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Ethical portrait of the Nigerian health sector

Most people are familiar with the Hippocratic Oath – an oath of ethics upheld by medical doctors in almost all parts of the world. But not many are familiar with the specific ethical components health care workers are expected to uphold. Principlism is one of such ethical frameworks. It encompasses four major principles: The principle of autonomy; principle of beneficence; principle of nonmaleficence and the principle of Justice.

The principle of autonomy upholds that patients should have authority over the health intervention or care they receive. This is why in high risk interventions; health care workers have to get an express written informed consent from their patients. The principle of beneficence, on the other hand insists that health care givers must in their practice only do that which is considered of benefit to their patients’ wellbeing. Similarly, the principle of nonmaleficence stands on the proclamation of “primum non nocere” which means “first, do no harm”.

It obligates health care givers to not inflict harm on their patients as a result of inappropriate, inadequate or absent care. The principle of justice obligates fairness on the part of health workers. It speaks to the rights of patients in their interactions with the health system. Basically, all patients have equal rights and health resources should be distributed among them equally. This also means that patients should be able to seek redress and compensation when a health care worker causes some form of harm (whether intentionally or not) to the patient.

At this juncture, I am sure you are as curious as I am to know how the Nigerian health sector fairs with regards to these four principles. I believe it is important to state for the benefit of non-locals that the average Nigerian does not consider the existence and implications of these ethical principles and are grateful when their health care workers show up!

Back to the question. How does Nigeria fair? This question was the crux of a recent research (2020) commissioned by the Christopher Kolade Centre for Research in Leadership and Ethics- a research Centre at Lagos Business School. Through a survey of both health care professionals and health care users, the researchers aimed to ascertain just how well these ethical principles are upheld by medical practitioners in Nigeria.

It will please you to know that the findings were not as bad as one would have thought. Overall healthcare workers recognize these ethical principles:

Autonomy

Most of the respondents were of the opinion that healthcare workers do uphold & allow the autonomy of their patients. However, more than a quarter of the respondents did not even believe they had the rights to such autonomy. And of those who did, more than half of them still felt their health care professionals should have the final say in their health decisions. Such over reliance and dependence while not totally farfetched (afterall ‘the practice of medicine is rooted in a covenant of trust among patients, physicians, and society’) is still somewhat disturbing especially in Nigeria, where the health system is such that patients need to act as their own advocate. There have been known cases where doctors act not necessarily in the best interest of their patients.

Individual patients have to know that they have a level of responsibility to themselves as regards their health. So, even though you trust and should trust your health care professional – do not forget that they are humans, humans with flaws and prone to errors. At every stage of any health intervention you should and have the right to be aware of your health and health interventions. As a popular adage in my culture goes “oju meiji, o le dabi oju te ni”. Remember, you are first and foremost your own advocate.

Beneficence

On the principle of beneficence – respondents were almost unanimous in their response that healthcare workers do their best to ensure their health and wellbeing. This certainly speaks to why most believed their healthcare workers should have the final say in their health decisions. If you believe your doctor has your best interest at heart you are more likely to submit your personal agency to him/her. However, this is contradicted by findings from the research, as you will see in the next paragraph on nonmaleficence.

Nonmaleficence

The findings showed that about a third of respondents (healthcare users) had experienced some form of harm while dealing with their health care providers. It is important to note that this observation cuts across users of both public and private hospitals, as it is often assumed that private hospitals are less likely to be involved in issues of maleficence. Among all the indicators of maleficence recorded in the study, perhaps the most alarming was the proportion (11 percent) of respondents who indicated that they had been treated by a medical practitioner under the influence of alcohol or other intoxicants. In addition, more than quarter of the respondents indicated that professionals had taken advantage of their health situation in one way or the other to advance their own interest.

The healthcare providers surveyed in the research also affirmed this noting that it is not unusual for practitioners to advance a treatment plan – that may not necessarily be the best for the patient (in terms of finance, duration) but holds the best outcome for the practitioners. Needless to say, this is totally unacceptable. Under no condition should a health practitioner attend to a patient under the influence of alcohol or any intoxicating substance. Similarly, treatment plans should be based solely on that which is best for the patients. The pecuniary benefits of the practitioner should never be a factor.

Unfortunately, practitioners who commit this sort of atrocities hardly face any redress/repercussion. It will interest you to know that the body responsible for reviewing cases of medical malpractice in Nigeria (the Medical and Dental Council of Nigeria, MDCN) did not have a governing council for a very long time. This meant practitioners facing disciplinary actions during that period continued to work without any consequence for their actions.

Justice

This brings us to the last and final principle – Principle of Justice. As earlier stated, this principle prescribes that health practitioners treat all patients equally without regard to status or any other such considerations. Findings from the study indicate that practitioners are mostly fair in this regard. The healthcare system however makes it such that quality healthcare is out of reach for many individuals.

Speaking to our earlier discussion on seeking redress, although many of the respondents affirmed that healthcare breaches should be reported, more than half had no idea whom to report to and more importantly over 47 percent of the respondents did not trust that anything will be done. This is also evidenced by responses from Healthcare practitioners who participated in the study.

Over 20 percent of the health practitioners surveyed clearly stated they had no confidence health breaches even when reported will be acted upon adequately and for this reason a fraction of them indicate they do not bother to report instances of misconduct by their colleagues.

It thus seems that given the apparent absence of checks and balances of medical professionals in Nigeria it becomes imperative for consumers (patients) to be armed with knowledge as regards their rights in health situations, that is, their interactions with the health system. Perhaps we consumers should start considering innovative ways to ensure there is transparency in the actions and practice of health practitioners. In the past, online public health registers have been suggested as an innovative way to ensure some form of transparency in the medical field. In such a register, individuals will be able to enter complaints and rate their experiences with health practitioners. It is my hope that this piece will at least help to continue such conversations and provide a lens through which consumers of health services can base their expectations.

Do not sleep on your rights, stay woke!

This article was adapted from the Ethical Portraits of the Nigerian Health Sector Report originally written by Dr. Yetunde Anibaba. It has been adapted by Rukayat Baderinwa for the Christopher Kolade Centre for Research in Leadership and Ethics (CKCRLE) at Lagos Business School (LBS). CKCRLE’s vision is creating and sharing knowledge that improves the way managers lead and live in Africa and the World. You can contact CKCRLE at crle@lbs.edu.ng

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