Download International Emergency Medicine Ethical Dilemmas

International Emergency Medicine
Ethical Dilemmas
Jim Holliman, M.D., F.A.C.E.P., Program
Manager
Afghanistan Health Care Sector Reachback Project
Center for Disaster and Humanitarian Assistance Medicine
(CDHAM)
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences (USUHS)
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.
June 2010
Presenter’s Disclosure
• I have no conflict of interest
memberships or situations related to the
content of this presentation to report
International Emergency Medicine
(EM) Ethical Dilemmas
• Objectives of this session:
– Session participants will be able to recognize
international EM situations with potential ethical
pitfalls at the individual, institutional, and global
levels
– Session participants will have gained some
insight and specific skills to identify and
ameliorate these dilemmas in future practice
– Stimulate discussion and interest in international
EM ethical issues
Classification of International
EM Ethical Issues
• Individual
– Clinical
– Cultural
• Institutional
– Financial
– Academic
• Global
– Political
– Armed Conflict
Examples of International EM
Ethical Dilemmas
• Medical resource limitations :
– Don’t intubate if:
•
•
•
•
•
•
No ventilators
No oxygen
No suction
No “round the clock” staff
No reliable electric power
No transport to higher level of care
You may have to watch someone die
who you know you could have saved
if they were in the U.S.
Examples of International EM
Ethical Dilemmas (cont.)
• More resource limitations :
– If medication stocks are limited :
• ? shorten treatment courses ?
• ? restrict use based on age ?
• ? send to another facility ? (maybe the patient
will not carry through)
• ? substitute a less effective but more plentiful
med ?
Examples of International EM
Ethical Dilemmas (cont.)
• Financial limitations :
– Families may be required to pay for procedures
and / or medications “up front”
– Even the proportionally reduced fees in developing
countries may still add up to bankrupt a poor
family
– Should bribes be tolerated to allow care access ?
– Are different standards of care for “public” versus
“private” (i.e., self-paying) patients acceptable ?
Examples of International EM
Ethical Dilemmas (cont.)
• Case example :
– Central Africa
– 50 year old male
– Abdominal mass, either tumor or amoeboma,
diagnosed by local doctor
– General surgeon capable of performing laparotomy
at district hospital 20 miles away
– Full service hospital with pathology and
chemotherapy services 250 miles away
Examples of International EM
Ethical Dilemmas (cont.)
• Financial and resource limitations :
– Should a patient be sent (and by what means of
transport) to a far away facility for specialized
or higher care ? (will they have any support
there, will the family be able to have any
contact with them, how do they get back, can
they afford re-travel for followup care, and can
they and their local healthcare practitioner
comply with extended followup care such as
chemotherapy ? )
Examples of International EM
Ethical Dilemmas (cont.)
• Cultural situations :
– “Blockage” of care based on :
•
•
•
•
Gender
Religious affiliation
Tribal affiliation
Age
– Lack of compliance based on the
practitioner not being in synch with the “hot
/ cold” folk classification of disease /
treatment
Examples of International EM
Ethical Dilemmas (cont.)
• More cultural situations :
– Is “informed consent” applicable ?
– Do patients not want to be notified of
specific “bad” diagnoses ?
– Does the patient or the local tribal leader
make treatment decisions ?
– Is male dominance of decision making for
female patients acceptable ?
Examples of International EM
Ethical Dilemmas (cont.)
• More cultural situations :
– How is death of a patient dealt with ?
• May need to have ceremony or extended grieving
in the hospital
• Religious or burial practices may conflict with
institutional rules
• Beliefs about autopsy vary among cultures, and
the procedure, if done, may be charged to the
family
Casket and
funeral
ceremony for a
deceased
patient at the
Hospital
Behrhorst,
Chimaltenango,
Guatemala
Examples of International EM
Ethical Dilemmas (cont.)
• Institutional situations :
– Financial
• Relative pay scales of U.S. expatriate versus local faculty
• U.S. endorsement or support of an institution with
restrictive care policies
• Possible competition with local system (see next slide)
– Academic
• Who gets relative credit for projects or papers ?
• Can projects be done without I.R.B. preapproval ?
• Are research projects linked to any clinical care
improvements ?
Examples of International EM
Ethical Dilemmas (cont.)
• Related case example :
– Bosnia mid 1990’s : large donation of blankets puts
the only local industry : a blanket factory, out of
business
• Medical case example :
– Central America
– U.S. church mission sets up a clinic in a village
– U.S. volunteers staff the clinic on a rotating basis
– Supplies and meds donated from U.S.
Examples of International EM
Ethical Dilemmas (cont.)
• Outcomes of the medical case example :
– Local pharmacist goes broke from lack of customers
– The only local doctor in the adjacent village leaves
due to decrease in paying patients
– Patients with chronic illnesses do not have
continuity of care
– The mission clinic closes when its funding is not
renewed, so then the village has no healthcare
service
Examples of International EM
Ethical Dilemmas (cont.)
• The major and perhaps most common
“Institutional” ethical dilemma situation :
– The direct clinical care provided by well meaning
“outside” or foreign personnel actually interferes or
competes with the local or regional healthcare
system
– This is why the U.S. military has officially
downplayed conducting MEDCAPS (Medical Civic
Action Projects) except in certain Special Forces
situations
Examples of International EM
Ethical Dilemmas (cont.)
• Potential problems with international projects
that provide direct clinical care :
– May financially compete with or lower the reputation
of local healthcare practitioners
– May cause false expectations and resentment
– May not provide extended or followup care for
chronic conditions
– If not including training of local workers, may not
have any capacity building or long term positive
effect
Current Major Ethical Quandary for U.S.
Military Medical Mentors in Afghanistan
• Instruction to not directly intervene in
poor or negligent patient care by an
Afghan healthcare worker (but instead
counsel the worker later and not in the
presence of other Afghans)
• This can also be a difficulty in civilian
situations (but then perhaps the
healthcare worker’s primary
responsibility is to the patient ??? )
Examples of International EM
Ethical Dilemmas (cont.)
• “Global” situations :
– Political
• Restrictions of care access by the government
• “Required” bribery payments
– Armed conflict
• Provision of care for combatants
• Notification of authorities
• Healthcare workers potentially putting themselves
at risk to provide care
Reassurance About International
EM Ethical Issues
• In the vast majority of international EM
clinical rotation sites, the ethical issues
situations you will face will be the same
as we deal with in the U.S.
• Probably most common are issues
related to release of medical information,
refusal of care, and determination of
futile care
Ruins of Darulaman Palace in south
Kabul
Hopeful sign from
a refugee camp in
Kabul
QUESTIONS ?
Thanks for Your Attention