MEDICAL ETHICS

S. L. Pitmang
Department of Family Medicine
Jos University Teaching Hospital, JUTH
Jos, Plateau State
ETHICS

• The study of the philosophy of human conduct

with emphasis on the determination of right and
wrong
or the
• System of moral principles or rules of conduct to
distinguish between right from wrong and to
practice the former and abstain from the latter
• Right and wrong is determined by culture
MEDICAL ETHICS

 Medical ethics is defined as the

moral standards with respect to
professional conduct that are
traditionally accepted by members
of the medical profession, or as
promulgated by professional
organizations, from time to time.
 4
Aims of Medical Ethics
• To ensure that the doctor does not use the special
knowledge that he possesses to do evil.
▫ Hippocrates –The oath “I will use treatment to help
the sick according to my ability and judgment but
never with a view to injury and wrong doing”
• Ensuring that a practitioner of medicine or
dentistry carries on his activities in such a way as
to;
▫ Achieve the best possible good for his patients and
never do evil to them
▫ Conduct himself in such a manner that he does not
scandalise the society and bring odium to the
profession.
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▫ Conduct himself in such a manner that he does not

create resentment among his colleagues and create
disharmony in the profession.
▫ Be a good and law abiding citizen who deserves and
attracts respect and is an exemplary character among
the citizenry
▫ Demonstrate such courage, firmness and strength of
character as not to give room to persons with
dishonorable intentions to use him to achieve
unwholesome ends
HISTORY OF CODE OF ETHICS

• CODE OF HAMUURABI
• HIPPOCRATIC
• PERCIVAL
The First Code of Ethics

• The Code of Hammurabi (also known as the

Codex Hammurabi and Hammurabi's
Code) was created ca. 1760 BC and is one of the
earliest extant sets of laws.
Hippocratic Oath (Original Version)
• History Of This Piece:
This relief shows the famous hippocratic oath
developed by Hippocrates in Ancient Greece. The
oath reads as follows: ôI swear by Apollo Physician
and Asclepios and Hygieia and Panacea and all the
gods and goddesses, making them my witnesses,
that I will fulfill according to my ability and
judgement this oath and this covenant: To hold him
who has taught me this art as equal to my parents
and to live my life in partnership with him, and if he
is in need of money to give him a share of mine, and
to regard his offspring as equal to my brothers in
male lineage and to teach them this art - if they
desire to learn it - without fee and covenant; to give
a share of preceptss and oral instruction and all the
other learning to my sons and to the sons of him
who has instructed me and to pupils who have
signed the covenant and have taken an oath
according to the medical law, but no one else. I will
apply dietetic measures for the benefit of the sick
according to my ability and judgement; I will keep
them from harm and injustice. I will neither give a
deadly drug to anybody who asked for it, nor will I
make a suggestion to this effect. Similarly I will not
give to a woman an abortive remedy. In purity and
holiness I will guard my life and my art etc, etc.ö
Nuremberg Trial
• The Doctors’ Trial or the Nuremberg Trial was a
landmark trial following the 2nd world war in
Germany.
• 23 people were tried out of which 20 were doctors.
They were charged with 4000 charges largely for
Nazi human experimentation without informed
consent, mass murder in gas chambers and
injection of lethal substances etc.
• Karl Brandt, Hitler’s personal physician was
sentenced to death by hanging.
Karl Brandt -Hitler’s personal
physician’s trial.
Tuskegee Syphilitic Trial- natural
syphilis progression observed in blacks
without treatment for 40years.
Tuskegee Syphilis Study…
• The true nature of the experiment had to be kept
from the subjects to ensure their cooperation
• During World War II, 250 of the men registered for
the draft and were consequently ordered to get
treatment for syphilis, only to have the PHS exempt
them
• At the end:
▫ 28 of the men had died directly of syphilis,
▫ 100 were dead of related complications,
▫ 40 of their wives had been infected,
▫ 19 of their children had been born with congenital syphilis
United States president Bill Clinton and a survivor of a government-sanctioned
experiment on syphilis take part in a formal ceremony at the White House on May 16,
1997. During the ceremony, Clinton offered a formal apology to the surviving black
men who participated in the experiment. The study, formally known as the Tuskegee
Study of Untreated Syphilis in the Negro Male, was conducted from 1932 to 1972 and
involved 399 black men from rural Alabama who were infected with syphilis. The U.S.
Public Health Service closely monitored and evaluated the effects of the disease on the
study’s participants. In what Clinton described as a shameful act, throughout the 40-
year study the men were never told that they had syphilis, and they were never offered
penicillin to treat the disease. When left untreated, syphilis can lead to mental illness,
paralysis, and death. By the time the study was halted, more than 120 men had died of
syphilis and related complications, at least 40 wives had been infected, and 19
children had contracted the disease at birth.
Geneva Declaration of 1948-
Physician’s Oath.
Oath at the time of being admitted as a member of the medical
profession:
I solemnly pledge myself to consecrate my life to the service of
humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity; the health of
my patient will be my first consideration;
I will maintain by all the means in my power, the honour and the noble
traditions of the medical profession; my colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party
politics or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from the time of
conception, even under threat, I will not use my medical knowledge
contrary to the laws of humanity;
I make these promises solemnly, freely and upon my honour.
Geneva Declaration- amended in 1968,
1984,1994,2005 and 2006.
Currently Reads-
At the time of being admitted as a member of the medical profession:
I solemnly pledge to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble
traditions of the medical profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin,
gender, nationality, political affiliation, race, sexual orientation, social standing
or any other factor to intervene between my duty and my patient;
I will maintain the utmost respect for human life;
I will not use my medical knowledge to violate human rights and civil liberties,
even under threat;
I make these promises solemnly, freely and upon my honour.
Common Values of Medical Ethics
• Autonomy – The pt has the right to refuse or
choose their treatment
(voluntas aegrotis suprema lex)

• Beneficence- A practitioner should act always

in the best interest of his patient
(salus aegroti suprima lex)
• Non-maleficence- ‘‘First do no harm’’-
(primum non nocere)
 Values of Medical Ethics contd.
• Justice – concerns distrib. of scarce resources
as to who gets what (fairness and equity)
• Dignity – The patient (and the doctor) have the
right to dignity.
• Truthfulness and honesty- truth and honesty in
dealing with the patients- informed
consent is required now following
Doctor’s trial and the Tuskegee Syphilis
Trial.
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Ethical considerations in practice

• We shall consider medical ethics in practice in the

following three broad areas:
1. Compliance with various articles of the physician’s
oath
2. Compliance with various laws and regulations
which guide medical practice in any locality
3. Ethical considerations in the conduct of research
Ethical Imperatives
• A properly registered and duly licensed doctor
to practice faces a set of ethical imperatives
relating to
1. The doctors responsibilities to his patients
2. The doctors responsibilities to his colleagues
3. The doctors responsibilities to the profession
4. The doctors responsibilities to the society
5. Ethical imperative of continuing professional
education
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Doctor’s Responsibilities to His Patients

• Pledge to consecrate ones life to the services of
humanity and the health of the patient will be the
first consideration of the doctor
• Duty of care to the patient—failure to discharge
such duties leads to a charge of professional
negligence (the consideration is what a qualified
reasonable doctor would do in the same
circumstance)
• A doctor is not under any obligation to accept a
patient but if he decides to accept/render help, he
must exercise reasonable care in the treatment of
the patient
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• The doctor must treat a patient with the required

standard, methods and decorum acceptable to the
generality of the members of the profession.
• The doctor must know the limitation as regards his
skills, facility and resources.
• Patients should be referred to colleagues who have
better knowledge, skill or facilities to give the
patient the best management that the profession
can offer in the circumstance
▫ It is unethical to cling to a case one cannot handle
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• A recalcitrant patient who refuses to accept the

appropriate management as recommended by the
doctor should be referred out to some other
colleague who would convince him of the need for
the intervention
▫ E.g. refusing crucial procedures, surgical
intervention, blood transfusion or even a simple
injection
• Imperative of confidentiality
▫ Information from a patient to the doctor is given on
trust—contents of the medical records inclusive.
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• Exceptions to the rule of confidentiality

a) The doctor is giving evidence under oath
b) The doctor giving statutory notification of
infectious diseases
c) The doctor is reporting the case of a minor to the
parent or guardian
d) A doctor is making a medical report to an
employer—(patient should consent to it except
where there is a waiver)
e) The confidence is of a nature that affects public
good.
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• “The right of a doctor to withdraw services once

assumed, arises only from good cause. Even the
desire or consent of the patient is not always
sufficient. The doctor should not relinquish the
management of a patient to the detriment of the
patient. Even when he has reasons for doing so
on grounds of honour or self-respect he should
hand over the patient properly to another
medical practitioner”
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• Striking doctors
▫ Ethical imperative demands that the doctors must
give enough notice to the patients and opportunity
to engage the services of another doctor.
▫ Must satisfy the labour laws by giving the hospital
authorities adequate notice.
• A doctor must not exploit a patients weakness
▫ Seduction of his/her patient (--infamous conduct)
▫ Playing on the fears of the patient to obtain larger
fees (---guilty of unethical practice)
▫ Carrying out procedures that are not medically
indicated with the motive of attracting higher fees
(unethical practice)
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• Regular review of patients on admission in course

of management is consistent with good patient
care (best Practice)
• Adequate notes written frequently on each visit of
the patient, especially in-patients
• Adequate communication of the doctor to the
patient or relations within limits allowed by the
rules of confidentiality
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Doctor’s Responsibility To His Colleagues

• “ give to their teachers the respect and gratitude
which are their due”—physicians oath.
▫ And to consider all colleagues as brothers
▫ Every doctor requires to show due respect to his
senior under all circumstances
▫ Disagree respectfully with your seniors
▫ Hippocratic oath enjoins doctors to make their
seniors (teachers) partners in their livelihood;
happily sharing their resources with them if the
need arises
▫ Treat a colleague as a brother
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• It is improper for a doctor to charge another

doctor for services rendered (--professional fees,
consultations)
• The golden rule –”Do unto others as you would
have them do unto you”
• Ethical imperative of not running down a
colleague
▫ Advise him if he does what is unethical or report
him to the NMDCN for disciplinary action.
▫ Enticement of patients from colleagues. This
follows from running a colleague down
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▫ Self advertisement may follow also and

undercutting a colleague (infamous conduct)
• Referral of patient on time if necessary
▫ Ethical imperative to acknowledge (write back to
the referring doctor) a referral---to advise him on
the findings and management of the patient.
▫ The patient should be sent back to the referring
doctor after the referral has been concluded.
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▫ Charging corporate patients fees that are below

the minimum agreed to by the generality of
doctors in any locality—I.e.undercutting (prices)
colleagues and enticing clients away---infamous
conduct
▫ Discretionary fees to friends or relations in good
faith is not infamous conduct
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Doctor’s Responsibility To The Profession

• Doctors have pledged to maintain the honour and
noble traditions of the medical profession
▫ Doctors are expected to expose without fear or
favour, before the MDCN, any colleague who
engages in corrupt, dishonest, unprofessional or
criminal conduct
▫ Exposure of any act of malpractice or medical
negligence by a doctor—provided that it is done in
good faith and for the greater good of the entire
profession
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• A doctor is duty bound to respond to the

invitations of the investigating panel of the
council or the Disciplinary tribunal to testify
either as a defendant doctor or as a witness
▫ It is unprofessional to ignore such summons from
these organs of the council
• Duty to teach the art of medicine to colleagues
who desire more knowledge in the profession
• Employment of unregistered and unlicensed
persons by a doctor into his practice is
unethical/criminal
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• Personal conduct must not cheapen the

profession
▫ A doctor must resist the attempt to use his name
in aiding and abetting unauthorized or
unprofessional practice of medicine by anybody
e.g. circulating complimentary cards through
opticians, insurance agents, patent medicine
dealers, etc
▫ Registration of a maternity home by a midwife
using a doctor’s name carries the same
responsibilities—supervision and liability
(vicarious liability)
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• Publications/claims of discoveries in non-

professional journals—peer review and evaluation
necessary
• Engagement in self advertisement or acquiesce to
his being advertised by other persons
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Doctor’s’ Responsibility To Society

• Appropriate use of knowledge and skills
▫ Not to use knowledge contrary to the laws of
humanity e.g. taking of life
▫ Indulgence in abortion, euthanasia (mercy killing)
or assisting a suicide
▫ Guiding philosophy behind the protection of life
by the medical profession
a) A doctors calling is to save life and not take it.
Therefore a doctor must in every thing he does,
seek to prolong life and not terminate it.
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b) In spite of all our knowledge and advances in

medicine, no doctor has been able to create one
life or resurrect a dead one. Therefore, it is
immoral for any doctor to arrogate himself the
right to take that which he can neither create nor
restore
c) In almost every instance in which the taking of life
is espoused by a doctor the underlying rationale is
almost always selfish rather than altruistic.
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d) Consider that our ethics requires the informed

consent of every victim of an invasive technique
before such a procedure is carried out. Informed
consent of the fetus, a patient in coma or a patient
of severe depressive illness secured before any
misguided doctor undertakes to terminate his life
through abortion, euthanasia or assisted suicide?
e) No matter how helpless or defenseless a patient
seems do not take life
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• A doctor must attest only to those things which

he knows to be true
▫ Issues of sick leave, falsely certified (unethical
conduct)
▫ Issuing of death certificate on a diseased person
whom he did not attend to in life and whose cause
of death he does not know for sure.
▫ Aiding and abetting deceit is unethical.
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Ethical Imperative of Continuing Professional Education

• Acquired knowledge decay in an exponential

pattern
• Knowledge and skills acquired during formal
training ceases leading to obsolence.
• Rapid rate of development and expansion in
medical knowledge, equipment,skills and
procedures;emergence of new diseases
• Best practice as exposed all over the world
demands continuing professional education
programmes and participation by all doctors.
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Compliance With Laws

• Regulations of medical practice is by
1) Federal and State ministries of Health & Social
Services
2) The Medical and Dental Council of Nigeria-MDCN
 Enabling Laws
a) Various laws
b) State edicts –establishment of hospital and clinics
c) The Medical and Dental practitioners Act 1990 cap
221 laws of the Federal Republic of Nigeria
(Decree 23 of 1988 with amendment, Decree 78 of
1992) which enables all activities of the MDCN.
 41

State Edicts For Registration Of Hospitals

• State edict for hospital registration for medical
practice specify
▫ Minimum standards for facilities personnel and
infrastructure that must be available in any
registered hospital or clinic.
▫ Inspectorate units in every SMOH is charged with
the responsibility of inspecting premises intended
for use as hospitals or clinics to ensure that all
requirements are met.
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The MDCN
• Act 1990 cap 221 laws of FRN—Decree 23 of
1988- Amended Decree 78 of 1992.
• By virtue of the powers conferred by the above
has responsibility
1) To determine the standards of knowledge and skill
to be attained by persons seeking to become
members of the medical or dental profession
2) To ensure that a register is maintained of persons
entitled to practice as members of the medical or
dental profession and to ensure the publication of
such register from time to time for the guidance of
those who need the services of doctors
 43

3) To prepare from time to time a code of conduct

which it considers desirable for the practice of the
medical and dental profession in Nigeria
4) To investigate all cases of alleged professional
misconduct by practice of medicine and dentistry
in Nigeria and to apportion appropriate penalties
on guilty ones through the appropriate organs of
the council.
 44

The Responsibilities of MDCN

a) To ensure that only those who have the requisite
knowledge and skill engage in the practice of
medicine
b) To ensure that the population is not unduly
exposed to unwholesome practices
c) To ensure that an acceptable minimum standard
of safety, facilities and environmental sanitation
exists in premises where medical practice is
undertaken.
d) To ensure that those who practice medicine are
guided by and conform to certain norms and
ethical requirements.
 45

Licensing Of Practitioners
 The prevailing laws guiding medical practice in
this country require that
 Every medical; or dental practitioner must be
appropriately registered and licensed before he
can legally practice any where with in the
territories of the FRN. Basic requirements
emanating from this include the following
1) A fresh medical or dental graduate must obtain a
provisional registration and license and
subsequently only practice as an intern under
supervision by doctors of appropriate
specialization and / or seniority, in an approved
hospital
 46

2) An intern who has satisfactorily completed his

internship must obtain his full registration before
proceeding with further practice
3) A practitioner who has successfully undergone
specialist training must be registered with the
council as a specialist before he can pass himself
off as a specialist
4) An expatriate who wishes to practice in this
country even for one second, must obtain a
temporary registration with the council.
 47

Licensing Of Practitioners
5) All practitioners must obtain their annual
practicing license before they can practice in any
year
 Note that the employers of doctors would be
breaching the law if they engage the services of
persons who have breached any of the articles
above
 Practitioners are encouraged to report infractions
of the law to the MDCN. It is illegal for any one to
take title of doctor, physician, surgeon, MD,etc
implying that he is authorized by law to practice
medicine
 48

Associations
 Other associations sharing responsibility to ensure
dignity of our profession include
a) NMA, and MDCAN
b) AGPMPN
c) Various specialist associations
d) NARD
e) Guild of Medical Directors
 In every hospital whether owned or not owned by a
doctor, he is responsible for the maintenance of the
minimum standards of medical practice and the
sustenance of the ethics of medical practice in that
hospital
 49

Ethical Issues in Research

• When conducting research we ensure that
i. The research will be of benefits to humanity
ii. The research would not in any way compromise
the dignity and integrity of the human being
iii. The research would not result in harm to the
human subject
iv. Every subject of the research is fully aware of the
procedure and consequences of the research
v. Every subject of the research gives an informed
consent for the research
vi. A subject is not coerced or blackmailed into
submitting to the research
 50

vii. A subject’s ignorance or mental incompetence is

not exploited
viii.The research does not offend societal norms and
morals, even if there are willing subjects
 51

Ethical Dilemmas for Doctors

 Practicing doctors are often faced with ethical
dilemmas which arise when a doctor is
confronted with a situation in which the course of
events apparently run counter to ethical pre-
requisites.
a) What should a doctor do if a patient in need of
medical attention is unable to pay price of such
services?
b) What should a doctor do if a person in superior
position orders him to do what is unethical
 52

c) What should a doctor do if he is being

blackmailed to under take an unethical course of
action?
d) What should a doctor do if he is faced with a
patient whose condition threatens his own life or
well being?
 There are many more examples of ethical
dilemmas
 53

References

1. MDCN; Revised guidelines on minimum

standards of medical and dental education in
Nigeria 1993 ed.
2. MDCN; Revised Rules of Professional conduct for
medical & dental practitioners in Nigeria 1995 ed.
THANK YOU