The relation between law, religion, culture and medical ethics in Nigeria

Abstract

Nigeria consists of over 250 ethnic groups with various customs and values. There are three dominant religions: Christianity, Islam and sundry traditional religions. The religion and cultures of the various peoples control the lives and transactions of the various groups. Nigerian law is based on English common law, customary law and Islam-based Sharia law. Medical ethics came into focus in the early 1960s after independence, when the Medical and Dental Council of Nigeria (MDCN) was set up to regulate the practice of medicine and dentistry. The law that established the Medical and Dental Council was updated in 1990, under the Medical and Dental Practitioners Act, Cap 221, laws of the Federal Republic of Nigeria. Medical ethics in Nigeria is based on the core principles of the Hippocratic oath, and the Nigerian code of medical ethics was revised in 1990 and 2004. However, the core principles remain the same. The law, religion and culture of the Nigerian people seem to be in firm accord with the code of medical ethics as it relates to abortion and euthanasia. The Nigerian penal code regards euthanasia as murder. Abortion, except done in order to save the life of the mother, remains a criminal offence. However, litigations against those who commit abortion are few and far between. This harmony between law, religion, culture and medical ethics, however, does not apply to the medical practices of organ transplantation, assisted conception and its related practices, and limb amputations. This paper discusses in detail the polemics and discordant dynamics of the emerging ethical controversies and proffers suggestions for a way forward, in order to obviate possible ethical conundrums.

Keywords:

• law
• religion
• culture
• medical ethics
• Nigeria

Introduction

Nigeria is the most populous country in Africa and among the 10 most populous countries of the world. It was founded in 1914 by the British following the amalgamation of the British Northern and Southern protectorates. It became an independent country in 1960. In 1963, it became a republic.

Nigeria is a multi-ethnic, multi-religious and multi-cultural country. It has over 250 ethnic groups, with varied indigenous languages and cultural values. The dominant ethnic groups are the Hausas, the Ibos and the Yorubas. There are 36 states in Nigeria with a capital territory area. The Hausas are mainly in the Northern part of Nigeria, while the Ibos are in the South East. The South West consists of the Yorubas.

However, other ethnic and linguistic groups also assert themselves in Nigeria. These include the Kanuris in the North East, and the Edos, Ibibio, Ijaws and Efiks in the South South of Nigeria (Chinenye & Ogbera, 2013).

Nigerian law is based on English common law derived from the colonial authority. However, Nigerian law is also based on case law, customary law and ratified international treaties, charters, concordant conventions, declarations and protocol (Odia & George, 2008). In some states in Northern Nigeria, the Islam-based Sharia law has also been incorporated.

Medical ethics came into its own in Nigeria a few years after independence. In 1963, the Federal Parliament enacted the Medical and Dental Practitioners Act which became operational from 18 December 1963. The law established the Nigerian Medical Council (www.mdcnigeria.org).

The Nigerian Medical Council was replaced by the Medical and Dental Council of Nigeria (MDCN) in 1980 by military decree n. 23 of 1988 (for a history of the MDCN, see http://www.mdcn.gov.ng/index.php/about-us/history-of-mdcn). This decree later became an act of parliament under the Medical and Dental Practitioners Act, Cap 221, laws of the Federal Republic of Nigeria 1990.

The MDCN is charged with the regulation of medical practice in Nigeria, and of doctors and dentists, as well as reviewing and preparing from time to time a statement on the code of conduct which the council considers desirable for the practice of the profession in Nigeria. The code of medical ethics was formally published in 1963 and reviewed in 1995 and 2004. Medical ethics in Nigeria is based on the core principles of the Hippocratic oath, as well as appropriate international conventions.

The relationship between law, religion, culture and medical ethics in Nigeria is discussed below with reference to abortion, euthanasia, assisted conception, organ transplantation and limb amputations.

Abortion

Abortion, defined in this context as the deliberate termination of pregnancy, is illegal in Nigeria except when carried out to save the life of a pregnant woman (Okagbue, 1990). This is in agreement with the Nigerian code of medical ethics formulated by the MDCN and the views of various religious groups. Despite this firm stand against abortion by both the law, the MDCN and the various religious groups, there are hardly any prosecutions of persons in Nigeria that commit abortions. Many cases of illegal abortions occur in Nigeria.

A survey done in 1984 showed that 125 cases of abortion were recorded within a month in Lagos, Nigeria. In Oyo state, 81 cases of abortion were recorded within a month, while complications of abortions were treated in 103 patients at the University Teaching Hospital in Zaria, Northern Nigeria (Okagbue, 1990).

In one study, 1836 women were interviewed in three hospitals in South West Nigeria, from 1998 to 1999. Data on pregnancy outcomes was obtained from the women, aged between 15 and 49 years. Analysis revealed that 29.7% of the women had aborted their first pregnancy. Out of these women, 43.1% were unmarried at the time. As many as 30% of the women that had abortions developed complications like heavy bleeding and infections (Mitsunaga, Larsen, & Okonofua, 2005).

In a study in Port Harcourt, Nigeria, reported in 2008, abortions carried out in five clinics were studied prospectively over a three-month period. A total of 793 women were involved. The average abortion rate was 1.76 per day. The average age of the women aborting was 23.73 years and 72.01% of them were unmarried. A total of 66.22% were aborting their first pregnancy. The reasons for abortion were: unmarried status, 63.43%; contraceptive failure, 3.9%; and lack of financial means to support the baby, 60.15%. Only 3.91% of the women did not want any more children (Ordinoha & Owhonda, 2008).

In 1982, a termination of pregnancy bill was sponsored by the Nigerian Society of Obstetrics and Gynaecology in the national assembly. The Nigerian legislature failed to pass the bill due to overwhelming opposition by religious groups (Okagbue, 1990). The bill was intended to have permitted abortion, if two physicians certified that the continuation of pregnancy was harmful to the mother or the existing children in the family, and also if the baby had physical or mental abnormalities which would have resulted in it being seriously handicapped. Recently, the Governor of Imo State in the South East of Nigeria was accused of attempting to legalize abortion in the state under the guise of an apparently innocuous bill that would prohibit violence against persons. The bill was passed into law in 2012. However, there was an outcry by various religious and cultural groups, including the Association of Catholic Medical Practitioners of Nigeria. As a result, the Governor had to ask for the repeal of the law and gave a public apology (Nkwopara, 2013).

Despite these setbacks to the abortion law reforms in Nigeria, there are still advocacy groups fighting for the liberalization of the abortion law and the promotion of contraception, reproductive health and the training of service providers to ensure safe abortion in accordance with the law, and the improvement of post abortion care (Oye-Adeniran, Long, & Adewole, 2004).

The current abortion law in Nigeria is driving abortion services underground and naturally this gives rise to unsafe abortions, with all attendant short and long-term complications.

Euthanasia

The term euthanasia, sometimes defined as mercy killing, or the killing of a person in order to relieve intractable pain or suffering, is not explicitly used in the Nigerian criminal or penal code (Bambose, 2004). However, as far as Nigerian law is concerned, “The consent of a person to an act causing his or her death is not valid defense.” Euthanasia is usually classified as either voluntary or involuntary. Involuntary euthanasia is usually regarded as illegal in all countries. However, voluntary euthanasia is legal in some countries.

In the eyes of the law in Nigeria, euthanasia is akin to murder or manslaughter, depending on the proven intentions. The two Abrahamic religions in Nigeria seem to be in harmony with the law as far as euthanasia is concerned, whether it is voluntary or involuntary.

However, there is an aspect of the traditions of some ethnic groups in Nigeria that seem to favour or turn a blind eye to euthanasia. The Yorubas in the South West have the tendency to believe that death is more honourable than protracted pain and suffering due to chronic illness (Bambose, 2004). Some other ethnic or tribal groups have been known to intentionally kill children that are deformed or physically handicapped at birth (Strauss, 1985). There are also the well-known cases of killing babies that are believed to bring bad luck or abomination to the society or community. The old tradition of the killing of twin babies or children thought to be witches may fall into these categories. Although the killing of twins has since been abolished in communities in South South Nigeria, there are recent reports that infanticide still persists in some communities (Benjamin, Adebayo, Mohammed, & Adekeye, 2013). The infanticide that was practised in some Nigerian cultures in the past, and which, as some say, is still being practised in the present day, may not qualify as euthanasia. However, these practices may explain why some Nigerian ethnic groups turn a blind eye to euthanasia even though it is illegal.

The MDCN has this to say about euthanasia in its code of medical ethics 2004:

A practitioner shall be adjudged to be in breach of the ethical code of practice if found to have encouraged or participated in any of the following acts:

1. Termination of a patient's life by administration of drugs even at the patient's explicit request.

2. Prescribing or supplying drugs with the explicit intention of enabling the patient to end his or her life.

3. Termination of a patient's life through the administration of drugs with or without the patient's explicit request thinking the same to be in the patient's best interest.

This admonition by the MDCN seems to suggest that euthanasia can only be actively performed with the use of drugs, and not passively as with withholding vital medications or nutrients.

Assisted conception and organ transplants

There are no laws governing these relatively new medical technologies in Nigeria. The first organ transplant to take place in Nigeria was a kidney transplant in 2009. Stem cell transplantation as a therapy for sickle cell disease recently commenced at the University of Benin Teaching Hospital, Benin City, South South, Nigeria (Bazuaye, 2013). Organ transplants, as well as assisted conception, remain uncharted territory in Nigeria and therefore are subject to abuse by opportunistic practitioners.

The MDCN has provided some guidelines for medical practitioners in these fields. However, these guidelines are non-specific and are, at best, advisory (Odia & George, 2008).

The views of religious leaders are divergent and sometimes discordant, and lack a clear ethical and legal direction for assisted conception and organ transplantation. The only legal signpost appears to be Section 34 of the Nigerian Constitution. This refers to the dignity of the human person and relies on the principle of informed consent. The question is, how informed are the people of Nigeria?

In a study in Northern Nigeria (Adesiyun, Ameh, Avidime, & Muazu, 2011), 196 women attending an infertility clinic were interviewed. Out of the 196 women, 150 (76.5%) had heard of assisted reproductive technology treatment. The main sources of information were from their relations and friends. The study further showed that 50.7% of women knew that the treatment could fail. When asked about their perception of the babies conceived from assisted conception treatment, 52% of the women interviewed did not know if the babies could be regarded as normal or natural babies. The majority of the women were not sure if they would accept the use of donor gamete or zygote for their own treatment.

In another study in Okija, South East Nigeria, 500 women were interviewed in an infertility clinic (Okwelogu, Azuike, Ikechebelu, & Nnebue, 2012). Only 37% of the respondents were aware of in vitro fertilization. Out of the 37.6% of the women who were aware, only 37.2% accepted to undergo the procedure. The main reason for rejecting the procedure was the opinion that babies produced by this technology would be abnormal.

Regarding the ethical issues of in vitro fertilization techniques, Ajayi and Dibosa-Osadolor (2013) administered a 33-point questionnaire to a group of obstetricians and gynaecologists. Among this group of specialists drawn from various states of the Nigeria Federation, there were varied and divergent views on ethical issues that arise from assisted conception. Their views were mainly based on their religious and cultural backgrounds. The authors then emphasized the need for a clear-cut regulatory framework and code of ethics (Ajayi & Dibosa-Osadolor, 2013).

Regarding organ donation, Odusanya and Ladipo (2006) studied 428 randomly selected adults in Lagos, South West Nigeria, using a structured self-administered questionnaire. The authors found that 60% of the subjects were aware of organ donation and transplantation, especially kidney transplantation. However, only 30% of the subjects were willing to donate their organs. The willingness to donate an organ was not related to educational status or gender. They also found that younger persons were more willing to donate their organs.

In a related study, 383 randomly selected adults in Kano, Northern Nigeria were interviewed. Out of the 383 respondents, 79.6% were aware of organ donation. In addition, 79.1% were willing to donate their organs if necessary. The reasons given for their willingness to donate organs included: religious obligations (51.2%), moral obligations (21.5%) and compassion (11.9%). However, many of the subjects did not know what the religious precepts were concerning organ donations (Iliyasu, Abubakar, Lawan, Abubakar, & Adamu, 2014).

Limb amputation

Therapeutic amputations are usually indicated for traumatic injury, uncontrollable infections and gangrene. The most common reason for non-traumatic injury amputations is uncontrollable sepsis and gangrene caused by diabetic leg ulcers (Ngim, Ndifon, Udosen, Ikpeme, & Isiwele, 2012).

The prevalence of Type 2 diabetes in Nigeria is 2.2%. However, in Port Harcourt, South South Nigeria, it is 6.8% (Nyenwe, Odia, Ihekwaba, Ojule, & Babatunde, 2003).

Acceptance of therapeutic amputations is still low in Nigeria due to some cultural beliefs regarding reincarnation and traditional rites (Udosen et al., 2009). In some cultures, a person with an amputated limb is not regarded as complete and therefore may not be accorded appropriate burial rites. In a study done in Calabar, South South Nigeria, 155 patients were interviewed at the orthopaedic unit of the University of Calabar Teaching Hospital. One hundred and forty subjects knew about limb amputations.

However, only 32% indicated a willingness to have amputations. Some of the reasons for refusal were the belief in divine healing and traditional treatments by others. The ethical dilemma faced by practitioners managing these patients who refuse therapeutic amputations is akin to the dilemma posed by the refusal of blood transfusions by Jehovah's Witnesses.

Punitive limb amputation is practised in some states in Northern Nigeria under the Islamic Sharia law. However, there has been a massive outcry by other religious groups and civil liberties organizations against punitive amputations. The MDCN has also issued a warning to all doctors practising in Nigeria, to refrain from participating in punitive amputations, citing its code of ethics.

Conclusion and recommendations

There is the need for harmony between law and medical ethics in Nigeria, to obviate ethical conundrums. The MDCN needs to work with other medical professional bodies and update the country's code of medical ethics, especially as it relates to emerging issues like assisted conception, organ transplants and stem cell therapies. The MDCN should also liaise with the Senate and House Committees on Health to draft bills on organ transplants, assisted conception and related practices. The national legislative assembly should in turn organize public hearings of such bills, with wide stakeholder involvement (civil societies, religious and cultural leaders, women's associations, etc.) in order to have robust input into the draft bills.

Assisted conception and organ transplantations require definite, unambiguous laws that will govern their practice in Nigeria. European laws could be consulted, not with a view to adopting them wholesale, but with a view to adapting their good aspects. The laws and code of ethics in these fields should be culturally acceptable to the general population. The laws should be proactive and anticipate loopholes that can easily be exploited by unscrupulous practitioners. The law on euthanasia should also be better defined for clarity. The current lack of any clear laws on euthanasia and the absence of clear-cut directives on passive and active euthanasia under the 2004 Nigerian Medical and Dental Code of Ethics, should be reviewed and corrected.

In its deliberations, the MDCN should engage experts in bioethics, especially medical ethics. The principles of paternalism vs. principlism will need to be analysed and balanced in any decisions on law, and in codes of medical ethics. The core principles of autonomy, beneficence, non-maleficence and justice should be considered on all sides of the discussion.