Professional Documents
Culture Documents
SM - CMT 04211 Health Policy and Medical Ethics
SM - CMT 04211 Health Policy and Medical Ethics
Ministry of Health and Social Welfare
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Table of Contents
Acknowledgements .................................................................................................. iv
Introduction .............................................................................................................. ix
Abbreviations ........................................................................................................... xi
Module Sessions
Session 1: National Health Policy..............................................................................1
Session 2: National Health Guidelines ....................................................................11
Session 3: National Guidelines for Management of HIV and AIDS and for
Prevention of Mother-to-Child Transmission of HIV .............................................31
Session 4: National Health Guidelines for Malaria and for Collaborative
TB/HIV Activities ....................................................................................................37
Session 5: Ethical Theories and Principles in Medical Practice ..............................43
Session 6 : Confidentiality in Medical Practice .......................................................49
Session 7 : Rights of the Client/Patient ...................................................................55
Session 8: Rights of the Health Care Provider ........................................................61
Session 9: Laws Related to Medical Practice ..........................................................65
Session 10: Negligence in Medical Practice ............................................................71
Session 11: Relationship Between Law and Confidentiality...................................77
Session 12: Legal Issues Related To Consent in Medical Practice .........................83
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Background and Acknowledgements
In April 2009, a planning meeting was held at Kibaha which was followed up by a Task
Force Committee meeting in June 2009 at Dodoma and developed a proposal which guided
the process of the development of standardised Clinical Assistant (CA) and Clinical Officer
(CO) training materials which were based on CA/CO curricula. The purpose of this process
was to standardize the entire curriculum with up-to-date content which would then be
provided to all Clinical Assistant and Clinical Officer Training Centres (CATCs/COTCs).
The perceived benefit was that, by standardizing the quality of content and integrating
interactive teaching methodologies, students would be able to learn more effectively and that
the assessment of students’ learning would have more uniformity and validity across all
schools.
The new training package for CA/CO cadres includes a Facilitator Guide, Student Manual
and Practicum. There are 40 modules with approximately 600 content sessions. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders and
experts of different organizations and institutions, from within and outside the country.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these materials for CA /CO cadres. We would first like to
thank the U.S. Centers for Disease Control and Prevention’s Global AIDS Program
(CDC/GAP) Tanzania, and the International Training and Education Center for Health (I-
TECH) for their financial and technical support throughout the process. At CDC/GAP, we
would like to thank Ms. Suzzane McQueen and Ms. Angela Makota for their support and
guidance. At I-TECH, we would especially like to acknowledge Ms. Alyson Shumays,
Country Program Manager, Dr. Flavian Magari, Country Director, Mr. Tumaini Charles,
Deputy Country Director, and Ms. Susan Clark, Health Systems Director. The MOHSW
would also like to thank the World Health Organization (WHO) for technical and financial
support in the development process.
Particular thanks are due to those who led this important process: Dr. Bumi L.A.
Mwamasage, the Assistant Director for Allied Health Sciences Training, Dr. Mabula Ndimila
and Mr. Dennis Busuguli, Coordinators of Allied Health Sciences Training, Ministry of
Health and Social Welfare, Dr. Stella Kasindi Mwita, Programme Officer Integrated
Management of Adults and Adolescent Illnesses (IMAI), WHO Tanzania and Stella M.
Mpanda, Pre-service Programme Manager, I-TECH.
Sincere gratitude is expressed to small group facilitators: Dr. Otilia Gowele, Principal, Kilosa
COTC, Dr. Violet Kiango, Tutor, Kibaha COTC, Ms. Stephanie Smith, Ms. Stephanie
Askins, Julie Stein, Ms. Maureen Sarewitz, Mr. Golden Masika, Ms. Kanisia Ignas, Ms.
Yovitha Mrina and Mr. Nicholous Dampu, all of I-TECH, for their tireless efforts in guiding
participants and content experts through the process. A special note of thanks also goes to
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Dr. Julius Charles and Dr. Moses Bateganya, I-TECH’s Clinical Advisors, and other Clinical
Advisors who provided input. We also thank individual content experts from different
departments of the MOHSW and other governmental and non-governmental organizations,
including EngenderHealth, Jhpiego and AIHA, for their technical guidance.
Special thanks goes to a team of I-TECH staff namely Ms. Lauren Dunnington, Ms.
Stephanie Askins, Ms. Stephanie Smith, Ms Aisling Underwood, Golden Masika, Yovitha
Mrina, Kanisia Ignas, Nicholous Dampu, Michael Stockman and Stella M. Mpanda for
finalising the editing, formatting and compilation of the modules.
Finally, we very much appreciate the contributions of the tutors and content experts
representing the CATCs/COTCs, various hospitals, universities, and other health training
institutions. Their participation in meetings and workshops, and their input in the
development of content for each of the modules have been invaluable. It is the commitment
of these busy clinicians and teachers that has made this product possible.
Tutors
Ms. Magdalena M. Bulegeya – Tutor, Kilosa COTC
Mr. Pius J.Mashimba – Tutor, Kibaha Clinical Officers Training Centre (COTC)
Dr. Naushad Rattansi – Tutor, Kibaha COTC
Dr. Salla Salustian – Principal, Songea CATC
Dr. Kelly Msafiri – Principal, Sumbawanga CATC
Dr. Joseph Mapunda - Tutor, Songea CATC
Dr. Beda B. Hamis – Tutor, Mafinga COTC
Col Dr. Josiah Mekere – Principal, Lugalo Military Medical School
Mr. Charles Kahurananga – Tutor, Kigoma CATC
Dr. Ernest S. Kalimenze – Tutor, Sengerema COTC
Dr. Lucheri Efraim – Tutor, Kilosa COTC
Dr. Kevin Nyakimori – Tutor, Sumbawanga CATC
Mr. John Mpiluka – Tutor, Mvumi COTC
Mr. Gerald N. Mngóngó –Tutor, Kilosa COTC
Dr. Tito M. Shengena –Tutor, Mtwara COTC
Dr. Fadhili Lyimo – Tutor, Kilosa COTC
Dr. James William Nasson– Tutor, Kilosa COTC
Dr. Titus Mlingwa – Tutor, Kigoma CATC
Dr. Rex F. Mwakipiti – Principal, Musoma CATC
Dr. Wilson Kitinya - Principal, Masasi ( Clinical Assistants Training Centre (CATC)
Ms. Johari A. Said – Tutor, Masasi CATC
Dr. Godwin H. Katisa – Tutor, Tanga Assistant Medical Officers Training Centre (AMOTC)
Dr. Lautfred Bond Mtani – Principal, Sengerema COTC
Ms Pamela Henry Meena – Tutor, Kibaha COTC
Dr. Fidelis Amon Ruanda – Tutor, Mbeya AMOTC
Dr. Cosmas C. Chacha – Tutor, Mbeya AMOTC
Dr. Ignatus Mosten – Ag. Principal, Tanga AMOTC
Dr. Muhidini Mbata – Tutor, Mafinga COTC
Dr. Simon Haule – Ag. Principal, Kibaha COTC
Ms. Juliana Lufulenge - Tutor, Kilosa COTC
Dr. Peter Kiula – Tutor, Songea CATC
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Mr. Hassan Msemo – Tutor, Kibaha COTC
Dr. Sangare Antony –Tutor, Mbeya AMOTC
Content Experts
Ms. Emily Nyakiha – Principal, Bugando Nursing School, Mwanza
Mr. Gustav Moyo - Registrar, Tanganyika Nursesand Midwives Council, Ministry of Health
and Social Welfare (MOHSW).
Dr. Kohelet H. Winani - Reproductive and Child Health Services, MOHSW
Mr. Hussein M. Lugendo – Principal, Vector Control Training Centre (VCTC), Muheza
Dr. Elias Massau Kwesi - Public Health Specialist, Head of Unit Health Systems Research
and Survey, MOHSW
Dr. William John Muller - Pathologist, Muhimbili National Hospital (MNH)
Mr. Desire Gaspered - Computer Analyst, Institute of Finance Management (IFM), Dar es
Salaam
Mrs. Husna Rajabu - Health Education Officer, MOHSW
Mr. Zakayo Simon - Registered Nurse and Tutor, Public Health Nursing School (PHNS)
Morogoro
Dr. Ewaldo Vitus Komba - Lecturer, Department of Internal Medicine, Muhimbili University
of Health and Allied Sciences School (MUHAS)
Mrs. Asteria L.M. Ndomba - Assistant Lecturer, School of Nursing, MUHAS
Mrs. Zebina Msumi - Training Officer, Extended programme on Immunization (EPI),
MOHSW
Mr. Lister E. Matonya - Health Officer, School of Environmental Health Sciences (SEHS),
Ngudu, Mwanza.
Dr. Joyceline Kaganda - Nutritionist, Tanzania Food and Nutrition Centre (TFNC),
MOHSW.
Dr. Suleiman C. Mtani - Obstetrician and Gynecologist, Director, Mwananyamala Hospital,
Dar es salaam
Mr. Brown D. Karanja - Pharmacist, Lugalo Military Hospital
Mr. Muhsin Idd Nyanyam - Tutor, Primary Health Care Institute (PHCI), Iringa
Dr. Judith Mwende - Ophthalmologist, MNH
Dr. Paul Marealle - Orthopaedic and Traumatic Surgeon, Muhimbili Orthopedic Institute
(MOI),
Dr. Erasmus Mndeme - Psychiatrist, Mirembe Refferal Hospital
Mrs. Bridget Shirima - Nurse Tutor (Midwifery), Kilimanjoro Chrician Medical Centre
(KCMC)
Dr. Angelo Nyamtema - Tutor Tanzania Training Centre for International Health (TTCIH),
Ifakara.
Ms. Vumilia B. E. Mmari - Nurse Tutor (Reproductive Health) MNH-School of Nursing
Dr. David Kihwele - Obs/Gynae Specialist, and Consultant
Dr. Amos Mwakigonja – Pathologist and Lecturer, Department of Morbid Anatomy and
Histopathology, MUHAS
Mr. Claud J. Kumalija - Statistician and Head, Health Management Information System
(HMIS), MOHSW
Ms. Eva Muro, Lecturer and Pharmacist, Head Pharmacy Department, KCMC
Dr. Ibrahim Maduhu - Paediatrician, EPI/MOHSW
Dr. Merida Makia - Lecturer Head, Department of Surgery, MNH
Dr. Gabriel S. Mhidze - ENT Surgeon, Lugalo Military Hospital
Dr. Sira Owibingire - Lecturer, Dental School, MUHAS
Mr. Issai Seng’enge - Lecturer (Health Promotion), University of Dar es Salaam (UDSM)
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Prof. Charles Kihamia - Professor, Parasitology and Entomology, MUHAS
Mr. Benard Konga - Economist, MOSHW
Dr. Martha Kisanga - Field Officer Manager, Engender Health, Dar es Salaam
Dr. Omary Salehe - Consultant Physician, Mbeya Referral Hospital
Ms Yasinta Kisisiwe - Principal Nursing Officer, Health Education Unit (HEU), MOHSW
Dr. Levina Msuya - Paediatrician and Principal, Assistant Medical Officers Training Centre
(AMOTC), Kilimanjaro Christian Medical Centre (KCMC)
Dr. Mohamed Ali - Epidemiologist, MOHSW
Mr. Fikiri Mazige - Tutor, PHCI-Iringa
Mr. Salum Ramadhani - Lecturer, Institute of Finance Management
Ms. Grace Chuwa - Regional RCH Coordinator, Coastal Region
Mr. Shija Ganai - Health Education Officer, Regional Hospital, Kigoma
Dr. Emmanuel Suluba - Assistant Lecturer, Anatomy and Histology Department, MUHAS
Mr. Mdoe Ibrahim - Tutor, KCMC Health Records Technician Training Centre
Mr. Sunny Kiluvia - Health Communication Consultant, Dar es Salaam
Dr. Nkundwe Gallen Mwakyusa - Ophthalmologist, MOHSW
Dr. Nicodemus Ezekiel Mgalula -Dentist, Principal Dental Training School, Tanga
Mrs. Violet Peter Msolwa - Registered Nurse Midwife, Programme Officer, National AIDS
Control Programme (NACP), MOHSW
Dr. Wilbert Bunini Manyilizu - Lecturer, Mzumbe University, Morogoro
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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IT support
Mr. Isaac Urio - IT Consultant, I-TECH
Mr. Michael Fumbuka - Computer Systems Administrator – Institute of Finance and
Management (IFM), Dar es Salaam
Dr. Gilbert Mliga
Director of Human Resources Development, Ministry of Health and Social Welfare
CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Introduction
Module Overview
This module content has been prepared to enhance learning of students of Clinical Assistant
(CA) and Clinical Officer (CO) schools.. The session contents are based on the sub-enabling
outcomes of the curricula of CA and CO. The module sub-enabling outcomes are as follows:
5.1.1 Provide Care According to Ethical Guidelines
5.1.2 Maintain Confidentiality in Medical Practice Including Disclosure of HIV and TB
5.1.3 Recognise Self and Patients/Clients Rights
5.1.4 Perform According to Legal Requirements
5.2.1 Operate within Boundaries of Client Service Charter
5.2.2. Recognize the National Health Policy and Policy Guidelines for Malaria, HIV and
AIDS, TB, Leprosy and Reproductive and Child Health services
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be assigned to 5 students and it is the responsibility of the tutor to do this assignment for easy
use and accessibility of the student manuals to students.
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Abbreviations
AMTSL Active Management of Third Stage of Labour
CHGC Council Hospital Governing Committee
CHMT Council Health Management Team
CHMT Council Health Management Team
CHSB Council Health Service Board
HMIS Health Management Information System
HRH Human Resources for Health
HSR Health Sector Reforms
HSSP III Health Sector Strategic Plan Three
ICT Information Communication Technology
ILO International Labour Organization
IMR Infant Mortality Rate
MCP Malaria Control Programme
MDGs Millennium Development Goals
MMR Maternal Mortality Rate
MNCH Maternal, Newborn and Child Health
NGOs Non-Governmental Organization
PHC Primary Health Care
PITC Provider Initiated Testing and counselling
PMORALG Prime Minister’s Office Regional Administration and Local Government
PMTCT Prevention of Mother To Child Transmission
PPH Post Partum Haemorrhage
PPP Public Private Partnerships
RHMT Regional Health Management Team
RRHB Regional Referral Hospital Boards
RRHMT Regional Referral Hospital Management Team
RTIs Reproductive Tract Infections
SOPs Standard Operating Procedures
UN United Nations
WHO World Health Organization
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CMT 04211 Health Policy and Medical Ethics NTA Level 4 Semester 2 Student Manual
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Session 1: National Health Policy
Learning Objectives
By the end of this session, students are expected to be able to:
• Define health policy
• Explain the background of National Health Policy
• Describe objectives of the National Health Policy
• List health policy statements
• Link the National Health Policy with national and international initiatives
Definition of Terms
• Policy: Statement on how the government is to achieve its goals and objectives with
regard to a specific area such as health, education, agriculture. It can be described as a
deliberate plan of action to guide decisions and achieve rational outcome(s).
• Policy may also refer to the process of making important organizational decisions,
including the identification of different alternatives such as programs or spending
priorities, and choosing among them on the basis of the impact they will have.
• Health policy: A visionary program of action adopted by the government to have a
healthy society, with improved social wellbeing that will contribute effectively to
personal and national development.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 1
o Improve partnership between public sector, private sector, religious institutions, civil
society and community in provision of health services
o Plan, train, and increase the number of competent health staff
o Identify and maintain the infrastructures and medical equipment
o Review and evaluate health policy, guidelines, laws and standards for provision of
health services
Instructions
You work in small manageable groups and use Tanzania National Health Policy Booklet
to identify the key elements of the National Health Policy. Your group will have 15
minutes to complete the task. One group will present their findings and other groups will
participate in discussion.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 2
Linkage of the National Health Policy with National and International
Initiatives
Vision 2025
• Tanzania Vision 2025 is a document providing direction and a philosophy for long-term
development.
• Tanzania wants to achieve by 2025, a high quality of livelihood for its citizens, peace,
stability and unity, good governance, a well-educated and learning society and a
competitive economy capable of producing sustainable growth and shared benefits.
• The document identifies health as one of the priority sectors contributing to a higher
quality livelihood for all Tanzanians.
• This is expected to be attained through strategies, which will ensure realisation of the
following health service goals:
o Access to quality primary health care for all
o Access to quality reproductive health service for all individuals of appropriate ages
o Reduction in infant and maternal mortality rates by three quarters of levels in 1998
o Universal access to clean and safe water
o Life expectancy comparable to the level attained by typical middle-income countries
o Food self sufficiency and food security
o Gender equality and empowerment of women in all health parameters
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Refer to Handout 1.1: MDGs and Health Sector Reforms
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Session 1: National Health Policy 4
• The Health Sector Strategic Plan III promotes delegation of authority.
o This means that the dispensaries, health centres and hospitals should be the key actors
in the planning process.
o It also means that they will be held responsible for implementing what they have
planned.
Refer to Handout 1.2: Strategies of Health Sector Strategic Plan III
• To improve health status of the people, the types of services described below are
emphasized.
Types of Services
• Health promotion
o This includes activities to increase behaviour change and to ensure that lifestyles of
individuals are conducive to personal development and environmental safety.
• Community participation and ownership
o These are the keys to success of the primary health service delivery programme.
• Preventive health services
o These prevent diseases by promoting optimal nutrition and control of infectious
disease transmission, reduce epidemics and improve working environments to
maintain the highest standards of occupational health.
• Care and treatment (curative services)
o These services correctly treat diseases and conditions to reduce complications or
death by improving quality and quantity of care to patients and ensuring availability
of basic services and supplies.
• Rehabilitation services
o These are services to patients such as physical rehabilitation, mental rehabilitation and
psychological support to vulnerable groups.
• Provision of care to the chronically ill and the elderly
o This includes catering for life-long treatment like hypertension, diabetes, AIDS
patients on ARVs, renal conditions, cancer and any other chronic conditions.
Hospital Reforms
• Hospital reforms refer to:
o ‘A strategy to strengthen management systems, structures, values, methods and
capacity’
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 5
o ‘Introduction of quality improvement mechanisms in hospitals so that these reforms
are able to solve health care delivery problems themselves as well as improve quality
of health services provided in line with the ongoing health sector reforms’
• There has been growing concern that the services delivered at hospitals are not up to
expected standards.
• Therefore MOHSW over a period of time realized that there are various needs and
difficulties that are common to hospitals all over the country.
• The main areas of concern to address include:
o Inadequate planning
o Inadequate management and control of resources
o Inability to deliver the range and level of diagnostic and treatment services expected
from the hospitals
o Shortage of human resources and inappropriate mix of skills
o Low work morale
o Poor attitudes towards patients
o Inadequate funding for a long time which led to deterioration of equipment,
infrastructure and transport
o Poor preventive maintenance planning of hospital facilities and equipment
Key Points
• Health policy is a visionary program of action adopted by the government to have a
healthy society, with improved social wellbeing that will contribute effectively to
personal and national development.
• The mission of the government is to provide basic health services in accordance to
geographical conditions, which are of acceptable standards, affordable and sustainable.
• Health policy links with other national and international initiatives such as:
o Vision 2025
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
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o National Strategy for Growth and Reduction of Poverty (NSGRP / MKUKUTA)
o Millennium Development Goals
o Primary Health Care (PHC)
Evaluation
• What is health policy?
• What are the objectives of the National Health Policy?
• What are the key elements of the National Health Policy?
References
• UNDP. (2005). A Practical Plan to Achieve the Millennium Development Goals;
Investing in Development’ Millennium Project. New York: United Nations Development
Programme.
• MOHSW. (2004). District Integrated Management Cascade. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.
• MOHSW. (2008). Health Sector Strategic Plan (HSSP) III. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.
• MOHSW. (2007). National Health Policy. Dar es Salaam, Tanzania: Ministry of Health
and Social Welfare.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 1: National Health Policy 7
Handout 1.1: MDGs and Health Sector Reforms
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Handout 1.2: Strategies of Health Sector Strategic Plan III
The MOHSW has identified eleven strategies which the health sector should achieve during
the period of implementation:
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Strategy 7: Maternal, Newborn and Child Health
1. Increase access to Maternal, Newborn and Child Health (MNCH) services
2. Strengthen the health systems to provide quality MNCH and nutrition services
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Session 1: National Health Policy 10
Session 2: National Health Guidelines
Learning Objectives
By the end of this session, students are expected to be able to:
• Define policy guideline
• List different national health policy guidelines
• Describe objectives of different health policy guidelines
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Description of Different Health Guidelines
• Aiming at improving health services delivery within the country; various guidelines have
been formulated by the Ministry of Health and Social Welfare to guide health work
providers and other high authority in planning and decision making.
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National Guidelines for the Management of HIV and AIDS
• The National Guidelines for Clinical Management of HIV and AIDS; was produced only
a few years ago. However, recent developments and experience in the field of HIV and
AIDS care and treatment has made it necessary for the country to come up with another
edition of these guidelines, to reflect the changes that have taken place.
• This will help to improve the quality of care and treatment of HIV and AIDS has been
expanded to give clinicians more flexibility in providing quality care.
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Refer to Handout 2.6: Summary of National Guidelines for more information on
Infection Prevention and Control (IPC) and Health Care Waste Management guidelines
National Guidelines for Management of HIV and AIDS for Frontline Workers
• This document is intended to provide guidelines for health care workers on various
aspects of care and support.
• Frontline workers include health care workers involved in the provision of nursing care,
treatment of opportunistic infections, prevention of transmission of the infection,
counselling and care during pregnancy, labour and postnatal period.
• The document also contains a section on continuum of care which emphasizes the
delivery of comprehensive care at home at various levels of health care system.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 14
• But efforts to address the two problems have been carried out separately, resulting in an
inadequate global impact on the dual epidemics. The guideline is aimed at providing
guidance in collaborative TB/HIV activities.
• The policy stated the objectives of collaborative TB/HIV activities as follows:
o To establish the mechanisms for collaboration between TB and HIV and AIDS
programmes.
o To reduce the burden of TB in people living with HIV and AIDS.
o To reduce the burden of HIV in TB-infected patients.
Key Points
• Guidelines are an essential part of the larger process of governance.
• These are standards, protocols, and procedures that govern day-to-day operations of an
organization and that determine who provides what care to which clients.
Evaluation
• What is a guideline?
• Mention at least five national health guidelines for Tanzania.
• If you have a patient in your ward and you want to perform an HIV test, which
Guideline(s) will you refer to?
References
• MOHSW. (2004). National guidelines for Screening and Treatment of Syphilis during
Pregnancy. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
• MOHSW. (2005). Management of Acute Malnutrition National Guidelines. . Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare.
• MOHSW. (2008). Guidelines for use of Uterotonics in Active Management of 3rd Stage of
labour. . Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
• NACP. (2009). National Guidelines for the Management of HIV and AIDS, 3rd Edition.. .
Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• NACP. (2007). National Guideline of Prevention of Mother-To-Child Transmission of
HIV. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS
Control Programme.
• NACP. (2005). National Guidelines for Voluntary Counselling and Testing. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• MOHSW. (2007). National Infection Prevention and Control Guidelines for Healthcare
Services in Tanzania. . Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
• NACP. (1999). Guidelines for Home Based Care Services in Tanzania. Dar es Salaam,
Tanzania: Ministry of Health and Social Welfare, National AIDS Control Programme.
• MOHSW. (2006). Healthcare Waste Management National Policy Guideline, Health
Education Unit. . Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 15
• NACP. (2007). Guidelines for HIV Testing and Counselling in Clinical Setting.Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• MOHSW. (2006). Guidelines for the Management of Malaria for Health Service
Provider. MCP. Dar es Salaam.
• NACP. (2007). National guidelines for Management of Sexually Transmitted and
Reproductive Tract Infections, 1st Edition. Dar es Salaam, Tanzania: Ministry of Health
and Social Welfare, National AIDS Control Programme.
• NACP. (2003). Guidelines for Management of HIV/AIDS for Frontline Workers. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• NACP/NTLP. (2008). Nation Policy Guidelines for Collaborative TB/HIV Activities. Dar
es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme/National TB/ and Leprosy Control Program.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 16
Handout 2.1: Summary of National Guideline for Screening
and Treatment of Syphilis During Pregnancy
Overview
The national guidelines for screening and treatment of syphilis in pregnancy have been
developed by MOHSW with the purpose of providing health service provider with guiding
principles on how screening and treatment of syphilis in pregnancy should be done over the
country. Sexually transmitted infections (STIs) are of public health importance because are
highly preventable; cause considerable morbidity, consume resources to manage and are
know to facilitate sexual transmission of Human Immunodeficiency Virus (HIV)
Definition
Syphilis is a sexually transmitted disease caused by a spirochete called Treponema pallidum.
Transmission can also occur through blood transfusion and vertically from a pregnant mother
to the foetus. It can also be acquired through contact with blood contaminated materials. The
infection is systemic from the outset, capable of involving every organ of the body.
Clinically, syphilis can be staged as primary, secondary, latent and tertiary syphilis. Signs and
symptoms of primary syphilis occur from 10-90 days after the initial exposure, while those of
secondary syphilis may occur 1-6 months after the primary infection. In latent syphilis, there
is infection but no signs or symptoms of the disease. Latent syphilis is divided into early and
late latent syphilis. Early latent syphilis refers to having syphilis (but no signs or symptoms)
for 2 years or less, while late latent syphilis refers to having syphilis for more than 2 years.
Signs and symptoms of tertiary syphilis may occur from 1-10 years after the initial infection
although in some cases it may take up to 50 years.
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Session 2: National Health Guidelines 17
• Promotion of ANC services: All ANC services including syphilis screening and treatment
should be provided as an integrated comprehensive package.
Guideline Contents
The guideline is composed of key components included in the process of managing syphilis
in pregnancy. These components include:
• Health education
• Management of syphilis in pregnancy
• Training and capacity building
• Logistic support
• Supportive supervision
• Monitoring and evaluation
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 2: National Health Guidelines 18
Handout 2.2: Summary of Management of Acute Malnutrition
National Guideline
Overview
• The guidelines have been developed to accommodate recent advance and approaches to
alleviate the burden of diseases associated with malnutrition and to contribute to the
reduction, in infant and under five morbidity and mortality in Tanzania.
• Studies have revealed that children suffering from severe malnutrition have 5 to 20 time’s
higher risk of death compared to well-nourished children.
• Severe acute malnutrition can be a direct cause of child death, or it can act as an indirect
cause by dramatically increasing the case fatality rate in children suffering from common
childhood illness such as pneumonia and diarrhoea.
• The 55th World Health Assembly endorsed the global strategy for infant and young child
feeding, which recommends actively searching for malnourished infants and young
children so that they can be identified and treated.
• The development of the community-based approaches for the management of severe
acute malnutrition provides a new impetus for putting this recommendation into practice.
• Therefore this approach, along with preventive action is added to the list of interventions
to reduce infant and child mortality the vision of Tanzania by 2025.
• The guidelines in this document address the management of acute malnutrition, in the
community and in health facilities throughout the country depending on the degree of
severity and associated complications. These will provide a framework for the proper
management of acute malnutrition in Tanzania.
Objective
The ultimate goal of the guidelines is to reduce child mortality in Tanzania by giving
clear guidance on improving the quality of the management of acute malnutrition in
the light of new scientific evidence and technological advances.
Specific Objectives
• Provide practical, task-orientated guidance to health care providers involved in the in-
patient management of severe acute malnutrition in health facilities.
• Provide practical guidance to health care providers working at grass-root levels to engage
and equip communities to treat moderate acute malnutrition and uncomplicated cases of
severe acute malnutrition within the community.
• Demonstrate collaboration and linkages between inpatient and community based
management and provide guidance on how health care providers from both sides will
work together.
• Describe how inpatient and community-based management will be implemented within
the existing health system in Tanzania.
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• Describe the provisions that are necessary to support the above strategy including
procurement, logistics and storage, and how these will be made available.
• Provide guidance to health care providers to monitor and evaluate the implementation of
the strategy to ensure a continuous process of learning and improvement.
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Handout 2.3: Summary of National Guidelines for:
A. RCH
B. Use of Uterotonics in Active Management of Third Stage of
Labour
Rationale
• For a number of years, the government has been the main provider of health services in
the country. Most of the planning and management of health issues where done at the
central level through vertical programmes.
• This encouraged a cumbersome and fragmented management hierarchy of health-service
delivery including those for reproductive and child health.
• Another rationale for strategy is the lack of integrated RCH communication, strategies,
which could be used by the government, private sector and NGOs.
Key Elements
The RCH Progamme in Tanzania will focus on five thematic areas, namely:
• Maternal health
• Family planning (FP)
• Adolescent Reproductive Health (ARH)
• Infant and child health
• STIs, HIV and AIDS
These areas were seen as key areas for the improvement of reproductive and child health
countrywide.
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Handout 2.4: Summary of National Guidelines for:
A. Management of HIV and AIDS
B. PMTCT
Guideline B: PMTCT
• The National guidelines for prevention of mother to child transmission of HIV summarize
national recommendation for delivery of prevention of mother to child transmission
(PMTCT) programme services.
• The national PMTCT guidelines are intended to promote and support the delivery of
quality HIV prevention, care, and treatment and support services.
• HIV prevention in mothers and families mother to child transmission (MTCT) of HIV
refers to the transmission of HIV infection from HIV infected mother to their infants.
MTCT can occur during pregnancy, labour and delivery and breast feeding. Without
intervention; the overall risk of MTCT is approximately 25 – 45%.
• Key elements in these guidelines are:
o Overview of HIV prevention in mothers and families
o Stigma and discrimination associated with HIV and AIDS
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o Counselling and testing
o Specific interventions to prevent MTCT
o Infant feeding in the context of HIV infection
o Comprehensive care and support for mothers and families with HIV infection
o Safe and supportive care in the work setting
o PMTCT programme management, monitoring, supervision and logistics
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Session 2: National Health Guidelines 23
Handout 2.5: Summary of National Guidelines for:
A. Voluntary Counselling and Testing
B. Provider Initiated Testing and Counselling
Rationale
• Currently there is a global and national movement to accelerate universal access to HIV
prevention, treatment care and support services for PLHIV. This calls for urgent scaling
up of HIV testing and counselling using different approaches.
• This will allow early identification and hence increase the number of HIV infected
persons who access care, treatment and support services.
• In Tanzania, knowledge of one’s HIV status has mainly been through VCT where by
clients proactively seek HIV testing and counselling services. In PITC, health care
providers initiate HIV testing and counselling to persons attending health facilities with
informed consent.
These guidelines include guidance on the aspects including implementation of PITC; process
and elements of PITC; HIV testing; ethical and legal considerations; supply chain
management; and supervision, monitoring and evaluation.
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Handout 2.6: Summary of National Guidelines for:
A. Infection Prevention and Control (IPC)
B. Health Care Waste Management
Content organization
• The material in this infection prevention and control pocket guide is divided into topics.
Each topic stands on its own. The topics are arranged in such a way that the reader needs
to know some basic IPC principles. The first principle of IPC is ‘The disease transmission
cycle’ Each topic is described briefly under the Standard Precautions section.
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• People working at community level to promote quality health care services, including
front line health care providers, facility health management committee and home based
care workers.
• Individuals, group and international organization engaged in healthcare service provision.
• Policymakers, health managers, program officers and health administrators.
• Various health team including regional and council health management teams.
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Session 2: National Health Guidelines 26
Handout 2.7: Summary of National Guidelines for:
A. Home Based Care Service
B. Management of Malaria for Health Service Providers
Goals
• The goal of appropriate malaria diagnosis and treatment is to reduce morbidity, mortality
and socio-economic losses.
• This guideline for diagnosis and treatment of malaria was developed in 2006. The
purpose is to promote prompt, effective and safe treatment of malarial disease at health
centre and dispensary levels.
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Handout 2.8: Summary of National Guidelines for
Management of Sexually Transmitted and Reproductive Tract
Infections
Introduction
• Sexually Transmitted Infection (STI) is a group of infections that are predominantly
transmitted through unprotected sexual contact with infected person.
• Reproductive Tract Infections (RTIs) are infections of genital tract.
• Not all reproductive tract infections are sexually transmitted. STI refers to the way of
transmission whereas RTI refers to the site where the infections develop.
Rationale
• Effective management of STIs and RTIs is one of the cornerstone of their control, as it
prevents the development of complication and recurrence, decreases the spread of those
infections and HIV in the community and offers a unique opportunity for targeted
education about reproductive health.
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Handout 2.9: Summary of National Guidelines for:
A. Management of HIV and AIDS for Frontline Workers
B. Policy Guidelines for Collaborative TB/HIV Activities
Purpose of Guideline
• This document is intended to provide guidelines for health care workers on various
aspects of care and support.
• These include nursing care, treatment of opportunistic infections, prevention of
transmission of the infection, counselling and care during pregnancy, labour and postnatal
period.
• The document also containing a section on continuum of care which emphasizes the
delivery of comprehensive care at home at various levels of health care system.
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Session 3: National Guidelines for Management of
HIV and AIDS and for Prevention of Mother-to-Child
Transmission of HIV
Learning Objectives
By the end of this session, students are expected to be able to:
• Explain the background and rationale of National Guidelines for Management of HIV and
AIDS and for Prevention of Mother-to-Child Transmission of HIV (PMTCT)
• Describe the objectives of National Guideline for PMTCT
• Describe key elements of the National Guideline for the Management of HIV and AIDS
and for PMTCT
Background
• Since the first three AIDS cases were reported in Tanzania in 1983, the HIV epidemic has
spread rapidly to all districts and communities and has affected all sectors of the society.
• During the year 2003 a total of 18,929 AIDS cases were reported to the National AIDS
Control Programme (NACP) from the 21 regions bringing the cumulative total of
reported cases since the epidemic broke to 176,102.
• The National Guidelines for Clinical Management of HIV and AIDS was produced only a
few years ago.
• However, recent developments and experience in the field of HIV and AIDS care and
treatment has made it necessary for the country to come up with another edition of these
guidelines to reflect the changes that have taken place.
• This expansion of the guidelines will help to improve the quality of care and treatment of
HIV and AIDS and to give clinicians more flexibility in providing quality care.
Rationale
• HIV and AIDS is a rapidly evolving field. This is particularly true in the field of care and
treatment of individuals infected with HIV.
• Newer and more potent drugs are continuously being developed and used; and knowledge
of the existing drugs in terms of efficacy, as well as short and long-term side effects is
becoming clearer as we gain more experience.
Instructions
You will work in small manageable groups to discuss the key elements of HIV and AIDS
Guidelines for 10 minutes. One group will present their findings and other groups will
participate in discussion.
• The National Guidelines for Management of HIV and AIDS has 16 chapters which
consist of the following key elements:
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Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 31
Organization of HIV and AIDS Care and Treatment
• This part provides guidance on the identification of people living with HIV and AIDS in
need of care and treatment and sensitization of communities. It further explains scope and
organization of care and treatment services by highlighting staffing and team approach,
patient visit plans, medical records systems, reporting and monitoring.
• Certification of health facilities to deliver HIV and AIDS care and treatment with
tabulated minimum criteria to start/expand ART for hospitals are detailed in this section.
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• Thus, it identifies the current existing and commercially available ART drugs under 5
main categories, i.e. binding and fusion inhibitors, nucleoside reverse transcriptase
inhibitors, non-nucleoside reverse transcriptase inhibitors, nucleotide reverse transcriptase
inhibitors and protease inhibitors.
• Guidance in treatment using ARV drugs in adult and adolescents and recommended ARV
drugs in Tanzania are detailed explained in this part.
Other Areas
• The guideline also gives detailed guidance in the management of mental health problems
in HIV and AIDS, community and home based care for people living with HIV and
AIDS, and nutrition in HIV and AIDS.
Background
• The National Guidelines for Prevention of Mother-to-Child Transmission of HIV
(PMTCT) of 2007 summarizes national recommendation for delivery of prevention of
mother to child transmission (PMTCT) programme services.
• The guidelines are based on national HIV and AIDS policies and replace that of March
2004.
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Activity: Large Group Discussion
Instructions
You will be given copy of the PMTCT Guidelines to read the introductory part and identify
key messages. You will be required to contribute in large group discussion.
Instructions
You will work in small manageable groups to discuss and agree on “key elements of the
guideline.” Your group will have 10 minutes. One group will present their findings and
other groups will participate in discussion.
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• Counselling pregnant women with special needs, testing women of unknown HIV status
at the time of labour and delivery, quality assurance and control and national
recommendations for HIV testing in PMTCT programme are covered.
Comprehensive Care and Support for Mothers and Families with HIV Infection
• In this part of the guideline, comprehensive care, treatment and support, postpartum care
and support, care and support of HIV-exposed and HIV-infected infants and children,
common signs and symptoms of HIV infection in infants and diagnosis of HIV in infants
and young children are explained in detail.
Finally, among other things, the document is annexed with the following:
• HIV prevalence in women and men
• Post-test counselling checklists
• National recommendations: ART prophylaxis regimens to prevent MTCT
• Advantages and disadvantages of infant feeding options for HIV-infected mothers
• Steps to express and pasteurise breast milk
• How to feed an infant from a cup
• Comprehensive care for PMTCT of HIV
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Key Points
• The Guidelines for Management of HIV and AIDS consist of:
o Organization of HIV and AIDS Care and treatment in health facility
o HIV and AIDS prevention and HIV prevention in health care settings
o Laboratory tests for HIV and AIDS
o Management of common symptoms and opportunistic infections in HIV and AIDS
o Antiretroviral therapy in adults, adolescents, infants and children
o TB and HIV co- infection
o HIV and AIDS in pregnancy
o Counselling related to HIV testing and treatment adherence
• National PMTCT Guidelines focus on maternal, child and family health, and intend to
promote and support the delivery of quality HIV prevention, care, treatment and support
services.
• PMTCT Guidelines should be referred to when developing institutional policies and
procedures, training and quality assurance initiative for PMTCT programmes.
Evaluation
• What is the rationale for National Guidelines for Management of HIV and AIDS?
• What are the key elements of the guidelines for the Management of HIV and AIDS?
• What is the rationale for National Guidelines for PMTCT?
• Mention key elements of the PMTCT guideline.
• If you want to recommend pasteurization for a pregnant mother, which part of the
PMTCT Guidelines would you refer to?
References
• NACP. (2009). National Guidelines for the Management of HIV and AIDS (3rd ed). Dar
es Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme.
• NACP. (2009). National Guidelines for the Prevention of Mother-to-Child Transmission
of HIV (PMTCT). Dar es Salaam, Tanzania: Ministry of Health and Social Welfare,
National AIDS Control Programme.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 3: National Guidelines for Management of HIV and AIDS and PMTCT 36
Session 4: National Health Guidelines for Malaria and
for Collaborative TB/HIV Activities
Learning Objectives
By the end of this session, students are expected to be able to:
• Explain the background of Guidelines for Malaria and for Collaborative TB/HIV
Activities
• Describe the rationale and objectives of National Guideline for Malaria and for
Collaborative TB/HIV Activities
• Describe key elements of the National Guideline for Malaria and for Collaborative
TB/HIV Activities
Objectives
• The broad objective of this guideline is to provide standard management reference for the
care of patients with malaria. They form part of the National Drug Policy.
• These recommendations represents the minimum level of care that patients should expect
at different level of health care in public and private sectors.
• Specifically, the objectives of the guideline are to:
o Stipulate at all level of health care delivery that specific antimalarial drugs should be
made available at all times
o Promote prompt and accurate malarial diagnosis
o Promote rational antimalarial drug management
o Promote intermittent preventive treatment for malaria in pregnancy
o Provide consistent guidance to prescribers and users on the appropriate use of
chemoprophylaxis for specific at- risk groups
o Provide information to health care managers and service providers on the detection of
antimalarial drug resistance
Rationale
• The rationale for the guideline was a result of increased resistance of the malaria parasites
to antimalarial monotherapies, in order to preserve the efficacy and effectiveness of the
existing drugs and to ensure an optimal cure.
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Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 37
Key Elements of National Malaria Guidelines
Instructions
You will work in small manageable groups to discuss “the key elements of the national
malaria guidelines. Your group will be given a copy of the guideline if available. Your
group will have 10 minutes to complete the task. One group will present their findings and
other groups will participate in discussion.
• The National Guidelines for Malaria Diagnosis and Treatment has 16 chapters which
consist of the following key elements:
Introduction
• Explains background or history of malaria, diagnosis and treatment in Tanzania.
• Further highlights on the guidelines’ broad objectives and specific, rationale and choice
of antimalarial drugs.
Diagnosis of Malaria
• This part explains clinical features of malaria, assessment of the patient and laboratory
investigations.
• Provides details on the clinical assessment of the patient and gives distinguishing features
of uncomplicated malaria in relation to age groups, clinical and laboratory features of
severe malaria.
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Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 38
Anaemia and Malaria
• Provides the definition of anaemia and gives the clinical presentation of anaemia and its
classification and management of life threatening anaemia associated with malaria when
it is severe, or mild/moderate.
Malaria Chemoprophylaxis
• The section explains the indication for malaria chemoprophylaxis and its recommendation
for use in various groups, i.e. patients with anaemia, non-immune travellers and non-
immune pregnant women.
Malaria Epidemics
• Gives the definition of malaria epidemic as the occurrence of new cases of malaria clearly
exceeding the number expected at that particular time and place.
• The section explains measures to be considered during malaria epidemics and diagnosis
in the event of malaria epidemics.
Other Sections
• In this guideline, the last chapters are about public health education on malaria case
management, other antimalarial drugs available in Tanzania, management of antimalarial
drugs and pharmaco vigilance which are set of activities related to the detection,
assessment and prevention of drug adverse reaction.
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Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 39
Background, Rationale and Objectives of the TB/HIV Guideline
• TB and HIV and AIDS pose significant global public health problems.
• TB and HIV are overlapping epidemics.
• Both have been declared global emergencies demanding global attention.
• The World Health Organisation (WHO) declared TB to be a global emergency in 1993,
and the United Nations (UN) declared HIV and AIDS to be a global emergency in 2001.
• UN member countries and other international organisations have committed themselves
to address the TB and HIV and AIDS crises with urgency.
• Efforts to address the two problems have been carried out separately, resulting in an
inadequate global impact on the dual epidemics.
• There is an increasing recognition of the need to strengthen collaboration between
national TB and HIV and AIDS programmes and other stakeholders in countries around
the world because of the overlapping nature of TB and HIV infection.
• There is evidence that HIV infection weakens the immune system, thereby fuelling the
TB epidemic among people living with HIV and AIDS (PLHIV). On the other hand, TB
is the main opportunistic infection and leading cause of deaths among PLHIV.
• In many countries, TB cases have been increasing together with rising HIV prevalence. In
sub-Saharan Africa, for instance, a fourfold rise in TB cases related to the HIV epidemic
has been reported.
• The situation in Tanzania is not different from that in many sub-Saharan countries.
Rationale
• A review of the implementation of collaborative TB/HIV activities that took place in
2005 showed that TB/HIV activities had been established, but there was no national
policy framework to guide the implementation process.
• Thus, a policy framework was needed to guide stakeholders in scaling up collaborative
TB/HIV activities to address the dual epidemics.
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Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 40
Key Elements of the National TB/HIV Guidelines
Instructions
You will work into small manageable groups to discuss the key components of the
collaborative TB/HIV policy guidelines for 10 minutes. Your group will be given a copy of
the guideline if available. One group will present their findings and other groups will
participate in discussion.
Key Points
• The National Guidelines for Malaria Diagnosis and Treatment are an essential part of the
larger process of governance.
• They are standards, protocols, and procedures that govern day-to-day operations of within
health sector and that determine who provides what care to which clients.
• The National Guidelines for Collaborative TB/HIV Activities is one dimension of the
Government of Tanzania’s efforts to combat the dual epidemics of TB and HIV.
• The vision of these policy guidelines is to create a sound framework and guiding
principles for best practices of rationality, effectiveness, efficiency, and consistency in
developing and implementing strategies for collaborative TB/HIV activities.
Evaluation
• What is the rationale for National Guidelines for Malaria Diagnosis and Treatment?
• Mention key elements of the guidelines for malaria.
• What is the rationale for National Guidelines for Collaborative TB/HIV Activities?
• List key elements of the National guidelines for collaborative TB/HIV activities.
• If you were asked to establish a TB/HIV committee at your centre, which topic would you
refer to in the guideline?
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 41
References
• MCP. (2006). National Guideline for Malaria Diagnosis and Treatment. Dar es Salaam,
Tanzania: Ministry of Health and Social Welfare, Malaria Control Programme.
• NACP/NTLP. (2009). National Guidelines for Collaborative TB/HIV Activities.. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare, National AIDS Control
Programme/National TB and Leprosy Control Programme.
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Session 4: National Health Guidelines for Malaria and for Collaborative TB/HIV Activities 42
Session 5: Ethical Theories and Principles in Medical
Practice
Learning Objectives
By the end of this session, students are expected to be able to:
• Define common terms related to ethical theories and principles in medical practice
• Identify major ethical theories in medical practices
• Identify the importance of systematic study of ethics to medicine
• Identify the ethical principles in medical practice
• Analyze ethical principles in medical practice
• Apply ethical principles when managing patients/clients
Definition of Terms
• Ethics: A systematic study of what a persons’ conduct and actions ought to be with
regard to himself or herself, other human beings and the environment.
• The word ethics originated from the Greek word ‘ethos’ meaning customs or character.
• It is concerned with judgement about what is right or wrong conduct.
• Virtue: Moral excellence, goodness and rightness.
• It is also defined as conformity of one’s life and conduct to moral and ethical principles,
uprightness, and rectitude.
Virtue Ethics
• Refers to a virtue of character as a health practitioner rather than rules governing conduct
or consequences of any action by a health practitioner.
• Virtue ethics demands the practitioner to exercise loyalty, devotion and trustworthiness,
good temperament, compassion and integrity.
Ethical Principle
• Is a basic concept by which behaviour can be judged. Ethical Principles help people to
make decisions, because they serve as a standard with which to measure actions.
• Governing rules of conduct, as code of conduct by which life and action can be directed,
or as generalization that provide a basis for reasoning.
• A principle is an established rule of action to be followed in implementing a set of
activities.
Values
• Is something of worth or excellence or that which is esteemed, prized, or highly regarded.
• Values refer to one’s evaluative judgement about what one believes is good or what
makes something desirable.
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Session 5: Ethical Theories and Principles in Medical Practice 43
Ethical Theories
Consequentialism or Utilitarianism
• This is a moral theory that holds that an action is judged as good or as bad in relation to
the consequence, outcome or end result that is derived from it.
• According to the utilitarianism school of thought, right action is that which has great
utility or usefulness. Utilitarianism holds that the only factors that make actions good or
bad are the outcomes, or end results, that are derived from them.
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Session 5: Ethical Theories and Principles in Medical Practice 44
The Principle of Goodness or Rightness
• This principle demands that human beings attempt to do three things:
o Promote goodness over badness (evil) and do good (beneficence)
o Cause no harm or badness (non-maleficence)
o Prevent badness or harm (non-maleficence)
Goodness or Rightness
• Individuals and societies, groups and cultures have different values and ideas of what
‘good’ implies.
• Certain things, however, seem to be generally recognizable as good. Examples of these
things are life, pleasure, happiness, truth, knowledge, beauty, love, friendship, self-
expression, freedom, peace, honour and security.
• A medical practitioner is obliged to avoid harm or injury/hurt to the patients/clients in all
aspects by demonstrating high level of competence in her/his practices.
• This principle provides justification for condemning any act that unjustly injures a person
or causes them to suffer an avoidable harm.
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Session 5: Ethical Theories and Principles in Medical Practice 45
Activity: Case Study
Instructions
Read the scenario below, and then answer the questions.
Scenario: You are the in-charge of a health centre where resources are limited and you have
few in store. Most of the patients are in a bed without bed sheets. On the same day you
receive a seriously ill patient who is the daughter of the council chairperson. You decide to
provide this patient with a new bed sheet from the store and you allocate one nurse to ensure
the wellbeing of this patient.
Questions
• What do you think about this practice?
• Is it fair? Explain.
• What can be done to ensure justice and fairness in a situation like this?
Activity: Example
Instructions
Read the following example of the ethical principle of ‘truth telling and honesty’.
• A patient came to hospital with uterine fibroid, and the doctor promised to remove the
fibroid and leave the uterus intact. However, in the process of the operation, he did total
hysterectomy without informing the patient. Two years later, the patient learned at the
infertility clinic that her uterus was removed and she can never get pregnant.
Note: The lesson here is that health workers should be truthful on patient’s condition and
outcomes of care.
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Session 5: Ethical Theories and Principles in Medical Practice 46
• The concept of autonomy involves respect, the ability to determine personal goals, the
capacity to decide on a plan of action, and the freedom to act on the choice which has
been made.
• It involves consent, which is a process whereby patients are informed of possible
outcomes, possible alternatives and risks of their treatment.
• Managing clients without consent will result in non-compliance. Autonomy also values
patient’s advance directives.
• In some situations, not all patients are competent to make decisions themselves.
o Examples include young children, individuals affected by certain neurological and
mental health conditions and those who are temporarily unconscious. These patients
require substitute decision-makers, usually a next of kin or significant others.
Instructions
Read the scenario below, and then answer the questions.
Scenario: A 15-year-old girl comes to the Reproductive and Child Health Clinic (RCH)
where you are working and she requests an oral contraceptive. The next day her mother
confronted you for giving her daughter oral contraceptive without her consent.
Questions
• What is your opinion concerning the reaction of that mother?
• Do you think it was ethically proper for the health worker to offer contraceptives?
Key Points
• There are five types of ethical principles that are important in providing quality care:
o The value of life principle
o The principle of goodness or rightness
o The principle of justice or fairness
o The principle of truth telling or honesty
o The principle of individual freedom
Evaluation
• Define common terms related to ethical theories and principles.
• List two major ethical theories.
• Identify the importance of systematic study of ethics to medicine.
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Session 5: Ethical Theories and Principles in Medical Practice 47
References
• Beuchamp and Childress. (1994). Principles of Biomedical Ethics. Oxford: Oxford
University Press.
• Burkhardt, Margareth A., and Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subjects. Geneva: Council for International Organizations of Medical Sciences.
• Furrow, Dwight (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mellish, J.M. and Paton, Frieda, (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.
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Session 5: Ethical Theories and Principles in Medical Practice 48
Session 6 : Confidentiality in Medical Practice
Learning Objectives
By the end of this session, students are expected to be able to:
• Define confidentiality
• Explain the principles of confidentiality in medical practice
• Describe the importance of confidentiality in medical practice
• Identify limitations of confidentiality in medical practice
Definition of Terms
• Confidentiality: The ethical principle that requires non-disclosure of private or secret
information with which one is entrusted.
• In research, confidentiality refers to the researcher’s assurance to participants that
information provided will not be made public or available to anyone other than those
involved in the research process without participants consent.
• The obligation to respect confidentiality applies when a person has information in
confidence.
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Session 6: Confidentiality in Medical Practice 49
Activity: Case Study
Instructions
Read the scenario below, and then answer the questions.
Scenario
A medical practitioner was playing pool with his colleague, during that time they were
discussing about the seriousness of a tumour of one school teacher. This conversation was
overheard by a relative of the patient and the patient was informed.
Questions
• Was the practitioner right to discuss this issue at that location?
• Do you think the patient will prefer again being attended by this doctor? Why?
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Session 6: Confidentiality in Medical Practice 50
• Anyone who feels that the disclosure of confidential information in certain instances is
morally justifiable or even obligatory bears a burden of proof which cannot be denied.
Instructions
Read the scenario below, and then answer the question.
Scenario: You are a passenger in a public bus. Upon boarding a bus from Kibaha to Dar es
Salaam, Dr. X realized that the driver is a person who is attending epileptic clinic at his
hospital. Alarmed by likelihood of accident if the drive gets an attack, Dr. X stood up and
loudly announced to all passengers that your life is in danger as the driver is epileptic, and
any time he can get an accident, then he disembarked from the bus.
Question
• Was the action taken by Dr. X proper?
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• In determining the proportionality of these respective harms, the medical practitioner
needs to assess and compare the seriousness of the harm and the likelihood of their
occurrence.
o In case of doubt, it would be wise to seek expert advice.
o When a medical practitioner has determined that the duty to warn justifies an
unauthorised disclosure, two further decisions must be made.
Whom should the medical practitioner tell?
How much to tell?
o The disclosure should contain only that information necessary to prevent the
anticipated harm and should be directed only to those who need the information in
order to prevent the harm.
o In case of HIV-positive patient, disclosure to a spouse or current sexual partner may
not be unethical and, indeed, may be justified when the patient is unwilling to inform
the person at risk. Such disclosure should require that all of the following conditions
are met:
The partner is at risk of infection of HIV and has no any other reasonable means
of knowing the risk
The patient has refused to inform his or her sexual partner
The patient has refused an offer of assistance by the physician to do so on the
patient’s behalf
The healthcare provider has informed the patient of his or her intention to disclose
the information to the partner
o In medical care of suspected and convicted criminals, healthcare provider should
safeguard confidentiality by not revealing details of the patient’s medical conditions
to prison authorities without first obtaining the patients consent.
Key Points
• Confidentiality is the ethical principle that requires non-disclosure of private or secret
information with which one is entrusted.
• A confidential relationship arises whenever one person entrusts confidential information
of another person.
• Professional Pledge of Service for medical professional states in as follows; ‘I will hold in
confidence all personal matters coming to my knowledge’.
• Health care personnel are obliged both legally and ethically to maintain strict
confidentiality in respect of the patient.
• There are few exceptions whereby the health care practitioner is obliged to reveal some of
the patient’s information relevant authority/persons only.
Evaluation
• What is confidentiality?
• Why should medical personnel keep confidentiality?
• What are the limitations of confidentiality in medical practice?
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
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Session 6: Confidentiality in Medical Practice 52
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
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Session 7 : Rights of the Client/Patient
Learning Objectives
By the end of this session, students are expected to be able to:
• Define the terms right, patient, culture and values
• Identify rights of the patient/client
• Identify the culture and values that influence comprehensive health care
• Demonstrate the application of the patient rights when providing medical service
Definition of Terms
• Rights: Is a privilege or fundamental power to which an individual is entitled unless is
revoked by law or given up voluntarily.
o Are social or economical privileges to which some has to claim legally or morally
• Patient/Client: Is any person who receives medical attention, advice, care or treatment
often ill or injured.
• Culture: Is defined as a belief, value, norms and customs of a specific group.
• Values: Are particular characteristics or qualities, which single out a person, department,
an institution, or an organisation to be recognised as it is.
o Value is something that is perceived as desirable or ‘the way things ought to be’ (Ellis
& Dean, 2000; Husted & Husted, 2001).
Examples of Compassion
• A patient with cancer of the oesophagus had no spiritual counselling before. Once a
clinician touched on this aspect the patient said, ‘Oh yes I really and badly wanted to see
a priest’, the priest was called and after a spiritual session the patient died peacefully.
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• A reason commonly given by mothers who opt for delivery at home is lack of compassion
by health providers in the facilities.
o A young woman had her first delivery in nearby hospital. The abusive language she
underwent from the nurses made her decide never to deliver in that health facility
again. Instead, she had her second and third deliveries at another health facility where
she claimed there was more compassion.
o Some patients prefer to go to certain hospitals because they believe there is more
compassion.
Right to Information
• Information is something, which gives knowledge in the form of facts and news.
• The patient has the right to receive adequate and appropriate information about any
proposed medical care as the patient may need to give informed consent or to refuse the
course of treatment.
• In some situations, such as when a patient is asked to sign a document that he/she has not
read, cannot read or could not understand it from the beginning, the patient’s/client’s right
to information and participation in medical care has not been observed.
Instructions
Read the scenario below, and then answer the question.
Scenario: Mrs. M and her family were involved in a motorcar accident whereby her husband
and her two children died on the spot. Mrs. M was brought to the hospital unconscious with
head injury. After gaining consciousness, she kept on asking for her husband and her two
children. The clinician made up a story to conceal the fact fearing that by telling her the truth
might result in upsetting her emotions and worsen her condition.
Question
• Was the clinician doing right by concealing the truth to the patient? Explain.
Right to Privacy
• Privacy is defined as a desirable state of being away from other people so that they cannot
see or hear what you are doing. Refers to ones ownership of one’s body or information
about oneself.
• Right to privacy is important in order to establish communication and a trusting
relationship so that the person is able to submit his/her body during medical care.
• Privacy for patient’s body, information and their hospital documents is one of the
observed human rights when providing care. Clinicians should safeguard patient’s
privacy in order to maintain his/her human dignity.
Right to Confidentiality
• Confidentiality is defined as ensuring that information will not be made public and will be
accessible only to those authorised to have access.
• Confidentiality is one of the cornerstones of information security.
• Patients give confidential information to health practitioners voluntarily believing that it
will help in their receiving correct diagnoses and appropriate treatment.
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• We observe confidentiality because we respect our clients and their autonomy and it is the
essential element of building trust in relationships.
• It is a duty of health practitioners to maintain confidential information revealed to them
by their patients/clients and shall not disclose the information to unauthorised people.
• However, in the process of caring for patients, health practitioners shall share this
information with other members of health-care team for continuity of care.
Instructions
Read the scenario below, and then answer the question.
Scenario: A patient came to hospital with an obstructed labour and refused to be operated
saying ‘I cannot undergo this because I believe I will deliver in a normal way’. Then medical
practitioner did not proceed with the operation recognising the right of the patient to give
consent. But this resulted that, the patient was not operated immediately and child was born
with low APGAR score.
Question
Was the health provider right?
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• The medical profession has a duty to train practitioners to provide care which is
meaningful and sensitive to the needs of patients of all cultures. It is important that a
practitioner should carefully consider the following cultural rights of the client:
o Recognition of his/her own cultural orientation, meaning that there is need for
medical practitioners to analyse their own beliefs which may influence their
willingness to care for other people
o Understanding of the importance of the patient’s perspectives in that it enables the
medical practitioner to identify differences and then to find ways of working with
such differences.
o Development of communication skills in order to examine the patient’s perspectives;
the health provider cannot identify a patient’s perspectives or involve the patient in a
discussion if for some reasons the patient is unable to communicate effectively
• Identification of issues and factors which influence provision of care to people of other
cultures is an important aspect in provision of effective medical care
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• Client confidentiality and privacy
• Respect for colleagues and clients
• Individual right to health care
• Affordability of care
• Partnership in health care provision
Key Points
• A right is a privilege or fundamental power to which an individual is entitled unless it is
revoked by law or given up voluntarily.
• Any person who seeks health services deserves specific rights, and health workers are
obliged to safeguard them.
Evaluation
• What are the patient’s/client’s rights?
• Identify the culture and values that influence comprehensive health care in your area.
ASK students if they have any comments or need clarification on any points.
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• James H. Husted & Gladys L. Husted. (2001). Ethical Decision Making in Nursing and
Health Care. Springer Publishing Company.
• Kathryn Ellis & Hartley Dean. (2000). Social Policy and the Body: Transitions in
Corporeal Discourse. Macmillan, Basingstoke.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Vonduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.
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Session 8: Rights of the Health Care Provider
Learning Objectives
By the end of this session, students are expected to be able to:
• Define the terms right, health provider
• Identify health provider’s rights
• Describe guidelines on health and safety programs for health providers
• Identify responsible stakeholders for health provider safety
• Describe compensation rights for health providers injured at work
Definition of Terms
• Health care provider: A person who has acquired the expert knowledge base in health
matters, decision-making skills and clinical competencies for practical practice, the
characteristics of which are shaped by context and/or country which he/she is legally
allowed to practice.
• Right: Is a privilege or fundamental power to which an individual is entitled unless is
revoked by law or given up voluntarily.
o Also is defined as social, economical or privileges to which some has to claim legally
or morally.
Instructions
You will work in small groups to discuss and list rights of health care provider. Record your
answers. One group will present their responses and other will share in the discussion.
• Basic human rights of all Tanzanians are provided in the Constitution of the United
Republic of Tanzania.
• Together with these rights, the health care provider has the right to:
o Recognition of their competence and potential as well as respect for their human
action
o Health providers have the right to opportunities for professional advancement
o Practice in an environment that allows them to act in accordance with professional
standards and authorised scopes of practice
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o Work in an environment that supports and facilitates ethical practice in accordance
with Code of Professional Conduct
o Negotiate the condition of their employment, either as individuals or collectively in
all practice setting
o Work in an environment that is safe to herself/himself and to her/his patients
o Fair compensation for her/his work consistent with their knowledge, experience and
professional responsibility
o Freely advocate for themselves and their patients/clients
o Get rest, leisure time and family life
o Compensation for injuries happening in the course of their work
Instructions
Read the scenario below, and then answer the question.
Scenario
Clinician X is working in a rural health centre for 6 years. He feels that in order to execute
high quality care, he needs to advance himself further by enrolling in a degree program. He
applies to the university and is granted admission. He wrote a letter to the employer in order
to be released for his studies.
The employer reads the letter, bangs the table and says ‘What is this? Nonsense! A clinical
officer for a degree? No way’! He calls the clinician and tells him that permission is not
granted for him to go for the studies.
Questions:
1. What right has the clinician been denied?
2. What further action should the clinician take to get his right?
3. What is the best way of dealing with such an employer?
Key Points
• Right is a privilege or fundamental power to which an individual is entitled unless is
revoked by law or given up voluntarily.
• Health care providers have right to; recognition, professional advancement, better
enabling environment, negotiation, fair compensation and time for rest and family
Evaluation
• Please mention the different rights of health providers.
• Can a volunteer explain the guidelines on health and safety programs for health
providers?
• Can someone please identify responsible stakeholders for health provider safety?
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
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Session 8: Rights of the Health Care Provider 62
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Vonduct.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
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Session 9: Laws Related to Medical Practice
Learning Objectives
By the end of this session, students are expected to be able to:
• Define law, constitutional law, statutory law, administrative law, common law and public
law
• Recognise the relationship between ethics and law
• Describe sources of law
• Describe the differences between criminal and private law
Definition of Terms
Instructions
Work in small groups to define law. Record your responses. One group will present and other
group will share in the discussion.
• Law: A system of binding rules of action or conduct that govern the behaviour of people
in respect to relationship with others and with the government.
• Laws, meant to reflect the moral belief of a given population, are designed by groups of
people serving in official capacity.
• The law establishes rules that define our rights and obligations, and sets penalties for
people who violate them. Law also describe how government will enforce the rules and
penalties.
• In general, laws ensure the safety of the citizens, protects properties, promote non-
discrimination, regulate the professions, provide for the distribution of public goods and
services, and protects the economic and environmental interests of the society.
Constitutional Law
• A constitution is a formal set of rules and principles that describe the powers of a
government and the rights of the people.
• The principles laid out in a constitution, coupled with description of how these principles
are to be interpreted and carried out, forms the basis of constitutional law.
Statutory/Legislative Law
• These are formal laws written and enacted by the Parliament or local government
legislatures. Because many people think that every problem in the society can be solved
by passing a law, legislature makes more and more laws to satisfy the demand of the
society.
Administrative Law
• Administrative law consists mainly of the legal powers granted to administrative agencies
by legislative bodies and the rules that the agencies make to carry out their powers. It
involves the operation of government agencies.
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• The state sets up administrative agencies to do the work of the government. These
agencies regulate such activities as education, public health, social welfare programs and
professions.
o The Medical Council of Tanganyika is example of these types of agencies.
Common Law
• Is a law system based upon earlier court ruling in similar cases. This type of law is also
known as case law. Earlier court ruling in similar cases are also known as precedents.
Public Law
• Is a law which deals with a person’s rights and obligations in relation to the government
and describes the various divisions of government and their powers. One important
branch of public law is criminal law.
Instructions
Read the scenario below, and then answer the questions.
Scenario
A medical practitioner has placed a huge advertisement on the service he is providing and
expresses how good he is in managing complicated surgeries.
Questions
1. Is this ethically appropriate?
2. Did he break any law?
3. Is this both a legal and ethical issue?
• Laws are intended to reflect popular belief about ‘rightness and wrongness’ of a particular
acts and are, like ethics, built upon moral foundation.
• In most countries laws represent an attempt to codify ethics. One would expect that laws
would be congruent with prevailing moral values of the society.
• For example, most people would agree that the murder of innocent person is an immoral
act. Laws that prohibit murder reflect this ethical standard. Murder of the innocent is both
ethically and legally prohibited in every culture.
Sources of Law
• At least four different sources of law affect the practice of medicine: constitutional law,
statutory (legislative) law, administrative law, and common law.
• Additionally, law can be divided into two main branches: private law and public law.
Constitutional Law
• The Constitution of the United Republic of Tanzania is the preeminent source of this
country’s law. Ensuring legal rights and responsibilities of citizens and establishing
general organisation of the government, constitutional law supersedes all other laws.
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• The Bill of Rights of the United Republic of Tanzania Constitution guarantees each
citizen the rights, among others, of equal protection, freedom of speech, freedom of
movement, freedom of religion.
• A medical practitioners’ action should take into account these basic rights. Bills of Rights
are consistent with the ethical principles of autonomy, confidentiality, respect of person
and veracity.
• These same rights that apply to patients also apply to medical practitioners. As
participants in the health care system, we cannot be forced to forfeit our constitutionally-
guaranteed rights.
Statutory/Legislative Law
• Statutory or legislative law has more power because it is passed by the parliament of the
United Republic of Tanzania.
• It has disadvantages such as, it is not easy to be reviewed and it cannot cover technical
details of the service it intends to regulate.
Administrative Law
• The state set up administrative agencies to do the work of the government. These
agencies regulate such activities as education, public health, social welfare programs and
professions.
• The law establishing these administrative agencies and regulation/rules/by-laws issued by
these agencies are sources of law.
• Rules propagated by the administrative bodies carry the same weight as other law.
Common Law
• Tanzania and other English-speaking countries have a common law system as one source
of law.
• Judicial decisions depend on previous court ruling as the guidance in making subsequent
ruling.
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Private Law
• It is also called civil law. It determines a person’s legal rights and obligations in many
kinds of activities that involve other people. These activities include everything from
borrowing or lending money to signing a job contract.
• There are six branches of private law: contract and commercial law, tort law, property
law, inheritance law, family law, and corporation law.
• Non-compliance with private law generally leads to monetary compensation granted to
the injured or complaining party.
• Branches of private law that are most applicable to medical practice are:
o Contract law
o Tort law
Contract Law
• A contract is a binding legal agreement that is enforceable in a court of law.
• Contract law is based on the principle saying ‘agreements are to be kept’. Breach of
contract is recognized by the law and remedies can be provided.
• Medical practitioners do not normally enter into contractual relationship with patient. The
patient usually enters into a contract with a hospital.
• If a health practitioner were to act negligently or unprofessionally, the patient who suffers
the damage could hold either the practitioner or the hospital liable on the basis of
contract.
• However, if the practitioner were to be in private practice, the contract clearly exists
between the practitioner and the patient. A breach of this contract will be subject to
normal legal remedies applied to contract.
Key Points
• The law establishes rules that define our rights and obligations, and sets penalties for
people who violate them.
• The main four different sources of law affect the practice of medicine are: constitutional
law, statutory (legislative) law, administrative law, and common law.
Evaluation
• Define law, constitutional law, statutory law, administrative law, common law and public
law.
• Explain the relationship between ethics and law.
• What are the differences between criminal and private law?
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 68
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Vonduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, I
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 9: Laws Related to Medical Practice 69
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Session 10: Negligence in Medical Practice
Learning Objectives
By the end of this session, students are expected to be able to:
• Define negligence
• Describe factors necessary to establish negligence
• Explain action which can be taken on a negligent practitioner
• Describe factors which can help to minimize negligence
Definition of Terms
• Brief criteria for testing someone’s conduct for negligence can be stated as follows:
o Would a reasonable man placed in the doer’s position:
Have anticipated (foreseen) the possibility of harm?
Have taken steps to prevent such harm?
o Did the doer’s conduct deviate from the above mentioned standards?
If so, the doer was negligent, if not, he is not negligent.
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Establishing Negligence in Order to Get Compensation
• In event that a client who has suffered harm because of negligent action of the health
worker, and the client have instituted claims for compensation in a court of law, the
following conditions must be proved:
o That the defendant was under a recognized legal duty to provide care
o That the legal duty extended to cover the claimant in the particular circumstances
o That the defendant breached that legal duty
o That as a result of that breach of duty by the defendant, the claimant suffered loss or
damage or injury
o That the loss, damage or injury was the proximate result of the breach of duty by the
defendant
Instructions
Read the scenario below and then answer the questions.
Scenario
A medical practitioner was examining a mother in labour pain at a health centre.
Unfortunately, he did not examine foetal heart rates. After several hours of delayed labour,
the mother delivered a still birth. It was established that the baby went through a period of
foetal distress which would have been noted by the practitioner if he would have taken
foetal heart rate.
Questions
• Was this practitioner negligent or not?
• Why?
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• In addition, the same negligent conduct can lead to the victim claiming for compensation
in a civil case. The claimant may be the patient or his next of kin, and the defendant can
be the health practitioner or the hospital.
• The claimant may demand compensation citing negligent conduct of the practitioner that
if not for the negligence in providing transport to bring in the anaesthetist, the patient
wouldn’t suffered the injury or death.
• The claimant will sue the hospital because it is the responsibility of the hospital to ensure
that it employs practitioners who are competent and of the right conduct.
• Also, in many health facilities, clients do not come to be seen by a specific practitioner,
rather they are coming to be attended by the hospital.
• Another reason for suing the hospital is because it is much more likely to get
compensation from the hospital than getting from a practitioner.
• Some of the medical practitioners’ actions might be crimes. Crimes are dealt with the
Penal Code and the Criminal Procedures Act.
• In Tanzania it is a crime to conduct abortion or assist in conducting abortion. In a
problem like this, the practitioner will be charged by the police and punishments will
include fine or imprisonment or both fine and imprisonment.
Instructions
Read the scenario below and then answer the questions.
Scenario
A two-year-old child was admitted in a certain hospital due to complicated malaria. He was
put under IV quinine. On the third day his grandmother noticed that his left hand has turned
bluish and is very cold. It was later established that the hand has become gangrenous due to
forgotten tourniquet and it was amputated. Several practitioners and nurses have attended this
child during his three days stay.
Questions
1. Was the gangrene due to negligence?
2. Who was negligent? Why?
You will work in groups to discuss the steps to take when in practice, in order to minimise
negligence at their workplaces. Record your answers. One group will present their responses
and other will share in the discussion.
• Commonly, negligence happens when the medical practitioner does not follow
established protocol or standard operational procedure. We come across situations
whereby practitioners have opted for short cuts or just followed the way the institution
operates instead of following approved guidelines.
• The following points must be observed in order to minimise negligence:
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o Documentation: It helps in informing other members of health care team of actions
already taken in a care of patients. In event of charges brought against the practitioner,
documentation will help in proving what has been done to the patient.
o Communication: Often, lack of effective communication has led to many grievances.
Sometimes the client is not sufficiently informed about a procedure and expected side
effects or complications.
In many occasions, the way the medical practitioner speaks to clients may cause
more misunderstanding leading to serious unwanted consequences.
The practitioner may become rude, arrogant or even assault the clients verbally.
Client may want to see that the medical practitioner has realised her weakness and
similar consequences may not happen to another patient.
o Responsible/accountable conduct: A responsible health worker will respond
appropriately and effectively to the needs of the clients. In addition, they must be
personally accountable for their action. If practitioners will observe these
requirements, complaints will become fewer.
Key Points
• Negligence is the omission to do something that a reasonable person, guided by those
ordinary considerations which ordinarily regulate human affairs would do.
• A negligent medical professional will be subjected to disciplinary proceedings from his
professional regulatory authority or by court in cases of crime.
• Some of the medical practitioners’ actions might be crimes. Crimes are dealt with the
Penal Code and the Criminal Procedures Act.
• In Tanzania, it is a crime to conduct abortion or assist in conducting abortion.
• In order to minimise negligence, the following should be encouraged: documentation,
communication, and responsible/accountable conduct of health providers.
Evaluation
• Ask students to mention some of the examples that might be interpreted as negligent that
they have observed in their daily life
• What are the steps to establish negligence?
• Which steps will the students as health care workers do to minimize negligence?
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Conduct.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 74
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 75
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 10: Negligence in Medical Practice 76
Session 11: Relationship Between Law and
Confidentiality
Learning Objectives
By the end of this session, students are expected to be able to:
• Define confidentiality
• Describe the scope of duty of confidentiality
• Mention limitations of duty of confidentiality
• Describe consequences arising from the breach of confidentiality
Definition of Terms
• Confidentiality: The statutory protected right afforded to (and duty required of)
specifically designated health professionals not to disclose information obtained during
consultation with a patient.
• It originates from the concept of confiding and trust.
• Healthcare clients are willing to share their private information with health service
providers because they trust that the information will not be accessed by other persons.
Confidence
• The health professionals have long accepted a professional obligation of respect a
patients’ medical confidence. Health profession regulatory authorities have insisted that
patients have the right to expect that information about them will be held in confidence by
their doctors.
• Confidentiality is central to trust between doctors and patients. Without assurance about
confidentiality, patients may be reluctant to give doctors the information they need in
order to provide good care.
• If a health worker is asked to provide information about their patients, they should:
o Seek patient’s consent to disclosure wherever possible, whether or not he judge that
the patient can be identified from the disclosure
o Anonymous data where unidentifiable data will serve the purpose
o Keep the disclosure to the minimum necessary.
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Session 11: Relationship between Law and Confidentiality 77
• Confidentiality and right to privacy are also protected in the Constitution of the United
Republic of Tanzania.
• A duty of confidence is established when confidential information comes to the
knowledge of a person (the confidant) in circumstances where he has notice, or is held to
have agreed, that the information is confidential. This duty is related to the duty of the
priests who gains information in their professional capacity.
• The information can be acquired from observation, conversation or examination. The
duty still exists even if the information is not released deliberately or is released
inadvertently.
• The fact that information has been anonymised does not of itself remove the duty of
confidence.
• Importance of sharing information in the medical field is understood. However, it is
reminded that health workers are supposed to ensure that anyone whom they disclose
personal information understands that it is given to them in confidence which, they have
to respect.
Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.
Scenario
While playing Bao in the evening, two clinical officers were also discussing the extent of
tearing experienced by one patient at their health centre during delivery. One of the two
clinical officers was in fact working in paediatric ward and had nothing to do with patients
admitted in the labour ward.
Questions
• By sharing this information with another clinical officer, was this practitioner guilty of
breaching duty to confidentiality?
• Give examples of situations whereby it is allowed to share patients’ confidential
information with other health worker.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 78
• In disclosing confidential information regarding a patient who is not competent to give
consent due to various factors such as unconsciousness, it should be believed that he
would have allowed the procedure to proceed and that only information relevant to
treating or caring for the patient should be disclosed to relevant people only.
• Disclosure without consent to employers, insurance companies, or any other third party,
can be justified only in exceptional circumstances, for example, when they are necessary
to protect others from risk of death or serious harm.
Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.
Scenario
In a British case of W v Egdell [1990]1 All ER 835, (1989) 4 BMLR 96 (CA), a consultant
psychiatrist decided to send a copy of his medical report to the Ministry of Health in addition
to the Medical Tribunal where he was supposed to send it. The report was on a criminal
schizophrenic patient who was applying for review so that he could be transferred to a less
secure hospital. The doctor suspected that his critical report may have not reached relevant
authorities, hence creating a chance of the patient to be released.
Questions
1. Was it proper for this consultant to breach confidentiality?
2. What actions would have made his action wrong?
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 79
• Publication of a defamatory statement in respect of another person without lawful
justification.
o Can be written or spoken. Action of one can also defame another.
o There are two kinds of defamation, namely:
Slander (when spoken)
Libel (if made in a permanent form and visible)
Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.
Scenario
A court in Scotland considered a case AB vs. CD whereby a claimant demanded
compensation from a doctor who has disclosed to the priest that the claimant’s wife has given
birth to a full term baby six months after marriage. The claimant won the damage as the court
held that there was a duty on the part of the doctor not to reveal confidential information
about his patients unless he was required to do so in court or if the disclosure is conclusive to
the end of science.
Questions
What medical practitioner was supposed to do?
Key Points
• The most fundamental ethical obligations owed by a medical practitioner to his patient
are to respect the confidence of his patient.
• Health profession regulatory authorities have insisted that patients have the right to expect
that information about them will be held in confidence by their doctors.
• Confidentiality is central to trust between health providers and patients.
Evaluation
• Define confidentiality.
• Explain the scope of the duty of confidentiality.
• Mention limitations of duty of confidentiality.
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 80
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Conduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association, Inc.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 81
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 11: Relationship between Law and Confidentiality 82
Session 12: Legal Issues Related To Consent in
Medical Practice
Learning Objectives
By the end of this session, students are expected to be able to:
• Define consent in medical practice
• Describe the forms of consent in medical practice
• Mention requirements for true consent in medical practice
• Mention legal implications from lack of consent in medical practice
Definition of Terms
• Consent: The clinical principle that each person has a right to self determination and is
entitled to have their autonomy respected finds its expression in law through the notion of
consent.
o Any intentional touching of a person without lawful justification or without their
consent amount to the tort of battery and may also constitute a criminal offence.
o The law relating to consent is one of the most important to medical law, serving as the
means of protecting and preserving the right of the patient to decide what is to happen
to him/her.
o Consent can be in the form of expressed or implied.
• Expressed consent: Is when the patient explicitly agrees to what is proposed by the
doctor, it does not need to be set out in any specific form and it does not need to be in
writing.
o The vast majority of time when a patient is touched, it is done in the examination
rooms where none of apparatus of consent is present.
• Consent forms: Have been part of hospital procedure for a long time.
o The form usually covers statements like ‘I confirm that I have explained the
operation, investigation or treatment, and such appropriate options as are available
and the type of anaesthetic, if any proposed to the patient in terms which in my
judgement are suited to the understanding of the patient and/or to one of the parents or
guardians of the patient’.
o The form is signed by both the doctor and the patient.
o Most of forms have a statement saying ‘I understand that any procedure in addition to
the investigation or treatment described on this form will only be carried out if it is
necessary and in my best interests and can be justified for medical reasons.’
Implied Consent
• Consent may just be implied meaning the client did not expressly authorise the doctor to
conduct a procedure.
• Actions often speak louder than words. Holding up one bare arm to a doctor at a
vaccination point is as clear as agree as if it were expressed in words.
• Even silence and inaction may, in some circumstances, be interpreted as expression of
willingness.
• Failure to resist or protest indicates consent if a reasonable person who is aware of the
consequences and capable of protest or resistance would voice his objection. A girl who
is silent to an amorous proposal, cannot, afterwards complain of assault.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 83
Requirements for a True Consent in Medical Practice
• There are three relevant issues which have to be determined:
o Did the patient have capacity in law? (Was the patient competent to give consent?)
o Was the person giving consent appropriately informed before hand?
o Was the consent voluntarily given?
• Each of these issues may be analyzed by reference to the nature and extent of the doctor’s
duty, that is, to inform or to ensure voluntariness and competence.
• The need for consent derives from the law’s respect for patient’s right to decide. Consent,
therefore, has a positive and a negative property.
• This means it is an exercise to make one’s own decisions to say ‘yes’ (consent) or to say
‘no’ (refuse).
• It is also a right to change one’s mind. Hence the patient may withdraw their consent to
treatment. Obviously, this could be done before the procedure but it may also be done
during the procedure.
General Issues
• In court issues, responsibility of proving absence of consent rests on the patient.
• Liability in trespass results in responsibility for all the consequence of the trespass and
may be concurrent with criminal liability for assault.
• Consent must be to the actual physical ‘invasion’ in issue. It is a battery if the patient
consents to removal of his left leg and the surgeon removes the right leg.
• Surgery may be authorized either by a provision in a standard consent form or by defence
of necessity.
• Further treatment must be shown to be necessary at the time of the original operation.
• Doing surgery for removing woman’s ovaries without express consent, or any non-
consensual treatment may constitute serious professional misconduct.
• It is not sufficient that the doctor believes that what she/he does is in patient’s best
interests or that 99% of patients would have consented.
• Advance directive of the patient must be respected.
• Failure to provide adequate information is actionable. It is the doctor’s duty to provide
not just competent treatment, but competent advice as well.
• Consent for detained mental patients must be obtained for non-mental problems.
Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.
Scenario: In a famous British case, Re T., (adult: refusal of treatment) [1992] 4 All ER 649
(CA) in which an adult woman, apparently a Jehovah’s Witness, refused a life-saving blood
transfusion. The judge concluded that her decision was legally effective on the basis that the
patient was competent to understand the serious nature of her decision. The judge further said
that this decision was right even though most would find it unreasonable and irrational.
Questions
What are your opinions on this decision regarding the right to decide on any matter even if it
is going to affect the client?
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 84
Legal Implications from Lack of Consent
• Non-consensual medical treatments entitle the patient to sue for damages for battery
which is committed.
• It is also possible to base a claim on the tort of negligence, which is the theory that the
doctor has been negligent in failing to obtain the consent of the patient.
Instructions
Read the scenario below and answer the questions. Record your answers on a piece of paper.
One group will present their responses and other will share in the discussion.
Scenario
A surgeon was taken to court because when he was on duty, he operated on a lump on the
back of the patient while the patient had actually consented to the operation on his toe. On his
defence, the surgeon said that he noticed the lump and believed that instead of waiting for
another operation, he believed that removing the lump would spare the patient extra
suffering.
Question
Was the surgeon right or wrong in this case? Give reasons on whatever answers you provide.
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 85
Key Points
• Consent forms have been part of hospital procedure for a long time.
• Any intentional touching of a person without lawful justification or without their consent
amounts to the tort of battery and may also constitute a criminal offence.
• A patient’s right to choice is not limited to decisions which others might regard as
sensible.
Evaluation
• Define consent in medical practice.
• Describe the forms of consent in medical practice.
• Mention requirements for true consent in medical practice.
References
• Beauchamp, T.L., & Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary
Nursing (3rd ed.). New York: Thomson.
• CIOMS. (1993). International Ethics Guidelines for Biomedical Research Involving
Human Subject. Geneva: Council for International Organizations of Medical Services.
• Devettere, R.J. (1995). Practical Decision Making in Health Care Ethics: Cases and
Concepts. Washington, DC: Georgetown University.
• Furrow, Dwight. (2005). Ethics: Key Concepts in Philosophy. New York: Continuum.
• Mason, J.K., McCall Smith R.A., and Laurie G.T. (1999). Law and Medical Ethics.
London: Butterworths.
• Mellish, J.M. and Paton, Frieda. (1999). An Introduction to the Ethics of Nursing.
Capetown: Heinemenn.
• Tanzania Medical Practitioners Code of Conduct.
• Tanzania National Health Research Forum. (2001). Guidelines on Ethics for Health
Research in Tanzania. Dar es Salaam, Tanzania.
• The Tanzania Medical Practitioners and Dentist Ordinance.
• Williams, John R. (1942). Medical Ethics Manual. World Medical Association,
CMT 04211 Health Policy and Medical Ethics NTA L 4 Semester 2 Student Manual
Session 12: Legal Issues Related To Consent in Medical Practice 86
The development of these training materials was supported through funding from the President’s Emergency Plan for AIDS Relief
(PEPFAR) through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)
Cooperative Agreement No. 6 U91 HA 06801, in collaboration with the U.S. Centers for Disease Control and Prevention’s Global AIDS
Programme (CDC/GAP) Tanzania. Its contents are solely the responsibility of the authors and do not necessarily represent the official
views of HRSA or CDC.