CMT 06106 Ethics and Professionalism: United Republic of Tanzan

UNITED REPUBLIC OF TANZANIA

Ministry of Health and Social Welfare

CMT 06106 Ethics and

Professionalism

NTA Level 6 Semester 1

Student Manual

August 2010
Copyright © Ministry of Health and Social Welfare – Tanzania 2010
CMT 06106 Ethics and Professionalism NTA Level 6 Semester 1 Student Manual
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Table of Contents
Background and Acknowledgement ........................................................................ iv

Introduction .............................................................................................................. ix
Abbreviations ........................................................................................................... xi
Module Sessions
Session 1: Overview of Ethics and Professionalism..................................................1
Session 2: Human Dignity in Medical Services ........................................................7
Session 3: Moral Standards and Society ..................................................................11
Session 4: Patients Rights ........................................................................................15
Session 5: Professional Values and Provision Quality Health Services ..................19
Session 6: Workers’ Responsibility for Own Actions .............................................25
Session 7: Ethical Issues in Special Situation ..........................................................29
Session 8: Ethical Dilemmas in Medical Practice ...................................................33
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Background and Acknowledgement
In April 2009, a planning meeting was held at Kibaha which was followed up by a Task
Force Committee meeting in June 2009 at Dodoma and developed a proposal which guided
the process of the development of standardised Clinical Assistant (CA) and Clinical Officer
(CO) training materials which were based on CA/CO curricula. The purpose of this process
was to standardize the entire curriculum with up-to-date content which would then be
provided to all Clinical Assistant and Clinical Officer Training Centres (CATCs/COTCs).
The perceived benefit was that, by standardizing the quality of content and integrating
interactive teaching methodologies, students would be able to learn more effectively and that
the assessment of students’ learning would have more uniformity and validity across all
schools.
In September 2009, MOHSW embarked on an innovative approach of developing the

standardised training materials through the Writer’s Workshop (WW) model. The model
included a series of three-week workshops in which pre-service tutors and content experts
developed training materials, guided by facilitators with expertise in instructional design and
curriculum development. The goals of WW were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials.
The new training package for CA/CO cadres includes a Facilitator Guide, Student Manual
and Practicum. There are 40 modules with approximately 600 content sessions. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders and
experts of different organizations and institutions, from within and outside the country.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these materials for CA /CO cadres. We would first like to
thank the U.S. Centers for Disease Control and Prevention’s Global AIDS Program
(CDC/GAP) Tanzania, and the International Training and Education Center for Health (I-
TECH) for their financial and technical support throughout the process. At CDC/GAP, we
would like to thank Ms. Suzzane McQueen and Ms. Angela Makota for their support and
guidance. At I-TECH, we would especially like to acknowledge Ms. Alyson Shumays,
Country Program Manager, Dr. Flavian Magari, Country Director, Mr. Tumaini Charles,
Deputy Country Director, and Ms. Susan Clark, Health Systems Director. The MOHSW
would also like to thank the World Health Organization (WHO) for technical and financial
support in the development process.
Particular thanks are due to those who led this important process: Dr. Bumi L.A.
Mwamasage, the Assistant Director for Allied Health Sciences Training, Dr. Mabula Ndimila
and Mr. Dennis Busuguli, Coordinators of Allied Health Sciences Training, Ministry of
Health and Social Welfare, Dr. Stella Kasindi Mwita, Programme Officer Integrated
Management of Adults and Adolescent Illnesses (IMAI), WHO Tanzania and Stella M.
Mpanda, Pre-service Programme Manager, I-TECH.
Sincere gratitude is expressed to small group facilitators: Dr. Otilia Gowele, Principal, Kilosa
COTC, Dr. Violet Kiango, Tutor, Kibaha COTC, Ms. Stephanie Smith, Ms. Stephanie
Askins, Julie Stein, Ms. Maureen Sarewitz, Mr. Golden Masika, Ms. Kanisia Ignas, Ms.
Yovitha Mrina and Mr. Nicholous Dampu, all of I-TECH, for their tireless efforts in guiding
participants and content experts through the process. A special note of thanks also goes to
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Dr. Julius Charles and Dr. Moses Bateganya, I-TECH’s Clinical Advisors, and other Clinical
Advisors who provided input. We also thank individual content experts from different
departments of the MOHSW and other governmental and non-governmental organizations,
including EngenderHealth, Jhpiego and AIHA, for their technical guidance.
Special thanks goes to a team of I-TECH staff namely Ms. Lauren Dunnington, Ms.
Stephanie Askins, Ms. Stephanie Smith, Ms Aisling Underwood, Golden Masika, Yovitha
Mrina, Kanisia Ignas, Nicholous Dampu, Michael Stockman and Stella M. Mpanda for
finalising the editing, formatting and compilation of the modules.
Finally, we very much appreciate the contributions of the tutors and content experts
representing the CATCs/COTCs, various hospitals, universities, and other health training
institutions. Their participation in meetings and workshops, and their input in the
development of content for each of the modules have been invaluable. It is the commitment
of these busy clinicians and teachers that has made this product possible.
These participants are listed with our gratitude below:
Tutors
Ms. Magdalena M. Bulegeya – Tutor, Kilosa COTC
Mr. Pius J.Mashimba – Tutor, Kibaha Clinical Officers Training Centre (COTC)
Dr. Naushad Rattansi – Tutor, Kibaha COTC
Dr. Salla Salustian – Principal, Songea CATC
Dr. Kelly Msafiri – Principal, Sumbawanga CATC
Dr. Joseph Mapunda - Tutor, Songea CATC
Dr. Beda B. Hamis – Tutor, Mafinga COTC
Col Dr. Josiah Mekere – Principal, Lugalo Military Medical School
Mr. Charles Kahurananga – Tutor, Kigoma CATC
Dr. Ernest S. Kalimenze – Tutor, Sengerema COTC
Dr. Lucheri Efraim – Tutor, Kilosa COTC
Dr. Kevin Nyakimori – Tutor, Sumbawanga CATC
Mr. John Mpiluka – Tutor, Mvumi COTC
Mr. Gerald N. Mngóngó –Tutor, Kilosa COTC
Dr. Tito M. Shengena –Tutor, Mtwara COTC
Dr. Fadhili Lyimo – Tutor, Kilosa COTC
Dr. James William Nasson– Tutor, Kilosa COTC
Dr. Titus Mlingwa – Tutor, Kigoma CATC
Dr. Rex F. Mwakipiti – Principal, Musoma CATC
Dr. Wilson Kitinya - Principal, Masasi ( Clinical Assistants Training Centre (CATC)
Ms. Johari A. Said – Tutor, Masasi CATC
Dr. Godwin H. Katisa – Tutor, Tanga Assistant Medical Officers Training Centre (AMOTC)
Dr. Lautfred Bond Mtani – Principal, Sengerema COTC
Ms Pamela Henry Meena – Tutor, Kibaha COTC
Dr. Fidelis Amon Ruanda – Tutor, Mbeya AMOTC
Dr. Cosmas C. Chacha – Tutor, Mbeya AMOTC
Dr. Ignatus Mosten – Ag. Principal, Tanga AMOTC
Dr. Muhidini Mbata – Tutor, Mafinga COTC
Dr. Simon Haule – Ag. Principal, Kibaha COTC
Ms. Juliana Lufulenge - Tutor, Kilosa COTC
Dr. Peter Kiula – Tutor, Songea CATC
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Mr. Hassan Msemo – Tutor, Kibaha COTC
Dr. Sangare Antony –Tutor, Mbeya AMOTC
Content Experts
Ms. Emily Nyakiha – Principal, Bugando Nursing School, Mwanza
Mr. Gustav Moyo - Registrar, Tanganyika Nursesand Midwives Council, Ministry of Health
and Social Welfare (MOHSW).
Dr. Kohelet H. Winani - Reproductive and Child Health Services, MOHSW
Mr. Hussein M. Lugendo – Principal, Vector Control Training Centre (VCTC), Muheza
Dr. Elias Massau Kwesi - Public Health Specialist, Head of Unit Health Systems Research
and Survey, MOHSW
Dr. William John Muller - Pathologist, Muhimbili National Hospital (MNH)
Mr. Desire Gaspered - Computer Analyst, Institute of Finance Management (IFM), Dar es
Salaam
Mrs. Husna Rajabu - Health Education Officer, MOHSW
Mr. Zakayo Simon - Registered Nurse and Tutor, Public Health Nursing School (PHNS)
Morogoro
Dr. Ewaldo Vitus Komba - Lecturer, Department of Internal Medicine, Muhimbili University
of Health and Allied Sciences School (MUHAS)
Mrs. Asteria L.M. Ndomba - Assistant Lecturer, School of Nursing, MUHAS
Mrs. Zebina Msumi - Training Officer, Extended programme on Immunization (EPI),
MOHSW
Mr. Lister E. Matonya - Health Officer, School of Environmental Health Sciences (SEHS),
Ngudu, Mwanza.
Dr. Joyceline Kaganda - Nutritionist, Tanzania Food and Nutrition Centre (TFNC),
MOHSW.
Dr. Suleiman C. Mtani - Obstetrician and Gynecologist, Director, Mwananyamala Hospital,
Dar es salaam
Mr. Brown D. Karanja - Pharmacist, Lugalo Military Hospital
Mr. Muhsin Idd Nyanyam - Tutor, Primary Health Care Institute (PHCI), Iringa
Dr. Judith Mwende - Ophthalmologist, MNH
Dr. Paul Marealle - Orthopaedic and Traumatic Surgeon, Muhimbili Orthopedic Institute
(MOI),
Dr. Erasmus Mndeme - Psychiatrist, Mirembe Refferal Hospital
Mrs. Bridget Shirima - Nurse Tutor (Midwifery), Kilimanjoro Chrician Medical Centre
(KCMC)
Dr. Angelo Nyamtema - Tutor Tanzania Training Centre for International Health (TTCIH),
Ifakara.
Ms. Vumilia B. E. Mmari - Nurse Tutor (Reproductive Health) MNH-School of Nursing
Dr. David Kihwele - Obs/Gynae Specialist, and Consultant
Dr. Amos Mwakigonja – Pathologist and Lecturer, Department of Morbid Anatomy and
Histopathology, MUHAS
Mr. Claud J. Kumalija - Statistician and Head, Health Management Information System
(HMIS), MOHSW
Ms. Eva Muro, Lecturer and Pharmacist, Head Pharmacy Department, KCMC
Dr. Ibrahim Maduhu - Paediatrician, EPI/MOHSW
Dr. Merida Makia - Lecturer Head, Department of Surgery, MNH
Dr. Gabriel S. Mhidze - ENT Surgeon, Lugalo Military Hospital
Dr. Sira Owibingire - Lecturer, Dental School, MUHAS
Mr. Issai Seng’enge - Lecturer (Health Promotion), University of Dar es Salaam (UDSM)
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Prof. Charles Kihamia - Professor, Parasitology and Entomology, MUHAS
Mr. Benard Konga - Economist, MOSHW
Dr. Martha Kisanga - Field Officer Manager, Engender Health, Dar es Salaam
Dr. Omary Salehe - Consultant Physician, Mbeya Referral Hospital
Ms Yasinta Kisisiwe - Principal Nursing Officer, Health Education Unit (HEU), MOHSW
Dr. Levina Msuya - Paediatrician and Principal, Assistant Medical Officers Training Centre
(AMOTC), Kilimanjaro Christian Medical Centre (KCMC)
Dr. Mohamed Ali - Epidemiologist, MOHSW
Mr. Fikiri Mazige - Tutor, PHCI-Iringa
Mr. Salum Ramadhani - Lecturer, Institute of Finance Management
Ms. Grace Chuwa - Regional RCH Coordinator, Coastal Region
Mr. Shija Ganai - Health Education Officer, Regional Hospital, Kigoma
Dr. Emmanuel Suluba - Assistant Lecturer, Anatomy and Histology Department, MUHAS
Mr. Mdoe Ibrahim - Tutor, KCMC Health Records Technician Training Centre
Mr. Sunny Kiluvia - Health Communication Consultant, Dar es Salaam
Dr. Nkundwe Gallen Mwakyusa - Ophthalmologist, MOHSW
Dr. Nicodemus Ezekiel Mgalula -Dentist, Principal Dental Training School, Tanga
Mrs. Violet Peter Msolwa - Registered Nurse Midwife, Programme Officer, National AIDS
Control Programme (NACP), MOHSW
Dr. Wilbert Bunini Manyilizu - Lecturer, Mzumbe University, Morogoro
Editorial Review Team

Dr. Kasanga G. Mkambu - Obstertric and Gynaecology specialist, Tanga Assistant Medical
Officers Training Centre (AMOTC)
Dr. Ronald Erasto Msangi - Principal, Bumbuli COTC
Mr. Sita M. Lusana - Tutor, Tanga Environmental Health Science Training Centre
Mr. Ignas Mwamsigala - Tutor (Entrepreneurship) RVTC Tanga
Mr. January Karungula - RN, Quality Improvement Advisor, Muhimbili National Hospital
Prof. Pauline Mella - Registered Nurse and Profesor, Hubert Kairuki Memorial University
Dr. Emmanuel A. Mnkeni – Medical Officer and Tutor, Kilosa COTC
Dr. Ronald E. Msangi - Principal, Bumbuli COTC
Mr. Dickson Mtalitinya - Pharmacist, Deputy Principal, St Luke Foundation, Kilimanjaro
School of Pharmacy
Dr. Janeth C. Njau - Paediatrician/Tutor, Kibaha COTC
Mr. Fidelis Mgohamwende - Labaratory Technologist, Programme Officer National Malaria
Control Programme (NMCP), MOHSW
Mr. Gasper P. Ngeleja - Computer Instructor, RVTC Tanga
Dr. Shubis M Kafuruki - Research Scientist, Ifakara Health Institute, Bagamoyo
Dr. Andrew Isack Lwali - Director, Tumbi Hospital
Librarians and Secretaries

Mr. Christom Aron Mwambungu - Librarian MUHAS
Ms. Juliana Rutta - Librarian MOHSW
Mr. Hussein Haruna - Librarian, MOHSW
Ms. Perpetua Yusufu - Secretary, MOHSW
Mrs. Martina G. Mturano -Secretary, MUHAS
Mrs. Mary F. Kawau - Secretary, MOHSW
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IT support
Mr. Isaac Urio - IT Consultant, I-TECH
Mr. Michael Fumbuka - Computer Systems Administrator – Institute of Finance and
Management (IFM), Dar es Salaam

Dr. Gilbert Mliga
Director of Human Resources Development, Ministry of Health and Social Welfare
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Introduction
Module Overview
This module content has been prepared to enhance learning of students of Clinical Assistant
(CA) and Clinical Officer (CO) schools.. The session contents are based on the sub-enabling
outcomes of the curricula of CA and CO. The module sub-enabling outcomes are as follows:
3.1.3 Take responsibility for own actions, including errors, recognition and acceptance of
limitations and need for supervision and self-assessment
4.3.1 Describe challenges to medical professionalism caused by conflicts of interests and
business practice
4.3.2 Demonstrate accountability to patients, society and profession
4.3.3 Adhere to professional ethics and standards in health care delivery
Who is the Module For?

This module is intended for use primarily by students of CA and CO schools. The module’s
sessions give guidance on contents and activities of the session and provide information on
how students should follow the tutor when he/she teaches the module. It also provides
guidance and necessary information for students to read the materials on his/her own. The
sessions also include different activities which focus on increasing students’ knowledge,
skills and attitudes.
How is the Module Organized?

The module is divided into 8 sessions; each session is divided into several sections. The
following are the sections of each session:
• Session Title: The name of the session.
• Learning Objectives – Statements which indicate what the student is expected to have
learned at the end of the session.
• Session Content – All the session contents are divided into subtitles. This section
includes contents and activities with their instructions to be done during learning of the
contents.
• Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
• Evaluation – The last section of the session consists of short questions based on the
learning objectives to check if you understood the contents of the session. The tutor will
ask you as a class to respond to these questions; however if you read the session by
yourself try answering these questions to evaluate yourself if you understood the session.
• Handouts – Additional information which can be used in the classroom while the tutor is
teaching or later for your further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the students to study material on their own and to reference after the session. Sometimes,
a handout will have questions or an exercise for students to answer.
How Should the Module be Used?

• Students are expected to use the module in the classroom and clinical settings and during
self study. The contents of the modules are the basis for learning Ethics and
Professionalism. Students are therefore advised to learn all the sessions including all
relevant handouts and worksheets during class hours, clinical hours and self study time.
Tutors are there to provide guidance and to respond to all difficulty encountered by
students. One module will be assigned to 5 students and it is the responsibility of the
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tutor to do this assignment for easy use and accessibility of the student manuals to
students.
x
Abbreviations
AIDS Acquired Immune Deficiency Syndrome
CHMT Committee for Health Management Team
CMT Clinical Medicine Technical Award
HIV Human Immunodeficiency Syndrome
HMO Health Management Organizations
NTA National Technical Award
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Session 1: Overview of Ethics and Professionalism
Learning Objectives
By the end of this session, students are expected to be able to:
• Explain professionalism in clinical medicine practice
• Identify the characteristics of a profession
• Describe the code of ethics for medical profession
• Recognize the roles of professional associations and licensing bodies
Explanation of the Term Profession

• The words ‘profession’ and ‘professional’ come from the Latin word ‘professio’ which
means a public declaration with the force of a promise.
• Professions are groups which declare in a public way that their members promise to in
certain ways and that the group and the society may discipline those who fail to do so.
• The profession presents itself to society as a social benefit and society accepts the
profession, expecting it to serve some important social goal.
• The profession usually issues a code of ethics stating the standards by which its members
can be judged.
• It is a vocation in which knowledge of some department of science or learning, or the
practice of an art founded on it, is used in the service of others.
• Its members profess a commitment to competence, integrity, morality, humanity, and the
promotion of the public good within their domain.
• These commitments form the basis of a social contract between a profession and society,
which in return grants the profession autonomy in practice and the privilege of self-
regulation.
• Professions and their members are accountable to those served and to society.
• Medical professionalism differs from other professions in both content and motivation.
• It is a service profession dedicated to patients, centering on the doctor-patient
relationship.
• Medicine seeks the prevention of disease and injury, the promotion and maintenance of
health, the relief of pain and suffering, the care and cure of those with illness, the
avoidance of premature death, and the pursuit of a peaceful death.
• The true professionalism in medicine will always put in first place the well-being of the
patient and the community as principal objective.
• Medicine is a moral endeavour which demands integrity, competence, and high ethical
standards among other key attributes.
• Medical professionalism embodies the relationship between medicine and society as it
forms the basis of patient-physician trust.
• It attempts to make tangible certain attitudes, behaviours, and characteristics that are
desirable among the medical profession.
Characteristics of a Profession
• Body of knowledge
o Usually the knowledge is not easily understood by the public, and consequently the
professions are given substantial control over its use.
CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Session 1: Overview of Ethics and Professionalism 1
o They acquire responsibility for its integrity, for its proper application, and for its
expansion, which for medicine, means the support of science.
o Professions have an obligation to transmit their knowledge by teaching it to future
practitioners, the general public, and their patients.
• Service
o The knowledge is used in the service of others.
o Clinicians use their knowledge primarily to benefit individual patient.
• Altruism
o There is agreement that the trust placed in the professions and their privileged status
are only justified by the expectation that they will be altruistic.
o For clinicians this means consistently placing the interests of individual patients and
society above their own.
o Professions must be devoted to the public good.
• Autonomy
o This is another important characteristic of a profession.
o Individually, clinicians are granted sufficient autonomy to act in the best interests of
their patients.
o In the early days, autonomy was expressed in a paternalistic fashion, but modern
society, recognising patient autonomy, now views the clinician-patient relationship as
a partnership.
o The profession is also granted collective autonomy through self-regulation.
o It has the privilege and obligation to set and maintain standards for education and
training, entry into practice, and the standards of practice.
o It must guarantee the competence of its practitioners, and has an absolute obligation to
discipline unprofessional, incompetent, or unethical conduct.
o This means that professionals have a particularly strict duty to assure that their
decisions and actions serve the welfare of their patients or clients, even at some cost
to themselves.
• Code of ethics
o Professions have codes of ethics which specify the obligations arising from their duty.
o Professionalism requires that the practitioner strive for excellence in the following
areas which should be modelled by mentors and teachers and become part of the
attitudes, behaviours, and skills integral to patient care:
Altruism: Clinician is obligated to attend to the best interest of patients, rather
than self-interest.
Accountability: Clinicians are accountable to their patients, to society on issues of
public health, and to their profession.
Excellence: Clinicians are obligated to make a commitment to life-long learning.
Duty: Clinicians should be available and responsive when ‘on call,’ accepting a
commitment to service within the profession and the community.
Honour and integrity: Clinicians should be committed to being fair, truthful and
straightforward in their interactions with patients and the profession.
Respect for others: A Clinician should demonstrate respect for patients and their
families, other physicians and team members, medical students, residents and
fellows.
These values should provide guidance for promoting professional behaviour and
for making difficult ethical decisions.
o One of the principal attributes of professionalism is independent judgment about
technical matters relevant to the expertise of the profession.

o The purpose of this independent judgment is to assure that general technical
knowledge is appropriately applied to particular cases.
Code of Ethics for the Medical Profession
Activity: Small Group Discussion
Instructions
You will work in small groups to discuss the ‘code of ethics for medical profession’ for 5
minutes. One group will present their responses and other groups will share in discussion.
• Clinicians’ dual roles-as healer and professional-are linked by codes of ethics governing
behaviour and are empowered by science.
• Being part of a profession entails a societal contract.
• The profession is granted a monopoly over the use of a body of knowledge and the
privilege of self-regulation and, in return, guarantees society professional competence,
integrity and the provision of altruistic service.
• Societal attitudes to professionalism have changed from supportive to increasingly critical
with health workers being criticised for pursuing their own financial interests, and failing
to self-regulate in a way that guarantees competence.
• Professional values are also threatened by many other factors.
• The most important are the short of resources in the health care delivery, and
dissatisfaction from the public on service provided.
• In order for professionalism to survive, health professionals must understand that service
to the public is their role in the social contract.
• Professionals must meet the obligations necessary to sustain professionalism and ensure
that healthcare systems support, rather than weakening, behaviour that is compatible with
professionalism's values.
• The principal threats to professional status come from public mistrust of the profession as
a whole.
• Two major factors contribute to this mistrust public perception that health profession
failed to self regulate in a way that can guarantee competence, and that it put its own
interest above that of patients and the public.
• The profession presents itself to society as a social benefit and society accepts the
profession, expecting it to serve some important social goal.
• The profession usually issues a code of ethics stating the standards by which its members
can be judged.
• The fundamental principles of professionalism are stated as the primacy of patient
welfare, patient autonomy and social justice.
• Professional responsibilities that follow from these principles are commitment to
competence, to honesty with patients, to confidentiality, to appropriate relationship with
patients, to improving quality of care, to improving access to care, to a just distribution of
limited resources, to scientific knowledge, to maintaining trust by managing conflicts of
interests and to professional responsibilities.
• Individual clinician must consider the consequences of being seen to put self-interest
above that of their patient.
• Altruism and ethical conduct must serve as the backbone against which medicine is
practised.

• Accountability: All health professional are accountable to their patients and to their
profession, accountable for patient care and self-regulation.
• Morality and integrity: The professions are expected to be moral, ethical, and carry out
their activities with integrity.
Professional Responsibility
• Any professional health worker has the following responsibilities
o Professional competence
o Honesty with patients
o Patient confidentiality
o Appropriate relations with patients
o Improve quality of care
o Improve access to care
o Just (fair) distribution of resources
o Scientific knowledge
o Manage conflicts of interest
Roles of Professional Associations and Licensing Bodies

• Professional associations and licensing bodies are characteristics of all professions.
o They operate under government authority, which may be altered if society becomes
dissatisfied with their performance.
• The role of professional bodies in self-regulation is major, as is the expectation that they
will advise the public as experts in their domain.
• The associations and licensing bodies have a primary role in guaranteeing the quality of
healthcare services.
• Medical associations also have an obligation to protect the interests of their individual
members.
• Function of professional associations is so important; they require the support of their
members.
• Each health worker is responsible for the actions of their associations.
• Professional associations and licensing bodies must not engage in activities which detract
from the morality and integrity of the profession.
• Morality and virtue must be integral to the rules, processes and procedures by which
Medicine governs and regulates itself.
• Medicine's professional associations must be extremely wise in how they negotiate for
their members.
• Any hint that the public good is being ignored during these negotiations can be damaging
to the credibility of the profession and result in loss of the trust, which is so essential to
the healing process.
• The privilege of self-regulation entails an absolute obligation to guarantee the
competence of members.
• The setting and maintenance of standards is of overriding importance, and issues such as
recertification and revalidation are, without question, now regarded as professional
obligations.
• The disciplining of unethical or incompetent practitioners must be rigorous, open, and
have the support of every practising clinician.
• Not only are individual clinicians are expected to demonstrate morality and virtue, but so
are the institutions which represent them.

Key Points
• The principal objective of true professionalism in health is to put in first place the well-
being of the patients and the community.
• Medicine is a moral endeavour which demands integrity, competence, and high ethical
standards among other key attributes.
• Medical professionalism embodies the relationship between medicine and society to make
tangible certain attitudes, behaviours, and characteristics that are desirable among the
medical profession.
• The fundamental principles of professionalism are the foundation of patient welfare;
patient autonomy and social justice.
• The associations and licensing bodies have a primary role in guaranteeing the quality of
healthcare services.
Evaluation
• What is a profession?
• What are the characteristics of a profession?
• What are professional responsibilities?
• What are the roles of professional bodies?
References
• Emanuel, E.J. (1996), Emanuel LL. What is Accountability in Health Care? Ann Intern
Med. 124:229–239.
• Ham, C. & Alberti, K.G. (2002). The Medical Profession, the Public, and the
Government. BMJ.324:838–842.
• Kultgen, J.H. (1988). Ethics and Professionalism. Philadelphia: University of
Pennsylvania Press.
• Mechanic, D. (1996). Changing Medical Organization and the Erosion of Trust. Milbank
Q. 74:171–189.
• Moran, M. & Wood, B. (1993). States, Regulation and the Medical Profession.
Buckingham: Open University Press.
• Pellegrino, E.D. (1991). Trust and Distrust in Professional Ethics. In Pellegrino (ed.)
Veatch R.M.,& Langen JP, (ed.). Ethics, Trust, and the Professions. Washington, DC:
Georgetown University Press, pp. 69–85.
• Pellegrino, E.D. & Relman, A. (1999). Professional Medical Associations: Ethical and
Practical Guidelines. JAMA. 282:1954–1956.
• Sohl, P, and Bessford, R. (1980). Codes of medical ethics: Traditional Foundations and
Contemporary Practice. Soc Sci Med. 22:1175–1179.

Session 2: Human Dignity in Medical Services
Learning Objectives
• Explain the term human dignity
• Recognize challenges of human dignity in medical science
• Describe approaches to uphold human dignity in health services
Human Dignity
• Dignity is a term used in moral, ethical, and political discussions to signify that a human
being has an innate right to respect and ethical treatment.
• Individuals have inherent, inviolable rights, and thus are closely related to concepts like
virtue, respect, self-respect, autonomy, human rights, and enlightened reason.
• Human dignity is the innermost and social right to respect with regard to values and
dignity, and to which each and every person is entitled purely because they are human.
• Every person is born with human dignity and it cannot be lost, the unborn and the dead
are also entitled to it.
• Respect of human dignity means the health professionals must constantly respect people
as persons, it may not regard people as being available for use for acts of the scientific
research, and may not misuse people as an ends to a means.
• Protection of human dignity means that the health professionals must do everything in its
power to counter violations of human dignity including those through third parties.
• The dignity of the human person is not only a fundamental right in itself but constitutes
the real basis of fundamental rights.
• Recognition of the inherent dignity and of the equal and indisputable rights of all
members of the human family is the foundation of freedom, justice and peace in the
world.
• Core element of humans is that each human is seen as own character, unique and central
basic right.
Challenges of Human Dignity in Medical Science

• In medical practice challenges of human dignity originates from the challenges of modern
technological and modern science.
• Modern medicine is leading in achievements in biomedical science and technology
becoming more powerful in its battle against diseases and death.
• Advances in genetic and reproductive technologies, in neuroscience and
psychopharmacology, in the development of artificial organs and computer-chip implants
for human brains, and in research to control biological aging, we now clearly recognize
new uses for biotechnical power beyond the traditional medical goals of healing disease
and relieving suffering which can be a challenge to medical ethics.
• Science promises new and effective routes to better children, superior performance,
ageless bodies, and happy souls.
• For anyone who cares about preserving our humanity, the time has come to pay attention
to human dignity and human rights.
• Examples of advanced technology leading to question about the respect to human dignity
o Invitro fertilization

Session 2: Human Dignity in Medical Services 7
o Genetic screening
o Genetic manipulation
o Organ transplant
• Although these scientific advancement are not currently available in our society, but is
necessary for us to be aware of their existence and to start discussion right now on their
respect to human dignity.
Approaches to Uphold Human Dignity in Health Services
Instructions
Work in small–sized groups to discuss approaches to use in upholding human dignity in
health services. One group will present their responses and other groups will share in the
discussion.
• Human dignity is the conceptual basis for human rights.

• All humans should be treated with love and respect simply because they are humans and
regardless of class, race, gender, nationality, culture, sex, education, religion or any other
divisions.
• Human dignity is inherent in the human.
• Every individual shall have the right to the respect of the dignity inherent in a human
being.
• All human beings are born free and equal in dignity and rights.
• Humans are endowed with reason and conscience and should act towards one another in a
spirit of love and peace.
• Every human being should be acknowledged as an inherently valuable member of the
human community and as a unique expression of life.
• Health practitioners are expected to respect human dignity and in so doing they refrain for
doing unethical conducts that ignore the dignity of the human.
• All health personnel must respect the human being both as an individual and as a member
of the human species and recognizing the importance of ensuring the dignity of the
human being.
• Health professions should safeguard human dignity and the fundamental rights and
freedoms of the individual with regard to the application of biology and medicine.
• Health professionals must respect for human dignity that must guide both the
development of knowledge and the limits or rules to be observed by research.
• The law of Tanzania prohibits the willful destruction of human embryos (induced
abortion) but directed that human embryos could be destroyed under medical grounds.
• All humans should be treated with love and respect simply because they are humans and
regardless of class, race, gender, nationality, culture, sex, education, religion or any other
divisions.
• Human dignity should not have to be earned; it is inherent in the human.
• Human dignity is the idea that every human has inherent worth.
• All health professionals should strive to respect this right.

Key Points
• Dignity is a term used in moral, ethical and political discussions to signify that a being
has an innate right to respect and ethical treatment.
• Challenges of human dignity originate, from challenges of modern technological projects
and the pride of modern science.
• Health practitioners are expected to respect human dignity and refrain from doing
unethical conducts that ignore the dignity of the human.
Evaluation
• What is human dignity?
• What are the challenges of human dignity in medical science?
• What are the approaches to uphold human dignity in health services?
References
• Aldergrove, J. R. (2000). Why We Are Not Obsolete Yet. Genetics, Algeny, and the Future
(Stentorian: Burnaby) at 71.
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007) Ethics and Issues in Contemporary
Nursing. (3rd ed.) New York: Thomson.
• Devettere, R.J. (1995). Practical Decision Making in Health care Ethics: Cases and
Concepts. Washington DC: Georgetown.
• Egonsson, D. (1998). Dimensions of Dignity: The Moral Importance of Being Human.
Dordrecht, Sweden: Kluwer Academic.
• Furrow, D. (2005). Ethics: Key Concepts in Philosophy. New York, Continuum
• Knoppers, B.M. (1991). Human Dignity and Genetic Heritage: Study Paper (Law Reform
Commission of Canada) note, at 23.
• Mason, J.K., McCall Smith R.A. & Laurie, G.T. (1999). Law and Medical Ethics.
London: Butterworths
• Myres S., McDougal, Harold D., et al. (1980). Rights and World Public Order: The Basic
Policies of an International Law of Human Dignity. New Haven: Yale UP at 376.
• Wertheimer, R. (1974). Philosophy on Humanity in Abortion: Pro and Con, R. L. Perkins
(Ed.). Cambridge, Mass.: Schenkman, 107-28.
• World Medical Association (2009). Medical Ethics Manual (2nd ed.). France: World
Medical Association.

Session 3: Moral Standards and Society
Learning Objectives
• Explain the social role of a profession
• Identify the reasons for conflicts between health professionals and society
• Describe health personnel obligations to patients and society
• Describe the challenges of dual loyalty
• Describe the challenges of resource allocation
• Describe clinicians ethical responsibilities in public health issues
Social Role of a Profession

• The social role of a profession is to prepare practitioners with the knowledge and skill
necessary for the practice of that profession.
• The public must be able to trust the profession and believe that all its members will
possess a particular level and quality of knowledge and skill.
• The public should trust members of the profession as:
o Persons with high moral standards.
o Having genuine desire to help those who are in need of their service and that will do
so with integrity and compassion.
o Persons characterized by a particular set of moral virtues and ethical guidelines that
they exercise even when unobserved.
• These requirements are necessary in order for social trust (sometimes called a social
contract) to exist.
• The professionals must be competent in both knowledge and technique of its practice.
• The professionals must continue to learn throughout life, to practice with virtue, to seek to
enhance the knowledge base of the profession itself and to observe the moral guidelines
of the profession.
• Thus both the education and professional associations are essential to the moral life and
excellence of the profession.
Reasons for Conflicts Between Health Professionals and Society

• Unethical behaviour of the clinician
o Drunkardness during working hours
o Soliciting bribery (including sexual favours)
o Harsh language to patients/clients
o Favouritism (biasness)
o Putting your interests ahead of those of patients/clients
o Superiority/inferiority complexes
o Not adhering to privacy and confidentiality of patients information
• Community Factors
o Over expectation of the patients/clients from a clinician. (Some health issues not
managed by the clinician - too difficult for him/her)
o Negative attitudes of the community towards clinician (tribalism)
o Religious segregation

Session 3: Moral Standards and Society 11
o Gender sensitivity
o Personal grudges
o Political biasness
Obligations to Patients and to Society

• Medicine is a profession and the term ‘profession’ has two distinct, although closely
related meanings:
o An occupation that is characterized by dedication to the well-being of others, high
moral standards, and a body of knowledge and skills, and high level of autonomy.
o Individuals who practice that occupation.
• Medical profession involves not just the relationship between a clinician and a patient,
and relationship with colleagues and other health professionals but it also involves a
relationship with society.
• This relationship can be characterized as a social contract whereby society grants the
profession privileges, including exclusive or primary responsibility for the provision of
certain services and high degree of self-regulation, and in return, the profession agrees to
use these privileges primarily for the benefits of others and only secondarily for its own
benefit.
• Medicine is today, more than ever before, a social rather than strictly individual activity.
The Medical Profession and Society

• The term society refers to the community or nation.
• It is not synonymous with government, government not always representing the interests
of the society, but even when they do, they are acting for society, not as society.
• Clinicians are also called upon to play a major role in the allocation of society’s scarce
healthcare resources, and sometimes they have a duty to prevent patients from accessing
services to which they are not entitled.
• Implementing these responsibilities can raise ethical conflict, especially when the interest
of the society seems on conflict with those of the individual patients.
Challenge of Dual Loyalty

• When clinicians have responsibility and are accountable both to their patients and to a
third party and when these responsibilities and accountabilities are incompatible, they
find themselves in a situation of dual loyalty.
• Third parties that demands clinicians’ loyalty include governments, employers, insurers,
military officials, police, prisons officials and family members including the law.
• It is generally accepted that medical practitioners may in exceptional situations have to
place the interests of others above those of the patient.
• The ethical challenge is how and when to protect the patient and face the pressure from
third parties.
• At one end of spectrum are requirements for mandatory reporting of patients who suffer
from designated diseases such as cholera and HIV although patients should be informed
that such reporting will take place.
• Clinicians should report to appropriate authorities any unjustified interference in the care
of their patients, especially if fundamental human rights are being denied.
• They should resolve any conflict between their own interest and those of their patients in
their patients favour.
• Conflict of interest can happen when the clinician has been supported by a
pharmaceutical company or medical devices manufacturers.

• A common underlying motive for such company is to convince the clinician to prescribe
or use the company’s products, which may not be the best one for the patients and may
add unnecessary cost.
Challenge of Resource Allocation

• Justice entails a more social approach to the distribution of resources, one that considers
the needs for other patients.
• According to this approach, clinicians are responsible not just for their own patient but, to
a certain extent, for others as well.
• In circumstances where a choice must be made between potential patients for a particular
treatment which is in limited supply, all such 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 clinicians can exercise their responsibility for the allocation of resources is by
avoiding wasteful and inefficient practices, even when patients request them to do so.
• The overuse of antibiotics is just one example of a practice that is both wasteful and
harmful.
• Clinicians have a moral responsibility to advocate for expansion of these resources where
they are insufficient to meet patient’s needs.
• This usually requires that clinicians work together, in their professional association, to
convince decision makers in government and elsewhere of the existence of these needs
and how best to meet them.
Ethical Responsibilities in Public Health Issues

• Public health measures such as vaccination campaigns and emergency responses to
outbreaks of contagious diseases are important factors in the health of individuals but
social factors such as housing, nutrition and employment are equally significant.
• Clinicians can contribute, even if indirectly, to long term solutions of health problems by
participating in public health and health education activities, monitoring and reporting
environmental hazards.
• Clinicians should attempt to find ways to minimize any harm that individual patient may
suffer as a result of meeting public health requirements.
• When reporting is required, the patient’s confidentiality should be protected to the
greatest extent possible while fulfilling the legal requirement.
Key Points
• Clinicians should resolve any conflict between their interests and those of their patient.
• One way clinicians can exercise their responsibility for allocation of resource is by
avoiding wasteful inefficiency practices even when patient request them.
• Clinicians have to participate in solving health problem in public health and health
education activities, monitoring and reporting environmental hazards.
Evaluation
• What are the causes of conflict between the clinician and the community?
• What are the challenges of dual loyalty?
• What are the challenges that can be encountered during allocation of medical resources?

References
• Beauchamp, T.L. and Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New
York: Oxford University Press.
• International Ethics Guidelines for Biomedical Research Involving Human Subject,
CIOMS, Geneva, 1993.
• Mellish, J.M. & Paton, F. (1999). An Introduction to the Ethics of Nursing. Capetown:
Heinemenn.
• Tanzania National Health Research Forum (2001). Guidelines on Ethics for Health
Research in Tanzania.

Session 4: Patients Rights
Learning Objectives
• Define the term patient rights
• Name five patient rights
• Describe how to meet patients rights in the provision of health services
Explanation of Patient Rights

• Patient rights encompass legal and ethical issues in the provider-patient relationship and
include person's right to privacy; the right to quality medical care without prejudice; the
right to make informed decisions about care and treatment options, and the right to refuse
treatment.
• Many issues comprise the rights of patients in the medical system, including a person's
ability to sue a health care provider; access to emergency and specialty care, diagnostic
testing, and prescription of medication without prejudice; confidentiality and protection
of patient’s medical information; and continuity of care.
• Besides basic rights of care and privacy, is the education of patients concerning what to
expect of their health care facility and its providers.
Recognition of Patient Rights

• The right of individuals to be treated with respect and dignity.
• The rights of the individual to life, liberty, and security.
• The right of individuals to have their religious and cultural identity respected.
• The right to a competent professional and quality care.
• The right to an appropriate standard of care to meet individual needs.
• The right to privacy and confidentiality, which includes access to medical records upon
request.
• The right to personal safety self-determination.
• The right to be recognized as human beings who are social beings with social needs.
• The right to participate in the development and implementation of the plan of care.
• The right to be informed about condition, treatment options, and the possible results and
side effects of treatment.
• The right to refuse treatment in accordance with the law, and receive information about
the consequences of refusal.
• The right to quality health care without discrimination because of race, creed, gender,
religion, national origin, or source of payment.
• The right to know the identity of the person treating the patient, as well as any
relationship between professionals and agencies involved in the treatment.
• The right to informed consent for all procedures, including the medical records by the
patient or by the patient's legally authorized representative and hospital charges.
• The right to consultation and communication freely without fear.
• The right to complain or compliment without the fear of compromising access to quality
care.

Session 4: Patient Rights 15
• Together with these rights the patient has a responsibility to follow the plan of care
agreed upon, and providing relevant, complete and accurate health information.
• The patient is further responsible for consequences of refusal of treatment, of not
following the rules and regulations of a hospital, and of not being considerate of others'
rights.
Meeting Patient Rights in the Provision of Health Services

Instructions
You will work in small groups to discuss how patient rights can be met in the health
facility during provision of health services. One group will present their responses and
other groups will share in the discussion.
• In accordance to patient rights health care providers have the obligation to adhere to these
patients rights.
• Each provider has to adhere to ethical code of practice and has responsibilities for
provision of quality of care as guided below.
The Right of Individuals to be Treated with Respect and Dignity

• Health providers should promote an environment that engenders mutual respect including
respect for the dignity and rights of all concerned.
The Right of Individuals to Life, Liberty and Security

• Promote emotional security, provide physical security, and enable religious and spiritual
security for patients while in hospital care.
• Assure patients that their independence will be encouraged.
• Provide mechanisms that enable patients and staff to offer feedback or make complaints
without fear of revenge to quality care.
• Provide and promote a safe working environment for patients and all staff.
• Respect and protect rights of staff to freedom of association, (including the right to
choose whether or not to join an employee association).
The Right of Individuals to Have Their Religious and Cultural Identity Respected
• Provide care in an environment that supports the cultural and language needs of residents
and their families.
• Provide food and drink which meet the needs for reasonable personal, cultural and
religious preferences.
• Provide ease of access to spiritual advisers and a place (not necessarily a dedicated place)
for religious observances appropriate to the wishes of the patient.
The Right of Competent Individuals to Self-determination

• Promote an environment that provides patients with opportunities for self-development
and that maximise their potential for well-being, especially patients who stay for long
time in the hospital.
• Respect the right of patients to their reasonable choices of care provision.
• Encourage patients to take responsibility for their actions and choices.

• Provide access to independent social, legal or other advice and help, which are relevant to
patient care.
• Develop protocols, within the law, to assist patients with self-medication for this type of
care.
The Right to an Appropriate Standard of Care to Meet Individual Needs

• Act in the best interests of patients in determining, particularly before admission, whether
or not the hospital has the capability of providing them with care appropriate to their
needs.
• Provide food, drink, care and support to the standard appropriate to the needs of patients
in order to maintain optimal health and well-being.
• Develop ways of consulting with residents and their families or representatives on all
aspects of the provision of care.
• Provide appropriately qualified staff and staffing levels necessary for the safe, efficient
and effective delivery of care, treatment, support and protection and encouraging them to
maintain and upgrade their qualifications by providing opportunities for education and
training, including awareness of appropriate ethical standards.
• Ensure the safety of patients in relation to medication provision, making sure that patients
get right drug, right dose, and right route at right time.
• Promote risk reduction programs and foster a culture among staff where mistakes and
adverse events are identified, reported without blame, discussed and corrected, by putting
in place appropriate communication and management structures.
• Encourage all professionals to comply with the ethical standards of the profession and
that of the hospital.
• Provide the buildings, fittings and furnishings necessary to provide the optimal standard
of care for patients, having regard to the right to make a fair profit or surplus, after
meeting all legal and ethical obligations.
The Right to Privacy and Confidentiality

• Providers should promote an environment that supports the privacy and confidentiality of
residents, families, and staff.
The Recognition that Human Beings are Social Beings with Social Needs
• Enable patients to meet their social needs whenever possible.
• Enable ease access for families and friend to visit the patient following hospital
regulations and policies.
• Recognize the needs of patients for social contact and provide opportunities for social
interaction.
Key Points
• Patient rights encompass legal and ethical issues in the medical care provider-patient
relationship, including person’s right to privacy.
• Patient rights also include the right to quality medical care the right to make informed
decisions about care, treatment option and the right to refuse treatment.
• The health care providers have the obligation to meet these rights through practicing
professionally using the ethical code of practice.

Evaluation
• What are patient rights?
• How can we meet patient rights?
References
Heinemenn.

Session 5: Professional Values and Provision Quality
Health Services
Learning Objectives
• Define the terms values and integrity
• Explain the link between values and a profession
• Describe values in the provision of quality health services
Definition of Values
• Although there is a definite link between ethics and values, the two concepts are not
identical.
• Values can be defined as relatively stable convictions about what is good or desirable.
• The difference from ethics here is clearly that one can have values that are not ethical or
that have nothing to do with ethics.
• Some values examples:
o Respect
o Transparency
o Fairness
o Justice
Values and Profession

• The values of a profession will be reflected in their ethical code of practice.
• Values of a profession will be reflected through the behaviour of their professional
members, who have to practice in a specific manner accepted by ethical code of practice,
ethical principles and standards of the profession.
• Professional values include:
o Punctuality
o Commitment
o Respect
o Fairness and equality
o Quality of services
o Creativity and innovativeness
• For any profession to function optimally, good relations and interactions between
stakeholders are required.
• In order to ensure such good relations and interactions occur, members of the profession
need to commit themselves to specific ethical codes of practice and professional ethics.
Integrity within the Profession

• Integrity is another concept that is closely aligned to ethics.
• Integrity is however a more restricted concept than ethics.
• It refers specifically to human character.
• A person is regarded as someone with integrity when she/he consistently adheres to a set
of ethical standards.
• Integrity, is often associated with concepts like
o Fairness
o Consistency

Session 5: Professional Values and Provision of Quality Health Services 19
o Uprightness
o Wholeness
• These characteristics make a person of integrity, reliable and trustworthy.
• The person with integrity will always adhere to her or his values.
• People with good moral characters can turn to unethical behaviour if they find themselves
in organizations where unethical conduct is the norm.
• People can be restrained from unethical behaviour if find themselves in organizations that
do not tolerate unethical behaviour, but reward ethical behaviour.
• Ethical behaviour should not only be addressed on the individual level, but also on the
system or organizational level.
Characteristics of Quality Health Services

• Every person regardless of age or condition is afforded access to quality health care.
• The service is to be timely, reliable and adequate.
• Services to be provided to all in need guaranteeing equal access to medical services.
• Service that allow exercise of moral and religious freedom when receiving health care.
• Services where medical personal do not harm, do positive good, and respect the
autonomy of persons, and adhere to principles of justice.
• Services that create a bond of trust between patients and health care providers which is
built on shared decision-making.
• Services where patients or their relatives are provided with complete information in order
to participate fully in their own care.
• Services that recognize the quality and availability of health care services for women
affect the health and wellbeing of their children and families so that limitations to these
services have a profound long-term effect on the public’s health.
• Services where medical professionals exercise their professional judgment in the best
interests of their patients; and recognizing the professional obligation of medical
providers to support access to medical care for all people in the interest of the public
good.
• Services which respect and protect the dignity and autonomy of each person regardless of
the person’s health issues, religious views or social status.
• Respecting every person’s dignity means that each person should enjoy the right to
health, to health care, to direct access to health care, and to the continuation of that care,
regardless of the ownership of the institution from which they seek care.
• Services where patient expects and has the right to expect the health care professional to
employ the highest standard of care and best medical practices.
• Services that respect transplantation of organs from living donors is permissible when
such a donation will not sacrifice or seriously impair any essential bodily function of the
donor.
Values and Provision of Quality Health Services

• In the provision of quality care, there are many values which result in the desired
behaviour of a practitioner including:
o Good therapeutic relationship.
The term ‘therapeutic relationship’ includes all professional interactions between
care providers, individually or as a team, and recipients of care.
Good therapeutic relationships are centred on the needs and informed choices of
the person receiving care.
Such relationships are based on respect and mutual giving and receiving.
Good therapeutic relationships help to prevent conflicts about the goals and means
of care.
A good therapeutic relationship is founded on mutual trust and respect between
providers and recipients of care.
When care providers lose this sense of mutuality, they become mere experts and
the human quality in the relationship is lost.
When persons receiving care lose this sense of mutuality, they experience a
perceived or real loss of control and increased vulnerability.
Because persons receiving care are often weakened by their illness and may feel
powerless in the health care environment, the primary responsibility for creating a
trusting and respectful relationship rests with the care providers.
o The needs, values and preferences of the person receiving care should be the primary
consideration in the provision of quality health care.
o Sensitivity to and understanding of the personal needs and preferences of persons
receiving care, their family members and significant others is the cornerstone of a
good therapeutic relationship.
o These needs and preferences are diverse and can be influenced by a range of factors
including cultural, religious and socioeconomic backgrounds.
o Open communication, within the confines of privacy and confidentiality, is essential.
o All those involved in decision-making should be encouraged to express their points of
view, and these views should be respectfully considered.
o Health Care providers should ensure that they understand the needs, values and
preferences of the person receiving care.
o Health care providers to avoid misunderstanding or confusion, they should make their
communications direct, clear and consistent.
o They should verify that, the person receiving care understands the information being
conveyed, silence should not be assumed to indicate agreement.
o The person receiving care should be provided with the necessary support, time and
opportunity to participate fully in discussions regarding care.
o The competent person must be involved in decisions regarding his or her care.
o The primary goal of care is to provide benefit to the person receiving care.
o The competent person has the right to determine what constitutes benefit in the given
situation, whether with respect to physical psychological, spiritual, social or other
considerations.
o Informed decision-making requires that the person receiving care or a relative be
given all information and support necessary for assessing the available options for
care, including the potential benefits and risks of the proposed course of action and of
the alternatives, including palliative care.
o The competent person has the right to refuse, or withdraw consent to any care or
treatment, including life-saving or life-sustaining treatment.
o Although parents or guardians are normally the primary decision makers for their
minor children, children should be involved in the decision-making process to the
extent that their capacity allows, in accordance to the existing regulations and
policies.
o When the person receiving care is incompetent, that is, lacking in adequate decision
making capacity with respect to care and treatment, every effort must be made to
ensure that health care decisions are consistent with his or her known preferences.
o These preferences may be found in an advance directive or may have been
communicated orally.

o In situations where decision making concerning care and medical treatment for
incompetent persons is specifically addressed in law, the requirements of that
legislation should be met.
o When an incompetent person's preferences are not known and there is no family
member to represent the person, decisions must be based on an attempt to ascertain
the person's best interests, taking into account:
Person’s diagnosis, prognosis and treatment options.
Person’s known needs and values.
Information received from those who are significant in the person's life and who
could help in determining his or her best interests.
Aspects of the person's culture, religion or spirituality that could influence care
treatment decisions.
o When conflicts arise despite efforts to prevent them, they should be resolved as
informally as possible, moving to more formal procedures only when informal
measures have been unsuccessful.
o In cases of disagreement or conflict, the opinions of all those directly involved should
be given respectful consideration.
o Disagreements among health care 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 health care team so as not to compromise their relationship with the person
receiving care.
o Disagreements between health care 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 person receiving care.
o Health care authorities and health facilities should develop conflict resolution policies
for dealing with such issues and monitor their use.
o When the needs, values and preferences of the person receiving care cannot be met,
he or she should be clearly and frankly informed of the reasons for this, including any
factors related to resource limitations.
o Health care providers should not be expected or required to participate in procedures
that are contrary to their professional judgement or personal moral values or that are
contrary to the values or mission of their health facility.
o Health care providers should declare in advance their inability to participate in
procedures that are contrary to their professional or moral values.
o Health care providers should not be subject to discrimination or reprisal for acting on
their beliefs.
o The exercise of this provision should never put the person receiving care at risk of
harm or abandonment.
o Health care providers have a responsibility to advocate together with those for whom
they are caring in order that these persons will have access to appropriate treatment.
Key Points
• Values are convictions about what is good or desirable.
• Values of a profession will be reflected through the behaviour of the professional.
• A person of integrity is reliable and trustworthy and adheres to professional values.
• Every person, regardless of age or condition, is afforded access to quality health care.
• A good therapeutic relationship is founded on mutual trust and respect between providers
and patients/clients.

Evaluation
• What are values?
• What is integrity?
• What are the values that a health profession needs to observe?
• List characteristics of quality services.
References
Heinemenn.

Session 6: Workers’ Responsibility for Own Actions
Learning Objectives
• Explain the worker’s responsibility for his/her own actions
• Explain the importance of workers’ responsibility for own action
• Describe how workers can take responsibility for own action
Definition of Workers’ Responsibility for Own Actions

• Taking responsible for own action is being answerable or accountable, as for something
within one’s power, control, or management.
• People want to feel responsible for successes when they occur, but it’s not easy taking
responsibility for failures.
• Acknowledging failure is the initial stage of developing sense of responsibility for own
action and being aware of ones capability for growth and development.
Importance of Workers’ Taking Responsibility for Own Action

• Taking responsibility is a very important principle.
• One is solely responsible for all the actions have taken and blaming others or
circumstances for the things that are not right are an attitude of self-destruction.
• Once accepting and taking responsibility for our actions, then we are in a better position
to move forward and to learn from our mistakes.
• Taking responsibility of own action results in building self-esteem to higher levels.
• Many smaller problems you experience regularly such as negative thinking, self-defeating
behaviour and troubled relationships with yourself and others start to correct themselves
as your self-esteem improves.
• You gain an inner stability and can create your own positive feelings without the help of
validation from other people.
• Taking responsibility for own action is a sign of wisdom and maturity; is when you come
to terms with the realization that your decisions cause your rewards and consequences.
• You are responsible for your life, and your ultimate success depends on the choices you
make.
• One of the key determinants of how we perform is life, is not defined by what actually
happens to us, but rather how we respond to the events life puts in our way.
• The reality is that if you had approached the situation in a positive and open frame of
mind, the outcome would almost certainly have been considerably different, with a
positive outcome.
• If you own up your actions, your life becomes better and smoother.
• In medical services one is trying to ‘do well’ and prevent harm in all cost, but mistakes
can occur, it is very ethical to report the error so that immediate action can be taken to
safe life.
• In situation where you did a mistake in the course of your care, it is very ethical to admit
the mistake and take the consequences, which shows a level of maturity and
self-actualisation.

Session 6: Workers’ Responsibility for Own Actions 25
The Consequences of Not Being Responsible for One’s Own Actions
• The inability to accept responsibility for own actions and behaviours is a result of
insecurity.
• By accepting responsibility one feels they are admitting to being weak, powerless, or an
opportunity to lose the respect of others.
• It may cause one to feel they will lose their sense of value and importance.
• Accepting responsibility is a sign of personal growth and maturity and definitely not a
sign of weakness.
• The consequences for not taking responsibility can be very serious indeed and result into
personality disorder and spoiling whole life.
• The typical indicators for failing to take responsibility are:
o Dependent on others for recognition, approval, affirmation, and acceptance
o Angry, hostile or depressed.
o Fearful of taking action being afraid of doing it wrong again.
o Unable to trust yourself to take a risk or make a decision, frightened of everything.
o Over responsible and guilt ridden.
o Unable to trust or to feel secure with others.
o Resistant to vulnerability, fear of being vulnerable, often linked to past trauma.
• Terms used to describe those who have not accepted personal responsibility include:
o Self-pitying, depressed, losers, quitters, chronically angry, dependent personalities,
complainers, addictive personalities, blamers, stubborn, persons in denial, troubled
people, stuck, fearful, pessimists, despondent, mentally unstable, obstinate, hostile,
aggressive, irresponsible, weak, guilt ridden, resistant to help, passive, irrational,
insecure, neurotic, obsessed, lost.
• Accepting responsibility result into positive attitude and growth as when we accept
responsibility we are accepting the blame for our actions and also accepting the
responsibility for making improvements in our lives.
• Accepting responsibility is a measure of one's self-worth, their level of security, and the
true sign of strength and courage.
• It will empower you to grow in ways that would bring you great rewards and
accomplishments in your life.
Developing Ability to Take Responsibility for Own Actions

• Identification and accepting that, you do have a problem in this area and learning ways of
taking responsibility for your actions, in this way you are taking your life to a higher level
of existence.
• You will find yourself feeling more vibrant and happier.
• Let go of feelings of victimization and learn to see yourself as a victor and not a victim.
• Develop your spiritual life by adding a spiritual dimension to your life which can help to
bring more self-awareness.
• Take your degree of success to a higher level.
• Build your self-confidence as when you are confident in your abilities, you won't become
defensive when you make a mistake and therefore, owning your contribution to a
situation and taking responsibility becomes natural.
• Giving of self in service to others, teaches empathy and compassion, characteristics helps
one to overcome self-centeredness.
• Learn ways to let go of fear since fear can create insecurities.
• Acceptance of who you are, learn to love yourself unconditionally and accept who you
are.

• Learn how to see things objectively without bias and prejudice.
• Accept responsibility for your responses to the people, actions, and events in your life.
• Accept that you are completely responsible for your own choices
• Be open to change, new ideas or concepts about life and the way life is.
• Get help from others.
• Let go of fear and irrational beliefs.
• Release anger, fear, blame, mistrust, and insecurity.
• Take some risks, be prepared to become vulnerable to change and growth in your life.
• Open up and use positive affirmations.
• A sense of personal responsibility for one’s own actions is at the root of it all.
• All people want world peace, but this will only start at individual level; taking ownership
of own actions.
• Take responsibility for own actions, including errors, recognition and acceptance of
limitations and need for supervision and self assessment.
Key Points
• Taking responsibilities for own action is being answerable or accountable, as for
something within one’s power, control, or management.
• Once accepting and taking responsibilities for our actions, then we are in a better position
to move forward and to learn from our mistakes.
• Taking responsibility of own action results in building self-esteem to higher levels.
• Many smaller problems you experience regularly such as negative thinking, self-
defeating behaviour and troubled relationships with yourself and others start to correct
themselves as your self esteem improves.
• The consequences for not taking responsibility can be very serious indeed and result into
personality disorder and spoiling whole life.
• Accept that you are completely responsible for your own choices.
Evaluation
• What is workers responsibility for own action?
• What is the importance of workers responsibility for own action?
• How can workers develop abilities to take responsibility for own action?
References
• Burkhardt, Margareth A. & Nathaniel, A.K. (2007. Ethics and Issues in Contemporary
Heinemenn.


Session 7: Ethical Issues in Special Situation
Learning Objectives
• Describe several special situations with implications in medical ethics
• Explain approaches in addressing special situations based on medical ethics
Special Situations with Implication in Medical Ethics

• In medical practices there are various situations that can be encountered and found to be a
dilemma to the performance of medical duties.
• These working situations include:
o Medical research
o Torture to human being
o Capital punishment
o Abortions
o Prisoners
o Disaster & emergency situations.
o HIV and AIDS and other infectious diseases
o Medical examination required by employer
o Publicity and advertisement
o Diagnosis of death (Brain dead)
o Health management organizations
o Practitioners appearance, presentation and attire
Approaches to Special Situations Based on Medical Ethics

• Health care providers face different issues that require some ethical solutions.
• The kind of solution is normally determined by nature and situation of the task as follows:
Medical Research
• Familiarity with research methods is essential for competent medical practice and the best
way to gain this familiarity is to take part in research projects.
• The most common method of research for practicing clinicians is clinical trial.
• In conducting research, the ethical values of the medical practitioner compassion,
competence, autonomy, dignity apply to medical researcher as well as long as the medical
practitioner understand and follow the basic rules of research ethics
• There are several procedures required to make the research legal and this shall be dealt
with in Research Module.
Torture of Human Being

• It is the obligation of the practitioner in the service of humanity, to preserve and restore
physical and mental health of the client.
• The practitioner shall:
o Not participate in any way in the practice of torture of human being or other forms of
cruel, inhuman or any form of degrading procedures no matter whether such practice
or procedure is ordered after due process of law.

Session 7: Ethical Issues in Special Situations 29
o Not provide any premises, instrument, substance or knowledge to facilitate the
practice of torture or other forms of cruel, inhuman or degrading treatment, or to
diminish the ability of the victim to resist such treatment.
Abortion
• Medically induced abortion is not allowed by the laws of the country.
• Abortion is not legal in Tanzania, only in some medical conditions where mother’s health
is compromised by the presence of the pregnancy.
Prisoners
• The practitioner while attending a client held in prison or detention is urged to provide
professional services to the best interest of the health of the prisoner or detainee and the
general community of that prisoner.
o Draw to the attention of the responsible authority of an existing or impending
unhealthy environment or condition.
o Take all necessary steps to preserve dignity of the prisoner or detainee.
Disaster and Emergency Situation

• In disastrous and emergency situations like floods, road accidents, earth quakes, and fire
outbreak, practitioner shall practice the profession with conscience and dignity, and the
health of the clients shall be paramount.
• The practitioner shall have an obligation during life threatening emergencies to take
immediate steps to ensure that necessary treatment is given to the victim without
discrimination and undue delay.
HIV& AIDS and other Infectious Diseases

• In the management of HIV and AIDS and other infectious diseases, the practitioner may
encounter ethical problems embodied in the special nature of the disease, its fatality, and
absence of cure, public stigma and imminent danger to the society.
o Balance the need to observe confidentiality and save human life against deliberate
acts likely to infect potential victims.
o Acquire adequate knowledge and skills on counselling related to the special aspects of
HIV&AIDS other infectious diseases including prevention and transmission.
o Ensure that individuals infected with HIV or suffering from AIDS and other
infectious diseases are informed or supportive measures available.
o Ensure that individuals infected with HIV&AIDS or any other chronic disease are
afforded opportunity to agree or decline from being research subjects and to the
method applied for scientific research, teaching, and taking of photographs, video or
film.
Medical Examinations Requested by Employer

• Practitioners shall ensure that an employee is fully aware and consent to medical or dental
examination requested by the employer
Publicity and Advertisement

• Sound relationship between a practitioner and colleagues is essential for fostering the
esteem and truthfulness of the medical profession.

• Practitioners shall be aware that matters of general interest are paramount and practitioner
shall refrain from adopting methods aimed at advertising a particular person, institution,
remedy or technique.
Diagnosis of Death
• A situation may arise whereby the human body is controlled by a brain which is
damaged to an uncertain degree and poses ethical dilemma for termination of life.
• In such a situation a patient shall be considered dead when there is irrevocable
establishment of brain stem death.
• Death shall be clinically ascertained by not less than two physicians and one of them
shall be the doctor in charge of the care and another one should be an experienced and
clinically independent of the first.
• In any case the examination must be done over twenty four hours at eight hourly
intervals.
Health Management Organizations

• Health Management Organizations (HMOs) have their basis, profit making by
‘managing’ health funds.
• This, at times, leads to unreasonable exclusion from key investigations, drugs therapy,
surgical procedures and others and interference in the confidentiality of the clients.
• Practitioners must have interest of their clients at heart and should not barge to HMO’s
pressures.
• In every aspect of practice the patient’s welfare remains the practitioner’s responsibility
irrespective of the influences of the health agents.
Practitioner Appropriate Presentation and Attire

• A practitioner shall, at all times in and outside the place of work, appear in smart, proper
and decent dress and behave in a manner becoming of the profession.
• At a place of work, a practitioner shall present himself and appear in official attire that
shall include proper uniform and identification name tag.
Activity: Case Study
Instructions
Read the scenario below.
Scenario: Chakubanga was admitted in the ward 3 weeks ago with complaints of difficulty
in breathing, cough and fever. Laboratory test results revealed that he is HIV positive.
During routine medical rounds, it was observed that some doctors on duty have been
skipping Chakubanga’s bed. Usually it is said that ‘this is a known case let him continue
with prescribed treatment’. But Chakubanga was having a new problem which was not
reported when he was admitted. This situation caused difficulties to him as he did not have
a place to voice his concern for management.
Work in small groups to answer the questions below. Each group will have opportunity to
present in plenary for five minutes.
• What medical ethics do you think these doctors/clinicians have violated?
• What rights does Chakubanga deserve?
• How should Chakubanga be treated if one is observing medical ethics?

Key Points
• There are several working situations which any medical practitioner must make sure that
are handled properly so that the rights of the patient are preserved.
• Often the rights of infectious and chronically ill patients are neglected; therefore care
should be taken to ensure this does not happen.
Evaluation
• What are the special situations which have implications to medical ethics?
• What approaches used to address these special situations basing on medical ethics?
References
London: Butterworths.
Heinemenn.

Session 8: Ethical Dilemmas in Medical Practice
Learning Objectives
• Define the term ethical dilemmas
• Explain the characteristic of ethical dilemmas
• Explain common ethical dilemmas
• Identify sources of ethical dilemmas
• Describe strategies used to solve ethical dilemmas
Definition of Ethical Dilemmas and their Characteristics

• An ethical dilemma is a situation having two or more undesirable alternatives.
• It can also be defined as a confusing problem that offers a choice between equally
unsatisfactory alternatives.
• An ethical dilemma is a situation that will often involve a conflict that brings questions on
which to obey as one would result affecting the other.
• Ethical dilemma addresses ethical questions of right vs. wrong.
Characteristics of Ethical Dilemmas

• In order for a problem to be an ethical dilemma it must have three characteristics
o The problem cannot be solved using only empirical data (empirical data is
information derived from observation/experiences)
o The problem must be so confusing that deciding what facts and data need to be used
in making decision is difficult.
o The results of the problem must affect more than the immediate situation; and there
should be far reaching effects.
Common Ethical Dilemmas
Instructions
You will work in small groups to discuss common ethical dilemmas in medical practice.
Record your responses on note books or flip chart. One group will present for 5 minutes and
other groups will add what first group did not mention if any.
Dilemmas of Beneficence
• Involve deciding what is good as opposed to what is harmful.
• Often occur when a clinician, patients, or family members disagree about what course of
action is in the best interest of the patient.
Dilemmas of Non-Malfeasance
• Involves the avoidance of harm.
• These issues often involve a clinician’s responsibility to ‘blow the whistle’ if she sees
others compromising the patient’s safety.

Session 8: Ethical Dilemmas in Medical Practice 33
• In these situations, a clinician notifies higher authorities on weaknesses in the care they
provide by not following established communication channels.
Dilemmas of Autonomy
• Involves deciding what course of action maximizes the patient’s right of self-
determination.
• Autonomy issues are related to beneficence issues, especially when individuals other than
the patient must determine what is best for the patient.
Dilemmas of Justice
• Involves issues of fairness and equality, such as dilemmas that involve dividing limited
health care resources fairly.
Dilemmas of Fidelity
• Involves issues that involve honouring promises.
• These may include the extent and limits of a clinician’s role and duties to patient that
might conflict with other duties such as duties of the laboratory technician.
Dilemmas of Veracity
• This is an obligation to be truthful to patients and to cultivate their understanding of
relevant consideration.
• This may involve even delivering bad news to patients and relatives.
Sources of Ethical Dilemmas

• Problems arise when one or more ethical principles conflict with each other.
• Patients and clinicians- For example human rights are involved when a patient refuses to
commit herself in signing consent while the clinician believes it is ethically appropriate to
get his/ her permission.
• The value system, beliefs and culture- For example a patient who belongs to Jehovah’s
Witnesses refuses blood transfusion at the time when blood will save the life of that
individual.
• Dilemma may arise from justice and conflicts between clinician and other health care
professionals, health care organizations, administrators or patients and family members.
o Example one: Quick service provided to patients who can pay extra money and
leaving patients with low economical status to wait.
o Example two: Family members may demand the HIV results of a patient and create a
difficult situation.
o Example three: A woman may demand abortion for her school age girl who has been
raped by a school teacher.
• Technology advancement- Knowledge among people is growing and patients may come
to the hospital with full information of their expectations including services like DNA,
such as when the clinician is asked to conduct tests to confirm if the claimed father is a
true father of the child or not.
• Technological advancement provides challenges when we are required to extend life
support services for terminally sick patients and simplifies accessibility to information.

Strategies Used to Solve Ethical Dilemmas
• There are no clear ways of solving the dilemmas.
• Different strategies and ways need to be applied in solving the dilemma as described
below.
o First the medical practitioner defines her obligations, to patients and fellow employees
which helped her to analyze ethical conflicts.
o She notes that six steps proved useful to define those obligations:-
To maximize a patient’s wellbeing.
To balance the patient’s need for autonomy and, in the case of a minor, his/her
parents’ responsibilities for his or her wellbeing.
To support each family member and enhance the family support system.
To carry out the hospital’s policies.
To protect the other patients’ good.
To protect his or her own standards of care.
o After examining one’s obligations, it is usually recommended that four additional
steps should be taken:
Collect as much information as possible about the patient and other significant
persons in the situation.
Describe probable consequences of each of the courses of action being considered,
for the patient and the significant others in the situations.
Consider who should make the final decision in the matter.
Consult other health practitioners, especially those who are prepared by practice,
ethical committee and education to contribute meaningfully to solving problems
of an ethical nature.
o Even after taking the steps described above, solutions may not necessarily be
forthcoming when ethical conflicts are present.
o Commitment to ethical standards of practice is an essential part of medical care, as is
the commitment to respecting the rights and dignity of the person receiving care.
Key Points
• An ethical dilemma is a situation having two or more undesirable alternatives.
• An ethical dilemma must have three characteristics:
o The problem cannot be solve using only empirical data
o The problem must be so confusing to decide what facts are needed for making
decision
o Results of problem must be affect more than the immediate situation
• Commitment to ethical standard of practice is an essential part of medical care as is the
commitment to respect the rights and dignity of the person receiving care.
Evaluation
• What are the characteristic of a dilemma?
• What are the common ethical dilemmas in medical practice?
• What are the sources of the ethical dilemmas?
• What are the strategies for solving ethical dilemma in medical practice?

References
Heinemenn.

The development of these training materials was supported through funding from the President’s Emergency Plan for AIDS Relief
(PEPFAR) through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)
Cooperative Agreement No. 6 U91 HA 06801, in collaboration with the U.S. Centers for Disease Control and Prevention’s Global AIDS
Programme (CDC/GAP) Tanzania. Its contents are solely the responsibility of the authors and do not necessarily represent the official
views of HRSA or CDC.

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UNITED REPUBLIC OF TANZANIA

CMT 06106 Ethics and

Background and Acknowledgement ........................................................................ iv

In September 2009, MOHSW embarked on an innovative approach of developing the

These participants are listed with our gratitude below:

Editorial Review Team

Librarians and Secretaries

Who is the Module For?

How is the Module Organized?

How Should the Module be Used?

Explanation of the Term Profession

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Code of Ethics for the Medical Profession

Activity: Small Group Discussion

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Roles of Professional Associations and Licensing Bodies

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Challenges of Human Dignity in Medical Science

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Approaches to Uphold Human Dignity in Health Services

Activity: Small Group Discussion

• Human dignity is the conceptual basis for human rights.

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Social Role of a Profession

Reasons for Conflicts Between Health Professionals and Society

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Obligations to Patients and to Society

The Medical Profession and Society

Challenge of Dual Loyalty

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Challenge of Resource Allocation

Ethical Responsibilities in Public Health Issues

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Explanation of Patient Rights

Recognition of Patient Rights

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Meeting Patient Rights in the Provision of Health Services

The Right of Individuals to be Treated with Respect and Dignity

The Right of Individuals to Life, Liberty and Security

The Right of Competent Individuals to Self-determination

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

The Right to an Appropriate Standard of Care to Meet Individual Needs

The Right to Privacy and Confidentiality

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Values and Profession

Integrity within the Profession

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Characteristics of Quality Health Services

Values and Provision of Quality Health Services

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Definition of Workers’ Responsibility for Own Actions

Importance of Workers’ Taking Responsibility for Own Action

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

Developing Ability to Take Responsibility for Own Actions

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual

CMT 06106 Ethics and Professionalism NTA L 6 Semester 1 Student Manual