ACTIVITY DISCLAIMER. Common Ethical Issues in Global Health DISCLOSURE. Learning Objectives. Audience Engagement System Step 1 Step 2 Step 3

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1 Common Ethical Issues in Global Health Calvin Wilson, MD ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE Calvin Wilson, MD It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Associate Professor (Emeritus), Department of Family Medicine, University of Colorado School of Medicine, Aurora; Associate Professor (Emeritus), Colorado School of Public Health, Aurora; Associate Professor of Family Medicine, National University of Rwanda. Dr. Wilson has been involved in the development of family medicine and education in a variety of settings for more than 25 years, and in international community and medical development projects for more than 18 years. He is recently retired as an associate professor of family medicine at the University of Colorado School of Medicine, Aurora, and as an associate professor of public health at the Colorado School of Public Health, Aurora. Dr. Wilson also served as the director of the Center for Global Health at the University of Colorado, which is dedicated to promoting and coordinating a variety of global healthrelated activities. Most recently, he has been working in Rwanda as the director of a partnership between the University of Colorado and the National University of Rwanda to develop their newly reopened residency programs and develop a new family and community medicine residency. He has a range of interests, including the control of tropical illnesses such as malaria, the effectiveness of community health programs and medical training methodologies across cultures, and the sustainability of health development interventions in the developing world. Learning Objectives 1. Identify ethical issues commonly seen in global health activities. Audience Engagement System Step 1 Step 2 Step 3 2. Provide examples of how some cultural characteristics can modify the application of accepted ethical principles. 3. Explain the essential principles of common international ethical issues, and justify an ethical course of action for each. 1

2 Quito, Ecuador You are volunteering in the OPD of a small hospital in Ecuador. A very ill 60 year old woman is seen with an infected gallbladder and accompanying pneumonia. As you prepare her for admission to hospital and surgery, the accompanying large family prepares to pay the $45 copay. She refuses to be admitted and demands to be taken home to die, saying That is the money for the children s uniforms and school I will not take that from them. Reluctantly, the family takes her home. Discussion What are you feeling during this scenario? How might you deal with this situation? Common Western Values Respect for Human Life Dignity and worth of each individual Universal human rights and responsibilities Equal rights to reasonable income, education, health care Importance of personal health and functionality Freedom and Autonomy Ability to pursue personal choices A sense of empowerment and control over self Adapted from: Benatar SR et al. Global health ethics: the rational for mutual caring, International Affairs 2003;79: Common Western Values Social justice and equity Solidarity Benefiting from and contributing to a community Humility Aware of your own faults and failings and therefore reluctant to judge others Honesty and Transparency Adapted from: Benatar SR et al, Global health ethics: the rational for mutual caring, International Affairs 2003;79: Values and Ethics Ethical principles formed by personal, social, and corporate/cultural values Realities of life may generate conflict with accepted values and ethical principles Ethical principles may vary according to social/cultural context Are there universal ethical principles that transcend cultural values? Adapted from: Benatar SR et al, Global health ethics: the rational for mutual caring, International Affairs 2003;79:

3 Accepted Bio-Ethical Principles in the Western World Autonomy personal rule of self Beneficence benefits > cost Non-Maleficence primum non nocere Justice and Equity to each his/her due Equal shares for equal needs Confidentiality What is NOT to be divulged abroad Truth-Telling Full disclosure Context of Global Health Care (short-term) Common elements of context: Pervasive poverty Focus on differences in cultures and resources Communal society (community > individual) Inadequate communication Training and skill disparities between local health workers and visitors Scenario #1 Dr. Bill is a young FP with a small group of internists, pediatricians and nurses providing ambulatory care to a small village in rural Haiti over one week. One of the morning patients is a 46 year old woman with a 2 day old angulated mid-forearm fracture, with some decrease in the radial pulse and distal finger sensation. Dr. Bill has had very little orthopedic experience in his training, but is very concerned that a rapid reduction of the fracture is needed. The nearest adequate facility that could care for this is a day s walk away. The patient insists that she cannot pay the fee and begs Dr. Bill to fix this. Poll Question Scenario #1 Should Dr. Bill attempt a reduction? 1. Yes he should attempt the reduction because she may develop gangrene and/or neurologic injury if he does not, and he is the best qualified in the immediate area. 2. No he should NOT attempt the reduction, but send her to a local traditional bone setter. 3. No he should NOT attempt the reduction, but should give her the money needed and provide transportation to a medical facility that can appropriately deal with this. Poll Question Scenario #1 Which of the following principles best addresses the ethical dilemma in which Dr. Bill found himself? 1. Autonomy 2. Beneficence 3. Non-Maleficence 4. Justice and Equity 5. Confidentiality 6. Truth-Telling QUESTIONS? 3

4 Common Ethical Issues in Global Health Care 1. Practicing beyond one s scope and training 2. Provision of perceived inappropriate care because of lack of resources 3. Favoritism in provision of health care because of social position or economic status 4. Obtaining truly informed consent for research, procedures, and illness management strategies Common Ethical Issues in Global Health Care 5. Ensuring appropriate patient education 6. Power and decision-making disparities between visiting and local physicians 7. How much information to disclose to seriously ill patients 8. Confidentiality in a communal society Common Ethical Issues in Global Health Care 9. Negative perception of local health workers because of visiting Western physicians 10. Health services and/or medications provided by or paid for by visiting health team Poll Question Choose one global ethical issue you would like to discuss 1. Practicing beyond one s scope and training 2. Provision of perceived inappropriate care 3. Favoritism in provision of health care 4. Obtaining truly informed consent 5. Ensuring appropriate patient education 6. Power and decision-making disparities 7. How much information to disclose to ill patients 8. Confidentiality in a communal society 9. Negative perception of local health workers 10. Payment for health services and/or medications Ethics and Culture Scenario #2 Dr. Wilson was attending on the family medicine service of a program in Quito, Ecuador with a senior FP resident. One of the patients was a 52 year old male with metastatic pancreatic cancer, now unresponsive to chemotherapy or radiation, who was responsive but in significant pain. In discussing the end-of-life counseling that the resident had provided, the resident indicated that the family had strongly insisted that the patient not be told of his terminal status. All medical personnel and visitors were instructed to act as if he was slowly improving. He also indicated that this was the case in most of his terminal patients. Poll Question - Scenario #2 Question: Which of the following principles most influences your thinking in this case? 1. Autonomy 2. Beneficence 3. Non-Maleficence 4. Justice and Equity 5. Confidentiality 6. Truth-Telling 4

5 Discussion - Scenario #2 Questions: What cultural issues may be influencing this scenario? How might Dr. Wilson deal with this in a culturally-sensitive manner? Ethics and Culture Scenario #3 You are seeing ambulatory patients with two young Rwandan doctors in a small district hospital, and a large group crowds into the exam room with an adolescent girl in their midst. They are concerned because after starting oral contraceptives 2 months ago (without consulting anyone else) she is now bleeding constantly, dizzy, and pale. Only a few of the surrounding group appear to be relatives; the remainder are neighbors or friends. There is a barrage of questions with concerns over her unmarried status and about her prognosis. Poll Question - Scenario #3 Question: Which of the following principles most influences your thinking in this case? 1. Autonomy 2. Beneficence 3. Non-Maleficence 4. Justice and Equity 5. Confidentiality 6. Truth-Telling Discussion - Scenario #3 Questions: What cultural issues may be influencing this scenario? How might this be dealt with in a culturally-sensitive manner? Summary Ethical issues are extremely common in global health activities, and must be considered Many ethical issues arise out of conflicts between our culturally-mediated values and those of another culture Accepted ethical principles can provide a framework for consideration of perceived ethical conflicts. Specific cultural values may require some modification in the application of accepted medical ethical principles Recommended Practice Changes Improved attention to ethical issues within the context of a patient s cultural background and identity in your daily practice Provide global health care only in the context of an enduring partnership with the national or local health care system Consistent contextualized application of ethical principles to global medical practice, international research, and medical care in the context of scarcity 5

6 Thank You! QUESTIONS? Calvin L. Wilson MD 6