The objective of ethical analysis is to conclude to minimize harm to all participants while remaining within a law. A moral dilemma occurs because of inconsistency between the correctness of action and the quality of the outcome of an action. An ethical dilemma occurs when the wrong action produces good results, or when good behavior produces incorrect results. Care providers who are working in Health institutions are regularly confronted with cases having an ethical dilemma. One important question is: how we can deal with an arisen ethical dilemma?

Based on Jonsen et al medical ethics theory and different ethical theories, clinicians and ethicists use four approaches to make ethically and morally justifiable decisions. This narrated history is an attempt to openly explain the ethical dilemma confronted with the Care provider at Mizan-Tepi teaching hospital. Care providers primarily narrate the real scenario and then make use of the Jonsen et al clinical ethics theory and deontology and utilitarian theory of ethics to a thorough clinical ethical dilemma case analysis. This case presents the two undesirable alternatives, that is, “whether to respect the patient autonomy” and “Violate the country’s law on abortion” and vice-versa and the Jonsen et al clinical ethics theory was used to deal with these dilemmas.

Keywords: abortion, ethical dilemma, Ethiopia, morality

CAC, comprehensive abortion care; PID, pelvic inflammatory disease; MVA, manual vacuum aspiration.

In 2019, when we were visiting Mizan-Tepi University teaching hospital, for the sake of research work, a young woman came to the hospital where Comprehensive abortion care (CAC) is given. Mrs. Bertukan Woldie (fictitious name), 24 years old, the nulliparous woman was come to Mizan-Tepi University teaching hospital, complaining absence of menses for two consecutive months. She has had nausea but not vomiting, nausea becomes worsening during the morning just after she wakeup from her bed. She feels tired than usual since the last week, she has lost her appetite especially for types of foods that contain food odor. She noticed she has a frequency of urination but not urgency. She has no abdominal cramp, discomfort, or abdominal bloating. She has no chance of bowel habits. She was worrying if she is pregnant, which is unplanned, unwanted, and unsupported. She had regular monthly bleeding of 27 – 30 days cycle since her 14 years of age up to two months ago without interruption. She had used to Depo-Provera for 1½ years for contraception. She received her last dose 9 months back. She had no side effects of contraception. On her personal and social history, she had married a man who was arrested 3 years back. She is a farmer. She has no habit like chewing khat and drinking alcohol. Two months back she met a man at the wedding ceremony to whom she had sex with him. She has no history of hospital admission for medical or surgical problems. 

Her physical examination revealed: On her general appearance she looks anxious. Her vital sign is stable. She has pink conjunctiva and white sclera. Non-abnormal diagnosis seen on her lymph nodes, chest, and CVS. On abdominal examination, her abdomen is flat and moves with respiration. No abnormal mass felt on palpation. On Bimanual pelvic examination, the cervix is positioned anterior and no cervical motion tenderness, no adnexal mass, and the fundus measured 8 – 10 weeks size. 

Laboratory finding: Urine HCG test revealed a positive result.

The ethical dilemma

The care provider was such in a twisted situation that if he refuses to perform the procedure of termination of pregnancy, either she may go to unsafe abortion or may take measures on her own life; if he performs the procedure, clearly he violates the law of abortion service. However, despite the fact it is illegal to violate the law, he has decided to do the procedure to save her life which will be endangered. This is one of Ethical Dilemma that he has faced while he is working in the health institution "respecting patient’s autonomy and terminating the pregnancy vs. breaching client autonomy and respecting the law of abortion of the country”. This case presents an ethical dilemma (Situation in which two or more choices are available, it is difficult to determine which choices are best and will not be solved by available alternatives. The decisions may have favorable and unfavorable outcomes). It is necessary to go through ethical analysis to pass an ethically appropriate decision or choice

Regarding Birtukan Wolfie’s case, her decision to terminate the pregnancy was undesirable. Based on the penal code of the Federal Democratic Republic of Ethiopia article 551, if the pregnancy is the result of rape or incest the induced abortion is not punishable. But, no cross-checking of the rape or incest will be made. On the other hand, interruption of pregnancy is not punishable if the child has an incurable deformity, the pregnant mother, has a physical or mental defect.² It is necessary to explore the nature of the relationship between ethics and the law. According to Dickens, the law is described as the minimal ethic which prescribes what people must do or not do. What is lawful may however not be ethical and what is considered ethical may not be lawful.³ On the other hand, Article 550 permits moderation of sentence for termination of pregnancy done "on account of extreme poverty." and the clinician's decision to violate the autonomy of the client is also undesirable. Even though Birtukan’s case is punishable by law, Article 550 of the penal code allows mitigation of the punishment (not more than 1000 birr or not more than 3 months imprisonment).⁴

To recognize that the ethical dilemma is the first step to solve it. Solving an ethical dilemma means finding a solution to immediate problems. Individuals facing a dilemma before the ethical dilemma is resolved thoroughly analyze the problem by understanding what the dilemma is and then compare the results of the fundamental actions and those of the results. The objective of ethical analysis is to conclude to minimize harm to all participants while remaining within a law. A moral dilemma occurs because of inconsistency between the correctness of action and the quality of the outcome of the action. An ethical dilemma occurs when the wrong action produces good results, or when good behavior produces incorrect results. The experience in such dilemmas of patient autonomy and safeguarding the law from being violated can be analyzed using the model for clinical analysis. The analysis can help in decision making or resolve an ethical dilemma. This model includes a medical indication, patient preference, quality of life consideration and related factors.⁵

Criminal law against termination of pregnancy and constitutional right of the women

Abortion plays out on two different levels. Thus, the level for the woman who has an unwanted pregnancy and personal experience of it for whom it is a problem that has occurred and she needs a very simple straight forward and safe medical resolution. But, on the other hand, it remains the kind of political moral issue to policymakers. As a legal issue abortion is discussed in light of the principles of criminal law. Depending on contexts, nevertheless, abortion can also be discussed from the standpoint of constitutional law. In the criminal law, the issue usually takes the form of criminalizing or decriminalizing the termination of pregnancy, while, in the latter, the issue becomes whether a pregnant woman has a constitutional right to terminate her pregnancy. The issue thus commonly involves the opposing arguments in favor of the right of the fetus to be brought onto life the usually involves the competing arguments in favor of the “right” of the fetus to be brought onto life concerning the right of the mother to abortion based on her interests and choices. 

Is abortion morally permissible action to do?

What is the morality of abortion depend on? Is it just a question of women's right to bodily autonomy, right to procreative control or it also depends on whether we think an embryo fetus is a person with the right to life. A vast number of issues might be implicated in abortion ethics. Abortion is a problem about what constitutes personhood? What makes a being a person? Starting from the centrality of the personhood, the question of why should we care, why is it important what moral status will describe the fetus for the ethics of abortion? When we talk about abortion ethics, the term human being is usually taken to denote a biologically human organism. Whereas the term person is taken to denote the category of morally important beings that we think possessed the fundamental rights of life. So, the zygote or embryo is a human being, certainly, it is not a frog or any other animal. If an embryo is a person, so, abortion is certainly a homicide. So, it accounts against abortion morally if that involves homicide-violating the fetus's right to life. On the other hand, when in favor of abortion, we have women entrusted bodily autonomy which can only be protected by the right to end a pregnancy if that was they want. But the right to life is stronger than bodily autonomy. So, ordinarily, the right to bodily autonomy cannot justify the intention of killing another person. So, if abortion is killing a person, then, probably it is impermissible in almost all circumstances.

Arguments against abortion from the perspective of deontological ethics

Deontological ethics is centered on a different understanding of the nitty-gritty of humanity. According to this perspective, each person or human being is a form of divine creation. All people are created "in the image and likeness of God. "Life is the gift of God, and everyone should enjoy this gift unconditionally. The right to life is based on this horizon, that God as absolute Principle and universally unique, is the only source of life, and also only divinity has moral legitimacy and right to end all life. Every human and implicitly each product of human conception has the right to life unconditionally. No human is entitled or legitimate to end a form of human life. In these circumstances, abortion is a sin because it contradicts divine order, which is the natural order of the universe.⁶ Hindu holy texts are stated quite clearly about abortion, correlating it with the wickedest evils that a Hindu follower can commit. Arguments of this kind have a problem in the logic that relies on unconfirmed rationally assumption that God exists. This assumption can always be argued by a person who is declared an atheist, or a scientist who wants to have access to observable evidence.⁷

Religion and termination of pregnancy

The Ethiopian Orthodox Church made its position on abortion clear that the patriarch gave a press statement that was reported in Ethiopian Herald and Addis Zemen on December 25, 2003. The core contents of the statement underlined that: “as humanity begins from birth, any attempt to or act of abortion is imperious and sacrilegious; abortion is inhuman and antireligious because it is an act of trespassing the laws of providence in creation in which parents serve the means of god’s will; abortion is a contravention of the Devine command; “thou shall (not) kill”; and the movement to make abortion legal only emanates from selfish and capricious motives.”⁸

Medical indication

In the medical aspect of the case, I am concerned with the patient's eligibility. The client came to me with a complaint about the absence of menses. Therefore, her history, Physical examination, and laboratory result suggested that she is pregnant. The GA calculated from her LNMP is 10 weeks. Physical examination revealed that uterine size is comparable with gestational age and favorable uterus. It now appears the diagnosis is first-trimester pregnancy from a casual partner. The pregnancy is not wanted, for the fact, it is from a casual partner. The management planed was to terminate the pregnancy with manual vacuum aspiration (MVA). The probability of mortality and severe complication of the procedure is very rare. A determination to go through MVA would end in the safe termination of the pregnancy and the relief of psychosocial stress. The goal of management was to relief her psychosocial pain, terminate the pregnancy safely, and use the opportunity to educate on future reproductive health. But due to the law of abortion service in the country do not allow me to do; I was in stress until I decided the condition.

Patient preference

It is the Principle of Respect for Autonomy. This quadrant gives attention to the needs of the client if competent, and her assumed need if not. It is by far clear that the client was mentally alert enough when I assessed her; she most probably believed to be oriented and conscious throughout the clerking time. However, the level of consciousness circumstance alone is not enough to determine the information provided is within the scope and the decision was probably made. In this case, my client was 22 years old, so that she was legally competent to have a decision about her concern. The client decided to terminate the pregnancy for which she preferred dying than having a baby from a casual partner who has his wife and children. Therefore, as indicated here she is mentally and legally competent enough to make a decision.

Quality of life consideration: The Principles of Beneficence, Non-maleficence, and Respect for Autonomy

 It is absolutely clear that she would benefit a lot from the procedure in terms of psychosocial wellbeing and physical health that would have easily get her to start her normal life; on the contrary, if she would fail to have the safe abortion care she would have gone to traditional abortion caregiver who is unskilled and do their procedure unsafely. She would experience several actual & potential complications from the procedure such as sepsis, uterine perforation, HIV/AIDS, bleeding, infertility, pelvic inflammatory disease (PID) physical disability and death.

Contextual (related) features surrounding the case: This is The Principles of Justice and Fairness. In my case scenario, the remarkable contextual feature affecting the case analysis is the fear of the legal issue that can affect clinical decisions.

The specific dilemma which was faced at that time was between respecting patient autonomy and terminating the pregnancy and breaching patient autonomy to safeguard the law.

In this case, the decision made was right in a patient's preferences perspective, though the care provider has violated the law. It is because of her honesty and being lonely that makes her tell the reality and put him in a dilemma to do and not to do. One of the ethical codes of clinical care is autonomy (the right of self-determination, respecting the choice of the person who can decide). The health workers must respect the patient's choice and the right to get treatment because she was mentally competent enough to decide by herself. It is up to her to decide about her pregnancy.

None.

No conflicts to declare.

None.

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