MEDICAL ETHICS

1.0. ​Definition
​Ethics means, ​relating to morals​
Thus, ​medical ethics​ equals morals pertaining to medical practice; i.e. they are the moral
principles or rules governing medical practice.

The word E ​ THICS​ is derived from the Greek word ​ETHOS​ meaning ​custom or practice​, a
characteristic manner of acting, a more or less constant mode of behavior in the deliberate
actions of men.
More technically, ethics is defined as that science which studies the morality of human acts
through the medium of Natural reason.
Morality is the effort to guide one​s behavior by reason ​ that is to do what there are the best
reasons for doing ​ while giving equal weight to the interests of each individual who will be
affected by ones actions.

It is the science, which is a directive of moral acts of man​s will according to basic rational
principles. In short, ethics teaches us how to judge accurately the moral goodness or badness of
any human action.

Medical ethics is embedded in the dilemmas of everyday practice.

2.0. ​Historical Developmental stages of medical practice

2.1. ​The era of magic and Alchemy
There was little or no scientific understanding.
There was fear of the unknown and magic
Beliefs (religious etc) played a major part
Many ailments were explained as originating from bad air or spirits (shamanism)
The practitioners (shamans had sole authority)

2.2. ​The era of Science and Technology

This is the period of the great discoveries and the beginning of rational linkages of disease
causality and effects.
There were invention and use of microscopes to detect microorganisms that facilitated proper
diseases diagnosis and appropriate treatment.
During this era there was discovery of antibiotics that cure diseases
People had developed much trust with the medical services and were seeking for medical help

2.3. ​The era of Lifestyle

This is the beginning of the modern period.
There was a realization that health is regulated primarily by the relationships, feelings and
beliefs and care given to self, family and the environment.
Here emphasis shifted from medicine (cure) to health (prevention and promotion). This is the
era of PHC (Primary Health Care) and Community Based Health Care (CBHC). This is also
the era of choice among many alternatives. The right to participate and not to be a mere
passive consumer. This is the beginning of the concept of ​Health for All​. During this era
people have become aware of their rights:
of access to quality health care.
to demand or seek for health care
to be informed and to know
to question, complain or sue
to believe and be treated with dignity
to be protected, not to be abused or taken advantage of
They have also become aware that Health is a fundamental human right and not a privilege.

3.0. THEORIES OF PROFESSIONAL ETHICS:

A HISTORICAL OVERVIEW
Ethics has a long history.
3.1. ​The Theories relating to virtues
The Natural goal theory or role defined ethics
th th
From at least as early as the time of Homer (from 8 to 6 century BCE, Greek ethics
assumed that things developed towards a natural goal. Thus, in Greek medicine, what
made a good physician was ​ the purpose of medicine ​ to heal the sick. The virtues needed
were ​ Compassion, knowledge of healing and skill in human relations.
Role - defined ethics remains powerful today and is the basis on which more universal
principles are build e.g. medical ethics, nursing ethics e.t.c.
Virtue Ethics Theory of the Greek Philosophers - The morality and character theories
The teaching of the Ancient Greek Philosophers including Socrates, Plato and Aristotle and the
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general culture of 5 century (BCE) Athens, advocated virtue ethics i.e. the ethical theory that
emphasizes acquiring good traits of character and morality.
Socrates, Plato and Aristotle argued that there were distinctive ethika aretai (skills of character)
of a good person. In their view these were the cardinal (primary) virtues of: courage,
temperance, wisdom and justice. These are the distinctive excellences necessary for a person
to function best in human society. Virtue theory applied to medicine emphasizes creating
physics with such traits.
Morality is essentially to do with our attitudes, behavior and relations one to another.
Christian Virtues Ethics
By the fourth century CE, Christianity had added its theological virtues of faith, hope
and charity (compassion ​ to suffer with) to the list of human virtues. While naturalistic
physicians emphasized technical competence in curing disease, religious physicians
emphasized compassion in being with patients, especially when the limits of technical
competence had been reached, when compassion became the supreme virtue.
Both traditions contributed to today​s definition of good physicians. Every patient wants
a physician who is both knowledgeable and technically competent and who is also
merciful and compassionate.
Virtue ethics in medicine also underlies the apprentice system of medical education in
which young medical students gradually assume more responsibility by assisting older
physicians in treating patients. The consultant teaches the Registrar, who teaches the
Medical Officer, who teaches the Intern, who teaches the medical student (especially
junior clerk). What is taught is not only the skill i.e. how to perform a procedure, but
also the attitude i.e. how to be compassionate, wise, courageous and patient ​ centered.
3.2. ​ heories Relating to conduct
T
The more contemporary version of ethics has shifted from character to conduct i.e.
​What should a professional do?
Kantian Ethics (Kant 1724-1804)
Kantian theories hold that ​a person should do his/her duty​ Kantian ethics focuses on ​rights​
and ​duties​ e.g. a right to life or to information; a duty to save life or to preserve confidence.

The weakness of this theory is that sometimes rights and duties may
 conflict.
The distinctive elements of Kantian ethics are:
Ethics is not a matter of consequences but of duty. Why an act is done is more important than
its good or bad results. An act must be done for the right motive. The right motive is the
desire to do ones moral duty. How do we know what is a right act?

A right act has a maxim that is universalizable. An act is right if one can will its maxim (rule to
be acted on by all others). ​

A right act always treats other humans as ends ​ in-themselves, never as a mere means to an end.
Thus, for example, patients should not be unwillingly used as guinea pigs in dangerous
medical research simply to advance scientific knowledge. Always tell patients the truth.
This rule is the basis of trust and of treating patients as ​ends ​in-themselves​. 4 people are
free only when they act rationally. The only time a person can act morally is when he/she
exercises his/her rational, free will to understand why certain rules are right and then
chooses to bind his/her way AUTONOMY. For him it gives humans higher worth than
non-human animals.

However David Hume, Charles Darwin and Sigmund Freud (father of Psychiatry)
considered reason to be the tip of the moral iceberg because much of ethical life is
emotional and not changeable by reason.
Kant​s most important legacy to modern medical ethics is his emphasis on the ​autonomous
will​ of the free, rational individuals as the seat of moral value. Autonomy explains why
informed consent is necessary to legitimate participation in research. When combined with
the emphasis on personal liberty in our democracies, Kant​s emphasis on autonomy sets the
stage for modern medical ethics.
Utilitarian Theories
These rest on the premise that ​the right thing to do is to create the greatest good for the
greatest number i.e. ​Diminish suffering and increase happiness so as to obtain net
overall benefit. In Health this may be difficult since outcomes are not only quantitative
but also qualitative.
th th
Utilitarianism originated in the late 18 and early 19 century in England as a secular
replacement for the Christian ethics. Jeremy Bentham (1748-1832) and John Stuart Mill
(1806-1873) were its two theorists.
The essential idea of utilitarianism is that right acts should produce the greatest amount of good
for the greatest number of people, which is called ​Utility​.

Utilitarianism was a reform movement intended to humanize outmoded (religious)

institutions. It focused on large, practical changes that could benefit the vast majority of
people who were not aristocrats.
Utilitarianism​s essence can be summed up in 4 basic tenets:
Consequentatialism: Consequences count, not motives or intentions.
The maximization principle: The number of people affected by consequences matters; the
more people the more important the effect.
The theory of value (or of ​good​): Good consequences are defined by pleasure (hedonic
utilitarianism) or what people prefer (preference utilitarianism).
A scope ​of-morality premise: Each being​s happiness is to count as one and no more. Thus,
for utilitarian, the right acts produce the greatest amounts2 of good3 consequences, for
the greatest number2 of being4
In medicine, the 2 areas where utilitarianism applies most powerfully are Public Health and
triage situations. In triage, because consequences count, utilitarianism implies that a physician
should not attempt to treat all the patients equally but should focus only on those who can
actually benefit. Thus, he/she should abandon those who will die even if he/she tries to help,
and just as ruthlessly, abandon those who will live without his/her help; and help only those
who will survive because of his/her help.
3.3 ​The Natural Law Theory
This refers to what has culturally become to be accepted as right or wrong. One example of
natural law theory in medical ethics concerns homosexuality. God made 2 sexes for
procreation. It is natural and rational for a man and a woman to mate to have children. Any
other sexual relationships, such as homosexuality, are immoral.

Natural law theory bequeathed to medical ethics the doctrine of ​double effect​. This doctrine
held that if an action had 2 effects, one good and the other evil (bad), the action was morally
permitted if:
The action itself was good or not evil
The good followed as immediately from the cause as did the evil
Only the good effect was intended
There was as important a reason for performing the action as for allowing the evil
effect.
Examples of the double effect include:
Allowing abortion incase of an ectopic or cancerous uterus (save mother​s life)
Allowing hysterectomy in case of cancer of uterus (save woman​s life)
Allowing physician to be present to ease the suffering of a prisoner condemned to execution
(Capital punishment) but not to take part in the execution itself.
Also derived from the natural law tradition is the principle of totality, which covers what kinds
of changes may be made to the human body. Changes are permitted only to ensure the
proper functioning of the total body. This arises from the belief that ​one​s body is not
something that one owns​, but that ​one holds in trust for God​. Thus, if the fundamental
health of the body is at risk e.g. cancer, gangrene e.t.c, then the affected part of the body
may be removed. However, operations such as those for sterilization (vasectomy, tubal
ligation, hysterectomy), cosmetic reasons (facial changes, breast reduction or
augmentation, liposuction or rhinoplasty) are not allowed. This principle is more deeply
embedded in our thinking than we may at first imagine
3.4 ​Social Contract Theories
Social contract theory (contractarianism) is essentially secular and independent of belief in
God. It assumes that people are fundamentally self-interested and that moral rules have
evolved for humans to get along with one another. Social contract theory does not separate
ethics from politics. Indeed, hypothetical political bargaining is viewed as the foundation of
the kind of behaviour that is allowed as ethical.

3.5 ​Feminist Ethics: Ethics of Care

In the early 1970s a modern version of feminism shook American Medicine to its foundations
and buttressed its sister movement, the patient​s rights movement. A landmark book called ​Our
Bodies, ourselves​ resulted which sold millions of copies. The ethics of care resulted. This may
be considered a branch of virtue ethics that promotes the ​female​ virtues of caring, nurturing,
trust, intimate friendship and love. It is, however, not settled whether these virtues are inherent
in females because of their nature or only exist because they are developed in most females by
traditional, sexist, gender roles.

The ethics of care may be seen as an antidote to moral views that are cast only in terms of rights,
utility and duty. It is not yet a complete ethical theory because it does not tell us how to treat
people we do not know or care about. Also it does not tell us how to resolve conflicts among
those we care about e.g. a female doctor attending to a patient or to her daughter in the process of
delivery her first child.

4.0 ​PRINCIPLES OF MEDICAL ETHICS

4.1: ​Our practice must be in accord with techne (Skilled form of knowledge) or art whose aim is
to confer substantial benefit on suffering human beings. This techne is governed by an ethic
 that is committed to restoring and repairing, as far as possible, the form and function of a
human being. Any health care provider should be able, with sincerity and integrity, to assure
patients that the care they will receive is at least as good as that defined by the accepted
standards of contemporary medical practice.

4.2: ​We must always treat patients as persons not people , involving them in those significant
decisions about their care that will affect their lives and well-being. Thus, our conception of
substantial benefit is and should remain patient oriented.

4.3: ​We must safeguard the continuity and standards of medicine and other health care
professions, taking care to ensure that what is done and taught is consistent with an ongoing
enterprise in service of the people.

4.4: ​We must practice health care in the light of the patients​ needs without being influenced or
prejudiced by factors that have nothing to do with their illness. Thus, we must act with justice
and impartiality; ensuring that our care is given in a spirit of compassion and a desire to
benefit the patients rather than being distorted by any other motive or interest.
Dilemmas may be Analyzed using 4 principles, namely:
4.5: ​Autonomy ​ the right to make decision about one​s own life and body without coercion by
others. Insofar as is possible in a democracy, and to the extent that their decisions do not harm
others, individuals should be allowed (left alone) to make fundamental medical decisions
(given the necessary information) that affect their own bodies allowed to make their own
decisions about who to marry, whether to have children, how many children to have, what kind
of career to pursue, and what kind of life they want to live.
Since the beginnings of modern medical ethics in the early 1960s autonomy has meant the
patient​s rights to make her own decision about her body, including dying and reproduction.
The ethics of autonomy evolved as a rejection of paternalistic ethics which had their roots in
both secular and religions versions of virtue ethics.
4.6: ​ Beneficence ​ ​doing good to others​. This is similar to the religious virtue of compassion
and helping others. This comes to the fore in efforts to distinguish therapeutic from non-
therapeutic research on human participants. Beneficence can be seen both as a principle and a
virtue for physicians. Self-sacrifice is part of medicine. Beneficence may sometime come into
conflict with autonomy e.g. whether or not to treat a psychiatric patient against his/her will.
Balancing the two in such cases may be difficult.
4.7: ​Non-malfeasance ​ ​not harming others​. This implis that if a practitioner is not technically
competent to do something, he/she should not do it. Taken further, medical students should not
harm patients by practicing on them (unless the patients consent). This principle prohibits
corruption, incompetence and dangerous, non-therapeutic research. Harm can also be done by
unsolicited intrusions (help, advice or even concern).
4.8: ​ Justice ​ has both a social and political interpretation socially, justice means treating similar
kinds of people similarly. A just practitioner treats all the patients in the same way regardless
of their circumstances such as financial capability e.t.c Politically it amounts to distributive
justice, which in medicine may refer to allocation of the scarce medical resources. Also equal
access to medical care for every citizen. In the usual sense, justice requires practitioners to
treat patients impartially, without bias on account of gender, race, sexuality or wealth.

5.0. ​THE OATHS/DECLARATIONS AS BASIS FOR MEDICAL/

NURSING ETHICS
5.1. ​The Hippocratic Oath
5.2. ​The Declaration of Geneva
5.3. ​Nightingale​s Oath
6.0. ​THE PRACTITIONER​S RELATIONSHIP WITH OTHER
PEOPLE
Making of Professionals
​What makes one a health professional is not only the acquisition of knowledge and skills,
but also acquisition of a whole set of attitudes that the profession has acquired over many
years, and which are passed on in many subtle ways by more experienced practitioners as they
instruct the younger less experienced doctors under their tutelage. This set of attitudes may be
described as the ​ethos​ of medicine. Such an ethos must include a profound respect for the
individuality of each patient if it is to serve the true purpose of medicine ​ the health of the
patient.
​
​Patient
The term ​Patient​ means ​the person who is suffering​.
Some other terms have been used such as ​Client​. This term originates from Latin ​Client​, which
originates from Latin ​Cliens​ signifying ​person under protection or patronage of a superior​. In
health professions, therefore, use of the term client, with such connotations, would be
unfortunate.

6.1. ​The Practitioner ​ patient relationship: One of the obligations of the (doctor) practitioner
is commitment to an open, truthful and fully co-operative relationship with patients. The
practitioner ​ patient relationship is a contract, which is guided by the Hippocratic Oath (Geneva
Declaration), which states for example that:
The health of my patient will be my first consideration.
I will respect the secrets, which are confided in me.
I will not permit consideration of religion, nationality, race, party politics or social
standing to intervene between my duty and my patient.
I will maintain the utmost respect for human life from the time of conception, even
under threat.
The principles that govern this contract include:
(a) Confidentiality
The provision of medical care always involves an invasion of privacy by gaining access to the
patient​s body and to a wide range of personal information about the patient. This is necessary in
order to make an adequate diagnosis and to prescribe appropriate treatment.
This privileged access, however, is justified only because it brings the patient benefits. It is only
obtained with the patients consent (except in emergency situations).
This information is usually contained in medical records that are the property of either the
individual practitioner or a Health Board. It should normally be used only for those purposes
agreed between the practitioners and the patient (i.e. authorized by the patient).
Any other use of the information represents a breach of contract and trust that made the patient
willing to consult the practitioner in the first place.
There are circumstances in which maintaining absolute confidentiality may be difficult. For
example when active harm to others is likely to be caused. The problem here is defining ​active
harm​. Another example is where a court of Law orders that the information must be provided.
Here the practitioners must operate within the legal constraints of privacy legislation. Thus,
whatever the circumstances, breach of privacy must have clear ethical justification.
The origin of the professional confidentiality:
One section of the Hippocratic Oath reads: ​Whatever in connection with my professional
practice or not in connection with it, I see or hear in the life of men, which ought not to be
spoken abroad, I will not divulge, as ​reckoning that all such should be kept secret.
One section of the World Medical Association Declaration of Geneva (1948) reads:
 ​I shall respect the secrets which are confided in me​.
The English Text of the International Code of Ethics based on the Declaration of Geneva
amongst other sources, states: ​A Doctor shall preserve absolute secrecy on all that he
knows about his patients because of the confidence entrusted to him​.

Confidentiality and the Law:

Many countries recognize the right of Medical personnel to withhold in civil courts such
confidential information as is acquired through professional conduct with the patient i.e. on the
grounds of medical privilege.
The common law of England, on which laws of the countries in the East African region
are based, does not have these provisions i.e. no medical privilege is allowed in court.
In Kenya Ministry of Health Code of professional conduct and Discipline it states. ​Every
Medical Practitioner or Dentist shall respect his patient​s confidence, and shall hold secret
to himself all that he may learn in confidence from his patient or anyone acting on behalf
of a patient...​

Exceptions to the general rule of confidentiality:

Most countries (including Kenya) accept that absolute secrecy is impracticable. They allow
certain exceptions including:

The patient or his/her legal advisor may consent to the disclosure, preferably in writing; e.g. when a
patient makes a claim for re-imbursement of medical expenses from an insurance company or when
claiming damages from another person or insurance company as after a road traffic accident ​ the
medical report may be seen by ​the over side​.

Statutory duty e.g. those rules and regulations requiring the doctor to notify the relevant authority
​regarding:
Infectious diseases
Occupational diseases
Births and deaths

In a court of law the court may insist and if the doctor refuses, he/she may be held in contempt of the
court.
Sharing information with colleagues
Professions supplementary to medicine ​ paramedics, including:
Chiropodists, Dieticians
Lab technicians (now called Medical Scientific Officers)
Occupational Therapists; orthopists.
Physical Therapists, Radiographers, Remedial Gymnasts.

Relatives
Research
Medical Education (patient​s name should not be revealed)
Public interest especially in maintenance of law and order.

iv) General approach to problems

In the final analysis the doctor has to make his/her decision according to his conscience.
​Conscience may be defined as a dictate of man​s practical reason deciding that a particular act is
morally right or wrong​. We all have different consciences in that what may appear as a problem
to one person may not appear so to another.
 v) ​Specific problems
Epilepsy and driving
​A problem arises if the doctor knows the patient is continuing to drive in spite of having
seizures.
Collaboration with the police
A problem arises if the police are unwilling to allow the doctor to approach his patient
(being suspected of criminal activity) to ask for his/her consent for him/her to submit a
report about him to the police. Refusal to submit the report may constitute obstruction to
police work.
The drunken driver
The doctor required to examine such a subject should provide the correct findings.
Suicide (attempted)
​Regarded as an illegal act in some countries
​Regarded as a cry for help in medical circles
​Doctor usually not obliged to report the case to police.
Special relationships
Husband and wife e.g. if one is diagnosed as having HIV but does not want the spouse told
​ Also if a couple decides on divorce proceedings and medical reports are requested for.
Employer and employee e.g. when employer requests (and even pays for) a medical examination of
a prospective employee. If after the examination the patient objects to the doctor​s submission of the
report to prospective employer ​ doctor may give the report to the patient and tell him/her to do what
he/she wants to do with it.

Occupational Health - but also certain diseases associated with occupation are notifiable.
Storage and access to clinical information
The doctor has a duty to examine record storage systems and if he/she is not satisfied with the
security and confidentiality of the patient​s records, he/she should refuse to place clinical
information in them. Use of computers has complicated the situation.
The patient doctor relationship is a contract guided by the dictates of the Hippocratic Oath.
(b) ​Informed consent
i) ​The general duty to obtain consent
Before undertaking any medical or surgical procedure, a doctor must obtain the patient​s
consent.
The doctor, who fails or ignores to obtain consent, exposes himself/herself to claims of
medical malpractice or violation of the patient​s civil rights. The doctor​s duty to obtain
consent arises from the patient​s right to self-determination. Every adult human being, who
is sound in mind, has a right to determine what shall be done with or to his/her own body.
Thus, a doctor who administers management modality without the patient​s consent would be
deemed to have committed an assault for which he/she is liable in damages
In medical emergencies, however, consent is generally implied. Thus, a doctor is deemed
legally authorized to treat a patient in an emergency situation without having received the
patient​s explicit consent.
ii) ​The concept of informed consent
The concept of ​informed​ consent implies that consent is ineffective unless the doctor has
fully disclosed, the risks involved in giving a particular treatment and alternative
management modalities and how their effectiveness and risks compare to the one being
proposed, before consent is given by the patient.
Consequently, the doctrine of ​informed consent​ is meant to enable the patient and not the
doctor to be the one who makes the final decision.
 The American society of law and medicine distinguishes 2 standards or forms of informed
consent.

The ​Professional medical standard​

​This relies on either the customary practice of doctors in the community or on what a
responsible medical practitioner would disclose under ordinary circumstances to an
ordinary patient. This ​implies that the scope of a doctor​s duty to disclose
information is measured by those ​communications, which a reasonable medical
practitioner in that branch of medicine would make under the same or similar
circumstances.

The ​patient ​ centered standard​

​This centres on a hypothetical reasonable patient​s right to know as much
​ ecessary
information as is n ​so as to be able to make an intelligent decision. This
implies that a medical doctor, b​ eing an expert, is p​ rofessionally expected to
appreciate:
the risks inherent in the procedure he/she is prescribing.
the risks of a decision by the patient choosing not to undergo the treatment.
the probability of a successful outcome of the treatment.
Once this information has been disclosed to the patient, the doctor​s function as expert has
been performed and decision-making is left entirely to the patient.

In both professional and patient-centered standards the doctor is viewed as an adviser and
not as the ultimate decision maker.
Tension between patient and doctor may develop in situations where a patient refuses to take
the prescribed management modality which the doctor believes or professionally knows is
correct, appropriate and indeed necessary for the preservation of the patient​s health.
iii) ​Refusal to give consent for medical treatment
​This may occur because of many reasons, including

Religious beliefs that forbid a certain type of procedure e.g. Jehovah​s witnesses refusing
to be transfused with blood or blood products.
Fear e.g. of discomfort or disfigurement or even death e.g. a patient refusing limb
amputation, radical mastectomy or ileostomy.
Viewing the proposed treatment modality as constituting an artificial prolongation of life
without hope for recovery. This includes terminally ​ ill patients for whom it is suggested
that they be put on life support equipment e.g. respirator, or should have a palliative
surgical operation.

iv) ​Truthfulness
In the concept of informed consent, the principle of truthfulness is implied. Truthfulness is
much more than simply the passing on of accurate information. It is expressed in an attitude
towards the other person that is seeking to create open and mutually respectful
communication.
It is possible to avoid lying to a person and yet disregard truthfulness by concealing facts or
creating false impressions. There are situations in which concealments; however, is the
preferable moral choice. For example, when the condition of the patient is so fragile that a
full disclosure of all known facts would be overwhelming for him/her at that time (give
examples such as husband and wife involved in motor accident, one dies, the other is
 critically injured but is now recovering but wants to know about his/her spouse. Mother
suffers eclamptic toxemia. Is delivered of a live baby who dies shortly afterwards. Mother is
initially critically ill and as she is beginning to recover she wants to see her baby).
Truthfulness is not the bald communication of facts, it is the kind of sensitive communication
of information to individuals related to the individual​s needs at the time, in which there is a
time to speak and a time to remain silent.
v) ​Controversies/Dilemmas/Paradoxes
Age Effect
According to law, a person who is under age (a child / a junior / a minor) is legally
incompetent to give consent. If such a person is recommended for treatment requiring
informed consent surgical operation, a parent/guardian is the one authorized to give
consent.
Dilemmas occur because of age effect e.g. a 16 year old girl consulting a doctor and
requesting to be prescribed oral contraceptive pills without the parent​s/guardian​s
knowledge. If the request is not granted, the same girl may come back to the doctor at the
age of 17 years (still a minor) pregnant and requesting for a termination of pregnancy still
without the parent​s/guardian​s knowledge. If this second request is also denied, the girl
may turn up again two days later as an emergency with incomplete illegal abortion!
Situations involving married subjects.
A married woman with many children requests for bilateral tubal legation (sterilization).
She signs the informed consent for the operation. There are no legal requirements for
nd
involving the husband. When the husband later knows, he divorces her or marries a 2
wife. Both are socially and economically disadvantaging to the woman.

Situations involving mentally handicapped subjects.

Should mentally handicapped adult males/females be sterilized? Who should give
informed consent?
Research to be done using mentally handicapped people e.g. those with age-related
dementia requires informed consent who should give such consent?
6.2. ​Relationship with professional colleagues
​a) General guidelines
Share knowledge with colleagues
Do all he/she can to promote medical knowledge, education and research.
Avoid any action, which may be regarded as self-laudatory.
Not condemn his colleagues or use derogatory language about them.
Maintain a bond of fellowship amongst all his/her colleagues irrespective of the
colleges they qualified from.
Shall not charge fees directly for attention to another medical practitioner or his
immediate dependants (wife/husband legal children or immediate parents). This may
be extended to practicing nurses and other cadres. Exemptions rest on the Council.
The doctor must not entice patients from his colleagues
The practitioner must regard his/her colleagues as his/her brothers/sisters.

b) ​Consultations and referral

Ethical issues arising out of consultation and referral
Consultation means a visit by a patient to a practitioner or exchange of ideas/opinions
by practitioners about a patient​s condition. Consultation should be done with
approval of the patient previously examined by the one consulting. This ends when
the consultant has written his report or opinion and recommendation to the referring
practitioner.
Referral means transfer of responsibility for the condition existing at the time of referral
 ​The health of my patient will be my first consideration,​ reminds us that the practitioner​s
first loyalty is not to his/her colleagues but his/her patients.

However, in order to serve the best interests of the patients, every practitioner must learn to
share the decision making process with others, to consider alternative diagnoses and modes
of treatment and to find correction or support when the decisions are especially difficult and
uncertain.

c) ​Difference between Ethics and Etiquette

We must, however, distinguish between ethics and etiquette in collegial relationships. The
rules of medical etiquette have tended to create a medical hierarchy in which each
consultant is king in his territory and not subject to ​interference​ by colleagues, even those
of equal rank. However, a totally independent professional is not necessarily the best
safeguard for the patient​s best interests.
The ideal relationships between colleagues within the medical profession and among health
care professionals generally is a mutual one of both support and honest, constructive
criticism. The modern professional is expected to be accountable to both his/her colleagues
and the public that grants the profession the privilege of self-regulation.
In conclusion
The professional relationship described here is designed to assist both the patient and the
practitioner through all the vicissitudes of illness.
To cure sometimes
To relieve often
To comfort always.

6.3. ​Relationships between practitioner and the public/community

a) ​The Hippocratic Oath
When swearing the Hippocratic Oath as expressed in the Geneva Convention, the practitioner
has said he/she will:
Dedicate his/her life to serve humanity.
Give his/her teachers the respect and gratitude, which is their due.
Practice his/her profession not influenced by religion, nationality, race, party politics or
social standing.
Maintain the utmost respect for human life from the time of conception, even under
threat.
Not use medical knowledge contrary to the laws of humanity.
Thus the practitioner must:
Respect all aspects of human life, including:
Doing all possible to preserve and improve the quality of human life (prevention and
promotion).
Prevent and /or remove all that will cause suffering or terminate life.
Give advice and /or treatment appropriately to eliminate his/her patient​s pain.

In doing the above, he/she shall be courteous and respectful to the patient and any other person
accompanying the patient. The practitioner also accepts that receiving any money in
connection with services rendered to a patient, other than a proper professional fee, even with
the liaison of the patient is unethical.
He/she will:
Conduct one self in the community with utmost dignity and ideals of his noble profession.
Endeavour to do all in his/her power to promote the general well-being of the community
in which he/she lives.
Avoid any behaviour in the community, which is unbecoming of the noble profession.
b) ​Advertising
No doubt there are some who study medicine only for money, power and prestige.
 Consequently, medicine in recent times has become seriously corrupted by the spirit of
enterpreneurship. In the current era of medical practice, the age-long medical tradition of
humane service has clearly become eroded essentially by commercial objectives. Many
medical practitioners are now entrepreneurs and hustling businessmen.
In order to achieve this, some doctors openly advertise.
Adverting by doctors has always been regarded as unethical on the grounds that patients
would be unable to evaluate claims made by different doctors.
As advocated by the General Medical Council (GMC) of Britain, publication in any form,
commending or drawing attention to the professional attainment or services of a doctor may,
if the matter is published in a manner likely to attract patients or create professional
advantage or financial benefit to the doctor, amount to professional misconduct.
The following is accepted:
Clinic sign-Post not exceeding six inches in black or blue (not carrying bright colours)
Protective gear for all health professionals must be white and must reach below the knees.
Hospitals must be discrete in putting up their signposts; and under no circumstances should
these be displayed in public places or public service vehicles.
There should be no advertisement in mass media including newspapers, and radio or TV
broadcasts.

6.4 ​Relationship with Councils

6.4.1. P​ ractitioner should know and understand that the council is the legally constituted
body to serve t​ he interests of the general public while at the same time serving the
interests of the p​ ractitioners. Therefore co-operation and assistance are expected from each
other-council a​ nd practitioners.

​ he practitioners is expected to abide by all the lawful directives from the council.
6.4.2. T

​ he council expects the practitioner to function in accordance with the medical ethics.
6.4.3. T

​For example:
To practice his/her profession with conscience and dignity.
To maintain by all means in his/her power the honour and the noble traditions of the
medical profession.

7.0. ​HEALTH PROFESSIONAL CODES OF ETHICS AS THEY

RELATE TO OTHER PUBLIC NORMS OF BEHAVIOUR

7.1. ​Culture and Ethics

a) ​ thical universalism (absolutism) holds that there is a single true morality, one true
E
view of the right and perhaps one true view of the good as well, that applies across cultures
and within them, and can be called upon to settle ethical disputes locally and globally.
b) ​Ethical relativism holds that no set of moral standards is universally binding. Thus,
no single moral f​ ramework can be called upon to settle disputes within nations and across
the world. Instead, moral j​ udgments and accepted moral standards are fundamentally
 different across cultures or individuals. ​What a given person should do must be assessed
relative to his/her individual or cultural standards.
According to ethical relativism, a given person​s actions can be accurately judged only by
applying ​his/her own cultural standards and not by applying those of someone else​s
culture, which differs from ​his/hers.
Examples
Female circumcision.
Same sex ​marriages​
Loss of virginity before marriage
Modes of moaning loss of a loved one (Ugandan experience, Nigerian experience etc)
Taking widows property from them ​ Nigeria.
Pluralism ​ implies that there is more than one true morality.
Nihilism ​ implies that there is no true morality, and that moral judgments are simple
expressions or emotional reactions to what another person does or says, and that these vary
from person to person or group to group.

c) ​Cultural Diversity ​ implies that moral judgments and practices vary substantially
from culture to culture. Thus for example, some practices are favoured in some societies
while they are strongly condemned in others e.g.
Cannibalism
Male prostitution
Infanticide (Eskimos)
Killing the elderly

William Graham Summer (relativist anthropologist 1840-1910) puts his position as follows:
​The folkways are the right ways to satisfy all interests, because they are traditional and exist
in fact​​.The ​right​ way is the way which the ancestors used, and which has been handed down.

The tradition is its own warrant. It is not held subject to verification by experience. The
notion of right is the folkways​..Therefore rights can never be ​natural​ or ​God ​ given​ or
absolute in any sense. The morality of a group at a time is the sum of the taboos and
prescriptions in the folkways by which conduct is defined​.

Cultural diversity provides a strong basis for condemning intolerance by one group of people
for other people​s cultural practices.

d) Change of cultural norms - Members of a cultural group can change what is ​right for
them​ by replacing their moral standards at anytime and for any reason whatever. Change in
cultural practice makes it different not better. This is so because it is simply changing to the
standard (what is right) for future without changing what was the standard for the past.

e) Moral rules which are common in various cultures - There are some moral rules that
all societies will have in common ​ these are mainly those which are necessary for the very
existence of society. Examples of these include those against telling lies and against murder.
The problem of individual departure from cultural norms is present in many multicultural
settings. When we listen to the stories of those for whom we care, we will appreciate what it
is for this person to live a culturally embodied worthwhile life and act accordingly.
When we fail to do this, problems will arise:
There will be silence rather than communication,
Resistance rather than co-operation,
Anger and resentment rather than appreciation and respect.

7.2. ​Traditional Values and Health Professional Ethics

 Harmonization of traditional values and practice of health professions. Traditional
values are the basis of traditional systems of ethics. Modern medical practice and its
ethical systems can only be meaningful if they are harmonized with traditional values of
the communities to which they are applied. This will enhance the adaptability of the
health professional in the community he/she is going to serve.
​The codes of ethics for the health professions are concerned with regulating the
manner in which the ​health professionals behave towards the patient and the public.
​The success of this expectation depends very heavily on the cultural environment in
which it is a​ pplied. I​ n particular, the social values to which the general public
adhere are of vital importance.

b) ​Examples of traditional values

Human relations
​One of the areas where traditional values have been very specific has been in defining
relations ​ etween people of different ages.
b
​Example: a young male doctor trying to touch the vulva of a 70-80 year old woman
e.g. during PV exam or c​ atheterization may meet with absolute refusal by the old
woman.
Alcohol consumption
​The social controls that have been used traditionally to control alcohol consumption
have included: age limit and social status. These controls had traditionally prevented
development of problems related to alcohol consumption. Change in these social controls
has led to the problems we currently see related to alcohol consumption.
Sexuality counseling
The counseling processes have been controlled by very strict ethical controls and taboos
to ensure that their values for survival of the community have been sustained from
generation to generation. Breakdown of this system is partly responsible for the
HIV/AIDS pandemic currently experienced by our communities.
Need for harmonization
There is need to harmonize traditional values and practices with modern scientific
medical practice and ethics. When the two are in harmony, modern medical practice and
ethics will be enriched and made more effective. This is so because the real human
values underlying many traditional practices are universal and form very fertile ground
for the teaching and application of medical ethics.
​
8.0. ​GENETIC DILEMMAS
8.1. ​Genes
Each human cell, except the germ cells, contains 46 chromosomes in its nucleus. Each
chromosome contains thousands of pairs of four different nucleotides or bases. Altogether
each human cell contains about 3 billion base-pairs of nucleotides, which can be roughly
divided into about one hundred thousand sequences known as genes. DNA structure was
described by Watson and Crick who worn the Nobel Prize for this in 1962.
Within the chromosome, there are also intervening sequences whose function is as yet not
known. Each gene contains the code (formula), which enables the cell to form at least one
type of protein. When a particular protein is required for a particular purpose, a message is
sent to the cell nucleus to have the gene, which has the code for forming the protein to be
copied in form of messenger Ribonucleic acid (mRNA) from the Deoxyribonucleic Acid
(DNA) on the chromosome.
The mRNA gets out of the nucleus into the cytosol (cytoplasm) of the cell where it is used as
 a template for the formation of the protein. Proteins are used for various purposes by cells
e.g.
Structural to form the structures of the tissues.
Enzymes determining reactions in the body cells.
Receptors used to receive messages carried by hormones e.t.c.
Carrier proteins to enable substances go into and out of cells e.t.c
Thus, indirectly the genes determine what we are and what we can do.

Genetic dilemmas
Molecular medicine encompasses 3 broad areas:
The study of genes and gene products
The detection of abnormal gene expression in disease states
Therapeutic modifications of abnormal gene expression.
8.2. ​Somatic Gene Therapy
First approved for use in humans 1989.
First used 1990
Involves correction of gene defects in patients own cells.
Strategy involves: Gene correction,
​ : Gene replacement,
​ : Or gene augmentation.
The genes are introduced via retroviral vectors (i.e. viruses used to carry the genes into the
cells. At present none of the vectors is trouble free; all have advantages and disadvantages
both in vitro and in vivo situations.

Severe combined immune deficiency disease (SCID), cystic fibrosis and muscular dystrophy
have all been successfully treated using somatic cell gene therapy.

8.3. ​Germ Line Gene Therapy (GLGT)

Involves inserting a gene into the germ line 9sperm, eggs and embryos) so that when the
modified individual reproduces, all offspring will have the inserted gene instead of the
original defective one.
GLGT is not permitted by existing official guidelines.
8.4. ​Genetic Manipulation
a) Eugenics
Negative eugenics involves elimination of defective genes by aborting the affected foetuses.
This is population manipulation rather than manipulation of given individual. The ethical
dilemma here revolves around abortion.

Positive Eugenics
This is the science of breeding for desirable human qualities i.e. improving specific attributes
in the community, such as intelligence. This is similar to breeding for desirable qualities in
other animals or in plants. It involves identifying and then promoting only those genes
responsible for the desired characteristics. Apart from the problem of deciding which genes
to promote, control of this order lies outside the realm of feasible science. Thus positive
eugenics is considered both unscientific and unethical because it would be done at the
expense of individual freedom of choice (self determination). An example of this was the
Nazi eugenic program in Germany in the 1930s.

b) Cloning (Dolly the lamb 23/02/1997) (Wilmut et al)

This leads to producing carbon copies of human individuals, it uses a sexual reproduction i.e.
the new individual is derived from a single parent and is genetically identical with the parent.
To achieve this, the nucleus from a mature but unfertilized egg is removed and replaced by
the nucleus of a specialized body cell of an adult organism. This leads to production of an
unlimited number of clones of identical individuals.
 In as far as cloning is used to produce individuals with a specified value to society, it
undermines the intrinsic worth and dignity of human beings.

8.5. ​Genetic Screening Eg

a) Presymptomatic testing
This is testing of individuals before any symptoms have appeared in order to determine
whether the individual is a carrier of a particular genetic condition.
b) Prenatal Screening
This is identifying whether a foetus has a genetic predisposition for a particular disease (such
as Huntington​s disease). The usual aim of this is so that abortion of an affected foetus may
be considered. The alternative would be for it to be treated and possibly cured.

While both presymptomatic and prenatal screening may help individuals to avoid possible
disaster and suffering in future, they also confront individuals with the predicaments of
having to make choices they would otherwise not have to make or would have preferred not
to have to make. Information from genetic screening should be obtained and handled using
the general principles of ethics, including:
Prior informed consent
Confidentiality.
Careful processing and storage of the information.

Moreover, in principle there should be no stigmatization of those with the genetic disorders.
Also passing on of information to relatives (siblings, spouse, parents, and children) should be
done, if at all, guided by the usual ethical principles.
Also consider use of genetic information by: the employer, which may lead to discriminate:
Insurance companies ​ ideally should not request for it.
Genetic screening for susceptibility to diseases e.g. cardiovascular disease, diabetes, cancers
e.t.c when it becomes technically feasible it will make a shift in health care, allowing those at
high risk to modify their life styles in appropriate ways. Nevertheless, ethical handling of
such information will be necessary in order to avoid stigmatization.
Emphasis on individuals with genetic disorders or predispositions may pause ethical
dilemmas.

Patenting of Human Genes

Discovery (description) of a human gene or gene fragment and the products (proteins) and
the mutations of this gene would come under the category of ​Manufacture​ or ​composition of
matter​ ​ patenting is still being debated.

Human Genome Project (HGP)

AIM: To analyze and sequence all the DNA on all the human chromosomes. A complete
physical map was completed in 1994. This map consists of a set of DNA chunks the same
size as yeast chromosomes. This crude map is now being supplemented by a second
generation map on a finer scale. Also RNA libraries are being built up which currently
include more than 90% of the genes in the genome.

The HGP has raised a number of ethical issues, which have been classified into 3 categories.
Issues related to individuals
Issues related with society
Issues related with species.
Individual issues revolve around autonomy and confidentiality.
Autonomy requires ​: Voluntary participation
​ : Informed consent
Confidentiality requires: No disclosure of information without the individuals authorization.
 Society Issues revolves around:
Resource allocation ​ what percentage of research funds.
Commercialization ​ who owns the information?
Eugenics ​ society may be forced to decide whether or not to use the information to improve
the species.
Issues relating to species include the fact that human beings may be considered as products
that can be manufactured i.e. made to measure, leading to the idea of a ​Standard​ human
genome.

9.0. ​ISSUES BEFORE BIRTH

BIOLOGICAL DEFINITIONS
9.1. ​Embryological development
Ovum + sperm produce zygote.
Over the next one-week the cells of the zygote repeatedly divide to form a solid mass of cells
called a morula. By this stage the mass consists of 100 or more cells.

At the end of about 7 days the morula implants i.e. digs into and becomes embedded into the
uterine endometrium. The moment of zygote formation is taken as the beginning of
embryonic development. The zygote is still capable of splitting to form 2 individuals, a
potential that remains for up to 2 weeks after fertilization.

The first cell divisions of the fertilized ovum produce a cluster of equivalent cells
(blastomeres), which in the early stages are not integrated into a multicellular organism. The
non-integrated state persists for a few days after fertilization. During this period, one or more
cells may be removed without affecting the outcome of development, i.e. the remaining cells
are still capable of developing into a complete being.

After this, the outer cells begin to differentiate to form the surface layer, the trophectoderm,
which becomes the trophoblast when implantation occurs. The trophoblast tissue establishes
the uteroplacental circulation of the inner cells. Some are destined to form the foetus
(embryo-foetus). The remainder (embryo placenta) represent forerunners of extra embryonic
tissues.

The first blastomeres appear within 30 hours of fertilization. By 3 days a ball, (morula) of 16
or 80 cells is formed. The morula enters the uterus shortly after this. After another day or 2
the structure consists of 50 or 60 cells. During this time a fluid filled cavity gradually
develops within the morula; when this is established, the whole structure is known as a
blastocyst.

At about six days the blastocyst adheres to the wall of the uterus and some of its outer cells
begin to invade the uterine wall. This is the beginning of implantation.
2 or 3 days later the amniotic cavity makes its first appearance. By 12-14 days implantation
is complete and a primitive placental circulation has developed.

The primitive streak develops a midline thickening at 15-16days, and early features of the
nervous system make their appearance. Appearance of the primitive streak is seen by some
as marking the onset of individuality. Development up to this point (first 2 weeks) may be
called the pre-embryo stage.

9.2. ​Personhood of the embryo and Foetus:

The embryo is to be regarded as a human person from the time of fertilization. The
probability of survival from fertilization to clinical pregnancy has been estimated as 42%
 indeed many studies have set pregnancy wastage from fertilization onwards in the vicinity of
70%. The main factors contributing to this wastage are chromosomal abnormalities. Stages
from 6 weeks all the way to 28 weeks of gestation have been quoted as the beginning of a
​brain​ or as the earliest indication of consciousness.

9.3. ​Research on embryos and Foetuses.

Research attention has focused on the following areas:
Understanding the normal pattern of development and metabolism in the developing human
embryo.
Treatment of infertility through invitro fertilization.
Prevention of genetic disease
Improvement of contraception
e.g. production of a vaccine against hCG, a hormone produced by pre-implantation embryos.

Foetal research
Research has been done on:
Foetuses in uterus prior to abortion or normal delivery.
Foetuses in the uterus during abortion.
Foetuses outside the uterus following abortion
Is the foetus regarded as a human being?
Consent has to be given by mother.
9.4. ​Abortion
Wishes of the pregnant woman
Ethical demand made on us by the foetus (silently)
Relevance of the stage of foetal development.
Conflicting ethical assessment of abortion within society.

9.5. ​Foetal Neural Transplantation (brain grafting)

Became possible in the 1980s and raised a host of issues:
It is transplantation of foetal tissues.
It is use of human material.
Reasons:
Alleviation of brain diseases e.g.
Parkinson​s disease
Alzheimer​s disease
Huntington​s disease.
Tissues are obtained from foetuses made available by induced abortion.
Objections:
Results may not warrant clinical application.
Abortion morally wrong.

Support
There is nothing morally wrong with abortion.
Abortion and transplant are separate issues.

Principles:
Foetus must be dead
Abortion must not be influenced.
Abortion and grafting must be kept separate
There should be a genuine possibility of significant benefit.
Good expected greater than any possible harm.
Therapy to be used as last resort
Fully informed consent from pregnant woman.
Recipient in position to give fully informed consent.
Anonymity between donor and recipient.
 Research design sound ​ community benefits.

10.0. ​BIRTH AND BEYOND

​Birth Rights
10.1. ​The rights of a child at birth
The rights of the mother giving birth must also be respected.
The dilemma reaches it​s most acute when the birth itself threatens the life of both mother and
baby, with the possibility that only one can be saved. In the past, some religious teaching
encouraged women to ​Sacrifice​ themselves for the sake of the baby on the grounds that the
stronger moral claim was from the life yet to be lived (not much support for this view).

The practitioner needs to act as the baby​s advocate, seeking an outcome through persuasion
that will respect the woman​s bodily integrity, but also involve her in caring about her baby​s
welfare. Unless the mother​s life is in danger, the first medical responsibility is to ensure the
safety of the baby.

10.2. ​Dilemmas after Birth:

Where there is neither the capacity nor the potential for personal life (i.e. can show neither
awareness of, nor response to the care and love ​ conscious life, or potential to enter into human
relations), we may say that we are released from any obligation to keep them alive. Examples
include those with microcephaly, anencephaly, hydranencephaly and certain other major
deformities of central nervous system.

In some cases the baby has some capacity for participation in human relationships but has such
severe handicaps that intervention gains little more than prolonged suffering e.g. babies with
Cri-du-chat syndrome. In such cases, simple basic comfort and custodial care may be all that is
correct to do.
Parental decisions regarding treatment options. In most jurisdictions there is a fuzzy boundary
between the age at which a child can give consent for its own treatment and below which
parental consent must be sought.

Most ethicists advise that the child be included as far as possible in the decision-making
process, but for children up to at least 16 years old the parents should give consent for medical
treatment. This is regarded as the ​natural role​ of parents and is recognized universally in legal
codes. It is assumed that the parents will make decisions in the best interests of the child. In
certain situations, however, the assumption cannot be sustained (e.g. story of Julius and Grace ​
Jehovah​s Witness). Parents must not be forced to suffer a burden of responsibility and perhaps
guilt for a decision that practitioners can and should be prepared to share in making. They
must be helped to do what is right in such a way that they do not feel that they have the role of
arbiters of life and death for the child they have produced.

10.3. ​Child Abuse and Child Protection and the concept of ​Best Interest of the Child​ ​
Criterion

In any society there are children who suffer various forms of abuse ​ physical, sexual,
psychological as victims of their parental situations.

Medical practitioners should always bear this possibility in mind when examining children
brought for medical care. Where evidence exists that the child has been abused, they should
act in the best interest, short-term and Long-term, of the child. Criteria for action may be
difficult, and second opinion should always be sought and social services involved.
 Resource Allocation and At-Risk Children.
When considering treatment of at risk children viz​ a-viz resource allocation, the wider picture,
i.e. how best the resources available can be used for the general child population should be
considered.

11.0. ​THE CHALLENGE OF AIDS

11.1. ​Ethical responses to AIDS
Human Immunodeficiency Virus (HIV) causes the infection. HIV transmitted in fresh bodily
fluids e.g.
During sexual intercourse
Through sharing needles in I V drug abuse
Through receiving contaminated blood products.
From infected mother to foetus (30-40%)
Most cases of HIV infection probably proceed to Acquired Immune Deficiency Syndrome
(AIDS).

The rate of progression of HIV infection to AIDS varies, and this variation is currently being
widened further by anti retroviral drugs such as AZT (Zidovudine) which are causing
prolongation of lives of infected persons. As of now, progression from HIV infection to AIDS
is generally fatal.

11.2. ​Informed consent and HIV Testing

The response that one is HIV infected varies from person to person.
Typically it follows the pattern of: shock, guilt, denial, fear, anger, sadness, bargaining,
acceptance and resignation.
Some patients enter into a state of irresponsible hedonism (belief that pleasure is the chief
good) in which they become determined to ​enjoy​ their remaining life with an intensify that
sometimes borders on the pathological.
In some (a few) others a darker motive appears and they form the intent to infect others.
Yet others become withdrawn, ascetic (leading a life of severe self-discipline) and severe in
their personal relationships.
Thus, learning that one is HIV infected leads to a change in one​s outlook to life. The
implications of one​s HIV status are often misinterpreted, leading to profound emotional effects.

For this reason, it is important to counsel the potential patient, and to give realistic information
and preparatory advice before the test is taken. There is, in fact, wide spread consensus that
HIV testing should be the subject of informed consent and that people should not be tested
surreptitiously (secretly) or against their will.

11.3. ​Public Health Issues

The single most effective public health measure to limit the spread of HIV infection is
education and the encouragement of responsible and caring sexual behaviour.

HIV testing for epidemiological purpose is important. However, if informed consent must be
obtained, and if, as is well known, those who refuse to take the test voluntarily are those most
likely to have positive results then the results obtained will be inaccurate. Is it ethical to take
unidentified blood samples (for epidemiological tests of HIV status without informed consent
of those whose blood is to be tested?
 HIV, AIDS and Societal Injustice
Aggravating factors
Poverty
Systematic repression of women and their exclusion from any kind of power over their own life
choice,
Epidemiology and preventive medicine must work hand in hand with ethics, law and sociology
to have any impact on HIV infection.
HIV Tests and Conflicts between patients.
Ethical considerations dictate that informed consent should be obtained before testing anybody
for HIV status, and that no one should be forced to take the HIV test. This is based on
principles of autonomy and respect for individuals. However, there are situations in which
more than one persons are concerned. In such a situation, a conflict of interests suggests that
we must pay some regard to the principles of justice and the rights of others.
Examples include:
Volunteers for blood donation
Surgeon prinking self accidentally while operating on a patient of unknown HIV status.
(Note, the risk to a practitioner from exposure to body fluids from a patient with HIV infection
is between 0.1% and 0.7%. However, even with this little risk, the practitioner has a right to
know).
The patient should be convinced to accept to take the HIV test. If the patient refuses, then an
authorization for mandatory testing may be ethically justified. But who will give the authority?
Court? The patient would then have the right not to know the results.

11.4. ​Doctor ​ patient relationship

Any health threat to a community needs a balanced relationship among the practitioners,
patients and the community to deal with it. At the beginning of the AIDS pandemic this
relationship was anything but balanced. Practitioners were frightened of the patients. The
patients were a stigmatized and hostile group. The community wanted to detect and isolate the
patients.

As information became available the fear by the practitioners was found to be groundless. The
help for the patients which was forth coming made them less hostile. The wide spread nature
of the pandemic made isolation of patients by the community not possible while the scientific
knowledge showed that it was not necessary. The three cornered relationships are now getting
better.

The practitioners who encounter new cases need to develop a deep commitment new cases
need to develop a deep commitment to their patients, and to earn the trust of those groups from
which the new cases are coming. This is important because new patients always need support,
some of which only the practitioner can provide. E.g. the practitioner may need to fill the role
of:
Counselor
Confidant
Helping the patient find personal resources to meet the crisis.

Confidentiality
There is a difficult conflict between confidentiality and the duty to warn others. The GMC
advises:
​There are grounds for disclosing that a patient is HIV positive to a third party without the
consent of the patient only where there is a serious and identifiable risk to a specific individual
who, if not so informed, would be exposed to infection​. (GMC 1988). This is a delicate path
to tread! This is justified on grounds of ​bad faith​. Otherwise called ​Moral Free Loading​
Practitioners cannot be ethically obliged to act as accomplices in immoral and dangerous
actions.

12.0. ​ETHICAL ISSUES IN PSYCHIATRY

 Patients with psychiatric disorders suffers, in one way or another from an impairment of the
mental faculties which affects their moral behaviour. The patient​s autonomy ​ the ability to
make reasonable decisions about his/her own preferences and interests is affected, and yet this
is the basis of the medical partnership. Thus, this patient cannot be treated in a way similar to
that of a physically unwell person whose thoughts and emotions remain more or less intact.
Diagnosis, classification and stigmatization. The diagnosis that a patient is psychiatrically
disordered classifies him/her as ​abnormal​ in a very fundamental way. They are called names.
They are marginalized, set apart from the rest of society.
They have no insight in their illness and may refuse to be treated.
Thus we may have to override their right of self-determination in order to treat them. The
problem of classification and diagnosis is loaded with ethical significance even before we
consider treatment issues.

12.1. ​Clinicians, Patients and Therapeutic Relationships

a) Guidelines
Ethical practice should follow the following guidelines:
Methods used must be attested to and validated as likely to benefit the patient i.e. tend to
return the patient to proper functioning as a responsible and self-directed individual.
Clinician must refrain from harming or damaging the patient by his/her advice or actions.
The professional must always preserve a certain ​distance​ from the patient so as to act in
accordance with good clinical practice and not on the basis of emotional entanglement
​The most obvious and widely publicized type of professional misconduct
involves sexual entanglement with patients.
b) Compulsory Treatment
Is required only where the patient will not co-operate with efforts to treat the problem. It
contravenes the requirement to seek informed consent to medical interventions that is part of a
therapeutic relationship with any reasonable person. The concept of the patient having a
​mental defect​, along with considered opinion that he patient may well act to the detriment of
his/her own or others​ welfare, is a legally required aspect of the justification of compulsory
treatment in most jurisdictions. The mental defect means that one of our foundations of our
ethical framework is absent, in that the patient concerned is not thinking and acting as a
rational social being would.
c) Psychosurgery and ECT
Psychosurgery started with frontal-lobotomy i.e. cutting of the major connections between the
frontal lobe and the rest of the brain. The frontal lobe is the seat of personality, higher-order
motivations and socialization. The resulting state includes ​: Reduced emotional reactions
​: An impoverishment of personality and character
​: A state of motivational destitution that many would
regard as inhuman.
Between 1942 and 1954, 10365 patients were treated using this procedure in England alone.
The treatment was used for severely depressed and disturbed patients.
Amygdalotomy is used to treat patients with aggressive disorders and some types of
hyperactivity. Changes are not well documented but include motivational alteration.
Both procedures carry a risk of death or permanent alteration of psychological function.
Ethical justification for the procedures is hard to find.

ECT involves passing an electric current through the brain at a level that, unmodified by
anticonvulsant and anesthetic medication, would cause an epileptic fit. It is claimed that
ECT:
Has a dramatic effect on certain patients with severe depression.
Causes no demonstrable harm if administered properly.
All these modes of treatment are difficult to justify ethically.
d) Confidentiality
It has been agreed that in certain situations such as HIV/AIDS, potentially dangerous drivers
and children at risk of abuse, the magnitude of the harm resulting from an absolute respect for
confidentiality out weighs the harm from breach of confidentiality. This also applies in the
 case of psychiatric patients who pose dangers to other people. That means, where the
practitioner becomes aware that a patient has disclosed information suggesting that an
identifiable person is at significant risk or harm, any measures possible should be taken to
protect that person. If this involves suspending the practitioner​s normal duty to respect
confidentiality, then so be it.
Note that there is also a suspension of the normal terms of the practitioner ​ patient relationship
in the compulsory treatment of the insane.
12.2. ​Suicide and Psychiatric Illness:
A number of those who attempt suicide make the choice while in a disturbed state, and will not
choose that way again.
Although we can never be certain about the conditions of and rationale for an attempt, we
know that if we do not intervene, the decision is irreversible. Most failed suicide are glad that
their lives were saved.

The ethical weight in this area therefore seems to fall heavily on the medical policy that runs
counter to putting absolute value on patient autonomy.

People in general are not clear-cut forward planners who have an autonomously formulated and
rationally justified agenda to pursue. They feel things and react to things in myriad ways that
change over time and through the vicissitudes of relationships and adverse circumstances.
Patients who are psychologically disturbed are particularly vulnerable to instability in their
thoughts and intentions. Thus, the accepatiented practice of the medical profession in relation
to suicide has been to take whatever steps necessary to prevent a suicide.

This is not just because suicide questions our sense of the sanctity of life but also with the
realization that a person must be desperate before he/she attempts to commit suicide. There is
doubt whether the decision to take one​s own life is generally well reasoned. The psychiatric
illness makes the doubt even stronger. However, the possibility of suicide is considered by
almost every human being at some stage of his/her life, but most of us turn away from that step.

12.3. ​Reproduction, Sexually and Mental Impairment

It is in the best interest of a mentally subnormal patient to be sterilized. In most common
wealth jurisdictions, it is thought appropriate to leave the decision to the doctors and the
parents as long as they are in agreement. This is to spare such a person the problems of
pregnancy and childbirth for which she has no capacity to understand.
Certain categories of psychiatric patients may be in the same category.
Note, however, that this is not to be used as a general policy. Rather, each individual case
should be considered on his/her own merit.

13.0. ​AGING, DEMENTIA AND MORTALITY

Aging brings limitations to our abilities in general. It also brings dementia in particular.
13.1. ​Neurobiology of aging
Those who are aging normally show no sign of dementia. During normal aging the following
changes in brain may be observed.
Decline in brain weight (starting between 45 and 80 years).
Enlargement of ventricles
Decline in brain volume
Loss of clear differentiation between grey and white matter. Changes in white matter
associated with slowing of attentional and motor functions and the speed of mental
processing.
Loss of large neurons especially in frontal and temporal lobes and the motor cortices.
Loss of large neurons in mid frontal and parietal regions.
 Loss of cells in some areas in the hippocampus (which is involved in relational memory,
which declines).
Loss of monoaminergic neurons in various brain regions associated with changes in mood,
sleep, appetite and other non-cognitive functions.
Generalized decrease in the size of neurons.
Brainstem neuronal populations are almost unaffected.
Dendrites degenerate and their branches disintegrate and lose pines leading to reduction in
synaptic connections.
In normal aging, surviving neurons develop expanded dendritic trees to compensate for the
loss of their neighbours ​ plastic changes. Thus capacity to form new synapses is
retained into old age.
The end result of the decline in function inherent in aging is death ​ natural death.
The basic ethical principles of relevance in caring for the aged include: -
Justice
Beneficience
Autonomy
Privacy

13.2. ​Neurobiology of Alzheimer​s Disease (AD)

The most frequent initial symptom of AD is amnesia, especially disruption in memory for
recent events, with particular difficulty in remembering names or faces.

Depression is common as are hallucinations and delusions. The disease progressively involves
cognitive abilities leading to difficulties in finding words and eventually to aphasia.
Skilled motor acts (driving, cooking e.t.c) may be affected. Visual and auditory perceptual
difficulties may develop. Later basic activities (bathing, toileting, feeding e.t.c) may become
difficult or even impossible. Thus, the patient may become completely dependent on others,
incontinent and unable to recognize caregivers or even spouse!
Up to 50% of patients have a family history of the disease. True autosomal ​ dominant AD
affects only about 5%-10% of the sufferers. Duration has a median of 7-10 years from time of
diagnosis. Death is most commonly due to bronchopneumonia. In the familial form, the gene
responsible in on chromosome 14, 19 or 21. The majority of cases are non-familial and may
have origin in head injury, inflammation e.t.c

AD patients aged 70-90 years have cortical neuronal losses of up to 30%. Those aged 50-69
years have losses of up to 60%. Even more severe losses have been reported in the
hippocampus (involved in memory). There is loss of different types of synapses, which
correlates cognitive impairment.

The AD patient may be likened to an infrahuman being who lives among human beings but is
no longer able to share their world. Many of the features generally considered to make life
worth living are absent in advanced dementia e.g. they are unable to enjoy human interactions
or to plan a head and look forward to anything new.

13.3. ​What is in the best interest of the severely demented?

The patient is living in a physically, emotionally and socially impoverished state. In this case,
are the patients​ best interests served by the use of technologies that donating more than prolong
simple biological existence?

13.4. ​Genetic Counseling

Genetic knowledge is still fragmentary
Presymptomatic screening and disclosure.
 Prenatal screening and selective abortion.
14.0. ​ENDING HUMAN LIVES
​ he death of a person
14.1. T
​a) Death criteria
Most Western countries now accept the brain ​ death criteria. These criteria include:
Absence of eye-opening
Absence of verbal or motor response to pain.
Loss of brain stem reflexes such as papillary responses, corneal reflexes, caloric response to
vestibular stimulation, cough reflex, response to hypercarbia.
These indicate not only that the person concerned has no mental or conscious activity but also
that there is loss of significant function at all levels of brain activity. If he human being
concerned is totally unresponsive to these tests, and there is good evidence that there is
irreversible structural damage to the brain causing that condition, then there is no hope of that
human being. Ever regaining consciousness. The purpose of medical intervention and life
saving treatment is to benefit the patient (i.e. to effect changes in the patient​s condition that
now or in the future he/she will regard as worth while).
b) Coma vigilante
In ​coma vigilante​ or ​Locked in syndrome​ the patient​s cerebral cortex is intact. These patients:
Experience things around them
Understand what is said
EEG is active (as in waking state) indicating active cortical processing of information.
Have lost all voluntary control of motor function except, usually, upward movement of the
eyes. Thus, these patients can sometimes establish effective communication with others using
eye movements.
c) Coma
d) Persistent vegetative state - A person in a persistent vegetative state (PVS) may swallow,
breath, absorb nutrients from the gut and blink. Sometimes the eyes may open and rove around
in the head without direction or focus. There is no electrical or clinical sign of activity of his
cerebral cortex. He/she may be kept alive by feeding him/her through a nasogastric tube and
treating any infections that may develop. No evidence that these ever recover. The person in
PVS is in profound irreversible coma
e) Thus, 5 states may be identified, namely:
Alive and normal
Locked syndrome ​ cerebral cortex alive and active.
Coma ​ cerebral cortex not functional? Temporarily.
Vegetative state - parts of brainstem alive
- Cerebral cortex dead
Brain dead ​ subject dead
In states (iv) and (v) the patient will not benefit from any measures to keep him/her alive.
14.2. ​Facing Death:
For virtually all of us, death represents an unknown state whose approach generates fear. We
therefore need to prepare our patients for the end of their lives by being honest.
There is no worse situation in clinical practice than the terrible web of deceit that is often
woven around a dying patient.
It is unpleasant to tell people that soon they are going to die. The need for honesty does not
mean that we should be stark and brutal in our communications to patients.

However, honesty, gentleness and sensitivity are congenial companions in terminal care. Hope,
however slight, is always needed to sustain patients through terminal illness. Thus, hope
should never be destroyed, but this does not justify deceit or evasion.
Create a climate of care in which terminal illness and the fear of death can be confronted and
dealt with.
14.3. ​Suicide
Suicide is in no circumstances permissible. Humanity in one​s own person is inviolable, it is a
holy trust.
Virtually all the main worlds​ religions reject it on the basis that God has given human beings
 the gift of life and human beings should not destroy that gift. This is not as straight forward as
it may sound. Consider for example the situations of:
Martyrdom ​ isn​t this condoned by religion and such people even declared saints!
Forgoing of life ​ saving treatment when applying the principle of self-determination should this
be interpreted a suicide?
When discussing psychiatry it was considered that people who consider and attempt suicide
cannot be in their right mind at that moment in their lives and that in a sense they are crying for
help (depressed, hurt or emotionally unstable) on this basis, laws in many countries empower
other persons to prevent suicide from succeeding.
Suicide is not a crime, however, it is also not a human right! It is not morally right. A
completed (successful) suicide is irrevocable and the person concerned does not have a chance
to reconsider.
Are there circumstances in which decisions to commit suicide are made rationally after a clear
assessment of one​s future life?

If so, isn​t interference, in such situations, leading to prevention of the suicide unjustified?
Would it, therefore, be morally right (ethical) to let such people succeed in committing suicide?
What are these circumstances and how is the other person to know?

In general we seem to have good reasons to intervene in suicide attempts, if we have a chance,
even when this may seem to be against the wishes of the person attempting suicide. This may
be justified by considering attempting suicide to be an act of desperation, so that our
intervention may be regarded as an act of buying the individual time to reconsider, and society
to help in reconstructing those things needed to make the individual​s life worthwhile.
14.4. ​Euthanasia
This is the act of offering active assistance to another person to end his/her life, i.e. assisting a
person to commit suicide.
Consider the following situation:
George is going through intolerable suffering.
There is no chance for cure.
Attempts to release suffering have failed. Comforting him is impossible
He is mentally normal and capable of rational self determination (principle of autonomy).
George decides that his life is not worthwhile and wants to end it.
His options are either to commit suicide one way or another, or to request the practitioner to
help him in ending his life. He decides it is better to request for assistance from you.
On the grounds of the principle of self-determination, has George got a moral right to decide to
end his life under these conditions?
Using the principle of the health of my patient shall be my first consideration; would it be
ethical for the practitioner to assist George under these conditions?

The practitioner​s assistance may be of two different types, namely:

Active euthanasia ​ this is when the practitioner kills the patient. If this killing is requested by
the patient, it is Voluntary active euthanasia. It may involve a patient who could meaningfully
consent to death but did not do so before his/her life was ended. This is involuntary active
euthanasia.

On the other hand, it may involve a patient who is incapable of giving meaningful consent for
his death. This is non-voluntary active euthanasia. Passive euthanasia involves allowing a
person to die by omission (declining to perform a life saving act) or by withdrawing medical
treatment. Most patients in terminal care do not want their death hastened, and of those who do
most are found to have a diagnosable psychiatric disorder likely to contribute to such a request.

Active euthanasia by doctors is available in the Netherlands and seems to answer a real set of
needs.
Remember ​ The criteria for treatment is that it offers a benefit to the patients; and the benefit is
to be measured in terms of what the patient would find worthwhile.
14.5. ​Requests to die
Elizabeth Bouvia, a 25 year old physically disabled (paralyzed) destitute patient fought battles in
courts leading to court ruling that:
​No criminal or civil liability attaches to honoring a competent, informed patient​s refusal for
medical service​
​We do not believe it is the policy of this state that all and every life must be preserved against the
will of the sufferer. It is in congruous, if not monstrous, for medical practitioners to assert their
right to preserve a life that someone else must live, or more accurately endure​​
The implication of the judgment was that:
Competent, adult patients have a constitutional right to refuse medical treatment in order to die.
Interestingly, after this victory, Bouvia changed her mind about staring herself to death and chose
to live.
Larry Mc Afee (A C-2 quadriplegic)
Also filed court cases for him to be allowed to die but also ended up changing his mind.
Terminologies:
Euthanasia ​ Killing of one person by another (or others) for allegedly merciful reasons. The two
cases here did not belong to this group.
Suicide ​ the definition is often broadened to include indirect ways of bringing about one​s own
death. This will include cases where a competent adult without a terminal illness causes his/her
own death. However, it does not include a terminally ill patient who foregoes medical treatment.
Request for assisted suicide may suit the Bouvia and McAfee cases.
Different groups of people in society oppose assisted suicide.
Women attempt suicide more often than men but are less often successful. In young adults only
1 in 50 attempts at suicide succeed while in elderly people in 1 and 3 succeed. The difference
between males and females may be because females use drugs while males tend to use more
violent means such as guns.

Autonomy ​ according to this principle, when applied to the right to die, a person who has not
been proved incompetent has the right to make decisions about when to end his/her own life.
[Note hat according to the law, a person is assumed to be competent until proved otherwise.]

14.6. ​Physician ​ Assisted Dying

German physicians during Nazi era killed 90,000 patients in the name of ​euthanasia​, because of
presumed mental or physical inferiority such as retardation. In another program, ​final solution​ to
the problem of cleansing Germany of racially inferior non-Aryan stock, the Nazis killed: ​
approximately 6 million Jews
​ : 600,000 Poles
​: Thousands of Gypsies
​: Thousands of homosexuals.
All this happened because of acceptance by the German physicians of the idea that some people,
because their quality of life is poor, are better off dead than alive. The Nazis carried out the
destruction of ​life unworthy of life​ in five steps:
Coercive sterilization
Killing of ​Impaired​ children in hospitals.
Killing of ​Impaired​ adults-mostly collected from mental hospitals in centers especially equipped
with carbon monoxide.
The same killing centers were then used for the murders of ​Impaired​ inmates of concentration
camps.
Final step was mass killing, mostly of Jews, in the extermination camps themselves.

In Nazi Germany, it was physicians, especially professors in elite medical schools, who took the
first step. This was not voluntary physician-assisted dying by competent patients as occurs in
Holland or Oregon.
Netherlands (Holland) began to decriminalize physician-assisted suicide in 1971. It started with
 the physician Geertruida Postma killing her mother who had had a stroke. ​
In 1973 the Dutch Medical Association reached an agreement with Dutch prosecutors that
physicians would not be prosecuted for murder if they abided by the following guidelines.
Only competent patients can request death.
The patient​s request must be repeated, unambivalent, unpressured and documented.
The physician must consult another physician for a second opinion.
The patient must be in unbearable pain or suffering without likelihood of improvement.

In 1994 the Dutch Supreme Court held that unbearable mental suffering could also justify
euthanasia. The Dutch do not distinguish between assisted suicide and mercy killing, as
Americans do. Both are still technically illegal in Holland. The Dutch have moved closer and
closer to legalizing voluntary, physician-assisted death without actually doing so.

In 1990, of the 130,000 deaths in Holland, 2.300 (2%) were from euthanasia. Another 1000
deaths occurred in incompetent patients. Virtually 100% of the patients killed were terminally ill
(Most had been given between a week and a month to live). Also physicians had turned down
2/3 of requests for death from competent patients.

After passage of a new law requiring physicians to notify authorities of any assisted deaths, in
1995 another study found much the same results. Most of the thousand incompetent patients
killed had cancer or AIDS and had previously expressed a wish to die should they become
incompetent.
Note that everyone in Holland has free medical care, including long-term nursing home care.
Also patients have a physician who makes home calls, who has known them for years whom
they trust and who will be the one they ask to help them die.

14.7. ​The Hemlock Society

Was founded in US in 1980 by Derek Humphrey, a former British journalist, to help people with
terminal illness die painlessly and with dignity. It advocates limits on assisted suicide and
believes that laws should be liberalized only to assist dying for people who are both competent
and terminally ill-not for chronic invalids, mental patients or comatose patients. It writes books,
which give detailed instructions on how to kill one-self quickly and painlessly. One such book
​Final Exit​ became a best seller.

14.8. ​The Hospice Movement and Palliative Care

It started in 1990 by 2 physicians, Elizabeth Kubler-Ross (born in Switzerland but living in America)
and Cicely Saunders (born and living in Britain), They developed special instructions that did not
try to fight death or delay it but merely made the dying patient as comfortable as possible. A
hospice tries to give dying patients dignity and maximal control over the final months of their
lives.
Originally hospices were special separate facilities but the concept soon evolved to emphasize
care in which most treatment is delivered by visiting nurses and physicians, thus allowing dying
patients to stay at home.

Through the Hospice movement, doctors now know more about relief of pain and the
psychological needs of dying patients.
In-home medical care, which includes hospice, is now one of the fastest-growing fields of
medicine.
Palliative care is anew movement within medicine whose goal is to reduce the painful and
undignified symptoms of the dying patient. ​

15.0. ​RESEARCH ETHIC

15.1.Principles guiding Research with Human subjects as participants
​a)Codes of ethics
The basic principles guiding research with human subjects as participants were firmly
enunciated in the Nuremberg Code drawn up at the conclusion of the War Crime Trials
(1947). The code stressed the necessity of getting fully informed consent from participants,
the obligation on the researcher to ensure that there were no undue risks, and that any
minimal risks were clearly outweighed by the benefits to be gained. Although the code was
promulgated in 1947, its application to biomedical research was not always perceived.

The World Medical Association (WMA) (1962) prepared a draft code of ethics relating to
human experimentation, which after wide circulation and comment was adopted by the WMA
Assembly meeting in Helsinki 1964. The declaration of Helsinki has gone through several
revisions, a recent one in 1989. If forms the basis for the ethical monitoring and control of
medical research worldwide.

b) Scientific Validity
A research proposal cannot be ethical if it lacks scientific validity. Every proposal to undertake
research must be subjected to scientific assessment to determine if there is a clear and prima-
facie useful hypothesis to be tested and to make sure that the research design will yield the
results sought after.
c) Risks and benefits
The balance of risks and benefits of a scientifically valid project must be assessed. The
declaration of Helsinki has drawn a basic distinction between therapeutic and non-therapeutic
research.
In therapeutic research the basic principles in medical care have to be maintained, and these are
that each patient should be given the best treatment available for that particular condition; and
that harm should never be knowingly caused (premium no nocere). Thus, one cannot, justify
with holding a treatment of known benefit to patients merely in the interest of research.
A research design is acceptable only when the safety of participants throughout the trial period
is the paramount concern.

In non-therapeutic research there may not be any specific advantage to the participants. Here
the protection of the rights of participants must be of paramount importance. When persons are
enlisted as controls in a therapeutic trial, that aspect of the trial is non-therapeutic research
since these individuals do not stand to gain. Thus, the risk to this group must be so minimal as
to be negligible, particularly in circumstances where the subjects themselves cannot (are not
legally competent to) give informed consent (e.g. children, psychiatric patients e.t.c).
In assessing risk, account must be taken not only of possible physical injury but also of levels
of discomfort, inconvenience, anxiety or invasion of privacy.
d) Information and consent
In all research involving human subjects, provision of comprehensive and accurate information
to participants or their proxy decision-makers is crucial. Without such information the consent
given will be invalid. The consent must be given freely and with full understanding that it can
be withdrawn at any stage during the research. All explanations must be in non-technical
language that the subject can fully understand. Such information must be given in both written
and spoken forms. The information must contain a clear description of any risks. The
participant must be assured that refusal to grant consent will not alter in any way the health
care the person is receiving. The subjects must not be coerced or induced into participation.
Payments to participants that are substantial enough to constitute an inducement invalidate the
consent.
The participant must be respected as a human being and not be regarded simply as a means to
an end. Hence the use of the term ​participant​ instead of ​subject​ since persons should
participate in, and not be simply subjected to, research.

Cultural beliefs must be considered, especially in use of tissues e.g. those removed during
surgical procedures, placentas e.t.c.
Research on human participants or human tissues without informed consent constitutes an
 invasion of the personal integrity of the participant (including one from whom any tissue may
be obtained) even if no physical harm has been caused.
Consent for use of medical records may be given by IREC (Institutional Research and Ethics
Committee) in conjunction with the Hospital e.t.c Board. Sometimes it may have to be given
by the individual patients.

15.2. ​Children as research participants

One cannot make children into adult volunteers. Has anyone the right to give consent on
behalf of the child? This question becomes more difficult to answer if the procedures are not
going to carry any benefits to the child and may indeed carry an element of risk. In situations
where the child is capable of understanding information provided, the child should always be
consulted about his/her participation and no action should be taken to which the child does not
give clear consent, regardless of the legal age for consent.
All paediatric research that is of direct benefit to the research subjects must carry minimal or
negligible risk. The project must be well designed, safe and worth doing i.e. scientifically valid
and sound. The research should never be allowed to proceed when the child is clearly
distressed by the procedures.
No research that could equally well be done on adults should ever be done on children.
Research with children as participants should be for the welfare of children in particular.
Children should never be used merely because they are accessible (e.g. as patients in an
institution) and reasonably compliant.
15.3. ​Procedures for censuring research
a) Setting up of committees
Committees that censure research in different countries have different: titles e.g. IREC e.t.c
​: Constitutions (membership)
​: Rules of procedure
​: Accountability to bodies such as hospital boards.
The main principles of these committees include:

b) Independence and impartiality

Membership must include experts in:
Scientific research
Law
Religion
Philosophical ethics
Social values and morals
The rules of procedure for such a committee should ensure that every members voice shall be
heard and their opinions respected. The committee that functions best is one in which the
division between lay and scientific/professional is not noticeable. Such a committee will be
independent and impartial in its functioning.
c) Due process
In order to achieve consistency, each protocol must be subjected to the same scrutiny with
regard to:
​: Scientific validity
​: Ratio of risks to benefits
​ Adequacy of information and consent procedures.
Application forms should elicit at least the following information.
Design of study
Safety procedures
Qualifications of researchers
Methods of obtaining consent
Sources of participants and their relations to the researchers
 Funding of project, including payments to participants and researchers
Procedures to be carried out and risks involved
Methods for monitoring and detecting adverse out comes
Compensation arrangements in case of injury
Use of results.
Safeguard of confidentiality.
Communication of results to participants.

The due process should therefore protect both participants and researchers. Therefore
mechanisms for second opinion should exist in the case of the committee rejecting a project
e.g. on ethical grounds.

d) Accountability
The accountability of the committee should first be ensured by a declaration that its decisions
are taken in accordance with an internationally recognized set of guidelines, such as the
declaration of Helsinki of the World Medical Association ​ its most recent revision; or from
guidelines issued by the council for international organization of medical sciences (COIMS).
In addition each nation has its modifications and elaborations produced by government
agencies or professional bodies or incorporated in statutes, e.g. IREC in Kenya.

The Committee must in some way be answerable to those responsible for the health care of the
community or health care facility within which the research is to be carried out. This may
require a system of reporting that allows both the health authorities and the public to be aware
of the activities of the committee, without allowing either breaches of confidentiality or undue
influence on its decision ​ making.

In the final analysis, the worth of such a thorough system of ethical monitoring of research
must be seen in the quality of the research work itself.
However, since medicine is primarily concerned with the well-being of individuals and of the
community as a whole, no research should override the human values medicine seeks to serve.

15.4. ​Use of animals in medical research

The Declaration of Helsinki (1989 revision) states that any health research involving human
participants ​should be based on adequately performed laboratory and animal experimentation​.

In the same document, it is stated that ​the welfare of animals used for research must be
respected​.
Many species of animal are capable of suffering, not only in the sense of physical pain, but in
terms of psychological distress caused by fear, deprivation, being in an alien environment or
being isolated from members of their own species.

Humans have an obligation not to inflict such suffering on the animals because we are moral
agents who possess constraints on our behavior, and the non-human animals have no voice to
defend themselves. The obligation to protect the animals from unnecessary harm is expressed
in both international and national guidelines on the use of animals in research. Our obligation
include:
Proper care for and use of the animals
Avoidance or minimization of discomfort, distress or pain
Using the minimum number necessary for validity of the results
 Alternative methods of research to be devised in place of those procedures that would
inflict pain or distress to the animals.
Invasive and/or painful procedures to be carried out under appropriate sedation,
analgesia or anesthesia.
If the animal is to subsequently suffer severe or chronic pain, distress, discomfort or
disablement that cannot be relieved, it must be painlessly killed. Thus, death of animals
but not infliction of suffering is regarded as morally acceptable.
Research involving animals is now the subject of regulation worldwide. Properly
constituted committees for authorizing and monitoring research ensure that the inhumane
practices will be eliminated from both commercial and scientific research on animals.

16.0. ​LAW AND ETHICS

16.1. ​Why study law and ethics
Today​s health care consumers are likely to consider themselves partners with health care
providers in the healing process and to question fees and treatment modes.
Because rising costs, state statutes and ethical and moral standards affect daily decisions in the
workplace, health care practitioners must have a working knowledge of those aspects of law
and ethics that are relevant to health care.

16.2.Comparing Aspects of Law and Ethics

A Law is defined as a rule of conduct or action prescribed or formally recognized as binding, or
enforced by a controlling authority. Laws are enacted by government to keep society running
smoothly and to control behaviour that could threaten public safety. They are considered the
minimum standard necessary to keep society functioning.
Enforcement of laws is made possible by penalties, for disobedience, which are decided by a
court of law or are mandatory as written into the Law itself.

Many laws affect health care practitioners, including criminal and civil statutes as well as state
medical practice acts. Licensed health care professionals convicted of violating criminal, civil
or medical practice laws may have their license to practice cancelled (withdrawn).

Ethics ​ Standards of behaviour developed as a result of one​s concept of right and wrong.
Moral values ​ one​s personal concept of right and wrong of formed through the influence of the
family, society and culture, serve as the basis for ethical conduct.

An illegal act by a health care practitioner is always unethical, but an unethical act is not
necessarily illegal.
While most individuals, in society, can rely upon a well-developed personal value system,
organizations for health professions also have formalized codes of ethics to govern behaviour
of their members and to increase the level of competence and standards of care within the
profession for example:
(American) Nurses​ Association Code for Nurses.
(American) Medical Association principles of Medical Ethics.
(American) Society of Radiologic Technologists Code of Ethics.
Code of Ethics of the (American) Association of Medical Assistants.

Bioethics is a discipline dealing with the ethical implications of biological research methods
and results, especially in medicine.
Etiquette refers to standards of behaviour considered good manners within a profession. This
is to be compared with professional codes of ethics, which focus upon the protection of the
patients and their rights to appropriate, competent and humane treatment.
Protocols are standard rules of etiquette applicable specifically to a given place of work.
16.3. ​Qualities of successful Health Care Practitioner
Good communication and listening skills, courtesy and tact
Trustworthiness and a sense of responsibility
An understanding of and empathy for others
A relaxed attitude when meeting new people
An aptitude for working with hands
Proficiency in English, Science and maths
A willingness to learn new skills and techniques
Ability to leave private concerns at home
Ability to impart information clearly and accurately
Ability to keep information confidential
Patience in dealing with others

16.4. ​Working in a health care profession

Examples of unprofessional conduct include:
Physical abuse of a patient
Inadequate record keeping
Failure to recognize or act on common symptoms
Prescription of drugs in excessive amounts or without legitimate reason
Impaired ability to practice due to addiction or physical or mental illness.
Failure to meet continuing education requirements.
Performance of duties beyond the scope of a license.
Dishonesty. Falsifying records. Fee splitting
Conviction of a felony.
Betrayal of patient confidentiality.
Delegation of the practice of medicine to an unlicensed person.
Sexual misconduct.
Using unprofessional methods to treat a disease.

16.5. ​License Revocation or Suspension

A physician​s license can be revoked (canceled) or suspended (temporarily recalled) for:
Conviction of a felony (crime more serious than misdemeanour ​ petty crime)
Unprofessional conduct
Personal or professional incapacity
A felony is a crime that is punishable by death or a year or more in prison. Felonies include
such crimes as murder, rape, larceny (theft), manslaughter, robbery, arson, burglary, violation
of narcotic laws, tax evasion.

Personal or professional incapacity may be due to senility, injury, illness, chronic alcoholism,
drug abuse and any other conditions that impair the practitioner​ ability to practice (effectively).
A practitioner is considered guilty of fraud if ​intent to deceive​ can be proved (shown). Acts
generally classified as fraud include:
Falsifying medical diplomas, applications for licenses, licenses or other credentials.
Billing a governmental agency for services not rendered.
Falsifying medical reports.
 Falsely advertising or misrepresenting to a patient ​Secret cures​ or special powers to cure
an ailment

16.6. ​Professional liability and medical malpractice

Liability
Liable means accountable under the law. All competent adults are liable i.e. legally responsible
for their actions both on the job and in their private lives.

As employers, practitioners have general liability for:

The practice​s building and grounds.
Theft, fire and liability insurance to cover the look place is a must.
Automobiles ​ liability insurance in case of accident employees safely including guidelines
for handling or hazardous laboratory wastes and materials.

In addition to general liability, practitioners also have certain professional liabilities.

16.7. ​Privacy, Confidentiality and Privileged Communication

Confidentiality -The act of holding information in confidence, not to be released to
unauthorized individuals. It is the practitioner​s ethical and legal duty to safeguard a patient​s
privacy and to maintain confidentiality.
Privileged Communication is information held confidential within a protected relationship.
Under certain circumstances the law protects the holder of such information from forced
disclosure on the witness stand.

Examples of such relationships include:

Doctor-patient and Attorney-client.
Breach of confidence is grounds for patient suing doctor, which may lead to revocation of
doctor​s license.
Do not disclose any information about a patient, including acknowledging whether or not the
person in question is a patient to a third party, including insurance companies, attorneys and
curious neighbours, without signed consent. If a patient is unwilling to release privileged
information, information should not be released.
Exceptions include:
Legally required disclosures, such as those ordered by subpoena (writ requiring attendance at a
court of law, summon); those dictated by statute to protect public health or welfare; those
considered necessary to protect the welfare of a patient or a third party.
Confidentiality may be waived under the following circumstances:
rd
When a 3 party requests a medical examination, such as for employment, and that party
pays the practitioner​s fees.
When a patient sues a practitioner for malpractice.
When a waiver has been signed by the patient authorizing the release of the information.
Note that autopsy reports are medical records and not public records and are therefore
subject of confidentiality

16.8. ​The Tort of Negligence

The international tort of negligence is the basis for professional malpractice claims. It is the
most common on liability in medicine. It is also referred to as medical professional liability
(MPL). It may be:
Malfeasance ​ performance of a totally wrongful and unlawful act,
Misfeasance ​ performance of a lawful act in an illegal or improper manner,
Nonfeasance ​ failure to act when one should.
Note: Feasance means performance of an act.
 There are 4 elements that must be present in a given situation to prove a practitioner guilty of
negligence
(the 4 Ds of negligence).
Duty of care to the patient)
Derelict (breach of the duty)
Direct cause (of the patient​s injury)
Damages ​ there is a legally recognizable injury to the patient.
Damages are the monetary awards sought by the plaintiffs (patients) in lawsuits. They are awarded
if the defendant (practitioner) is found guilty of the tort (negligence). Other torts for which damages
may be awarded include breach of contract, libel, slander. The amount depends on:
Extent of injuries
Loss of income
Damage of reputation
Other harm that can be proved.
16.9. ​Public Health Statutes
Communicable and other Notifiable Diseases include: diphtheria, cholera, Meningococcal
meningitis, plague, smallpox, tuberculosis, anthrax, AIDS, brucellosis, infectious and serum
hepatitis, psittacosis, rheumatic fever, rubella, typhoid fever, trichinosis, tetanus. May also
include other diseases if a higher that usual incidence occurs, including influenza,
streptococcal and staphylococcal infections. Certain sexually transmitted diseases (STD​s)
(Venereal diseases) must also be reported whenever diagnosed, including: gonorrhoea,
syphilis, Chlamydia (Lymphogranuloma venereum) chancroid and granuloma inguinale
(genifal warts).

Other reportable cases may include

Certain types of injuries resulting from an act of violence e.g. assault, rape, domestic violence
e.t.c Child abuse (in America every 13 seconds a child is reported abused or neglected.

16.10.Drug regulations
Controlled substances Act ​ regulates drugs under the following 5 schedules, based upon their
potential for abuse and their medical usefulness.
Schedule 1 ​ drugs with no proven or acceptable medical use and a high abuse potential
include: heroine, marijuana, peyote, mescaline, LSD, THC e.t.c. They are used for
research only.
Schedule 2 ​ narcotic drugs with a high potential for abuse ​ used for treatment include
opiates, cocaine, methadone, meperidine. Schedule 2N ​ non- narcotic drugs with a high
potential for abuse include amphetamines, phenmetrazine, methyl/phenidate and short
acting barbiturates. These drugs require a properly executed, manually signed
prescription. No refills are permitted on these prescriptions.
Schedule 3 - narcotics in combination with other, non-narcotic drugs e.g. Codeine
combined with acetaminophen or aspirin, phenacetin & caffeine. Schedule 3N​ non-
narcotic CNS depressants e.g.glutethimide, methyprylon and barbiturates not listed in
other schedules; anorectant agents (suppositories) that are not part of other schedules.
Schedule 4 ​ narcotics in combination with other non-narcotic drugs, antidiarrheals, mild
CNS depressants, mild CNS stimulants and tranquilizers. Also includes chloral hydrate,
meprobamate, Phenobarbital, diphenoxylate with atropine sulphate, chlordiazepoxide,
diazepam, diethylpropion and phentermine.
Schedule 5 ​ drugs containing small amounts of narcotics e.g. cough medications with
codeine and drugs used for diarrhea such as Lomotil and Donnagel

Violation of a law dealing with controlled substances is a criminal offense and can result in
fines, jail sentences and loss of license to practice medicine.

16.12.Capital punishment
An individual​s opinion on capital punishment is his or her personal moral decision. However,
as health professionals committed to preserving life, practitioners should not participate in
legally authorized executions.
 A practitioner cannot be compelled to provide medical testimony concerning the legal
competency of a prisoner awaiting execution, if capital punishment is against the practitioner​s
personal beliefs.

​ AW AND THE COURTS

17.0. L
17.1 ​Source of law
Case law
​Common law ​ The body of unwritten law developed in England, primarily from judicial
decisions based on c​ ustom and tradition.
Statutory law ​ is enacted by Legislatures. Individual laws in this body of law are called
statutes.
Administrative law ​ related to agencies.
17.2. ​Classification of law
After laws are created through case, statutory or administrative law, they are classified
according to type e.g. as criminal, civil, military or international. Criminal and civil laws are
the ones which most often affect health care practitioners.
Criminal Law
Crime ​ an offense against the state of sovereignty, committed or omitted, in violation of a
public law forbidding or requiring it.
Criminal law is part of public law.
Criminal laws prohibit such acts as murder, burglary, robbery, arson, rape, sodomy, larceny
(theft), mayhem (needless or willful damage or violence) and practicing medicine without
license. Also it includes matters affecting national security (e.g. treason), crimes involving the
country​s borders, kidnapping, hijacking e.t.c
A criminal act may be a felony or a misdemeanor. Misdemeanors include some traffic
violations, theft below a certain amount attempted burglary and disturbing the peace.

Civil law ​ involves crimes against persons. Under civil law a person can sue another person, a
business or the government. Issues may involve contract violation, slander, libel, trespassing,
product liability or automobile accidents, divorce, child support, child custody.

17.3. ​Tort Liability

A tort is a civil wrong committed against a person or property (excluding breach of contract).
a) Intentional torts
It may be assault, battery, defamation of character, false imprisonment, fraud, invasion of
privacy as in breaching the confidentiality of medical records. Others include trespass,
Nuisance, interference with contractual relations, Deceit, conversion, misuse of legal
procedure, infliction of emotional distress.
b) Unintentional torts
The more common torts within the health care delivery system are those committed
unintentionally. They are acts that are not intended to cause harm but are committed
unreasonably or with disregard for the consequences, thus constituting negligence in legal
terms.
Negligence is an intentional tort alleged when one may have performed or failed to perform an
act that a reasonable person would or would not have done in similar circumstances.
In health services provision negligence is charged when a practitioner fails to exercise ordinary
care and a patient is injured (did not intend to do it or should have known better).

17.4. ​CONTRACTS
Contract ​ a voluntary agreement between two parties in which specific promises are made for a
consideration. For a contract to be legally binding, 4 elements must be present in a contract:
Agreement ​ an offer by one party and its acceptance by another.
 Consideration ​ something of value that is bargained for as part of the agreement.
Logical subject matter ​ an offer for legal services or purposes made in the agreement.
Contractual capacity ​ competent parties who enter into the agreement.

For a contract to be legal and foreseeable, the persons entering into the transaction must be
capable of fully understanding all of its terms and conditions. This is called contractual
capacity. Thus, for example:
A mentally incompetent person cannot enter into a legal contract e.g. persons declared legally
insane, persons in a drug-altered mental state and in some cases, persons under extreme duress.
Exceptions may be made for situations in which a contract is necessary to sustain life.

Health care practitioners cannot treat a minor without the consent of a responsible parent or
legal guardian.
A minor is defined as anyone under the age of majority ​ 18 years in some countries and 21
years in others
Exceptions may be made:
In situations of a medical emergency when the patient is a mature minor (mid to late teens)
when the patient is an emancipated minor, e.g. self-supporting, legally married or serving in the
armed forces.
Types of contracts
Expressed contracts ​ may be written or oral, but all terms of the contract are explicitly stated.
Implied contracts - are those in which the conduct of the parties, rather than expressed words,
creates he contract. Most contracts in a medical office are implied. The contract is valid if
both parties understand the offer, both are competent and the services provided are legal.

​ atient​s rights to;

17.5. P
Receive considerate and respectful care.
Receive complete current information concerning diagnosis, treatment and prognosis.
Receive information necessary to give informed consent prior to the start of any procedure and for
treatment.
Refuse treatment to the extent permitted by law.
Receive every consideration of his/her privacy.
Be assured of confidentiality
Obtain reasonable responses to requests for services.
Obtain information about his/her health care
Know whether treatment is experimental
Expect reasonable continuity of care
Examine his/her bill and have it explained.
Know which hospital rules and regulations apply to patient conduct.

17.6. ​Patient​s implied Duties

To follow any instructions given by the practitioner.
To give all relevant information to the practitioner in order to reach the correct diagnosis
To follow the practitioners orders for treatment
To pay the fees charged for services rendered.

17.7. ​Practitioner​s rights and responsibilities

Practitioner has a right to:
Set up a practice within the boundaries of his/her license to practice
Specialize.
Decided which services will be provided and how they will be provided.

Is Not Bound to:

Treat every patient who seeks his/her services
Restore the patient to his/her original state
Possess the highest skills possible within the profession
Effect a recovery with every patient
Be free from mistakes of judgments in difficult cases
Display infallibility of judgment
Is Obliged to:
Use due care, skill, judgment and diligence in treating patients.
Stay informed about the best methods of diagnosis and treatment
Perform to the best of his/her ability.
Exercise his/her professional judgment in all cases
Abstain from performing experiments on patients without informed consent
Take every precaution to prevent spread of contagious diseases
Advise patients against needless or unwise operations.

Standards of death
Whole-body standard of death
Brain death-an alternative to whole body death was first described in the Medical Literature
in 1959 (P. Mollaret and M. Goulon, ​Le coma Depass​, Revie Neurologie, Vol IDI, NO3,
1959). There are more than one standards of brain death.
(a) The Harvard Criteria of brain death
In 1968, shortly after Christian Barnard​s heart transplant operation, an adhoc committee at
Harvard Medical School developed the Harvard criteria of brain death (Ad Hoc Committee of the
Harvard Medical School to examine the Definition of Brain Death, ​Definition of irreversible
come​ JAMA, vol 205 No 337, 1968).
The Harvard Criteria operationally defined brain death as:
Behavioural that indicated unawareness of external stimuli
Lack of bodily movements
No spontaneous breathing
Lack of reflexes
Two isoelectric (nearly flat) EEG readings 24 hours apart.
These would indicate loss of whole of brain activity including brainstem activity. No one
declared dead by these criteria has ever regained consciousness.

Cognitive Criterion-based on loss of ​Core properties​ i.e. mental capacities without which a body
is no ​longer to be considered a ​person​. Most conducive to organ transplants.
Irreversibility standard ​ defines death as having occurred when unconsciousness is irreversible
(operationally, when persistent vegetative state (PVS) has lasted over one year).
In a study published in 194 by the multi-society task Force on PVS, of 434 adults with traximatic
head injuries, seven (1.6%) made good recoveries and regained consciousness after being in PVS
fro more than 12 months (Multi-society Task Force on PVS, ​Medical Aspects of the persistent
vegetative state​ parts 1 and 2, NEJM vol. 330 No22 PP 1572 ​ 1579 may 26 1994, June 2, 1994).
Karen Quinlan and Nancy Cruzan were in PVS for longer than that and did not recover. None
have ever recovered after being comatose for 30 months or more.
Note, the longest case of PVS so far has been that of Rira Greene who became comatose in 1952
aged 24 years after open-heart surgery and whose body was still living in a nursing home by
2000 in West Virginia.
 The American Medical Association (AMA) in 1973 declared: ​The intentional termination of the
life of one human being by another ​ Mercy Killing ​is contrary to that which the medical
profession stands and is contrary o the policy of the AMA​ The cessation of the employment of
extra ordinary means to prolong the life of the body when there is irrefutable evidence that
biological death is imminent is the decision of the patient and/or immediate family​.
Consider the following categories of human beings:
Competent adults with terminal illness
Competent adults without terminal illness ​right to refuse treatment
Incompetent but formerly competent patient
A surrogate for infant and child patients-presently incompetent but later to be competent patient
Never competent patients (severely retarded individuals)

Advance directives
A living will ​ conditions under which a person would or would not want medical support
continued.
A values inventory ​ specifies what a person values in life.
A durable power of Attorney ​ assigns to someone else the right to make financial and life ​and-
death medical decisions if the person becomes incompetent.

According to AMA directives, since 1986 it is ethically possible for a physician, after consulting
with the family, to withdraw a ventricular and feeding tubes from an irreversibly comatose
patient.

Heurologists now believe that consciousness has 2 dimensions or components, namely:

Wakefulness or arousal
Awareness
On this analysis PVS patients can be described as wakeful but not aware.

ETHICAL & LEGAL OBLIGATIONS OF DENTAL PRACTITIONERS

PROFESSIONAL CONDUCT AND FITNESS TO PRACTICE BY M. AWORI 1993

​For the purpose of the (Kenyan) Act, the practice of dentistry shall be deemed to include the
performance of any such treatment, advice or attendance as is usually performed or given by dentists,
and any person who performs any operation or gives any treatment, advice or attendance on or to any
person as preparatory to or for the purpose of or in connection with the fitting, insertion, or fixing of
dentures, artificial teeth or other dental appliances shall be deemed to have practised dentistry within
the meaning of the act.​ ​
Professional conduct
Under Cap 253, one of the principal functions of the medical practitioner​s and Dentists Board is to
promote high standards of professional conduct among the practitioners.
Dentists must at all times:
Ensure that their conduct is compatible with the high standard which the public and their profession
have a right to expect from them.
Remember that their responsibility to their patients is their first priority.
Practitioners may be removed from the register for reasons of professional misconduct or criminal
offences. The issues are initially handed by the preliminary proceedings committee (PPC) which
may then refer the case to the professional conduct committee (PPC). The PPC has powers to
suspend practice.
The PPC has powers to remove to name from the register. The practitioner, however, can appeal to
the judicial committee (JC) of the ministry of health. Offences may include:
Criminal deception (formally known as false pretences) forgery. Theft and comparable offences.
Offences involving: ​
Drunkenness
Misuse of drugs
Indecency etc

The board will in general hold a practitioner responsible for the actions of his/her employees.
Examples of serious professional misconduct:

General anaesthesia and sedation can only be used under specified conditions. If such conditions
are not fulfilled it may constitute serious professional misconduct.
Sterilization to protect his/her staff and patients from the risk of cross-infection.
Abuse of professional relationship as any act of immorality, indecency or dishonesty.
Improper statements or certificates; misleading announcements including any act or omission
calculated to mislead the public.
Covering
A dentist who knowingly or through neglect of his duty enables a person to do dental work
which that person in not permitted by law to do.
It is unethical for a practitioner to delegate responsibility for instructing points in the
principles and practice of oral hygiene unless:
The practitioner is satisfied that the person to whom the responsibility is given is full competent to
discharge it.
The practitioner understands that he is personally responsible for whatever instructions are given in
his name

Drinking
Consuming prohibited drugs
Advertising
Publicity or advertising material shall not:
Be of a character that could reasonably be regard as likely to bring the profession into
disrepute.
(ii) ​Contain any reference to the efficiency, skill or knowledge of any other practitioner or
practice.
(iii) ​Make claim, which is not capable of substantatiation.
(iv) ​Make claim, which suggests superiority over any other practitioner or practice.

(i) ​Canvassing
Leaving a practice ​ arrange for treatment started to be completed.
Screening of windows- of waiting room and surgery areas.
Carrying on of business of dentistry by laymen.

FITNESS TO PRACTICE
Chap 253 gives the Board jurisdiction in cases where the fitness to practice of a practitioner is
seriously impaired by reason of his/her physical or mental condition.

RESPONSIBILITIES OF A NURSE IN THE PROMOTION HEALTH, LAW & ETHICS- TM

ODUORI 1990.

The Nurse and the Law

In various countries there are acts (eg in Kenya, the Nurse Act 1983, chapter 257 of the laws of
Kenya) of parliament to make provision for Nursing education, registration, enrolment and licensing
of nurses, to regulate their conduct and to ensure their maximum participation in the health care of
the community and for connected purposes.

The act establishes a council (eg the Nursing council of Kenya) charged with the functions of
looking after the training system of the nurses and also their discipline in order to maintain the high
standard of conduct and etiquette that is very necessary among the members of the nursing
profession. The other regulatory checks are the code of Ethics for Nurses.

Definition of a Nurse as defined by the International council of Nurses. ​A nurse is a person who has
undergone a prescribed course of instruction or training and has passed the appropriate examination
conducted or prescribed by the recognized authority and is registered or enrolled or licensed to
practice Nursing in that country.​ The recognized authority is usually the Nursing council of that
country.

The professional nursing is that which dates from the Florence Nightingale era. Under the Nurses
Act., it is the responsibility of each nurse to ensure that his/her name is entered in the register, or
roll, or license maintained by the Nursing council of the country. It is an offence for any person
trained or untrained to engage in nursing practice under the name without being registered, or
enrolled or licensed by the Nursing council.

Code of Ethics
The code of Nurses Ethics clearly states that the nurse in the course of her work assumes
responsibility for individual nursing action and judgment.

Individually and collectively, the nurses first responsibility is to the consumer- the patient or client.
Nurses in practice must guarantee that patients/client receive professional nursing care. Nurses must
promote safe practice within a changing society, evaluate prescribed regimens for accuracy and
effectiveness, provide physical, Psychological and social aspects of patient care, evaluate nursing
care given by other nurses as well as care given by other members of the health team to provide
health maintenance, prevention and treatment of illness.

A nurse must have: personal integrity, so that he/she can respect patient confidence about his/her
private affairs which come to her knowledge in the course of her duties. Such information must be
disclosed only with the express permission of the patient.
Reliability in carrying out instructions
Reliability in recording observations (on vital signs)
Punctuality in administering drugs (treatment)

A nurse must be conscientious and see to it that nursing procedures are carried out properly even
though no one is watching.

Nursing Responsibilities:
The goal in nursing is to help persons to attain, retain and regain (good) health.
Nursing is a process through which care is provided to individuals, families or communities
primarily around circumstances and situations that arise from health related problems.

The nurse has the greatest contact with the patient and therefore has more chances to build a
friendly relationship and an intimate rapport with the patient.

This makes the nurse the closest confident of the point. The functions of nurse require
identification with and understanding all kinds of people in all sorts of situations. This requires
 that the nurse understands the fundamental needs of man, in order to help provide those needs for
the patients.

Factors Necessary for Effecting Nursing Services

1. ​The Nursing profession through the Nursing council and the National Nurses Association
must ensure sound educational programmes designed to train competent Nurse practitioners
equipped with:
Knowledge including Health & law
Ethics
Skills
Attitudes
Relevant to the needs of the community they will serve.

2. ​At all levels provision must be made for continuous education to maintain high quality patient
care.

3. ​The professional association must set standards of practice, which should provide guidelines
for sound nursing practice.

4. ​Employers should define responsibility lines to enable nurses assume responsibility and
accountability of those professional responsibilities vested in them, i.e there should be clearly
stated job descriptions for all the members of the health care team so that they all know what is
expected of them and what they should expect of the other members of the team.

Conclusion:
The nurses Act provides framework for:
Protection of the Public means by which nurses may achieve, maintain & increase professional
competence and approach excellence.
Removing the right to practice from those who cease to be competent.

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