|Year : 2018 | Volume
| Issue : 2 | Page : 89-96
Medical ethics in a resource-constrained context: A cross-sectional study of awareness, attitude, practice, violations of its principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria
Gabriel Uche Pascal Iloh1, Prince Ezenwa Ndubueze Onyemachi2, Miracle Erinma Chukwuonye1, Chukwuneke Valentine Ifedigbo1
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Community Medicine, Abia State University Teaching Hospital, Aba, Nigeria
|Date of Submission||15-Jun-2018|
|Date of Acceptance||13-Jul-2018|
|Date of Web Publication||26-Dec-2018|
Dr. Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
BACKGROUND: Ethics of medical care are global health concerns. It is universally acknowledged that medical practice should be guided by ethical principles which serve as yardsticks for regulation of professional conduct and discipline.
AIM: The study was aimed at describing the awareness, attitude, practice, violations of ethical principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria.
MATERIALS AND METHODS: A descriptive study was carried out on a cross-section of 210 medical practitioners in Abia State, Nigeria. Data were collected using pretested, self-administered questionnaire that elicited information on awareness, attitude, practice, violations of ethical principles, and ethical dilemmas. Attitude and practice of principles of medical ethic (ME) were assessed in the previous 1 year. Violations and ethical dilemmas were assessed over lifetime practice as a medical doctor.
RESULTS: The age of the participants ranged from 26 to 77 years. There were 173 (82.4%) males and 37 (17.6%) females. The participants were most commonly aware of principles of autonomy (100%) and nonmaleficence (100%), while the least was justice (91.9%). The positive attitude to principles of ME was predominantly oriented toward autonomy (92.4%) and the least was justice (76.2%). The most adequately practiced principle was autonomy (78.1%) and the least was justice (71.4%). The most violated ethical principle was autonomy while the most common ethical dilemma was issues related to rights of patients. The attitude (P = 0.042) and practice (P = 0.034) of principle of autonomy were significantly associated with >10 years of medical practice.
CONCLUSION: Awareness of principles of ME was very high but did not translate to appropriate positive attitude and adequate practice orientations. The most violated principle was patients' autonomy and most common ethical dilemma was issues related to the rights of the patients.
Keywords: Attitude, dilemmas, medical ethics, medical practitioners, Nigeria
|How to cite this article:|
Pascal Iloh GU, Ndubueze Onyemachi PE, Chukwuonye ME, Ifedigbo CV. Medical ethics in a resource-constrained context: A cross-sectional study of awareness, attitude, practice, violations of its principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria. BLDE Univ J Health Sci 2018;3:89-96
|How to cite this URL:|
Pascal Iloh GU, Ndubueze Onyemachi PE, Chukwuonye ME, Ifedigbo CV. Medical ethics in a resource-constrained context: A cross-sectional study of awareness, attitude, practice, violations of its principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria. BLDE Univ J Health Sci [serial online] 2018 [cited 2019 May 23];3:89-96. Available from: http://www.bldeujournalhs.in/text.asp?2018/3/2/89/248549
Medical care has been an issue of decades and its ethical principles are health-care concerns that are increasing globally.,, Medical practice from ancient times has code of medical ethics (CME) that is unique to the profession which demands persons of trust and integrity to be admitted into its membership fold., As a member of human family, the notions of ME are enshrined in the national and international CME.,,,,, ME refers to professional obligations of the physicians toward the patients as contained in the CME that are promulgated by professional medical organizations from time to time. It involves a combination of moral principles, values, and judgments that are applicable in medical practice, education, and research.,, There is national and international consensus that the principles of ME are autonomy, beneficence, nonmaleficence, and justice., These ethical principles are applicable to medical practice and research since both involve the patients and benefit the patients.
The ethics in medical practice have been reported within and across global medical professionals in the United States of America (USA), Canada, India,, Saudi Arabia, Pakistan, Lithuania, and Nigeria. Although what constitutes the national CME may vary in different nations, the principles of ME are universally accepted by medical professionals worldwide.,,, These ethical principles provide basic principles which medical profession observes to provide the highest standard of care.
Globally, substantial canons of the principles of ME are abused, especially in developing economies,,,, and this leads to erosion of patients confidence in the health delivery system., Nowadays, conflicts of interests between medical practitioners and patients are getting more complex as the medical community struggles to delineate the defining components of the principles of ME.,, However, the increasing litigations arising from violations of the principles of ME is eroding the absolute and referent power enjoyed by physicians, especially in resource-constrained environment where practitioners knowingly or unknowingly violate the principles of ME.,,, The ethical dilemmas encountered during the process of care have been reported in different parts of the world with the more prominent conflicts being ethical issues related to the patients' rights,,, patient–doctor relationships, patient safety and medical errors, professional misconduct,, beginning,, and end-of-life issues,,, euthanasia,,, equity of health resources, religious issues related to blood transfusion,,, and discharge against medical advice. In this regard, ME have gone through changes over time to reflect the trend in advancement of medical information, technology, and procedural justice., The International CME by the World Medical Association (WMA) emphasizes that a physician shall maintain the highest standard of professional conduct, respect patients rights, owes his patients complete loyalty, and all the resources of his sciences and safeguard patient confidence, while Physicians Oath as amended in 2017 pledges inter alia that “I will not use my medical knowledge to violate human rights and civil liberties even under threat.”
In Nigeria, ME are not a prevalent research area. However, medical professionals in the region wittingly and unwittingly infringe on CME,,, which impact substantially on patients safety and satisfaction with the quality of health care., At graduation in Nigerian Universities, every medical graduate takes the Hippocratic Oath. The Nigerian Medical Professionals therefore pledge to abide by the principles of ME. To ensure that the principles of ME and its conduct are not compromised in health-care delivery, the Medical and Dental Council of Nigeria (MDCN) compiled relevant information on the national and international CME. It is the duty of the medical professionals to acquaint himself with the informational content of the book. Research studies in Nigeria have shown that the attitude toward the CME has been a persistent problem and a large gap exist among medical practitioners orientation to the practice of its principles.,,, The creation of positive attitude and all-times practice of principles of ME rely on medical practitioners' orientation to the ethical principles surrounding patient care. There is, therefore, the need to study the principles of ME among medical practitioners in the region in order to make imperative improvement in patient outcomes as well as safeguarding medical practitioners from litigations. It is against this backdrop that this study was designed to describe the awareness, attitude, practice, violations of principles of ME, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria.
| Materials and Methods|| |
This was a descriptive cross-sectional study carried out on 210 private and public medical practitioners who participated in continuing professional development (CPD) program for 2017 physicians week of Nigerian Medical Association (NMA), Abia State, held on October 23, 2017 or CPD program organized by Directorate of Postgraduate Studies (DPGS) of Federal Medical Centre (FMC) Umuahia, Nigeria, for medical professionals in Abia State, on May 3 and 4, 2017. The questionnaire tool was administered to each eligible medical practitioner once either during CPD program organized by NMA, Abia State, during the physicians week or by DPGS of FMC, Umuahia, respectively.
The inclusion criteria were private and public medical practitioners in Abia State who participated in the 2017 physicians week CPD program by NMA, Abia State, or CPD program organized by DPGS of FMC, Umuahia, Nigeria, for medical professionals in Abia State.
The sample size was determined using online sample size calculating software. The input criteria for sample size estimation was set at 95% confidence level, confidence interval of 5, and accessible sample of 300 medical practitioners based on the previous Abia State physicians week and FMC and Umuahia CPD attendance registers. This gave a sample size estimate of 169 participants. However, sample size of 210 medical practitioners was used in order to improve the precision of the study. The online sample size calculator is available at www.surveysystem.com, accessed on February 1, 2017.
The eligible medical professionals for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 210 was achieved.
The study instrument consisted of sections on sociodemographic data such as age, sex, years of practice and information on awareness, attitude, practice, violations, and ethical dilemmas.
The data collection tool was designed by the researchers to suit Nigerian environment through robust review of appropriate literature on principles of ME.,,,,,,,,,, The face, content, concept, and construct validity of the instrument was evaluated by a consensus of panel of knowledgeable experts in legal medicine, hospital epidemiology, and public health who were not part of the study. The questionnaire was pretested using 10 medical doctors at FMC, Umuahia. The pretesting was done to find out how the questions would interact with the respondents and ensure there were no ambiguities. However, no change was necessary after the pretesting as the questions were interpreted with the same meaning as intended. The usability of the instrument was assessed to determine the administration, interpretation by participants and authors. The usability criteria for the use of an instrument where there is no existing prevalidated tool were met. The questionnaire was self-administered since the participants are health literate.
The specific domains of principles of ME studied were patient autonomy, beneficence, nonmaleficence, and justice. Each item of principles of ME was scored on a 5-point Likert ordinal scale of all-times, most-times, sometimes, rarely, and none. All-times response to each attitude-based question indicated positive attitude, while most-times, sometimes, rarely, and none responses meant negative attitude. Similarly, all-times response to each practiced-based question indicated adequate practice while most-times, sometimes, rarely, and none responses to practice question meant inadequate practice of principles of ME. The attitude and practice of principles of ME were inquired in the 12 months preceding the study. Violations and ethical dilemmas were assessed over lifetime practice as a medical doctor.
Ethical certification was obtained from Health Research and Ethics Committee of FMC, Umuahia. Informed consent was also obtained from the respondents included in the study.
The data generated were analyzed using the software Statistical Package for the Social Sciences version 21, New York, USA. Categorical variables were described by frequencies and percentages. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables. In logistic regression analysis for principle of autonomy, the dependent (outcome) variables were the attitude and practice of principle of autonomy, respectively, and the independent variables were age, sex, and years of practice. In all cases, P < 0.05 was considered statistically significant. Odds ratio (OR) which is an indicator of degree of association of attitude and practice of principle of autonomy and a predictor demographic variable was estimated at 95% confidence limit.
| Results|| |
Of the 210 medical professionals who participated in the study, 111 (52.8%) were middle-aged adults (40–59 years), 76 (36.2%) were young adults (18–39 years), and 23 (11%) were aged 60 years and above. The age of the participants ranged from 26 to 77 years with mean age of 36 ± 8.4 years. There were 173 males (82.4%) with 37 females (17.6%) with female-to-male ratio of 1:4.7. One hundred and ninety-four (92.4%) of the respondents had positive attitude to the principle of autonomy while 164 (78.1%) had adequate practice of patient autonomy. Other demographic characteristics and frequencies of attitude and practice of principles of ME are depicted in [Table 1].
|Table 1: Demographic characteristics and distribution of the study participants by attitude and practice of specific principles of medical ethics|
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Two hundred and ten (100%) of the study subjects were aware of the principles of autonomy and nonmaleficence with the most common source of awareness of information on the principles of ME being undergraduate medical education (94.3%). Eighty-eight (41.9%) of the participants had violated the principle of autonomy and the most common ethical dilemma encountered by the respondents was issues related to the rights of patients. Other awareness, sources of awareness of information, frequencies of violation of other principles of ME, and encountered ethical dilemmas are depicted in [Table 2].
|Table 2: Awareness, sources of awareness, and distribution of the study participants by violations of ethical principles and encountered ethical dilemmas|
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Bivariate Chi-square analysis of the demographic characteristics of the study participants as related to attitude and practice of principle of autonomy showed that years of practice was significantly associated with attitude (χ2 = 5.08; P = 0.042) and practice orientation (χ2 = 4.02; P = 0.034) of principle of autonomy, while other demographic factors were not statistically significant [Table 3].
|Table 3: Association of demographic variables with attitude and practice of the principle of autonomy, respectively|
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On logistic regression analysis of demographic variables as related to attitude and practice of practice of principle of autonomy showed that years of practice remained statistically significant for attitude (OR = 3.64 [1.20–6.21]; P = 0.023) and practice (OR = 4.21 [1.17–6.92]; P = 0.019), while other demographic factors were not statistically significant [Table 4]. The most significant demographic predictor of positive attitude to principle of autonomy was years of practice more than 10 years. A significantly higher proportion of medical professionals who had years of practice more than 10 years (64.0%) had positive attitude compared to their counterparts whose years of practice were 10 years and less (36.0%). Medical practitioners with years of practice more than 10 years were three and half times more likely to have positive attitude to the principle of autonomy (OR = 3.64 [1.20–6.21]; P = 0.023). Similarly, the most significant demographic predictor of practice orientation of the principle of autonomy was years of practice >10 years. A significantly higher proportion of medical practitioners who had years of practice >10 years (72.0%) had adequate practice of principle of autonomy compared to their counterparts whose years of practice were 10 years and less (28%). Medical practitioners who had years of practice more than 10 years were four times more likely to have adequate practice of principle of autonomy (OR = 4.21 [1.17–6.92]; P = 0.019).
|Table 4: Logistic regression analysis of demographic variables as related to attitude and practice of principle of autonomy|
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| Discussion|| |
Awareness of principles of medical ethics
This study has demonstrated that 100% of the study participants were aware of the principles of autonomy and nonmaleficence, while 95.2% and 91.9% were aware of the principles of beneficence and justice, respectively. Accordingly, in Nigeria, at induction ceremony into the medical profession by the MDCN, every medical graduate takes Hippocratic Oath and therefore pledges to abide by the principles and codes of ME. Inadequate awareness of the principles of beneficence and justice may be detrimental to the medical profession and health-care system in the subregion as it indicates disconnect with national and international declarations, codes, canons, and conventions. Although the fundamental principles of ME do not give answers on how to handle a particular ethical situation, they serve as a guide to medical practitioner on what principles to apply in circumstantial ethical issues. Raising the awareness of medical practitioners on principles of beneficence and justice can lead to the fruitful advancement of medical practice for broad health services and other diverse benefits. Adequate awareness of the principles of ME among the medical professionals will help to minimize breaches of its principles and the attendant ethical fallacies and legal issues related to patient care., There is need to strengthen the existing awareness of principles of ME through approaches that promote the principles of ME, especially at the point of entry into the medical profession and subsequently at postgraduate medical education and CPD for annual renewal of practicing licenses.
Attitudinal orientation to the principles of medical ethics
This study has shown that the predominant positive attitudinal orientation was toward the principle of autonomy. The finding of this study has lent credence to the principle of autonomy which is the cornerstone of the ME and laws.,,, It is also in consonance with the global trend on self-determination as emphasized in The Modern-Day Physicians Pledge which stated inter alia “I will respect the autonomy and dignity of my patients.” In general, paternalistic and doctor-oriented view of medical practice has gradually been supplanted by the promotion of patient autonomy.,, Developing positive attitude to the principles of ME promotes patient–physician relationship which will only be symbiotic when ethical and legal concerns are considered during clinical communications, consultations, and encounters. Regrettably, negative attitude to the principle of ME could create dissatisfaction with patient–doctor relationship with implications for poor patient's outcomes, especially in resource-poor countries where there are limited options for standard patient care. Positive attitude to the principles of ME is, therefore, a suitable target for CPD and medical education in Nigeria.
Practice of principles of medical ethics
This study has shown that 164 (78.1%) of the medical practitioners had adequate practice orientation to the principle of patient autonomy. The finding of this study is a reflection of the relevance given to patient autonomy in health-care environment, in addition to 2017 revised Declaration of Hippocratic Oath, now called a Modern-Day Physician Pledge. The principle of autonomy is opposed to paternalism or maternalism and requires recognition of rights of patient's canons and covenants.,, Admittedly, the Hippocratic Oath which is the nucleus of ME has undergone modifications to suit medical situation but fundamentally underscores that “I will practice my profession with conscience and dignity and in accordance with good medical practice.” Good medical practice, therefore, requires that physicians should give consideration to the principles of ME and maintain the highest standard of professional conduct and owes his or her patients complete loyalty and all the resources of his or her sciences. This invariably requires partnership between the patient and the physician., Building and trusting patient–physician relationship, patient engagement, and empowerment is a professional calling of every medical practitioner involved in the art and science of medicine.,,, The practice of the principles of ME is, therefore, the need of the hour, particularly in the modern medical world in order to provide specific answers to different ethical challenges and dilemmas confronting medical practice.
Attitude and practice of principles of medical ethics
This study has shown that the least positive attitudinal and practice orientations were to the principle of justice. This finding has lent credence to the generalization that contemporary medical practice is challenged by ethical principle of justice during patient–physician encounter that requires ethical sensitivity and enabling health care and national laws.,, However, ethical principle of discrimination in medicine is contained in the Declaration of Munich by the 27th World Medical Assembly of the WMA and highlighted by The Physician Pledge which declares that “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient.” Research studies have also documented overt and covert, implicit and explicit injustice against human patients in health-care environment that are in conflict with the principle of justice.,,, Medical professionals should appreciate that service to patients are service to Almighty God who created all the humans alike and ensures equity in rendering medical care as well as strive at all times to provide care for the whole society. The patient should, therefore, receive health care that is consistent with the justice they are owed as human beings. Ethical practice of the principle of justice should be encouraged while unethical practice of injustice should be discouraged. By changing our attitudes to patients appropriately, other stakeholders in health sector, particularly the government will also change their own because justice in health-care environment also comes with patient responsibilities as a citizen of the country during the process of care.
Violations of principles of medical ethics
The most violated principle of ME among the study participants was autonomy. Although the ethical issues relating to patient autonomy among medical professionals are common in the region, patient autonomy is an international ethical, legal, social, and quality of care standard that is in tandem with good medical practice and quality of care. Compliance with patient autonomy provides public assurance of the patient's rights and safety that is consistent with The Modern Physician Pledge and international CME., In cognizance of the ethical difficulties as related to patients care and the fiduciary nature of the patient–doctor relationship, a physician should always deal honestly and truthfully with the patient and act according to his or her conscience and always in the best interest of the patient. Of great interest in Nigeria, is that despite the swearing of Physician Oath or Pledge, formal or informal instruction on national CME, medical practitioners still breach the principles of autonomy.,,, The increasing health literacy, social awareness, and easier access to medical information on internet in Nigeria are expected to make consumers of health services to play more active roles in decisions concerning their health care. It is therefore important that medical professionals should acquaint themselves with the fundamental principle of patient autonomy in order to avert malpractice lawsuits and litigations. In addition, medical professionals should understand the relationships and limitations of ethics and laws as they relate to the principles of autonomy in medical practice. There is, therefore, the need to create and activate appropriate ethical climate with focus on the principle of autonomy among medical professionals in the region.
The most common ethical dilemma encountered by the respondents was patient's rights issues. The ethical dilemma associated with patients' rights have also been reported in Toronto, Canada, India,, Saudi Arabia, Lithuania, Israel, and Nigeria.,, The rights of the patients make a medical practitioner accountable for provision of high-quality care and refer to ethical, professional, social, and legal principles of entitlement such as rights of confidentiality of all medical information and records, right to informed consent for surgery, medications, and invasive procedures among others. In the changing health-care Nigerian environment, some contemporary ethical issues in medicine do not affect the medical practitioner as a medical doctor only, but they also affect him or her as a citizen of the country. The medical professionals in the region should understand the ethical and legal framework of health care and other diverse service delivery requirements. The Government of Nigeria is emphatic that the citizens have the right to be served right as contained in the SERVICOM principles and charters. Failure to recognize and respect the rights of patients exposes the medical professional to legal liability and aggravated damages may be awarded when convicted. It is therefore imperative that medical practitioners should understand that patients right movement is growing globally and develop positive attitude to rights of patients as well as being carefully informed of the ethical, legal, and social implications of preserving the rights of patients. A health system that provides health services to the society should adhere to the extent declarations, principles, and laws to adequately protect patient's rights and ensure patient safety in health-care settings.
Associations of demographic factors with attitude and practice of principle of autonomy
Attitude and practice of principle of autonomy were significantly associated with years of practice of more than 10 years. The finding of this study could be a reflection the fact that longer years of practice influence receptivity and acceptability of information on principles of autonomy and afford a wider scope for interactions and information exchange among medical professionals in the region.,, Medical professionals irrespective of the years of practice should serve as advocate for the principles of autonomy through dedicated approaches that protect and promote the ethical principle of autonomy, especially at the point-of-care encounters. This will ensure quality health care for patients and safeguard the integrity of the medical profession. It is therefore quintessential that every practitioner of the noble art and science of medicine be aware of the principles of autonomy. This will go a long way to improve the quality of care received by the consumers of health-care goods and services.
Limitations of the study
The limitations of this study are recognized by the researchers. First and foremost, the study was on four basic principles of ME without providing exhaustive details. Secondly, the attitude and practice of principles of ME were based on respondents' subjective responses and were not verified. However, there is a tendency to underreport episodes of violations and breaches of the principles of ME in addition to social desirable responses.
Strengths of the study
The study draws its strength in being the first study in the region that examined violations of ethical principles in addition to the ethical dilemmas encountered by medical professionals during patient–physician encounters. Logistic regression analysis of variables as related to attitude and practice of principles of ME to determine independent predictors of adequate practice of principles of ME was also highlighted in the study.
| Conclusion|| |
Awareness of principles of ME was very high but did not translate to appropriate attitude and adequate practice orientation. The most violated principle of ME was patients' autonomy and most common ethical dilemma encountered by the participants was rights of the patients' issues. The most significant predictor of positive attitude and adequate practice of principle of autonomy was years of practice of >10 years.
Principles of ME should be the target of intensive CPD and medical education in addition to greater regulatory support, especially in resource-poor settings where there are limited options for standard medical care. This will help the medical practitioners to develop positive attitude and adequate practice of the principles of ME and empower them with competence and capacity to effectively handle ethical dilemmas that occur during patient care in health facilities.
Future directions of the study
Future research directions are required to explore risk factors that predispose to violations of ethical principles. This will provide additional epidemiological data for comparative, consultative, and intervention purposes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics manual: Sixth edition. Ann Intern Med 2012;156:73-104.
Ewuoso OC. Bioethics education in Nigeria and West Africa: Historical beginnings and impacts. Glob Bioeth 2016;27:50-60.
Pellegrino ED. Medical ethics in an era of bioethics: Resetting the medical profession's compass. Theor Med Bioeth 2012;33:21-4.
Ahmed F. Are medical ethics universal or culture specific. World J Gastrointest Pharmacol Ther 2013;4:47-8.
Jooste K. Ethics in healthcare. Afr Health 2003;3:10-5.
Gillon R. Medical ethics: Four principles plus attention to scope. BMJ 1994;309:184-8.
Monsudi KF, Oladele TO, Nasir AA, Ayanniyi AA. Medical ethics in Sub-Sahara Africa: Closing the gaps. Afr Health Sci 2015;15:673-81.
Ramana KV, Kandi S, Bompally PR. Ethics in medical education, practice and research: An insight. Ann Trop Med Public Health 2013;6:599-602. [Full text]
Jhala CI, Jhala KN. The hippocratic oath: A comparative analysis of the ancient text's relevance to American and Indian modern medicine. Indian J Pathol Microbiol 2012;55:279-82. [Full text]
Breslin JM, MacRae SK, Bell J, Singer PA; University of Toronto Joint Centre for Bioethics Clinical Ethics Group. Top 10 health care ethics challenges facing the public: Views of Toronto bioethicists. BMC Med Ethics 2005;6:E5.
Singh S, Sharma PK, Bhandari B, Kaur R. Knowledge, awareness and practice of ethics among doctors in tertiary care hospital. Indian J Pharmacol 2016;48:S89-93.
Mohammad M, Ahmad F, Rahman SZ, Gupta V, Salmanet T. Knowledge, attitudes and practices of bioethics among doctors in a tertiary care government teaching hospital in India. J Clin Res Bioeth 2011;2:118.
Alkabba AF, Hussein GM, Albar AA, Bahnassy AA, Qadi M. The major medical ethical challenges facing the public and healthcare providers in Saudi Arabia. J Family Community Med 2012;19:1-6.
Shiraz B, Shamim MS, Shamim MS, Ahmed A. Medical ethics in surgical wards: Knowledge, attitude and practice of surgical team members in Karachi. Indian J Med Ethics 2005;2:94-6.
Bankauskaite V, Jakusovaite I. Dealing with ethical problems in the healthcare system in Lithuania: Achievements and challenges. J Med Ethics 2006;32:584-7.
Fadare JO, Desalu OO, Jemilohun AC, Babatunde OA. Knowledge of medical ethics among Nigerian medical doctors. Niger Med J 2012;53:226-30.
] [Full text]
Iloh GU, Chuku A, Amadi AN. Medical errors in Nigeria: A cross-sectional study of medical practitioners in Abia State. Arch Med Health Sci 2017;5:44-9. [Full text]
Iloh GU, Amadi AN, Chukwuonye ME, Ifedigbo CV, Orji UN. Patients' rights in an underserved Nigerian environment: A cross-sectional study of attitude and practice orientation of medical professionals in Abia State. BLDE Univ J Health Sci 2017;2:97-104.
Odia OJ. The relation between law, religion, culture and medical ethics in Nigeria. Glob Bioeth 2014;25:164-9.
Ilkilic I. Bioethical conflicts between Muslim patients and German physicians and the principles of biomedical ethics. Med Law 2002;21:243-56.
Olick RS. It's ethical, but is it legal? Teaching ethics and law in the medical school curriculum. Anat Rec 2001;265:5-9.
Smith DH. Ethics in the doctor-patient relationship. Crit Care Clin 1996;12:179-97.
Iyalomhe GB. Medical ethics and ethical dilemmas. Niger J Med 2009;18:8-16.
Oye-Adeniran BA, Long CM, Adewole IF. Advocacy for reform of the abortion law in Nigeria. Reprod Health Matters 2004;12:209-17.
Ajayi RA, Dibosa-Osadolor OJ. Opinion of obstetricians and gynaecologists on ethical issues in the practice of in vitro
fertilisation and embryo transfer in Nigeria. Afr J Reprod Health 2013;17:130-6.
Ong WY, Yee CM, Lee A. Ethical dilemmas in the care of cancer patients near the end of life. Singapore Med J 2012;53:11-6.
Dickenson DL. Practitioners' attitudes towards ethical issues at the end of life: Is the UK actually more autonomy-minded than the US? J Palliat Care 1999;15:57-63.
Bamgbose O. Euthanasia: Another face of murder. Int J Offender Ther Comp Criminol 2004;48:111-21.
Gostin LO, Roberts AE. Physician-assisted dying: A Turning point? JAMA 2016;315:249-50.
Prokopetz JJ, Lehmann LS. Redefining physicians' role in assisted dying. N Engl J Med 2012;367:97-9.
Cookson R, McCabe C, Tsuchiya A. Public healthcare resource allocation and the rule of rescue. J Med Ethics 2008;34:540-4.
Parsa-Parsi RW. The revised declaration of Geneva: A Modern-day physician's pledge. JAMA 2017;318:1971-2.
Famuyiwa KM. Knowledge of public health ethics among medical doctors in Nigeria. South Am J Public Health 2014;2:457-5.
Cassell EJ. Autonomy and ethics in action. N Engl J Med 1977;297:333-4.
Aryeh L, Goldberg BA. Rethinking the art of medicine: Why healing is no longer sufficient. J Gen Pract 2014;2:140.
Sadan B, Chejk-Saul T. Attitudes and practices of patients and physicians towards patient autonomy: A survey conducted prior to the enactment of the patients' rights bill in Israel. Eubios J Asian Int Bioeth 2000;10:119-25.
Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: Paternalism versus patient-centered (autonomous) care. Curr Opin Crit Care 2008;14:708-13.
Gallagher TH, Levinson W. A prescription for protecting the doctor-patient relationship. Am J Manag Care 2004;10:61-8.
Rider ME, Makela CJ. A comparative analysis of patients' rights: An international perspective. Int J Consum Stud 2003;27:302-15.
Dieterich A. The modern patient – Threat or promise? Physicians' perspectives on patients' changing attributes. Patient Educ Couns 2007;67:279-85.
Imber JB. Trusting doctors: The decline of moral authority in American medicine. Internet J Law Healthc Ethics 2010:7:1.
Krupat E, Bell RA, Kravitz RL, Thom D, Azari R. When physicians and patients think alike: Patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract 2001;50:1057-62.
Chin JJ. Doctor-patient relationship: A covenant of trust. Singapore Med J 2001;42:579-81.
Lynch HF. Discrimination at the doctor's office. N Engl J Med 2013;368:1668-70.
Goldberg AL, Jacob A. Creating better doctors or merely finding better patients? Fam Med Med Sci Res 2013;2:e108.
Iloh GU. Quality of care in Africa: Managing patients' expectations and renewing their confidence in service delivery: The best baseline for calibration in Africa. In: Saldana JR, editor. Quality of Health Care: From Evidence to Implementation. New York: Nova Publishers; 2015. p. 269-90.
Federal Government of Nigeria. The SERVICOM index. In: The SERVICOM Book. Abuja, Nigeria: The SERVICOM Office; 2006. p. 1-25.
Levinson W. Physician-patient communication. A key to malpractice prevention. JAMA 1994;272:1619-20.
[Table 1], [Table 2], [Table 3], [Table 4]