Module 8: Ethics

For both visiting and local surgeons, the field of surgery has inherent ethical challenges. “The surgeon must always make the protection and promotion of the patient’s interests the primary consideration in the therapeutic encounter. Any and all elements of the surgeon’s self-interest, however legitimate, must be considered secondary to the welfare of the patient. Most of everything else in the clinical application of surgical ethics derives from this principle.” (1) Though it is clear that the surgeon must place the patient’s best interests above everything else, often this concept must be balanced with the issue of informed consent. The surgeon is responsible for explaining the nature of the patient’s disease to the patient, so that the s/he can make an informed decision about treatment. The surgeon must also respect and listen to any religious or cultural beliefs that the patient may hold, while promoting what is best for the patient. However, sometimes acting in a patient’s best interest and respecting the patient’s decision to undertake (or not undertake) a specific procedure do not align, presenting the surgeon with an ethical dilemma. For example, a surgeon may see a patient who is a Jehovah's Witness.  Due to the patient’s religious beliefs, the patient states that he will not accept a blood transfusion under any circumstances.  During surgery, however, the patient loses blood and requires a transfusion. The surgeon is thus confronted with a serious ethical dilemma: should he listen to the patient, and as a consequence put the patient’s health at risk, or should he go against the patient’s wishes and save him by giving the blood transfusion? Since no surgical case is exactly the same, there is no one answer for these types of ethical dilemmas. Nevertheless, it is important to try to maximize doing what is the best for the patient, while abiding by the patient’s beliefs.(2)

Ethics of Visiting Surgeons

Surgeons who travel abroad to provide surgical care face additional ethical dilemmas. Due to the severe human resource shortage and lack of access to surgical care in developing countries, it is often tempting for surgeons from high-income countries to travel to developing countries and provide much needed surgical care. It has become increasingly common for physicians, medical students, and other health workers to travel abroad, and it was estimated that 2,072 international health volunteers were deployed in sub-Saharan Africa alone in 2005. “The concept of the medical mission has been around for a long time. Many come to Ethiopia and other developing countries every year. They bring much-needed equipment, surgical expertise, and caring professionals who do their best to confront the huge backlog of patients with advanced or neglected disease. At their best, such missions leave behind better equipped surgery departments and well cared-for children. At their worst, they dump expired supplies, leave sophisticated medical equipment that quickly fails (often for want of a fuse), and abandon incompletely treated patients.” (3) Though the surgeons who travel abroad may receive gratification from helping others who otherwise would not receive care, and think that they are undoubtedly doing good and providing a service, there are significant ethical considerations that must be taken into account when surgeons travel from abroad to work in developing countries. First, the surgeons must be sure that they are providing the same quality of care and services that they would in their native country. Many times physicians bring expired medicines into the field when they would not use such medicines in their home country. The use of “substandard procedures and medicines are inappropriate.” (4) Similarly, innovations should not be introduced without appropriate ethical and clinical review. “Surgeons who travel from abroad with a ‘new idea’ to try out should be prepared to submit their ideas to formal scrutiny by an ethical review board both at the local hospital where they intend to operate as well as in their home countries. If the proposal does not meet basic ethical standards, it should not be carried out.” (5)

It is also important to take into account the actual impact that surgical missions have on the health of the country where the mission takes place. A study on surgical missions in Ethiopia found that the Ethiopians “were truly appreciative of the efforts of the well-meaning surgeons who visited their hospitals, provided equipment and supplies, and cared for desperately ill patients. What was unspoken, but obvious, looking at the existing standards of medical practice, was that 20 years of this patient-centered approach had not improved medical care for the vast majority of Ethiopians. The specter of ‘surgical tourism’ was everywhere. From rooms filled with nonfunctional donated equipment to closets piled high with outdated suture material, to children saved from death who still lived in the hospital suffering from incompletely managed disease. ‘Don’t give me a fish, teach me to fish,’ became the Ethiopian physicians’ mantra. We wanted to help as many children as we could with our own hands- they wanted our skills and a steady stream of supplies to end their dependence on us.”(6) Thus, it is important that surgeons who go abroad examine whether their work is best for the patients and the health care systems in the countries they travel to, or if what they are doing is the most “fun” and beneficial for themselves in terms of the adventure and types of cases seen.

It is also necessary that surgeons who travel to developing countries understand their own limitations, in terms of language, culture and pathologies that they are capable of treating. Oftentimes surgeons who travel abroad are confronted with advanced pathologies that they have never before seen. “The first rule of medical practice since the days of Hippocrates has been primum non nocere – first of all, do no harm. It is easy for neophyte surgeons who have traveled to exotic settings and are confronted with unfamiliar pathology without the normal surgical support systems to which they are accustomed to make bad, sometimes tragic, clinical decisions. The tendency to put one’s surgical ego first and the best interests of the patient second must be resisted at all costs.” (7) There is also the ethical dilemma of who to treat. Surgeons (both local and visiting) must be sure to only take on cases that they will have the resources to fully treat, for “even the finest surgeon can find herself in deep trouble when the blood bank is empty, or the intensive care unit has no functioning ventilators.” (8) Similarly, in order to put the patient’s best interests in mind, it also important to only perform a surgery if the surgeon can ensure that the patient will receive the appropriate follow up care. “You have a moral obligation as a surgeon to insure that your patients receive appropriate post-operative care. It is unethical to leave the country right after you have done surgery if you have not made sure that all of your patients will receive adequate post-operative nursing care. It is unethical to perform complicated reconstructive operations only to have them fall apart because patients do not receive appropriate ongoing attention after you have gone.” (9)

Another ethical consideration with surgical missions is the attitude of paternalism that they represent and their unintended consequence of undermining local health infrastructure and local physicians. Local physicians are the ones who are most competent at treating their community members. They are able to speak the local dialects, understand the cultural norms, and are familiar with the types of prevalent pathologies. Unfortunately, “international agencies can undermine national and local capacities through overwhelming presence and dominance of relief work.” (10) Thus, surgeons who travel abroad should be aware that what they are doing, in the long run, might not be beneficial to the very people they hope to serve; in fact, their efforts may prove detrimental. Instead, surgeons who are planning to work abroad must work in partnership with their local counterpart surgeons.

Footnotes

(1) Jones, J., McCullough, L., Richman, B. “The ethics of surgical practice: cases, dilemmas, and resolutions.” (Oxford University Press, 2008).  

(2) Ibid.

(3) Isaacson, G., Drum, E., and Cohen, M. “Surgical missions to developing countries: Ethical conflicts.” Otolaryngology-Head and Neck Surgery, 143. (2010): 476-479.

(4) Chiu, T. “The Ethics of Medical Practice in Humanitarian Missions.” Ethics and Healthcare. 16.1 (2007):12-19.

(5) Wall, L., Arrowsmith, S., Lassey, A., and Danso, K. “Humanitarian ventures of ‘fistula tourism?’: the ethical perils of pelvic surgery in the developing world.” Int Urogynecol J. 17 (2006): 559-562.

(6) Isaacson, G., Drum, E., and Cohen, M. “Surgical missions to developing countries: Ethical conflicts.” Otolaryngology-Head and Neck Surgery, 143. (2010): 476-479.

(7) Wall, L., Arrowsmith, S., Lassey, A., and Danso, K. “Humanitarian ventures of ‘fistula tourism?’: the ethical perils of pelvic surgery in the developing world.” Int Urogynecol J. 17 (2006): 559-562.

(8) Isaacson, G., Drum, E., and Cohen, M. “Surgical missions to developing countries: Ethical conflicts.” Otolaryngology-Head and Neck Surgery, 143. (2010): 476-479.

(9) Wall, L., Arrowsmith, S., Lassey, A., and Danso, K. “Humanitarian ventures of ‘fistula tourism?’: the ethical perils of pelvic surgery in the developing world.” Int Urogynecol J. 17 (2006): 559-562.

(10) Chiu, T. “The Ethics of Medical Practice in Humanitarian Missions.” Ethics and Healthcare. 16.1 (2007):12-19.