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)
- 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.
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.
- 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?
- Weigh the arguments for and against assisting the surgeon in this tubal ligation.
- What do you think is the best way to manage this situation?
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).
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:
- Professional and ethical responsibilities to patients in humanitarian emergencies.
- 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.
- Abu-Sada C (2012) In the Eyes of Others. Center on International Cooperation, Humanitarian Outcomes, Doctors without Borders, New York.
- 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.
- 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.
- Hunt M (2011) Establishing moral bearings: Ethics and expatriate health care professionals in humanitarian work. Disasters 35(3):606-22.
- ICRC (1994) Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief. Geneva.
- 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.
- 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.
- 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
- WMA Medical Ethics Manual https://www.wma.net/wp-content/uploads/2016/11/Ethics_manual_3rd_Nov2015_en.pdf (accessed May 9 2014)
- WMA International Code of Ethics https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ (accessed May 9 2014)
- 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)
- WMA Declaration of Geneva https://www.wma.net/policies-post/wma-declaration-of-geneva/ (accessed May 9 2014)
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