International Emergency Medicine: Ethical Dilemmas

1. 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

2. Presenter’s Disclosure • I have no conflict of interest memberships or situations related to the content of this presentation to report

3. 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

4. Classification of International EM Ethical Issues • Individual • Clinical • Cultural • Institutional • Financial • Academic • Global • Political • Armed Conflict

5. 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.

6. 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 ?

7. 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 ?

8. 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

9. 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 ? )

10. 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

11. 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 ?

12. 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

13. Casket and funeral ceremony for a deceased patient at the Hospital Behrhorst, Chimaltenango, Guatemala

14. 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 ?

15. 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.

16. 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

17. 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

18. 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

19. 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 ??? )

20. 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

21. 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

22. Ruins of Darulaman Palace in south Kabul

23. Hopeful sign from a refugee camp in Kabul

24. QUESTIONS ? Thanks for Your Attention