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8.2 Under pressure to act in a humanitarian emergency (Patient�s best interest in a humanitarian emergency)

Elys�e Nouvet Ph.D., Research Fellow in Humanitarian Healthcare Ethics, McMaster University / Co-Domain Planner in Ethics and Moral Reasoning Professional Competencies, Michael G. DeGroote School of Medicine)

Trisha Murthy, MD, FRCPC, MHSc (Bioethics), Co-Domain Planner in Ethics and Moral Reasoning Professional Competencies, Michael G. DeGroote School of Medicine

Lisa Schwartz (PhD), Arnold L. Johnson Chair in Health Care Ethics, Associate Prof CE&B Director, PhD in Health Policy Associate Director CHEPA Co-Domain Planner in Ethics and Moral Reasoning Professional Competencies, Michael G. DeGroote School of Medicine), McMaster University (member of the RCPSC Ethics Committee)

Educational objectives

  • Demonstrate an understanding of some unique ethical dilemmas faced by healthcare workers volunteering in countries with poor health infrastructure or where access to healthcare is limited due to war or natural disaster, as opposed to those faced during practice in their home country.
  • Identify ethical considerations when assessing a patient�s best interest based on limited knowledge of an unfamiliar context and possible differences in its social and clinical realities and norms.
  • Anticipate and appraise appropriate professional responses to feeling morally distressed by care practices observed as part of an international humanitarian healthcare team.

Case

You are a newly registered Canadian physician volunteering in a public hospital as part of its surgical team, in a country that has just experienced devastating losses of life due to genocide. The local health system is dramatically strained under the pressures of the recent fighting, and welcomes assistance, but you know that your presence is still precarious as tensions within the country are still high. You, like the other foreign volunteers, do not know the local languages very well.

You are assisting with a surgery in the clinic; there is only one surgeon � a local who has been with this hospital for over a decade. The operation is an emergency abdominal surgery for a woman who came to the hospital confused and in distress. After the abdominal issue has been repaired, the surgeon announces his intention to sterilize the patient by performing an irreversible tubal ligation.

The patient�s fertility has not been risked with the surgery. The surgeon has not spoken to the patient about the possibility of such a surgery, but the surgeon appears sincere as he assures you the tubal ligation is �for the best.� The patient is already under anesthetic and is, according to the surgeon, known to hospital staff as being developmentally challenged.

This places her at higher risk of sexual assault. She is almost certain to get pregnant, your colleague explains, and �That�s not something you want. Poor girl: she�s suffered enough.�

You reviewed the woman�s chart before the surgery. There was no diagnosis of the woman�s mental health on record. The woman did appear emotionally distressed, but this would not normally be sufficient basis in your view to judge she is incapable of informed decision-making on such a life-altering surgery.

The anesthetized patient is unable to provide consent. No family members are with her.

Questions

  1. Are your professional and ethical responsibilities different as a physician volunteering in a foreign conflict zone and/or as a representative of an international humanitarian organization?
  2. Weigh the arguments for and against assisting the surgeon in this tubal ligation.
  3. What do you think is the best way to manage this situation?

Discussion

Providing healthcare in humanitarian and conflict and post-conflict settings is tense work. Patients seeking and receiving medical attention in such contexts are often particularly vulnerable. The stress of needing healthcare in the face of limited options may be compounded by the survival of traumatic events as well as extra-ordinary family responsibilities. Local clinic and hospital personnel are likely seriously overworked and emotionally drained, as they struggle to perform professionally where demand dramatically outpaces resources. Local clinic and hospital staff�s ability to provide care is also likely dependent on a number of factors beyond medical professionals� control, including the availability of foreign and local volunteers, attacks on convoys of supplies, unpredictable surges in patient numbers, and threatened or actual interruptions to water or electricity services.

Many Canadian doctors and nurses report feeling they were poorly prepared for the ethical challenges they faced during their humanitarian health missions (Elit et al 2012; Hunt 2012; Schwartz et al 2010; Sinding et al 2010). Lack of ethical training for high-stress humanitarian work can result in a failure to identify and respond in a professional and adequate manner to ethical problems in field clinics and hospitals, and can cause significant moral distress to doctors and nurses alike (Hunt 2011; Schwartz et al. 2010).

Q1: Are your professional and ethical responsibilities different as a physician volunteering in a foreign conflict zone and/or as a representative of an international humanitarian organization?

In short no. International volunteers working with most major humanitarian healthcare organizations are required to provide medical care in accordance with international principles and standards, laid out in such documents as the World Medical Association (WMA) Code of Medical Ethics. This rule is often a requirement of host governments and institutions as well. Moreover, practicing surgeons and physicians are bound by the professional obligations and duties of their home regulating bodies and may be bound by additional codes of the organizations with which they are volunteering.

Core duties of physicians in any context include respecting �a competent patient's right to accept or refuse treatment� and �acting in the patient's best interest when providing medical care� (WMA Code of Medical Ethics). These often go together, as the patient may consent or refuse a treatment based on their understanding of their best interests. Even in humanitarian/emergency contexts, where patients cannot provide consent as a result of being unconscious or lacking competence, proxy consent should be sought from an individual close to the patient (i.e., a spouse, parent). Under exceptional circumstances, healthcare teams may provide care without a patient�s consent. If a patient�s life is in the balance, there may be no time to seek their consent. In a war zone or otherwise highly tense environment, if a patient comes in unaccompanied, it may not be feasible to locate and/or involve an appropriate proxy, such as a family member, in the decision-making process. In such scenarios, the physician�s duty is to provide the care they determine is in the patient�s best interest.

Physicians working in contexts that are culturally, politically, economically, and institutionally unfamiliar to them should anticipate encountering and needing to learn how, when, and on the bases of what logics clinical practices may be different in the context that is hosting them as compared to their home context. Travelling from Canada to a LMIC, a physician might encounter differences in, for example,

  1. available therapies;
  2. medical equipment;
  3. patient expectations and preferences for care;
  4. HCP-patient norms of interaction;
  5. and/or, factors to consider in evaluating a patient�s best interests.

The latter is of particular importance in this case. The local surgeon intends to carry out a tubal ligation on their patient without her consent, on the basis that doing so is in the patient�s best interest. Whether or not this tubal ligation is in the patient�s best interest would be difficult for any physician to determine in a context that is clinically, culturally, or even geographically unfamiliar to them. Linguistic barriers, where these exist, may compound these difficulties, limiting the amount of information an expatriate physician can gather about local medical options and their implications for patients, and/or their family or community.

Physicians should be careful not to presume differences they observe in clinical communication, decision-making, or practice are based on cultural differences, social inequalities, or some lack of training or knowledge. While medical education and culture, including specific values, religious beliefs, social relations, and institutional norms, shape healthcare in important ways, it is important for the physician working in a foreign context to recognize that their local colleagues are experts in the local social and healthcare context. It is important for the foreign volunteer not to diminish the importance of this local knowledge, and along with it the authority and expertise of local HCPs. With a humanitarian role comes the expectation that one will respect and support, rather than erode or undermine, the authority and expertise of local medical professionals (ICRC 1994). The humanitarian healthcare worker should aim to preserve strong working relations with the local staff to best serve a population in need, and so that the humanitarian organization can continue to do so. At the same time, physicians are expected to act based on their conscience. They have a right to refuse to participate in a medical practice if they feel this is not in the patient�s best interests, so long as doing so does not put the patient at risk.

As a representative of an international humanitarian organization, upholding ethical standards of practice remains as important as ever, if not more so. How expatriate humanitarian healthcare actors are perceived by the local population can impact the safety, effectiveness, and possibility of future interventions (Abu-Sada 2012: 4). The actions of one humanitarian healthcare team member can reflect on the reputation of all in that organization operating in that country and elsewhere. Thus your actions and those of your team can reflect on the reputation of all in that organization operating in that country and beyond. The mistrust of your organization could lead to mistrust of all healthcare volunteers or organizations in the region.

Q2: Weigh the arguments for and against assisting the surgeon in this tubal ligation

IN FAVOR OF ASSISTING
There are a number of reasons the newly registered Canadian physician might feel obligated to assist the surgeon with the tubal ligation. First, there is the obligation to the patient�s safety. There is no one other than the Canadian, the local surgeon, the anesthesiologist and the anesthesized patient in the room. Given the understaffed clinic context, it is unlikely, should the Canadian volunteer refuse to participate in the tubal ligation, that another physician will be available to assist the surgeon.Secondly, the surgeon is a local who, unlike the newly registered Canadian, has been working in this region for a significant period of time. These credentials make the surgeon�s assertion that the tubal ligation is in this patient�s best interest more compelling. The surgeon may judge the harm of conducting a life-altering surgery on this woman without her consent as justifiable given the context-specific factors that could put her at risk should she become pregnant. These could include high rates of maternal mortality or pregnancy complications in the face of very limited or difficult to access emergency obstetric care, discrimination, abuse, social abandonment, and high maternal mortality rates. The surgeon�s suggestion that having children will increase the woman�s suffering may be a reference to potential social, rather than medical consequences, for this woman should she get pregnant from rape. Perhaps the surgeon is referring to the stressful responsibility of a woman who is already struggling to survive caring for a child or children, or the risk of the mother�s suffering should harm come to her children in a context of violence. The mother and children might suffer increased discrimination, abuse or even social abandonment if the social-cultural context is one that condemns the sexual activity of unmarried women. There may be limited or no social or family supports available to this woman should she get pregnant. In some cultural contexts, it may be normal and expected for physicians to paternalistically make decisions for patients, whether patients are mentally incompetent or not.

The Declaration of Geneva states that, �My colleagues will be my sisters and brothers,� and �I will give my teachers the respect and gratitude that is their due.� Refusing to assist the surgeon could be interpreted as a lack of respect for the surgeon and/or local expertise. This could also jeopardize the Canadian volunteer�s relationship with the only surgeon at this site, lead to divisions between local and expatriate staff at the clinic, and/or compromise the humanitarian healthcare organization�s relationship with the surgeon and their clinic.

If the physician opts out of participating in the tubal ligation and the surgeon continues, the surgeon will be forced to complete the surgery alone which may result in immediate risks to the patient�s life and health. Complications including damage to major organs or life threatening bleeding may arise which cannot be optimally managed without the aid of an assistant. Furthermore the quality of the surgery may be compromised if the surgeon is left without an assistant and this may lead to short and long-term post-operative complications.

AGAINST ASSISTING
Consent as a fundamental right

The patient�s immediate health safety is not at risk without the tubal ligation. The patient�s records do not show any record of a mental health assessment demonstrating her incompetence to consent/refuse this particular medical procedure. Even if this patient were documented as mentally challenged or incompetent, this would not justify her exclusion from deciding whether to have this life-altering decision. According to the Lisbon Declaration on the Rights of the Patient, physicians retain an obligation to involve patients who are not competent to the greatest extent possible in decision-making related to their medical treatment, and/or to involve an appropriate substitute decision-maker in those decisions patients cannot make for themselves.

While it is not entirely clear from the case description, the surgeon may harbor what, based on international codes of conduct, could be deemed a discriminatory attitude towards individuals with disabilities. The surgeon does appear to assume patients with mental disabilities are not able, and therefore need not be, informed or involved in medical decision-making. The Declaration of Geneva warns physicians not to �permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.� Even if mentally incompetent, this woman should be engaged in and partake, to the best of her ability, in decision-making regarding her medical care.

In Canada, the surgeon�s completion of the tubal ligation without the patient�s consent would most likely be considered battery, as per the Supreme Court�s 1986 ruling in the case of Eve v. Mrs E. (where the court rejected the mother�s request for the sterilization of her mentally incompetent daughter on the premise that she, not her daughter, would have to care for a child).

Non-maleficence
Good intentions do not preclude harm. It may be that however well intentioned, this tubal ligation might do this woman more harm than good. There may or may not be clear evidence of high rates of pregnancy complications or maternal mortality rates in this context. Even with such information, however, most would argue this is not sufficient ethical defense for involuntary sterilization. An actual harm cannot be justified through reference to a potential but unprovable health benefit. Likewise, the harm of involuntary sterilization would not be ethically defensible on the basis that the woman might suffer socially if she bears children from rape.

If it becomes known that the patient has had an involuntary sterilization and is thus infertile there may be farther reaching culturally-specific negative consequences for the patient. These may include not being considered as a potential spouse, or shunning from a spouse or spouse�s family for being unable to bear children. These implications may then lead to other physical and emotional abuse. In a post-genocide context in particular, the sterilization of any member of the community might be lived as a harm at the community level.

Advocacy
The International Code of Medical Ethics defines advocacy as a duty physician has to act as the patient�s advocate, which means doing everything in their power to ensure the patient�s interests are protected.

Trust
The patient-physician relationship depends on trust. Participating in this proposed tubal ligation puts this trust and relationship at risk. The tubal ligation may also lead to distrust of this healthcare facility, of other public clinics, of the humanitarian healthcare organization the Canadian represents, and/or of all expatriate volunteers. One patient�s distrust can spread to a population: the Canadian physician should err on the side of caution and assume this breach of international guidelines for involving patients in medical decision-making is more likely to harm than benefit patient-physician relationship and this humanitarian organization�s relations in the region.

The war-zone context
Fertility can be assumed to be a sensitive issue in the region given the recent genocide; the repercussions for the clinic and for the humanitarian healthcare organization if it becomes known that this woman was sterilized without her consent are unknown.

Q3: What do you think is the best way to manage this situation?

The proposed sterilization of this woman without her consent raises many fundamental and complex ethical issues. Performing a medically unnecessary and life-altering surgery on a patient without their consent goes against the basic principle of consent to medical treatment. This denies the patient her right to autonomy and dignity, and may have negative consequences on the patient�s life and beyond: for example impacting trust of the clinic or impacting a humanitarian organization�s reputation. The surgeon committed to the tubal ligation in this case appears sincere in his intention to act in his/her patient�s best interest. Perhaps this tubal ligation actually is in this patient�s best interest, but more information is needed to ascertain whether this is the case.

Where a physician volunteering in a foreign setting finds their assessment of a patient�s best interest at odds with that of a colleague�s, the first and best course of action is to express their concern clearly to that colleague. This of course needs to be done with utmost tact. Rather than question the colleague�s practice, the expatriate physician could ask questions that would allow them to understand the surgeon�s rationale in more depth. It is unclear, for example, why the woman would suffer should she get pregnant and/or have children. The surgeon might be asked if there are any alternatives to involuntary tubal ligation for the patient. Perhaps there is a safe alternative available, that would satisfy both the surgeon�s concerns about the patient�s unwanted pregnancies and your own interests in ensuring the patient�s rights to consent/refuse are upheld. It may be that with greater understanding of the circumstances, the expatriate physician might come to agree with the surgeon that it is better for the woman to be sterilized than not. The expatriate physician has a responsibility, if they are not convinced the tubal ligation is in the woman�s best interest, to explain to the surgeon why they are uncomfortable or even unable to support the surgeon in their decision. The surgeon may be responsive and complete the surgery without the tubal ligation. This would be best achieved if the topic can be discussed in a professional and respectful manner.

If the expatriate volunteer physician remains unconvinced that the tubal ligation is in the patient�s best interest after obtaining more details, and the surgeon insists on proceeding, the situation becomes more difficult. While the Canadian physician might excuse themselves from the surgery as a point of principle, this may be impossible if it jeopardizes the patient�s safety.

Given that truth-telling is a core principle in medical ethics, the patient should be informed of the procedures completed. The physician in this case might work with a local nurse once the patient is awake and emotionally stable to gently disclose the procedures and the implications of each to the patient and apologize. There are rare circumstances in which the disclosure of medical information is deemed to be much more harmful than beneficial to a patient, thus ethically allowing the withholding of medical information by a physician. This is called �therapeutic privilege�. Given that this is a post-genocide context, and that the patient�s preferences and values were never recorded, news of a non-consensual sterilization may be quite psychological shattering to her. If news of the sterilization could lead to serious psychological or emotional harm, i.e. lead to a suicide attempt, the physician may decide it is in the patient�s best interest to withhold information of the tubal ligation from her at this time.

It may be that the surgeon�s good intentions are based in a discriminatory or otherwise problematic attitude towards certain populations. If this clearly emerges as being the case through further discussion, and the surgeon insists on and completes the sterilization, the expatriate physician has an obligation, as a representative of an international organization, to take action to reduce the harm to future patients. This should be done with utmost tact. The WMA Medical Ethics Manual states that �reporting colleagues to the disciplinary authority should normally be a last resort after other alternatives have been tried and found wanting� (p. 87). The first normal course of action in such a situation is to discuss matters directly and in private with the colleague. Should this fail to yield a satisfactory outcome, the HR department of the humanitarian healthcare organization for which the Canadian physician works can be a helpful resource. There may be organizational guidelines for such cases. Consulting with HR is also an opportunity to discuss if misconduct has occurred and how best to fulfill ones professional and legal obligation to report a colleague. The physician should document in the patient�s chart the extent of their involvement in patient care and a factual account of events.

Conclusion

This case is especially problematic because all the physicians involved truly believe they are doing what is best for the patient. The differences based on context, values and perceptions of patient interests create an environment where cultural differences figure prominently. Ordinarily, respect for difference and celebration of distinct cultures working harmoniously are the preferred responses, but in some circumstances yielding to cultural difference may feel out of place, and beyond the comfort zone of a visitor. It is essential in these contexts to open an atmosphere of honesty and non-prejudicial discourse. Using questions, discussion and reflective practices will go a long way toward preserving the integrity and dignity of all those involved, while simultaneously ensuring the best outcomes for the patient.

Ethical issues addressed in this case

This case aims to aid physicians working in humanitarian emergency contexts and/or remote and culturally unfamiliar communities to anticipate and better prepare for unique ethical dilemmas and personal moral distress that may arise in these environments. The case reviews the following ethical issues:

  1. Professional and ethical responsibilities to patients in humanitarian emergencies.
  2. Challenges of determining a patient�s best interest in an international setting where access to healthcare is limited and without clear understanding of cultural norms and societal implications of certain conditions/treatment.

References

  1. Abu-Sada C (2012) In the Eyes of Others. Center on International Cooperation, Humanitarian Outcomes, Doctors without Borders, New York.
  2. Elit L, Schwartz L, Sinding C, Hunt, M, Redwood-Campbell L, Adelson N, Ranford J (2011) Ethical issues encountered by medical students during international health electives (IHE). Med Education 45(7):704-711.
  3. Hunt M, Schwartz L, Elit L (2012) Experience of ethics support and training for health professionals in international aid work. Public Health Ethics 5(1):91-99.
  4. Hunt M (2011) Establishing moral bearings: Ethics and expatriate health care professionals in humanitarian work. Disasters 35(3):606-22.
  5. ICRC (1994) Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief. Geneva.
  6. Schwartz L, Sinding C, Hunt M, Elit L, Redwood-Campbell L, Adelson N, Ranford J, De Laat S. (2010) Ethics in humanitarian aid work: Learning from the narratives of humanitarian health workers. Am Jl of Bioethics: Primary Research 1(3):45-54.
  7. Sinding C, Schwartz L, Hunt M, Elit L, Redwood-Campbell L, Ranford J (2010) �Playing God because you have to�: Canadian health professionals� narratives of rationing care in humanitarian and development work. Public Health Ethics 3(2): 89-90. Singh J (2012) Humanitarian Medicine and Ethics. In: Abu-Sada C (ed) In the Eyes of Others. Center on International Cooperation, Humanitarian Outcomes, Doctors without Borders, New York, p 164-172.
  8. Singh J (2012) Humanitarian Medicine and Ethics. Dans : Abu-Sada C (ed) In the Eyes of Others. Center on International Cooperation, Humanitarian Outcomes, Doctors without Borders, New York, p 164-172

Resources:

  1. WMA Medical Ethics Manual https://www.wma.net/wp-content/uploads/2016/11/Ethics_manual_3rd_Nov2015_en.pdf (accessed May 9 2014)
  2. WMA International Code of Ethics https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ (accessed May 9 2014)
  3. WMA Declaration on the Rights of the Patient https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ (accessed May 9 2014)
  4. https://www.cma.ca/Assets/assets-library/document/en/PD04-06-e.pdf#search=code%20of%20ethics
  5. WMA Declaration of Geneva https://www.wma.net/policies-post/wma-declaration-of-geneva/ (accessed May 9 2014)

Acknowledgements

This case study draws on Canadian health care professionals� first-hand accounts of ethical dilemmas in humanitarian healthcare recorded within the framework of the CIHR funded study �Ethics in conditions of disaster and deprivation: learning from health workers' narratives (grant no. EOG 84636)�. The authors would like to express their thanks to respondents of this study, as well as to members of the McMaster/McGill Humanitarian Healthcare Ethics Research team (in alphabetical order) for their helpful input: Sonya DeLaat, Laurie Elit, Leigh-Anne Gillespie, Matthew Hunt, Lynda Redwood-Campbell