the top for European doctors [6,9].

Previous studies among a small sample of Saudi physicians found the major ethical challenges for healthcare specialists were patients’ rights, equitable resource allocation, and patients’ confidentiality [10]. There were also studies addressing ethical issues in specific situations such as dealing with physician’s behavior or treating patients with do-not-resuscitate (DNR) status [1113]. However, these studies did not assess other related factors such as knowledge of physicians about medical ethics, professional codes of ethics, ethics guidelines and their gender, nationality, and years of experience.

Because healthcare professionals in Saudi Arabia originate from various nationalities, cultures, and training backgrounds and the healthcare delivery systems also differ between private and government hospitals, there is need to assess how these might result in differences in the perception of ethical dilemmas by physicians.

This study aims to identify the major ethical challenges and issues facing the physicians in general, in terms of possible differences between ethical issues among physicians working in government and private hospitals, and in assessing the association between healthcare professionals’ perception of ethical issues and their background, education, nationality, and specialty.

2. MATERIALS AND METHODS

This is a cross-sectional descriptive study conducted using a self-administered questionnaire. The study objectives were explained to the participants and their agreement to complete the questionnaires was considered consent to participate. This study was approved by King Abdullah International Medical Research Center Institutional Review Board (SP/17/137//R). We distributed 600 questionnaires, 455 respondents agreed to participate and completed the questionnaires, giving 76% response rate.

The questionnaire was distributed directly to physicians ranked as senior residents (third year of training or higher) and consultants across six government and three private hospitals in Riyadh. This was a convenient sampling by distributing questionnaire directly to physicians during general symposia, conferences, and clinics between June and December 2017.

The questionnaire consisted of three sections. The first section covered demographic data including, age, gender, country of origin, specialty, religion, years of experience, and type of hospital in which the participant works (government or private). The second section listed 20 common healthcare ethical issues/dilemmas and the participants were asked to rank them as per their frequency and importance. The third section requested that participants rank the top 10 most common ethical issues and most difficult-to-resolve ethical issues or dilemmas that they faced from the listed 20 common ethical challenges or moral dilemmas.

The list of ethical issues and dilemmas or difficulties generated in the questionnaires were established after reviewing published studies about ethical issues in Saudi Arabia and other countries.

2.1. Data Analysis

The data were entered and analyzed by IBM SPSS (IBM SPSS Statistics 22; SPSS, Chicago, IL, USA) to measure the frequencies and percentages, and a scoring system was used to assess the most frequent ethical issues encountered by healthcare workers according to the following scoring system: rare/seldom = 0 points and sometime/often = 1 points. We assessed the effect on responses of gender, seniority of physicians, practicing in private or government hospitals, nationality, and training. Chi-square tests were used to assess difference in the proportion of respondents who sometimes or often encountered each ethical dilemma by demographic and vocational factors. Tests were repeated to assess significant differences in confidence in ethical knowledge and referral of cases to ethical committees by these factors as well. Significance for chi-square tests was set at p < 0.05.

3. RESULTS

A total of 455 participants were analyzed. The mean age of the participants was 34.29 ± 10.5 years, females were 29.7%, and mean years of practice was 13.0 ± 11.5. Saudi physicians accounted for 82% of participants. Participants from medical specialties represented 35.2%, surgical specialties 23.1%, and general and family medicine specialties 30.1%. The majority of participants (76.2%) received their knowledge of ethics in medical college, 59.3% through self-teaching means, and 78.5% felt confident about handling ethical issues in their practice. Ethics committees were available in 73% of the hospitals and 11.8% of the physicians consulted their ethics committees. Other demographics are shown in Table 1.

N (%)
Gender
  Female 135 (29.7)
  Male 320 (70.3)
Saudi nationality
  Yes 361 (82.0)
Religion
  Muslim 425 (98.8)
Location of training/education
  Local 327 (71.9)
  International 128 (28.1)
Current position
  Consultants 109 (23.9)
  Associate/Assistant consultant (Senior Registrar/Registrar) 94 (20.7)
  Resident/Fellow 252 (55.4)
Primary practice site
  Hospital 406 (89.2)
  Clinics 49 (10.8)
Admitting hospital
  Government/teaching 345 (75.8)
  Non-government (private) 110 (24.2)
Participant specialties
  Medical specialties 160 (35.2)
  Surgical specialties 105 (23.1)
  General/family medicine 137 (30.1)
  Others 54 (11.6)
Knowledge about ethics
  Through medical college curriculum 347 (76.2)
  Attended ethics conference/courses 119 (26.1)
  Self-teaching 270 (59.3)
Confident about handling ethical issues in medical practice?
  Confident 357 (78.5)
Availability of ethics committee in your hospital
  Yes 335 (73.6)
Have you ever referred a case to an ethics committee
  Yes 54 (11.8)
Table 1

Demographic characteristics and knowledge about ethics

The most commonly encountered ethical issues were: disagreement among patients/family and healthcare professionals about treatment decisions (91%), patients’ disagreements with decisions made by professionals (84%), treating patients with impaired or uncertain decision-making ability (79%), disagreement with administration policies and procedures (77%), and other major ethical issues as shown in Table 2. Three most important ethical dilemmas listed by participants were DNR, “improperly taken consent”, and “relationship with the drug industry”. The most difficult-to-resolve ethical issues were DNR and “handling end-of-life issues”.

Rank Top ethical issue as ranked by participants N (%)
1 Disagreement among patients/family and healthcare professionals about treatment decision 414 (91)
2 Patient disagreement with decision made by professional 382 (84)
3 Treating patients with impaired or uncertain decision making 359 (79)
4 Conflict with administration policies and procedures 350 (77)
5 Scarcity of resources in the clinic 372 (72)
6 Making decisions about life-sustaining treatment or do-not-resuscitate order 309 (68)
7 Uncertainty whether to disclose diagnosis to the patient/delivering “bad news” 304 (67)
8 Handling end-of-life issues in general 300 (66)
9 Conflict on the appropriateness deciding on a “no code status” with family or colleagues 295 (65)
10 Improperly taken informed consent 287 (63)
Table 2

Top ethical issues facing healthcare providers

Ethical issues commonly seen in practice include: disagreement among patients/family and healthcare professionals about treatment decision (91.1%), patient disagreement with decision made by professional physicians (84.4%), treating patients with impaired or uncertain decision-making ability (79.1%), conflict with administration policies and procedures (77.3%), scarcity of resources in the clinics (72.8%), making decision about life-sustaining treatment or DNR order (67.9%), disclosing the diagnosis or delivering “bad news” to the patients (67.4%), and disclosing medical errors made by others (66.6%). Other common ethical issues are shown in Table 3.

N (%)
Disagreement among patients/family and healthcare professionals about treatment decision
  Rare/seldom 34 (8.9)
  Sometime/often 346 (91.1)
Patient disagreement with decision made by professional physicians
  Rare/seldom 59 (15.6)
  Sometime/often 319 (84.4)
Treating patients with impaired or uncertain decision-making
  Rare/seldom 79 (20.9)
  Sometime/often 299 (79.1)
Conflict with administration policies and procedures
  Rare/seldom 86 (22.7)
  Sometime/often 293 (77.3)
Scarcity of resources in the clinic
  Rare/seldom 102 (27.2)
  Sometime/often 273 (72.8)
Making decision about life-sustaining treatment or do-not-resuscitate order
  Rare/seldom 121 (32.1)
  Sometime/often 256 (67.9)
Uncertainty whether to disclose diagnosis to the patient/delivering “bad news”
  Rare/seldom 123 (32.6)
  Sometime/often 254 (67.4)
Disclosure of medical error by others
  Rare/seldom 125 (33.4)
  Sometime/often 249 (66.6)
Conflict on the appropriateness deciding on a “no code status ” with family or colleagues
  Rare/seldom 132 (34.8)
  Sometime/often 247 (65.2)
Handling end-of-life issues in general
  Rare/seldom 128 (34.4)
  Sometime/often 244 (65.6)
“Withdrawal” versus “withholding” of therapy
  Rare/seldom 130 (34.7)
  Sometime/often 245 (65.3)
Disclosure of medical error by yourself
  Rare/seldom 137 (36.5)
  Sometime/often 238 (63.5)
Improperly taken informed consent
  Rare/seldom 136 (36.7)
  Sometime/often 235 (63.3)
Uncertainty whether to maintain confidentiality
  Rare/seldom 143 (38.2)
  Sometime/often 231 (61.8)
Perceived unnecessary use of futile therapy
  Rare/seldom 164 (43.5)
  Sometime/often 213 (56.5)
Perceived premature cessation of therapy
  Rare/seldom 178 (47.6)
  Sometime/often 196 (52.4)
Favored care for only some groups of patients above others
  Rare/seldom 186 (49.3)
  Sometime/often 191 (50.7)
Relationship related to drug industry
  Rare/seldom 227 (60.7)
  Sometime/often 147 (39.3)
Surpassing formally specified clinical privilege
  Rare/seldom 199 (52.9)
  Sometime/often 177 (47.1)
Using/adopting a new untested therapy or procedure without prior formal arrangement agreed on
  Rare/seldom 274 (72.7)
  Sometime/often 103 (27.3)
Table 3

Common ethical issues in daily practice

Female physicians were less confident about their knowledge in ethics (p = 0.026), had more difficulties handling end-of-life issues in general (p = 0.021), making decisions about life-sustaining treatment or a DNR order (p = 0.007), and having conflicts with families and colleagues about the appropriateness of “no code status” decisions (p = 0.002). Furthermore, female physicians were less likely to disregard formally specified clinical privilege (p = 0.003), to adopt a new untested therapy or procedure (p = 0.002), or to have a professional relationship with the drug industry (p = 0.050). Other variables are shown in Table 4.

Female, N (%) Male, N (%) p-value
How confident are you about your knowledge about ethics in medical practice? Confident/not confident
  Confident 107 (72.3) 250 (81.4) 0.026*
  Not confident 41 (27.7) 57 (18.6)
Disagreement among patients/family and healthcare professionals about treatment decision
  Rare/seldom 10 (9.3) 24 (8.8) 0.86
  Sometime/often 97 (90.7) 249 (91.2)
Making decision about life-sustaining treatment or do-not-resuscitate order
  Rare/seldom 45 (42.5) 76 (28.0) 0.007*
  Sometime/often 61 (57.5) 195 (72.0)
Treating patients with impaired or uncertain decision-making
  Rare/seldom 20 (26.7) 57 (19.5) 0.18
  Sometime/often 55 (73.3) 235 (80.5)
Conflict on the appropriateness deciding on a “no code status” with family or colleagues
  Rare/seldom 50 (46.7) 82 (30.1) 0.002*
  Sometime/often 57 (53.3) 190 (69.9)
Handling end-of-life issues in general
  Rare/seldom 46 (43.4) 82 (30.8) 0.021
  Sometime/often 60 (56.6) 184 (69.2)
Perceived unnecessary use of futile therapy
  Rare/seldom 51 (47.7) 113 (41.9) 0.30
  Sometime/often 56 (52.3) 157 (58.1)
Perceived premature cessation of therapy
  Rare/seldom 55 (51.4) 123 (46.1) 0.35
  Sometime/often 52 (48.6) 144 (53.9)
“Withdrawal” versus “Withholding” of therapy
  Rare/seldom 39 (36.8) 91 (33.8) 0.587
  Sometime/often 67 (63.2) 178 (66.2)
Patient disagreement with decision made by professional “physicians”
  Rare/seldom 16 (15.1) 43 (15.8) 0.863
  Sometime/often 90 (84.9) 229 (84.2)
Improperly taken informed consent
  Rare/seldom 41 (38.7) 95 (35.8) 0.609
  Sometime/often 65 (61.3) 170 (64.2)
Uncertainty whether to maintain confidentiality
  Rare/seldom 47 (44.3) 96 (35.8) 0.127
  Sometime/often 59 (55.7) 172 (64.2)
Uncertainty whether to disclose diagnosis to the patient/delivering “bad news”
  Rare/seldom 34 (32.4) 89 (32.7) 0.950
  Sometime/often 71 (67.6) 183 (67.3)
Disclosure of medical error by yourself
  Rare/seldom 41 (38.7) 96 (35.7) 0.588
  Sometime/often 65 (61.3) 173 (64.3)
Disclosure of medical error by others
  Rare/seldom 33 (31.1) 92 (34.3) 0.555
  Sometime/often 73 (68.9) 176 (65.7)
Conflict with administration policies and procedures
  Rare/seldom 31 (29.0) 55 (20.2) 0.067
  Sometime/often 76 (71.0) 217 (79.8)
Scarcity of resources in the clinic
  Rare/seldom 33 (31.7) 69 (25.5) 0.222
  Sometime/often 71 (68.3) 202 (74.5)
Favored care for only some groups of patients above others
  Rare/seldom 53 (49.5) 133 (49.3) 0.962
  Sometime/often 54 (50.5) 137 (50.7)
Relationship related to drug industry
  Rare/seldom 72 (68.6) 155 (57.6) 0.051
  Sometime/often 33 (31.4) 114 (42.4)
Surpassing formally specified clinical privilege
  Rare/seldom 69 (65.1) 130 (48.1) 0.003*
  Sometime/often 37 (34.9) 140 (51.9)
Using/adopting a new untested therapy or procedure without prior formal arrangement agreed on
  Rare/seldom 90 (84.1) 184 (68.1) 0.002*
  Sometime/often 17 (15.9) 86 (31.9)
*

The Chi-square statistic is significant at the 0.05 level.

Table 4

Knowledge confidence about ethics and common ethical issues they face in daily practice according to gender

Saudi physicians state that they are more confident about their knowledge in ethics (p = 0.001). Non-Saudi physicians making decision about life-sustaining treatment or DNR orders consulted with the ethical committees in their hospitals more frequently than Saudi physicians (p = 0.001 and 0.009, respectively; Table 5).

Saudi, N (%) Non-Saudi, N (%) p-value
How confident are you about your knowledge about ethics in medical practice: confident/not confident
  Confident 343 (95.0) 14 (14.9) 0.001*
  Not confident 18 (5.0) 80 (85.1)
Have you ever referred a case to an ethics committee? Y/N
  Yes 34 (9.4) 18 (22.8) 0.001*
  No 327 (90.6) 61 (77.2)
Treating patients with impaired or uncertain decision-making
  Rare/seldom 57 (19.5) 20 (26.7) 0.18
  Sometime/often 235 (80.5) 55 (73.3)
Disagreement among patients/family and healthcare professionals about treatment decision
  Rare/seldom 24 (8.2) 8 (10.5) 0.519
  Sometime/often 269 (91.8) 68 (89.5)
Making decision about life-sustaining treatment or do-not-resuscitate order
  Rare/seldom 104 (35.7) 15 (20.0) 0.009*
  Sometime/often 187 (64.3) 60 (80.0)
Conflict on the appropriateness deciding on a “no code status” with family or colleagues
  Rare/seldom 105 (36.0) 22 (28.9) 0.252
  Sometime/often 187 (64.0) 54 (71.1)
Handling end-of-life issues in general
  Rare/seldom 101 (35.2) 24 (32.4) 0.656
  Sometime/often 186 (64.8) 50 (67.6)
Perceived unnecessary use of futile therapy
  Rare/seldom 131 (45.0) 29 (38.7) 0.323
  Sometime/often 160 (55.0) 46 (61.3)
Perceived premature cessation of therapy
  Rare/seldom 144 (50.0) 30 (40.0) 0.123
  Sometime/often 144 (50.0) 45 (60.0)
“Withdrawal” versus “withholding” of therapy
  Rare/seldom 108 (37.2) 20 (27.0) 0.100
  Sometime/often 182 (62.8) 54 (73.0)
Patient disagreement with decision made by professional “physicians”
  Rare/seldom 45 (15.4) 12 (16.0) 0.900
  Sometime/often 247 (84.6) 63 (84.0)
Improperly taken informed consent
  Rare/seldom 100 (35.1) 32 (42.7) 0.226
  Sometime/often 185 (64.9) 43 (57.3)
Uncertainty whether to maintain confidentiality
  Rare/seldom 109 (37.3) 32 (45.1) 0.230
  Sometime/often 183 (62.7) 39 (54.9)
Uncertainty whether to disclose diagnosis to the patient/delivering “bad news”
  Rare/seldom 95 (32.8) 26 (34.2) 0.811
  Sometime/often 195 (67.2) 50 (65.8)
Disclosure of medical error by yourself
  Rare/seldom 107 (36.9) 25 (33.8) 0.619
  Sometime/often 183 (63.1) 49 (66.2)
Disclosure of medical error by others
  Rare/seldom 96 (33.2) 26 (35.1) 0.755
  Sometime/often 193 (66.8) 48 (64.9)
Conflict with administration policies and procedures
  Rare/seldom 65 (22.3) 19 (25.0) 0.612
  Sometime/often 227 (77.7) 57 (75.0)
Scarcity of resources in the clinic
  Rare/seldom 78 (27.0) 21 (28.0) 0.861
  Sometime/often 211 (73.0) 54 (72.0)
Favored care for only some groups of patients above others
  Rare/seldom 139 (47.6) 43 (58.1) 0.106
  Sometime/often 153 (52.4) 31 (41.9)
Relationship related to drug industry
  Rare/seldom 183 (63.3) 38 (50.7) 0.046*
  Sometime/often 106 (36.7) 37 (49.3)
Surpassing formally specified clinical privilege
  Rare/seldom 161 (55.5) 32 (42.7) 0.047*
  Sometime/often 129 (44.5) 43 (57.3)
Using/adopting a new untested therapy or procedure without prior formal arrangement agreed on
  Rare/seldom 212 (72.9) 54 (72.0) 0.883
  Sometime/often 79 (27.1) 21 (28.0)
*

The Chi-square statistic is significant at the 0.05 level.

Table 5

Knowledge about ethics and common ethical issues they face in daily practice according to nationality

Physicians who received their education and postgraduate training abroad were confident about their ethics knowledge in medical practice (p = 0.001) but had less confidence in making decisions about life-sustaining treatment or DNR orders (p = 0.001) and referred more cases to the ethics committee (p = 0.002). Also, international trainees surpassed the requirements for formally specified clinical privilege (p = 0.001) or had a professional relationship with drug industry (p = 0.001) compared with local trainees (Table 6). When we adjusted our analysis as shown in Table 6, no predictor was correlated with knowledge about ethics and common ethical issues they face in daily (p > 0.05).

Local, N (%) International, N (%) p-value
How confident are you about your knowledge about ethics in medical practice (confident/not confident)
  Confident 244 (74.6) 113 (88.3) 0.001*
  Not Confident 83 (25.4) 15 (11.7)
Have you ever referred a case to an ethics committee? Y/N
  Yes 29 (8.9) 25 (19.5) 0.002*
  No 297 (91.1) 103 (80.5)
Disagreement among patients/family and healthcare professionals about treatment decision
  Rare/seldom 25 (9.3) 9 (8.1) 0.713
  Sometime/often 244 (90.7) 102 (91.9)
Making decision about life-sustaining treatment or do-not-resuscitate order
  Rare/seldom 101 (38.0) 20 (18.0) 0.000*
  Sometime/often 165 (62.0) 91 (82.0)
Conflict on the appropriateness deciding on a “no code status” with family or colleagues
  Rare/seldom 102 (38.1) 30 (27.0) 0.040*
  Sometime/often 166 (61.9) 81 (73.0)
Handling end-of-life issues in general
  Rare/seldom 96 (36.6) 32 (29.1) 0.162
  Sometime/often 166 (63.4) 78 (70.9)
Perceived unnecessary use of futile therapy
  Rare/seldom 124 (46.3) 40 (36.7) 0.089
  Sometime/often 144 (53.7) 69 (63.3)
Perceived premature cessation of therapy
  Rare/seldom 131 (49.4) 47 (43.1) 0.266
  Sometime/often 134 (50.6) 62 (56.9)
“Withdrawal” versus “withholding” of therapy
  Rare/seldom 94 (35.2) 36 (33.3) 0.730
  Sometime/often 173 (64.8) 72 (66.7)
Patient disagreement with decision made by professional “physicians”
  Rare/seldom 39 (14.5) 20 (18.3) 0.350
  Sometime/often 230 (85.5) 89 (81.7)
Improperly taken informed consent
  Rare/seldom 92 (34.7) 44 (41.5) 0.220
  Sometime/often 173 (65.3) 62 (58.5)
Uncertainty whether to maintain confidentiality
  Rare/seldom 98 (37.0) 45 (41.3) 0.436
  Sometime/often 167 (63.0) 64 (58.7)
Uncertainty whether to disclose diagnosis to the patient/delivering “bad news”
  Rare/seldom 88 (33.0) 35 (31.8) 0.830
  Sometime/often 179 (67.0) 75 (68.2)
Disclosure of medical error by yourself
  Rare/seldom 105 (39.3) 32 (29.6) 0.077
  Sometime/often 162 (60.7) 76 (70.4)
Disclosure of medical error by others
  Rare/seldom 92 (34.6) 33 (30.6) 0.454
  Sometime/often 174 (65.4) 75 (69.4)
Conflict with administration policies and procedures
  Rare/seldom 63 (23.5) 23 (20.7) 0.556
  Sometime/often 205 (76.5) 88 (79.3)
Scarcity of resources in the clinic
  Rare/seldom 79 (29.7) 23 (21.1) 0.089
  Sometime/often 187 (70.3) 86 (78.9)
Favored care for only some groups of patients above others
  Rare/seldom 129 (48.3) 57 (51.8) 0.536
  Sometime/often 138 (51.7) 53 (48.2)
Relationship related to drug industry
  Rare/seldom 177 (66.8) 50 (45.9) 0.000*
  Sometime/often 88 (33.2) 59 (54.1)
Surpassing formally specified clinical privilege
  Rare/seldom 155 (58.3) 44 (40.0) 0.001*
  Sometime/often 111 (41.7) 66 (60.0)
Using/adopting a new untested therapy or procedure without prior formal arrangement agreed
  Rare/seldom 198 (74.2) 76 (69.1) 0.316
  Sometime/often 69 (25.8) 34 (30.9)
*

The chi-square statistic is significant at 0.05 level.

Table 6

Knowledge about ethics and common ethical issues they face in daily practice according to nationality, education local vs international

Physicians practicing in private hospitals faced more cases that offered unnecessary use of futile therapy (p = 0.003) or premature cessation of therapy (p = 0.027), and they had more relationships with the pharmaceutical industry compared with physicians working in government hospitals (p = 0.011). There were no significant differences regarding confidence about knowledge in ethics, treating incompetent patients, or making decisions regarding DNR (Table 7).

Government, N (%) Private, N (%) p-value
How confident are you about your knowledge about ethics in medical practice: 455
  Confident 267 (77.4) 90 (81.8) 0.33
  Not confident 78 (22.6) 20 (18.8)
Have you ever referred a case to an ethics committee?
  Yes 39 (11.3) 15 (13.6) 0.517
  No 305 (88.7) 95 (86.4)
Treating patients with impaired or uncertain decision-making
  Rare/seldom 151 (39.9) 51 (13.5) 0.66
  Sometimes/often 135 (35.7) 41 (10.8)
Disagreement among patients/family and healthcare professionals about treatment decision
  Rare/seldom 25 (8.7) 9 (9.7) 0.777
  Sometime/often 262 (91.3) 84 (90.3)
Making decision about life-sustaining treatment or do-not-resuscitate order
  Rare/seldom 95 (33.3) 26 (28.3) 0.365
  Sometime/often 190 (66.7) 66 (71.7)
Conflict on the appropriateness deciding on a “no code status” with family or colleagues
  Rare/seldom 99 (34.6) 33 (35.5) 0.879
  Sometime/often 187 (65.4) 60 (64.5)
Handling end-of-life issues in general
  Rare/seldom 98 (34.9) 30 (33.0) 0.739
  Sometime/often 183 (65.1) 61 (67.0)
Perceived unnecessary use of futile therapy
  Rare/seldom 136 (47.9) 28 (30.1) 0.003
  Sometime/often 148 (52.1) 65 (69.9)
Perceived premature cessation of therapy
  Rare/seldom 143 (50.9) 35 (37.6) 0.027
  Sometime/often 138 (49.1) 58 (62.4)
“Withdrawal” versus “withholding” of therapy
  Rare/seldom 100 (35.3) 30 (32.6) 0.633
  Sometime/often 183 (64.7) 62 (67.4)
Patient disagreement with decision made by professional “physicians”
  Rare/seldom 47 (16.4) 12 (13.0) 0.436
  Sometime/often 239 (83.6) 80 (87.0)
Improperly taken informed consent
  Rare/seldom 105 (37.8) 31 (33.3) 0.436
  Sometime/often 173 (62.2) 62 (66.7)
Uncertainty whether to maintain confidentiality
  Rare/seldom 105 (37.0) 38 (42.2) 0.732
  Sometime/often 179 (63.0) 52 (57.8)
Uncertainty whether to disclose diagnosis to the patient/delivering “bad news”
  Rare/seldom 94 (33.1) 29 (31.2) 0.732
  Sometime/often 190 (66.9) 64 (68.8)
Disclosure of medical error by yourself
  Rare/seldom 104 (36.9) 33 (35.5) 0.808
  Sometime/often 178 (63.1) 60 (64.5)
Disclosure of medical error by others
  Rare/seldom 96 (34.2) 29 (31.2) 0.597
  Sometime/often 185 (65.8) 64 (68.8)
Conflict with administration policies and procedures
  Rare/seldom 68 (23.8) 18 (19.4) 0.377
  Sometime/often 218 (76.2) 75 (80.6)
Scarcity of resources in the clinic
  Rare/seldom 76 (26.9) 26 (28.3) 0.792
  Sometime/often 207 (73.1) 66 (71.7)
Favored care for only some group of patients above others
  Rare/seldom 140 (49.3) 46 (49.5) 0.978
  Sometime/often 144 (50.7) 47 (50.5)
Relationship related to drug industry
  Rare/seldom 181 (64.4) 46 (49.5) 0.011*
  Sometime/often 100 (35.6) 47 (50.5)
Surpassing formally specified clinical privilege
  Rare/seldom 152 (53.7) 47 (50.5) 0.595
  Sometime/often 131 (46.3) 46 (49.5)
Using/adopting a new untested therapy or procedure without prior formal arrangement agreed on
  Rare/seldom 206 (72.3) 68 (73.9) 0.760
  Sometime/often 79 (27.7) 24 (26.1)
*

The chi-square statistic is significant at 0.05 level.

Table 7

Knowledge about ethics and common ethical issues they face in daily practice according to private and government hospitals

Consultants compared with non-consultants had significantly more knowledge about ethics, less conflict with family, and were at ease in making decisions about DNR or end-of-life issues (p < 0.05). Furthermore, consultants compared with non-consultants faced a scarcity of resources (p = 0.049), had more relationship with the pharmaceutical industry (p = 0.001), and surpassed requirements for formally specified clinical privileges (p = 0.007).

4. DISCUSSION

Ethical issues and dilemmas are frequently encountered in daily medical practice. The spectrum of these dilemmas varies across cultures and specialties [38,14]. These issues have an impact on physicians by creating moral distress when making or avoiding or uncertainty about choosing the appropriate management or making the right decision for their patients [38].

In this study we found that Saudi healthcare providers face important ethical challenges during their daily practice. These issues pose challenges to healthcare providers and may cause moral distress to physicians and effect on their quality of care. The advantage of this study is addressing the real and common ethical issues faced in daily practice by physicians. Although these challenges have been addressed in the literature as isolated ethical issues in healthcare, no attempt has ever been made to collate and prioritize them in our community [1012,1524]. This study encompasses a different spectrum of physicians regarding gender, different subspecialties, training level, and whether they practiced in private or government hospitals. However, it is still limited to Riyadh, which may not be generalized to other regions within Saudi Arabia or other countries. Ethical issues facing healthcare providers differ from one country to another. For example, among European physicians, Hurst et al. [25] reported uncertain or impaired decision-making capacity, disagreement among caregivers, and limitation of treatment at the end-of-life ethical difficulties were the most often encountered ethical issues. Among Australian physicians, majority reported the most common ethical concerns related to issues of “not for resuscitation orders”, the treatment of patients with HIV and AIDS, interprofessional conflict, and the allocation of resources [26], whereas discharge against medical advice and confidentiality were recognized as major ethical issues facing Nigerian physicians [23].

Comparing our results (which concluded that the top three were disagreement among patients/family and healthcare professionals, treating patients with impaired or uncertain decision-making, and conflict with the administration policy) with the only local study done by Alkabba et al. [10], which showed the top three ethical issues were patients’ rights, equity of resources, and patients’ confidentiality. Disagreement among patients/family and healthcare professionals about treatment decisions, handling end-of-life issues or DNR decisions, and disclosing the diagnosis were commonly reported ethical issues in other countries as well [3,6,9]. Small number of physicians (11%) referred consult ethics committee when faced with ethical dilemma or concerns. DuVal et al. [22] reported most of the physicians consult colleagues or discuss with patients family when faced with ethical issues rather than consulting ethics committee.

The role of ethical committees in hospitals is not clear and needs to be explored in further studies. Although more than two-thirds of the hospitals have such committees, only 11% of physicians consulted them. Either the objectives of these committees were not clear for physicians or the committee was not actively engaged. Ethical committees can engage in helping physicians make decisions in cases of ethical dilemma by promoting ethics discussions, education, resolution of dilemmas, and establishing guidelines.

Globally, there is documented shortage in the teaching of ethics to undergraduate students and knowledge about ethics issues and how to deal with them among practicing physicians [2730].

The study by DuVal et al. [22] revealed the source of physicians’ knowledge about ethics to be through attendance of bioethics rounds (53%), attendance at a bioethics conference (55%), and serving on an ethics committee (21%). In this study, 76% of respondents received their knowledge in medical college curriculum; this is probably because most of them are junior staff and new graduates, and because there has been more emphasis recently in teaching ethics in medical colleges [24].

There are limited studies comparing physicians by gender regarding how they handle ethical issues and dilemmas. In our study, female physicians expressed concerns regarding making decisions about end-of-life issues and DNR, which is probably because female participants were less confident about ethical knowledge in their daily practice compared with male physicians, and most of the female physicians in our study were not consultants and with limited experience. However, this issue needs to be studied in greater depth to determine how much gender affects decisions for handling ethical issues and dilemmas in daily practice, and why.

Physicians working in private compared with government hospitals were perceived to unnecessarily use futile therapy and were perceived to have premature cessations of therapy. Although this sounds contradictory, it is known that not all patients managed at private hospitals are insured, which may entail more costs for therapy, and there may be hesitation to proceed with more expensive and prolonged therapy, particularly in cases that are chronic but not futile, in contrast to patients who are insured and may receive unnecessary futile therapy. This is documented by Weiner, who revealed that the insured patients receive better medical coverage and therefore their physicians deal with fewer ethical issues and dilemmas compared with the self-paid patients [31].

Our study has a number of limitations. This is a self-report study that may lead to under- or over-reporting of ethical difficulties or even the priority of ethical issues. However, our results are consistent with other international literature indicating the legitimacy of the findings. Also, we did not assess the reasons for such difficulties that face physicians at different facilities or their level of training and experience. The list of top ethical issues and dilemmas or difficulties that we generated in our study questionnaire is based on reviewing the limited published studies about ethical issues in Saudi Arabia and other countries, and is based on the experiences and interest in the ethics of investigators. One other limitation: we did not assess the influence of religion of physicians regarding these ethical issues and dilemmas. Religion and culture of both physicians and patients may play a major role in handling ethical issues. Studies have shown that religion affects physicians in their relationship with patients and their medical decisions, and this may ultimately affect treatment decisions [5,32]. In our sample, the majority of the patients encountered in practices, as well as treating physicians, were Muslims. Also, one of the limitations is that the response rate from private hospitals was low due to the fact that most private hospitals lacked research infrastructure to review and approve our research proposal, and this affected their willingness to participate in our study. This study affirms previous national and international documented urgent need for continuous education on medical ethics specially after graduating from medical schools [10,14,27,28,30,3337]. Our findings indicate that healthcare providers need more teaching and training in practical ethical dilemmas to face them in their daily practice. Similarly, in a study from USA, it was reported that medical students and residents supported ethics teaching initiatives in various topics using clinically based teaching rather than theoretical ethics narratives [22].

5. CONCLUSION

Saudi healthcare providers face important ethical challenges during their daily practice. These issues pose challenges to healthcare providers and may cause moral distress to physicians. We recommend further study of ethical issues specific to each specialty as they differ in their environment and perception of ethical dilemmas. Furthermore, medical colleges and residency training programs should act in response to these issues and prepare their students to deal with these dilemmas, as they are the future for healthcare workers.

CONFLICTS OF INTEREST

The authors declare they have no conflicts of interest.

AUTHORS’ CONTRIBUTION

AMA, MAA, YHA and HA participated in the study concepts, design of the study, developing the questionnaires, and data acquisition and entry. YHA and AEA contributed in data analysis and statistical analysis of the data. HA, Al-Shaikh A, AlHarbi A and SB participated in the intellectual content, reviewing and summarizing the published literature search, clinical studies, outlining the result themes and manuscript preparation, manuscript editing, and manuscript review. YHA takes the responsibility of the integrity of the work as a whole and he is the point of correspondence.

ACKNOWLEDGMENT

We thank Prof Abdullah Sayyari and Prof Abdulaziz Algabaa in reviewing and editing our manuscript.

Footnotes

Data availability statement: Availability of data and material – available.

REFERENCES

[8]K Leslie, Physicians’ Top 20 Ethical Dilemmas - Survey Results. Medscape, 2012. Available from: https://www.medscape.com/features/slideshow/public/ethical-dilemmas (accessed January 1, 2019).
Journal
Journal of Epidemiology and Global Health
Volume-Issue
10 - 2
Pages
143 - 152
Publication Date
2020/01/13
ISSN (Online)
2210-6014
ISSN (Print)
2210-6006
DOI
10.2991/jegh.k.191211.001How to use a DOI?
Copyright
© 2020 Atlantis Press International B.V.
Open Access
This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).

Cite this article

TY  - JOUR
AU  - Amar Mansour Almoallem
AU  - Mohammed Abdulaziz Almudayfir
AU  - Yassar H. Al-Jahdail
AU  - Anwar E. Ahmed
AU  - Adnan Al-Shaikh
AU  - Salim Baharoon
AU  - Abdullah AlHarbi
AU  - Hamdan Al-Jahdali
PY  - 2020
DA  - 2020/01/13
TI  - Top Ethical Issues Concerning Healthcare Providers Working in Saudi Arabia
JO  - Journal of Epidemiology and Global Health
SP  - 143
EP  - 152
VL  - 10
IS  - 2
SN  - 2210-6014
UR  - https://doi.org/10.2991/jegh.k.191211.001
DO  - 10.2991/jegh.k.191211.001
ID  - Almoallem2020
ER  -