Wachemo University

College of Medicine & Health Science

School of Medicine

MODULE TITLE: CLINICAL METHODS

MODULE CODE: CLMD 4011

DURATION: 6 WEEKS

Medical Ethics

Lecture by: Markos S. (MPH, Assistant professor of PH)

markos2014@wcu.edu.et
 What is Ethics?

₋ Ethics is a system of moral principles.

₋ They affect how people make decisions and lead their lives.

₋ Ethics is concerned with what is good for individuals and

society and is also described as moral philosophy.

Ethics covers the following dilemmas:

how to live a good life

our rights and responsibilities

the language of right and wrong

moral decisions - what is good and bad?

 What is Medical Ethics?

Medical ethics : is a system of moral principles that apply

values and judgments to the practice of medicine.

Basic principles of medical ethics:-

A) respect for patient autonomy.

B) not inflicting harm on patients.

C) a positive duty to contribute to the welfare of patients

D) justice or fair treatment of patients.

Why Ethics Become Important?
 Ethics and Morality

• The terms ethics and morality are often used interchangeably

• Ethics and morals both relate to “right” and “wrong”

conduct.

• However, ethics refer to the series of rules provided to an

individual by an external source. e.g. their profession.

• On the other hand, morals refer to an individual’s own

principles regarding right and wrong.
 Relationship b/n Ethics and Morality

Ethics Moral
– The rules of conduct recognized in
respect to a particular class of human ˉ Principles or habits with respect to right
actions or a particular group, culture, or wrong conduct .
etc. ˉ It defines how things should work
– It defines how thing are according to according to an individuals' ideals and
the rules. principles.
– Social system – External ˉ Individual – internal
– Why we do it? ˉ Why we do it ?
– Because society says it is the right thing ˉ Because we believe in something being
to do. right or wrong.
– What if we don't do it? ˉ What if we don't do it?
– We may face peer/societal disapproval, ˉ Doing something against one's morals
or even be fired from our job. and principles can have different effects
– Acceptability on different people, they may feel
uncomfortable,
– Ethics are governed by professional and
legal guidelines within a particular time ˉ Acceptability
and place ˉ Morality transcends cultural norms
 Ethics vs Laws
1. Ethics are rules of conduct.
Laws are rules developed by governments in order to provide balance in
society and protection to its citizens.
2. Ethics comes from people’s awareness of what is right and wrong.
Laws are enforced by governments to its people.
3. Ethics are moral codes which every person must conform to.
Laws are codifications of ethics meant to regulate society.
4. Ethics does not carry any punishment to anyone who violates it.
The law will punish anyone who happens to violate it.
5. Ethics comes from within a person’s moral values.
Laws are made with ethics as a guiding principle.
Professional ethics, medical
ethics, bioethics, clinical ethics
 1.Professional Ethics
• Professional ethics are standards of conduct that apply to
people who involve a professional occupation or role.

• A person who enters a profession acquires ethical obligations

because society trusts them to provide valuable goods and
services that cannot be provided unless their conduct conforms
to certain standards.

• Professionals who fail to live up to their ethical obligations

betray this trust.

• Professional ethics studied by ethicists include medical ethics.

 Medical ethics
• Concerns issues related to practice of medicine

• Explores and promotes principles guiding conduct of health

care professionals

• Involves the consideration of others in deciding how to act

• It is applied ethics.

• It consists of the same moral principles and rules that we

would appeal to ,and argue for, in ordinary circumstances.
 Bioethics

• Bioethics is the study of ethical issues and decision-

making associated with the use of living organisms

• Bioethics includes medical ethics.

• Bioethics is learning how to balance different benefits, risks

and duties.
o Clinical medical ethics is a practical and applied discipline

o improve patient care and patient outcomes

o Focusing on reaching a right and good decision in individual cases.

o It focuses on the doctor-patient relationship and takes account of the ethical

and legal issues that patients, doctors, and hospitals must address to reach

good decisions for individual patients.

The content of clinical ethics includes
1. truth-telling,

2. informed consent,

3. end of life care,

4. palliative care,

5. allocation of clinical resources,

6. the ethics of medical research,

The study of the doctor-patient relationship, including such issues as

1. honesty,

2. competence, integrity,

3. respect for persons.

 Reading Assignment

Hippocratic oath ????????

Four basic Principles of Medical
Ethics
1) Autonomy
2) Beneficence
3) Non maleficience
4) Justice
 Autonomy

• Patient has freedom of thought, intention and action when

making decisions regarding health care procedures

• For a patient to make a fully informed decision, she/he must

understand all risks and benefits of the procedure and the
likelihood of success.

• Always respect the autonomy of the patient - then the particular

patient is free to choose

• Such respect is not simply a matter of attitude, but a way of

acting so as to recognize and even promote the autonomous
actions of the patient.
 Autonomy…
• The patient must be informed clearly the consequences of his action that
may affect him adversely.

• Desiring to "benefit" the patient, the physician may strongly want to

intervene believing it to be a clear "medical benefit."

• The physician has a duty to respect the autonomous choice of the patient,

• as well as a duty to avoid harm and to provide a medical benefit for pts.

• But the physician should give greater priority to the respect for patient
autonomy than to the other duties.

• In the case of a child, the principle of avoiding the harm of death, and the
principle of providing a medical benefit the child's parents as surrogate
decision makers.
 Beneficence
• The practitioner should act in “the best interest” of the
patient - the procedure be provided with the intent of
doing good to the patient
• This needs health care provider to,
- develop & maintain skills & knowledge by
continually updating training
- consider individual circumstances of all patients
 Non maleficence

• “Above all, do no harm,“ – Make sure that the procedure does not harm
the patient or others in society

• When interventions undertaken by physicians create a positive outcome

while also potentially doing harm it is known as the "double effect."

Eg,. the use of morphine in the dying patient. eases pain and suffering
while hastening the demise through suppression of the respiratory drive

• Physicians are obligated not prescribe medications they know to be

harmful.

• Some interpret this value to exclude the practice of euthanasia

• Violation of non-maleficence is the subject of medical malpractice

litigation
 Medical malpractice

• An act or omission by a health care

provider that deviates from accepted
standards of practice in the medical
community which causes injury to the
patient.
 Justice

• The distribution of scarce health resources, and the decision of who

gets what treatment “fairness and equality”

• The burdens and benefits of new or experimental treatments must be

distributed equally among all groups in society

• The four main areas that Health care provider must consider when
evaluating justice

1. Fair distribution of scarce resources

2. Competing needs

3. Rights and obligations

4. Potential conflicts with established legislations

 Code of Medical ethics
Q. What are the common code of medical ethics?
• Integrity,
• Objectivity,
• Professional competence
• Confidentiality, and
• Professional behaviour
• Accountability
• Independence and impartiality
• Respect
 Cont…
• PROFESSIONAL COMPETENCIES:- are skills, knowledge and attributes that
are specifically valued by the professional associations, organizations

• INTEGRITY:- to behave in accordance with ethical principles, and act in

good faith, intellectual honesty and fairness

• ACCOUNTABILITY:- is take responsibility for one’s actions, decisions and

their consequences

• RESPECT:- is the dignity, worth, equality, diversity and privacy of all

persons

• PROFESSIONAL COMMITMENT:- to demonstrate a high level of

professionalism and loyalty to the organization, its mandate and objectives
 General Code of Medical ethics
• A PHYSICIAN:-
−always exercise maintain the highest standards of professional
conduct
−respect a competent patient’s right to accept or refuse treatment
−not allow judgment to be influenced by personal profit or unfair
discrimination
−be dedicated to providing moral independence, with compassion and
respect for human dignity
−deal honestly with patients and colleagues, and report
−who practice unethically or incompetently or who engage in fraud or
deception
−not receive any financial benefits or other incentives solely for
referring patients
−respect the rights and preferences of patients, colleagues, and other
health professionals
 DUTIES OF PHYSICIANS TO PATIENTS
A PHYSICIAN:-
−strive to use health care resources in the best way to benefit
patients and their community.
−seek appropriate care and attention suffers from mental or
physical illness
−always bear in mind the obligation to respect human life
−act in the patient’s best interest when providing medical care
−respect a patient’s right & ethical to disclose to confidentiality
−not enter into a sexual relationship with current patient or into
any other abusive or exploitative relationship.
Doctor-patient and Doctor-community Relationships
• A doctor–patient relationship:- is considered to be the core
element in the ethical principles of medicine

• Is usually developed when a physician tends to a patient’s

medical needs via check-up, diagnosis, and treatment in an
agreeable manner

Core element Doctor-patient Relationships:-

a) Communication: Good communication skills are essential to

establish issues
improved medical, functional, and emotional condition of
 Cont…

b) Doctor empathy: Empathy is vital to ensure the quality of

doctor–patient relationship

c) Trust: doctors allows patients to effectively discuss their

health issues

d) Informed consent: is based on the moral and legal

arguments of the patient’s autonomy

e) Professional boundaries: deals with any behavior on the

part of the doctor that transgresses (break rules of law) the
limits of the professional relationship, or boundary violations.
 PHYSICIAN PATIENT RELATIONSHIP
• The physician-patient relationship is the cornerstone of medical practice

• “A physician shall owe his/her patients complete loyalty and all

the resources of his science

• belief that all human beings deserve respect and equal treatment is
relatively recent

• Physicians in treating AIDS patients puts it: AIDS patients are entitled to
competent medical care with compassion and respect for human
dignity

• Medical ethics do not permit categorical discrimination against a patient

 COMMUNICATION AND CONSENT

• Informed consent is one of the central concepts of present-

day medical ethics.

• The right of patients to make decisions about their healthcare

has been preserved in legal and ethical statements

• The patient has the right to self-determination, to make free

decisions regarding himself/herself.

• The physician will inform the patient of the consequences of

his/her decisions

• A mentally competent adult patient has the right to give or

Principles of Informed Consent
Informed consent is a dialogue, including:

• An assessment of patient competence to decide

• Disclosure of relevant information
• An assessment patients’ comprehension
• Affirmatively obtain consent from patient or surrogate

Informed consent occurs before a patient or surrogate signs

anything
Informed consent is not a signature on a document.
 Practical Informed Consent
Disclosure
• The “reasonable person” standard
What a “reasonable person” would want/need to know

• The nature of the procedure and indications

• Expected benefits, advantages

• Possible risks, disadvantages (cannot be exhaustive)

• Uncertainties inherent in the intervention

• Reasonable alternatives, including observation

 Practical Informed Consent
Documentation
• Rationale: Why the treatment is proposed

• Benefits: The advantages of the treatment

• Risks and Complications: Potentially adverse effects

If everything goes right
If something goes wrong

• Alternatives: What else can be done

(e.g. observation)
 CONFIDENTIALITY

• The physician’s duty to keep patient information confidential has

been a cornerstone of medical ethics since the time of
Hippocrates.

• The Hippocratic Oath states: “What I may see or hear in the

course of the treatment or even outside of the treatment in regard
to the life of men,

• The Oath, and some more recent versions, International Code of

Medical Ethics requires that “A physician shall preserve absolute
confidentiality on all he knows about his patient even after the
patient has died.
 Cont…

The WMA Declaration on the Rights of the patient

summarizes the to confidentiality as follows:

• All identifiable information about a patient's health status,

medical condition, diagnosis, prognosis and treatment

• and all other information of a personal kind, must be kept

confidential, even after death.

• Information can be disclosed to other healthcare providers

only on a strictly "need to know" basis unless the patient has
 Torture
• Torture means any act by which severe pain or suffering, whether physical
or mental,

• is intentionally inflicted on a person for such purposes as obtaining from

him or a third person information or a confession,

• punishing him for an act he or a third person has committed

All four elements of

― severe pain or suffering,

― intentionality,

―specific purpose, and

―official capacity are considered

 Punishment

• word punishment to describe anything we think is painful;

• Is the infliction or imposition of a penalty as retribution for

an offence.

• Is "crime demands just punishment“

• Punishment- is the imposition of an undesirable or unpleasant

outcome upon a group or individual,

• Punishment- according to the dictionary , involves the infliction of

pain or forfeiture, it is infliction of a penalty, the purpose of
punishment is to cause physical pain to the wrong-doer, it serves
little purpose.
 Undisclosed Gains

• Undisclosed gains, the identity of the principal and the fact of the
agency are not made known to the third party at the time of making
the contract,

• when a third party has no notice that the principal exists, but the
undisclosed principal has authorized an agent to act on the
principal's behalf

• The agent does not represent that they are forming the contract on
a principal's behalf to the third party.

• Physician -----------Patients-------Caretakers====== Undisclosed

r/ship
 Advertisement and Publicity
• Advertisements are a guaranteed method of reaching an audience.

• By creating an engaging aids, & spending enough to reach your target

users

• Advertising is the non-personal communication of information usually

paid for and usually persuasive in nature about products, services or
ideas by identified sponsors through the various media.

• Advertising is the practice and techniques employed to bring attention to

a product or service

• An advertisement is a form of promotion for a brand, product or service

• E.g Medical equipment's

 Advertisement and Publicity

• Publicity is the public visibility or awareness for any product, service, person or
organization.

• It may also refer to the movement of information from its source to the
general public, often via the media.

• The giving out of information about a product, person, or company for

advertising or promotional purposes
 Public relation Perspective

Customers
Customers

Community
Community Investors
Investors

Public
PublicRelations
Relations

Suppliers
Suppliers Government
Government

Employees
Employees
 Advantages of Public Relations

Credibility
Credibility

Image
ImageBuilding
Building Cost
CostSavings
Savings

Public
Public
Relations
Relations
Provides
Provides
Avoidance
Avoidanceof
of
Selectivity
Selectivity Clutter
Clutter

Lead
LeadGeneration
Generation
 Supervisory Role of the Doctor
Supervision is a process of professional learning and development that
enables individuals to reflect on and develop their knowledge, skills
and competence, through regular support from another professional.
 Clinic/practice supervision: day-to-day support provided by a
named/duty senior/more experienced clinician for patients.
 Clinical/professional supervision: regular support from a named
senior/experienced clinician/practitioner to promote high clinical
standards
 Educational supervision: supports learning and enables learners
to achieve proficiency
 Research Ethics

• Research is the systematic gathering of information to learn about a topic

and identify patterns.

• Ethics are rules, guidelines, and norms that we follow.

• Ethics are defined as a set of moral obligations that define the

principles of right and wrong conduct in a community or profession,
and which can be used by individuals to guide their choices and
behaviors'.

• Involves the application of fundamental ethical principles to

planning, conducting & publishing of research
 Key concepts in ethics
Ethical behavior describes a set of actions that abide by certain
rules of :
• Responsibility means accepting the potential costs, duties, and
obligations of one’s decisions
• Accountability means being answerable to others for decisions
made and actions taken Liability means accepting responsibility
and accountability so individuals can recover damages done
• Due diligence means investigating or exercising care to ensure
individuals can examine or appeal how responsibility,
accountability, and liability are applied
 Why are ethics important in
research?
• We should protect the rights of people who participate in
research.

• Unethical research can harm people and communities.

• Unethical research can lead to distrust of science and research,

and ultimately hinders scientific progress.
 Basic principles
• Respect for persons
• Beneficence (“do no harm”)
• Justice
 Respect for persons

• Obtaining informed consent.

o Make sure that people know that the research is voluntary.
o Give people time to ask questions so that they can decide whether they
want to participate.
o Do not unfairly influence people to participate.
o Even after someone decides to participate, make sure that he/she
understands that he/she can decline to answer a question or stop at any
time.

• Protecting vulnerable people and groups.

Beneficence and non-maleficence (“do no harm”)

• Balancing the potential benefits of the research with the risks of

harm.

• Examples of harm are physical harm (e.g., violence and

discrimination owing to breach of privacy), psychological harm
(e.g., emotional distress), and social harm (e.g., loss of a job).

• Benefits may be to society rather than to individual participants.

• The goal is to minimize the risk of harm to individuals and groups.

 Justice

• Choosing research participants and groups fairly

• Making sure that everyone who could benefit from the

research has the opportunity to participate

• Working to bring beneficial results of research to people and

groups who have contributed to the research
 Regulatory requirements

• All research involving human subjects should have:

o Institutional Review Board approval

o Informed consent

• All persons conducting research involving human

subjects should complete human subjects protection
training.
Ethical review committee (Institutional Review Boards)

Convened to
• maintain ethical standards of practice in
research
• ensure protection of subjects/research workers
from harm or exploitation
• to provide reassurance to the public
• protect researchers from unjustified criticism
 Procedure for ethical clearance
• Fill ethical clearance form and attach proposal,
questionnaires, informed consent forms, information
leaflets etc., and submit

• When ethical clearance is granted, data collection can

commence according to the approved methodology
 Severely handicapped children
• Handicap = somatic, mental, sensory or social limitation resulting
from defect of somatic development, psychomotor development

• acquired diseases with secondary irreversible abnormalities

• pathological social environment

Types of handicap in childhood

Somatic and locomotor defects
Congenital anomalies organs or systems (heart, lungs, kidney,
brain…. )
locomotor system (dysplasia, hypoplasia, syndactyly…)
 Cont…

• Syndactyly is a children are born with fused or webbed fingers.

• About half of children with syndactyly have it in both hands

(bilateral).

• Most of the time, syndactyly affects the fingers

• Sometimes it affects the toes, but not as often

 Euthanasia
• Euthanasia is the practice of intentionally ending life to eliminate
pain and suffering.
• Physician-assisted suicide refer to a deliberate action taken with the
intention of ending a life to relieve persistent pain
• Murder is the unlawful killing of another human without justification
• The word “euthanasia” itself comes from the Greek words “eu” (good)
and “thanatos” (death)
• which is used to describe an easy and painless death, so called-good
death,
• while in medicine euthanasia means a process of setting the patient
free of pains by giving him narcotics or killing the patient who suffers
from incurable disease
• First countries in Europe that made euthanasia legal Netherlands and
Belgium and soon after them Luxembourg and Switzerland; Besides
 Euthanasia

• Different countries have different euthanasia laws:-

Legality,

Voluntary euthanasia,

Involuntary euthanasia,

Non-Voluntary euthanasia,

Active euthanasia,

Passive euthanasia,

Animal euthanasia
 Types of Euthanasia:
• Voluntary- The person wants to die and says so:-
- refusing medical treatment
- asking for medical treatment to be stopped
- asking for life support to be switched off
- refusing to eat
• Non-Voluntary- The person cannot make a decision or their wishes
known:-
- coma patients
- child and infant patients
- severely brain damaged patients
- senile/confused patients
 Types of Euthanasia (cont.):
• Involuntary- The person wants to live but is killed anyway:
- patient being refused a life sustaining treatment
- drugs being too costly
- a limited supply of organs for a transplant
- patient being on a long waiting list
• Active- the medical professionals, or another person, deliberately do something that
causes the patient to die.
• Passive- the patient dies because the medical professionals either don't do something
necessary to keep the patient alive, or when they stop doing something that is keeping
the patient alive:
- switching off life-support machines
- disconnecting the feeding tube
- not carrying out a life-extending operation
- not giving the patient life-extending drugs
 What is HIV
• Human
• Immunodeficiency
• Virus
• HIV is a retrovirus that attacks the immune system.
• Its genetic material, RNA, must be converted in to DNA during
replication.
• Over time, the immune system and the body loses its ability to
fight the virus.
 What is HIV?

Human Immunodeficiency Virus

• A virus spread through body fluids and affects specific cells of the
immune system, called CD4 cells or T cells.

• A virus that kills the CD4 cells (T cells) damaging the immune
system.

• A virus that replicates inside the human body, so it must invade a

healthy cell in the body to survive.
61
 HIV Transmission
• Blood • Comes into contact with:
• Semen • mucous membranes,
damaged tissue, or is
• Vaginal Secretions injected into the body
• Breast milk • Through:
• Vaginal, anal, or oral sex
• Contaminated needles
• IV drug use

03/12/2025 62
What Fluids Can Transmit HIV?

Blood
Rectal fluids
Semen
Vaginal fluids
Breast Milk

63
 How does HIV Enter
the Body?

Mouth Vagina
Nose Penis
Eyes Anus
Open Skin

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 HIV Transmission
• Perinatal transmission during pregnancy, labor and deliver, or
breastfeeding

• Occupational exposure via needle stick or exposure to eyes,

nose, or open wound

• Blood transfusion or organ donation from an HIV infected

donor
 HIV Transmission
• HIV is NOT transmitted by casual contact
• Working or playing with an HIV positive person
• Closed mouth kissing
• Shaking hands
• Public pools
• Hugging
• Public toilet
• HIV is not transmitted by air, food, or mosquito and does not
survive long outside the body.
 HIV Testing
Communicable Disease Control recommends routine HIV testing
for ALL patients:
• Aged 13-64

• Initiating TB treatment

• Seeking treatment for STI’s

• Who are pregnant

Repeat Screening Recommended

• Annually people at high risk

• Before beginning a new sexual relationship

• When clinically indicated

• After an occupational exposure

 HIV Testing
Benefits of routine opt-out HIV testing
• Reduces the stigma of testing
• Reduces transmission
• Majority of people aware of their HIV status reduce behaviors
that transmit infection
• Perinatal transmission can be prevented if mother’s HIV
status is known
• Improves patient outcomes (with early diagnosis of HIV)
 What is AIDS?

Positive HIV Test

+
Very low CD4 count
OR
presence of specific cancers or
opportunistic infections
=
AIDS

• AIDS occurs in the late stages of the HIV infection process.

• Once diagnosed, the body has a hard time fighting diseases and certain
cancers.
• NO cure for AIDS, but there is treatment.

03/12/2025 69
 AIDS
• AIDS is characterized by certain infections that take advantage
of the body’s weakened immune system.

• A diagnosis of AIDS is made when an HIV positive patient has a

CD4 count of less that 14% or the patient is diagnosed with an
AIDS defining condition

• Progression from initial infection with HIV to advanced HIV/AIDS

varies among people and can take several months to up to 10
years or more.
 Opportunistic Infections
Opportunistic infections are infections that take advantage of a weakened
immune system to cause more frequent or severe illness
• Prophylactic drugs may be given to prevent illness for some conditions
• Other clinical options include
 Effective ART

 Vaccination

 Avoiding exposure to certain pathogens

 Disease treatment

 Preventing disease recurrence (secondary prophylaxis or chronic maintenance

therapy)
Clinical Progression
 Antiretroviral Therapy
• Recommended for all HIV-positive people
• To prevent disease progression

• To prevent transmission of infections

• Strength of recommendation based on

• CD4 count

• Transmission risk
 HIV as a Chronic Disease
ARVs change HIV from a terminal (fatal) disease to a “chronic
disease”

Examples of chronic diseases:

• Diabetes

• High blood pressure

• Asthma

• Schizophrenia

74
 Goals of Treatment

• Improve quality of life

• Reduce HIV-related morbidity and mortality

• Restore and/or preserve immunologic function

• Maximally and durably suppress HIV viral load

• Prevent HIV transmission

03/12/2025 75
 How do ARVs control HIV?
• ARVs reduce the ability
of the HIV virus to HIV
replicate Replication

• In turn, this increases the

ability of the body to fight Immune
disease
Response
• Reduces the risk of HIV
03/12/2025 76
 What is an STI/STD?

An infection that can be transmitted through sexual contact

with an infected individual. They are sometimes called
sexually transmitted infections (STIs).
STDs can be transmitted many different ways, but most can be passed
by:

1. Vaginal sex
2. Anal sex
3. Oral sex
4. Skin-to-skin contact
5. Infected Mother to child

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 Are STDs Curable?
Treatment can improve the lives of
Antibiotics can cure bacterial many people living with viral
STDs, but cannot reverse the
long-term damage: STDs, but there is No cure.

• HIV
• Chlamydia
• Gonorrhea • Herpes

• Syphilis • HPV

• Trichomoniasis • Hepatitis B
* (parasitic protozoan)

03/12/2025 78
 Chlamydia
Most frequently reported STD
How is it Spread?
1. Vaginal, anal, or oral sex with someone who has chlamydia.
2. Infected pregnant women can pass it to their baby during
pregnancy or childbirth.

03/12/2025 79
 Chlamydia
Possible symptoms include:
 Abnormal vaginal/penile discharge
 Burning sensation when urinating
 Rectal pain, discharge, or bleeding
 Pain/swelling in one or both testicles (less common)
Can lead to:
 Sterility or infertility
 Infection of tube that carries sperm to/from the testicles (pain and/or fever)
 Pelvic Inflammatory Disease (PID)
o Long-term abdominal/pelvic pain
o Scar tissue formation in fallopian tubes
o Ectopic pregnancy
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 Gonorrhea
2nd most common disease reported
How is it Spread?
1.Vaginal, anal, or oral sex with someone who has
gonorrhea.
2.A pregnant woman can give the infection to her baby
during childbirth.

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 Gonorrhea Symptons

Possible symptoms include:

 Painful or burning sensation when urinating
 Abnormal vaginal/penile discharge (white, yellow, or green)
 Rectal discharge, itching, soreness, Vaginal bleeding between periods
 Painful or swollen testicles (less common)
Can lead to:
 Sterility or infertility
 Disseminated infection (rash, arthritis, fever, meningitis, etc.)
 Painful infection of tubes attached to the testicles
 Pelvic Inflammatory Disease (PID)
o Scar tissue formation in fallopian tubes
o Ectopic pregnancy
o Inability to get pregnant
o 03/12/2025
Long-term pelvic/abdominal pain 82
 Primary & Secondary Syphilis

How is Syphilis Spread?

• Direct contact with a syphilis sore (chancre) during vaginal, anal,

or oral sex.

• Can be spread from an infected mother to her unborn baby.

Primary Secondary Syphilis Tertiary/Late Syphilis

Syphilis

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 Primary Syphilis

Chancre - syphilis sore

• Firm, round, and painless

• Appears within 2-6 weeks after exposure usually but possibly up to 3

months
• Found on the part of the body exposed to the infection (penis, vagina, anus,
lips, in rectum, or in mouth)
• Typically disappear after a few weeks without treatment (still progresses to
next stage)
03/12/2025 84
 Secondary Syphilis
• Appears about 4 weeks after chancre heals.
• Will go away without treatment, but infection will progress.
• Condylomata lata (C. lata) or “fleshy warts” in anogenital region

non-itchy RASH with rough red or Alopecia or Mucous Patches usually in the mouth,
reddish brown spots patchy hair loss vagina, or anus

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 Late (Tertiary) Syphilis
Typically Occurs 10-30 years after infection begins!

 Can damage almost any part of the body including the heart, brain, spinal

cord, eyes and bones

• Can result in mental illness, blindness, deafness, heart disease and death

• Gumma: soft, gummy tumor

Types

• Cardiovascular Syphilis

• Late Benign Syphilis

• Neurosyphilis Syphilis
03/12/2025 86
• occurs sooner among HIV co-infected
 Congenital Syphilis
40% will be stillborn or die in the hospital.

Transmission can occur during any stage of syphilis and during any
trimester of pregnancy.

Can cause:

• Prematurity

• Birth defects

• Hutchinson’s teeth

• Osteochondritis

• Developmental
03/12/2025 delays 87
 Trichomoniasis

• Parasite passed during vaginal sex

• 70% of infected people have no signs/symptoms

Possible symptoms include:

Itching, burning, redness or soreness of the genitals

Burning with urination or ejaculation

Thin discharge: can be clear, white, yellowish, or greenish - Can

produce unusual or foul smell
Infection usually occurs:
Lower genital tract (vulva, vagina, penis or urethra)
03/12/2025 88
 Genital Herpes (HSV-1 and HSV-2)
• How is it Spread?

• Vaginal, oral, or anal sex OR skin-to-skin contact

• with someone who has the virus.

Symptoms:

One or more blisters on or around the genitals, rectum, or mouth.

Blisters break & leave painful sores that take weeks to heal.

Symptoms are sometimes called “Having an outbreak”.

Usually characterized by NO or very mild symptoms… No cure.

1 in03/12/2025
8 people aged 14-49 years old have genital herpes. 89
 Human Papillomavirus (HPV)
 Mainly transmitted through vaginal & anal sex, but can also
occur through oral sex and skin-to-skin contact.
• Most people with HPV do not know they are infected and
never develop symptoms or health problems.
• There is No treatment for HPV, but, there are treatments for
the health problems that HPV causes:
• Genital warts
• Cervical pre-cancer
• Other HPV-related cancers
03/12/2025 90
 Hepatitis “Inflammation
of the liver”
Hepatitis A Hepatitis B Hepatitis C

How is it Person ingests infected Blood, semen, or other Blood from a person
spread? fecal matter—even in body fluids from a person infected with the virus -
very small amounts— with the virus - even in even in very small
from contact with very small amounts - amounts - enters the
contaminated objects, enters the body of a non- body of a non-infected
food, drinks. infected person. person.
How long A few weeks to several Mild illness (a few Mild illness (a few
does it last? months. weeks) but Lifelong or weeks) but Lifelong.
chronic condition.

How serious Most recover from mild 15-20% develop chronic 75-85% develop chronic
is it? illness with no lasting liver disease including liver disease, 5-20%
liver damage, cirrhosis, liver failure, or develop cirrhosis and
but death can occur liver cancer. 1-5% will die.
(although rare).

03/12/2025 91
 External (Male) Condoms
More than 98% effective when used
correctly and consistently

Latex: Most common and effective

Non-Latex: Polyurethane, Polyisoprene
Natural Membrane: Lambskin (not protect against HIV and STIs)

03/12/2025 92
 Abortion

• Induced abortion or the deliberate termination of pregnancy is one of the

most controversial issues in legal discourse. As a legal issue, abortion is usually
discussed in light of the principles of criminal law.

• Induced abortion may be defined as the termination of pregnancy using drugs

or surgical intervention after implantation and before the conception has
become independently viable
Article 551 of the Penal Code Allows Termination
of Pregnancy Under the Following Conditions:
a. The pregnancy is a result of rape or incest

b. When the mother’s life is threatened by other serious disease

c. Where the birth of the child is a risk to the life or health of

the mother

d. The fetus has an incurable and serious deformity or severely

malformed

e. The pregnant woman is physically as well as mentally unfit to

bring up the child
EMA’s Medical Ethics for Doctors in Ethiopia XII: Abortion
Article 54: The first moral principle imposed upon the doctor is
respect for human life from its beginning.
Article 55: An abortion is justified only when it is performed for the
purpose of saving the endangered life or health of a woman.
Article 56: Abortion is justifiable if performed by a doctor in health
institutions where appropriate facilities are available.
Article 57: It is mandatory to treat a patient who is suffering from
the effect of an abortion induced by another person.
Article 58: The doctor must never disclose the cause of her/his
patient's condition to anyone else without the consent of the
patient unless ordered to do so in court of law.
Article 59: An abortion leading to death should be reported to the
concerned authorities by the treating doctor.
Ethiopian Medical Associations (EMA’s) Medical
Ethics for Doctors in Ethiopia XIII: Family Planning

Article 60: It is ethical for a doctor if she/he informs, educates

and communicates knowledge of family planning to
individuals, families or the general public.

Article 61: It is the duty of a doctor to prescribe scientifically

acceptable means and methods of family planning to individuals
or couples who have attained the age of 18 years and who freely
and responsibly decide to postpone or prevent pregnancy.
 The Ethiopian Law in Abortion

• Articles 14, 15, and 16 under Section I (Human Rights) of the

Constitution refer to the rights to life, liberty, and security of
the person.

• Article 35 refers to women’s equality with men and their

rights to information and the capacity to be protected
from the dangers of pregnancy and childbirth.
 Classification of Abortion
By occurrence

1. Spontaneous abortion

2. Induced abortion
Safe
Unsafe

3. Therapeutic abortion
 Classification of
Abortion
By clinical stages

A. Threatened Abortion

B. Inevitable Abortion

C. Incomplete Abortion

D. Complete Abortion

E. Missed Abortion
 Threatened abortion

• Vaginal bleeding

• Uterus is enlarged

• Cervix is closed

• Lower abdominal pain is either minimal or absent

• The fetus is alive & there is a chance of continuing the

pregnancy to viability.
 Inevitable abortion
• Vaginal bleeding of variable amount.

• Crampy lower abdominal pain.

• Cervix is open.

• No products of conception have been expelled.

• There is no chance of salvaging the pregnancy.

• gross rupture of membrane and evidenced by leaking amniotic

fluid
 Incomplete abortion
• Vaginal bleeding

• Cervix is open

• Expulsion part of the products of conception

Complete abortion

• Vaginal bleeding stops

• Pain will cease

• Cervix closes following expulsion of products of conception

 Missed abortion
• Retention of the fetus in utero after death.

• There is usually Hx of threatened abortion preceding it.

• Brownish discharge.

• Pregnancy symptoms like morning sickness, breast tenderness &

abdominal increment disappear.

• Cessation of fetal movement is reported by the mother if it

occurs after 18 wks.

• Failure of uterine growth small for GA uterus.

 Septic abortion
• Offensive vaginal discharge.

• Fever

• Lower abdominal pain/ tenderness

• Any of the clinical stages of abortion.

 Cont…

• Reading assignment on Diagnosis,

Treatment, procedure, & Management of
Abortion
 FAMILY PLANNING

03/12/2025 106
 Family Planning (F/P)

Family Planning: is use of various methods of fertility control at

individuals or couples

Why use family planning?

– Mothers and babies are healthier when risky pregnancies are

avoided.

– Smaller families mean more money and food for each child.

– Delaying first or second pregnancy lets young people stay in

03/12/2025 107
school.
 Cont…

F/P programs provide services people to achieve:

Reduce the number of unwanted pregnancies

Reduce the risk of STI/HIV by using condom

Improve the health of women and children by spacing birth

Individuals & couples have plan the timing, number, &

spacing of pregnancies, they desire way

03/12/2025 108
 Global population and fertility
 High fertility and rapid population growth has negative effect on:

• Standards of living & human welfare

• Economic productivity
• Natural resources
• Environment

• There fore it is important to decrease the population growth by

using family planning method.

03/12/2025
 cont’d

• Worldwide Fertility has fallen from about 6 in 1950 to around 3

in 1998 and 2.5 in 2011.

• Women in Africa have the highest number of children: on

average 5-7 children.

• Women in more developed countries have the fewest children,

with an average birth rate of 1.7.

• This low level of childbearing, combined with an older

population, accounts for population declines in many European
countries
03/12/2025
World Population, 1950-2050
10
Less Developed Countries
More Developed Countries
8

0
1950 1970 1990 2010 2030 2050

03/12/2025
 FP progress in Ethiopia

• Despite Ethiopia’s long history, there were no estimates of the

total population of Ethiopia prior to the 1900s.

• Available estimates indicate that the population increased

fourfold between 1900 and 1988.
In 1900 = 11.8 million and this
doubled to 23.6 million in 1960, sixty years later.

• Since then, there has been a steady increase in the population.

03/12/2025
Ethiopian Population 1900-2020
120

Millions 100

80

60

40

20

0
1900 1925 1940 1955 1960 1970 1980 1990 2000 2005 2010 2015 2020

03/12/2025
 Fertility Rate in Ethiopia
• With low use of family planning, fertility has
remained high.

03/12/2025
 Unmet need for family planning

• Proportion of women who

• Are not pregnant and not postpartum
• Amenorrhoeic and are considered fecund and want to
postpone their next birth for 2 or more years or stop
childbearing altogether but are not using a contraceptive
method, or
• Have a mistimed or unwanted current pregnancy, or
• Are postpartum Amenorrhoeic and their last birth in the last
2 years was mistimed or unwanted.
03/12/2025
 Coverage of Family planning in Ethiopia
• Overall, 41% of currently married women are using a method of family planning: 40% are

using a modern method, and 1% are using a traditional method.

• The most popular methods are injectables (27%), implants (9 %), IUD, and the pill (2 %
each).

• In SNNPR the contraceptive prevalence rate among currently married women is 45%.

• Among sexually active unmarried women, 58% are currently using a contraceptive method:

55 % are using a modern method and 3% are using a traditional method.

• The 22% of currently married women have an unmet need for family planning

• The 22% of currently married women have an unmet need for family planning services.

• Among unmarried sexually active women, 26 percent have an unmet need for family planning

03/12/2025
(EMDHS, 2019)
 Figure 1 Trends in contraceptive use
03/12/2025
 Contraceptive methods
Hormonal Emergency contraception (EC) or postcoital contraception
 Progestogen-only contraceptives 1. Copper-bearing IUDs (Cu-IUD) for EC
1. Progestogen-only pills (POPs) 2. Emergency contraceptive pills (ECPs)
2. Progestogen-only injectable contraceptives (POIs)
3. Progestogen-only implants
4. Progesterone-Releasing Vaginal Ring Intrauterine devices (IUDs)
1. Copper-bearing IUDs (Cu-IUD)
 Combined hormonal contraceptives 2. Levonorgestrel-releasing IUDs (LNG-IUD)
1. Combined oral contraceptives (COCs)
Permanent methods
2. Combined contraceptive patch
3. Combined contraceptive vaginal ring (CVR) 1. Female sterilization (tubal ligation)
4. Combined injectable contraceptives (CICs) 2. Male sterilization (vasectomy)
Barrier methods
1. Male and female condoms
2. Other barrier methods
Spermicides
Fertility awareness methods
1. Standard Days Method (SDM)
2. Others
Lactational amenorrhea method
03/12/2025
 Hormonal Contraception: Mechanisms
of Action
Suppress ovulation

Reduce sperm transport

in upper genital tract
(fallopian tubes)

Change endometrium
making implantation less
likely

Thicken cervical
mucus (preventing
sperm penetration)

03/12/2025
03/12/2025
 Classification contraception methods
Natural Contraception Methods

• Abstinence

• Coitus interrupts/withdrawal method

• Lactational Amenorrhoea Method (LAM)

• Rhythm or calendar method

03/12/2025 121
Modern Contraceptive Methods (Artificial methods)

–Hormonal Methods: Oral contraceptives (COC, POP),

Injectables (DMPA, Depo-Provera), Implants (Norplant)

–Non hormonal Methods (Barrier Methods): IUDs (Copper

380), Condom (male/female), Spermicides, Diaphragm,
Cervical Cap, Sponge), Surgical methods (vasectomy, tubal
ligation)

Emergency Contraception

(ECPs) –within 3 days & Copper-releasing IUDs-for 5days

03/12/2025 122
 Comparing family planning methods
Very effective but must be carefully
Most effective used
IUD Injectables
Implant Pills
Tubal ligation (ligating the Condom

oviduct)
Effective but must be
Vasectomy (ligating the sperm carefully used
duct) Calendar methods
Breastfeeding

03/12/2025 123
 Natural Methods
Breastfeeding (Lactational Amenorrhea Method)-LAM

– Breastfeeding in a way that prevents pregnancy

– Prevents release of egg

How to use:

– Breastfeed often, day and night & give no other food or liquids

– If you breastfeed less, your monthly bleeding (mense) starts,

& it is 6 months after you have had your baby, the method will not work

03/12/2025 124
 Abstinence
Compliance

0 % failure rate

Most effective way to prevent STD & HIV/AIDS

Withdrawal (Coitus interrupts):

– The man withdraws his penis from his partner's vagina and ejaculates outside the vagina

– Interfere with sexual satisfaction of both partners

– Can be used at any time

– Not as effective as other methods

03/12/2025 125
 Calendar methods or standard days method
How to use:
Shortest cycle 26 days:
Use calendar to count days of the
26-18=day 8 cycle
Longest cycle 30 days Start with first day of monthly
30-11= day19 bleeding
no sex from day 8 to day 19 Days 8 through 19 of every cycle
are 'fertile days‘
Avoid unprotected sex during
fertile days or use condoms for
12 days in a row, every month
This method doesn’t protect
from STIs or HIV/AIDS

03/12/2025 126
 IUD
– Small, flexible, plastic "T" wrapped in copper wire that is inserted into
uterus

– Prevents sperm from meeting the egg & speeds ovum transport

– Safe to use & the most effective methods

– Can be used for up to 12 years

– Can be removed any time if you already want to get pregnant

03/12/2025 127
 Cont…
A copper-bearing IUCD can interfere with fertilization
in two main ways:
The copper slows down the movement of sperm within
the woman’s uterus to prevent sperm from reaching the
fallopian tubes and fertilizing the egg.
The device can stimulate a strong reaction in the wall of
the uterus, which prevents implantation of the egg even
03/12/2025 if it is fertilized. 128
 IUD
– Specially trained provider inserts and removes IUD

– Local inflammatory response in uterine cavity- endotoxins are

releases that destroys sperm

Side Effects:
Increased bleeding (anemia)
Dysmenorrheal (pain during the menstrual cycle)
Pelvic infections
03/12/2025
Ectopic pregnancy 129
 IUD
Contraindications:
Multiple sexual partners (risk for STD’s)
Active, recent, or chronic pelvic infection
Postpartum endometritis or septic abortion
Pregnancy
Endometrial or cervical malignancy
Valvular heart disease
Immunosuppression
03/12/2025 130
 Norplant Implants

Long acting hormonal method & 6 silastic membrane

capsules filled with 35 mg progestin

Inserted upper arm & used for 3-5 years

Effective within 24 hours after insertion

Mode of action: suppress ovulation, thicken cervical

mucus, creates a thin atrophic endometrium, causes more
rapid tubal transport of ovum
03/12/2025 131
 Cont…

Side Effects
Menstrual irregularities

Absence of menstruation during the reproductive years (Amenorrhea) after a few months

Abdominal pain

Hair growth / hair loss

Contraindications:
Liver Disease

Pregnancy

Unexplained vaginal bleeding

Breast Ca
03/12/2025 132
Hx thrombophlebitis-swelling (inflammation) of a vein.
 Depo- Provera (DMPA)
Medroxyprogesterone Acetate & injectables progestin

Mode of action: prevents ovulation, thickens cervical mucus

Dose 150 mg single dose vial IM

Get an injection every 2 months (NET-EN) or 3 months (DMPA)

If breastfeeding, can start 6 weeks after childbirth

03/12/2025 133
 Cont…

Contraception begins immediately & last for 3 months

Instruct client to F/U for injection 2 weeks before 3 months

is up

Usually will not have period after 1 year of use

Side effects and contraindications same as Norplant

May be used during lactation

Women who plan to get pregnant within 6 – 9 months

03/12/2025
suggest another method 134
 Combine Oral Contraceptive pills

Safe & effective when a pill is taken one pill every day

Prevents release of egg, & blocks sperm from meeting egg

When you finish a pack of pills, start a new pack the next day
increased estrogen--Diminishes Hypothalamic effect on

GRHR--- inhibits the release of FSH / LH---no ovulation occurs

If you miss a pill:

Take missed pill as soon as possible, take 2 pills at the same time.
03/12/2025 135
 Cont…

If you miss pills in week 3, also skip the reminder pills and start a new pack.

If you miss more than 2 days of pills in a row, use condoms for 7 days and
keep taking pills.

Side effects:
ACHES – Should call health care provider immediately

A= Abdominal pain

C= Chest pain

H= Headache (severe)

E= Eye problems (blurring)

S= Severe
03/12/2025 leg pain (calf or thigh) 136
 Progestin only pills (Minipill)=oral birth control pills

If breastfeeding, can start 6 weeks after childbirth

Blocks sperm from reaching the egg

Take one pill at the same time every day

When you finish a pack of pills, start a new pack the next day

Late taking pill, for women who are breastfeeding:

Take a pill as soon as you remember, & continue taking pills

Late taking pill, for women who are not breastfeeding:

If you take a pill more than three hours late, use condoms for the
03/12/2025 137
  With mini-pills there are hormones in each pill, and there are no spacer pills,

• Mini-pills preferably at the same time each day. Forgetting a mini-pill, or taking it late,

increases the chance of pregnancy more than missing a COC pill,

• As soon as she finishes one pack the woman has to begin the next one, and start

her next pack even if she is still bleeding, or has not started her period.

03/12/2025 138
 Emergency Contraception-post pills

Prevents or delays release of egg

Can be taken immediately & up to 5 day

Taken 2 doses; 2nd dose taken 12 hrs first

Major SE – Nausea, vaginal bleeding for a few days

Call health care provider if severe – may prescribe antiemetics

Next period should begin within 2 – 3 weeks

Start immediately with an acceptable method of birth control

03/12/2025 139
03/12/2025
 Vasectomy
Men or couples who will not want more children

Specially trained provider makes two small cuts to reach the tubes
that carry sperm

Cut tubes, Testicles are not removed.

After the operation, the couple should use another method for 3
months, to ensure there are no sperms coming in the ejaculation
fluid

Now the sperm will not mix with the semen

Do not need to be put to sleep during procedure

03/12/2025 141
 Vasectomy
Q1. Is vasectomy the same thing as castration?

No, castration is done to animals, and involves

permanently damaging the testicles. Vasectomy does not
affect the testicles so the man functions like a man in the
same way as he has been

Q2. Does it make men impotent?

No, men remain with the same sexual desire and ability
to have sexual intercourse.
03/12/2025 142
 Female sterilization

Most effective methods & specially trained provider makes

one or two small cuts to reach the tubes that carry eggs to the
uterus

The womb is not removed & can be done right after you have
a baby as well as other times

After procedure, nothing to remember and no side-effects

Do not need to be put to sleep during procedure

03/12/2025 Monthly bleeding will continue as usual for you. 143

 Special situations
When to start other methods:

IUD: just after childbirth or wait 4 weeks after childbirth.

Female sterilization: wait 6 weeks after childbirth.

Minipills, injections, implants: 6 weeks after childbirth if

breastfeeding &

immediately after childbirth if not breastfeeding

Pills: 6 months after childbirth if breastfeeding & 6 weeks

03/12/2025
if not breastfeeding. 144
 Individual/couples choice FP based on:

Safe

effectiveness

Free of side effects

Easily available

Affordable

Acceptable to the user & sexual partner

03/12/2025 Free of effects on future pregnancies 145

 FP counseling: GATHER method
This method of counseling has 6 elements, or steps

G — Greet (Greet the client)

– Be polite, friendly and respectful: greet client, introduce yourself, and
offer a seat. Give her your full attention as soon as you meet her.

A — Ask (Ask the client about herself)

• Ask clients about their reasons for coming;

• ask for any info needed to complete their records.

03/12/2025 146
T — Tell (Tell the client about her choices)
 Cont…
H — Help (Help the client choose)
• Tell client that the choice is hers. Offer advice, but avoid making decisions for
her. After the client has made a choice, give supplies, if appropriate.

E — Explain (Explain what to do)

• After the client has made a choice, explain how to use the method and
demonstrate, where possible; if the method or services cannot be given now,
explain how, when and where they will be provided.

R — Return (Return for follow-up visit)

• Conduct
03/12/2025 follow-up visit and assess client satisfaction 147
Thank You