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1. Ethical dilemma and ethical
decision making
3/22/2023 Ethics for MWR by ESTELA

2. Definition
⚫ Situation that requires an individual to make a
choice between two equally unfavorable
alternatives.
• Conflict between one individual's rights and those of
another, or between one individuals obligation and the
rights of another, usually form the basis of the
dilemma.
• The alternatives in dilemma may have favorable or
unfavorable features.
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3. Cont…
• Ethical dilemmas in health care involve issues
surrounding professional actions and client care
decisions.
• They can lead to discomfort and conflict among
the members of the health care team or between
the providers, the client and the family.
3/22/2023 Ethics for MWR by ESTELA

4. I. Models for ethical decision-making
• Ethical issues are real life issues.
• There is no one way of resolving such situations.
• Each situation will be different, depending on
the people involved and the context.
• However ethical decision-making models;
provide mechanism or structure that help you
think through or clarify an ethical issue.
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5. Cont…
• There are a number of models from which to
choose from, but there are no best way to
approach ethical decision –making.
• Ethical decision making models are not formulas
and they do not ensure that the decision you
make will be the right one.
3/22/2023 Ethics for MWR by ESTELA

6. Model 1; guide to ethical decision
making
1.Recognize the moral dimension;
• Is recognizing the decision as one that
has the moral importance.
2. Who are the interested parties?
• What are their relationships?
• Carefully identify who has a stake in the
decision in this regard,
3. What values are involved?
• Think through the shared values that are at
stake in making this decision.
• Is there a question of trust, personal autonomy,
fairness or any one harmed / helped?
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7. Cont…
4. Weigh the benefit and burdens;
• Benefits must include such things as the production of good (physical,
emotional financial, and social etc) for various parties.
5. Look for similar cases.
• Can you think of similar decision in the past?
• What course of action was taken?
• Was it a good one?
• How is the present case like that one?
• How is it different?
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8. 6. Discuss with relevant others
7. Does it follow organization or legal rules.
8. Am I comfortable with this decision?
◦ Telling my family?
◦ Be example to my children?
◦ Can I live with this decision?
◦ Is it an appropriate decision made by informed
person?
3/22/2023 Ethics for MWR by ESTELA

9. Model 2: Clinical Ethics grid system;
⚫ This system helps to construct a summary of the facts
that must be considered along with ethical principles
to guide ethical decisions in a clinical setting outlined
as follows.
1. Medical indications;
• What is the patient‟s medical problem? History? ,
Diagnosis?
• Is the problem acute? Chronic? Critical?
Emergent? Reversible?
• What are the goals of treatment?
3/22/2023 Ethics for MWR by ESTELA

10. • 2. Patient’s preference;
• What has patient experienced about
preferences for treatment?
• Has the patient been informedof benefits
andrisk, understood and given consent? etc
• 3.Quality of life;
• What are the prospects with or without
treatment, for a return of the patient's to a
normal life?
• 4.Contextual factors;Are therefamily
issues that may influence treatment
decisions?
3/22/2023 Ethics for MWR by ESTELA

11. Illustrative case study
• A mother brought her 16 year-old daughter who
has intellectual disability and requests for
hysterectomy for her daughter.Her daughter has
started menstruating one year earlier, has been
experiencingirregular and heavy menstruation,
and has been unable to care for herself, which
hasled to hygieneissues.The mother has been
having difficulty in getting the child to take the
medication prescribed.She is also concerned
that her daughter may be sexually abused
resulting in pregnancy as she has started to show
keen interest in the opposite sex.
3/22/2023 Ethics for MWR by ESTELA

12. Laws
⚫Rules of social conduct devised by people
to protect the society.
⚫Based upon concerns for fairness and justice.
⚫Their fundamental role is preservation of the
species,through promotion of peaceful and
productive interaction between individuals
and groups.
⚫Are enforceable.
3/22/2023 Ethics for MWR by ESTELA

13. Laws…
⚫Promote order by:
• Resolving conflicts and disputes non-violently
• Defining responsibilities
• Protecting the health, safety &welfare of
state citizens.
• Until now there is no clear law governing the
practice of Midwifery in Ethiopia except for
the Code of Ethics for Midwives produced by
the Ethiopian MidwivesAssociation.
3/22/2023 Ethics for MWR by ESTELA

14. 1. Public Law:
⚫The body of law that deals with relationships
between individuals and governmental
agencies.
⚫An important segment of public law is criminal
law which deals with actions against the safety
and welfare of public.
• 🞄Example,theft,homicide
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15. Types of public
law
• Criminal laws
• Violation of criminal status stated by the law
or offences against society /person or
property/ as spelled out in the criminal
code.
• Guilt established by proof beyond a
reasonable doubt.
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16. • 2.Private Law :
⚫is the body of law that deals with relationships,
between individuals.
⚫It is categorized as contract law and tort law.
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17. A.Contract Law:
◦ involves the enforcement of agreements among
private individualsor the paymentof compensation
for failure to fulfill the agreements.
B.Tort Law:
⚫ The word tort means 'wrong " or "bad" in Latin.
⚫ It defines and enforces duties and rights among
private individuals that are not based on
contractual agreements.Example
◦ Negligence and malpractice
◦ Invasion of privacy and assault.
3/22/2023 Ethics for MWR by ESTELA

18. Health related Legal issues in
Ethiopia
⚫ Abortion:
◦ • Abortion is not allowed in Ethiopia, unless there is medical,
maternal and fetal indication
◦ • but, It is mandatory to treat a patient who is suffering
from the effect of acriminal abortion induced by another.
◦ Euthanasia
◦ Death
◦ Suicide
◦ OrganTransplantation
3/22/2023 Ethics for MWR by ESTELA

19. Areas of potential liabilities
⚫The legal responsibility for one‘s actions
or failure to act appropriately—personal
and vicarious.
• A person found guilty of a tort or crime is
considered legally liable, for the outcome,
whether intended or unintended.
• The guilty person is subject to punishment
depending on the nature of the act/s.
• Liability can extend to more than one person.
3/22/2023 Ethics for MWR by ESTELA

20. Three major levels of liability
• Personal liability:
◦ the midwife is responsible for performing those acts ,
and only those acts to he/she is licensed.
(Omission/commission).
• Employer liability:
◦ The employer is held responsible for actions of an
employee such ashiring qualified personnel, providing
appropriate environment for correct functioningand
providing appropriate supervision to prevent errors or
injury.
◦ Employer still has apersonal liability.
3/22/2023 Ethics for MWR by ESTELA

21. ◦ Supervisor liability:
• 🞄the person in a supervisory position is
responsible for exercising good judgment in
makingdecisions about assignments and
delegation of tasks;decisions concerning care
givenbymidwife over whom the supervisor
is assigned if involved with these decisions.
3/22/2023 Ethics for MWR by ESTELA

22. Good Samaritan statutes
⚫Are laws enacted by various states that protect
health care providers and from being sued when
they are giving an emergency help to a victim
provided the person used prudent, reasonable
guidelines for care using the available resources at
the time of the accident.
⚫Good Samaritan laws do not provide absolute/full
protection from malpractice claims
3/22/2023 Ethics for MWR by ESTELA

23. T
o trigger the protection of such an
act the following conditions must be satisfied:
It must be a volunteer act
The action of the rescuer must be agood- faith
effort to help
A professional should not leave a patient
unless care is transferred to an equally
competent professional
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24. ⚫ Crimes and torts
◦ A crime is an act committed in violation of public
(criminal) law and punishable by afine and/ or
imprisonment.
◦ A crime does not have to be intended in
order to be a crime.
• 🞄For example, if you accidentally giveaclient an
additional andlethal dose of narcotic to relive
discomfort.
3/22/2023 Ethics for MWR by ESTELA

25. Crimes could be felonies and / or
misdemeanors
⚫ Felonies:
◦ Acts or omissionspunishablebylawandthey may be
committed not only by means of deceit (dolo) but also
by means of fault (culpa)
◦ An act punishable by or > 1 year imprisonment or even
death
• 🞄Ex.murder, theft, child abuse,illegal drug useand selling,
violation of state practice act,etc
3/22/2023 Ethics for MWR by ESTELA

26. Misdemeanors:
◦ Other lesser crimes
◦ Is an offense of a less serious Nature and is
usually punished afine or short Term jail
sentence or both.
◦ For example,amidwife who slaps aclient‘s
face could be charged with a misdemeanor
3/22/2023 Ethics for MWR by ESTELA

27. Tort law
The word tort means 'wrong " or "bad" in Latin. It
defines and enforces duties and rights among private
individuals that are not based on contractual
agreements.
 Is a civil wrong committed against aperson or a
person‘s property.
 Torts are usually litigated in court by civil action
between individuals.
Intentional
Un intentional
3/22/2023 Ethics for MWR by ESTELA

28. • Intentional:
⚫ Assault: to threaten verbally or pretending to
hit them
⚫ Fraud:
◦ Falsepresentation of somefact with the intention
that it will be acted up on by another person
3/22/2023 Ethics for MWR by ESTELA

29. ⚫ Battery:
◦ Touching or treating without consent.
◦ Forcing treatment on unwilling person is no
different from attacking that person with a
knife
◦ Can be the basis of civil lawsuit
3/22/2023 Ethics for MWR by ESTELA

30. ⚫ Invasion of privacy:
◦ breach of confidentiality, photographing
patients without their consent.
⚫ Defamation of character:
◦ slander or Liable
◦ when one party makes an untrue and
damaging statement about another party and
then causes or allows it to be disseminated
to a third party
3/22/2023 Ethics for MWR by ESTELA

31. Unintentional torts:
⚫ Negligence:
◦ the failure to act as areasonably practical person would
have acted in aspecific situation.
◦ Conduct that fallsbelow the standards established by
law for the protection of others against unreasonable
risk of harm— good intentions do not enter in the
CONDUCT is the issue.
3/22/2023 Ethics for MWR by ESTELA

32. ⚫Malpractice:
◦ the failure of aprofessional to use such care asa
reasonably prudent member of profession would
use under similar circumstances,which leads to
harm.
• Elements of medical malpractice
• 🞄Duty
• 🞄Breach of Duty
• 🞄Damages
• 🞄Proximate cause
3/22/2023 Ethics for MWR by ESTELA

33. Potential Malpractice Situation
⚫ 1.Medication error:
◦ Failing to read the medication label.
◦ Misunderstanding or incorrectly calculating the dose.
◦ Failing to identify the client correctly.
◦ Preparing the wrong concentration or Administration
by wrong route (e.g.IV instead of IM)
⚫ Sponges or other small items can be left inside a
client during an operation.
3/22/2023 Ethics for MWR by ESTELA

34. ⚫ Burning a client:
◦ May be caused by hot water bottle,heating pads, and
solutions that are too hot for applications.
⚫ Clients often fall accidentally:
◦ leaves ababy unattended on abath table .
⚫ Ignoring a clients complaints
⚫ Incorrectly identifying clients
⚫ Loss of client‘s property: jewelry,money,eye
glasses and dentures.
3/22/2023 Ethics for MWR by ESTELA

35. ⚫ DUTY
• The midwives responsibility to provide care in an
acceptable way.
• Duty is based
– level of education
– Standards of care
– Standards of employer
3/22/2023 Ethics for MWR by ESTELA

36. ⚫ Breach of Duty
◦ The Midwife did not adhere to the
standard(s) of care
• Omission— expectation was NOT done
• 🞄
Commission—expectation was not done
correctly.
⚫Damages
◦ Damaged the patient due to the negligent act —
◦ there has to be actual damage
3/22/2023 Ethics for MWR by ESTELA

37. ⚫ Proximate cause
◦ There must be reasonable cause and effect
relationship that shows the Midwife did or didn‘t
do or cause the damage.
3/22/2023 Ethics for MWR by ESTELA

38. • Four circumstances must be present and must be
proven in the court of law to prove that negligence or
malpractice has occurred :
Harm must have occurred to the individual
One person must be in a situation where he/she had a
duty toward the person harmed
That person must be found to have failed to fulfill his/her
duty
The harm must be shown to have been caused by the
breach of the duty.
3/22/2023 Ethics for MWR by ESTELA

39. CODE OF ETHICS FOR MIDWIVES
• Is asystem of principles governing conduct of
midwives
3/22/2023 Ethics for MWR by ESTELA

40. Guiding Principles
⚫A profession is a means of livelihood.
⚫The midwife has the right to earn a living and
to secure for herself the necessities and
comfort of life.
⚫As aprivate practitioner, the midwife must
safeguard the reputation and good name of
her co-member in the profession,having
always in mind the ―GOLDEN RULE.‖
3/22/2023 Ethics for MWR by ESTELA

41. SENSEOF RESPONSIBILITY
⚫RESPONSIBILITY
• - Denotes moral integrity, trustworthiness,
and dependability.
• A midwife who possesses a sense of
responsibility
3/22/2023 Ethics for MWR by ESTELA

42. Midwives and their clients
⚫The midwives' primary responsibility is to the
clients they care for.
⚫Midwives should provide care according to
their clients‘ individual needs, regardless of
their gender, ethnicity, religion, age, social or
economic status.
⚫Midwives shall respect their clients‘ values and
autonomy. They should advocate on their
clients‘ behalf when necessary.
3/22/2023 Ethics for MWR by ESTELA

43. ⚫Respect client‘s individual values and needs
⚫Respect and promote clients‘ autonomy
⚫Respect clients‘ right to confidentiality
⚫Respect and preserve clients‘ privacy and
dignity
3/22/2023 Ethics for MWR by ESTELA

44. Midwives and their practice
⚫Midwives are responsible for providing the
highest standards of midwifery care and ethical
practice possible within any given situation.
⚫They should be familiar with the profession‘s
ethical stance on such issues as practice
accountability, preservation of confidentiality,
skills competency and the maintenance of
client privacy and dignity.
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45. ⚫Safeguard theWell-Being ofWomen and their
Newborns
⚫Provide care in a responsible and accountable
manner
⚫Maintain competency in the care of clients
⚫Advocate for the best interest of clients
⚫Maintain high ethical standard in conducting
research
3/22/2023 Ethics for MWR by ESTELA

46. Midwives and their profession
⚫All midwives are responsible for maintaining
and enhancing the reputation of the
profession.
⚫Midwives should act at all times in accordance
with ethical healthcare practices, actively
promote professional ethics, and foster public
trust and confidence in the midwifery
profession.
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47. ⚫Maintain a practice environment that is
conducive to the provision of ethical health
care
⚫Promote the profession‘s ethical standards
and maintain public trust in the midwifery
profession
3/22/2023 Ethics for MWR by ESTELA

48. Patients bill of right
⚫ American Hospital Association has affirmed a
• Patients‘ Bill of Rights which states in part that
the patient has the right to:
◦ Considerate and respectful care
◦ Obtain complete current information concerning hisor
her diagnosis,treatment andprognosis (expected
outcome)
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49. Patients bill of right
◦ Receive information necessary to give his or her
informed consent prior to the start of any procedure
or treatment
◦ Haveadvancedirectives for health care and/or refuse
treatment to the extent permitted under law
◦ Privacy concerning his or her medical care
program
◦ Confidential treatment of all communications
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50. Cont…
◦ Reasonable response to his or her request
for services
◦ Obtain information regarding any relationship
of the hospital to other health care and
educational institutions
◦ Be advised of and have the right to refuse
to participate in any research project
◦ Expect reasonable continuity of care
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51. Patients bill of right…
◦ Review medical records and examine the bill
and receive an explanation of all charges
◦ Be informed of any hospital rules or regulation
• What are the responsibilities of a patient???
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52. Thank you
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