Medical Ethics Serve to Protect People — November 1, 2001

Good research and clinical practice share at least one common element: They are conducted in an ethical manner, with careful planning and procedures to protect trial participants, clients, and patients.

Providers of contraceptives or other reproductive health products and services should be confident that those products and services have been proven to be safe and effective through trials that were reliable, accurate, and had the welfare of the user as the ultimate goal, according to the current issue of Network, a health bulletin published by Family Health International (FHI).

"The basic principles of sound medical ethics have evolved over time to fulfill an essential need, and that is to protect people," says Dr. Roberto Rivera, director of FHI's Office of International Research Ethics. "These principles protect people who volunteer to take part in medical and behavioral research — both quantitative and qualitative studies. These basic principles shape the ethical safeguards for each study, but the specific protocols involved must come from close collaboration with several interested groups, especially from those who best represent the volunteers and who are members of the community where the research is conducted."

It is now widely accepted that any type of study involving humans must be carefully designed and monitored to protect the physical and psychological well-being of the participants. Guiding the protocols for any study should be three widely accepted ethical principles: respect (recognizing the right of each individual to make his or her own decisions), beneficence (maximizing possible benefits and minimizing possible harm) and justice (dealing fairly and equally with all concerned).

These three cornerstones of medical ethics should similarly guide the practices of providers of reproductive health services who struggle daily with ethical decisions that can have profound consequences for the well-being of their clients. Serving adolescents, HIV-positive clients, and women whose partners are violent or who oppose contraception are among the many ethical issues that reproductive health service providers routinely face.

For example, "many providers do not see adolescents as having the same rights as adults," says Dr. Cindy Waszak, an FHI senior scientist with expertise in adolescent reproductive health. "Providers may be reluctant to serve them without parental consent, even when policies spell out the right of adolescents to receive non-permanent contraception or treatment for sexually transmitted infections without such consent. Many providers either deny services to adolescents or fail to provide confidentiality because they sincerely worry that freely making contraceptive methods available to adolescents will encourage them to be sexually active, although research indicates that this is not the case."

In the case of HIV-positive clients, health care providers are not only bound by their profession to keep HIV status confidential, but should do so because the consequences to clients of disclosure may be severe. Nevertheless, some providers fail to keep such sensitive information confidential. Disclosure is sometimes due to carelessness. In other cases, providers may be concerned that the confidentiality afforded infected people may jeopardize the well-being of uninformed, healthy partners. "In general, however, if a client is not ready to disclose his or her HIV-status to anyone, there is little a provider can do except repeatedly discuss with the client when and how to disclose and to whom," says FHI's Dr. Eric van Praag, an FHI expert on HIV/AIDS care and support services.

Both clients and research participants have the basic human right to make fully informed and voluntary decisions about their reproductive health. Medical providers and research scientists are obligated to protect this right in two ways: through informed choice and informed consent. Informed choice means that each client receives information about methods and services, including their risks and benefits. This information allows a client to make a fully informed decision about whether to obtain or decline treatment or services; which contraceptive method, treatment, or service to select; and whether to seek and follow up on a referral. Informed consent is a more formal, legal process in which the individual is fully informed about and then consents to receive a method or service, or to participate in a research study.

New and emerging technologies

New and emerging technologies that involve reproductive health offer the promise of better care and services, and improved quality of life. However, new technology can often raise unanticipated ethical concerns, including the potential for abuse and misuse.

For example, throughout the world, ultrasound scans that can reveal the sex of a fetus are being used by some couples to abort unwanted female fetuses. Abortion is a controversial procedure even in countries where it is safe, legal, and widely available. When abortion is used for sex selection, the controversy intensifies. Other relatively new reproductive health technologies that are becoming more widely available and raise ethical concerns include new ways to achieve long-term or permanent contraception, treatments for people living with HIV/AIDS, and the use of in vitro fertilization.

Meanwhile, some emerging technologies are shaping health research policies in developed countries like the United States and could eventually affect public health services or policies in other countries. For instance, the current debate in the United States over allowing embryonic stem-cell research is closely linked to an ongoing worldwide debate about elective abortion and in vitro fertilization, since the specialized cells are removed from human embryos that are being destroyed for other reasons.

FHI is a nonprofit research organization based in the United States that seeks to improve reproductive health worldwide, with an emphasis on developing countries. Network is provided free to family planning providers and others worldwide.

For more information, please contact:

Kim Best, Network Managing Editor, 919-544-7040