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. Please leave us your feedback in the comments section below, and send us ethical dilemmas you would like to see discussed.
Compiled by Dr. Majid Sadigh, Trefz Family Endowed Chair in Global Health at WCHN and Director of Global Health at UVMLCOM, and edited by Mitra Sadigh, Editor of Global Health Diaries.
Imagine a junior medical student from the Global North at a National Referral and Teaching Hospital in the Global South, her first time out of her home country. Most of the patients she encounters are very young and desperately sick with limited chances of survival. Staff in the wards are sparse and visibly overworked and overwhelmed. One patient begins to convulse, and the relatives start calling “Musawo, musawo! Our patient is dying.” The only nurse on duty is attending to another very sick patient who needs a blood transfusion.
The visiting student wishes she could help but has neither knowledge nor experience in dealing with a convulsing patient. The patient dies just as the nurse reaches him. The student is depressed and overcome with feelings of guilt that all she could do was stand there and watch.
What ethical dilemmas does this case bring to your mind?
Dr. Winter: This case conjures the ethical dilemma of feeling pressure as a student to act outside of one’s scope of knowledge or experience, and avoiding actions that may cause harm (nonmaleficence).
Dr. Kalyesubula: This is a case of global health resource scarcity and vulnerability. The collaborators from the Global South have limited staff and may also lack established protocols with which to manage emergencies. Avoidable deaths in young patients do not sit well with anyone, but do occur and should be an inherent part of the global health learning process.
Limitations such as being present but unable to help and consequent feelings of helplessness should be expected in all global health programs. The extent to which these feelings arise will vary, but this scenario will occur on all sides. For instance, an experienced faculty physician from the Global South in a clinical observership in the United States standing with a junior resident at the bedside of a critically sick patient has to withhold his opinion for a life saving intervention because of the legal consequences of not holding an American medical license.
Was guilt an appropriate response on the part of the student?
Dr. Winter: Certainly not! Unfortunately, guilt is likely the most common response for students and even very experienced faculty like myself. This feeling is usually coupled with a sense of helplessness complicated by our uncertainties of the most appropriate boundaries to respect when operating in another culture.
Dr. Kalyesubula: Yes, it is part of the process of recovery. The main issue of concern is how the situation is handled afterwards. The student needs to be supported through this ordeal in order to draw lasting lessons that can enable growth. The student may also contribute by striving to ensure that resources reach those in need in the future.
What would you suggest should be done to prepare visiting students for such incidents, which they may encounter from time to time?
Dr. Winter: The experience described is relatively common. Preparation should include discussion groups and scenario simulations to inform students of how they may handle this type of situation, their potential emotional response, and held expectations for behavioral and emotional responses. Pre-travel orientation and preparation are essential for beginning the process of dealing with these very difficult situations.
It would be meaningful to have sessions discussing ethical dilemmas together with local faculty and trainees during the in-country experience. While in Zimbabwe, I lead a session with senior faculty and Zimbabwean trainees comparing end-of-life decision-making and family interactions in the care of very ill patients in the Intensive Care Unit- including how we were personally affected and influenced by the cultures in which we worked. Hearing the heartfelt responses of the Zimbabwean house officers was one of the most powerful and meaningful teaching experiences of my career.
These ethical dilemmas are not unique to members of the Global North going to the Global South. These dilemmas are universal. As doctors, we share the uncertainties and emotional pain caused by seeing our patients suffer and die. There are many complex ethical problems that we all experience in our work. These questions do not only concern our students. We all benefit from this kind of intercultural exploration.
Dr. Kalyesubula: The collection of vignettes should be prepared and shared with students, and constantly grow with contributions from visiting students. Because partners from the Global South are often left out on this issue, efforts should be made to include the dilemmas they face, some of which are often bordered on technology and access. Additionally, global health program alumni should be encouraged to mentor and help prepare the new teams.
If you were her supervisor/attending/advisor what would you say to her at the end of the day?
Dr. Winter: I would say little and listen a lot to allow the student to ventilate feelings and find her intellectual and emotional response to the event- with my guidance if necessary. The way in which the student frames her thinking will give insight as to whether she is at risk for an adverse psychological response during the rotation and may require more intensive counseling or even removal from the environment.
Dr. Kalyesubula: I think I would let the student know that what she is feeling is a normal reaction, and that the experience can lead to the resolve that such scenarios and injustices be minimized- through the effort of the student and others- in the future.