The presence of a centralized healthcare system in a culturally diverse population and healthcare providers may give rise to a set of ethical issues. For example, the ethical issues related to patients’ waiting time for medical attention, lack of comprehension resulting from cultural differences, the language barrier between the healthcare providers and the patients, and issues relating to eligibility to health care. For instance, Saudi patients in many peripheral areas have to travel to one of the main cities to seek healthcare. Therefore, the introduction of an organized approach to handle these ethical issues, among others, is needed.
In addition to the results of rankings , the panel members’ comments during the meeting were taken as the basis for this discussion.
The highest ranked medical ethical challenge within the public in the healthcare system was the issue of patients’ rights
, whereas, in the Canadian study, the first priority was the disagreement between patients / families and healthcare professionals on decisions of treatment.[6
The only known national document is the ‘Manual Guide for Medical Practitioners’ issued to provide guidance to practitioners in Saudi Arabia. This clearly states the right of patients to: the access of ‘good’ treatment; give consent for any medical intervention; confidentiality of his / her medical information; and the right to refuse treatment against medical advice.[17
] Since it is only a document that ‘guides’, the onus has been on the main hospitals to develop their Patients’ Bill of Rights. Unfortunately, this is still in the process of being formulated, finalized, and endorsed.
The second highest ranked ethical challenge facing the public in the healthcare system is equity of access to resources
. The equity of distribution of health resources is a major issue in the Saudi healthcare system, as most of the resources are primarily in the main cities. Besides, there are inequities even within the cities and among Saudis and non-Saudis. Few exceptions are made for patients with some serious diseases, such as, tuberculosis and dengue fever, who should have access to free management, regardless of their legal status. This is an issue that needs to be addressed, for it is unlikely that an illegal resident would dare seeking medical treatment in a governmental hospital. Bin Saeed also draws attention to the more sensitive issue of, ‘favoring patients based on their race or gender’, which is considered an important ethical issue by 83.6% of the clinicians in his study.[16
The health resources are mainly distributed in favor of the specialist hospitals, that is, secondary and tertiary institutions, leaving the primary care and preventive care centers at a disadvantage. In the Canadian study, this issue was ranked the third most important because it was found that a major part of the funds was directed toward acute, live saving care, while long-term, rehabilitation, and mental healthcare were grossly underfunded.[6
The third highest ranked ethical challenge facing the Saudi Healthcare system was confidentiality of patient information
. The panel underscored the importance of this issue, which had to be given serious attention. There are no clear policies on the management of patient information, specifically the medical records, in many hospitals. The management of these records is usually left to the discretion of the clinician. This includes decisions on sharing any information about the patient without the proper consent of the patient. Unlike patients’ rights, not much effort is being made to develop policies on information security. This was also a finding made by Kahlid Bin Saeed, who indicated that 80% of the clinicians in his study had stated that patient confidentiality was a major ethical issue in their hospitals.[16
The most probable reason is that patients are unlikely to know that their confidential information has been shared, and therefore, are less likely to file a complaint against the treating doctor or the hospital. With an increasing number of patients suing their treating doctors in Saudi Arabia , the main hospitals have taken preventive measures, including the development of certain policies that mandate a physician to take an insurance policy against medical errors before registration in the Saudi Council for Health Specialties.
The fourth ranked ethical challenge was patient safety; this comprised their physical, emotional, and social safety. This issue was not considered one of the top 10 ethical challenges in the Canadian health care. The problem could be linked to the previous one, in that, a physician's feeling of insecurity made any potential source of ‘doctor–patient’ conflict an ethical priority. Despite the danger to themselves the moral responsibility of the doctors to look after their patients’ safety, remains paramount.
The fifth ranked ethical challenge chosen by the panel was the Conflict of Interests. The panel dealt with many issues here. Included were, the relationship between the healthcare team and the pharmaceutical, medical equipment, and companies that traded in medical supplies, especially during the conduct of research in which patients were participants. It also included ethical issues relating to privatization and doctors practicing in both public and private hospitals. No sustained effort has been made to formulate a clear policy on the conflict of interests within the main hospitals where the study took place.
The sixth ranked ethical challenge facing the public in Saudi Arabia was the ethics of privatization. According to the panel members, this item comprised many important issues, especially as health insurance was going to be made obligatory in the next few years. The panel members also drew attention to the fact that some physicians worked in the private sector during their official working hours, when they were supposed to be at their posts in government hospitals. This necessarily affected the time they had to devote to their patients in governmental sectors. Besides, their patients were sometimes advised to go to the private hospitals for their follow-up in order to avoid a long waiting list.
Other issues relating to the private sector included the concern that doctors were inclined to request more investigations for patients than was necessary, as also the problem of exorbitant fees charged by some private facilities. Moreover, employment by some private facilities of poorly trained health professionals, could affect patient safety. This issue was not considered an important ethical issue in the Canadian study, because of the nature of the Canadian health system, which depended almost exclusively on public funds.
The seventh challenge facing the public in Saudi Arabia was Informed Consent
: There was a lengthy discussion on this matter for many reasons. The patient / family members tended to sign the form for informed consent hurriedly without carefully reading a document with many difficult medical expressions, which neither the patient nor his / her family member could comprehend. Language was another issue. As many of the personnel working in the Saudi health sector are foreign, and therefore, unable to speak Arabic well, communication with a patient and / or his / her family member, who had to sign the consent form, became a problem. It is estimated that Saudi nurses represent only 22% of the total working force of nurses in the country.[18
The next ethical challenge in healthcare in Saudi Arabia is, ‘How to deal with the opposite sex’, that is, when male doctors have to examine female patients and vice versa. As the practices of the Saudi community are based on Islamic ethics and rules, this is a sensitive problem, especially when a male healthcare provider has to deal with a female patient. It is worth mentioning that this is permitted in Islam only under special circumstances, for example, when no competent female doctor is available for a male doctor to examine a female patient.
The ninth ethical challenge facing the public in Saudi Arabia was the matter of the beginning and end of life. This sensitive issue discussed by the panel has created much controversy between family members and the medical team. It has become more complicated because of the large amount of money used to purchase sophisticated equipment and supplies, which consequently have raised the expectations of patients and their families for a better quality of life as well as a longer life. Although mentioned in the Canadian study discussion, it was not one of their major ethical problems.
The tenth ethical challenge facing the public in Saudi Arabia was: The Ethics Health Care Team. This refers to ethical issues relating to disagreements, disputes, or even conflicts among the healthcare team members. The problems vary according to the attitudes of physicians and their colleagues toward one another and other professionals. This situation gets complicated because of the lack of clearly defined job descriptions, which lead to disputes or even conflicts within the health facility.
Apart from the top ten ethical issues, other important issues were raised, although not listed. These related to the language barrier and relations within the healthcare team, Islamic medicine, and ethics of Muslim doctors. The last issue is important in Saudi Arabia, which is a symbol of the modern Islamic state. Discussions revealed differences between the historical Islamic practice of medicine[19
] and western teaching, which most of the Saudi doctors had undergone . Moreover, the differences between the ethical and practice standards in the western hospitals where they were trained and what was obtained in this country aggravated this divergence.