Ethiopia - Springer

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Ethiopia Adamu Addissie and Markos Tesfaye

Yemen

Addis Ababa

Ethiopia

Kenya

Bioethics Development in Ethiopia The development of bioethics in Ethiopia can be traced back to around the introduction of biomedicine in to Ethiopia. Hence, it becomes relevant to discuss the development of biomedical science and modern medicine and health care in the country.

A. Addissie (*) School of Public Health, Department of Preventive Medicine, Addis Ababa University, Addis Ababa, Ethiopia e-mail: [email protected] M. Tesfaye Department of Psychiatry, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia e-mail: [email protected] H.A.M.J. ten Have, B. Gordijn (eds.), Handbook of Global Bioethics, 1121 DOI 10.1007/978-94-007-2512-6_19, # Springer Science+Business Media Dordrecht 2014

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A. Addissie and M. Tesfaye

Country Background Ethiopia is located in the eastern part of Africa, often called the “Horn of Africa.” It is the second most populous country in sub-Saharan Africa, with increasingly promising economic development. The oldest human fossils in human history so far are found in Ethiopia, and hence, it is considered as “Cradle of Mankind.” Unique to other African countries, Ethiopia is the oldest independent nation in the continent and an icon of freedom as it has never been colonized, with the exception of a shortlived Italian occupation from 1936 to 1941 which was accompanied by continued freedom fighting. Ethiopia is the tenth largest country in Africa with great geographical diversity with a variety of contrasts ranging from high peaks of 4,550 m above sea level to very low depression of 110 m below sea level. Ethiopia is a home to mosaic nations, nationalities, and peoples with more than 80 different spoken languages. The country is among the least-urbanized countries in the world with more than 80 % living in rural areas. And its population is predominantly a young population. The major health problems of the country remain largely preventable communicable diseases and nutritional disorders. Despite major recent progresses, the country still faces a high rate of morbidity and mortality and a low health status with life expectancy of 54 years (53.4 years for male and 55.4 for female), infant mortality rate of 77/1,000, under-five mortality rate of 101/1,000, and maternal mortality ratio of 590/100,000 (CSA, 2012). In addition to relatively inadequate availability of services, cultural norms and societal emotional support bestowed to mothers, distance to functioning health centers, and financial barrier were found to be the major determinant factors. Ethiopia is a Federal Democratic Republic, composed of nine regional states, having their own regional governments and two city administrations including the capital Addis Ababa. The country’s economy is mainly dependent on agriculture. The regular droughts combined with poor cultivation practices make Ethiopia’s economy vulnerable to climatic changes, and the country has suffered from various natural calamities until the recent past. Despite being one of the poorest economies in the world, there are very impressive and obvious changes and economic progress in the past decade to the level of meeting the Millennium Development Goal targets in certain areas such as education and health care. The Federal Ministry of Health of Ethiopia takes the main responsibility for medical services in Ethiopia. The private medical service is emerging and mainly urban centered. The Ethiopian health policy of 1993 is focused more on public health interventions and primary health care. The ministry has formulated and implemented a number of policies and strategies that afforded an effective framework for improving health in the country. The main objective of Ethiopia’s health services policy is to provide a comprehensive and integrated primary health care in health institutions at the community level.

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History of Modern Medicine in Ethiopia The Ethiopian health system has been in constant change corresponding to the socioeconomic and political changes that took place during the last century. There have been rapid developments in the last two decades in terms of new health policies and programs and growth of the private sector in the context of the global paradigm of health sector reform. Even though modern medicine began to be practiced in Ethiopia only at the beginning of the twentieth century, its introduction and utilization date back to the start of the sixteenth century. Western modern medicine was introduced to the country by foreigners such as religious and diplomatic missions to travelers, traders, invaders, and warriors. Further progress in the development of modern medicine was made during the reign of Emperor Menelik II (1889–1913). The Russian mission established the first hospital in the country (the Russian Red Cross Hospital) in 1897 and subsequently few Ethiopians were sent abroad for medical training. As signatory to the 1978 Alma Ata charter, Ethiopia has adopted the 1979 declaration of “Health For All by the year 2000” using the PHC strategy and it is one of the pioneering countries in implementing the basic health services approach with its “Health Center Team Training Program,” launched in 1954 with new cadre of health professionals (health officers, community nurses, and sanitarians) assigned to render services at the district level to perform mainly communityoriented health activities. The main strategic and policy focus of the national health program is on preventive and promotive aspects. Since 2002, the country has launched a massive community-based health program “The Health Extension Service” with more than 30,000 community-based health extension workers (Haile Mariam & Kloos, 2005). Ethiopia has a long tradition of indigenous medical practice, which deserves an important place in the country’s social and cultural history as Ethiopians have been familiar with a wide range of diseases and medical complaints for which they had long-established names, both in their ancient classical language, Ge’ez, and in other indigenous tongues of the country (Pankhurst, 1990).

History of Health Research and Research Ethics in Ethiopia Health Research in Ethiopia is more than a century old. The first publication was on “Abyssinia in Its Sanitary and Medical Aspects” in The Lancet (1868). Abyssinia is the old name for Ethiopia. However, output in terms of quality and quantity remains low as the total number of publications is still fewer in number. In Ethiopia, the agenda of health research ethics is a recent phenomenon. Despite the attention given to the issue, the knowledge and practice of standardized regulations and follow-ups remain shallow. The health department

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of the then Ethiopian Science and Technology Commission in collaboration with the National Health Science and Technology Council embarked to address health research ethics issues in the country. Accordingly, in 1994, the commission officially launched the National Health Science and Technology Policy and established a broad-based body at a level of a council with a function to advise the federal government on health science and technology issues in general and research and development in particular. One of the standing committees of the council was the National Health Research Ethics Review Committee which is given the responsibility to review health research ethics issues, fundamental principles of health research ethics, and their applications in the Ethiopian context. The first health research ethics guideline was developed by the commission in 1995 and has been revised twice, in 1997 and 2004 (ESTC, 2005). With the expansion of postgraduate programs in Addis Ababa University and other immerging universities and with the availability of funding related to HIV/AIDS and other diseases of public health importance, the number of research projects with human subjects on yearly basis is progressively increasing. This clearly puts demand on the current system to be more effective and efficient. Health research ethics review committees have been established at three levels: national, regional, and institutional. The National Research Ethics Committee is responsible for the final approval of all clinical trials, research on very sensitive issues, multicentered and collaborative research projects, research financed or carried out by external donors, research to be conducted in more than one region of the country, and projects that require sample transfer (ESTC, 2005). Regional ethics review committee is responsible for the ethical review of projects involving more than one institution in the region and can review projects other than those mentioned under the mandate of National Research Ethics Committee. Institutional ethics review committees review all health research proposals of an institute and are responsible for reviewing and deciding upon all proposals of the institute which do not come under the mandates of either the national or regional committees. Accreditation and recognition of ethics committees are mainly done by National Research Ethics Committee. All regional and institutional committees need to be registered at the secretariat of National Research Ethics Committee, to be renewed every 2 years.

Major Actors of Bioethics in Ethiopia The major actors for bioethics (for both medical ethics and research ethics) in Ethiopia include academic institutions, hospitals, government offices, and professional associations. Below are some of the prominent actors. These entities have played major roles in the initiation and development of a system for ethics in biomedical research and medical issues in Ethiopia. The contributions of each could vary but all have put significant contributions and remain to be both potential and major stakeholders.

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Addis Ababa University Established in 1950, Addis Ababa University (http://www.aau.edu.et/) is the oldest and largest higher education institution in Ethiopia, which has made a remarkable contribution to the country through provision of trained manpower, research, and community services. One of its main campuses is the College of Health Sciences, which for many years used to be the Medical Faculty having the country’s oldest and biggest specialized teaching hospital, the Tikur Anbessa [in Amharic Black Lion] Specialized Hospital. The college incorporates School of Public Health, School of Medicine, School of Pharmacy, School of Allied Health Sciences, and the teaching hospital integrated to form one administration center which envisions to be the center of excellence in health-related issues. The university has contributed as spearhead in higher education and research in Ethiopia and beyond. It has helped a lot in the establishment of national system for biomedical research ethical review under the Ministry of Science and Technology. Most of the national steering and standing committee members were and are from the Medical Faculty of Addis Ababa University. The then Faculty of Medicine and current College of Health Sciences run an IRB, which is the first African IRB to receive Strategic Initiative for Developing Capacity in Ethical Review (http://www. sidcer.org) recognition from WHO. The IRB serves in capacity building for the national research ethics review in collaboration with partners, i.e., professional associations and donors. In addition to research ethics, the university is expected to lead in the development of bioethics in Ethiopia. There have been efforts to establish Medical Ethics committees in the university’s teaching hospital, i.e., Tikur Anbessa Hospital. Yet, the progress so far is nor remarkable. Armauer Hansen Research Institute (AHRI) Armauer Hansen’s Research Institute (http://www. eaccr.org/sites/ahri/) is a biomedical research and capacity-building and training institute in Ethiopia. It is involved in conducting research with relevance to disease control, particularly in tuberculosis, leprosy, leishmaniasis, and other diseases of public health importance including malaria and HIV. The institute was founded in 1969 through the initiative of the Norwegian and Swedish Save the Children organizations seconded by the Ministry of Health of Ethiopia. More than 350 papers in peer-reviewed journals have been published from AHRI and it has produced a substantial number of theses and dissertations from international and Ethiopian scholars in biomedical research. It has played a key role in institutionalizing Bioethics and is the home office for Pan-African Bioethics Initiative (PABIN). Its ongoing projects, among others, include Establishing an African Coordinating Office for Ethics through PABIN (EDCTP) and Ethics Review Committee Establishment in the Universities in Ethiopia (with ETBIN). Ethiopian Health and Nutrition Research Institute (EHNRI) Ethiopian Health and Nutrition Research Institute is the result of the merger of three institutes: National Research Institute of Health, Ethiopian Nutrition Institute, and

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Departments of Traditional Medicine, under the Federal Ministry of Health of Ethiopia (http://www.fmoh.gov.et). The main objectives of the institute are to: contribute to the development of health science and technology; provide referral medical laboratory services relating to the causes, prevention and diagnosis of major diseases of public health importance; and establish and support National Laboratory Quality Assurance Programs and systems. Being a national research institute on public health and biomedical science, EHNRI has contributed a lot on the development of health research ethics in the country. The institute is one of the network members of the Ethiopian Bioethics Initiative and continues to help in capacity-building and ethical trainings. The institute owns its own IRB and its staff serve in various national ethics committees. The institute also runs capacity-building trainings and seminars on research ethics for medical researchers.

Ethiopian Medical Association (EMA) The Ethiopian Medical Association was founded in 1961 under the patronage of the then Emperor of Ethiopia (http://www.emaethiopia.org/). The association exists to promote professional excellence of Ethiopian medics in both preventive and curative medicine through medical research, annual and special conferences, and publications. It provides professional and technical advice to the Ministry of Health and other concerned organizations and the exchange of clinical knowledge and research information at the local and international levels. EMA runs continuing medical education sessions on ethics. It also runs various trainings on ethics for medical doctors, researchers, and editors. It has developed and published a guideline on “professional code of practice for physicians in Ethiopia.” EMA is one of the standing members of the Health Professional Ethics Committee at EFMHACA. These values allowed EMA to maintain a standard of behavior that is always humane and rational, for dealing with lives of people. Ethiopian Public Health Association (EPHA) Ethiopian Public Health Association (http://www.etpha.org/) is an association of public health professionals of varying categories and levels of training which envisions the attainment of an optimal standard of health for the people of Ethiopia, through promotion and advocacy for better health services and high professional standards, professional competence, relevant policies, and effective networking. The association stands for professional development of its members without prejudice as regards gender, religious, or ethnic affiliation. Like the Ethiopian Medical Association, it also serves as member of the national networks in medical ethics and runs various capacity-building sessions through continuing medical educations and trainings. It also runs regular trainings on “Research Methods and Ethics” for its members in different locations in the country. In addition, it owns an independent IRB which reviews proposals on health research. EPHA also contributes to the national dialogues in ethics.

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Food, Medicine and Health Care Administration and Control Authority (FMHACA) Food, Medicine and Health Care Administration and Control Authority (http:// www.fmhaca.gov.et/) is one of the wings under the Federal Ministry of health. Like the Federal Food and Drug Administration in the USA, it is responsible for the accessibility of quality health service to all citizens throughout the country. Accordingly, health and health-related services and products quality regulation core process are redesigned in the purpose of protecting the public from any emerging health risks. One of its major objectives is to standardize health services and protect the public from unqualified and unethical professionals and substandard health institutions. The authority is responsible for ensuring professional ethics. Its Professional Ethics Committee looks into medicolegal issues and does case-based deliberations and advises the legislative body on medical malpractice. In addition, all drug clinical trials need to be further registered, approved, and regulated by FMHACA. For this, a guideline had been developed incorporating Good Clinical Practice and made publicly available. Ministry of Science and Technology (MOST) Ministry of Science and Technology (http://www.most.gov.et), which used to be Ethiopian Science and Technology Commission (ESTC), is a governmental institution established with the mission to create a technology transfer framework that enables the building of national capacities in technological learning, adaptation, and utilization through searching, selecting, and importing effective foreign technologies in manufacturing and service-providing enterprises. The ministry has the powers and duties to forward recommendations based on studies for adopting and revising polices, strategies, laws, and directives on the development of science, technology, and innovation activities that support the realization of the country’s socioeconomic development objectives. As is mentioned under the section “development of research ethics in Ethiopia,” the then commission in collaboration with the National Health Science and Technology Council (NHSTC) embarked the first organized national initiative to address health research ethics issues in the country. The National Health Research Ethics Review Committee under the ministry is endowed with the responsibility of reviewing health research ethics issues at a national level and setting principles and standards on health research ethics and their applications in the Ethiopian context. ESTC launched three versions and revisions of the national research ethics guideline (1995, 1997, and 2004) (ESTC, 2005). The ministry is responsible for licensing and regulation of Research Ethics Committees at national, regional, and institutions levels. Its National Committee is composed of various independent stakeholder members responsible for reviewing proposals that need to be reviewed at national level. Ethiopian Bioethics Initiative (ETBIN) The Ethiopian Bioethics Initiative is a country chapter of the Pan-African Bioethics Initiative (PABIN) which aims to build capacity in ethical clearance of health research in the country. Established in 2002, its secretariat is based at AHRI,

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which is a founding member institution and itself important stakeholder in bioethics in Ethiopia. ETBIN hosted the Third PABIN Conference in Addis Ababa in 2006. ETBIN helped in implementing the initiation of capacity-building program that aimed at supporting other institutions establish Ethics Review Committees and to strengthen existing committees. The national network provides a forum for regular meeting and discussion on bioethics in Ethiopia in order to preserve and promote Ethiopian traditions in ethics and bioethics. It also aims to improve communication among ethics committees in reviewing biomedical research (health, behavioral, and social science) in Ethiopia. It assists in fostering education in bioethics and the trainings, promoting and assisting the development of ethical committees, acting as an Ethiopian collaborating center for fostering ethical review, organizing national meetings and symposia, and assisting with the implementation of standard operating procedures for ethical review in the country. ETBIN is in the UNESCO Bioethics databases and receives project support from EDCTP (European and Developing Countries Clinical Trials Partnership).

Resources Available and Steps Taken for Bioethics in Ethiopia There are some regulations and guidelines in Ethiopia made available to provide guidance on the ethical conduct of health professionals. These guidelines are developed by the government and by professional associations. The revised 2005 version of Criminal Code of the country (Proclamation 414/ 2004), which is based on the country’s Constitution, has addressed issues in the medical practice. Article “271 of the penal code” states as follows: (1) Whoever, in the circumstances defined above [i.e., in time of war, armed conflict or occupation . . . and in violation of the rules of public international law and of international humanitarian conventions] organizes, orders or engages in: . . .(c) compelling persons engaged in medical . . . activities to perform acts or to carry out work contrary to or to refrain from acts required by their . . . professional rules and ethics or other rules designed for the benefit of the wounded, sick or civilian population, is punishable in accordance with [rigorous imprisonment from five years to twenty-five years, or, in more serious cases, with life imprisonment or death]. (FDRE, 2004, Ethiopian Criminal code - FDRE, the Criminal Code of Ethiopia; Proclamation No. 404/2003).

There are also a number of professional codes of conduct by respective professional associations. “Medical Ethics for Physicians in Ethiopia” has been published by the Ethiopian Medical Association twice so far (EMA, 2010). Other resources include an introductory text on Professional Nursing and Ethics, which is a textbook and reference material for mainly nursing professionals (Cherie, Mekonen, & Shimelse, 2005); “Professional Code of Ethics and Conduct for Midwives” by the Ethiopian Midwives Association (EMWA, 2011); and Code of Ethics For Medical Laboratory Technologists Practicing In Ethiopia by the Ethiopian Medical Laboratory Association (EMLA, 2008). The federal ministry of health has developed a module for health extension workers on health management, ethics, and research, as a blended learning module for the Health Extension Program, for health

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extension workers, and as a guidance for research in primary health care (FMOH, 2011). The Ethiopian Society of Obstetricians and Gynecologists (http://www.esog. org.et) also has developed Sexual and Reproductive Health Ethical Guidelines for Ethiopia, which is available on the web. There are also curricula on general ethics for undergraduate students. However, the courses are more on civics than bioethics. There are very few or less available resources in Public Health Ethics and much is integrated to the public health systems and ethics is not treated separate such as tobacco proclamation and guideline. Several guidelines on research ethics exist in Ethiopia. The Ministry of Science Technology (MOST) has training modules on research ethics for the Ethiopian context and National Research Ethics Guideline on how the national research ethics review system should work at the national level which are made available (http://www.most. gov.et/). The Ethiopian Public Health Association (EPHA) has also developed a course on Research Methods and Ethics for its members and other public health professionals (http://www.etpha.org). EFMHACA has guidelines available on the web on the applications of Good Clinical Practice (http://www.fmhaca.gov.et/). In addition, most IRBs (such as Addis Ababa University) have their own SOPs and guidelines published in book formats available for applicants, reviewers, and IRB members.

Current Bioethics Infrastructure As explained under the section “Research Ethics System in Ethiopia,” there is a very good structure available for research ethics review. The public media also frequently hosts and broadcasts public debates and panel discussions on various topics on Bioethics.

Teaching of Bioethics at University and Other Levels Regarding training in bioethics, for very long, there have not been medical ethics courses in the medical curriculum. Recently, medical ethics is included as a course in undergraduate medical trainings in the medical school. The course is given for other health professionals such as nursing and medical laboratory technology. So far, there are no independent academic courses in research ethics. This is addressed under research methods trainings for postgraduate students. Professional associations such as EMA and other partners give various trainings on “research ethics.” But these are not very structured as such. Still, there are no full-blown graduating programs in bioethics.

Bioethics Committees Even though there are no bioethics committees in the hospitals, almost throughout the country, there are functional research ethics committees both at national,

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regional, and institutional levels. These are generally research ethics committees, but not bioethics committees dealing with clinical ethics and case deliberations. Tikur Anbessa Specialized Teaching Hospital is the first one to have a bioethics committee which is functioning below its capacity. The main reasons for the retarded progress in the clinical aspect of bioethics have to do with less awareness, less expertise, and existence of few ethical dilemmas, compared to much advanced countries.

Legislations The main legislation guiding medical ethics in Ethiopia is the Ethiopian Civil Code; there is a Professional Ethics Proclamation under review and a number of national guidelines available (see section on resources and guidelines above).

Public Debate Activities Media and panel discussions have taken place mainly in the areas of medical professional ethics organized by media groups, professional associations and agencies such as Ethics and Anticorruption Commission.

Major Bioethics Issues and Discussions Contemporary major bioethics issues in the Ethiopian context are dictated by the current socioeconomic and medical developments in the country and the sociocultural context. Below are issues pertinent to the Ethiopian context. The list is not exhaustive by any standard but demonstrates some of the major highlights.

End of Life There are few places which provide modern palliative care in Ethiopia. Many persons with terminal illness are treated in general wards or even at home. According to the Ethiopian code of medical ethics, physicians are not permitted to advocate or practice euthanasia (Nwafor, 2010; EMA website). There is no published data regarding public opinion about issues of end of life in Ethiopia.

Autonomy and Disclosure Decision-making in medical care and health research at an individual level is determined by ethno-cultural factors existent in the country. These factors vary

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according to the specific location and tribe. As in many other traditional societies, individual autonomy is not absolute in the Ethiopian context. In the Ethiopian society, individual decisions are not made on an autonomous basis; consensus from the public and the community elders is unusually sought in major community undertakings such as community-based interventions and research undertakings. The extended family is the most important institution. In the medical practice, direct and frank disclosure of certain medical information such as diagnoses and prognoses of grave illness or death of a family member is considered as inappropriate and insensitive. Therefore, in these conditions, doctors would communicate little information to patients and usually tell the bad news to a family member first. During illness and crisis, Ethiopians rely heavily on family members to help them cope. In the Ethiopian culture, the patient-healer relationship is paternalistic and protective, and trust is a major component of this relationship. Physicians and nurses therefore need to take time to understand and pay attention to such paradigms which could take different shape across ethnic differences in this multicultural country (Beyene, 1992). Confidentiality (keeping medical secrets) is more one sided with a patient telling his medical secret to a doctor in confidence. Sharing something in confidence would mean the issues to remain only between a certain group of individuals and not to be shared outside those boundaries. The more traditional the culture, there is less truth telling regarding the patient’s condition. (Blackhall et al. 1995; honesty is the most highly valued character trait in the Ethiopian culture and truth is socially defined. However, confidentiality is not very well maintained in medical care practice in Ethiopia). Existing national medical codes and guidelines affirm the importance of this principle; however, its application needs to be carefully laid out (EMA, 2010).

Health-Care System and Access to Health Care The Ethiopian health-care system is mainly a public health system. However, there are discrepancies between and within societies, regarding responsibility, decisionmaking, risk sharing, and fair distribution of resources. For instance, urban-rural discrepancies are documented in various surveys (CSA, 2012) as there appears an urban bias in the distribution of health facilities even though great majority of the country’s population resides in the rural areas. Current estimates put the coverage by the modern health system at about 50 %, which is merely geographic coverage of health services, disregarding actual utilization of services. Many residing in the catchment area of health facilities may not be utilizing any of the services for reasons of lack of awareness, cultural barriers, economic problems, and difficulty of physical access. Thus, the proportion of the population benefiting from the modern health sector is much less than the one calculated based on the geographic coverage. Furthermore, resources required for health care are very scarce. Compared with other policy sectors, the health sector has not been given due priority as evidenced by the very low MOH expenditure per capita per annum (Haile Mariam & Kloos, 2005).

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Reproductive Health According to the Ethiopian Society of Gynecologists and Obstetricians, there are a number of considerations for Ethiopia in relation to reproductive health. Reproductive health workers are expected to be instrumental in addressing ethical issues in gender and reproductive health. Gender inequality is a long-standing problem in Ethiopia, which is demonstrated via access to basic medical and social services, such as education and job opportunities. Traditional reproductive health practices such as female genital mutilation are common. Gender-based violence is a common phenomenon. Modern advancements in infertility treatment such as artificial reproductive technologies are still not well developed as average options for Ethiopians, and the ethical dilemmas associated with them are rare at this stage. Sexuality is a socially defined issue in Ethiopian society, which is considered very conservative compared to other countries even in Africa. Sex before marriage and abortion are taboo but the study indicates it is becoming common for minors and unmarried women (Alemu, 2010). A big area of debate is abortion, which will be discussed further later.

Traditional Medicine Another area of moral dilemma in the medical practice in Ethiopia is traditional medicine. For modern health professionals, traditional medical practices are considered wrong and inappropriate, while most Ethiopians do visit traditional practitioners, and there are at times conflicts between the two areas. Traditional Ethiopian practitioners possessed a wide variety of cures. Many of these came from medicinal plants. Much knowledge about traditional Ethiopian medicine is preserved in the folk memory of Ethiopians in many parts of the country. There are a number of traditional medicinal practices that reflect the diversity of Ethiopian cultures which are concerned not only with the curing of diseases but also with the protection and promotion of human physical, spiritual, social, mental, and material well-being. The health and drug policies of the Ethiopian Ministry of Health recognize the important role traditional health systems play in health care. However, little has been done to enhance and develop the beneficial aspects of traditional medicine including its possible integration into modern medicine (Kassaye et al., 2006). In some cases, traditional medicine is generally prescribed for mental illnesses and chronic conditions as the modern medical care is believed to not to help (Birhan, Giday, & Teklehaimanot, 2011). As there are beneficial practices, there also are a number of traditional medical practices which are harmful and are associated with immediate and long-term complications. False health beliefs and ineffective treatment caused delays in the treatment at modern health services of infectious and noninfectious diseases (Kloos & Kaba, 2005). There is always the possibility that traditional Ethiopian medicine possesses valuable ingredients for use in modern medicine. Most patients do visit traditional practitioners and continue to do so together with seeking modern health care. It is

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always good to explore and address such issues and use them positively and provide comprehensive awareness (Pankhurst, 1990).

Cultural Issues in Medical Research Especially in the rural areas, there is little understanding of research, which is often misinterpreted as treatment. The concept and even the terminology of research are nonexistent in most of the local languages. This therapeutic misconception is a challenge for proper consent processes in biomedical research. In addition, consent and decision-making mechanism are influenced by a number of cultural and social issues such as stigma and discrimination. Rural patients are afraid of participation in a genetic study, fearing that the study might aggravate stigmatization by publicizing the familial nature of the disease. That genetic study should be approved at family level before prospective participants are approached for consent (Tekola et al., 2009a). Like in other developing and traditional countries, there is increasing recognition of the need for research in developing countries where the burden of disease is high. Understanding the role of local factors is important for undertaking ethical research in developing countries. It is recommended that researchers should evaluate the effectiveness of consent processes in providing appropriate information in a comprehensible manner and in supporting voluntary decision-making on a study-by-study basis (Tekola et al., 2009b).

Disclosure and Data Ownership Issues in Public Health There are circumstances when the public health system has been very protective of public health data. Good communication policy and strategy are equally important in guiding response and creating a responsibly and trustworthy atmosphere. Ethiopia is one of the signatories of the new revised International Health Regulation (IHR) (WHO, 2008), which was ratified in the World Health Assembly (WHA) in 2005 and fully enforced starting from 2007 and has clearly established the importance of national and international responsibilities in epidemics by stating codes of conduct in reporting and notification. Irrespective of the impacts it might have, it is an ethical mandate of the public health system to be just and transparent in providing early notification to the country’s public and also to the international community in cases of travel-related risks and cross-border phenomenon. To this effect it is high time to reconsider the policy of nondisclosure of such outbreaks to the public and beyond. The moral laws of autonomy and justice would otherwise be violated (Addissie, 2009). It is to be understood that a country needs to have its own policies on how data should be shared and utilized, but this should not impede and get in conflict with the international regulations and agreed up on treaties like IHR (WHO, 2008). Recently, there are very useful movements implementing a datasharing policy in major research centers, for example, in EHNRI and the AAU Butajira Health Project.

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Medical Issues in Ethiopian Black Jews The Black Jews who lived for centuries in Ethiopia, as part of the exodus of Jews, are resettling back to Israel. Though the origins of the Ethiopian, Jews are obscure; they traditionally relate to the lost tribe of Dan. These Black Jews have faced different levels of stigma and discrimination in various forms including discarding blood donated for transfusion and involuntary forced contraceptive administration. In 1996, the Israeli government dumped hundreds of units of blood with the reason that the Ethiopian Jews could have HIV/AIDS. This instigated a fierce reaction from the public and from the Ethiopian Jews themselves (Weinstein, 1996). In addition, recent news in Israeli and other international media revealed the administration of involuntary contraceptives to the settlers by health professionals (Nesher, 2013).

Malpractice: Medical Professional Ethics Professional ethics among medical practitioners is a growing concern of the Ethiopian public and the media and panel discussions mention a lot about it. The medicolegal discipline is not developed in Ethiopia and currently falls under the digression of courts and the media. Medical malpractice is becoming a public concern and there is not a clear system. Yet, codes of practice exist. A study done by the School of Law (Simachew, 2011) revealed that medical malpractice claims in Ethiopia fall within the general ambit of private law. Medical malpractice claims might be raised based on the law of contract or extra-contractual liability. Generally, a claim for medical malpractice in Ethiopia is adjudicated based on the determination of fault which caused the injury.

Ethics of Public Health and Medical Emergencies Ethiopia is known to be affected by repeated public health disasters. Thus, dilemmas arise about how to respond to such emergencies. Public Health Emergency Management (PHEM) is a directorate under the FMOH, mandated to respond to public health emergencies and health-related disasters at national and regional levels. The PHEM guideline mentions of standard procedures to follow during such events but the ethical issues are not well explored (PHEM, 2012). Issues often raised include the need of ethical approval of such investigations and the consent from individuals as well as the ethical mandates of response. Even though it is taken for granted that there is no need for ethical appraisal of such investigations, there is no clear guideline available. The same analogy applies to clinical emergency care in Ethiopia. Issues arise concerning consent and mandates to responding to medical emergencies in the clinical setting. Emergency medicine is yet undergoing developments and there is a need to address the associated ethical issues (Germa, 2011). Another issue is the availability of resources and the dilemma of discontinuing some supportive interventions such as artificial ventilation.

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Abortion Another very controversial issue in Ethiopia is abortion and termination of pregnancy. Abortion has been illegal until 2004 when the Ethiopian Parliament voted to approve a new, progressive law. Though the new Criminal Code of the Federal Republic of Ethiopia (2005) maintains the legal prohibition of abortion, it stipulates that abortion is allowed by law in the following conditions: when the pregnancy results from rape or incest, when continuation of the pregnancy endangers the health or life of the woman or the fetus, in cases of fetal abnormalities, for women with physical or mental disabilities, for minors who are physically or psychologically unprepared to raise a child, and in the case of grave and imminent danger that can be averted only through immediate pregnancy termination. The revised law establishes that poverty and other social factors may be grounds for reducing the criminal penalty for abortion, and that in cases of rape or incest, no proof is required beyond the woman’s statement that it has occurred. However, the law does not allow abortion for economic and social indications and abortion is not available just on request (Wada, 2008). By allowing abortion for minors who are unprepared to raise a child, the law also marks a significant change for Ethiopia, where adolescents make up more than 45 % of those seeking abortions. In contemporary Ethiopia, abortion decision-making is a challenging process involving moral and religious dilemmas, as well as considerations of health and safety. Amidst widespread condemnation of female premarital sex and clear moral sanction against induced abortion, young Ethiopian women are nevertheless sexually active, and induced abortions are still sought and performed, with the potential for grave physical harm and social stigmatization (Kebede, Hilden, & Middelthon, 2012). The Ethiopian public is predominantly conservative and religious, and this makes it difficult to implement the law in uniformity. While there are health-care providers whose personal values do not conform to the new law. Others rather might abuse the system. The majority of unwanted pregnancies of minors are ended in abortion, which are undertaken without medical professional intervention (self-induced or with traditional medication and in illegal places). Most girls who undertook abortion feel ashamed and guilty of committed sin and crime; hence, they have no internal peace. Minors who are from relatively lower income families mostly go to traditional abortionists. The major religious institutions in Ethiopia have no official stand on the use of contraceptives by married women and leave the choice to individuals. However, the institutions highly condemn sex before marriage (Alemu, 2010).

HIV and AIDS Being located the sub-Saharan region, Ethiopia is one of the countries affected by HIV/AIDS. Currently, the burden and rate of infection is said to be decreasing. However, there are a number of moral dilemmas associated with HIV and AIDS.

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Examples include disclosure of HIV testing information to partners when the client is not ready to disclose, religion and condom issues, when to disclose serostatus for children, and treatment adherence issues. Another criticism is about the rationing of treatments: ART treatment guidelines developed using methods that do not fully satisfy the requirements of fair processes (Johansson et al., 2008).

Medical Tourism Due to the lack of medical advancement in Ethiopia, it has now become a common trend to refer patients for unavailable medical services to foreign countries. The list of countries where patients often visit includes Kenya, South Africa, Thailand, and India, while some patients travel to Europe and the USA. Especially the Thai and Indian markets are very appealing to most Ethiopian patients. The major reasons for such medical trips are malignancies, cardiac surgeries, and transplants. Reports have indicated that nearly 95 % of African citizens are travelling to countries like Thailand, Singapore, South Korea, and India for better treatment in orthopedics, cardiology, pediatrics, and internal medicine. Patients need an official referral from the government. Important issues concern the costs. But there are also brokers and agents who claim to facilitate. The question is whether they are genuine or looking for business. In general, post-trip follow-up is not often available in the country and one would ask the ultimate benefits of the clients.

Psychiatric Care Two major ethical issues exist within the psychiatric care system in Ethiopia. The first issue is the lack of resources for psychiatric care including infrastructure, trained manpower, and availability of effective psychotropic medications (WHO, 2006). For many years, modern psychiatric care was only available at a few centers located in the Capital, Addis Ababa (Alem, 2001). Among persons with severe mental illness living in rural Ethiopia, only less than 10 % had visited modern psychiatric care (Negash et al., 2005). Most families take their sick relatives to traditional treatment places (Girma and Tesfaye, 2011) and the treatments are applied against the patients’ will that are often shackled (Alem, 2000). In those treatment centers, there are no checks for the rights of patients. Many families keep their sick relatives restrained at home until they are no more violent (Alem, 2000). It is not uncommon to see patients presenting to psychiatric facilities with wounds from tight chains around their arms and legs. The second issue is the fact that there is no mental health legislation in Ethiopia (Girma and Tesfaye, 2011; WHO, 2006). It means that mental health professionals rely on the general ethical codes. In practice, clinicians only need informed consent of persons who escorted the patients for involuntary admission and treatment (Alem, 2001). It has been found that mental health professionals in Ethiopia are more likely to recommend involuntary hospitalization, inform the spouse against the patient’s wishes, and apply restraints

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compared to professionals in other countries. Also, there is a tendency to withhold information about side effects of medications when professionals thought that the patient might refuse to take the prescribed medications (Alem et al., 2002). The problems in the breach of ethics and patients’ rights in the context of psychiatric care in Ethiopia could be much worse as the reports might be affected by social desirability bias. In addition, Ethiopia does not have separate human rights body with authority to oversee mental health institutions and to ensure rights of patients (WHO, 2006). Consequently, none of the mental health institutions and residential facilities have been inspected or reviewed by an independent human rights body in the past (WHO, 2006).

Brain Drain Ethiopia has an inadequate number of health professionals of all categories. On top of this, many doctors migrate to the USA, Europe, Middle East, and Southern Africa for greener pastures. The Ethiopian government is determined to fight against brain drain and the quest for skilled nationals should be armed with enthusiasm. Others regard this as a positive phenomenon since doctors in the Diaspora continue to contribute to the country directly and indirectly. The American Health Professionals Association (ENAHPA) is making extreme efforts to the realization contributing back to the country and people by the Ethiopian medics practicing currently in North America. Ethiopia should do all it can to mitigate brain drain and make a maximum use of its skilled manpower in the Diaspora. Others argue that the disadvantages of brain drain are more significant than the advantages in the case of Ethiopia where manpower training is markedly under-subscribed. The country should formulate a government policy sooner than later to facilitate retention of skilled manpower and to serve as a springboard for moving forward in the development endeavor and catch up with the tempo of the rest of the world (Mengesha & Kebede, 2005). In response, Ethiopia is now planning for a flood of medical doctors within “three to four years,” an influx meant to save a public health system that has been losing doctors and specialists to internal and external migration. Some argue the quality of training is compromised with a rapid intake of medical students; for others, quality is relative and the number of professionals reflects also quality.

Summary and Future Challenges Ethiopia being a country with diverse social and cultural identities, the issue of bioethics is also diverse and dictated by context-specific realities. The country has tried to address bioethics issues in different ways; however, this is yet to be strengthened. There are a number of issues related to building bioethics capacity in the country using more indigenous and local experts and resources in the area.

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Having a supporting infrastructure and system is vital for the development of bioethics in Ethiopia. One of the challenges is the enforcement of existing laws and legislations. More attention needs to be paid to this issue. At times, there is confusion regarding the standard operating procedures for the implementation of the existing procedures. The same is true for the existing policies. Due to the lack of national standards, the governance of professional and research ethics is not very well defined by decree and a research act does not exist. Legislation needs to be in place to address emerging issues such as artificial reproductive technologies and genetic research.

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