Observing principles of medical ethics during family planning services at Tehran urban healthcare centers in 2007.

BACKGROUND: Family planning has been defined in the framework of mothers and children plan as one of Primary Healthcare (PHC) details. Besides quantity, the quality of services, particularly in terms of ethics, such as observing individuals' privacy, is of great importance in offering family planning services.
OBJECTIVE: A preliminary study to gather information about the degree of medical ethics offered during family planning services at Tehran urban healthcare centers.
MATERIALS AND METHODS: A questionnaire was designed for study. In the first question regarding informed consent, 47 clients who were advised about various contraception methods were asked whether advantages and disadvantages of the contraceptive methods have been discussed by the service provider. Then a certain rank was measured for either client or method in 2007. Finally, average value of advantage and disadvantage for each method was measured. In questions about autonomy, justice and beneficence, yes/no answers have been expected and measured accordingly.
RESULTS: Health care providers have stressed more on the advantages of pills and disadvantages of tubectomy and have paid less attention to advantages of injection ampoules and disadvantages of pills in first time clients. While they have stressed more on the advantages and disadvantages of tubectomy and less attention to advantages of condom and disadvantages of vasectomy in second time clients. Clients divulged their 100% satisfaction in terms of observing turns and free charges services. Observance degree of autonomy was 64.7% and 77.3% for first time and second- time clients respectively.
CONCLUSION: Applying the consultant's personal viewpoint for selecting a method will breach an informed consent for first and second time clients. System has good consideration to justice and no malfeasance.

Introduction

In order to facilitate people's accessibility to healthcare services, Ministry of Health and Medical Education run primary health care as the main core of health networks services. The Family Planning Programs carried out in many developing countries from the 1950s through the 1980s represent one of the important social experiments of the post-World War II period, but the details of their operations, their commonalities, and their differences have been insufficiently archived given the programs’ day-to-day pressures and the large numbers of people involved. The family planning programs helped pave the way for many subsequent health, social and economic programs (1).

Family Planning Services is one of the plans which aims at securing health of mothers and children on one hand and making coordination between population growth and social, economic and cultural development factors on the other hand, they will be resulted in securing social justice eventually (2). Family planning saves lives of women and children and improves the quality of life for all. It is one of the best investments that can be made to help ensure the health and well-being of women, children, and communities. Yet it is estimated that some 120 million women who do not wish to become pregnant are not currently using contraception. By providing all women and men of reproductive age with a choice of contraceptive methods and counseling about how to use those methods safely and effectively, programs can have a significant impact on the lives of their clients (3).

Medical ethic is an analytical activity by which various contemplations, beliefs, behaviors, emotions, reasons, and debates of ethical decisions in medical field are analyzed and criticized precisely and executive instructions would be issued if necessary. Decisions of medical ethics cover medical performance, axioms and values, good or bad, correct or incorrect issues, and norms. On the other word, medical ethics is the practical dimension of ethics in medicine. Such ethics regulate behaviors and performance of dominant principles of physicians and their colleagues' occupation (4, 5). Ethics are consisted of four important principles including autonomy, beneficence, no malfeasance and justice. The principle of autonomy means that the individual preserve dignity of others and values their independence. The principle of beneficence means that the individual should make determined effort to be useful to others. The principle of nonmalfeasence means that the individual should avoid causing damage or harming to others. From brule standing point justice means treat others fairly and distribute the profits in the society in the way that is acceptable morally (6-8).

Thus, observing ethics in each service must be stressed. All clients who seek information about family planning issues are entitled to be informed about advantages and how to access the plans of family planning, selection procedure, service immunity, privacy, confidentiality, respecting to personality, service convenience and continuation. They must be considered towards observing medical ethics. This study aims at performing a preliminary study for accessing the study process in order to determine degree of observing ethics during offering family planning services at urban clinics covered by Iranian state medical sciences universities.

Materials and methods

Initially, offering family planning services process in country’s health system was analyzed based on references of Family Health Department General (9-22). Then, main steps of this process were defined and a questionnaire was designed based upon such steps and regarding this fact that medical ethics are consisted of four important principles including autonomy, beneficence, non-malfeasance and justice for offering services as well as consultation of pundits of medical ethics. The prepared questionnaires were consigned to 47 clients of family planning clinic, who were there in order to take various contraception methods by Mr. Shahmardani who is expert member of Tehran University of Medical Sciences. This study was carried out in health care centers of Bagher Shahr in Ray City, Shahid Ayat South Tehran, Maysam South Tehran and Ghaemieh of Islam Shahr in November 2007. For the first question which was about informed consent, all clients (for each method) were asked whether all advantages and disadvantages (in association with attached details) of the method have been noted by the service provider to them? Then data analysis was done by use of SPSS.

A certain rank was measured for either client or method. For example, if 2 advantages and 9 disadvantages have been defined for pills and client claimed that she is informed about all of them completely, then 2 and 9 ranks would be considered for advantages and disadvantages of pills, respectively. Finally, average value of advantage and disadvantage ranks of each method was measured. Average value and average to desired value ratio are summarized in table I. For other questions about autonomy, justice and beneficence, only yes/no answers have been expected as final answers and yes answers rate has been measured and summarized in Table II, III accordingly.

Table І

Average value and average to desired value ratio of contraception methods

Methods			Pills		IUD	Injecting ampoules	Norplant	Condom	Tubectomy	Vasectomy
First time clients=17
	Number of clients			7	3	2		3	2
	Advantage value			2	4	8		4	2
	Disadvantage value			9	6	6		2	2
	Average ratio of advantages *			1.7	3	3.5		2	1
	Average ratio of disadvantages **			3.9	3	3.5	0	1	2	0
	Average value to desired value of advantages			85.7%	75%	43.8%		50%	50%
	Average value to desired value of disadvantages ***			42.9%	75%	58.3%		50%	100%
Second time clients=30
	Number of clients		7		6	5	1	5	5	1
	Average ratio of advantages *		2		2.8	4	3	1.8	1.6	3
	Average ratio of disadvantages **		3.6		3.5	3.2	3	1	1.8	1
	Average value to desired value of advantages		78.6%		70.8%	50%	75%	45%	80%	75%
	Average value to desired value of disadvantages ***		39.7%		58.3%	53.3%	42%	50%	90%	33.3%

: total of explained advantages/number of clients.

: total of explained disadvantages/number of clients

: (average value /total of advantages or disadvantage)*100.

Table П

Analyzing responses of first time clients

Question	Situation	BA consultant		Associate diploma consultant
		advantages		disadvantages
		Number	Percentage	Number	Percentage
Autonomy
	Degree of welcoming variables	8	100	6	67
	Repeating pre explained issues	8	100	8	89
	Observing privacy during consultation	3	37/5	2	22
	Using same sex consultants for clients	8	100	9	100
	Free debating during consultation	7	87/5	7	78
	Attention of consultant to clients expression	7	87.5	7	78
	Understandable nature of issues	8	100	9	100
	Responding to clients expressions	4	50	6	67
	Asking question	7	87.5	6	67
	Selecting contraception method by the client	8	100	9	100
	Consulting in the presence of spouse	1	12.5	2	22
	Offering strategy during expressing causes and taking authorization in the case of referring to hospital	7	87/5	7	78
	Examination by same sex nurses	3	100	4	100
	Clean space of examination environment	3	100	4	100
	Observing privacy during examination	3	100	4	100
Justice
	Observing turns	8	100	9	100
	Not paying charge	8	100	9	100
Non-malfeasance
	Violation free examination	3	100	4	100

Table Ш

Analyzing responses of second time clients

Question	Situation	BA consultant		Associate diploma consultant
		advantages		disadvantages
		Number	Percent	Number		Percent
Autonomy
	Degree of welcoming variables	15	88	12	92
	Repeating pre explained issues	14	82	11	85
	Observing privacy during consultation	6	35	3	23
	Using same sex consultants for clients	17	100	13	100
	Free debating during consultation	17	100	13	100
	Attention of consultant to clients expression	17	100	12	92
	Understandable nature of issues	17	100	13	100
	Responding to clients expressions	13	76	11	85
	Asking question	14	82	11	85
	Selecting contraception method by the client	16	94	13	100
	Consulting in the presence of spouse	5	29	2	15
	Offering strategy during expressing causes and taking authorization in the case of referring to hospital	4	100	3	100
	Examination by same sex nurses	14	100	10	100
	Clean space of examination environment	14	100	10	100
	Observing privacy during examination	14	100	10	100
Justice
	Observing turns	17	100	13		100
	Not paying charge	17	100	13		100
Non-malfeasance
	Violation free examination	14	100	10		100

The study is supposed as a preliminary one and it would be used based upon its results and measured validity and reliability rates of the questionnaire in other medical and health centers in order to determine degree of observing ethic codes during offering family planning services. This article is student thesis and it enjoys no financial support.

Results

The quantities of first-time and second-time clients were 17 and 30 people, respectively. In order to compare expressing advantages and disadvantages of various contraception methods regarding different advantages and disadvantages of each method, it was observed from average to desired value ratio. It was calculated from dividing average value of explained advantages and disadvantages of each method to standard value of each method.

During expression of average value to desired value of contraception methods’ advantages, the highest ratio for first-time clients was equal to 85.7% (for pills) and lowest ratio was equal to 43.8% (for injecting ampoules). This ratio for explained disadvantages of tubectomy was 100% (as the highest value) and of pills was 42.9% (as the lowest value). For more than one time clients, the highest average ratio of explained advantages was belonged to tubectomy with 80% and the lowest ratio was related to condom with 45%; for explained disadvantages the highest ration was belonged to tubectomy with 90% and the lowest ration was related to vasectomy with 33.3%. The valid variables including welcome procedure, repeating pre-explained issues, observing privacy during consultation, using same sex consultants for clients, free debating during consultation, understandable nature of issues, attention of consultant to client’s expressions, responding to client’s expressions, asking question, selecting contraception method by the client, consulting in the presence of spouse, examination by same sex nurses, clean space of examination environment and observing privacy during examination, offering strategy during acute complications, expressing causes and taking authorization in the case of referring to hospital are classified in a class and would be used for measuring observing autonomy degree. Examining these results for first-time clients shows that average ratio of desired responses in terms of abovementioned variables is acceptable providing B.A consultation (66.4%), Associate Diploma (63.2%) and totally (64.7%). Questions about observing turns and paying charges by the patients were categorized in the second class and were used for evaluation of system condition in terms of observing medical ethics (justice). 100 percent of service receivers including first-time and second time clients (both BA and associated diploma consultants) were satisfied. Violation free examination rate indicates non-malfeasance Nature of services and service receivers were satisfied for this completely (100%).

Discussion

According to medical ethics, patients are entitled to make decision about their medical and health cares, so necessary information must be submitted to them for this purpose. Taking patient’s satisfaction for offering medical and health services is compulsory and it means that the MD can interfere with patients affairs or not.

Informed consent is consisted of three parts:

1. Offering information

2. Decision making capacity

3. Voluntary decision making

Offering information in this process means that the MD must explain related information to the patient in a way that he/she can understand them. Both factors are necessary for an informed consent. For offering medical services and their tangible aftermaths, the patient must be informed. Also, other service and their advantages and disadvantages as well as potential aftermaths due to avoiding using services or using them by delay must be explained for the patient. The client as a reasonable individual must be enjoyed from all necessary information for decision making.

Therefore, some considerations such as possible effect of the suggestion on the vocation, income, family life and other personal aspects must be considered. Moreover, cultural and religious beliefs of the patients must be respected as well. Determining observed average value to desired explained advantages and disadvantages for first time clients about various contraception methods indicates high concentration of consultant to advantages of pills (85.7%= ratio of observed average to desired value) and low concentration to advantages of injecting ampoules (43.8%= ratio of observed average to desired value) and also indicates high attention of consultant to disadvantages of tubectomy (100%= ratio of observed average to desired value) and low concentration on disadvantages of pills (42.9%= ratio of observed average to desired value). Clients must select a contraception method with complete autonomy and beneficence, so it must be said that full explanation about advantages and disadvantages of the method is necessary for taking a conscious decision. Applying personal viewpoint of consultant for selecting a method will breach an informed consent for the first time; hence this system must revise about this problem. Again this problem is valid for explanation of advantages and disadvantages of second-time clients which demands active attempts of the system to solve it. In a study about using healthcare services in Islamic Republic of Iran observance degrees of seven dimensions of healthcare services were examined. Degrees dignity and respect observance, prompt attention, communication, involvement at decision making processes, information confidentiality, selection power and quality of environment were equal to 89, 82.1, 85.9, 76.9, 89.1, 77 and 80.3%, respectively. Evidence and Information for Policy (EIP) belong to WHO embarked to study health rate and to measure accountability degrees in 17 countries including I. R. Iran in 2006. Various dimensions of observing rights of healthcare receivers including selection power or right, participation at decision making, keeping confidentiality of information, observing dignity and respectability, prompt attention, communication and quality of environment were equal to 86.2, 57.6, 80.9, 87.7, 73.2, 76.2 and 72.4% respectively. Average value of all of abovementioned dimensions was equal to 75.4% (23, 24). Use by comparison method of analysis between this study and above mentioned studies we found that comparative variables are: respect to autonomy (87.7%, 89%), attention to clients expression (73.2%, 82.1%), making relationship (76.2%, 85.9%), authority of choices (86%, 77%), and environment quality (72.4%, 80.3%). Analysis of answers show that rate of respect to autonomy for bachelor consultant and associate degree is 100%, 67% (advantages responses) and this value as it relates to aforementioned two studies is (87.7%, 89%). The comparison of these values represent that the bachelor consultant services with high respect towards others. As far as we concerned the rate of attention to clients expression for bachelor consultant is 87.5% and there is 78% for associate degree consultant. This value is in respect of the aforesaid two studies is (82.1%, 73.2%) which is indicative of a relatively acceptable of variable. Concerning making relationship the value is 50% for bachelor consultant and there is 67% for associate degree consultant and this value as it relates to aforementioned two studies (85.9%, 76.2%) which the comparison of figures suggests a low value in this study. In respect of authority of choices the value is 100% for both consultant and this value as it relates to aforementioned two studies is (77%, 86%) which the comparison of figures are indicative of an acceptable variable. On the subject of environment quality the value is 100% for both consultant and this value as it relates to aforementioned two studies is (80.3%, 72.4%) which the comparison of figures are indicative of an acceptable variable. The results represent the rather acceptable attention by family planning service for autonomy principle in centers. Analyzing responses to other questions show relative good consideration of system to autonomy principle at health centers; however there is a long distance to achieve the desired parameters of autonomy. Also, it has been proved that justice is regarded across the family planning services system. Non-malfeasance principle has been analyzed in the framework of free-violence examination in this study and service receivers were satisfied for this completely (100%).

Suggestions

1. Importance of expressing pills’ disadvantages during first-time clients’ consultation process, more concentration must be directed on expressing disadvantages of pills.

2. Giving consultation in the presence of spouse in instruction of offering family planning services and possibility of violating confidentiality principle, taking viewpoint and satisfaction of clients prior to consultation is suggested.

3. Regarding small-scale of the study, performing a pervasive research with desired subjects in terms of evaluation of medical ethics codes for family planning services across the country is suggested.

4. Regarding this fact that learning medical ethics and being familiar with practical concepts of medical ethics for medical staff is necessary, so their participation in short-term training courses about family planning services as a temporary strategy is offered.

5. Preparing textbooks of medical ethics and predicting related credits for students of Family Health Major are suggested.

6. In order to take informed consent from clients about various contraception methods, advantages and disadvantages of various contraception methods must be explained by balanced and similar consultants.

7. More attention to environment of services especially giving consultation in a calm and proper space is highly suggested.