BY

PROF.J.I.B.ADINMA
DEPARTMENT OF OBS/GYN,
NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL NNEWI, NIGERIA

LECTURE DELIVERED AT A SYMPOSIUM ORGANIZED BY NIGERIAN MEDICAL ASSOCIATION, KADUNA STATE BRANCH, KADUNA, NIGERIA.

13TH JUNE, 2009

INTRODUCTION 

Ø                    Man – a foremost enigma of God’s creation exists in societal aggregate, governed by cultures with set ethical standards – cultural ethics.

Ø                    Trans-cultural (universal ethics) cuts across cultural boundaries.

Ø                    Care of the sick (medical practice) for its objectivity and universality constitutes the foundation of universal ethics.

Ø                    Medical Practitioners should be governed by ethical principles in their day-to-day practice

SCOPE OF PRESENTATION

l       DEFINITIONS

l       ORIGIN/HISTORY

l       FUNDAMENTALS OF BIOETHICS

l       ETHICS AND MEDICAL RESEARCH

l       ETHICS, HUMAN RIGHTS, AND LAW

l       ETHICAL RESPONSIBILITIES OF THE MEDICAL PRACTITIONER

l       CONCLUSION

WHAT IS MEDICAL ETHICS?

§          Ethics ─ derived from the Greek  word “ethos” which means customs and habits

§          Medical Ethics are the principles or norms that regulate the conduct of the relationships between Medical Practitioners and other groups with whom they come in contact during the course of their practice.

ETHICAL CODES:

   Ethical codes are sets of principles or rough guides to practice, usually developed following serious breach of ethical standards. E.g.

l       The Nuremberg Code – 1946.

l       The Helsinki Declaration – 1964.

l       Ethical Codes of Medical and Dental Council of Nigeria (MDCN) – culled from the Hippocratic Oath of 4^th Century BC, sworn to by qualifying Medical Practitioners. 

BIOETHICS:

   Bioethics is regarded in a broad sense as a multidisciplinary field of enquiry, which addresses ethical issues in Clinical Practice and Health Care, Biomedical Research involving humans and animals, Health Policy, and the Environment.

ORIGIN/HISTORY

v                        Ancient Greek philosophers ▬ value system.

v                        Early Christian Physicians and Nurses ▬ conscientious approach to care of the sick.

v                        Maimonides – developed knowledge of Medical Ethics based on Jewish law.

v                        1846: Ethical Codes developed for American Medical Practitioners

v                        1946: The Nuremberg Trial, and Code.

v                        1932-1972:The Tuskegee Alabama syphilis research on black Americans. 

v                        1960’s (U.S.A) origin of Modern Bioethics.

v                        1964 the Helsinki Declaration.

v                        1971 Kennedy Institute, George town first used the word Bioethics.

v                        1971 establishment of the first ethical committee to disburse dialysis machine to patients with kidney failure – “god squad committee”.

v                        1979 U.S National Commission for the protection of human subjects of biomedical and behavioral research – Belmont Report. 

23 German Physicians & Administrators in the dock in Nuremberg – Dec.9, 1946

FUNDAMENTALS OF BIOETHICS

BIOETHICAL ORIENTATIONS

*     Historical orientation – reflect philosophical origin of Bioethics.

*     Duty base (Deontological orientation) – ethics of reason and natural law.

*     Consequentialist or Utilitarian Bioethics – recognizes moral responsibility for consequences of individuals’ bioethical choices – whatever promotes human well being is adjudged to be good; whatever does not is adjudged to be bad.

FUNDAMENTALS OF BIOETHICS [CONTD]

* Feminist Bioethics – ethics of care and connectedness – relates to the exclusion of women in social issues and the non-recognition of women’s roles and needs in the society.

Others:

* Communitarianism – advances human community as good.

* Casuistry – recognizes resolution of cases based on their merit and not on universal rules.

* Virtue – tenets that health practitioners should hold to ─ compassion, trustworthiness, sound judgment or discernment, and conscientiousness or integrity.

FUNDAMENTALS OF BIO-ETHICS [CONTD]

BIOETHICAL ANALYSIS

1. Based on four key principles developed by Tom Beauchamp, James Childress, and Raanan Gillon.

•   Respect for persons:

ü  Autonomy of capable persons.

ü  Protection of persons incapable of autonomy.

2. Beneficence

•   Non–maleficience

•  Justice

Others include:

5. Veracity

6. Fidelity

7. Scientific Validity

The Guiding Principles In Bioethics

The Guiding Principles In Bioethics

�        AUTONOMY - respect the right to self determination and individual liberty. (Informed voluntary consent and confidentiality). Overriding Autonomy – Medical Paternalism which is divided into strong and weak.

�       NON-MALEFICENCE - Ethical duties to do no harm or wrong.

�       BENEFICENCE- Responsibility to do and maximize good. (do good to others and maintain a balance between benefits and acceptable harms).

The Guiding Principles In Bioethics: (2)

�      JUSTICE - Fairness and equity in Medicare to persons. (Equitable distribution of potential benefits and risks).

�      VERACITY- tell all the truth.

�      FIDELITY - do what is promised.

�      SCIENTIFIC VALIDITY- ensure professional competence and scientific soundness.

APPLICATION OF BIOETHICAL PRINCIPLES –four analytical levels.

•                         Micro-ethical level – applies to relationship of individuals to one another.

•                         Macro-ethical level – applies to relationship between groups and communities.

•                         Meso-ethical level – falls between micro- and macro-ethics, relates to allocation of health resources by health managers.

•                         Mega-ethical – applies to issues that operate beyond national boundaries e.g. HIV/AIDS, effects of environmental pollution or degradation and status of women.

KEY HEALTH ISSUES ELICITING ETHICAL CONTROVERSIES

l    Reproductive health, including assisted reproductive technology

l    Organ transplant

l    Genomics including cloning

l    Stem cells studies

l    Brain death/Euthanasia

ETHICS AND MEDICAL RESEARCH

l    Research ethics developed following inhuman experiments especially during the 2^nd World War.

l    The trials of Nuremberg, and Nuremberg Code of 1946.

l    The World Medical Association (WMA) Helsinki Declaration of 1964 developed ethical principles in medical research involving human subjects.

Low oxygen experiment by German Airforce

Freezing experiment of Humans-
by German Air force

Two of Dr. Mengele’s twin pairs-1943

l         Helsinki consists of 35 Principles, the first 30 of which are solely on Medical Research, while 31-35 additionally involve Clinical Practice.

l         Over the years Helsinki revised 9 times (Helsinki 1; 1964 to Helsinki 9; 2008)
 

•                   The 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended by the:

•                   29th WMA General Assembly, Tokyo, Japan, October 1975

•                   35th WMA General Assembly, Venice, Italy, October 1983

•                   41st WMA General Assembly, Hong Kong, September 1989

•                   48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996

•                   52nd WMA General Assembly, Edinburgh, Scotland, October 2000

•                   53rd WMA General Assembly, Washington 2002.

•                   55th WMA General Assembly, Tokyo 2004.

•                   59th WMA General Assembly, Seoul, South Korea, October 2008

l       Helsinki declaration concerned humans, animals and the environment and took cognizance of national laws and regulations on them.

l       It recognizes the safety, autonomy, confidentiality, and the dignity of human subject in research.

l       It recognizes that potential benefits should accrue to research subjects, and that research should be discontinued if the risk outweighs its benefits.

l       Recognizes voluntarism, freedom of coercions and freedom to withdraw at any stage of research by a human subject.

l       Research protocol shall be screened, and its implementation over-seen by a duly competent ethical committee.         

l      Council for International Organizations of Medical Sciences (co-sponsored by WHO and UNESCO) – developed guidelines addressing bio-medical research and epidemiological studies.

l      Focuses on research in economically poor countries by companies from rich countries and benefits derivable by the people consequent upon the studies.

l       Other codes or guideline specific to particular types of research e.g. HIV vaccine development.    

ETHICS, HUMAN RIGHTS, & LAW

l         Ethics & human rights are both derived from same core values (Jonathan Mann).

l         Ethics is to Clinical Practice what Human Right is to Public Health.

l         Ethics – protected by Codes; Human Right protected by National Laws and Constitutions and International treaties.

•           Laws are believed to serve ethical principles of justice; however not all laws and policies have ethical justification.

•           Ethics and law interact but are different systems of rule-making.

•           Laws addresses what must be, or must not be done, while Ethics addresses what should be done, and what should not be done. 

ETHICAL RESPONSIBILITIES OF THE MEDICAL PRACTITIONER

l       Medical Practitioners should be guided by code of professional ethics.

Sources:

•       FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health.

•       The International Code of Medical Ethics (Declaration of Venice 1983).

•       General Principles of  Ethics of the Medical and Dental Council of Nigeria (Code of Medical Ethics in Nigeria from MDCN).

l                     Code of Medical Ethics in Nigeria: 74-page document with 8 parts.

�                   Preamble and General guidelines

�                   Professional conducts

�                   Malpractice

�                   Improper relationships with colleagues or patients.

�                   Aspects of Private Medical or Dental Practice.

�                   Self-advertisement and related offenses

�                   Convictions for criminal offences.

�                   Miscellaneous  

Highlights of the ethical responsibilities – hinged on 3 pedestals:

�                 Professional competence

�                 Patients autonomy and confidentiality

�                 Responsibility to community.

CONCLUSION

•      Medical Practitioners are expected to adhere strictly to ethical guidelines as contained in National Code of Ethics since their violation attracts sanction.

•      They should also guide Government towards the development of Ethics-based Medical Policies and Legislation to promote and uphold the health and overall well-being of the people.  

THANK YOU