This post, written by Dr. Randi R. Diamond, is in response to 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, or your responses to those already posted.
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.
I have been following the excellent entries in Global Health Diaries on Ethical Dilemmas in Global Health. I am currently here in Uganda seeing palliative care patients and wanted to respond to a recent case that others have written about, but from the perspective of a palliative care physician.
In regard to the ethical dilemma in which the visiting student encounters a young patient with a disease that can be cured by being admitted to the Intensive Care Unit, but doing so would render the family bankrupt: For visiting students and health workers, it is often frustrating to accept the resource limitations of the health system in a resource-limited environment, and humbling to come face-to-face with individual/family resource limitations that at times result in the inability to treat what might be a curable illness in a different circumstance or environment. Beyond the issue of allocation of scarce resources, and the importance of assessing the emotional and socioeconomic impact on the family of asking them to buy an expensive medication which may be futile in the face of a fatal condition, it is also of primary importance to address the issue of patient suffering- in every environment.
It is always difficult to watch a patient die, especially a young patient, and even more so if they are suffering as they are dying. However, palliative care may provide benefit to the patient, the family, and the visiting student. Although the expensive medications specifically targeting tetanus may not be available or accessible for this family, there are approaches to help mitigate some of the patient’s severe symptoms and suffering while supporting the family during this devastating experience. Morphine, available and free of charge in Uganda, would likely help manage this young patient’s pain and air hunger as respiration becomes increasingly difficult.
Attempting to alleviate the patient’s suffering in the process of dying is, according to the World Health Organization, a human right. It is our obligation as physicians to do so, and is entirely feasible even in Uganda. Presented to the family in a sensitive, respectful, and educational manner, palliative care is also a way to help the family find solace- perhaps not in doing all they could to save their loved one, but in having done all they could to ease his or her suffering. Demonstrating for the visiting global health student or resident that palliative care is available, effective, appropriate, and championed in the global setting is a valuable lesson and might also, by its nature of including the reflective process, allow the student to process the experience as an essential element of becoming a physician.