Pakistan is a developing country with 184 million populations; majority of people is living in rural areas, where literacy rate is very low. The burden of Chronic liver disease (CLD) is increasing day by day due to poor compliance to preventive measures. According to Qureshi, Bile, Jooma, Alam and Afridi (2010) the burden of hepatitis B and C is increasing in general population and it is currently 7.6%. High prevalence of hepatitis B and C will result in increased incidence of CLD. Quality of life among CLD patients is very poor and the only option for them is liver transplantation. Unlike liver transplantation renal transplantation started early in 1985, currently facility is available both in public and private hospital across the country. On other hand very few liver transplantation were performed in the country despite the fact that every year 10,000 people die due to CLD (Ali, Qureshi, Jilani, & Zehra 2013). The liver transplant project was initiated in 2011 at Pakistan Institute of Medical sciences under special instruction from prime minister of Pakistan. The purpose of this project was to provide liver transplant facility in the country on affordable cost.
32 years old male having three children diagnosed with CLD, was operated liver transplantation in public sector hospital. The liver was taken from live donor 28 years old wife of the patient. On 3rd post op day the patient start severe bleeding with tachycardia and hypotension. Patient become unconscious and was rushed to operation room (OR). Meanwhile patient crashed and Cardio Pulmonary Resuscitation (CPR) started. After 6 hours of CPR patient cardiac activity was resumed, but still bleeding from drain and body orifices. Patient was on high inotropic support and back to back transfusion of blood and blood product to maintain hemoglobin and platelet of patient. Later on patient expired and his wife remain in hospital till her recovery Analysis of ethical issue
The procedure was performed without enough resources and principle of non-maleficence was violated. The hospital management and transplant team were responsible for the malpractice. They assured the patient and his family that the hospital has cutting age technology, expert human resource and outstanding material resource comparable with other advance liver transplant center in the developed countries. But in reality the situation was worse with no training of health care staff, three bedded intensive care unit (ICU) without isolation, and small operation theater with poor infection control measures. Lack of standard laboratory without computerization increases the misfortunes of liver transplant center. In short these facilities were not sufficient for such advance level surgery which risks the life of donor as well recipient. These leads to negligence and malpractice on part of hospital management and liver transplant team which arise the question in mind that “Is this ethical to perform liver transplant in limited human as well material resources.”? The ethical principle of justice non-maleficence and virtue of veracity are violated. Moreover, the act of hospital management and transplant team were against the theory of deontology. According to news in media initially a memorandum was signed between the hospital and Royal Free Hospital, London but later on after inspection of infrastructure and human resource they refused to perform such complicated procedure in this facility (Wasif, 2012). Although government provided 200 million PKR to build state of the art facility in capital city of Pakistan but these huge amounts were wasted and golden opportunity of liver transplant in public sector hospital was misused.
Ethical principle violated in decision making to perform liver transplant
My preposition is that without adequate expertise and material as well as human resource performing such intricate surgery is not justifiable and against the ethical principles.
While performing their duties health care professionals must adhere to ethical principle and rules. Any breach or violation of these principles may lead to malpractice and negligence. The patient trust on health care professionals and believe that they will apply their knowledge and skills to provide benefit to patient. Similarly, according to Hippocratic pledge health care professionals will abstain their self from harmful and mischievous act (Markel, 2004). Obligation of non-maleficence not only include to avoid harm but also not to impose risk of harm (Beauchamp and Childress, 2001). In the above situation the health care workers lack proper training, skills and material resources to perform such sophisticated procedure. Moreover the professional standards were violated which determine due care in such situation and risk of harm was inflicted on patient. The hospital management and liver transplant team act negligently and harm the patient, his family and specially his wife.
Hospital management and transplant team stance
The health care team stance was to maximize the benefit and happiness to the society. They support their position using act utilitarianism for the greater happiness of greater number of people. According to act-utilitarianism an action is right if it produces consequences like any other action available to the agent (barns, 1971). The hospital management and transplant team argued that patient was known case of CLD with complication and no other alternative, So according to act-utilitarianism our action is justified and if successful this center will provide care to thousands CLD patients waiting for miracle in the country. Our intention was good and according to Islamic principle of ethics actions are judged according to intention. One of the saying of Prophet Muhammad peace be upon him “the reward of deeds depends upon the intentions and every person will get the reward according to what he has intended.” (Bukhari: 1).
Justification of my stance using deontology
To justify my position, I will refer to famous philosopher Emanuel Kant and his theory of deontology. I According to Emanuel Kant action are not justified on basis of consequences, rather they should be judged independently of its outcome (Beauchamp and Childress, 2001). If we judge the action of hospital management and liver transplant team independently of its outcome we came to result that action was performed without enough evidence which harm the patient and against the basic principle of ethics. According to Nathaniel and Burkhardt (2008) deontology stresses that individual must fulfill their obligation and in the above scenario the obligation to do no harm and provide beneficence was violated. Furthermore one principle of Islamic ethics is certainty which mean evidence based practice (Mustafa, 2013); this principle of certainty was violated as performing liver transplantation without standard human and material resource, which is against the evidence base practice.
Consequences of Acting on my Position
If the hospital management started this project after appropriate training for different professionals along with good infrastructure equipped with modern equipment and according to international standards, then the consequences will be different for patient me and other staff. The patient life could be saved and new patients will be enrolled for transplantation. The other staff will remain in the center providing care to liver transplant patients. I myself will be there taking care of patient and contributing towards the betterment of community and huge money will be utilized in appropriate place according to the need of public.
On basis of above scenario and analysis, I am going to put forward some suggestions to stakeholders. First of all such sophisticated project must be plan and each and every step should be taken according to plan. The second is hiring of proper and competent professional; these professionals include doctors, nurses, technicians, laboratory, and radiology staff. Training for these professionals should be arranged in leading liver transplant center of the world. The third is that all the units including ICU, OR, laboratory, radiology and pharmacy should be under one roof preferably in separate building and equipped with contemporary instruments. Moreover these units should be connected with each other through computer and internet.