Ethical Dilemmas in Global Health: Financial Barriers and Interventions

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Dr. Stephen Winter and Dr. Robert Kalyesubula

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:

A 30-year-old woman was admitted for small bowel obstruction of unclear etiology. Her hospital course was complicated by sepsis, requiring admission to the Intensive Care Unit. During the course of her hospitalization, it became apparent that a laparotomy was required to relieve her small bowel obstruction. However, her family was unable to pay for the surgery, thereby deciding to forfeit her life. My medical students and I considered paying $100 USD each to pay for her laparotomy, but the doctors deterred us from doing so, explaining that this was a daily occurrence and fact of life.

Dr. Winter: This represents a situation that is not uncommon when visitors from the Global North come face-to-face with the reality of true resource limitation. I think we often struggle with a response that speaks to our own emotional reaction when witnessing a death that could be prevented. What does it mean for physicians from the Global North doctors to pitch in enough money to save this patient? Perhaps it signals to the patient and others who know her that their doctors and system of care must be inferior to that of the Western doctors who have intervened with curative (albeit financial) treatment.

What does that mean for the next patient who needs an intervention, and the hundreds after that? How does one justify not also helping the next one? How do local physicians caring for this patient deal with their own feelings of distress from being unable to provide care to their patient, and having to watch them die for lack of resources? How do they feel when you directly point out the inadequacies of their system with a handful of cash?

I think it is an expression of cultural insensitivity that attacks the dignity and emotional resources of the treating local physicians that may even lead them to feel that the systemic inadequacies are somehow their own inadequacies. Just because the physicians are able to stoically deal with their own realities of patient suffering and death due to resource limitations does not mean that they are unaffected or unbattered by the emotional distress and grief inevitable with these situations. Helping provide compassionate emotional support and symptom palliation to the patient, along with support for her family and even her physicians, is the more relevant intervention. If the visitors have financial resources that they wish to share, they should explore ways to extend it through the institution. Or perhaps they can contribute to a fund that supports care for patients without resources (most hospitals have funds for this) or find another way to improve overall patient care. We should not be palliating our own emotional discomfort by amplifying the distress of others.

Dr. Kalyesubula: This is really a tough scenario which brings tears to my eyes. I would start by saying that every life counts in its own right. I would like to be nonjudgmental and maintain clear headedness, but I feel like this is really a very sad situation and therefore a tough decision. I would like to avoid echoing what I have already said, but allow me to repeat the fact that money really matters in decisions made by both doctors and patients.

Let’s first deal with the family in this scenario. The family gave up and decided to forfeit her life because they could not pay. There, you have it, the barrier of finances! Could this decision have been different if the patient was a man, breadwinner, and head of the family? I think the likely answer is yes, the family would have sold all they have to save the man. The family decision was purely influenced by lack of resources. They had very little choice.

Let us next move to the visiting doctor and medical student. Likely influenced by their previous experiences seeing people survive after even very serious illness, they were willing to do what was in their power to try to save this woman’s life. They could also have been influenced by the fact that this was a very young woman with a whole life ahead of her. Could it be that it was purely out of the goodness of their heart? These are all possibilities. Because they would probably never face this scenario in their home countries, they may feel compelled to do whatever is in their power.

I don’t think they were wrong, however their decision would have far-reaching consequences, particularly on the relationship between the patients and primary doctors. The family could easily perceive that the local doctors are not doing enough and visiting doctors have the “magic.” This perception could promote distrust and lack of appreciation for the local doctors even though the barrier to care is largely systematic. The visiting doctor and students need to be culturally sensitive.

Now we get to the last issue of the  doctors. I can only use my experience from a shared background of limited resources to imagine what might be going on in the doctors’ minds. They had probably seen so many such patients die in the ICU that they had developed the notion that nothing could be done. Death is so common that they feel powerless to do anything about it, and see it as inevitable. “Why waste the little money on such, when more patients could be saved? The patient is going to die anyway and that is a fact of life.” By seeing patients die on a daily basis, their value for life has probably been affected negatively, having accepted the systems inefficiencies and the costs that come with it.

The major dilemma here is how to reconcile these two extreme positions largely informed by previous experiences. “How do you let someone die when you have the power to save them? Life has no price tag!” On the other hand, “Why waste very scarce resources on an inevitable death? So many other lives could be saved instead. Death is normal and should be accepted.” I feel that this conversation should involve the family. What do they think is in the best interest of the patient? Surely they would want to give it a shot and see if their loved one could be saved. I feel the opportunity to save this woman should elicit a debate on how life is valued. If the doctors decides that death is inevitable, it has a lot of bearing on how they will react and the care they will subsequently offer.

Even in resource-limited settings, all efforts should be undertaken to ensure that life is saved. Discussions need to be held about what life really means, and time taken to explore the possibilities of rejuvenating interest and value for life. On the other hand, the visiting doctors need to reevaluate and look beyond the impact of the single patient. What happens when the next patient comes with similar complaints? Perhaps the best way is to solve this issue by engaging the leadership so that such funds are channeled through a central pool from which they can be disbursed to address problems from the higher end of the system. The visiting doctors and students should have a mechanism of dealing with extreme grief, and this situation should be addressed through the feedback sessions.

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