Medical Ethics in Nigeria

1. Medical Ethics in Nigeria By Dr. JaiyeolaOyetunji MBBS, MPH, FWACS Consultant Obstetrician/Gynaecologist, FMCBK

2. OBJECTIVES • By the end of this presentation, the knowledge of participants on medical ethics would have been updated

3. Outline • Ethics and Ethical Principles in Clinical Practice • Doctor-Patient Relationship • Confidentiality • Consent to Medical Treatment • Criminal abortion and Allied issues

4. Ethics and Ethical Principles in Clinical Practice • How many of us here have been approached by a patient in the course of our clinical practice with a request for an abortion?

5. Can any of us volunteer to tell us briefly the circumstances surrounding the case and what was done?

6. How many of us have managed HIV positive patients who have refused to disclose their HIV status to their partners

7. Can any one volunteer to tell us what was done in that situation.

8. What is Ethics?

9. Definitions • The word ethics is a derivative of the Greek word ‘ethos’ , which means customs, habits or practice. • It represents a set of principles that help to answer the question, ‘what should be done in a given situation, all things considered?’ • Ethics is regarded as an obligation of a moral nature which is voluntarily accepted as a code of conduct and behavior by members of a profession.

10. Medical Ethics • Medical ethics is the study of moral values and judgment as applied to medical practice. • They supplement the statutory laws that govern Medical and Dental practice in any given place.

11. Code of Medical Ethics • The Medical and Dental Practitioners Act empowers the MDCN to review and prepare from time to time a statement as to the code of conduct which the council considers desirable for the practice of the profession in Nigeria. • The ‘code of medical ethics in Nigeria’ (MDCN). • The provision of the code is binding

12. The Hippocratic Oath • Written circa 400 to 300BC • Is the fore-runner of all codes of medical ethics. • The Oath of Moslem Physician.

13. Unethical conduct • A conduct is said to be unethical when it derogates from those moral principles or standards. • A conduct occasioning a serious infraction of ethical standards expected of a medical practitioner constitutes infamous conduct.

14. Ethical values versus legal principles • Abortion is legal in some jurisdictions but ethically unjustifiable in others. • The law approves of a doctor to participate in capital punishment but ethics disallows this. • Euthanasia is legal and acceptable in some countries whereas medical ethics forbids it.

15. Ethical Principles The leading ethical principle include: • Autonomy • Beneficence • Non-maleficence • Justice • Fidelity • Paternalism

16. The ethical principle of Autonomy • An adult with capacity to decide has the right to determine what may be done with his own body. • The caveat is that such a decision should not impinge on the autonomy of others. • One incapable of making such decisions as a result of mental or psychological factors lack capacity.

17. Principle of Beneficence • ‘I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous’. • The duty of the physician is to do good to his patient. • Non-maleficence – cause no harm.

18. Beneficence vs Autonomy • The following points should be noted: • Autonomy overrides beneficence • A doctor who offers futile treatment to a patient is not behaving beneficially to that patient. • The principle of beneficence is not served when the risks of treatment outweighs the benefits. • P. Beneficence and Autonomy - not mutually exclusive

19. Beneficence vs Autonomy • Eg: A primigravida at 39weeks, SFH = 38cm, • USS confirmed a live fetus in breech presentation. Placenta was anterior fundal. • Patient was counseled for elective CS but declined. She prefers to have a vagina delivery. What should be the next line of action?

20. Options: • A. Insist that the best option is either to have the CS or be discharged against medical advise. • B. Support her to have vaginal delivery. • C. Counsel her and her spouse. • D. Counsel her again so that she may change her mind. • E. None of the above.

21. Non-maleficence • A Physician should abstain from what is deleterious and mischievous. • The potential physician is indoctrinated with the maxim: ‘primum non nocere, which means ‘ first do no harm’. • P. Non-maleficence may conflict with beneficence. • Risk/benefit analysis of treatment • Deviation from non-maleficence – • Malpractice suit

22. Beneficence vsNon-maleficence • Eg: A nulliparous woman with uterine fibroids has requested for a myomectomy. • What are the ethical issues?

23. Principle of Justice • All persons should be given what is their due or what they are owed. • Expression in medical practice: • Informed consent • - served only if adequate information is given to the patient by the doctor. • Surrogacy • - surrogate is a person who stands in the place of another.

24. Justice cont’d Surrogacy in clinical practice: • Required to make decisions on behalf of patients who lack the capacity to do so. • Simply an extension of autonomy. • Justice to the patient to provide a surrogate where a patient has lost capacity to decide for himself.

25. Eg • A nulliparous patient with uterine fibroids, undergoing myomectomy who started having uncontrollable uterine bleeding which failed to respond to all the conservative measures and hysterectomy is being considered as the last option. • What are the ethical issues?

26. Justice cont’d • Provision of religious personnel: • Universally accepted they bring succuor to the dying. • Availability to minister to the sick, particularly during serious illness, may be a matter of justice.

27. Principle of Fidelity • Finds expression in Hippocratic tenets which states: ‘ whatever in connection with my professional practice or not in connection with it, I may see or hear in the lives of men which ought not be spoken abroad, I will not divulge, as reckoning that all such be kept secret in confidentiality’. • Stresses the importance of doctor- patient relationship anchored on trust and confidence.

28. Principle of Paternalism • Based on the belief that physicians had superior knowledge of the patient’s condition and prognosis over and above that of the patient. • The practice of over-ridding or ignoring the patient’s preferences in order to prevent the patient from self-harm, is of ancient origin. • A reflection that beneficence is superior to autonomy

29. Principle of Paternalism cont’d • It has had to give way to the principle of autonomy. • In modern clinical practice, patient autonomy now over-rides the principle of beneficence. • Still practiced- where patients are illiterate and still want to trust their doctors to make the best decisions on their behalf (eg. FP).

30. Principle of Paternalism cont’d • Still ethical in some situations: eg. withholding information considered psychologically detrimental. • Eg:

31. A house wife who was admitted on account of severe HTN was visited by her husband. On his way home he was knocked down by a run-away driver and was rushed to the same hospital. He later died despite all resuscitative measures. It has been 3 days since the incident. The wife has been asking to see her husband. What are the ethical issues.?

32. Doctor-Patient Relationship • Hippocratcic Oath, now modified and called The declaration of Geneva or the Physicians’ Oath, give an insight to the doctor-patient relationship.

33. Physician’s Oat • I solemnly pledge • To consecrate my life to the service of humanity; • I will practice my profession with conscience and dignity. • The health of my patient shall by my first consideration. • I will respect the secrets that are confided in me, even after the patien has died.

34. Physician’s Oat • I will not permit consideration of age, disease or disability, creed, ethic origin, gender, nationality, political affiliation, race sexual consideration, or any other factor to intervene between my duty and my patient. • I will maintain the utmost respect for human life. • I will not use any medical knowledge to violate human rights and civil liberties, even under threats. I • I make these promises solemnly, freely and upon my honour.

35. It is obvious from the tenets of the Physicians’ Oath that the patient is the centre of the medical universe around which our world revolves and towards which all our efforts as physicians tend.

36. Medical rights of patients • Right to life • - 1999 constitution of the Fed Rep of Nig. • - Reinforces the physicians’ Oat. • Right to accept or refuse any recommended medical treatment including blood transfusion. • - conditions: - He is an adult • - reached decision freely - has clear decisional capacity - well informed

37. Medical rights of patients cont’d • Right to dignity, respect and prompt attention to patients’ needs. • Right to free choice in the selection of their physicians. • Right to a second medical opinion. • Right to confidentiality. • Right to appropriate privacy. • Right to refuse to be informed about his medical condition. • Right to continuity of medical care.

38. Fundamental rights of Patients • As articulated by NMA • These rights which are germane to proper patient care are paraphrased below as follows: • 1 Right to receive treatment without discrimination on any basis whatever including race, colour, religion, sex, tribal origin, source of payment or ability to pay. • 2 Right to considerate and respectful care in a clean and safe environment devoid of unnecessary restraints. • 3. Right to emergency care in an appropriate circumstances.

39. When a doctor may withdraw treatment • When a patient insists upon an unjust or immoral conduct in the course of his treatment. • If he deliberately disregards a valid agreement as to fees or expenses involved in the treatment. • In pursuit of his right under the labour law of Nigeria.

40. Fundamental rights of Patients cont’d • 4. Right to necessary information regarding the name and status of the doctor in charge of patients’ care. • 5. Right to information regarding the name, position and functions of any other hospital staff involved in the care of a patient. • 6. Right to receive itemized bill and appropriate explanation of all charges including the right to receive receipts of all payments at each visit to the hospital.

41. Fundamental rights of Patients cont’d • 7. Right to complete information regarding the diagnosis, treatment and prognosis of the patient’s condition without prejudice to therapeutic privilege of doctors. • 8. Right to be given all necessary information to enable informed consent for any proposed procedure or treatment.

42. Patient’s responsibility • To furnish the physician with a complete medical history of his illness • To corporate with the treatment plan agreed with the physician. • These include: • - compliance with drug treatment schedule and fidelity in actually taking the prescribed drugs. • Refusal to combine treatment with native or alternative medicine. • Meeting financial obligations.

43. Fundamental rights of Patients cont’d • 9. Right to privacy while in the hospital or clinic and confidentiality of all patient information and records. • 10. Right to participation in all decisions concerning treatment and discharge from the hospital.

44. False imprisonment • Hostage holding • Undue confinement against patient’s will

45. Confidentiality • Ethics of professional secrecy is taken very seriously • Refer to Hippocratic Oat. • Patient’s case notes/Hospital records • - confidential documents • Pre-employment Medical examination • - Is there a patient-doctor relationship or • - Employer- doctor relationship? • - treatment of incidental problems

46. Confidentiality cont’d • Pre-nuptial medical examination • - what amount of information is ethical? • Rationale for confidentiality • - use for criminal purpose (blackmail) • - loss of trust by patients

47. Exception to doctrine of confidentiality • Disclosure under compulsion of law. • Disclosure in public interest • Eg. – communicable diseases • - gunshot and knife injuries (self or others). • - acting in good faith (in case of epilepsy). • - child abuse. (eg. Multiple injuries in a 17/12 old baby). • - evidence of other crimes at the possession of a physician (eg. Penile bite)

48. Consent to medical treatment • Consent – act of giving approval or acceptance to something done or proposed to be done. • Basis of consent – P. Autonomy • Types – express (oral or written) - implied (without saying so directly) - eg: PR, VE, breast, genital exam, fundoscopy, auroscopy, Blood transfusion (note refusal) • - amputation should Never be implied

49. Presumed consent • Eg. Emergency cases such as unconsciousness following RTA. • Contoversies – consent for laparotomy and removal of a healthy appendix. • - BTL during repair of ruptured uterus

50. Performance of surgical procedures by GP • Background • If complication arises and doctor sued for negligence. • Message to younger colleagues.