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 [3–8]. 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 [11–13]. 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.

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.

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”.

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.

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.

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).

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).

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).

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 [3–8,14]. 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 [3–8].

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 [10–12,15–24]. 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 [27–30].

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 [10,14,27,28,30,33–37]. 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.