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.
A wide range of ethical dilemmas is integral to global health experiences. Please comment on the following scenario:
In a hospital in the Global South, a twenty-three-year-old woman was admitted to the cardiac intensive care unit (ICU) with severe mitral stenosis leading to pulmonary edema during her second pregnancy. This was the second time she was admitted to the cardiac ICU due to acute pulmonary congestion in the setting of severe mitral stenosis from untreated rheumatic fever in her childhood. Because her symptoms were exacerbated with each pregnancy, she had been asked to avoid future pregnancies given the risk to her life. However, her husband wanted more boys so they could help with the work on the farm. The family could not afford a mitral valve replacement for her. The medical students asked why she was unable to avoid endangering her life by receiving a tubal litigation.
Dr. Winter: This vignette raises several ethical issues. It is particularly interesting in that it is a situation that could arise in the United States where access to care and inequities in healthcare delivery could lead to a similar ethical dilemma, with many of the same issues applied.
The first applicable principal is autonomy. The patient and her husband have the right to make decisions related to her future health that may be against the recommendations of the treating physicians. We may discuss alternative approaches to treatment and make recommendations for care, but the final decision rests with the patient. A tubal ligation provided without the consent of the patient would be a profound violation of her autonomy.
An understanding of cultural context is also important. A woman who cannot conceive may be considered “damaged” in many societies, and lose her role as a wife, mother, and community member. In addition, a family without sons in a rural agricultural setting may lack the resources to generate a sustainable income to support an extended family, which may include elderly parents and relatives, who cannot contribute to the economic support of the household. Forcing an intervention such as tubal ligation in this setting may violate the principle of nonmaleficence by disrupting the social and economic integrity of the family.
The ethical obligation to provide the best possible care continues even when a patient does not follow our primary treatment recommendation. Once the team has determined that the husband and wife are committed to future pregnancies without a mitral valve replacement, and that a lower cost approach such as mitral valve repair is not feasible, the family and local health providers in their village should be counseled on how to recognize early signs of cardiac insufficiency in the event of another pregnancy so that monitoring, observation, and treatment can be instituted early in hopes of attenuating her heart failure and optimizing her potential for a safe outcome.
Dr. Kalyesubula: This scenario involves several ethical dilemmas that underlie the practice of medicine in resource-limited settings. First is the issue of poverty and resource limitations, and the ways in which this influences the choices of patient and doctor alike. The second is the gender balance and power dynamics within many impoverished families. The third is the doctor-patient power balance and its influence on healthcare delivery. The fourth is the girl child and society norms and beliefs. All these factors influence autonomy.
It is actually a good start that this particular setting had a cardiac intensive care unit and that the patient could actually access it. Most centers in resource-limited settings do not have access to such care and would struggle to make such a diagnosis of heart failure in pregnancy. The previous episode could have aided in early diagnosis in this particular case. As opposed to patients and doctors in high-resource countries, those in low-income countries have to make decisions about the choice of care provided based largely on the social status of the patient- especially for conditions that are out of the realm of “free” healthcare. Whereas Global North clinicians look for the best evidenced care, most of us have to settle for the most cost-effective.
Financial status has a lot to do with the care given or received. Because this family could not afford a vulvular replacement surgery, the patient ended up needing intensive care for the second pregnancy, which would not have been the case had a vulvular replacement been done after the first. With these facts in mind, the medical student feels she or he can help implement a permanent solution by ensuring that this woman gets a tubal ligation and never has to deal with the risk of getting pregnant again, and therefore never endanger her life in the process. It is fair to say that this would be a good approach in the medical student’s view, but it would impinge on the principle of autonomy which is essential to medical care. The underlying social circumstances beyond this simple solution is the husband’s influence on the patient’s choice as well as the family’s future plans in terms of looking at children as major sources of financial support.
What was not mentioned in this scenario is the fact that families still look at the boy child as the heir who will carry the family lineage forward. This notion is shared by both men and women from this part of the world. I have met women struggling to have a tenth child because all the first nine children are girls, and take the risk of pregnancy knowing that the tenth child could also be a girl. It is important to appreciate this concept and be culturally sensitive in global health. It is also important to appreciate that men wield more power in most relationships despite the fact that it is the woman who carries the child for nine months. In Uganda for example, all children belong to the man and his clan. This means that the decision maker, who is often the man, needs to be on board with most family choices. Unfortunately, most men are never present for the bird of their children, and often do not accompany their wives for antenatal visits. They do not hold the hand of the wife to witness the most beautiful gift of children taking their first breath.
This dichotomy is due to cultural issues, also to lack of space for such “luxuries.” Because one room is often shared by four women in labor, men are not welcome and have to wait outside to receive the baby, if they show up at all. For the medical student, this would be a good time to reinforce the ethics around patient autonomy. She or he should be able to give all the information to the family while respecting the decisions made by the patient and her family members. The student should focus not only on the woman in labor but also include the man in the conversation, and not shy away from sharing alternative sources of income for the family while emphasizing the fact that girl children have the same value as the boys. If the student is supported to pass on this information to the family, it may encourage the family to undertake a more informed tubal ligation, thereby shifting the balance onto the mother’s well-being. In any case, if the mother dies in labor, the highly sought-after boy child has low odds of survival in most resource-constrained countries.
That being said, the decision made by the family should be final and respected without judgment. The student should also use this case to learn that the patient has the ultimate say in regards to their health and it is not only up to the doctor(s) to determine what is good for them.