DAMBI DOLLO UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH SCIENCES

Department of Public Health
Public Health Ethics and Legal Medicine for public health students

By: Chimdesa Jabesa Goshu (BSc, MSc HN)

June 2021, Dambi Dollo

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Unit 1: Health Ethics
Objectives

At the end of the course students will be able to:-

Define Ethics and Morality
Identify Moral and Ethical issues
Describe fundamental principles of Ethics
Describe code of ethics for medical practice and public health services
Understand the principles of ethics for public health officers in Ethiopia
Know applied principles of professional conduct in their future relationships

1. Introduction
The word Ethics comes from Greek word ethos which means custom or culture.
Ethics is the philosophical study of the moral value of human conduct and the rules that govern
it. It is associated with specific groups in society that are considered to have societal
responsibility. Professions are among such groups who have a prestigious, powerful and
trusted place in society. Both the public and the law expect high standards of conduct from
professionals.

Throughout almost all of recorded history and in virtually every part of the world, being a
Health professional has been the most prestigious profession. People come to Health
professionals and they allow them to see, touch and manipulate every part of their bodies, even
the most intimate. They do this because they trust them to act in their best interests.

In order to meet the expectations of both patients and the society, it is important that
Health professionals know and exemplify the fundamental ethical principles. These ethical
principles are and always have been an essential component of Healthcare. Public health
activities are also covered by legal provisions at all levels of government in the Contemporary
societies.

Legal medicine applies principles and practices of different branches of medicine to

solve legal questions. Medical Ethics is principle applied in legal medicine to determine the

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legal responsibility of Health professionals. Public Health Ethics concerns the professionals,
individuals and the community at large.

Public Health Ethics focuses on the identification, analysis and resolution of ethical
problems arising in public health practice and research. Its mandate is to assure and protect the
health of the public-which is inherently moral one.

1.1 Public Health?

Public Health is the science and art of preventing disease, prolonging life, promoting
health efficiently through organized community efforts for the sanitation of the environment
and the control of community infections. (Winslow). The mission of public health is to fulfill
society interest in Assuring conditions in which people can be healthy. Its mission is achieved
through applications of health promotion and disease prevention technologies and interventions
designed to improve and enhance quality of life.

1.2 Ethics and Morality

The term “Morality” and “Ethics” are often used interchangeably but there is a subtle
difference between them. Ethics is a derivative or subset of morality or it has a narrower
connotations and application than morality.

Morality refers to moral norms about right and wrong that are stable and widely shared
in society. It is concerned with good/bad, right/wrong in human actions or behavior. Laws,
customs, ethos, taboos, civics, etc. are also derivatives or subsets of morality. Morality is
behaviors & beliefs about human decency, right or wrong, good or evil, proper or improper. It
is private or personal commitment to principles and values.

The word Ethics is derived from the Greek word „ethos‟, which means custom or
culture, a manner of acting or constant mode of behavior. It is the explicit, philosophical
reflection on moral beliefs and practices. It is a branch of philosophy that deals with
distinctions between right and wrong with the moral consequences of human actions. Ethics
refers to our inquiry or examination about what is good conduct and about our decision making
process when confronted with dilemmas about what is the right course of action. It provides us
with a moral map, a framework that we can use to find our way through difficult issues
 Ethics refers to the practices or beliefs of a certain group (i.e physicians‟ ethics,
nursing‟s ethics, health officers‟ ethics. It also refers to the expected standards as described in
their group‟s code of professional conduct. It is professionally and publicly stated which
teaches us how to judge accurately the moral goodness or badness of human action.

1.3 Types of Ethics

1. Descriptive: It is the description of the values and beliefs of various cultural,
religious or social groups about health and illness.
2. Normative: a study of human activities in a broad sense in an attempt to identify
human actions that are right or wrong and good and bad qualities. In public health
normative ethics addresses: scope of practice of different categories of public
health and, level of competence expected.
3. Analytical: analyzes the meaning of moral terms. It seeks the reasons why these action
or attitudes are either wrong or right.

1.4 Importance of ethics

It serves as a guide to conduct for members.
It provides standards of behavior for health workers.
It helps health professionals in identifying moral and ethical issues.
It helps to understand the application of ethical principles and rules in health care
delivery and biomedical research.
It uses to identify right and wrong things and know what should not be done for
and to clients.
It is important to know and respect the issue of human rights, personal and civil
society.

2. Historical development of Ethics

Since the beginning of human history, concern for medical ethics has been expressed in
the form of laws, decrees, assumptions and “oaths” prepared for or by physicians. Among the
oldest of these are the Code of Hammurabi in Babylonia (approximately 1750 BCE), Egyptian
papyri, Indian and Chinese writings, and early Greek writers, most notably Hippocrates (lived
between 460 and 377 BCE). Early medical ethical codes were written by individuals or by
small groups of people, usually physicians.

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 The Oath of Hippocrates is considered historically to be the first ethical code written in
an organized and logical way which describes the proper relationships between physician and
patient. Thomas Percival‟s writings, disseminated in 1803, represent the first ethical codes in
the United States and the Western world. Beginning in the second half of the nineteenth
century medical organizations began writing codes of medical ethics.

The ethics code of the American Medical Association (AMA)(1847)was the first ethical
code of a professional organization which outlined the rights of patients and caregivers. The
World Health Organization (WHO) issued the Declaration of Geneva in 1948. This is the first
worldwide medical ethical code and is modeled after the Oath of Hippocrates. One of the
major innovations of modern medical ethics involves the physician-patient relationship with
the dramatic change from paternalism to autonomy and its resultant requirement for informing
the patient, obtaining informed consent, and relating to the patient as an active partner in
decision-making.

3. Ethical Principles
Principles are basic ideas that are starting points for understanding and working through a
problem. Ethical principles presuppose that health officers should respect the value and
uniqueness of persons and consider others to be worthy of high regard. These principles are tents
that are important to uphold in all situations. There are four fundamental ethical principles are:-
Autonomy, Beneficence, Non-maleficence, justice

3.1. Autonomy
The word autonomy comes from two Greek words: “autos” (self) and “nomos” (rule);
meaning “self-rule” or “self-governance”. Autonomy is the promotion of independent choice,
self-determination and freedom of action. It implies to an individual who is master of himself or
herself which can act, make free choices and take decisions without the constraint of another.

The term autonomy suggests four basic elements. The autonomous person is respected,
must be able to determine personal goals, has the capacity to decide on a plan of action and he
has the freedom to act upon the choices. The application starts with the respect for a person‟s
right by providing them with adequate and relevant information. The application of this principle
is seen in the informed consent process.
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 Pre-conditions of autonomy are competence and liberty or freedom. Individual autonomy
may be diminished or completely absent as in the case of minor children, mentally handicapped
or incapacitated persons, prisoners, etc... Personal autonomy and freedom are ethically limited by
the autonomy and freedom of other persons; this is why in every society discussion, compromise,
legislation is crucial.

Competent adult patients have the right to consent or refuse treatment even if health care
providers do not agree with clients' decisions; their wishes must be respected. However, in most
instances patients are expected to be dependent upon the health care provider. Infants, young
children, mentally handicapped or incapacitated people, or comatose patient do not have the
capacity to participate in decision making about their health care.

Autonomy of patients is more discussed in terms of larger issues such as: informed consent,
paternalism, compliance and self-determination.

• Informed consent: is a process by which patients are informed of the possible outcomes,
alternative s and risks of treatments and are required to give their consent freely. It assures the
legal protection of a patient‟s right to personal autonomy in regard to specific treatments and
procedures.

• Paternalism: Restricting others autonomy to protect from perceived or anticipated harm or the
intentional limitation of another‟s autonomy justified by the needs of another. Thus, the
prevention of any evil or harm is greater than any potential evils caused by the interference of the
individual‟s autonomy or liberty. Paternalism is appropriate when the patient is judged to be
incompetent or to have diminished decision-making capacity.

•Non-compliance: Unwillingness of the patient to participate in health care activities or lack of

participation in a regimen that has been planned by the health care professionals to be carried out
by the patient. Noncompliance may result from two factors: When plans seem unreasonable to
the patient Patients may be unable to comply with plans for a variety of reasons including
resources, lack of knowledge, psychological and cultural factors that are not consistent with the
proposed plan of care

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3.2. Beneficence:
Beneficence is doing or promoting good and it is the basis for all health care providers. It
lays the groundwork for the trust that society places in the health profession and the trust that
individuals place in particular health care agencies. Public health aims at achieving good/benefits
(beneficence). The positive duty suggested by the principle of beneficence requires organizations
and managers to do all they can to aid patients “Act in the best interests of others”

The principle of beneficence has three components:

Promote good
Prevent harm
Remove evil or harm

3.3 Non-maleficence
Non-maleficence is the converse of beneficence. It means to avoid doing harm. When
working with clients, health care workers must not cause injury or suffering to clients. It is to
avoid causing deliberate harm, risk of harm and harm that occurs during the performance of
beneficial acts.

E.g: avoiding experimental research that has negative consequences on the client.

Non-maleficence also means avoiding harm as a consequence of good. In that case the
harm must be weighed against the expected benefit. Non-maleficence has been emphasized and
preserved in the medical slogan „Primum non nocere‟ which means “above all, first do no
harm!”

The principles of beneficence and non-maleficence translate into the duties to maximize benefits
while minimizing harms.

3.4. Justice
Justice is “fairness” or “entitlement”; it implies giving to each his/her due. It requires
that “equals be treated equally and un-equals unequally”. It implies that human beings as moral
equals should be treated equally unless there is a reasonable justification for treating them
differently. It ensure that health care is distributed in society in a way which is fair and equitable
 Justice is especially important in resource allocation. The principle of justice demands
fairness in the treatment of individuals and communities also the equitable distribution of the

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burdens and benefits of research. Has important implication for such issues like choice of study
population, recruitment of study subject, study and post-study benefits, etc…

E.g. justice would not permit using vulnerable groups as research participants for the exclusive
benefit of more privileged groups.

4. Ethical Theories
Ethical Theories may be compared to lenses that help us to view an ethical problem. They
allows us to bring different perspectives into our ethical discussions

There are Four Ethical Theories:

•Deontology •Teleology

•Intuitionism • Virtue Ethics

4.1 Deontology (Duty or Rule based theory)
The word „Deontology‟ comes from a Greek words „Deon‟ (duty) and „logos‟ (truth). The
theory proposes that the rightness or wrongness of an action depends on the nature of the act rather
than its consequences. It holds that you are acting rightly when you act according to duties and
rights. Therefore, it is not logically necessary to justify duties by showing that they are productive
of good. Only „What is right and Wrong?‟ is the moral question not „What is good and bad?‟

Disadvantage: It doesn't allow any flexibility for exceptions when duties conflict.

E.g. Killing punishment and Abortion are not right

4.2 Teleology (Utilitarian or End based theory)

The term „Teleology‟ derives from the Greek „teleo‟ (end) and „logos‟(truth). The question
of rightness or wrongness is answered in terms of the question of goodness. It tries to establish a
balance of good over bad consequences. It is focused on society versus individual.

This theory looks to the consequences of an action in judging whether that action is right or
wrong. Utilitarian hold that no action in itself is good or bad, the only factors that makes actions
good or bad are the outcomes or end results that are derived from them.

Types of Utilitarian Theories

I. Act utilitarianism suggests that people choose actions that will in any given
circumstances increase the overall-good.
II. Rule utilitarianism suggests that people choose rules that when followed consistently
will maximize the overall good

Disadvantage:-individual human rights can be sacrificed to attain a social goal and Predicting
and evaluating the consequences of actions is often very difficult.

4.3. Principlism
As its name implies, uses ethical principles as the basis for making moral decisions. it
applies these principles to particular cases or situations in order determine what is right thing to
do, taking into account both rules and consequences.
 Four principles in particular have been identified as the most important for ethical decision
making in medical practice. Principles do indeed play an important role in rational decision
making. However, the choice of those four principles, especially the prioritization of respect for
autonomy over the others, is difficult. Moreover, these four principles often clash in particular
situations and there is need for some criteria or process for resolving such conflicts.

4.4. Virtue ethics

Virtue ethics focuses less on decision-making and more on the character of decision-makers
as reflected in their behavior. It assumes ethical behavior follows from characteristics/traits that
people acquire. People will do the right thing because they have developed virtuous habits. As
noted above, virtues that are especially important for health professionals are compassion,
courage, generosity, commitment and responsibility. Protecting and enhancing client dignity are
also the other virtues.

None of these four approaches or others that have been proposed has been able to win
universal assent. Individuals differ among themselves in their preference for a rational approach
to ethical decision making. This can be explained partly by the fact that each approach has both
strengths and weakness. Perhaps a combination of all four approaches that includes the best
features of each is the best way to make ethical decisions rationally.

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5. Hippocratic principles of medicine and philosophy
Hippocrates was a Greek philosopher and physician who lived from460to377BC. He is
the “father of modern medicine”. His work included the Hippocratic Oath which described the
basic ethics of medical practice and laid down a moral code of conduct for doctors. His rational
medicine includes a parallel co-existence of both of Hippocratic (rational) and of asclepiad
(religious) medicine.

The name of Hippocrates is connected with the most creative period of scientific medicine
in ancient times. Hippocrates was concerned primarily with patient not only with disease of his
body organs, but also he treated his patient as psychosomatic (holistic) entity. Hippocratic
medicine was based on a right way of thinking (rationalism) and on whole humane approach to
the patient.

The relationship between Hippocrates and his patients was dictated by human and the
ethical principle “Benefit and do not harm the patient” rather than religious concepts.
Hippocrates considered the real knowledge, skills and professional competence as the
prerequisites of successful medical treatment.

In studying the works of Hippocrates no one can fail to remark his:-

Accuracy of clinical observation

Fundamental skills of recording patient history
Famous doctrine that pathology of an organ reflects the illness of the whole body.
High standards for all who wished to follow that he called “The art of medicine‟‟.

5.1 Hippocratic Ethics and Philosophy

The Father of Medicine; as Antiquity called Hippocrates has left rich medical and ethical
heritage for us. His heritage comprises not only general medical prescriptions, descriptions of
diseases, diagnoses, and dietary recommendations; but also his opinion on professional ethics of
a physician. The Hippocratic Oath (pledge), taken by ancient and medieval doctors, requires high
ethical standards from medical doctors. Its principles are important in professional and ethical
education of medical doctors even today.
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5.2 The classical Hippocratic Oath
“I swear by Apollo the Healer, by Aesculapius, by Health and all the powers of healing and to
call witness all the Gods and Goddesses that I may keep this oath and promise to the best of my
ability and judgment. I will pay the same respect to my master in the science as to my parents
and share my life with him and pay all my debts to him. I will regard his sons as my brothers and
teach them the science, if they desire to learn it, without fee or contract. I will hand on precepts,
lectures and all other learning to my sons, to those of my master and to those pupils duly
appointed and sworn and to none other.

I will use my power to help the sick to the best of my ability and judgment. I will abstain from
harming or wrong doing any man by it. I will not give a fatal draught to anyone if I am asked,
nor will I suggest any such thing. Neither will I give a woman means to procure an abortion. I
will be chaste and religious in my life and in my practice. I will not cut, even for the stone, but I
will leave such procedures to the practitioners of that craft.

Whenever I go into a house I will go to help the sick and never with the intention of doing harm
or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or
of men whether they be freemen or slaves. Whatever I see or hear, whether professionally or
privately which ought not to be divulged I will keep secret and tell no one. If therefore, I observe
this oath and do not violate it, may I prosper both in my life and in my profession, earning good
repute among all men for all time. If I transgress and foreswear this oath, may my lot be
otherwise.”

Professional codes of ethics

Profession

Profession is an occupation that regulates the activities of its members by requiring

specialized training, requiring some sort of certification, having professional organization,
having a code of ethics. All professions are occupations, but not all occupations are professions.
A profession is a calling that requires special knowledge and skilled preparation. A profession is
generally distinguished from other kinds of occupation by:

a). Its requirement of prolonged specialized training acquiring a body of knowledge pertinent to
the role to be performed and
b) . An orientation of the individual to ward service, ether to community or organization

6.1. Characteristics of a Profession

• Common body of knowledge
• Formal educational process
• Standards of entry
• Recognition of public responsibility
• Adoption of Codes of Conduct

Professional is a person who possesses specialized knowledge and skills which belongs to
and abides by the standards of a society and serves an important aspect of the public good. Four
qualities are attributed to professionals who are; competency, integrity, respect for person and
primary concern for service not prestige or profit.

Professionalism extends ethics to include the conduct, aims, and qualities that characterize
a professional or a profession. Professionalism relates to the behavior expected of one in a
learned profession. Professionalism embodies positive habits of conduct, judgment, and
perception on the part of both individual professionals and professional organizations.
Professionals and professional organizations give priority to the well-being and self-
determination of the patients they serve.

Professional Ethics relates to the behavior expected of one in a learned profession. It

embodies positive habits of conduct, judgment, and perception on the part of both individual
professionals and professional organizations. It includes the conduct, aims, and qualities that
characterize a professional or a profession

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6.2. Code of Ethics
A code of ethics for public health clarifies the distinctive elements of public health and the
ethical principles that follow or respond to those distinct aspects. It makes clear to populations
and communities the ideals of the public health institutions that serve them.

A code of ethics serves as a goal to guide public health institutions and practitioners and as
a standard to which they can be held accountable. It is formal statement of a group‟s ideas and
values that serve as a standards and guidelines for the groups‟ professional actions and informs
the public of its commitment. It can be “viewed as an ethical framework rather than a solution to
a problem.

Codes of ethics are moral standards that delineate a profession‟s values, goals and
obligations. They are usually higher than legal standards, and they can never be less than legal
standards of the profession. It is one of the hallmarks of a profession which provides a
framework of shared values within which public Health is practiced. The Code of Ethics is
grounded in fundamental ethical principles which are respect for person (autonomy), promotion
of social justice, active promotion of good, avoidance of harm.

6.3. Purposes of Professional code of ethics

Professional code of ethics has the following purposes:

To inform the public about the minimum standards of profession and to help
them understand professional conduct.
To provide a sign of the profession‟s commitments to the public it serves.
To outline the major ethical considerations of the profession.
To provide general guidelines for professional behavior.
To guide the profession in self- regulation.
To remind health care provider of the responsibility they assume when caring
for the sick.

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6.4. Professional Code of Ethics for Medical professionals
At the time of being admitted as a member of the medical profession:

I solemnly pledge to consecrate my life to the service of humanity;

I will give to my teachers the respect and gratitude that is their due;

I will practice my profession with conscience and dignity;

The health of my patient will be my first consideration;

I will respect the secrets that are confided in me, even after the patient has died;

I will maintain by all the means in my power, the honor and the noble traditions of the medical
profession;

My colleagues will be my sisters and brothers;

I will not permit considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, social standing or any other factor
to intervene between my duty and my patient;

I will maintain the utmost respect for human life;

I will not use my medical knowledge to violate human rights and civil liberties, even
under threat;

I make these promises solemnly, freely and upon my honor.

7. Principles of ethics in medical practice in Ethiopia

The need of ethics in medical practice is universal. Inherently it is respect for life, dignity
and rights of man. It is unrestricted by consideration of nationality, race, color, age, sex, politics
or social status.

The principles informs about:

• What should be the relation between physician and community?

• How the physician should act towards a patient?

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• In what condition the physician has the right to refuse to attend a patient?

Physician-patient and physician community relationship “30 articles”

Article 1: physician shall render service to the individual and the community with full respect
for life and the dignity of man.

Article 2: Physician shall give maximum possible care, devotion and consciousness to his
patient.

Article 3: Physician shall practice without discrimination.

Article 4: Physician shall help pt., the family and the whole community in the prevention of
disease.

Article 5: Physician shall cooperate with the public authorities in the prevention of disease.

Article 6: Physician shall use every opportunity to teach the pt. and his family the prevention
of disease and promotion of health.

Article 7: In case of emergency physician should extend all possible assistance to the pt.

Article 8: In the event of public danger, the Physician shall not abandon patients in his/her
immediate care until all appropriate measures have been taken to secure the safety of the
patients.

Article 9: The Physician shall do nothing wasteful or without justification for the health of
the individual or the community.

Article 10: The Physician shall be the defender of the child when he/she judges the health of
the child is not well protected.

Article 11: The Physician is obliged to consult colleagues when it is necessary to do so, and
shall inform the patient and his relatives about the consultations.

Article 12: The Physician has the right to refuse to attend a patient on reasonable
grounds except in emergency situations.

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Nevertheless, he/she shall ascertain that:

a. The patient will have adequate care

b. A colleague will replace him / her
c. All necessary information will be conveyed to the replacing colleague.

Article 13: The physician- patient relationship shall not be used as a means of
developing intimacy.

The Physician as a professional

Article 14: The physician at all times conduct himself in such a way that he may gain the
respect and the confidence of his/her fellow man and maintain the dignity of his/her
profession, and those conditions which are essential for the best practice of his/her profession.

Article 15: The responsibility of the physician shall be strictly personal.

Article 16: A physician shall at no time divest him/herself of his professional freedom.

Article 17: The physician shall endeavor to improve continuously his/her knowledge and
his skill and should make them available to his/her patients and colleagues.

Article 18: The physician shall use recognized scientific methods in his/her practice.

Article 19: The physician shall not administer unjustified treatment.

Medical secrecy

Article 20: The physician shall maintain his/her professional secrecy in respect for all matters
which have come to his/her knowledge in the course of his/her duties to the patients except in
those situations clearly stipulated by the law or when the patient gives written consent for the
release of information.

Article 21: In case of minors and unconscious patients or the patients of unsound mind, the
Physician may reveal his/her professional secret to the patient‟s relatives when such a revelation
would serve any useful purpose for the cure of the patient or when his/her condition otherwise so
requires.

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Article 22: The physician shall see to it that persons working with him/her respect
medical secrecy.

Article 23: the physician shall not disclose the identification of his/her patient in his/her
scientific publications or lectures unless there is a written consent of the patient.

Patient‟s informed consent

Article 24: It is the duty of the physician to inform the patient about the treatment (including
surgical procedures) the physician intends to carry out. He/she is always obliged to obtain the
written consent of the patient before carrying out procedures. In the case of minors or persons
who are unconscious or of unsound mind, the necessary consent should be obtained from parents
or legal guardians, if there is no other legal provision.

Article 25: On legitimate grounds, left to the discretion of the physician, information about
serious diagnosis and/or prognosis may be withheld unless the patient demands it. However, it is
desirable to inform the nearest r elative when the outcome is likely to be unfavorable.

Torture and punishment

Article 26: The physician shall not participate in the practice of torture or other cruel, in
human degrading procedures. The physician shall not provide premises, instruments, substances
or knowledge to facilitate the practice of torture.

Certificates, prescriptions and signatures

Article 27: Any document or certificate issued by the physician should bear his/her legible
name and signature.

Article 28: The issuance of a tendentious report or a false certificate is unethical.

Article 29: Upon request of the patient or legal authorities the physician shall issue certificates
based on his/her medical observation. Documents or testimonies should be issued when
authorized by courts of law.

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Article 30: The physician shall formulate his prescription with the necessary clarity. He/she
shall see to it that the patient or his family have well understood his/her prescription. He /she will
try their best to see that the treatment is carried out.

Undisclosed Gain

Article 31: It is unethical to accept any indirect gain based on a principle of dichotomy or
undisclosed division of professional fees for a medical act such as for prescriptions, appliance,
etc. with a medical partnership publicly known to exist.

Article 32: Complicity intended to get directly or indirectly any material benefit is forbidden
between physicians themselves, and between physicians and other health workers and between
physicians and any other person.

Article 33: The physician shall not allow a patient to obtain illegal or unjustified gains.

Advertisement and Publicity

Article 34: The physician in his/her practice shall avoid direct or indirect self- advertisement.

Article 35: The physician shall not use his/her mandate or administrative position in order
to promote his/her practice.

The physician and his/her professional colleagues

Article 36: The physician shall conduct himself/herself in a loyal, fraternal and courteous way
towards other members of his/her profession.

Article 37: A physician shall never in any way discredit the acts or words of a colleague except
where immoral words or acts directly harmful to the health of a patient or to the community are
involved, in which case he/she shall reveal his/her observation on to proper authorities. The
physician shall not tolerate than third parties disparage a colleague.

Article 38: Disputes between members of the medical profession must be resolved quickly and
amicably within the profession itself. If this fails the dispute shall be brought before the body
administering this code of medical ethics.

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Article 39: A consulted physician shall not take over the managing of the patient without the
knowledge of the regular attending physician.

Article 40: It shall be the duty and privileges of every physician to attend free of charge any sick
colleague or his dependents.

Supervisory role of the physician

Article 41: The physician shall not allow any medical student to take direct responsibility
of patient care.

Article 42: The physician shall closely supervise the intern in carrying out his duties
and responsibilities.

Mind and Behavior control

Article 1:

a) . The patient must be given necessary information even if complex, in order he reaches a
decision about whether to accept or refuse the recommended psychotropic drug.

b). In the case of the patient who is capable of comprehending the information given to him
about psychotropic drugs, the patients‟ right to refuse treatment must be respected.

c). When the patient is regarded as too disordered to arrive at informed judgment, the physician
can assume the duty to prescribe the medication he/she considers necessary for clinical needs,
but it should be properly documented.

Article 2: In case of social deviance, it is unethical to use psychotropic drugs as chemical

restraint as a form of social control as punitive measures in psychiatric hospital, prison practices
or elsewhere.

Article 3: In the treatments of addicts suffering from withdrawal symptoms, appropriate care and
support must be provided without discrimination.

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Article 4:

a). In the administration of Electro- convulsive Therapy (ECT), unless the patient is unable to
understand what is proposed, informed written consent is ethically required. However, the
patient may be withholding the consent at any time during the course of treatment.

b). When a patient is unable to understand what is proposed or when a patient refuses treatment
and Electro- convulsive Therapy is considered essential, consent must be obtained from the
relative.

c). With regard to the administration of ECT, senior psychiatrists must properly supervise it with
a continuing interest in treatment. The hospital must also meet internationally accepted ethical
and technical standards on ECT therapy.

Article 5: It is the duty of the physician to explain the mode and the program of
behavioral psychotherapy to the patient and the patient must give his consent.

Article 6: A version treatment may be used after full interdisciplinary discussion and
after obtaining written consent from the patient.

Article 7: Psychiatrists at times may find it necessary in order to protect the patient or the
community from imminent danger to reveal confidential information discussed by the
patient.

Abortion

Article 1: The first moral principle imposed upon the physician is respect for human life from
its beginning.

Article 2: An abortion is justifiable only when it is performed for the purpose of saving the
endangered life or health of a woman.

Article 3: Abortion is justifiable if performed by a physician in health institutions

where appropriate facilities are available.

Article 4: It is mandatory to treat a patient who is suffering from the effect of a criminal
abortion induced by another person.

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Article 5: The physician must never disclose the cause of his patients condition to anyone
else without the consent of the patient unless ordered to do so in court law.

Article 6: A criminal abortion leading to death should be reported to the concerned authorities
by the treating physician.

Family Health

Article 1: It is ethical for a physician if he/she informs, educates and communicates knowledge
of family planning to individuals, families or the general public.

Article 2: It is the duty of a physician to prescribe scientifically acceptable means and methods
of family planning to individuals or couples that have attained the age of 18 years and who freely
and responsibly decide to postpone or prevent pregnancy.

Artificial Insemination

Article 1: It is not unethical for a qualified and experienced physician to perform artificial
insemination.

Article 2: The physician should obtain a signed document from the wife and her husband setting
forth the desire of both parties.

Article 3: The name of the donor should not be disclosed to the husband or wife and the names
of the married couple should not be given to the donor.

Ethical problems in the management of severely Handicapped children

Article 1: It is unethical to withhold the means necessary for the survival of pregnancy.

Death

Article 1: It is part of the duty of the physician to issue a death certificate.

Article 2: The physician should summarily reject any suggestion to modify accuracy or to alter
truth when issuing a death certificate.

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Article 3: A physician should not sign a death certificate unless he has personally ascertained the
facts pertaining to the death.

Article 4: The protection of the confidential nature of the medical information contained in the
certificate must be ensured as much as possible.

Article 5: It is permissible to remove organs from the cadaver provided requirements for consent
have been fulfilled.

Article 6: It is not unethical to perform post-mortem examination with the consent of the
immediate relatives. In the absence of claimants this holds true when legitimate medical reasons
exist.

Euthanasia

Article 1: No physician can take life deliberately as an act of mercy even at the direct request
of the patient or the patient family.

Community Service

Article 1: The service of physicians also needs to focus on prevention of disease and promotion
of health.

8. Principles of ethics for Public Health Officers in Ethiopia

These principles are also intended to aid health officers individually and collectively in
maintaining a high level of ethical conduct.

They are not laws, but standards by which a health officer may determine the propriety of
his conduct in his relationship with:-

• Patients,
• Colleagues and physicians,
• Members of allied professions,
• Government authorities and the public.

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Section 1: The principal objective of the health profession is to render services to humanity with
full respect for dignity of the people. Health officers should merit the confidence of communities
and of individuals entrusted to their care, rendering always a full measure of service and
devotion.

Section 2: Health officers should strive continually to improve their knowledge and skill of
health, medicine and public health; they should strive to make available to their communities,
their patients, and their colleagues the benefits of their professional attainments.

Section 3: Health officer should practice a method of healing founded on a scientific basis and
he/she should not voluntarily associate professionally with anyone who violates these principles.

Section 4: The health professional should safeguard the public and itself against health hazards.
Health officer should observe all laws; uphold the dignity and honor of the profession. They
should expose, without hesitation, illegal or unethical conduct of fellow members of the
profession.

Section 5: The Health officers‟ primary responsibility is directed towards the comprehensive
health care „‟giving full emphasis to the prevention of disease, promotion of health, provision of
curative and rehabilitative services that will benefit individual, families and communities at
large‟‟.

Section 6: A Health officer should not voluntarily dispose of his/her services under terms or
conditions which would tend to interfere with or impair the exercise of his/her professional
judgment or skill or tend to cause a deterioration of the quality of his/her professional services.

Section 7: A Health officer should seek consultation in doubtful or difficult circumstances, or

whenever it appears that quality of his/her professional services may be enhanced thereby.

Section 8: A Health officer should refer difficult or serious cases to fully qualified physicians to
hospitals, or should seek professional consultation whenever it appears that the quality of
medical service may be enhanced thereby.

Section 9: A Health officer may not reveal the confidences entrusted to him/her in the course of
medical attendance or the deficiencies he/she may observe in the character of patients, unless

22
he/she is required to do so by law or unless it became necessary in order to protect the welfare of
the individual or community.

Undisclosed gain

Section 10: Complicity intended to get directly or indirectly any material benefit is forbidden
between health officer themselves and between health officer and other health workers and
health officer and any other person.

Advertisement and publicity

Section 11: The health officer in his/her practice shall avoid direct or indirect self
advertisement.

The health officer shall not use his/her mandate or administrative position in order to promote
his practice.

Section 12: The treasured ideals of his/her profession imply that the responsibilities of the
health officer extend to an active participation and interest in all activities of the community
which have the purpose or improving both the health and the well-being of the individual and the
community.

9. Public Health Code of Ethics in Ethiopia

Medical institutions have been more explicit about the ethical elements of their practice
than have public health institutions. However, the concerns of public health are not fully
consonant with those of medicine. Thus, we cannot simply translate the principles of medical
ethics to public health. In contrast to medicine, public health is concerned more with populations
than with individuals, and more with prevention than with cure. The need to articulate a distinct
ethic for public health has been noted by a number of public health professionals and ethicists.

A code of ethics for public health can clarify the distinctive elements of public health and
the ethical principles that follow from or respond to those elements. It can make clear to
populations and communities the ideals of the public health institutions that serve them, ideals
for which the institutions can be held accountable.

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This concise statement of 12 ethical principles is accompanied by a series of other documents,
including a preamble that explains the purpose of the code; a list of 11 values and beliefs
inherent to a public health perspective that underlie the ethical principles.

9.1. Public Health code of Ethics

1. Public health should address principally the fundamental causes of disease and
requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of
individuals in the community.
3. Public health policies, programs, and priorities should be developed and evaluated
through processes that ensure an opportunity for input from community members.
4. Public health should advocate for, or work for the empowerment of, disenfranchised
community members, ensuring that the basic resources and conditions necessary for
health are accessible to all people in the community.
5. Public health should seek the information needed to implement effective policies and
programs that protect and promote health.
6. Public health institutions should provide communities with the information they have that
is needed for decisions on policies or programs and should obtain the community's
consent for their implementation.
7. Public health institutions should act in a timely manner on the information they have
within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that
anticipate and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most
enhances the physical and social environment.
10. Public health institutions should protect the confidentiality of information that can bring
harm to an individual or community if made public. Exceptions must be justified on the
basis of the high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competence of their employees.
12. Public health institutions and their employees should engage in collaborations and
affiliations in ways that build the public's trust and the institution's effectiveness.

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 The code draws upon several ethical concepts. The more individualistic notion of human
rights appears in the second principle as a necessary point of tension with the communitarian
concern for the well-being of communities. Theories of distributive justice underlie the fourth
principle, which speaks of the need for basic resources and conditions necessary for health
among the disenfranchised.

One of the beliefs inherent to a public health perspective is that each person both
affects and depends upon others. This interdependence between humans underlies the most
fulfilling aspects of relationships and community as well as conflicts between people.
Interdependence is the complement to autonomy, a dominant principle in medical ethics.

The principle of interdependence between individuals lies behind the preeminence

given to the health of communities in the 2nd principle of the code. Interdependence between
institutions and the need for collaboration underlies the 12th principle, and the interdependence
inherent to ecological systems underlies the 9th principle, which addresses the physical and
social environments.

9.2. Values and Beliefs Underlying the Code

The following values and beliefs are key assumptions inherent to a public health perspective.
They underlie the 12 Principles of the Ethical Practice of Public Health.

Health

1. Humans have a right to the resources necessary for health. The Public Health Code of
Ethics affirms Article 25 of the Universal Declaration of Human Rights, which states in
part “Everyone has the right to a standard of living adequate for the health and well-being
of himself and his family…”

Community

2. Humans are inherently social and interdependent. Humans look to each other for
companionship in friendships, families, and community; and rely upon one another for

25
 safety and survival. Positive relationships among individuals and positive collaborations
among institutions are signs of a healthy community. The rightful concern for the
physical individuality of humans and one‟s right to make decisions for oneself must be
balanced against the fact that each person‟s actions affect other people.
3. The effectiveness of institutions depends heavily on the public‟s trust. Factors that
contribute to trust in an institution include the following actions on the part of the
institution: communication; truth telling; transparency (i.e., not concealing information);
accountability; reliability; and reciprocity. One critical form of reciprocity and
communication is listening to as well as speaking with the community.
4. Collaboration is a key element to public health. The public health infrastructure of a
society is composed of a wide variety of agencies and professional disciplines. To be
effective, they must work together well. Moreover, new collaborations will be needed to
rise to new public health challenges.
5. People and their physical environment are interdependent. People depend upon the
resources of their natural and constructed environments for life itself. A damaged or
unbalanced natural environment, and a constructed environment of poor design or in poor
condition, will have an adverse effect on the health of people. Conversely, people can
have a profound effect on their natural environment through consumption of resources
and generation of waste.
6. Each person in a community should have an opportunity to contribute to public discourse.
Contributions to discourse may occur through a direct or a representative system of
government. In the process of developing and evaluating policy, it is important to discern
whether all who would like to contribute to the discussion have an opportunity to do so,
even though expressing a concern does not mean that it will necessarily be addressed in
the final policy.
7. Identifying and promoting the fundamental requirements for health in a community are of
primary concern to public health. The way in which a society is structured is reflected in
the health of a community. The primary concern of public health is with these underlying
structural aspects. While some important public health programs are curative in nature,
the field as a whole must never lose sight of underlying causes and prevention. Because

26
 fundamental social structures affect many aspects of health, addressing the fundamental
causes rather than more proximal causes is more truly preventive.

Bases for Action

8. Knowledge is important and powerful. We are to seek to improve our understanding of
health and the means of protecting it through research and the accumulation of
knowledge. Once obtained, there is a moral obligation in some instances to share what is
known. For example, active and informed participation in policy-making processes
requires access to relevant information. In other instances, such as information provided
in confidence, there is an obligation to protect information.
9. Science is the basis for much of our public health knowledge. The scientific method
provides a relatively objective means of identifying the factors necessary for health in a
population, and for evaluating policies and programs to protect and promote health. The
full range of scientific tools, including both quantitative and qualitative methods, and
collaboration among the sciences is needed.
10. People are responsible to act on the basis of what they know. Knowledge is not morally
neutral and often demands action. Moreover, information is not to be gathered for idle
interest. Public health should seek to translate available information into timely action.
Often, the action required is research to fill in the gaps of what we don‟t know.
11. Action is not based on information alone. In many instances, action is required in the
absence of all the information one would like. In other instances, policies are demanded
by the fundamental value and dignity of each human being, even if implementing them is
not calculated to be optimally efficient or cost-beneficial. In both of these situations,
values inform the application of information or the action in the absence of information.

27
28
Unit Two: Ethical Issues in Medical Practice

Objectives

After the end of this unit the students will be able to understand about
will know about patient right and responsibilities
understand ethical issues regarding prenatal diagnosis and end of life decisions
gain understanding of ethical issues regarding patient, colleagues and community
Explain about fiduciary duty and malpractice insurance
Describe the ethical issues in Research
Will know applications of the general principles to research
Understand how to deal with Vulnerable Populations during a research

Introduction
This unit discusses about challenges which counter health professionals during health care
activities and doing researches and how to deal with these specific issues ethically. These topics
will inform health student about the guides to solve the problems in day to day activities.

1. Patient right and Responsibility

.1.1 Patient Right

Patient rights are formalized in 1948, the universal declaration of human rights
recognizes “the inherent dignity” and “equal and unalienable rights of the human family‟‟. It is
on this basic concept of the person, and the fundamental dignity of all human beings, that the
notion of patient right was developed.

Patient right are emanates from

• Human right • Constitutional right

• Civil right • Consumer

right

• Code of ethics of medical and nursing Profession

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 A patient is anyone, who has required to be or who is being evaluated by any health care
professional. Patient right are the basic rule of conduct between medical care givers include
hospitals, health care professionals and patients. patient right is general statement adopted by
most health professionals covering such matters as access to care, patient dignity, confidentiality
and content to treatment.

It is not possible to mention all lists of patient rights. However, we tried to mention some of it
(which is summarized in the table below.

• Dignity • Privacy

• Confidentiality • Informed
Consent

• Refusal of Drugs • Free from any Harassment

• Voice Complain • Reasonable Choice of Providers

• Access to Care • Spiritual and Personal Values

I. Dignity

Patient has the right to have dignity, as individual recognized and respected. They have a
right to the same consideration and respect as anyone else without discrimination based upon
race, color, age sex, beliefs, religions, lifestyle, etc..

II. Privacy

The patient has the right to privacy. They should expect that their discussion, examination
and treatment would be conducted in a private environment and that medical information be
maintained in accordance with accepted clinical records privacy and security guidelines.

III. Confidentiality

The patient has the right to confidential treatment of all communications and record
relating to them. Permission must be obtained from the patient before the provider gives
information to anyone not directly connected with the patient care. This requirement applies to

30
 parents, relatives and close friends. There are limited exceptions required by law such as on the
situations which threatens the patient‟s safety or the safety of other.

IV. Access

The patient has the right to have a reasonable access to information regarding diagnosis,
treatment and prognosis. The patient has the right to access to care and services; i.e. the health
care service need to be found to the patient local communities.

V. Informed consent

Except for emergencies all patients have the right to informed consent in treatment
decisions and timely access to care. Informed consent is consent or agreement by a patient to
surgical or medical procedure or participation in clinical study after achieving understanding of
the relevant medical facts and the risk involved. Before consenting to specific care choice, they
should receive complete and easily understood information about their confer and treatment
options.

VI. Refusal of drugs

A patient has the right to refusal of drugs, treatment or procedure offered by the hospital to
the extent permitted by law. A physician must or shall inform the patient about the medical
consequence of the patient‟s refusal of drug treatment, or procedures. The exception could be in
the case of children refusing intake of drugs because they do not know the usefulness of taking
drugs. In such case, we need to ask the parent of the children and give the treatment to the child.

VII. Voice complains

All patients have the right to voice complaining regarding his or her care on the health
service, to have those complaint reviewed when possible resolved.

VIII. Free from any harassment

All patients have the right to be free from mental, physical, sexual and verbal abuse, neglect
and harassment. All patients has the right to have his or her cultural, psychosocial, and personal
values, beliefs and precedence respected to the extent permitted by law.

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IX. Reasonable choice of providers

All patients have the right to a reasonable choice of provided and useful information about
provider option. This means that any health care provider do not persuade patient to come to
their services. Thus patient have the right to choose among the services found in the community.

1.1.2 Patient responsibility

Patient responsibility is patient‟s duty or obligation to perform for best treatment or to
live healthy life. Responsibilities of the patients are:-

• Provide illness history • Avoid intake of drugs

• Take recessing preventive • Pursue healthy life

measure

• Have to be punctual • avoid putting other at

risk

• Respectful for providers • report wrong doing

• follow the doctor‟s instruction • need to make the payment for

treatment

I. Provide illness history

Patients must provide information about present and past illness and those medications and
other matters related to his illness; because it may affect the present situation of the patient
directly or in directly. This is necessary for best treatment of the patient and to protect itself from
overdose and unnecessary drug effects.

II. Avoid intake of drugs not prescribed by a doctor

All patients must avoid intake of drugs which have not been administered by their doctors.
The reason is that the intake of unprescribed drugs results in drug abuse or the drug may result in
adverse effects such as damage of liver; thus the patient need to protect itself from unprescribed
drugs which have effect in the body.
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 III. Take necessary preventive measure

Patients need to take necessary preventive measures in case of infectious disease as per
doctor‟s instructions. This is to mean that patient once educated about the disease transmission
need to protect himself from exposure to the disease again and prevent himself from acquiring
the disease.

IV. Pursue healthy life style

They should pursue lifestyles known to positive health status such as proper diet and
nutrition, adequate rest, and regular exercise. Simultaneously they should avoid behaviors known
to be detrimental to one‟s health such as smoking, excess alcohol consumption and drug abuse.

V. Have to be punctual

Patients have to be punctual to attend the clinics or hospital for treatment at a given time
by respecting the appointment. They should arrive as scheduled for appointment.

VI. Avoid putting other at risk

It is the responsibility of a patient not to intentionally transmit his disease to other healthy
person. For example: A patient with HIVAIDS shouldn‟t transmit the disease intentionally or
deliberately to other healthy patient through making unprotected sex such as making sex without
using condom.

VII. Respect full for provides

Just as it is a patient right to expect respect; it is also the patient‟s responsibility to show
respect in return.

VIII. Report wrong doing

As it is the patient right to report or complain wrongdoing; through using their rights they
have a responsibility to report wrong doing happen in their care in the hospital.

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IX. Follow the doctor instructions

Patients also have a responsibility to follow the doctor‟s instruction diligently. Patient must
help their doctors and health care staff in their effort to care for them by following their
instructions and medical record.

X. Need to make payment for treatment

Patients need to make payments for the treatment taken for drugs taken; but doesn‟t mean
always. This patient responsibility sometimes may not be used that is during condition, when the
patient doesn‟t have money and his condition is severe.

1.2. Prenatal Diagnosis

Prenatal diagnosis is the process of ruling in or out fetal anomalies or genetic disorders, to
provide expecting parents with information and the opportunity to modify pregnancy
management and/or postnatal care.

Researchers are gaining knowledge about the genetic basis of heritable disorders, allowing
medical professionals to be increasingly equipped to diagnose such disorders in utero, although
some genetic disorders are compatible with long healthy lifespan; many are associated with
significant morbidity, mortality and mental retardation.

Expectant parents have many options available for prenatal screening and testing for
genetic disease. By identifying genetic disorders in utero, parents and professionals cane make
decisions regarding pregnancy maintenance and management.

Yet prenatal diagnosis opens the door to a whole new era of medicine, where the ability to
diagnose genetic disease often precedes the ability to treat or cure. Ethical principles are
intertwined with prenatal genetic testing; those seeking and providing it often face controversial
decisions and ethical dilemmas.

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1.2.1 Indications for prenatal diagnosis
1. Advanced maternal age

As a woman‟s age increases, so does the risk for chromosome abnormalities in the
fetus. After prenatal diagnosis; information about the natural history and prognosis of the
chromosomal disorder must be given. Concerns about raising a child with special needs and
the possible option of termination should be explored in a supportive, sensitive manner.
Regardless of the decision to continue or terminate pregnancy, parents should be reassured
that the recurrence risk of chromosomal disorder is not increased following the birth of an
affected child.

2. Multiple miscarriage and for fetal losses

Causes for multiple miscarriages (>3) can be chromosomal, anatomical, immunological, or

hormonal; so couples who have had three or more miscarriages may be interested in fetal
chromosome analysis or CVS

3. Known or suspected family history of genetic disease or multifactorial disorder

4. Teratogenes, maternal disease, infections( toxoplasmosis) and exposure to internal or
external substances
5. Abnormal material serum screen results

1.2.2. Methods of prenatal diagnosis

2. Chorionic Villus Sampling (CVS)
3. Amniocentesis
4. Percutaneous umbilical blood sampling
5. Abnormal ultrasound findings

1.2.3 Ethical issues regarding prenatal diagnosis

Before screening or testing pregnancies for underlying genetic disorders, it is
important to consider the ethics of a given situation. Genetic diagnosis may affect decisions
about maintaining or ending a pregnancy, place stress upon the family, and/or provide
information that may only be pertinent years into the future.

In some situations specially on extremely religious societies in which parents would

not alter their decisions to maintain or voluntarily terminate pregnancy and if treatment is not

35
 available for the given disorder; prenatal diagnosis may be of little, no or questionable
benefit.

Medical professionals should be aware that it may not be necessary, or ethical, to

diagnose prenatally adult-onset conditions. It is important to explore ethical issues in depth
before physically invasive tests are performed.

In Article 551 of the penal code of the Federal Democratic Republic of Ethiopia allows
termination of pregnancy under the following conditions.

“Termination of pregnancy by a recognized medical institution with in the period

permitted by the profession is not punishable where: the fetus has an incurable or serious
deformity and the continuation of the pregnancy endangers the health and the life of the
mother or the child or where the birth of the child is a risk to the life or health of the
mother.”

1.3. End of life Decision

Modern medicine is highly specialized, and technological interventions are commonplace,
allowing people with chronic illnesses to live longer lives. Advances in medicine have greatly
improved possibilities to treat seriously ill patients and to prolong life. However, there is
increasing recognition that extension of life might not always be an appropriate goal of medicine
and other goals have to guide medical decision-making at the end of life, such as improvement of
quality of life of patients and their families by prevention and relief of suffering.

Until the 1940‟s, medical care was often just comfort care, alleviating pain when possible.
During the last 50+ years, medicine has become increasingly capable of postponing death. In
some cases, hastening of death can be an accepted or by some people appreciated result of end-of
life care. As illnesses progress and the burdens of life maintaining interventions increase,
patients often exercise their autonomy by refusing continued treatment or requesting that current
therapy be withdrawn.

End-of-life care decisions are challenging, because emotions and ethics are attached to
actions that can lead to the hastening or perceived hastening of death. There are fairly universal
legal and ethical prohibitions for certain actions, such as active euthanasia, which is the direct

36
killing of a person. However, other actions, such as physician-assisted suicide, are now legal in
Oregon in the state of U.S.

What makes end-of-life decision making even more challenging for the provider, especially
during discussions with patients and surrogates, is that the end-of-life terminology that is often
used, (such as allowing to die, euthanasia, assisted suicide, physician-assisted death, etc.) can
have different meanings to different people. Medical decision-making for patients with life
threatening diseases increasingly entails a balanced consideration of medical, ethical,
psychosocial, and societal aspects.

The historical definition of death is cessation of blood circulation and vital functions such
as respiration and pulsation proved inadequate as technology advanced. Medical end-of-life
decisions include whether to withhold or withdraw potentially life-prolonging treatment.

E.g. Mechanical ventilation, tube feeding, dialysis; and antibiotic treatments

Withholding and Withdrawing Medical Treatment

When seriously injured or ill and approaching death, medical interventions may save or
prolong the life of a patient. But patients and loved ones often face decisions about when and if
these treatments should be used or if they should be withdrawn. Most people die in hospitals and
long term care facilities, and a majority of deaths in these settings involve withholding or
withdrawing the medical treatments. Therefore, this issue will likely affect many people as they
make decisions for themselves, a family member, or a loved one.

1.3.1. The ethical decisions regarding medical care at End of life

i. Resuscitation

Resuscitation treatments and technologies restore and maintain breathing and heart
Function. Cardiopulmonary resuscitation (CPR) doubles a person‟s chance of survival from
sudden cardiac arrest, which is the leading cause of death in adults. However, while CPR is
valuable for treating heart attacks and trauma, using CPR with some dying patients may be
inappropriate and cause complications for some terminally ill. However, the universal use of
CPR makes it difficult for health professionals to not use CPR with dying patients.

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 ii. Mechanical ventilation

Mechanical ventilation uses a machine to inflate and empty a patient‟s lungs allowing
oxygenation of the blood. Mechanical ventilation is delivered through tubes inserted through the
nose or mouth into the trachea, or through non-invasive ventilation (NIV) where air is delivered
with a mask.

Ventilation may help them sleep better, experience less anxiety, and eat and drink more
comfortably. Some care providers may regard mechanical ventilation as “death delaying” rather
than “life-prolonging.” Some patients become dependent on the ventilator or die while being
treated. Therefore, for some patients ventilation is considered a non-beneficial treatment that
negatively affects patients by delaying natural death or requiring families and physicians to
decide to withdraw treatment.

iii. Nutrition and Hydration

Enteral nutrition with feeding tubes: Delivers nutrients directly into a patient‟s stomach or
intestines with a feeding tube. Parenteral nutrition: Delivers nutrients directly into the
bloodstream. Decisions about nutrition and hydration are among the most emotionally and
ethically challenging issues in end of life care.

The main dilemma concerns the nature and social meaning attached to providing people
with food and water. Nutrition and hydration treatments may burden (or provide only minimal
benefit to) some dying patients. The idea that a treatment should provide the patient with some
benefit that is sufficient to outweigh the burdens has been called the principle of proportionality.
Thus, if a dying patient receiving nutrition and hydration suffers burdens that outweigh the
benefit of extended life; artificial nutrition and hydration may be ethically withheld or withdrawn
whether or not the patient will die as a result of this action.

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 iv. Kidney Dialysis

Kidney dialysis filters waste from the blood in patients whose kidneys no longer function.
Without dialysis, waste products would reach a toxic level in the body and result in death.
Dialysis is a time consuming and physical burden for patients with end stage renal disease. Some
patients may eventually decide that this burden outweighs the benefits and then wish to
discontinue this treatment.

Today, discontinuing dialysis is considered an appropriate treatment option that respects a

patient‟s autonomy and ability for self-direction. Withdrawal should occur when patients are
either: capable of making decisions and decide to forgo dialysis or a written health care directive
expresses a desire to discontinue dialysis and a health care agent considers discontinuation of
dialysis the best course of action or when the physician decides dialysis no longer beneficial.
Shared decision making between the patient and physician must occur, and if the patient lacks
decision-making capacity, the health care agent should be involved. Physicians should provide
patients with all available information –including available treatment options, consequences of
dialysis withdrawal, and other end of life care options like hospice and palliative care.

v. Antibiotic Treatments

For many patients with life-threatening diseases, infection will affect their final days, and
antibiotics may be given as a result. Anywhere between 32% and 88% of terminally ill patients
receive antibiotics. Antibiotic treatments may not cure an underlying cause of illness, but rather
alleviate symptoms. Some believe that antibiotics are part of routine care and should not be
denied to patients simply because they have a life-threatening condition.

One ethical concern raised by public health professionals is that excessive use of antibiotics can
contribute to bacteria that mutate and become resistant to treatments

1. Public health professionals express concern that over-prescribing antibiotics may result in
resistant bacteria that could be more harmful to future patients; Particularly in light of evidence
that antibiotics may not be effective for treating infection in terminally ill patients.

2.Whether to alleviate pain or other symptoms with, for example, opioids, benzodiazepines, or
barbiturates in doses large enough to hasten death as a possible or certain side effect; and

39
 3. Whether to consider euthanasia or doctor assisted suicide, which can be defined as the
administration, prescription, or supply of drugs to end life at the patient‟s explicit request.

1.3.2 Euthanasia
The word “euthanasia” comes from the Greek words for death (thanatos) and “good” or
“well” (eu-). Euthanasia means “a good death,” “dying well.” Good death means death which
is Peaceful, Painless, lucid and with loved ones gathered around..

Types of euthanasia

There are 4 types of euthanasia

Active euthanasia
Passive euthanasia
Voluntary euthanasia
Involuntary euthanasia
1. Active euthanasia occurs in those instances in which someone takes active means, such as
a lethal injection, to bring about someone‟s death. Active means that there are positive
steps to bring about death, an action that could be called killing.
2. Passive euthanasia occurs in those instances in which someone simply refuses to intervene
in order to prevent someone‟s death. Passive means that nothing is done to hasten death
the natural course of the disease causes death. All types of euthanasia include comfort care
and pain control.

In case for active euthanasia; there is no doubt that the patient will die soon. The
option of passive euthanasia causes significantly more pain for the patient (and often the
family as well) than active euthanasia and does nothing to enhance the remaining life of
the patient, and passive measures will not bring about the death of the patient.

3. Voluntary Euthanasia means that the person has freely consented. The patient chooses to
be put to death
4. Involuntary Euthanasia means that the person either has not freely consented or cannot
freely consent but is presumed to want to die. The patient is unable to make a choice at
all and the patient chooses not to be put to death, but is anyway

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1.3.3 Physician-assisted suicide
Many patients who want to die are unable to do so without assistance. Someone provides
an individual with the information, guidance, and means to take his or her own life with the
intention that they will be used for this purpose.

Physician assisted suicide occurs when a physician provides the means, medical advice
and assurance that death results. When it is a doctor who helps another person to kill themselves
it is called "physician assisted suicide." but it is different from euthanasia.

One way to distinguish them is to look at the last act –the act without which death would
not occur. If the person who dies performs the last act, assisted suicide has taken place. Thus it
would be assisted suicide if a person swallows an overdose of drugs that has been provided by a
doctor for the purpose of causing death.

Using this distinction, if a third party performs the last act that intentionally causes a
patient‟s death, euthanasia has occurred. For example, giving a patient a lethal injection or
putting a plastic bag over her head to suffocate her would be considered euthanasia.

1.3.4 Ethical Issues Surrounding Euthanasia

A range of different ethical and moral positions and arguments exist regarding active euthanasia:
1. Terminating life at the request of an individual is not immoral because it is the individual‟s
decision to make.
2. Terminating life may be justified in some circumstances if, and only if, there is compelling
evidence that to continue living would be more harmful to the person than dying.
3. Terminating life is unethical in today‟s society because there are not enough protections that
would allow for a just and fair practice of euthanasia.
4. Terminating life is always unethical because it violates the moral belief that life should
never be taken intentionally or the basic human right not to be killed.

1.3.5 Legal issues in Ethiopia

All forms of euthanasia are illegal except in states where right to die status and living will exist.

Article 1 of principle of medical practice says that “No physician can take life deliberately as
an act of mercy even at the direct request of the patient or the patient family.”

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1.4. Ethical Issues Regarding Patient and community

1.4.1 Ethical Issues Regarding Patient

The physician-patient relationship is the cornerstone of medical practice and medical
ethics. The Declaration of Geneva requires of the physician that “The health of my patient will
be my first consideration” and The International Code of Medical Ethics states, “A physician
shall owe his/her patients complete loyalty and all the scientific resources available to him/her.”

The relationships focus on four points which poses difficulty in physician daily activities
which are respect and equal treatment, Informed consent, decision-making for incompetent
patients, confidentiality

I. Respect and Equal Treatment

The belief that all human beings deserve respect and equal treatment is relatively recent.
Discrimination on the basis of age, disability or sexual orientation is widespread. In the 20th
century there was considerable elaboration of the concept of human equality in terms of human
rights.

One of the first acts of the newly established United Nations was to develop the
Universal Declaration of Human Rights (1948), which states in article 1, “All human beings are
born free and equal in dignity and rights.” Declaration of Geneva says that „‟health professionals
should not permit considerations of age, disease or disability, creed, ethnic region, gender,
nationality, political affiliation, race, sexual orientation, social standing or any other factor to
intervene between their duty and their patient.‟‟

II. Informed consent

Informed consent is one of the central concepts of present-day medical ethics. When
paternalism was normal before, communication was relatively simple; it consisted of the
physician‟s orders to the patient to comply with such and such a treatment. Nowadays
communication requires that the Health professionals should provide patients with all the
information they need to make their decisions.

Informed consent is a process by which patients are informed of the possible outcomes,
alternatives and risks of treatments and are required to give their consent freely. If the health

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professional has successfully communicated to the patient all the information the patient needs
and wants to know about his or her diagnosis, prognosis, and treatment options, the patient will
then be in a position to make an informed decision about how to proceed.

Evidence of consent can be explicit or implicit. Explicit consent is given orally by

affirming clearly or in writing by signing documentary evidence that he agrees to proposed
treatment. In Implicit (implied), the patient indicates a willingness to undergo a certain procedure
or treatment by his or her behavior. Consent for vein puncture is implied by the action of
presenting one‟s arm.

For treatments that entail risk or involve more than mild discomfort, it is preferable to
obtain explicit rather than implied consent. In written consent the forms should be legible,
unambiguous, unabbreviated, signed and understood by the patient, signed and understood by the
health professional.

XI. Decision-making for incompetent patients

Many patients are not competent to make decisions for them-selves. Examples include
Young children, individuals affected by certain psychiatric or neurological conditions, and those
who are temporarily unconscious or comatose. These patients require substitute decision makers;
if a legally entitled representative is not available, but a medical intervention is urgently needed,
consent of the patient may be presumed.

In cases of serious disagreement between the substitute decision maker and the physician,
the declaration on the rights of the patient offers the following device: „‟ If the patient is legally
entitled representative, or a person authorized by the patient, in the patient‟s best interest, the
physician should challenge this decision in the relevant legal or other institution.‟‟

Patients suffering from psychiatric or neurological disorders who are judged to pose a
danger to themselves or to others may have to be confined and/or treated against their will in
order to prevent harm to themselves or others.

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X. Confidentiality

The physician‟s duty to keep patient information confidential has been a cornerstone of
medical ethics since the time of Hippocrates. Confidentiality is important because human beings
deserve respect. One important way of showing them respect is by preserving their privacy.

The Declaration on the rights of the patient entails that 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. Confidential
information can only be disclosed if the patient gives explicit consent or if expressly provided for
in the law.

1.4.2 Ethical Issues regarding community

Medical professionalism involves not just the relationship between health professionals
and patient, it also involves a relationship with society. This relationship can be characterized as
a „social contract‟ whereby society grants the profession privileges. These privileges include
exclusive or primary responsibility for the provision of certain services , a high degree of self-
regulation, and in return, the profession agrees to use these privileges primarily for the benefit of
others and only secondarily for its own benefit.

Health professionals mainly of public health have a significant role in health education,
environmental protection, laws affecting the health or well-being of the community, and
testimony at judicial proceedings. Public health professionals are called upon to play a major role
in the allocation of society‟s scarce healthcare resources. They also have a duty to prevent
patients from accessing services to which they are not entitled. Implementing these
responsibilities can raise ethical conflicts, especially when the interests of society seem to
conflict with those of individual patients.

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Resource allocation

In every country in the world, including the richest ones, there is an already wide and steadily
increasing gap between the needs and desires for healthcare services and the availability of
resources to provide these services. The existence of this gap requires that the existing resources
be rationed in some manner. Resource allocation takes place at three levels:

a) At the highest („macro‟) level; the Government decides how much of the overall
budget should be allocated to health; which health care expenses will be provided at no
charge and which will require payment, how much will go to remuneration for health
staffs, to operating expenses and so on.
b) At the institutional („meso‟) level; which includes hospitals, health centers, etc.,
authorities decide how to allocate their resources: which services to provide; how much
to spend on staff, equipment, renovation, expansion, etc...
c) At the individual patient („micro‟) level; healthcare providers, especially physicians
and health officers, decide what tests should be ordered, whether the patient should be
hospitalized, which drug is required rather than the other.

The choices that are made at each level have a major ethical component, since they are
based on values and have significant consequences for the health and well-being of individuals
and communities. Declaration on the Rights of the Patient states: “In circumstances where a
choice must be made between potential patients for a particular treatment that is in limited
supply, all patients are entitled to a fair selection procedure for that treatment.‟‟ That choice
must be based on medical criteria and made without discrimination. One way that; health
professionals can exercise their responsibility for the allocation of resources is by avoiding
wasteful and inefficient practices. E.g. antibiotic treatments

In dealing with these allocation issues, health professionals must not only balance the
principles of compassion and justice. They should also decide which approach to justice is
preferable.

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There are several such approaches, including the following:

A. Libertarian –resources should be distributed according to market principles (individual

choice conditioned by ability and willingness to pay).
B. Utilitarian –resources should be distributed according to the principle of maximum
benefit for all.
C. Egalitarian –resources should be distributed strictly according to need.
D. Restorative –resources should be distributed so as to favors the
historically disadvantaged.

Many Health planners promote utilitarianism. The choice between these approaches will
depend on the health professional‟s own personal morality as well as the socio-political
environment in which he or she practices. Despite their differences, two or more of these
concepts of justice often coexist in national health systems. In addition to applying these
approaches, health professionals also have a responsibility to advocate for expansion of these
resources where they are insufficient to meet patient needs.

1.5. Ethical issues regarding colleagues and organization

Medicine is a complex profession; a single person can‟t be an expert in all the needs of
the patient. So it needs various types of skilled health professionals, such as physicians, health
officers, pharmacists, nurses…work together in a cooperative way.

The Declaration of Geneva includes the pledge, “My colleagues will be my sisters and
brothers.” So this pledge indicates what the relationship between the health professionals should
be. It informs that you should give respect and appreciate skill and experience of your colleagues
in so far as these can contribute to the care of patients. Medicine is at the same time a highly
individualistic and a highly cooperative profession. The WMA Declaration on the Rights of the
Patient, “The physician has an obligation to cooperate in the coordination of medically indicated
care with other healthcare providers treating the patient.”

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Conflict Resolution

Disagreements among healthcare providers about the goals of care and treatment or the
means of achieving those goals should be clarified and resolved by the members of the
healthcare team. Disagreements between healthcare providers and administrators with regard to
the allocation of resources should be resolved within the facility or agency and not be debated in
the presence of the patient. The Ethiopian principle of medical practice also has 5 articles
towards the relationship between physician and his professional colleagues. These are:

Article 36: The physician shall conduct himself in a loyal, fraternal and courteous way towards
other members of his profession.

Article 37: A physician shall never in any way discredit the acts or words of a colleague.

Exceptional is:-if immoral words or acts directly harmful to the health of the patient or to the
community are involved.

Article 38: Disputes between members of the medical profession must be resolved quickly and
amicably within the profession itself.

Article 39: A consulted physician shall not take over the managing of the patient without the
knowledge of the regular attending physician.

Article 40: It shall be the duty and privileges of every physician to attend free of charge any sick
colleague or his dependents

1.6 Fiduciary Duty

Fiduciary derives from the Latin word for „‟ confidence‟‟ or „‟trust‟‟. A fiduciary is
anyone who is elected or appointed to a position of trust, where his or her duty to act on behalf of
others, rather than solely for him or herself. Over the ages the physician-patient relationship has
been defined as a fiduciary one, as a relationship founded in trust. The bond of trust between the
patient and the physician is vital to the diagnostic and therapeutic process.

Fiduciary responsibility is the obligation for people entrusted with personal affairs to act
to their client‟s best interest. This duty is based on accepted codes of professional ethics which
recognize the special nature of physician- patient relationships.

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 Health professionals have a particularly stringent duty to assure that their parents or
clients, even at some cost to themselves. Ethical problems often occur when there appears to be a
conflict between those obligations or between fiduciary duties and goals.

Fiduciary Duties of health care provider to the Patients

Altruism: A Health professional is obligated to attend to the best interest of patients,

rather than self-interest.
Accountability: Health professionals are accountable to their patients, to society on
issues of public health and to their profession.
Excellence: Health professionals are obligated to make commitment to life- long
learning.
Duty: A Health professional should be available and responsive when „‟on call‟‟
accepting a commitment to service within the profession and the community.
Honor and Integrity: Health professional should be committed to being fair, thankful and
straight forward in their interactions with patients and the profession.
Respect for others: A Health professional should demonstrate to team members, medical
students and fellows.
Treat every patient politely and considerately
Respect patients' dignity and privacy
Give patients information in a way they can understand
Listen to patients and respect their views
Be responsible for whatever form of therapy given to patients
Respect the rights of patients to be fully involved in decisions about their care.

The Declaration of Geneva requires of the physician that “The health of my patient will
be my first consideration” and the International Code of Medical Ethics states, “A physician
shall owe his/her patients complete loyalty and all the scientific resources available to him/her.”

Health professionals have an obligation to be truthful with their patients. That duty
includes situations in which a patient suffers serious consequences because of a health
professional‟s mistake or erroneous judgment. The fiduciary nature of the relationship between a
health professional and patient requires that a health professional deal honestly with his patient

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and act in their best interest. These values should provide guidance for prompting professional
behavior and for making difficult ethical decisions.

1.7. Malpractice Insurance

While health professionals strive to provide the best care and treatment possible, there
are times when unforeseen events occur, while these are not intentional they can lead to injuries
to and lawsuits from the patients they care for.

Malpractice claims are lawsuits by a patient against a physician for errors in diagnosis
or treatment. Negligence cases are those in which a person believes that a medical professional
did not perform an essential action or performed an improper one, thus harming the patient.

Medical malpractice insurance covers medical professionals for law suits arising from
errors in the duty of the provider. This includes coverage for bodily injury of patients who are in
the care of the provider and the associated costs of law suits and damages awarded. This also
includes coverage for defense, costs for claims made against the provider, whether they have
merit or not, but the coverage does not include criminal prosecution.

Malpractice insurance is required by law in some areas for certain kinds of professional
practice especially medical practice. It is a type of professional liability insurance purchased by
health care professionals.

This insurance coverage protects health care providers against patients who sue them
under the claim that they were harmed by the physician‟s negligent or intentionally harmful
treatment decisions. This kind of insurance is not common in Ethiopia but it is widely applied in
developed countries. There are lots of companies in America that provide liability (malpractice
insurance) for individual medical professionals and their health care companies.

Examples of medical malpractice

Post-operative complications: For example, a patient starts to show signs of

internal bleeding in the recovery room. The incision is reopened, and it is
discovered that the surgeon did not complete closure of all the severed capillaries
at the operation site.

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 Fault and Misdiagnosis: If a surgeon are accidentally leaves a surgical instrument
inside the patient.
Failing to diagnose and prescription errors

Examples of Negligence

Abandonment: a Health care professional who steps care without providing an

equally qualified substitute can be charged with abandonment. For example, a
labor and delivery nurse is helping a woman in labor. The nurse‟s shift ends, but
all the other nurses are busy and her replacement is late for work. Leaving the
woman would constitute abandonment.
Delayed treatment: A patient shows symptoms of some illness or disorder, but the
doctor decides, for what reason to delay treatments. If the patient later learns of the
doctor‟s decision to wait, the patient may believe he has a negligence case.

Both malpractice and negligence are considered as torts. Tort is a civil wrong committed
against a person or a person‟s property. Torts are usually litigated in court by civil action
between individuals. Tort can be intentional or unintentional.

Measures to prevent Malpractice situations

Checking to be sure that all patients or their authorized representatives sign informed
consent forms before they undergo medical or surgical procedures.
Using good judgment and professional ability in handling patients and practice within the
scope of training and capabilities.
Prepare and maintain medical records
Document accurately
Use appropriate guidelines when releasing information
Follow legal guidelines and maintain awareness of health care legislation and regulations.

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1.8. Ethical Issues in Research
Research is a systematic investigation (including development, testing and evaluation)
designed to discover or contribute to a body of generalizable knowledge. Generalizable
knowledge consists of theories, principles or relationships, or the accumulation of information on
which they are based, that can be incorporated by accepted scientific methods of observation and
inference. Not all research involves human participants, but when they are involved, researchers
and their teams are legally and ethically obligated to protect them.

A researcher is the individual who undertakes the study. This term may be used
synonymously with “Investigator” which is the person who takes responsibility for the conduct
of the trial or study and the study site. The practice of medicine or behavioral therapy refers to a
class of activities designed solely to enhance the well-being of an individual patient or client.
The purpose of practice is to provide diagnosis, preventive or treatment therapy.

The human participant is a living individual about whom a researcher obtains either data
through intervention or interaction with the individual or identifiable private information. In
other words, this is the individual upon whom the investigator performs research. The following
terms are used interchangeably: “subject”, “volunteer”, “respondent” or “participant”.

If no private and individually identifiable information is obtained about third parties,

then they may not generally be considered as human subjects. Nevertheless, investigators should
treat all research information about individuals as confidential.

In addition to the traditional understanding of research participation, legal obligations to protect

human participants apply to research that uses:
Bodily material even if the researcher did not collect these materials.
Residual diagnostic specimens
Private information even if the information was not specifically collected
for the study in question.
DNA samples that can be associated with individuals falls in to this
category.
Benefits Versus Risks of research

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 Unfortunately the successes of research have come with a cost. Historically, even well
intended research has resulted into disasters which not infrequently cost life. Medical research
with humans is justifiable because it seeks knowledge that not only is of theoretical interest, but
also will benefit many people and society as a whole.

The term "risk" refers to a possibility that harm may occur; usually refer (often
ambiguously) both to the chance (probability) of experiencing a harm and the severity
(magnitude) of the envisioned harm. The most likely types of harms to research subjects are
those of psychological or physical pain or injury. The term "benefit" is used in the research
context to refer to something of positive value related to health or welfare.

1.8.1 Research History Tragedies and Major Codes of Ethics

Much of what we have as ethical codes and guideline have been influenced by tragic
events which cause public concerns. During the 1900, accounts of many atrocities in the name of
biomedical research are documented. Experiments were liberally done on underprivileged
children, the poor and prisoners. Genetic, height simulation, racial hygiene experiments were
conducted, and in all cases, there is little doubt that the subjects were not volunteers.

I. The Nazi Experiments (World War II 1939-1944)

Prisoners in Nazi concentration camps were forced to undergo experiments that included
exposing them to extreme temperatures, mutilating surgery, and lethal pathogens. The gruesome
experiments that maimed and killed helpless prisoners outraged the world and resulted in
criminal indictments against senior Nazi doctors, as well as calls for international regulation of
medical experiments. Public outcry culminated in the 1946: Nuremberg Doctors‟ Trial found
guilty of murder, torture, and other atrocities. During the trial at Nuremberg, the judges codified
fundamental ethical principles for the conduct of research

In 1947, the Nuremberg Code thus resulted with a set forth 10 conditions to be met
before research could be deemed ethically permissible. Nuremberg Code became the first
international standard for the conduct of research and introduced the modern era of protection for
human research participants. In 1948, The Universal Declaration of Human Rights was adopted
by the United Nations. The Universal Declaration asserted the principle that each human being
was entitled to certain rights and freedoms.

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 II. Human Radiation Experiments

The US government also sponsored many radiation experiments involving humans during
the period 1944–1974. In the majority of cases, the experiments were conducted to advance
biomedical science; however, some experiments were conducted purely to advance national
interests in defense or space exploration. Attention was not given to issues of fairness in the
selection of participants. Further, research was conducted on participants without their awareness
or consent and on participants not likely to derive direct medical benefit.

III. The Jewish Chronic Disease Hospital Study

In 1963, studies were undertaken at New York‟s Jewish Chronic Disease Hospital to
understand whether the body‟s inability to reject cancer cells was due to cancer or debilitation.
These studies involved the injection of foreign, live cancer cells into patients who were
hospitalized with various chronic debilitating diseases.

Consent had been given orally, but did not include a discussion on the injection of cancer
cells, and consent was not documented. The researchers felt that documentation was unnecessary
because it was customary to undertake much more dangerous medical procedures without the use
of consent forms. Further, patients were not told that they would receive cancer cells, because the
researchers felt it would unnecessarily frighten them.

Researchers defended this view with the assertion that they had good cause to predict that
the cancer cells were going to be rejected. Board of Regents of the State University of New York
found that the study had not been presented to the hospital‟s research committee and that the
physicians responsible for the patients‟ care had not been consulted

IV. The Willow brook Study

In a series of studies conducted from 1963 through 1966 at the Willow brook State
School, a New York institution for “mentally defective” children. In order to gain an
understanding of the natural history of infectious hepatitis under controlled circumstances, newly
admitted children were deliberately infected with the hepatitis virus.

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 Researchers defended the deliberate injection; the vast majority of them would acquire
the infection anyway while at Willow brook, given the crowded and unsanitary conditions, and
only children whose parents had given consent were included. Parents found they were unable to
admit their children to Willow brook unless they agreed to their participation in the studies

V. The Tuskegee Syphilis Study (1932-1972)

The main purpose of the study of the natural evolution of syphilis infection in the long-term

It was conducted at Tuskegee by the United States Public Health Service. More than 400
black men with syphilis participated, and about 200 men without syphilis served as controls. The
men were recruited without informed consent and, in fact, were misinformed that some of the
procedures done in the interest of research (e.g., spinal taps) were actually “special free
treatment.”

As early as 1936, it was clear that many more infected men than controls had developed
complications, and 10 years later, a report of the study indicated that the death rate among those
with syphilis was about twice as high as it was among the controls. In the 1940s, penicillin was
found to be effective in the treatment of syphilis. This study continued, none the less, and the
men were neither informed nor treated with the antibiotic.

Major Ethics Codes

•The Nuremberg Code •Declaration of Helsinki

The Nuremberg code (1947)

The voluntary consent of the human subject is absolutely essential. No experiment

should be conducted where there is reason to believe that death or disability will occur. The
degree of risk should never exceed that determined by the humanitarian importance of the
problem to be solved

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Declaration of Helsinki

Like the Nuremberg Code, the Declaration made informed consent a central requirement
for ethical research. It allowed for surrogate consent when the research participant is
incompetent, physically or mentally incapable of giving consent, or a minor.

The Declaration also states that research with these groups should be conducted only
when the research is necessary to promote the health of the population represented and this
research cannot be performed on legally competent persons.

Declaration of Helsinki amended 5 times (1975, 1983, 1989, 1996 & 2000)

1.8.2 Applications of the general principles

Application of the general principles to the conduct of research leads to consideration of
the following requirements:

1. Informed consent,
2. risk/benefit assessment, and
3. The selection of subjects of research.

1. Informed consent

Respect for persons requires that subjects, to the degree that they are capable, be given the
opportunity to choose what shall or shall not happen to them.

The consent process can be analyzed as containing three elements:

A. information
B. comprehension and
C. Voluntariness.

A. information

Specific items for disclosure intended to assure that subjects are given sufficient
information are: the research procedure, their purposes, risks and anticipated benefits, alternative
procedures (where therapy is involved), and a statement offering the subject the opportunity to
ask questions and to withdraw at any time from the research.

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 A special problem of consent arises where informing subjects of some pertinent aspect of
the research is likely to impair the validity of the research. In all cases of research involving
incomplete disclosure, such research is justified only if it is clear that:

– incomplete disclosure is truly necessary,

– there are no undisclosed risks to subjects, and
– There is an adequate plan for debriefing subjects and for dissemination of findings.

The manner and context in which information is conveyed is as important as the

information itself because the subject's ability to understand is a function of intelligence,
rationality, maturity and language. It is necessary to adapt the presentation of the information to
the subject's capacities.

B. Comprehension

Special provision may need to be made when comprehension is severely limited

…incompetent subjects (e.g., infants and young children, mentally disabled patients, the
terminally ill and the comatose). Even for these persons respect requires giving them the
opportunity to choose to the extent they are able, whether or not to participate in research and
seeking the permission of other parties in order to protect the subjects from harm.

C. Voluntariness

An agreement to participate in research constitutes a valid consent only if voluntarily given.

This element requires conditions free of coercion and undue influence.

2. Assessment of Risks and benefits

The assessment presents both an opportunity and a responsibility to gather systematic and
comprehensive information about proposed research. It is concerned with the probabilities and
magnitudes of possible harms and anticipated benefits.

This assessment is important for the investigator as a means to examine whether the
proposed research is properly designed; for a review committee as a method for determining
whether the risks that will be presented to subjects are justified and for prospective subjects, the
assessment will assist the determination whether or not to participate.

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3. Selection of Subjects

Just as the principle of respect for persons finds expression in the requirements for consent
and the principle of beneficence in risk-benefit assessment; the principle of justice gives rise to
moral requirements that there be fair procedures and outcomes in the selection of research
subjects. Justice is relevant to the selection of subjects of research at two levels: at the social and
the individual levels.

Injustice may appear in the selection of subjects, even if individual subjects are selected fairly by
investigators and treated fairly in the course of research. Injustice arises from social, racial,
sexual and cultural biases institutionalized in society.

Dealing with Vulnerable Populations

Vulnerable persons are those who are relatively (or absolutely) incapable of protecting
their own interests. More formally, they may have insufficient power, intelligence, education,
resources, strength, or other needed attributes to protect their own interests. Justification has to
be provided for the involvement of these populations in the research. Additional safeguards for
their safety and welfare have to be guaranteed and also the informed consent process should be
conducted with special care.

Who are in the vulnerable category?

• Pregnant women • Children

• Persons with mental and physical disabilities • Prisoners

• Elderly participants • Hospitalized people,…

Protection of children in research

Before undertaking research involving children, the investigator must ensure that the research
might not be equally carried out with adults well and the purpose of the research is to obtain
knowledge relevant to the health needs of children.

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 A parent or legal representative of each child must give permission. The agreement
(assent) of each child has been obtained to the extent of the child`s capabilities and a child`s
refusal to participate or continue in the research will be respected.

Pregnant women as research participants

Pregnant women should be presumed to be eligible for participation in biomedical

research. Investigators and ethical review committees should ensure that prospective subjects
who are pregnant are adequately informed about the risks and benefits to themselves, their
pregnancies, the fetus and their subsequent offspring, and to their fertility. Research in this
population should be performed only if it is relevant to the particular health needs of a pregnant
woman or her fetus, or to the health needs of pregnant women in general.

2.8.3 Institutional Review Board (IRB)

An ethics/institutional review board is an independent ethics committee/board
established by an institution to review the ethical merits of research protocols. The aim is to
safeguard the dignity, rights, safety and well-being of research participants. WHO guidelines
states that; ethical review committee is responsible for “safeguarding the rights, safety, and
wellbeing of research subjects”. Therefore, the role of ethical review in health research is simply
to ensure that the rights and wellbeing of research participants are adequately protected.

Common criteria for determining if a research is ethical or not are first and foremost, it
has to be scientifically sound. It generates generalizable knowledge. There should be fair subject
selection and balanced risks and benefits and the issue of informed consent is also another key
area.

Members of ethics/institutional review board must be at least five with varying

backgrounds (should not be all one race, gender, age, profession, etc.) and community members
or community representatives should be included.

Ethics review boards are responsible

1. For carrying out the review of proposed research.

2. To ensure that the goal of research never overrides the health, well-being and care of
research participants

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 3. To provide independent, competent and timely review of the ethics of proposed studies.

In some countries there are national ethics review boards and institutional ethics review
boards. Although the roles of these boards are similar, they differ in scope. In Ethiopia, the
Ethiopian Science and Technology Commission (ESTC) guides, coordinates, and facilitates all
science and technology activities. The Ethiopian National Health Research Ethics Review
Committee is established at national, regional and at institutional levels.

2.8.4 Basic principles for designing and conducting research

1. Social Value 2. Scientific validity

3. Favorable risk-benefit ratio 4. Informed consent

5. Confidentiality

1. Social Value

The importance of the project‟s objective, understood as both scientific and social
importance, should outweigh the risks and burdens to research subjects. Furthermore, the
populations in which the research is carried out should benefit from the results of the research.
This is especially important in countries where there is potential for unfair treatment of research
subjects, who undergo the risks and discomfort of research while the drugs developed as a result
of the research only benefit patients elsewhere.

2. Scientific validity

The research must have a complete description of the purpose of the study and research
procedures. It must provide reliable and valid data and practically feasible. Eligibility criteria
should set out well and targets the right population. Sample size estimates must be done
accurately and data analysis approaches should be well tested and thought out.

3. Favorable risk-benefit ratio

Once the scientific validity and social worth of the project have been established, it is
necessary for the researcher to demonstrate that the risk to the research subjects are not
unreasonable or disproportionate to the expected benefits of the research, which may not even go
to the research subjects. A risk is the potential for an adverse outcome (harm) to occur. A likely
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risk of a serious harm would be unacceptable unless the project provided the only hope of
treatment for terminally ill research subjects.

4. Informed consent

The first principle of the Nuremberg Code reads as follows: „‟ the voluntary consent of
the human subject is absolutely essential.‟‟ This principle requires that the research subject
should have sufficient knowledge and comprehension of the elements of the subject matter
involved as to enable him to make an understanding and enlightened decision. The informed
consent should e demonstrated by having the research subject sign a „consent form‟; but also
must involve a careful oral explanation of the project and all participation in it will mean to the
research subject.

5. Confidentiality

Unlike clinical care, research requires the disclosure of personal health information to
others, including the wider scientific community and sometimes the general public. In order to
protect privacy, researchers must ensure that they obtain the informed consent of research
subjects to use their personal health information for research purposes, which requires that the
subjects are told in advance about the uses to which their information is going to be put.
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Review Questions

1. What does prenatal diagnosis mean?

2. What are the fiduciary duties of health care provider to the patients?

3. Explain the four types of Euthanasia

4. Discuss the research tragedies happened in the past?

5. What are the examples of malpractice and negligence?

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Unit three: legal Medicine and Public Health Laws
Objectives

After the end of this unit the student will be able to:
Define Public Health Law and Legal Medicine
Describe Abortion and its legal provisions
Explain Legislations Regarding to crimes with Medical aspects
know Public Health Laws in Ethiopia
Understand how to write medico-legal report

Introduction
The preservation of the public health is among the most important goals of government.
Law creates a mission for public health authorities, assigns their functions, and specifies the
manner in which they may exercise their authority. The law is a tool in public health work which
is used to influence norms for healthy behavior, identify and respond to health threats, and set
and enforce health and safety standards.

1.1 Public health law

Public health law “is the study of the legal powers and duties of the state to assure the conditions
for people to be healthy and the limits on that power that constrain the autonomy, privacy,
liberty, proprietary, or other legally protected interests of individuals for protection or promotion
of community health.”

Law can be an effective tool to achieve the goal of improved health for the population.
Law, regulation and litigation, like other public health prevention strategies, intervene at a
variety of levels, each designed to secure safer and healthier populations.

Law in public health provides authority, limitation on state power, incentive and
disincentive behavior of the member of the profession. Law and ethics are complementary social
institutions in society to help public health officials mediate conflicts and questions about the
relationship between the individual‟s and the community‟s interests in health and about the
appropriate scope and means of public health.

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1.2 Legal medicine
Legal medicine is application of medicine to legal cases. It applies principles and
practices of different branches of medicine to solve legal questions. It is the application of
medical and paramedical sciences as demanded by law and administration of justice. It concerns
with the study of the rights, duties, and obligations of a medical practitioner with particular
reference to those arising from doctor-patient relationship. A physician who specializes or is
involved primarily with medico-legal duties is known as medical jurist or medico legal expert.

Distinction between an ordinary physician and a medical jurist

An ordinary physician sees an injury or disease on the point of view of treatment, while
a medico-jurist sees injury or disease on the point of view of cause. The purpose of an ordinary
physician examining a patient is to arrive at a definite diagnosis so that appropriate treatment can
be instituted, while the purpose of the medical jurist in examining a patient is to include those
bodily lesions in his report and testify before the court or before an investigative body; thus
giving justice to whom it is due.

2. Review of legislation relating to crimes with medical aspects

2.1 Abortion and Legal provisions for safe abortion services

Abortion is more than a medical issue, or an ethical issue, or a legal issue. Above all, it is
an issue of humanity, involving women and men as individuals, as couples and as members of
societies. Abortion is loss of pregnancy before viability spontaneously or induced. It implies
expulsion or extraction of products of conception before viability which is in Ethiopian context
28 week or 1000 gram

Classification of abortion

A. Clinically:

1. Threatened abortion 2. Inevitable abortion

3. Incomplete abortion 4. Complete abortion

5. Missed abortion 6. Septic abortion

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B. Gestational Age:

1. First trimester 2. Second trimester

C. Method

1. Spontaneous 2. Induced

Health workers involved in the care of women should be well aware of the provisions of this
guideline, which is an official interpretation of the law on safe abortion services.

Article 551 of the Penal Code of the FDRE allows termination of pregnancy under the following
conditions:

1. Termination of pregnancy by a recognized medical institution within the period permitted by

the profession is not punishable where:-

a. The pregnancy is a result of rape or incest

Termination of pregnancy shall be carried out based on the request and the disclosure of the
woman that the pregnancy is the result of rape or incest. This fact will be noted in the medical
record of the woman. Women who request termination of pregnancy after rape and incest are
not required to submit evidence of rape and incest and/or identify the offender in order to
obtain an abortion services.

b. The continuation of the pregnancy endangers:

I.the life of the mother or the child
II. the health of the mother
III. where the birth of the child is a risk to the life or health of the mother; or

The woman should not necessarily be in a state of ill health at the time of requesting safe
abortion services. It is therefore the responsibility of the health provider in charge to assess the
woman‟s conditions and determine in good faith that the continuation of the pregnancy or the
birth of the fetus poses a threat to her health or life.

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 c. The fetus has an incurable and serious deformity;

If the physician after conducting the necessary tests makes the diagnosis of a physical or genetic
abnormality that is incurable and/or serious, termination of pregnancy can be conducted.

d. The pregnant woman, owing to a physical or mental deficiency she suffers from or her
minority; is physically as well as mentally unfit to bring up the child.

A disabled person is one who has a condition called disability that interferes with his or her
ability to perform one or more activities of everyday living. It is therefore the responsibility of
the health provider in charge to assess the woman‟s conditions and determine in good faith that
the woman is disabled either mentally or physically.

2. In the case of grave and imminent danger which can be averted only by an immediate
intervention, an act of terminating pregnancy is not punishable.

Article 545 of criminal code

The intentional termination of a pregnancy is punishable according to the following

provisions, except as provided under Article 551. The nature and extent of the punishment given
is determined according to whether it is procured by the pregnant woman herself or by another,
and in the latter case according to whether or not the pregnant woman gave her consent.

Article 546-Abortion procured by the pregnant woman

1. A pregnant woman who intentionally procures her own abortion is punishable with
simple imprisonment.
2. Any other person who procured for her the means of, or aids her in the abortion, shall be
punishable as a principal criminal or an accomplice, with simple imprisonment.

Article 548-Aggravated cases

1. In cases where the crime is committed by a person who has no proper medical profession,
the punishment shall be simple imprisonment for not <1 year, and fine;

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2. In cases where a professional commits the crime, in particular, by health professionals, in
addition to simple imprisonment and fine, order prohibition of practice, either for a limited
period, or where the crime is repeatedly committed, for life.

2.2 Rape and its legislation

Rape is „‟ physically forced or otherwise coerced penetration, without consent-even if
slight of the vagina, using a penis, other body parts or an object. Rape is the most underreported
crime.

Article 620 of the Penal Code of the Federal Democratic Republic Ethiopia declares that
whoever compels a woman to submit to sexual intercourse outside wedlock, whether by the use
of violence or grave intimidation, or after having rendered her unconscious or incapable of
resistance, is punishable with rigorous imprisonment 5-15 years.

2.3 Unlawful Exercise of the Medical and Public Health Professions

1. Article 387-Issuing false medical certificate

Any health professional who makes out a certificate of medical nature which is untrue and
calculated to procure an unlawful advantage for, or to injure the legitimate interests of another
person, knowing that such certificate will be used, is punishable with simple imprisonment or
fine.

2. Article 399-Breaches of professional secrecy

Medical personnel, who disclose a secret, are punishable, upon complaint, with simple
imprisonment or fine.

3. Article 400-Authorized

Disclosures Any disclosure shall not

be punishable

a. Where it is made with the expressed consent of the patient

b. Where, at the suggestion or request of the possessor of the secret,
c. Where it is made following an expressed decision of a court of justice in a specific case
d. Where special provisions of the law permit or impose the duty, to give evidence before a
court of justice or to inform a public authority.
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4. Article 420 of criminal code-crimes committed in dereliction of duty
1. Any public servant who fails to carry out his duties in a proper manner and to the
prejudice of state, public or private interest, is punishable with fine not exceeding 1,000
birr or simple imprisonment not exceeding six months.
2. Where substantial damage has resulted from the crime, both simple imprisonment and
fine may be increased up to the general legal maximum.

Infringements of Curative and Protective Measure Provisions

5. Article 535 -Unlawful Exercise of the Medical or Public Health Professions

1. Whoever, having neither the professional qualifications prescribed and controlled by the
competent authority nor the authorization to set up in official practice required under the
relevant regulations or by exceeding his authorization, makes a practice of treating sick
persons in no matter what form, or does so for remuneration, whether it be by
consultations, treatment, the sale of remedies or any other medical or curative activity or
practice, is punishable with simple imprisonment not exceeding one year, or with
rigorous imprisonment not exceeding five years and fine.
2. A person who treats live-stock under the circumstances provided in sub-article (1) above
is punishable with simple imprisonment or fine.
3. Whoever manufactures, offers for sale, sells, distributes or puts on use drugs or medical
instruments:
a. the safety, efficacy and quality of which is not ascertained and duly authorized by
the appropriate organ; or
b. which are counterfeited or adulterated; or which have misleading labels written on,
affixed to or enclosed with, their packaging; or
c. that have expired; or
d. which are prohibited, spoiled, faked, contaminated or, for any other reason,
ascertained to be harmful to the health of the person using them, is punishable with
rigorous imprisonment for not less than five years, and fine from twenty thousand
to fifty thousand Birr.

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6. Article 537 of criminal code-refusal to provide medical assistance

Any health professional lawfully entitled to render professional attention and care, who,
contrary to his duty and without just cause refuse to provide his services in a cases of serious
need, whether from indifference, selfishness, cupidity, hatred or contempt or any other similar
motive, is punishable with fine, or, where the crime is repeated, with simple imprisonment not
exceeding six months.

7. Article 559 -Injuries Caused by Negligence

1. Whoever, by criminal negligence, causes another to suffer common injury to person or to
health is punishable with simple imprisonment not exceeding six months, or fine not
exceeding one thousand Birr.
2. The punishment shall be simple imprisonment for not less than six months, and a fine of
not less than one thousand Birr, where the injury inflicted is of the same kind as the one
stated in Article 555, or where it was caused by a person like a doctor or driver, who had
a special duty to safeguard the body or health of another.
3. The crime is punishable upon accusation, where the injury is grave, and upon complaint,
where it is common. The extent of the injury shall be determined in accordance with
Articles 555 and 556.
8. Article 565-Female Circumcision

Whoever circumcises a woman of any age, is punishable with simple imprisonment for not less
than three months, or fine not less than five hundred Birr.

3 .The physician/Health officers' duty as a witness

At any time a health officer may find themselves summoned to appear as a witness at the
court of law. A health officer cannot refuse to obey a subpoena (written order) that is personally
served on them. The appearance of a health officer as a witness is an event, which will test their
integrity and the soundness of their medical knowledge.

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3.1 Witnesses
Witnesses are of two kinds;

1. The common witness is who testifies to facts that have come under his observation and whose
opinions are not admitted.

2. The expert witness is who by reason of his specialized knowledge and experience of a subject
is called to give his opinion on the matter at issue. The witness must be examined on oath. This
is a statutory obligation for everyone duly called as a witness. An officer of the court will hand
the Bible/Quran to the witness, which he holds in the right (ungloved) hand while the words of
the oath are reported.

3.2 Rules to be observed

1. Attendance at a court of law is a serious & formal occasion so treat is as such in your
manner, department and dress. Appear well groomed and dress in clean, conservative
clothing.
2. Arrive punctually. Do not be late for scheduled hearings.
3. Speak slowly, clearly and professionally. Do not lose your temper or attempt to be
humorous.
4. Take all notes, reports, and anything else you intend to use into the witness box with you.
5. Before testifying, refresh your memory concerning all the facts observed about the matter
in question, such as dates, times, words spoken and circumstances.
6. Use simple language in your replies. Avoid technical terms because others are unfamiliar
with them. So e.g. voice-box for larynx, coverings of the brain for meninges& nosebleed
for epistaxis are preferable to use.
7. If asked to give your opinion say ‟‟In my opinion don‟t use phrases such as „‟I think‟‟
or „‟I imagine‟‟.
8. Address the judge of the court by his proper title „‟your honor‟‟, „‟my lord‟‟.
9. Answer all questions in a straight forward manner, even if the answers appear to help the
opposing side.
10. If you don‟t know the answer; don‟t attempt to evade questions, and don‟t argue.
11. The obligation of professional secrecy doesn‟t project to physician/ Ho from having to
disclose in the witness box.

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 12. You may be asked and should be prepared to give answers about these questions.
I.Date & time of arrival of the patient
II. Short history of the patient illness or accident
III. What was found on first examination of patient
IV. What treatment was given and what tests (if any) were carried out.
V. The progress of the patient
VI. The date and time of death and its probable cause.

4. Drafting of Medico legal Report

4.1. Medico legal cases

Medico legal cases (MLC) are an integral part of medical practice that is frequently
encountered by Medical Officers (MO). Proper handling and accurate documentation of these
cases is of prime importance to avoid legal complications and to ensure that the close relative
receive the entitled benefits.

Medico legal case (MLC) is defined as “any case of injury or ailment where, the attending
doctor after history taking and clinical examination considers that investigations by law
enforcement agencies are warranted to a certain circumstances and fix responsibility regarding
the said injury or ailment according to the law”.

Examples of MLCs

The following are some of the examples of MLCs and medical officers should use their
professional judgment to decide any other cases not enumerated in the list:

Cases of Assault and battery, including domestic violence and child abuse
Accidents like Road Traffic Accidents (RTA), industrial accidents etc.
Cases of Poisoning, Criminal abortions, Attempted suicide
Cases of asphyxia as a result of hanging, strangulation, drowning, suffocation etc.
Cases of Fire Arm injuries, trauma, Drug overdose, sexual offences
Dead brought to the Emergency Department

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4.2 General Guidelines for dealing with Medico legal cases
In emergencies, resuscitation and stabilization of the patient will be carried out first and
medico legal formalities may be completed subsequently. The consent for treatment is implied in
all emergencies. Cases of trauma will be labeled as MLCs, if there is a suspicion of criminal
action, even if the incident is not of recent origin. Personal information of the individual will be
noted. Information of the person accompanying the patient will also be noted.

Medico legal documents should be prepared in duplicate, with greatest care giving all
necessary details, preferably written with a ball-point pen and avoiding overwriting.
Abbreviations should be avoided.

Medico legal documents should be considered as confidential records and should be

stored under safe place to avoid damage. Prompt attention, correct triage and safe transfer of a
patient from one facility to another as required should be carried out in all cases and not delayed
because of the medico legal nature of the case. Opinion on severity of injuries should be given
after the X-ray reports are received in cases of injury to bones/joints.

Samples and specimens collected for medico legal purposes will be properly sealed,
labeled and handed over to the investigating officer detailed by the police. In cases where the
patient wishes to make a dying declaration, the court will be informed.

4.3. Medico-legal report

The medico-legal report is a structured and formal vehicle for communication between the
doctors and the legal system. Requests for medico-legal reports are common and originate from a
variety of sources such as police, lawyers, government tribunals, insurance companies or the
patients themselves.

Once prepared; medico-legal report may be used in criminal or civil proceedings with
consequences for the patient, the doctor, third parties and the judicial system. In view of these
potential implications they must be prepared with accuracy, diligence and basic understanding of
legal principles.

A proper request and informed consent are essential prior to commencing report
preparation. A structured format incorporating elements of background information, medical
history, physical examination, specimens obtained, treatment provided and opinion is suggested.

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 I. Request

The circumstances surrounding many emergency department attendances especially those

involving violence increase the likelihood of a request for a medico-legal report. The request
should be directed specifically to the most senior doctor who was involved with the clinical
management of the patient.

The request should specifically state:

Who should write the report?
The name and preferably the date of birth of the patient concerned;
The time and date of any incident;
The purpose of the report and

Any specific issues that need to be addressed and the request should be accompanied by a signed
statement of consent completed by the patient or legal guardian, allowing release of medical
information.

II. Consent

Consent for the release of medical information to a third party must be obtained prior to a
medico-legal report being dispatched to prevent inadvertent release without consent.

The following criteria must be met for consent to be valid:

I. The patient (or their legal guardian) must be competent to provide it;
II. It must be informed. That is, the patient must have a clear understanding of the
implications of the release of the information
III. It must be specific;
IV. It must be freely given. Release of privileged medical information in a medico-legal
report without valid consent is unethical and may be illegal.

In situations where a medico-legal report is requested but consent is withheld, the requesting
agency may apply for a court order for release of the material.

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III. Format

They are many formats for a medico-legal report. Style maybe directed either by the
personal preference of the author or by the requirements of the legal processor the requesting
agency. Within these boundaries they are some common features which include:

The date on which the report was prepared;

The name of the person to whom the report is directed;
The full name, date of birth and hospital unit record number of the subject.
Identification of the author: This should include the practitioner's full name, practicing
address, current employment and qualifications

The report must primarily be prepared from the original notes. There should be no
factual information that is unsupported by data contained in these notes. The terminology used
should be appropriate to the potential audience.

Medical terms not in common usage should be avoided or alternatively should be

adequately explained. E.g. nose bleeding is preferable to epistaxis. The use of the words like
'victim' or 'offender' or 'rape' presuppose that an offence has occurred and should not be used.
Ideally, assaults and other offences should be referred to as "alleged offences”.

4.4. Structure of medico legal report

A suggested structure has:

1. Background

Data such as the time date and place, and the reason for the examination and detail the
nature and extent of your involvement in the case should be written in the report first. A brief
account of the alleged offence and the sources of that information should also be included. A
specific comment should be made concerning the provision of consent.

2. Medical History

A brief account of any relevant medical conditions in the past is appropriate.

 3. Examination

Comments on the general presentation of the subject should be included. Emotional,

psychiatric and intellectual state and the effects of alcohol or other drugs should be described.
Specific attention should be given to sites of particular interest in the case; for instance, the
genito-anal examination in a rape case. If there are any difficulties or limitations encountered
during the examination (for example limited co-operation by the subject or a withdrawal of
consent to examine certain areas), this should be noted.

4. Specimens

It is uncommon for hospital staff to be required to take forensic specimens. Details of

all specimens obtained should appear in the medico-legal report. Comments should also be made
regarding the time and date of transfer of specimens to the care of another person. This ensures
that continuity of evidence can be proven later in court.

5. Opinion

It is advisable to distinguish if possible between fact and opinion. The facts being what
was seen or done and the opinion being what was inferred or assumed. Opinion evidence will
often come under particular scrutiny by the reader of the report, and may be publicly tested in
court. The authors experience and expertise are fundamental to the weight given by the court to
their opinion.

Some opinions sought may be beyond the expertise of the author. Under these
circumstances, the requesting agency may seek a, opinion from another more experienced
practitioner based upon the earlier report. When formulating an opinion it is essential to maintain
impartiality and objectivity. Resist fitting opinions to the allegation and acknowledge and weigh
alternative conclusions and only say what you would be prepared to repeat under oath in court.

Draft reports should be prepared and the contents compared with the original notes. On
completion of a final report all draft reports should be destroyed. This prevents any confusion at
a court hearing as to what was draft and what was final report. Requests to edit reports to remove
unfavorable material should never be accepted. Finally, whenever possible, ask a colleague to
review and comment upon the report before it is sent.

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 Constructive criticism at this time is preferable to cross-examination in the witness box.
Review of the notes, reports, diagrams and photos should occur before the start of court
proceedings. If, at this stage, any mistakes are noted in the report, these should be acknowledged
openly in court.

The preparation of a medico-legal report is an essential part of the service provided by

hospital doctors. It is a task that should be approached with a desire to accurately communicate
the clinical situation encountered. A structured format and objective opinion will enhance both
the readability and accuracy of the report.

5. Existing Public Health Laws in Ethiopia

Law is an instrument of social engineering it seeks to ensure harmonious social existence by
creating right and obligation which are enforceable through various organs of government in
creating, administering and enforcing the law.

While the modern health officer must be an educator rather than police officer, many of
his duties are still necessary concerned with law enforcement. Health officers must be familiar
not only with the extent of their power and duties but also with the limitations in posed upon
them by law.

A. Public health proclamation No.200/2000

Food or Medicine Seizure and Disposal

Water quality control
Occupational health control and use of Machinery
Waste Handling and Disposal
Availability of toilet Facilities
Disposal of dead bodies
Places prohibited for smoking
Organ and Tissue donation and transplantation principles

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The government organ assigned power enforce the provision of this proclamation is the ministry
of health and the health bureau of the regional state or of the city which are general described as
public health authority.

Article 6 empowers the Authority to appoint, inspectors, who are usually persons qualified in
relevant fields of public health , to enforce compliance by the general public health with the
provisions of this law.

Authority the Ethiopian food, medicine and health care administration and controlling authority

The powers of the inspectors are set out in Article 7. These include the power of entry and
inspection of any premises suspected to harbor anything injurious to public health, the power to
order the closure of any premises or seizure of the injurious item.

Any item seized must be kept safely as it may be used as evidence of for prosecution.

Food quality control: food quality is defined as a food that meets the biological, chemical and
physiological standards set nationally and internationally.

Under Article 8, of this proclamation, there is the general prohibition on importation,

distribution or production of public consumption any food which is unhygienic, contaminated,
unwholesome and mislabeled and does not meet the standard of food quality .

Food or Medicine Seizure and Disposal

1. The appropriate organ may seize food or medicine and order disposal or sending back to
the country of its origin where the food or medicine:
a) does not have market authorization;
b) is counterfeit;
c) has expired;
d) is of deteriorated quality;
e) is stored, distributed, offered for dispensing or dispensed by a person without
certificate of competence issued in accordance with this regulation; or
f) used in unauthorized clinical trial.

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Article 9 contains positive provision in relation to food standard requirement by making it
mandatory for any person engaged in selling, producing for cell , storing , preparing or
preserving of any food intended for human consumption , to meet the standard set by the
ministry.

Water quality control

Article 10 prohibits the supply of water for public consumption from wells , springs or through
pipes unless its quality is verified by the health authority.

Nobody is allowed to import, produce or distribute to the society bottled minerals or plane water
unless the quality is verified it is prohibited to discharge untreated liquid waste generated from
septic tanks, industries into, agricultural institution, schools and commercial areas that undergo
several changes due to biological and chemical reaction and which can affect the health of
human beings, animals and plants.

Occupational health control and use of Machinery

Article 11 places obligation on employers to provide conducive work environment for their
employee.

Where the machines used in the industry make excessive noise, the employer must ensure that
noise reducing apparatus or instrument is installed to protect the health of the employee

Waste Handling and Disposal

Article 12 requires that waste be collected in specially designated place and in the manner that
does not affect the health of the public, indiscriminate disposing of wastes is prohibited.

Hospitals wastes, for their sensitive nature , the law especially provides for extreme caution in
the manner provided by public health authorities.

Availability of toilet Facilities

Under article 13, institutions and organization providing public service are mandated to ensure
availability of clean, adequate and accessible toilet facilities for its customers.

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The city administrators have the responsibility to provide public toilets and ensure their
cleanness.

Control of bathing places and pools: Public bathing places are strictly regulated under article 14
as infections can easily spread from that source.

Person providing public bathing places or swimming pools must do so with the approval of the
appropriate health authority.

They must observe some level of circumcision in allowing person with visible evidence of skin
disease to make the use of the facilities so as prevent the spread of the disease.

Disposal of dead bodies

Article 15 provides that dead bodies or human remains must be buried or burnt in the
appropriate place.

Such remains cannot be exhausted or exposed in any way without the authorization of the health
authority

Control of entrance and exit ports

Under article 16 any passenger coming to Ethiopian or leaving Ethiopia must take the
vaccination required for internationally travelers and present with their health certificate
whenever requested by the health officer.

If the traveler is suspected of having any communicable disease he / she must cooperate with the
health officer in being subjected to appropriate health examination

A passenger may be disallowed from entering Ethiopia if he is coming from endemic area
without possessing medical certificate of fitness. There is an obligation placed on port authorities
to report any passenger suspected of having any communicable disease to the nearest health
officer.

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Places prohibited for smoking

1. No person may smoke tobacco in a place for public gathering or use.

2. Places for public gathering or use shall include the following:
a. rooms of health institution;
b. class rooms of educational institution;
c. public conveyances;
d. dining places like hotels and restaurants; and
e. such other places prohibited for smoking as may be determined by the appropriate
organ.
3. Notwithstanding the provisions of sub-article (1) of this Article, smoking places for
public gathering or use identified by the authority may be allowed at designated smoking
areas.

Organ and Tissue donation and transplantation principles

1. Transplantation of organs or tissues may only be carried out if there is no other better
means of preserving the life or physical integrity of the recipient as proved by a medical
board.
2. Any person may donate or prohibit the removal of his organs or tissues in any other way
while alive or after his death.
3. A person may, at any time, revoke the act by which he has promised to donate his organs
or tissues while alive or after his death.
4. Where a person who has promised to donate his organs or tissues revokes his promise,
pursuant to sub-article (3) of this article, in bad faith, the recipient shall be entitled to be
indemnified for the expenses which has incurred due to such.
5. The following acts shall be prohibited:
a. trading in human organ or tissue;
b. receiving, giving or promising to give monetary or non-monetary benefit for organ
or tissue donation;
c. advertising demand or supply of organ or tissues;
d. using animal organ or tissue for the purpose of transplanting it to human.

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Organs and tissues collection from deceased person

1. Where a person has consented to donate his organs or tissues upon his death, the organs
and tissues that can be used for transplantation may be collected upon his death.
2. No health institution may collect organs and tissues pursuant to sub-article (1) of this
article without obtaining special license from the authority.
3. Where there is no written evidence showing express prohibition of donation made by the
deceased, while alive, and where the spouse, children or parents or siblings of the
deceased, in the order of their list, agree with the donation, organs and tissues that can be
used for transplantation may be collected from the deceased person.
4. Where the individuals listed under sub-article (3) of this article are suspected of crime for
the death of the deceased, they may not have the right to give consent with the respect to
donation of organs and tissues of the deceased for transplantation.
5. Unless the donor ordered a particular recipient as beneficiary in accordance with
provisions of transplantation, selection of organs and tissues recipients shall be based on
compelling medical reasons and the principles of justice and equity.
6. Health professionals who declare the fact of death of the donor may not be less than two;
and be different from, and be different from, and have no monetary relationship with those
who conduct the transplantation.

Organs or Tissues collection from living persons

1. Collection of organ or tissue from a living person may be carried out where competent
health professionals believe removal of organ or tissue from the donor does not pose any
serious and permanent danger to his health or life and where:
a. the donor has the capacity to give consent and enter in to juridical acts, and agrees
in writing, based on informed consent in the presence of two witnesses; and
b. it is established by the National transplantation committee referred to in Article 62
of this regulation that:
(1) there is spousal bondage or relation by consanguinity or affinity between the
donor and the recipient; or
(2) in the absence of spousal bondage or relation by consanguinity or affinity,
there is no monetary relationship between the donor and the recipient.

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Transplantation

1. No health institution may transplant organs and tissues without obtaining special license
from the authority.
2. The authority shall establish National transplantation committee with a view to ensuring
that organ or tissue collection and transplantation is being carried out in accordance with
professional ethics.
3. Any transplantation may not be performed unless the national transplantation committee
approved the transplantation request; provided however, that the national committee may
where necessary, give delegation of power to transplantation committee established at
regional level.
B. Proclamation No.414/2004

False Medical Certificate

Contamination of Water
Environmental Pollution
Mismanagement of Hazardous Wastes and other Materials
Infringement of Preventive and Protective Public Health Measures

This Proclamation may be cited as "The Criminal Code of the Federal Democratic Republic of
Ethiopia 2004."

False Medical Certificate

Article 387- Issuing False Medical Certificate

(1) Any doctor, dentist, pharmacist, midwife or other person entitled professionally to issue
certificates of a medical nature who makes out a certificate which is untrue and calculated to
procure an unlawful advantage for, or to injure the legitimate interests of, another person,
knowing that such certificate will be used, is punishable with simple imprisonment or fine,
without prejudice to secondary professional penalties (Art.123(c)) in the event of repetition of
the crime.

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Based on the consideration of the situation the imprisonment not exceeding from 10-15 years or
fine 10, 000-20, 000Birr

Crimes Committed by Spreading Diseases and Polluting the Environment

Article 514 -Spreading of Human Diseases

Whoever intentionally spreads or transmits a communicable human disease, is punishable with

rigorous imprisonment not exceeding ten years.

Spreading of Animal Diseases

Article 515 -Spreading of Animal Diseases

Whoever intentionally spreads an animal disease among domestic animals or poultry, bees, fish
or wild animals the species of which are protected by law, is punishable with simple
imprisonment or fine.

Contamination of Water

Article 517-Contamination of Water

1. Whoever intentionally contaminates by means of substances harmful to health drinking

water serving the needs of man or animals, is punishable, according to the circumstances
and the extent of the damage, with fine or simple imprisonment for not less than one
month, or, in more serious cases, with rigorous imprisonment not exceeding seven years.
2. In cases of intentional poisoning of wells or cisterns, springs, water holes, rivers or lakes,
the punishment shall be rigorous imprisonment not exceeding fifteen years.
3. Where the crime under sub-article (1) or 2) above is committed negligently, it is
punishable with simple imprisonment, or, if less serious, with fine.

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Environmental Pollution

Article 519 -Environmental Pollution

1. Whoever, in breach of the relevant law, discharges pollutants into the environment, is
punishable with fine not exceeding ten thousand Birr, or with rigorous imprisonment not
exceeding five years.
2. Where the pollution has resulted in serious consequences on the health or life of persons
or on the environment, the punishment shall be rigorous imprisonment not exceeding ten
years.
3. Where the act of the criminal has infringed a criminal provision entailing a more severe
penalty, the provisions on concurrence of crimes shall apply.

Mismanagement of Hazardous Wastes and other Materials

Article 520 -Mismanagement of Hazardous Wastes and other Materials

Whoever:

a. fails to manage hazardous wastes or materials in accordance with the relevant laws; or
b. fails to label hazardous wastes or materials; or
c. Unlawfully transfers hazardous wastes or materials, is punishable with fine not
exceeding five thousand Birr, or rigorous imprisonment not exceeding three years, or
with both.

Infringement of Preventive and Protective Public Health Measures

Article 522 -Infringement of Preventive and Protective Public Health Measures

1. Whoever intentionally disregards the measures prescribed by law for the prevention, limit
or arrest of a communicable human disease, is punishable with .simple imprisonment not
exceeding two years, or fine.
2. Where the crime is committed negligently, the punishment shall be simple imprisonment
not exceeding six months, or fine not exceeding three thousand Birr.

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 7. Agencies for the protection of Public Health in Ethiopia
Ethiopian Food, Medicine and Healthcare ad administration and control authority
(EFMHACA) was established by proclamation No. 661/2009 to ensure the safety and quality of
products and Health services. In accordance with its proclamation, the authority is provided with
a mandate to regulate the 4ps (practice, promises, professionals and products).The council of
ministers has approved the naming of the regulatory authority as “Ethiopian Food, Medicine and
Health care Administration and Control Authority”.

The Ethiopian Food, Medicine and Healthcare ad administration and control authority
under the Ministry of Health is responsible for the accessibility of quality health service to all
citizens throughout the country. Accordingly, health and health related services and products
quality regulation core process is redesigned in the purpose of protecting the public from any
emerging health risks. The core process comprises of four sub-processes and one version. These
are:
Regulatory standards setting
Inspection and licensing
Product quality assessment registration
Regulatory information delivery

I. Objectives of EFMHACA
1. To establish and maintain an effective and efficient quality assurance, market
authorization, inspection and licensing system.
2. To ensure safety, efficacy and quality of medicines including complimentary and
traditional medicines.
3. To ensure that food consumed are safe, qualified, sanitary and free of contaminants.
4. To standardize health services and protect the public from unqualified and unethical
professionals and substandard health institutions.
5. To ensure and uninterrupted regulatory information, provision and promote relational
medicines use.

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III. Powers and Duties EFMHACA
Set standards for food safety and quality; safety, efficacy, quality and proper use of
medicines; competence and practice of health professionals; hygiene and
environmental health; competence of health and health related institutions and ensure
their implementation and observance.
Issue, renew, suspend, revoke or deny certificate of competence for specialized health
institutions, food or medicines processing plants, quality control laboratories,
importer, exporters, storage or distributors and trans-regional health service
institutions
Initiate policy to strengthen food, medicines, health professionals and health institutions
quality and efficacy; initiate draft legislation and forward the same for approval;
Serve as medicines, food, health professionals and health and health related institutions
information center.
Identify ingredients that caused death or ill health due to medicines residue or
adulteration of medicines and food and take appropriate measures by
conducting investigation on sample ingredients.
Organize quality control laboratories as needed to carry out its duty;
Give import or export permit for food, medicines, raw materials and packaging
materials and undertake dead bodies control and give entry or exit permit
Prepare list of medicines for the country, structure the medicines in the list into
different categories, revise the list whenever necessary
Evaluate and issue, renew, suspend, revoke or deny registration certificate for medicines
Undertake and coordinate post marketing surveillance in order to ensure the safety and
quality of food and safety, efficacy and quality of medicines that are put into use and
take appropriate measures
Authorize conducting clinical trial, monitor the process, evaluate the results and
authorize the use of the result in such a way that it benefits the public; as well as cause to
suspend or stop the clinical trial
Monitor and control manufacture, import, export, distribution, prescribing, dispersing,
use, recording and reporting of narcotic drugs, psychotropic substance and precursor
chemicals, prevent their abuse as well as report the same to the international narcotic
control board

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Undertake control of communicable diseases at entry and exit port on international
travelers, prohibit entry, exit or to be quarantined where relevant, ensure the relevant
prevention and control of trans-regional communicable diseases is done.
Ensure proper disposal of expired and unfit for use food, medicines and their
view materials
Ensure handling and disposal of trans-regional solid and liquid wastes from different
institutions are not harmful to public health
Monitor and control illegal food, medicines and health services and take
appropriate measures
Ensure the quality of trans-regional water supply for the public is up to the standard
Control, monitor and ensure the availability of necessary hygienic requirements in
health related institutions under the federal government;
Provide appropriate capacity support to regions on food, medicines and health care
regulatory bodies with a view to harmonizing federal and regional regulatory system
Perform other lawful activities as may be necessary for the attainment of
its objectives.

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References
1. World Medical Association, 2009. Medical Ethics Manual (2nd edition).
2. Thomas A. & Jane S. Zembaty, 1981. Biomedical Ethics. McGraw Hill Book.
3. Margot J. Fromer, 1981. Ethical Issues and Health Care.
4. Markotas S.G, 1994. Hippocratic medicine and philosophy at the turn of 20th century.
5. MOH, 1987. Medical Ethics for physicians practicing in Ethiopia.
6. World Medical Association, 1981. The declaration of rights of patients. Portugal.
7. 35th World Medical Assembly, 1983. International Code of Medical Ethics. Italy.
8. Public Health Leadership Society, 2002. Principle of the Ethical practice of public Health.
9. Victoria B. Nancy H., 2002. Prenatal Diagnosis. USA. Macmillan publishers.
10. Penal Code of Ethiopia, 1987. Ethiopian Code of laws and Medical Ethics.