Challenges to ethical integration of reproductive health education in schools of Tshwane District, South Africa

The Integrated School Health Policy was set to ensure the incorporation of a multi-disciplinary approach to health care in South African schools. However, the implementation of sexuality and reproductive health teaching and learning has not been without problems. Central to sexuality and reproductive health education is the common ethical application of the subject in teaching. School sexuality and reproductive health education have proved to be a sensitive issue across a socio-cultural environment. Compliance with ISHP programs in sexuality and gender orientation is related to the inclusion of a more comprehensive education for learners to cover human rights and sexual diversity. This paper aims to reflect on the ethical challenges related to the integration of reproductive health education and teaching in schools in the City of Tshwane. This study applied a descriptive exploratoryquantitative research design. Data was collected using a survey questionnaire and a checklist, and applied stratified random sampling to select schools that participated in the study. Data were analysed using descriptive statistics which included frequencies and percentages (%). The results show that the absence of health care values in organisational strategies will challenge the ethical dimension relating to sexuality and reproductive health education. The ethical dilemma of teaching sexual and reproductive health in schools can prove to be a challenging exercise since its a sensitive issue in most societies. Sexuality and reproductive health education is compounded by a lack of clear guidelines in the ISHP programs and the diversity of stakeholders that do not hold a common or standardised ethical framework. Furthermore, lack of sufficient teacher preparation adds to the ethical dilemma in managing school ethical issues in general. (Afr J Reprod Health 2022; 26[4]: 75-81).

Sufficient informed consent to medical treatment of adults legal and ethical perspectives from Malawi

This special communication discusses the current legal and ethical requirements for informed consent to medical treatment of adults in Malawi. It analyzes the scope of the laws and code of ethics on professional discipline, including criminal privilege for surgeries and clarifies when insufficient disclosures entitle patients to compensation under civil law. Inconsistencies and uncertainties in the law are made apparent. It evaluates to which degree disclosure standards of other Commonwealth jurisdictions (e.g. the case of Montgomery) would be suitable for the health care setting of a country like Malawi that is characterized by shortages of resources, high illiteracy rates and a communitarian cultural context. Doctor-patient communication is not alien to African culture and part of sufficient informed consent. In order to balance the need for efficiency in health care delivery, accountability for quality care, fairness and effective patient-doctor communication the authors suggest to adopt the reasonable patient test only, if a defence of heavy workload on case-to-case basis is introduced at the same time. This does not dispense the need for organisational diligence on part of the institutional health care provider within its capacity

Public health ethics and the COVID-19 pandemic

Health is a human right anchored in values as a basic necessity of life. It promotes the well-being of persons, communities, economic prosperity, and national development. The coronavirus disease-2019 (COVID-19) pandemic caught the world unaware and unprepared. It presented a huge challenge to the health and economic systems of every country. Across the spectrum of human endeavor and liberty, several ethical questions have been raised with regard to its management, particularly the public health control measures. Decisions for pandemic control measures are made under difficult circumstances driven by urgency and panic, with uncertainties and complexities for public goods over individual rights. Global solidarity in controlling the pandemic is being tested. National governments have the responsibility to protect public health on the grounds of common good. Political considerations should not be the basis for decision-making against the best available epidemiological data from pandemic disease dynamics. Hence, the need to adhere to the values of honesty, trust, human dignity, solidarity, reciprocity, accountability, transparency, and justice are major considerations. A literature search was conducted for the publications from academic databases and websites of health-relevant organizations. I discuss the ethical questions and challenges of the COVID-19 pandemic in the context of public health control measures using the standard ethical principles of respect for autonomy, beneficence, nonmaleficence, and social (distributive) justice. It is observed that, at the country level, the World Health Organization (WHO) guidelines are used to control the pandemic. As WHO through the COVAX strategy distributes the vaccines to less developed countries, a lot still needs to be done to address the complex bottlenecks of allocation and distribution. There is a need to ensure acceptable and transparent system that promotes cooperation, equitable access, and fair distribution of vaccines on a global scale.

Views of South African biomedical research ethics committee members on their own ethics review outcomes

Background. Current research ethics guidelines and legislation provide research ethics committees (RECs) with the prerogative to review and approve the ethical acceptability of human research before commencement. However, individual REC members' views on the ethical issues identified behind closed doors remain largely empirically unexplored. Objective. To investigate the views and perceptions of South African biomedical REC members on their own aggregated ethics review outcomes. Methods. Semi-structured interviews were conducted with nine REC members from two different institutions in South Africa. Results. All respondents concurred with the prioritisation of informed consent in the review outcomes, emphasising the importance of the use of simple and understandable language for participants. Respondents also discussed lack of scientific validity as a common problem when reviewing proposals. Interestingly, while the majority of respondents reiterated the common view that scientifically invalid research is unethical, some REC members believed that there was an overemphasis on evaluation of scientific validity, and that it was not within the remit of RECs to review the scientific quality of proposed studies. The REC members felt that HIV and tuberculosis research had high social value, because it addresses national and regional public health priorities. For this reason, there was no concern expressed that a high proportion of research proposals involved HIV and TB. Conclusion. Although most respondents found the aggregated results unsurprising, there was some disagreement with the ranked review outcomes, with a minority of respondents arguing that scientific validity was overemphasised. These findings have potential training and practice implications for RECs and researchers. The study findings call for further studies to validate such findings in other RECs

Social Media in the Healthcare Context: Ethical Challenges and Recommendations

The popularity of social media has grown rapidly and healthcare practitioners and students commonly use sites such as Facebook. The ethical and professional implications and their benefits and hazards must be considered. Concerns include blurring of boundaries between an individual's public and professional lives; maintaining privacy and confidentiality of patient information; damaging the public image of the profession and inter-professional relationships. The same laws that apply to conduct in the real world also apply in cyberspace. Harmful or derogatory posts may result in a defamation lawsuit. The internet may also provide opportunities for patient education through peerreviewed websites and to build professional networks. Institutions should have policies on the uses of social media. Emerging technology will continue to change the landscape of social media and social networking and the way patients and practitioners use websites will continue to evolve. Practitioners should proactively manage digital identity by reviewing publicly available material and maintaining strict privacy settings about their information

Ethical Considerations in Implementing a Biometric Co-Enrolment Prevention System in Clinical Trials in South Africa

Preventing co-enrolment in clinical trials ensures participant safety and data integrity. To facilitate co-enrolment checks; a novel biometric coenrolment prevention system (BCEPS) was developed and implemented in 2010 by the HIV Prevention Research Unit (HPRU) in collaboration with the South African Medical Research Council's (SAMRC) Information Technology Services Division. The use of this web-based system to capture participant's identification details in real time was approved by the SAMRC Ethics Committee. BCEPS was implemented at 13 other research organisations conducting clinical trials in South Africa (SA). Participants who screened at the clinical research sites (CRSs) had their names; SA identity or passport number and fingerprints captured onto BCEPS after comprehensive education and discussion. This information was verified at all study visits. If a participant attempted to screen or co-enrol at multiple CRSs; the system flagged this as a potential coenrolment By addressing the ethical concerns around participant consent and rights; participant confidentiality and privacy; data security and access; and data management and storage; we were able to successfully implement BCEPS within the clinical trials conducted at HPRU; while adhering to the principles of good clinical practice (GCP); including respect for persons; beneficence and justice

Ethical Guidelines for Military-Based Health Research: an Unmet Need in Africa?

"Background: Achieving the highest standards of ethics in military health research is a challenging but crucial undertaking. The military environment is complex and African military health professionals struggle to maintain a balance between ethics and military ethos. The objective of this paper is to review ten existing research ethics guidelines for their application to the military context; and describe the need for guidance in military research ethics in sub-Saharan Africa.Method: To achieve this; five prominent international research ethics guidelines and five African guidelines were selected using some inclusion/exclusion criteria. Thereafter; designed topics were used in analyzing them for their strengths and weaknesses in providing protection for military research participants.Results: Out of the five international guidelines reviewed; only the Council for International Organization of Medical Sciences (CIOMS) mentions the ""armed forces"". Similarly; the only African national guideline that specifically mentions the ""armed forces"" is the Ugandan national guideline.Conclusions: We conclude that national and international guidelines for human subject research may be too general and not suitable for research with military populations. There is a need for additional guidance in research ethics for militaries in sub-Saharan Africa."

Public Health and Social Justice: Forging the Links

The purpose of this article is to explore the concept and scope of public health and to argue that particularly in low income contexts; where social injustice and poverty often impact significantly on the overall health of the population; the link between public health and social justice should be a very firm one. Furthermore; social justice in these contexts must be understood as not simply a matter for local communities and nation-states; but in so far as public health is concerned; as a matter of global concern and responsibility. The interpretation of the scope of public health by any particular nation is I believe contingent on the current socio-political context and the conception of social or distributive justice that underpins this context. Furthermore I will argue here that the link between public health and social justice ought to be founded on a conception of social justice that adequately addresses issues of social injustice and patterns of systematic disadvantage that contribute to ill health and that so commonly prevail in many low and middle income social contexts

Moral Challenges in Managed Care

Managed health care in South Africa is faced with complex moral challenges; where different stakeholders appeal to different ethics principles to guide decision making. The traditional bio-medical ethics principles of beneficence; non-maleficence and respect for autonomy are typically emphasised in clinical practice; while third party funders appeal to the principle of justice to guide the allocation of limited; pooled resources. Health care professionals working in managed care are particularly exposed to these conflicts; vis-a-vis incongruence between the ethics guidelines from their professional bodies and the legislation pertaining to managed care. Common understanding of the claims and responsibilities of each of the stakeholders may promote a more coherent; sustainable health care system

Analysis of Medical Malpractice Clams and Measures Proposed by the Health Professionals Ethics Federal Committee of Ethiopia: Review of the Three Years Proceedings

Background: Medical malpractice is professional negligence by a healthcare provider in which the treatment provided falls below the standard and causes injury or death to the patient. Objective: To describe the adverse medical events; claims and decisions taken by the Ethiopian Health professionals Ethics Committee at the Federal level. Methods: A three-year report of the Ethics Committee and relevant documents of proclamations and regulations were reviewed. Results: Between January 2011 and December 2013; the committee reviewed 60 complaints against health professionals. About one third of the complaints were filed by the patients and/or their families; about 32 by the police or court and the rest were filed by Addis Ababa health bureau; health professionals and other unrelate4d observers. Thirty-nine complaints were related to death of the patient and 15 complaints were about disability. Twenty-five of the claims were against Obstetric and Gynecology specialists and 9 were against general surgeons. The committee verified that 14 of the 60 claims had ethical breach and/or negligence (incompetence). The committee took reasonable time to review complaints and respond the concerned authorities. Conclusion: The study showed that of the total claims lower than a quarter (23.3) were proven beyond the benefit of doubt. More than 3/4 (76.7) of the complaints were wrong. Hospitals should lead in preventing patient injury. Creation of more awareness among Obstetrics and Gynecology specialists; General and Orthopaedic Surgeons about medical errors is needed and special training should be given to those joining these specialities

Review Paper on Research Ethics In Ethiopia: Experiences and Lessons Learnt from Addis Ababa University College of Health Sciences 2007-2012

Health research in Ethiopia is increasing both in volume and type; accompanied with expansion of higher education and research since the past few years. This calls for a proportional competence in the governance of medical research ethics in Ethiopia in the respective research and higher learning institutes. The paper highlights the evolution and progress of the ethics review at Addis Ababa University- College of Health Sciences (AAU-CHS) in the given context of health research review system in Ethiopia. Reflections are made on the key lessons to be drawn from the formative experiences of the Institutional Review Board (IRB) and their implications to the Ethiopian health research review system. This article is a review paper based on review of published and un published documents on research ethics in Ethiopia and the AAU-CHS (2007-2012). Thematic summaries of review findings are presented in thematic areas - formation of ethics review and key factors in the evolution of ethics review and implications The IRB at AAU-CHS has been pivotal in providing review and follow-up for important clinical studies in Ethiopia. It has been one of the first IRBs to get WHO/SIDCER recognition from Africa and Ethiopia. Important factors in the successes of the IRB among others included leadership commitment; its placement in institutional structure; and continued capacity building. Financial challenges and sustainability issues need to be addressed for the sustained gains registered so far. Similar factors are considered important for the new and younger IRBs within the emergent Universities and research centers in the country

Research Ethics Review Practices: Experiences of The Armauer Hansen Research Institute/ All Africa Leprosy and Tuberculosis Rehabilitation and Training Center Ethics Review Committee; Ethiopia

The need for ethics review committees (ERCs) is imperative in the conduct of research to ensure the protection of the rights; safety and well-being of research participants. However; the capacities of most ERCs in Africa are limited in terms of trained experts; competence; resources as well as standard operating procedures. The aim of this report is to share experiences of one of the local institutional ERCs; the Armauer Hansen Research Institute (AHRI)/All Africa Leprosy and Tuberculosis Rehabilitation and Training Center (ALERT) Ethics Review Committee (AAERC); to other ERCs found in academic and research institutions inthe Country. In this report; we used an empirical approach to reviewarchived documents of the AAERC Secretariat to assess the Committee's strengths and weaknessesThe experiences of the AAERC in terms of its composition; routine work activities; learning practices and pitfalls that require general attention are summarized. In spite of this summary; the Committee strongly acknowledges the functions and roles of other ERCs in the Country. In addition; an independent assessment of the Committee's activity in general is warranted to evaluate its performance and further assess the level of awareness or oversights among researchers about the roles of ERCs

Ethical Issues that Confront Nurses in Private Hospitals in the Western Cape Metropolitan Area

Background: Nurses are faced daily with a variety of ethical issues which could be as a result of budget cuts; target setting; the shortage of nurses and expertise. Objectives: The objectives of the study were to identify ethical issues related to patient care; to describe ethical issues related to patient diversity; rights and human dignity. To describe ethical issues related to caring in nursing and to the workplace environment.Method: A quantitative explorative descriptive research design was applied. A stratified sample of (n = 142/5) was drawn from all nurses and caregivers (N = 2990) working in a selected group of eight private hospitals. Self-administered questionnaires were used to collect the data. Statistical tests were applied to determine statistical relationships between variables.Results: Results included (95) of respondents provided safe and committed care to their patients; (99) loved to care for their patients and (93) believed in the Nurses' Pledge of Service. Fifty percent (50) of the respondents indicated verbal abuse from patients and only (59) experienced openness and transparency in the work environment. Analysis further identified that the caregivers did not respect the noble tradition of the profession and experienced the most verbal abuse. Conclusion: This study has identified ethical issues which may give rise to conflict within the workplace environment if not adequately addressed by management. The study further showed that the use of caregivers not regulated in nursing practice may pose as a threat to the safety of the patient

Hospital Reform and Staff Morale in South Africa: a Case Study of Dr Yusuf Dadoo Hospital

Objectives: This study explored major factors that influenced staff motivation at a district hospital in South Africa following hospital reforms and comparison of these factors across the two main staff categories. Design: This study was a cross-sectional descriptive survey. Settings and subjects: This study included all medical and nursing staff working at the district hospital. Outcome measures: A semi-structured questionnaire coded for anonymity was used. It comprised three sections: the introduction; demographic information and a list of factors to which participants responded by indicating their level of agreement or disagreement using the Likert's scale. The questionnaire's reliability was confirmed using Cronbach's coefficient alpha with a value of 0.9. Results: Of the 179 participants; 122 returned the questionnaires. This equated to a response rate of 68. The staff expressed more demotivation than motivation. Major factors that played a role were institutional in character; namely poor management and leadership; unfavourable institutional policies and administration practices with regard to staff development; conflictual inter- and intraprofessional relationships; a paucity of equipment and retention and recruitment strategies. The unique motivator was the individual value of the vocational aspect of the profession. Distance travelled to the workplace did not have any association with the identified motivating and demotivating factors. Conclusion: Staff mo tivation is crucial in any institution or organisation. Presently; the South African healthcare sector is undergoing transformation in terms of implementation of National Health Insurance. The effectiveness of the healthcare system in achieving its goals will be impacted by the prioritisation of institutional strategies that contribute to staff motivation. Managers' skills in healthcare facilities are critical to the success of the implementation of reforms in South Africa

Provider-initiated HIV counselling and testing (PICT) in the mentally ill

The prevalence of HIV infection is substantially higher in mentally ill individuals than in the general population. Despite this; HIV testing is not yet standard practice among the mentally ill population; and many mental health settings do not encourage HIV testing. This paper discusses provider-initiated HIV counselling and testing (PICT) and some of the ethical dilemmas associated with it; on the basis that PICT may be used to increase the number of mentally ill persons tested for HIV. The authors conclude that PICT should be promoted to all psychiatric admissions and mentally ill individuals receiving outpatient services; and that this is within the parameters of existing policies and legislations in South Africa

The Initiation of Anti-retrovirals in Critically Ill Patients

The initiation of anti-retrovirals in critically ill patients is complicated. Although there are no prospective trials that address this issue; retrospective studies suggest that early initiation of treatment in these patients is probably beneficial. Hesitance to use these drugs in an intensive care population stems from problems related to anti-retroviral administration; toxicities; drug interactions; altered pharmacokinetics of the drugs and the immune reconstitution inflammatory syndrome (IRIS). In addition to this; critically ill patients are often unable to give informed consent for HIV testing; or undergo appropriate counseling; which raises ethical problems; as well as problems related to long-term compliance. This article summarizes the evidence available for the early initiation of anti-retrovirals in critically ill patients; as well as problems related to their administration

Knowledge of Medical Ethics among Nigerian Medical Doctors

Background: The knowledge of medical ethics is essential for health care practitioners worldwide. The main objective of this study was to evaluate the knowledge of medical doctors in a tertiary care hospital in Nigeria in the area of medical ethics. Materials and Methods: A cross-sectional questionnaire-based study involving 250 medical doctors of different levels was carried out. The questionnaire; apart from the bio-data; also sought information on undergraduate and postgraduate training in medical ethics; knowledge about the principles of biomedical ethics and the ethical dilemmas encountered in daily medical practice. Results: One hundred and ninety (190) respondents returned the filled questionnaire representing a response rate of 76 . One hundred and fifty-two respondents (80) have had some sort of medical ethics education during their undergraduate level in the medical education. The median duration of formal training or exposure to medical ethics education was 3.00 hours (range: 0-15). One hundred and twenty-nine respondents have read at least once the code of medical ethics of the Medical and Dental Council of Nigeria while 127 (66.8) have some general knowledge of the principles of biomedical ethics. The breakdown of the identified ethical dilemmas shows that discharge against medical advice was the most identified by the respondents (69.3) followed by religious/cultural issues (56.6) while confidentiality was recognized by 53.4 . Conclusion: The knowledge of medical ethics by Nigerian medical doctors is grossly inadequate. There is an urgent need for enhancement of the teaching of the discipline at both undergraduate and postgraduate levels in Nigeria

Ethical and Practical Challenges in Implementing Informed Consent in HIV/AIDS Clinical Trials in Developing or Resource-Limited Countries

Background/rationale: Ethical issues regarding HIV/AIDS human research in the developing world remain under continuous evaluation; a critical area of concern includes informed consent. This paper reviews several of the most important ethical and practical aspects of informed consent in HIV research in developing countries. Enhancement of overall understanding of such key issues might promote higher ethical standards of future research. Objectives: The major objective was to address informed consent in human research in non-Western societies; and specifically in HIV clinical trials of affected adults. Secondary end-points included the consent complexities in HIV research involving vulnerable patient populations in resource-limited nations; such as children; adolescents and women. Methods: A systematic review of the published literature using MEDLINE and EMBASE from 1998 until December 2008 was performed; using the search terms `HIV/AIDS'; `informed consent'; `clinical trials'; `developing world'. Results: Ethical complexities such as participants' diminished autonomy; coercion or monetary inducement; language difficulties; illiteracy or lack of true understanding of the entire study; cultural barriers mainly due to communitarianism and social diversities were identified in the 44 studies reviewed. Informed consent of vulnerable patient populations must be tailored to their sex and developmental age; while counselling is fundamental. Children and adolescents' assent must be ensured. Local language is to be used; while trusted community leaders and local cultural representatives may convey information. Discussion: Despite the heterogeneity of studies; similarities were identified. Providing adequate and comprehensive information and assessing the true understanding of the research represent fundamental prerequisites. Potential solutions to the critical areas of concern include peer counselling and meetings with local community leaders or local cultural representation. Conclusions: International investigators of HIV human research should bear in mind these ethical issues and their potential solutions; when trying to ensure ethical research conduct; based on a truly informed and culturally relevant consent