This post is part of a series of discussions about ethical dilemmas in global health, with responses from one global health leader in the Global South and one in the Global North. The post was originally featured as part of the Global Health Diaries, from the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network.
Dr. Stephen Winter, Director of Global Health at Norwalk Hospital, and Dr. Robert Kalyesubula, cofounder of the African Community Center for Social Sustainability, in Nakaseke, Uganda
A wide range of ethical dilemmas is integral to global health experiences. Please comment on the following two case scenarios:
A young patient with tetanus suffers from painful generalized muscle contractions every five minutes. The medication that would ease these symptoms is neither accessible nor affordable. A global health participant may be inclined to prescribe this medication for this patient even with a fatal prognosis, thereby hindering access to this medication for another patient who may need it for a nonfatal condition. How should this ethical matter be best discussed with a medical student or resident?
Dr. Winter: This is a good example of a dilemma that we do not yet frequently confront in the Global North: the means of allocating scarce resources in a way that meets the ethical principle of justice. Resource triage lies outside of the traditional doctor/patient relationship and is a societal construct that must be adjudicated by local law, cultural practice or organizational policy. It is not an appropriate decision for a visiting medical student, resident or faculty member. What would you think if a Ugandan Global Health Scholar visiting Norwalk Hospital argued against, or even tried to prevent, the transfer of a ninety-year-old patient with metastatic cancer to the Intensive Care Unit in accordance with the patient’s clearly expressed wishes, as an inexcusable waste of resources that could be better used in East Africa?
Dr. Kalyesubula: The drug is not available in the first place and needs to be purchased by the patient’s family. Therefore, I think the global health participant needs to assess the family’s needs and capacity depending on the context. After losing a loved one, most African families would find solace knowing they did all they could to save them.
If this drug were purchased by the hospital, the discussion should be centered on resource allocation. Shortly after returning from the United States, I proposed purchasing a dialysis machine to save critically ill patients in urgent need of dialysis. The permanent secretary to the Ministry of Health asked me how many malaria cases could be treated with that money. I stared at him straight in the face and left… But of course I understood him well. Thanks to the Kidney Foundation I founded shortly afterwards, we now have eighty dialysis units in the country, fifteen of which were purchased by the Ugandan government.
Palliative care should always be an option in medical care, but there are exceptions that should be approached with care and contextual and cultural understanding. Global participants should understand that whenever a pen is put to paper someone has to pay and it is, more often than not, an out-of-pocket expense. This simple fact can help guide the practices of global health participants.
A young patient with a treatable disease can be cured by being admitted to the Intensive Care Unit, but doing so would render the family bankrupt, thereby causing significant harm. How should this ethical matter be best discussed with a medical student or resident?
Dr. Winter: My approach to this problem is similar to that of the last question, with an emphasis on family dynamics and cultural norms. Who should get to decide these things in any society? Certainly the answer is never the visiting medical student.
Dr. Kalyesubula: The key here is to involve the family in the discussion and help them make an informed decision. These issues are deeply rooted in culture, and not necessarily the individual. Though the tendency here would be to persuade the family not to pursue treatment, the decision needs to be discussed with care because the family may consider this option as abandonment by the medical fraternity and failure of the medical system to provide care when it was most needed.