Health empowerment and health rights in Saudi Arabia

Abstract

Health rights are basic human rights. The right to health care is stipulated in Article 27 and 31 of the Basic Laws of Saudi Arabia, the Ministry of Health issued a Patient’s Bill of Rights (PBR) in 2006.1 Unawareness of health rules and the regulations of the Ministry of Health, and sometimes lack of clear laws, may contribute to morbidity and mortality. Empowerment is a process through which individuals, societies, and organizations gain control of their important matters. Through this process, the economic, political, social, educational, or spiritual strength of a person or group of persons is increased. Empowerment is a term that is referred to in our Holy Book, the Quran as “Tamkeen” and is mentioned in several parts of the Quran. “And thus, we established Joseph in the land to settle therein wherever he willed. We touch with our mercy whom we will, and we do not allow to be lost the reward of those who do good”.2 Empowerment of patients resulted in favorable health outcomes such as increased power of decision-making, freedom in making choices and accepting responsibility, increased trust in relations, informed choice, and improved quality of life. Additionally, empowerment is essential to promote health and assist in exploring health problems and developing strategic plans for the advancement of health care. Health care rights are basic human rights. The World Health Organization (WHO) acknowledges that the highest achievable level of health is a basic right to every human being. In Saudi Arabia, an individual’s right to health care is stipulated in Article 27 and 31 of the Basic Laws of Saudi Arabia that emphasize providing health care for every citizen, in emergencies, sickness, disability, and old age. The Ministry of Health issued a PBR in 2006 and affirms these health rights in its policies and procedures manual and through periodic circulars.1 History has shown how unawareness of health rules and the regulations of the Ministry of Health, and sometimes lack of clear laws, may contribute to morbidity and mortality. Two cases occurred in 1984 illustrating this issue. These include the case of fatal rupture of the uterus following a husband’s refusal to permit the medical team to perform a cesarean section on his spouse in obstructed labor and the case of a patient requiring urgent hemodialysis who suffered a 7-hour delay because the medical team was awaiting the husband’s consent for the procedure.3 These cases draw attention to the importance of clarifying the misconception regarding women’s rights to consent for their health care. This includes their right to consent to surgery, particularly cesarean section, which was stated clearly in Article 60 of Hospital Management and Medical By-Laws. It states, a written consent (allowing anesthesia or surgical procedures) shall be obtained, and it should be noted that a woman is legally responsible for herself and shall be asked to give her own consent.3 Women face problems in the area of health rights, and it is attributed mainly to religious factors despite this being contrary to Islamic rules and regulations, which support women’s health rights. Islam supports the right to health, and scholars have issued several reports asserting women’s rights, stating clearly that a mentally sound adult is the only one who has the right to consent for her surgery, particularly for cesarean section. This is stated in the Ministerial Resolution enacting the Regulations on the Practice of Medicine and Dentistry of the Royal Decree M/3 of October 2, 1988 stipulates that “In accordance with the stipulations contained in Royal Circular No. 4/2428/M dated 29.7.1404H based on resolution No. 119 dated 26.5.1404H (27 February 1984) and according to the Committee of Senior Ulema, prior to delivering medical treatment or carrying out an operative procedure, consent should be taken from the patient whether male or female.” This also applies to medically indicated hysterectomy and/or oophorectomy as per Senior Scholars Fatwa No 173, in 12/3/1413G, Page 183, stating that an adult, sound-minded woman can sign for herself, and husband or legal guardian’s approval is not required, as this is her health and she is the one who knows what could inflict harm to her health. Patients’ health rights are not widely understood in Saudi Arabia, and many health care providers are unaware of the rules and regulations designed to protect these rights, which may result in suboptimal care. Ignorance of these health rights gives way to misconceptions and portrays a false impression about Islam and Saudi Arabia. This situation was raised in the report published regarding Saudi Arabia in 2008 by the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) stating that women need male guardian approval before any medical or surgical treatment. The CEDAW drew this conclusion following an interview of Saudi doctors who were ignorant about the rights of female patients to obtain health care without the permission of their male guardians. Studies have shown that medical students and health care providers have poor knowledge about health rights. El-Sobkey et al4 found that training programs at the College of Applied Medical Science (CAMS), Riyadh were lacking in that they did not adequately address health rights, and the majority of students report that there is no specific course dedicated to patients’ rights (94%); and can be estimated only approximately 23.4% stated that lecturers mentioned patients’ rights during teaching sessions. In the survey conducted by Alghanim5 on 242 Saudi physicians and nurses, only 66.1% of the sample have knowledge about the existence of the PBR. In the Rights of Cancer Patients study conducted in 2013 by Al-Amoudi,6 20% of female medical students and 67% of male students believed that the patient had no right to hide information, with 73% of female students and 56% of male students believing that both the patient and their relatives had the right to be informed. To protect the rights of cancer patients, medical practitioners have an obligation to counsel their patients in a confidential setting regarding their desire to receive information and make decisions or whether they would rather have family members to be actively involved in the decision-making process. In a 2012 study that reviewed signatories of consent forms for breast surgery at King Abdulaziz Hospital, it was shown that 85% of the people in the 40-49 years age group signed the informed consent form and for the remaining patients, consent forms were signed by a male guardian, suggesting that not all female patients were aware of their right to consent for their health issues and surgery.7 Another important factor contributing to women’s decision making in daily practice is the role of the family. Family members contribute greatly to the management of patients and women themselves often delegate decisions to their father or husband, or even the doctor, as they believe they know better. Another important issue in conservative community is the preference of female patients to be treated by female doctors, particularly in issues related to breast or gynecological problems, due to ignorance of the patients or family to the fact that Islam does not preclude examination by a doctor of the opposite sex under certain circumstances; therefore, female patients should be empowered about these to avoid delay in providing access to or quality of services.8 In view of the ignorance of medical students and health care providers regarding patients’ health rights and the impact of this on patient morbidity and mortality, it is of vital importance to revise our teaching curriculum. Further, it is time to introduce the subject of health empowerment and health rights. This will aim to empower medical students who are our future doctors and part of the community. This effort should also include the rules and regulations of the Ministry of Health as early as during the pre-clinical years. We also believe that health rights topic should be introduced in school curricula as early as high school for both male and female students, as this will be reflected on social awareness and health empowerment. In 2016, a unit for health empowerment and health rights was established at the College of Medicine of King Abdulaziz University. The objectives of this unit were numerous: to educate health care providers about the rules and regulations of the Ministry of Health that govern patients’ health rights, to educate medical students about the PBR, to increase awareness of the community, and women in particular, about their health rights and the Islamic rules and regulations of medical issues in the era of modern and developed medicine. This subject was included in the undergraduate medical curriculum, and an ongoing study exists to assess the impact of this new curriculum. Ethical Consent All manuscripts reporting the results of experimental investigations involving human subjects should include a statement confirming that informed consent was obtained from each subject or subject’s guardian, after receiving approval of the experimental protocol by a local human ethics committee, or institutional review board. When reporting experiments on animals, authors should indicate whether the institutional and national guide for the care and use of laboratory animals was followed.