**3. Bioethical orientations**

The thinking and end result of bioethical considerations are directed along various set-lines, constituting different bioethical orientations. The ancient Greek value system and philosophy considered to be the origin of bioethics together with the input of various religions notably Christianity and Islam over the years represent the historical orientation of bioethics.

Duty based or deontological bioethical orientation is related to natural laws and reason, distinguishing vice from virtue as an indivisible accompaniment of any action or intention. The Catholic Church is a well known proponent of duty based bioethics and this is evident from the church's stand for instance against the use of condom for prevention of pregnancy or sexually transmitted infection or against artificial forms of contraception, while supporting natural family planning. St. Thomas Aquinas in the 13th century incorporated some natural laws developed and proposed by Aristotle into the doctrine of the Roman Catholic Church. Duty based bioethical orientation is believed to be absolutist and often unbending to the relativity and diversity that characterize ethical considerations. This may have serious implications to reproductive health in general, often replete with bioethical challenges.

Utilitarian or consequentialist bioethical orientation recognizes man's moral responsibility for his or her bioethical choices. Whatever promotes the well-being or happiness of man is considered to be good while whatever causes harm or unhappiness to man is bad. It recognizes man as an important end in himself rather than being a means to an end of whatever form. For example, a woman with an unwanted pregnancy, desirous of termination of the pregnancy should be assisted with safe and unencumbered induced abortion since this may promote her psychological and social well being.

Feminist bioethical orientation basically aims at incorporating women's social experiences, thinking and behavior into the value system of healthcare and clinical practice. It is also known as ethics of care or connectedness, and constitutes a reaction to the exclusion of women from historical sources of moral authority such as the clergy, top echelons of the military or legislature and other similar position exclusively "restricted" on the basis of sex or gender. value

Apart from these bioethical orientations considered to be key towards effective bioethical considerations, there are a few others that have become recognized which include the following:

Virtue – tenets to which biomedical institutions and practitioners should adhere to, such as kindness, trustworthiness, discernment, and integrity, all of which conform to the ethical ideals of Hippocrates.

Communitarianism – bioethical orientation that advances and promotes the good of the community.

Casuistry - proponents of this orientation subscribe to the resolution of issues on the basis of their merit rather than on a resort to universal rules.

Bioethics in Obstetrics 301

pregnant woman used for the purpose of a clinical examination for professional medical students' exams may have been promised free further antenatal care and delivery. The ethical principle of scientific validity enjoins the medical practitioners to ensure professional competence and scientific soundness in the conduct of medicare or research on patient.

There are four analytical levels to which bioethical principles are applicable. Each of these has its specific orientation and may or may not be related to the others. Microethical analytical level applies to relationship between individuals and in this case the health care provider and the patient, while the medical practitioner has an ethical obligation to give his patient enough and correct information on all available options to make an informed decision and consent, the patient is obligated to respect his or her medical practitioner's right to conscientious objection to any treatment being requested of him. For example, a medical practitioner's conscientious objection to induced abortion should be respected just as much as the medical practitioner is obligated to refer such patient to where competent treatment can be accessed. Macroethical level of bioethical analysis refers to the relationship between groups or communities – between members of the group of communities themselves, or between them and members of another group or community, for example, the ethical commitment to the provision of healthcare between an urban and rural population, or between different socio–economic classes of people within a group or community. Mesoethical analytical level otherwise known as ethics of intergenerational justice refers to discordance in resource allocation between groups by health managers at both public and private levels. Mesoethics falls between microethical and macroethical levels and implicates the ethical principles of beneficence and distributive justice, for instance contrasting high budgetary allocation to Senators to receive free medicare abroad even for trivial illness treatable locally, to the very low budget allocated to maternal health service delivery, in a developing country with unacceptably high maternal mortality. Megaethical level of bioethical analysis applies to issues operating beyond national boundaries, for example ethical issues related to the treatment of HIV/AIDS with Anti Retroviral Drugs where in the past the drugs are produced at reasonable cost in developed countries and exported to developing countries with a high burden of HIV disease and sold at prohibitive prices. Similar concerns are also manifest in reproductive health issues, and

Ethical considerations are perhaps more profoundly manifest in research than in most other aspect of medicine. Medical research especially those involved with human embryo and stem cell often bring to bear the demands and challenges posed by different bioethical orientations. Deontological bioethicists for their firm adherence to an orientation of natural laws and reasons are unlikely for instance to condone research targeted at exposing life threatening foetal abnormalities that would ordinarily require termination, in a pregnant subject. In the same vein, consequentialist and feminist bioethicists will employ macroethical reasoning to justify the conduct of research on a few human embryo and stem cells for the purpose of obtaining information that will lead to the development of therapy that will benefit many more sick patient (Stephens and Brynner, 2001). Ethical conflicts arise

**5. Analytical levels of bioethics** 

the effect of environmental pollution or degradation.

**6. Research ethical review** 

#### **4. Principles of bioethics**

The development of the principles of modern bioethics is inextricably linked to the contents of the Belmont Report (The Belmont Report, 1978). The Tuskegee Alabama public health service funded syphilis research over the 40 year period, 1932 – 1972, involved inhuman experimentation on 400 indigent black American males (James, 1993). The termination of this research led to American congressional passage of the National Research Act in 1974 and the establishment of the United State's National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research which in 1979 published its findings and recommendations known as the Belmont Report. The Belmont Report provided an analytical frame work to guide the resolution of ethical problems arising from research involving human subjects. Three basic ethical principles contained in the Belmont Report viz: Respect for persons, Beneficence, and Justice, essentially constituted the foundation for the development of the key principle of modern bioethical analysis. Implicit in the principle of beneficence (do good) is non – maleficence (do no harm) which has become recognized as a distinct key principle. These four key principles of bioethical analysis constitute a consensus resolution of different bioethical orientations notably from the works of two American bioethicists - Tom Beauchamp and James Childress and the British expert - Raanan Gillon (Beauchamp and Childress, 2001; Gillon, 1994). In addition to these four key principles, three others have been recognized in modern bioethical analysis – veracity, fidelity and scientific validity. These

The principle of respect for person occurs at two levels. The first level refers to autonomy of capable persons which upholds patient's right to voluntary informed consent, and choice based on comprehension of available options, for example, patients right to family size determination. The second level is the protection of persons incapable of autonomy. Three groups of persons are notable in this regard - the unconscious, the mentally sub-normal and the child – all of who require the protection of their autonomy. For example, the decision on the treatment of an unconscious pregnant woman, or the genital mutilation of an infant. This protection requires either the presence of a living will especially in the case of the unconscious patient or the obtaining of consent from the surrogate or where not feasible a clergyman, or the ethical committee of a health institution or as a last resort, the law court. Medical paternalism refers to the overriding of autonomy. Strong paternalism is the overriding of the autonomy of a capable person, and is not ethically permissible. While weak paternalism is the overriding of the autonomy of an incapable person which is permissible if performed for the overall well-being of the person. The principles of Beneficence refer to the ethical responsibility to do and maximize good. It emphasizes what is best to the patient with respect to preventive and curative healthcare. The principles of non–maleficence refers to the ethical duty of the health practitioners to do no harm or cause pain to the patient as in the giving and suturing of episiotomy without local anesthesia in a parturient woman. The principles of Justice refer to the ethical responsibility to uphold fairness and equity in medicare. It refers to the equitable distribution of potential benefits and risks. The ethical principles of veracity enjoins health practitioners to tell the truth explaining the potential benefits and risks alike involved in whatever treatment being giving to, and procedure being carried out on the patient. The principles of fidelity refers to the ethical responsibility of the health practitioners to carry out whatever promises made to a patient in relation to activities for which he or she has been employed. For example, a

The development of the principles of modern bioethics is inextricably linked to the contents of the Belmont Report (The Belmont Report, 1978). The Tuskegee Alabama public health service funded syphilis research over the 40 year period, 1932 – 1972, involved inhuman experimentation on 400 indigent black American males (James, 1993). The termination of this research led to American congressional passage of the National Research Act in 1974 and the establishment of the United State's National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research which in 1979 published its findings and recommendations known as the Belmont Report. The Belmont Report provided an analytical frame work to guide the resolution of ethical problems arising from research involving human subjects. Three basic ethical principles contained in the Belmont Report viz: Respect for persons, Beneficence, and Justice, essentially constituted the foundation for the development of the key principle of modern bioethical analysis. Implicit in the principle of beneficence (do good) is non – maleficence (do no harm) which has become recognized as a distinct key principle. These four key principles of bioethical analysis constitute a consensus resolution of different bioethical orientations notably from the works of two American bioethicists - Tom Beauchamp and James Childress and the British expert - Raanan Gillon (Beauchamp and Childress, 2001; Gillon, 1994). In addition to these four key principles, three others have been recognized in modern bioethical analysis –

The principle of respect for person occurs at two levels. The first level refers to autonomy of capable persons which upholds patient's right to voluntary informed consent, and choice based on comprehension of available options, for example, patients right to family size determination. The second level is the protection of persons incapable of autonomy. Three groups of persons are notable in this regard - the unconscious, the mentally sub-normal and the child – all of who require the protection of their autonomy. For example, the decision on the treatment of an unconscious pregnant woman, or the genital mutilation of an infant. This protection requires either the presence of a living will especially in the case of the unconscious patient or the obtaining of consent from the surrogate or where not feasible a clergyman, or the ethical committee of a health institution or as a last resort, the law court. Medical paternalism refers to the overriding of autonomy. Strong paternalism is the overriding of the autonomy of a capable person, and is not ethically permissible. While weak paternalism is the overriding of the autonomy of an incapable person which is permissible if performed for the overall well-being of the person. The principles of Beneficence refer to the ethical responsibility to do and maximize good. It emphasizes what is best to the patient with respect to preventive and curative healthcare. The principles of non–maleficence refers to the ethical duty of the health practitioners to do no harm or cause pain to the patient as in the giving and suturing of episiotomy without local anesthesia in a parturient woman. The principles of Justice refer to the ethical responsibility to uphold fairness and equity in medicare. It refers to the equitable distribution of potential benefits and risks. The ethical principles of veracity enjoins health practitioners to tell the truth explaining the potential benefits and risks alike involved in whatever treatment being giving to, and procedure being carried out on the patient. The principles of fidelity refers to the ethical responsibility of the health practitioners to carry out whatever promises made to a patient in relation to activities for which he or she has been employed. For example, a

has

**4. Principles of bioethics** 

veracity, fidelity and scientific validity.

pregnant woman used for the purpose of a clinical examination for professional medical students' exams may have been promised free further antenatal care and delivery. The ethical principle of scientific validity enjoins the medical practitioners to ensure professional competence and scientific soundness in the conduct of medicare or research on patient.
