ETHICS IN OBSTETRIC
AND GYNAECOLOGICAL
PRACTICE
Dr Terrumun Z Swende
Benue state University
Makurdi
OUTLINE
Definition of Medical Ethics
Scope of Ethics in Medical Practice
Theories and principles
Duties of a Doctor
Objectives
By using case based material you
will be able to:
1)Recognise ethical issues
2)Recognise ethical conflicts
3)Practice verbal reasoning skills
4)Be aware of own and others
moral values
WHAT IS ETHICS
The formal study of:
What is right and wrong.
The study of the bases or principles
for deciding right and wrong.
The analyses of the processes by
which we decide what is right and
wrong.
ETHICS IS NOT:
Merely obeying the law
Compliance
Although in many instances laws
are statements of considered
ethical positions and most of the
time obeying the law is an element
of ethical behavior.
MEDICAL ETHICS
a field of applied ethics, the study
of moral values and judgments as
they apply to medicine. As a
scholarly discipline, medical ethics
encompasses its practical
application in clinical settings as
well as work on its history,
philosophy, theology, sociology,
and anthropology
“
Long history
Third Dynasty (Egypt) 2700 BCE
Code of Hammurabi (Babylon) 1750 BCE: If the
physician succeeds, he gets paid. If he fails, at worst
he loses his hands.
Oath of the Hindu Physician (Vaidya’s Oath) 15th cy.
BCE
Hippocratic oath (Hippocrates, ca 460-370 BCE)
The Oath of Asaph and Yohanan (ca 6th cy. CE)
Advice to a Physician (Persia) 10th cy. CE
Oath of Maimonides 12th cy. CE
Ming Dynasty (China) 14th cy. CE
Seventeen Rules of Enjun (Japanese Buddhist
Physicians) 16th cy. CE)
Percival's Code (England) 1803 basis for first AMA Code
of Medical Ethics.
Beaumont's Code (United States) 1833: experimental
treatments when all else fails. Get voluntary, informed
consent. Stop experiment at subject’s request.
American Medical Association (AMA) Code of Medical
Ethics 1847
Claude Bernard (France) 1865
Walter Reed (United States) 1898: Introduces written
consent “contracts”. Allows healthy human subjects in
medical experiments.
Berlin Code, or Prussian Code (Germany) 1900: No
medical experiments when subject not competent to give
informed consent, in the absence of unambiguous consent,
or when information not properly explained to subject.
Reich Circular (Germany) 1932 Concerned with consent
Modern Issues and statements
• Nuremberg Code (1947)
Medical research
• Declaration of Geneva, W.M.A. (1948, 1968, 1984, 1994,
2005, 2006)
World Medical Association International Code of
Medical Ethics
• AMA revision (1957)
• Declaration of Helsinki, application to medical
research (1964, rev. 1975, 1983, 1989, 1996, 2000)
• Belmont Report (1979)
• AMA revision (2001)
Importance of Medical
Ethics
1. Increasing profile\Recent press
headlines:
Euthanasia
Genetic testing/ Selective feticide
Sex selection
Destroying frozen embryos
Abortions
Organ transplant eg uterus
Cloning
Importance of Ethical
Issues (contd.)
2)Increase in technology
3)Better informed society
4)Doctors in Management
5)Public scrutiny
THEORIES
TELEOLOGICAL THEORY
Ethical approach that studies
actions in relation to their ends or
utility
Consequence alone determines
right and wrong
consequentialist theory
THEORIES
UTILITARIANISM THEORY
Ethical doctrine of greatest good
Greatest happiness of the greatest
number is prime criterion of the
virtue of action
DEONTOLOGICAL THEORY
Study of what is morally
obligatory, permissible, right or
wrong
Some principles are intrinsically
right
- regardless of resulting
consequences.
Principles
1. Beneficence
2. Non-Maleficence
3. Doctrine of double effect
4. Autonomy
5. Justice
6. Confidentiality
BENEFICENCE
A practitioner should take actions
that serve the best interests of
patients.
However, uncertainty surrounds
the precise definition of which
practices do in fact help patients.
NON-MALEFICENCE
It is considered that first and foremost,
it is more important not to harm your
patient, than to do them good.
A physician should not prescribe
medications (or otherwise treat the
patient) unless s/he knows that the
treatment is unlikely to be harmful; or
at the very least, that patient
understands the risks and benefits,
and that the likely benefits outweigh
AUTONOMY
The patient has the right to refuse or
choose their treatment.
Exceptions are in persons who lack
mental capacity, and are generally
treated according to their best
interests (unless there is a clear
advance directive to the contrary) and
minors. A parent, relative or guardian
may serve as proxy.
Court order may be sort by the
DOCTRINE OF DOUBLE
EFFECT
Thomas Aquinas and Dr Adams
An action having good and bad
consequences is defensible if:
The nature of the act is good
The intention is for the good effect
The good effect outweighs the bad and the
situation is grave enough to risk yielding to
the bad effect
The good effect does not depend on the bad
effect
AUTONOMY
1. Capacity to think, decide, take
action
2. Mental incompetence= no
autonomy
3. Autonomy –v-Paternalism
When patient not autonomous –
no clash. When patient
autonomous-questionable
procedure
JUSTICE
This concerns the distribution of scarce
health resources, and the decision of
who gets what treatment (fairness and
equality).
Subjects must be treated equally as
much as possible.
The less disadvantaged members of
the community must not bear
disproportionate burden for a study
Truth Telling
“In much wisdom is much
grief:and he that
increaseth knowledge
increaseth sorrows”
(Ecclesiastics 1,18)
Truth telling (cont)
If you override it you endanger
doctor/patient
relationship(based on trust)
You offend against the principle
of autonomy(Dr.C Mooreland)
At times there are good reasons
for overriding the truth telling
principle
The case for
deception is founded
on three fallacies
1. Hippocratic obligations
2. Not in a position to know
the truth
3. Patients do not want the
truth if the news is bad
Confidentiality
Act against this principle and you
destroy patient’s trust
Clash –when keeping
confidentiality would harm others
eg child abuse
Should patients have access to
their notes?
Against
Layman unable to cope with data
Opinions not facts cause anxiety
Third party information
Defensive medicine
For
Data belongs to patient
Accuracy improved by sharing
Access to Records
Data Protection Act (1998)
What records are covered?
Does it matter when the record was
made?
Who can apply?
Are their exemptions?
Must copies be given if requested?
Access to records of deceased patients?
Exceptions to Medical
Confidentiality
Pt gives written and valid consent
To other participating professionals
Where undesirable to seek patients
consent info can be given to a close
relative
Statutory requirements
Ordered by Court
Public interest
Approved Research
Euthanasia
Active: an active intervention to end
life
Passive:deliberately withholding
treatment that might help a patient live
longer
Voluntary :euthanasia is performed
following a request from a patient
Doctor assisted suicide: a doctor
prescribes a lethal drug which is self
administered by the patient
Non-voluntary :ending the life of a
Contaception and Minors
1. Jane aged 15 yrs requests the
OCP
2. Her mum phones you the next
day
3. Several weeks later she tells you
her boyfriend slapped her across
the face
4. Her boyfriend is her history
teacher
RESEARCH AND ETHICS
Design must be scientifically
sound.
Experimental studies should
balance risks against benefits.
In clinical trials, medication should
not be withheld, particularly if an
alternative exists or if condition is
serious
Tuskegee Syphilis study (1932-1972):
Recruited poor, rural African-
Americans only to study the natural
progression of syphilis. Participants
were made to believe that the were
receiving free health care.
Of the 399 subjects, 28 died from the
disease, 100 died of complications, 40
wives were infected and 19 children
were born with congenital syphilis
4th Year- Case history
A 25 yr old lady comes to the
treatment room requesting
syringes.She is a lesbian and
wishes to inseminate herself.
1) What else would you like to
know
2)What are the ethical issues
3)What would you do
Baby K: Anencephalic. Mother
refused abortion and got a court
injunction for the use of life
support. Baby survived for 6
months.
Baby Doe: Mother declined
surgery for tracheo-oesophageal
fistula because the baby also had
Duties of a Doctor
Please apply ethical
principles
