Getting Comfortable with Grey

1. Getting Comfortable with Grey Global Health Elective Ethics Module Brenda Watkins

2. Ethics • also known as moral philosophy, is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong behavior

3. Ethical Theories • 3 Broad Categories: • 1. Meta-ethics: The focus of meta-ethics is on how we understand, know about, and what we mean when we talk about what is right and what is wrong. • 2. Normative ethics: The study of what makes actions right and wrong. • 3. Applied ethics: The discipline of philosophy that attempts to apply ethical theory to real-life situations. • Bioethics (medicine) • Engineering ethics • Public Service ethics • Business ethics

4. Meta-ethics and Normative ethics are: • Very important • If you’re interested in learning more, read: • David Hume, GE Moore, Immanuel Kant, Socrates, Aristotle, William James, John Dewey, Max Weber, Marx, Nietzsche, etc, etc… • But if we tried to tackle meta-ethics or normative ethics in the short time we have time, this would happen…..

7. Focus for tonight = Applied EthicsMain Objective = Getting comfortable with grey

8. Example: Black/White  Grey • Is it justifiable to treat an HIV positive mother to prevent transmission of HIV to her newborn child? • But only provide treatment for the two week period you are on your trip? • But not provide treatment after the baby is born realizing that the mother will likely die and leave that newborn orphaned? • But your patient has a history of only using half of her medications and selling the other half to make money to provide for her family? • But you have no experience treating HIV in pregnancy and you are all by yourself in a remote African area?

9. Objectives: Practical not Theoretical • Establish why this module is relevant: • In general • To healthcare professionals wanting to work/volunteer internationally • To students wanting to work/volunteer internationally • Discuss two pertinent real-life scenarios. • Identify ways to respond to ethical situations in international settings. • Identify ways to prepare for future ethical situations that may arise in an international setting.

10. Why is this module important for health care professionals? • “Unprecedented numbers of health care professionals are volunteering their services in poorer nations. But their altruistic motives are often quickly tempered by the reality of novel and daunting questions connected with very limited resources, and further complicated by unfamiliar cultural context.” (http://inmed.us/2009_news.asp)

11. Why is this module important for students? • Increasing numbers of medical students and residents are doing rotations and electives abroad. • The most recent survey of U.S. medical school graduates estimates that 27 percent of them have had international experience during their four years of medical school, up from 6 percent in 1982. • This number does not take into account people who travel before medical school, medical students who travel outside of official medical school avenues and residents who do electives abroad. • Despite the large numbers, it is only recently that the medical community has started to think about the ethical issues and consequences of these cultural experiences. • How should we prepare people for what they will see and do in these countries? Who are we helping most when we work abroad?” (http://virtualmentor.ama-assn.org/2006/12/toc-0612.html)

12. For those of you that have been on service/mission trips in other countries, what was your motivation? What if someone said, your going (even with altruistic motives) does more harm than good. What would you say to that?

13. Practice Scenarios: Rules of the Game • This is a safe place. • Feel free to voice your opinions and ideas. • Don’t let your passion drown out someone else’s voice. • If you disagree with someone, then RESPECTFULLY disagree. • Remember: This isn’t a graded activity and I am not looking for any particular “right” answer.

14. Practice Scenario #1 • “No one tells us what to do here. Besides, if you didn’t help us out, we wouldn’t be able to see as many patients and some people wouldn’t get the help they need. Is it better for the patient to get less expert care or no care at all?” • Source: American Medical Association Journal of Ethics. Virtual Mentor. December 2006, Volume 8, Number 12: 808-813.

15. “Phil Denton is a third-year medical student at a northeastern university. During the summer between his second and third year, he was selected to go to El Salvador with a team of surgeons who staff a rural clinic for two weeks twice a year. Phil thought that his main activity would be shadowing the surgeons. The clinic, however, was extremely busy with the doctors seeing hundreds of patients a day. On Phil’s first day, one of the surgeons gave him a white coat and told him to introduce himself as “Dr. Denton.” He saw patients by himself and, with his fairly fluent Spanish or through translators, gained their consent for surgical procedures. In the operating room, after a brief introduction to suturing and sterile technique, Phil was given the responsibility of prepping the patients before surgery and suturing the incisions afterward. The surgeons were usually out of the room while he performed these functions.

16. At first, Phil was thrilled to be getting such experience at so early a stage in his training. In the United States, that kind of responsibility was usually reserved for second- and third-year surgery residents. But after a patient he had prepped for surgery returned with a wound infection, Phil looked at the situation differently. He asked one of the surgeons at the clinic if it was appropriate for him to be performing functions on patients in El Salvador that he would not be allowed to perform on patients in the United States. The surgeon replied, “Relax, the rules here are different than at home. No one tells us what to do here. Besides, if you didn’t help us out, we wouldn’t be able to see as many patients and some people wouldn’t get the help they need. Is it better for the patient to get less expert care or no care at all?”

17. First, what are the facts?

18. First, what are the facts? • Phil is a student volunteering in El Salvador • Phil THOUGHT he would be shadowing surgeons • Surgeons saw hundreds of patients a day • Phil was told by a surgeon to introduce himself as Dr. Denton • Phil saw patients by himself • Phil prepped patients for surgery by himself • AFTER one of Phil’s patients returned with a wound infection, he questioned what he was doing • Etc…

19. What ethical issues do you notice? • Phil assumed he would be shadowing. • Supervisors and Phil lied (or at least let patients assume) about Phil being a doctor. • Phil treated patients unsupervised. • Phil performed procedures that he was not qualified to perform. • Phil was excited at first but after one of his patient’s got an infection, he started to feel uncomfortable. • The surgeon believed that “no one tells us what to do here.”

20. What would you do in Phil’s situation? Is it better for patients to get less expert care or no care at all?Is there a different way to frame the question?

21. What are you basing your opinions on? (personal experience, gut feeling, AMA Code of Ethics, religion, etc?)Will everyone come to the same conclusion?

22. Practice Scenario #2 • “I believed at the time that to be a doctor, to respond to the suffering of others, was to be apolitical.” • Source: Orbinski, J., M.D. (2008). An Imperfect Offering: Humanitarian Action for the Twenty-First Century. Walker Publishing Company, Inc.: New York, New York.

23. “Kouchner had been working with the French Red Cross, which had been invited by the Nigerian government to work in Biafra in 1968. In keeping with the Red Cross’s tradition of neutrality and discretion, Kouchner took an oath of silence. After a coup in newly independent Nigeria, across the country the Ibo people were slaughtered. The Ibo then declared the independence of their Biafran region. A brutal civil war ensued. Nigerian forces encircled the renegade region, imposed a blockade and left eight and a half million Biafrans to starve. One day, wounded villagers fleeing Nigerian soldiers overran the medical clinic where Kouchner and other French doctors were working. The doctors notified Red Cross headquarters and were ordered to abandon their posts. They refused, and in staying witnessed Nigerian troops slaughter unarmed men, women and children. The doctors were outraged by what they had seen and disgusted that the Red Cross’s strict adherence to neutrality prevented them from speaking publicly about it. They quit the Red Cross, and when they returned to France they broke their oath of silence and told the work what they had witnessed” (pg. 68).

24. Break into 2 groups. • Group 1 – pretend you are a Red Cross official. What are your reasons for wanting to be neutral and for wanting your doctors to take an oath of silence? Why did you want the doctors to abandon their posts when the medical clinic was overrun? • Group 2 – pretend you are the doctors. Why did you agree to take the oath of silence initially and be neutral? Why did you change your minds (i.e. refuse to abandon your post and then broke the oath of silence)?

25. Thoughts on Scenario #2 • On one hand, they • were employed by the Red Cross. • took an oath of silence. • were invited into Nigeria by the Nigerian government. • On the other hand, they • were working in the midst of a civil war. • were working with the Ibo people that were being persecuted. • were asked to “abandon” the Ibo people when they obviously needed medical help. • Any other thoughts?

26. What would you do?Are there pros and cons to each side? Is one side absolutely right and the other side absolutely wrong?

27. Other scenarios? • Would anyone like to share an experience they’ve had?

28. What have we established so far? • As a healthcare worker, especially one in an international setting, knowing how to deal with ethical situations is important. • BUT there are many different ethical scenarios. Different ones come up everyday. • AND knowing the “answers” to each individual ethical situation/moral question is pretty much impossible and definitely inefficient. • SO what do we do? How can we prepare ourselves to navigate through grey as best as we can?

29. What can we do? • Social workers like to think of things in terms of resources/tools  Build a “toolkit.” • A group of resources that will help you navigate ethical situations when they arise. • Another way of thinking about it is the medical student approach. What are the 4 or 5 questions/steps I must ask in this situation?

30. What are the two most important tools we can use, especially when time is an issue? • STOP and THINK! • Talk to someone

31. When time isn’t a factor, what are some other tools? • Codes of Ethics • http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page • Virtual Mentor (same link as Code of Ethics) • Academic research • World Health Organization • Personal experience from health professional who have worked in the same country • Informative websites such as: http://www.uniteforsight.org/global-health-course/

32. Be proactive: prepare before you go! • Read and learn your Code of Ethics • Research the population you will be working with (i.e. country, culture, beliefs on medicine and healthcare, their current resources) • Research best practices (i.e. have proven to be sustainable) • Interact with the leaders and doctors that will accompany you on the trip. • Establish healthy boundaries • Have an idea of what YOU feel comfortable doing.

33. Final Thoughts: The Process of Getting Comfortable with Gray • Learn  Act  Reflect  Learn  Act  Reflect • Learn = prepare for your trip • Act = act as professionally and ethically as you can using the resources you have at the time of the trip • Reflect = after acting, think about how the trip (outcomes, feelings, etc..), whether or not you should make different choices in the future, etc....and learn from your actions • Repeat the cycle • This is NOT rocket science but it does take lots and lots of practice.