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   2015| December  | Volume 18 | Issue 7  
    Online since December 1, 2015

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A pilot study of women's experiences after being offered late termination of pregnancy for severe fetal anomaly
L Govender, C Ndjapa-Ndamkou, C Aldous, J Moodley
December 2015, 18(7):71-76
DOI:10.4103/1119-3077.170825  PMID:26620625
Objective: We investigated the attitudes and experiences of women pregnant with an anomalous fetus after being offered late termination of pregnancy (LTOP) before and after delivery or TOP. Methods: This was a pre- and post-intervention structured interview questionnaire-based study. Pregnant women with severe fetal abnormalities (lethal and nonlethal) diagnosed after 24 weeks gestation were recruited. All were managed according to standard protocol. Interviews were conducted by the researcher over a 3 months period (August-October 2010). Experiences, demographic profile, and sociocultural characteristics were compared between the groups that accepted and declined LTOP. Results: Fifteen pregnant women with severe fetal anomalies were enrolled. Around 5 (33.3%) requested termination, and 10 (66.6%) continued the pregnancy. Those who continued their pregnancies were significantly younger (mean age 25 years, range 20–32 years) than those who requested termination (mean age 31 years, range 22–35 years) (P < 0.05). Mean parity was one (range 0–3) in the patients who continued the pregnancy, and 2 (1–3) in those who terminated it. Partners and immediate family members influenced decision making. All women reported a positive experience of the treatment protocol. Conclusion: The decision to continue or terminate a pregnancy for severe fetal abnormalities diagnosed after viability is complex and variable. Younger primigravidas were more likely to continue with the pregnancy in the hope that the baby would be born normal. Good support from partners and family, after delivery, was associated with less regret about the decision that had been made.
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Ethical and legal dilemmas around termination of pregnancy for severe fetal anomalies: A review of two African neonates presenting with ventriculomegaly and holoprosencephaly
SC Chima, F Mamdoo
December 2015, 18(7):31-39
DOI:10.4103/1119-3077.170820  PMID:26620620
Termination of pregnancy (TOP) or feticide for severe fetal anomalies is ethically and morally challenging and maybe considered illegal in countries with restrictive abortion laws. While diagnostic modalities such as fetal ultrasound, magnetic resonance imaging, and genetic screening have improved prenatal diagnosis, these technologies remain scarce in many African countries making diagnosis and counseling regarding TOP difficult. Ethical dilemmas such as women's autonomy rights may conflict with fetus' right to personhood, and doctor's moral obligations to society. In liberal jurisdictions, previable fetuses may not have legal rights of personhood; therefore, appropriate action would be to respect pregnant women's decisions regarding TOP. However, in countries with restrictive abortion laws the fetus maybe imbued with the right of personhood at conception, making TOP illegal and exposing doctors and patients to potential criminal prosecution. Birth of a severely disabled baby with independent legal rights creates further conflicts between parents and clinicians complicating healthcare decision-making. Irrespective of the maternal decision to accept or refuse TOP, the psychological and emotional impact of an impaired fetus or neonate, often lead to moral distress and posttraumatic stress reactions in parents. Doctors have legal and ethical obligations to provide an accurate antenatal diagnosis with full disclosure to enable informed decision making. Failure to provide timely or accurate diagnosis may lead to allegations of negligence with potential liability for "wrongful birth" or "wrongful life" following birth of severely disabled babies. Mismanagement of such cases also causes misuse of scarce healthcare resources in resource-poor countries. This paper describes ethical challenges in clinical management of two neonates born following declined and failed feticide for severe central nervous system anomalies with a critical appraisal of the relevant literature.
  4 7,310 1,021
A legal "right" to mental health care? Impediments to a global vision of mental health care access
N Glover-Thomas, SC Chima
December 2015, 18(7):8-14
DOI:10.4103/1119-3077.170822  PMID:26620626
Mental health law across many jurisdictions provides a legal framework for the compulsory detention and, where appropriate, treatment in hospital of people with mental health problems. Latent within many of these "systems" of mental health provision is the concern that the quality of care people receive does not always meet legal and ethical norms. For many, there remains the very serious recognition that access to mental health care in its entirety remains elusive. International human rights discourse has influenced the shaping of modern mental health laws in many developed countries. In 2008, the Convention on the Rights of Persons with Disabilities (CRPD) entered into force. For many countries, such as South Africa, the CRPD provides a human rights instrument with the scope to establish a worldwide means of bolstering human rights. This paper examines both the UK and the broader African position with regard to the extent redress can be sought if and when an individual does not receive the care and treatment needed. Within this, consideration will be given to one of the paradoxes of mental health care which bedevil mental health systems: How do legal frameworks for detaining and treating people without their consent work when there is no corresponding enforceable right that appropriate treatment or suitable conditions of detention must be provided. The focus of this paper is the question of whether there is indeed a legal "right" to mental health care.
  3 3,224 2,434
Religion politics and ethics: Moral and ethical dilemmas facing faith-based organizations and Africa in the 21st century-implications for Nigeria in a season of anomie
SC Chima
December 2015, 18(7):1-7
DOI:10.4103/1119-3077.170832  PMID:26620616
  2 11,235 8,642
Ethical issues in newer assisted reproductive technologies: A view from Nigeria
JO Fadare, AA Adeniyi
December 2015, 18(7):57-61
DOI:10.4103/1119-3077.170823  PMID:26620623
Background: Infertility is a prevalent condition in many developing countries with significant physical and psychosocial implications. The aim of this study is to discuss briefly the ethics of newer assisted reproductive technology (ART) with special emphasis on the peculiarities in Nigeria. Methods: MEDLINE and Google Scholar were searched for English-language articles from January 1990 to July 2014 using the search terms "ethics of ART AND Nigeria," "ethical issues in in vitro fertilization AND Nigeria." Using the above search phrases, a total of 43 articles were retrieved out of which only 5 dealt specifically with the subject matter. Results: The core ethical issues found in the reviewed literature are listed in [Table 1]. Inequitable access to ART due to its high cost, lack of regulatory body, safety of the procedure, and fate of the embryos were the main themes identified from the papers. Surrogacy, sex selection, and gamete donation were additional relevant ethical issues. Conclusion: There is an urgent need for stakeholders in developing countries to formulate cultural and context-specific guidelines to help address some of these ethical dilemmas.
  2 13,225 1,065
Impact of a short biostatistics course on knowledge and performance of postgraduate scholars: Implications for training of African doctors and biomedical researchers
SC Chima, NM Nkwanyana, TM Esterhuizen
December 2015, 18(7):62-70
DOI:10.4103/1119-3077.170818  PMID:26620624
Background and Objectives: This study was designed to evaluate the impact of a short biostatistics course on knowledge and performance of statistical analysis by biomedical researchers in Africa. It is recognized that knowledge of biostatistics is essential for understanding and interpretation of modern scientific literature and active participation in the global research enterprise. Unfortunately, it has been observed that basic education of African scholars may be deficient in applied mathematics including biostatistics. Materials and Methods: Forty university affiliated biomedical researchers from South Africa volunteered for a 4-day short-course where participants were exposed to lectures on descriptive and inferential biostatistics and practical training on using a statistical software package for data analysis. A quantitative questionnaire was used to evaluate participants' statistical knowledge and performance pre- and post-course. Changes in knowledge and performance were measured using objective and subjective criteria. Data from completed questionnaires were captured and analyzed using Statistical Package for Social Sciences. Participants' pre- and post-course data were compared using nonparametric Wilcoxon signed ranks tests for nonnormally distributed variables. A P < 0.05 was considered statistically significant. Results: Baseline testing of statistical knowledge showed a median score of 0, with 75th percentile at 28.6%, and a maximum score of 71.4%. Postcourse evaluation revealed improvement in participants' core knowledge with the median score increasing to 28.5%; and the 75th percentile score to 85.7%; signifying improved understanding of statistical concepts and ability to carry out data analyses. Conclusions: This study just showed poor baseline knowledge of biostatistics among postgraduate scholars and health science researchers in this cohort and highlights the potential benefits of short-courses in biostatistics to improve the knowledge and skills of biomedical researchers and scholars in Africa.
  2 2,514 330
Medical incidents in developing countries: A few case studies from Nigeria
FN Chukwuneke
December 2015, 18(7):20-24
DOI:10.4103/1119-3077.170821  PMID:26620618
The moral worth of a clinician's, action in patients' management depends exclusively on the moral acceptability of the rule of obligation to duty on which the clinician acts. Since every rational being thinks of him or herself as an end, all people must act in such a way that they treat humanity, whether in their own person or in the person of another, always as an end and never simply as a means. A duty of care is, therefore, paramount in the relationship between clinician and patient. While litigation in healthcare system is rapidly increasing globally, which affords individual explanation and compensation for perceived wrong diagnosis and treatment; it is still rudimentary in Nigeria. This default position has made most health care providers indifferent in the presence of gross clinical negligence and medical errors. Though most Nigerians may be aware of their rights to institute legal action in situations such as, negligence with serious harm or death, but, the socioeconomic factors, cultural, and religious notions among other reasons within the society often makes litigation impossible for an individual. Attributing every medical adverse event in the course of treatment as "God's Will" and the saying "It's God's Time" for every death among most African people has also become a great impediment to curbing clinical negligence in our environment. This paper presents a few case studies from author's experience and complaints from patients during clinical practice.
  2 8,821 1,282
"Because I want to be informed, to be part of the decision-making": Patients' insights on informed consent practices by healthcare professionals in South Africa
SC Chima
December 2015, 18(7):46-56
DOI:10.4103/1119-3077.170833  PMID:26620622
Background: Informed consent (IC) is a legally enforceable right in South Africa based on constitutionally protected rights to bodily integrity and well-being. In terms of the law, patients cannot be involved in medical treatment or research without IC. Healthcare providers must inform patients about diagnosis, risks, benefits, treatment options, and right of refusal in a language patients understand based their literacy level. This study reports an empirical study on patients' perceptions of IC as practiced by doctors and nurses in South Africa. Materials and Methods: A cross-sectional study, using a bilingual semi-structured questionnaire was conducted among patients attending randomly selected public hospitals in eThekwini Metropolitan Municipality (Durban), KwaZulu-Natal province. Competent patients or legal surrogates were eligible for inclusion. IC was obtained from all participants. Results: Four hundred and four participants completed questionnaires of which 68% were female. The median age of participants was 35 years (range 11–91 years). Most respondents spoke IsiZulu (55%), were single (56%), unemployed (66%), and with secondary school education (69%). Patients were generally informed about the diagnosis (81%), risks (57%), and benefits of treatment (61%). Few were informed about treatment options (41%), recommended treatment (28%), and right of refusal (25%). IC was obtained verbally in 73% of cases. Patients favored disclosure of all material risks (78%) and few consulted surrogates before decision-making (76%). There was an association between participant's age and knowledge of the age of consent (P = 0.005). Most patients were satisfied with information disclosed (91%) and did not feel coerced. Some were afraid to ask questions for fear of losing free treatment (8%). Conclusion: This study reveals that South African patients are aware of the right to IC, but many were vulnerable due to indigence. Barriers to IC include poverty, language, and low educational level. South African patients prefer disclosure of all material risks, better communication skills by healthcare workers, and a shift toward informed or shared healthcare decision-making.
  2 4,372 501
Challenges in regulation of biomedical research: The case of Kenya
M Wekesa
December 2015, 18(7):25-30
DOI:10.4103/1119-3077.170819  PMID:26620619
Unregulated biomedical research has previously caused untold suffering to humankind. History is full of examples of abuse of animal and human subjects for research. Several codes and instruments have been formulated to regulate biomedical research. In Kenya, the Science, Technology and Innovation Act, 2014, together with the Constitution of Kenya, 2010, provide a fairly robust legal framework. Possible challenges include capacity building, overlap of functions of institutions, monitoring and evaluation, scientific/technological advances, intellectual property rights, funding for research, and dispute resolution. It is hoped that the new legislation will adequately address these challenges.
  1 2,288 410
Ethics of palliative care in late-stage cancer management and end-of-life issues in a depressed economy
FN Chukwuneke
December 2015, 18(7):15-19
DOI:10.4103/1119-3077.170824  PMID:26620617
The Hippocratic Oath has often been referred to as the ethical foundation of medical practice with the key restriction "cause no harm" which is also the principle of benevolence in bioethics. In medical profession, the Oath still exemplifies the key virtues of a doctor in its emphasis on the obligations toward the well-being of the individual patient. In management of end-stage cancer in a depressed economy such as Nigeria, we frequently encounter a wide range of ethical issues that arise in the provision of palliative care mostly due to the prevailing economic situation and cultural setting. Since most of these patients came from a lower economic class of the society, with little or no formal education and lived at a subsistence level, they often find it difficult to provide the medications needed. In a poor setting where health inequity is rife, and ignorance and poverty are commonplace, a good understanding of medical ethics with a good model of health care system will contribute to the health professional's decision-making that will be in the best interest of the patients. Physicians must protect the lives of their patients and should never hasten their death. In end-stage cancer management, we have to relieve suffering and pains, promote palliative care, and give psychological support but never abandoning the patient or initiate terminating their life. This presentation is a clinical analysis of the ethical issues regarding the management of end-stage cancer patients in a poor economy with a critical overview of end-of-life issues in African perspective.
  1 3,556 1,119
A primer on medical law, bioethics, and human rights for African scholars
RL Moeketsi, SC Chima
December 2015, 18(7):77-78
  - 865 121
Ethics of physiotherapy practice in terminally ill patients in a developing country, Nigeria
NN Chigbo, ER Ezeome, TC Onyeka, CC Amah
December 2015, 18(7):40-45
DOI:10.4103/1119-3077.170826  PMID:26620621
Physiotherapy has been widely defined as a healthcare profession that assesses, diagnoses, treats, and works to prevent disease and disability through physical means. The World Confederation for Physical Therapy describes physiotherapy as providing services to people and populations to develop, maintain, and restore maximum movement and functional ability throughout the lifespan. Physiotherapists working with terminally ill patients face a myriad of ethical issues which have not been substantially discussed in bioethics especially in the African perspective. In the face of resource limitation in developing countries, physiotherapy seems to be a cost-effective means of alleviating pain and distressing symptoms at the end-of-life, ensuring a more dignified passage from life to death, yet referrals to physiotherapy are not timely. Following extensive literature search using appropriate keywords, six core ethical themes related to physiotherapy in terminally ill patients were identified and using the four principles of bioethics (patient's autonomy, beneficence, nonmaleficence, and justice), an ethical analysis of these themes was done to highlight the ethical challenges of physiotherapists working in a typical African setting such as Nigeria.
  - 4,620 637