saudi arabia is the second biggest arab country , with a surface area of 2,150 thousand sq km , and a population of 25.5 million , about 7 million of whom are non - saudis.[14 ] it is the leading muslim country , as two of the most holy sites for muslims ( makkah and madina ) where millions come to worship and work every year , are located here . compared to other countries in the eastern mediterranean region , it has one of the highest gross national incomes per capita and expenditure on health ( usd 22,300 and 6.4% ( as percentage of gross domestic product ( gdp ) ) , respectively . despite this relatively high expenditure on health ( 5% of gdp ) , most of the facilities in the healthcare system remain largely concentrated in the three main and most densely populated cities , namely : riyadh , the political capital with18% of the ministry of health ( moh ) hospitals and 18% of the primary health care centers ( phccs ) for 6.2 million people ; jeddah and makah with 9% of the moh hospitals and 7.5% of the phccs for a population of 4.9 million ; and the eastern region , including dammam and qasim , which has 15% of the moh hospitals , and 13.4% of the phccs for a population of 3.4 million . the development of the healthcare system in saudi arabia began in 1925 , when a public health department was established by a royal decree . the first school of nursing was opened in 1926 , followed by the school of heath and emergencies in 1927 . in 1951 , the ministry of health was established . since then , the health services have expanded immensely . from 1970 to 1980 , the health services were predominantly curative . however , the concept of primary health care ( phc ) became popular in the early 1980s ; when the world health organization ( who ) slogan health for all ( hfa ) gained recognition . by a ministerial decree in 1980 , the establishment of health centers was initiated . currently , the ministry of health has 1848 phc centers and 200 hospitals under its jurisdiction . there is growing international literature that discusses the ethical issues relating to healthcare systems in industrialized countries , although these generally deal with specific specialities or a given group of patients . a leading study done by jm breslin and colleagues identified the top ethical challenges that patients and their families in the healthcare system in toronto , canada , face . a modified delphi study was conducted and the top ten ethical challenges that canadians confronted within their healthcare were identified . the top three challenges in their study were : ( 1 ) disagreement between patients / families and healthcare professionals about treatment decisions ; ( 2 ) waiting lists ; and ( 3 ) access to needed resources for the aged , the chronically ill , and the mentally ill , respectively . likewise , other studies were carried out to identify the national ethical problems related to the healthcare system , the clinical situations doctors and nurses perceive as  ethical problems , and to describe the ethical issues deemed as highly important to oncology nurses . the conclusions reached by these studies reflected the ethical issues close to those revealed by the canadian study as frequently encountered , such as problems in the healthcare reform process , professional interactions , and doctor - patient relationships . the top three priority ethical issues for oncology nurses were assisted suicide , end - of - life decisions , and pain management . however , the literature relating to medical / clinical ethics in saudi arabia remains limited in terms of volume and scope . most of these studies focus on the islamic perspective of some clinical practices such as organ donation , do - not - resuscitate ( dnr ) orders , and end - of - life issues , or other issues like patient satisfaction . a study that is worthy of note was conducted by kalid bin saeed , to compare the views of physician executives and clinicians on ethical issues in saudi arabian hospitals and the contributory factors leading to the presence of these ethical issues . however , the ethical issues that confront the saudi healthcare system and public were not adequately studied , nor was there any attempt to collate and prioritize them . this study is aimed at defining , collating , and ranking the major ethical challenges encountered in the healthcare system in saudi arabia , as perceived by the healthcare providers and the public . it also proposes an approach to the management of these ethical issues in line with other international studies , especially the canadian study by breslin and colleagues . the study area included the three main saudi cities of riyadh , jeddah , and dammam , as well as other smaller cities ( taif ( west ) and tabuk ( north ) ) . the study population included : members of the ethics committees in the major health institutions ( hospitals ) , who taught or had experience in medical ethics and medical administration , and academic staff from 10 hospitals in the selected areas [ table 1 ] . out of 110 participants , 90 replied in the study period , giving a response rate of 82% ; and 83 ( 75.5% ) provided their professional and contact information . the participants were male and female clinicians and medical doctors , 46 ( 55% ) and 12 ( 15% ) , respectively ; medical doctors in public health and community medicine 12 ( 14% ) ; eight ( 10% ) non - medical hospital staff ; and five ( 6% ) pharmacists and other paramedical technicians . hospitals included from each city and the sample size in each participants from military hospitals were civilian staff without rank in the armed forces . the justification for the use of a panel of clinicians and ethics committee members rather than community members was that it was expected that they would provide a better insight into the overall ethical challenges than community members , because of their work . , 110 participants were asked to write down a list of what they perceived as the top 10 medical ethical challenges to health care . they were asked to rank the items from that list again as the top 10 ethical issues facing healthcare providers and return them to the researchers . in the third round , after ranking the obtained ethical issues from all participants responses , the list was sent again to the participants to indicate their agreement or otherwise to the ranking . if they did not agree with what they were sent , the re - ranked responses were returned by the participants to the research team . on receipt of the participants re - ranked forms , a meeting of experts of a select group of health professionals was held , to choose the top 10 medical ethical problems facing the saudi population from the medical health professionals point of view . at the experts meeting , an open session was held to : ( 1 ) unify the definitions of the problems ; ( 2 ) select the top 10 ethical problems ; and ( 3 ) re - rank these problems using a scale that depended on the following four items : ( 1 ) size of the problem ; ( 2 ) seriousness of the problem ; ( 3 ) feasibility of solving it ; and ( 4 ) status of public awareness of it . each one of these items was put on a scale of one ( + ; the lowest score ) to 4 ( + s ) , the highest score . later , the experts were put into two groups and each group was given a list of the ranked items and asked to rank the top 10 ethical problems facing the saudi care providers . at the end of these sessions , the top 10 ethical problems that the saudi providers faced were formulated and approved . 110 participants were asked to write down a list of what they perceived as the top 10 medical ethical challenges to health care . they were asked to rank the items from that list again as the top 10 ethical issues facing healthcare providers and return them to the researchers . in the third round , after ranking the obtained ethical issues from all participants responses , the list was sent again to the participants to indicate their agreement or otherwise to the ranking . if they did not agree with what they were sent , the re - ranked responses were returned by the participants to the research team . on receipt of the participants re - ranked forms , a meeting of experts of a select group of health professionals was held , to choose the top 10 medical ethical problems facing the saudi population from the medical health professionals point of view . at the experts meeting , an open session was held to : ( 1 ) unify the definitions of the problems ; ( 2 ) select the top 10 ethical problems ; and ( 3 ) re - rank these problems using a scale that depended on the following four items : ( 1 ) size of the problem ; ( 2 ) seriousness of the problem ; ( 3 ) feasibility of solving it ; and ( 4 ) status of public awareness of it . each one of these items was put on a scale of one ( + ; the lowest score ) to 4 ( + s ) , the highest score . later , the experts were put into two groups and each group was given a list of the ranked items and asked to rank the top 10 ethical problems facing the saudi care providers . at the end of these sessions , the top 10 ethical problems that the saudi providers faced were formulated and approved . out of 110 participants , 90 replied in the study period giving a response rate of 82% . following the first round , 32 ethical issues were identified , the top three of which were : patients rights ( 55 ; 61% ) , confidentiality of patients information ( 41 ; 46% ) , and medical negligence / error ( 31 ; 34% ) . the least important were : language barrier , private sections in public hospitals , and nursing practices ( 2 , 2 , and 1% , respectively ) . patients rights , patient confidentiality , and medical negligence / error were ranked the highest of the ethical issues . the third round and the meeting of the panel of participants resulted in the underlisted top 10 medical ethics problems facing the saudi population , from the participants point of view [ table 2 ] . 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 [ table 2 ] , 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 . good treatment ; give consent for any medical intervention ; confidentiality of his / her medical information ; and the right to refuse treatment against medical advice . 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 . 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 . 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 . 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 . 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 despite the danger to themselves the moral responsibility of the doctors to look after their patients safety , remains paramount . 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 . 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 . 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 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 . the major 10 ethical issues as perceived by the participants were : ( 1 ) patients rights , ( 2 ) equity of resource distribution , ( 3 ) confidentiality of patients , ( 4 ) patient safety , ( 5 ) conflict of interests , ( 6 ) ethics of privatization , ( 7 ) informed consent , ( 8) dealing with the opposite sex , ( 9 ) beginning and end of life , and ( 10 ) healthcare team ethics . however , this list was not exhaustive . the results of this study were intended for comparison with those of the canadian study . differences were indeed expected because of the differences in culture and healthcare systems of saudi arabia and canada . unlike the canadian study , this study included the opinions of administrators and legal representatives . although many of the challenges listed by the participants have received significant public and specialized attention worldwide , very little attention has been given to these top challenges in saudi arabia . the higher authorities in the health delivery system hierarchy have to initiate more in - depth discussions on the ethical issues , in order to ultimately bring about changes in policies , particularly on resource allocation . although a code of ethics need not lay down rules that are set in stone , it can provide guidance to deal with ethical issues as they arise . the top ethical issues reflected the national and cultural peculiarities of the saudi population and health system . however , one can reasonably assume that the issues discussed will be applicable to other countries of the region that share the arabic - islamic moral values . differences will , however , remain , as there will be issues that arise from different health delivery systems . the results were intended for comparison with those of the canadian study by breslin and colleagues . the main limitation relates to the ability to generalize the results within or outside saudi arabia . first , the study did not include the smaller underserved rural hospitals that could have revealed another set of ethical issues , although the issue of equity in access to resources was listed among the top five issues . second , although the study tried to involve non - clinicians , the dominance of saudi male clinicians in the selected sample could have given the results and conclusions a clinical bias . this also partly explains why no ethical issues dealing with paramedical staff and their relationship with doctors were mentioned . as the delphi process was not stratified , the peculiarities of the different settings were blurred . for instance , in this methodology , regional and gender differences and those related to the type of the health facility were indistinct . in addition , it appeared that there was no definite consensus on the meaning of some terms used . finally , there was also the fact that communication with the participants of the study was basically electronically supported by some phone calls and faxes . moreover , the modified delphi model , presented the possibility of some members dominating the discussions in the face - to - face expert meeting . the results were intended for comparison with those of the canadian study by breslin and colleagues . the main limitation relates to the ability to generalize the results within or outside saudi arabia . first , the study did not include the smaller underserved rural hospitals that could have revealed another set of ethical issues , although the issue of equity in access to resources was listed among the top five issues . second , although the study tried to involve non - clinicians , the dominance of saudi male clinicians in the selected sample could have given the results and conclusions a clinical bias . this also partly explains why no ethical issues dealing with paramedical staff and their relationship with doctors were mentioned . as the delphi process was not stratified , the peculiarities of the different settings were blurred . for instance , in this methodology , regional and gender differences and those related to the type of the health facility were indistinct . in addition , it appeared that there was no definite consensus on the meaning of some terms used . finally , there was also the fact that communication with the participants of the study was basically electronically supported by some phone calls and faxes . moreover , the modified delphi model , presented the possibility of some members dominating the discussions in the face - to - face expert meeting .
background : despite the relatively high expenditure on healthcare in saudi arabia , its health system remains highly centralized in the main cities with its primary focus on secondary and tertiary care rather than primary care . 
 this has led to numerous ethical challenges for the healthcare providers . 
 this article reports the results of a study conducted with a panel of practitioners , and non - clinicians , in saudi arabia , in order to identify the top ten ethical challenges for healthcare providers , patients , and their families.materials and methods : the study design was a cross - sectional , descriptive , and qualitative one . 
 the participants were asked the question :  what top ten ethical challenges are saudis likely to face in health care ?  the participants were asked to rank the top ten ethical challenges throughout a modified delphi process , using a ranking scale . 
 a consensus was reached after three rounds of questions and an experts meeting.results:the major 10 ethical issues , as perceived by the participants in order of their importance , were : ( 1 ) patients rights , ( 2 ) equity of resources , ( 3 ) confidentiality of the patients , ( 4 ) patient safety , ( 5 ) conflict of interests , ( 6 ) ethics of privatization , ( 7 ) informed consent , ( 8) dealing with the opposite sex , ( 9 ) beginning and end of life , and ( 10 ) healthcare team ethics.conclusion:although many of the challenges listed by the participants have received significant public and specialized attention worldwide , scant attention has been paid to these top challenges in saudi arabia . 
 we propose several possible steps to help address these key challenges .