Professionalism, Medical Ethics, and Medical Mission Trips

2. Professionalism, Medical Ethics, and Medical Mission Trips Richard L. Elliott, MD, PhD, FAPA Professor and Director. Professionalism and Medical Ethics Mercer University School of Medicine

3. A child with a harelip • Surgeons offer to repair a child’s harelip. The father refuses. He explains that he (the father) had killed a bird with a stone, but had done so in a manner that caused the bird to suffer. The child’s harelip was his punishment, and to allow the harelip to be repaired would be a refusal to accept his punishment. • Fadiman A. The Spirit Catches You and You Fall Down. (p 262)

4. Cancer of the eye • Doctors recommended removal of an eye in a child with retinoblastoma to prevent metastasis. His parents refused, believing that if the eye were to be removed, the child would be reborn with an incomplete body. • Fadiman A. The Spirit Catches You and You Fall Down. (p 263)

5. Inmate on lithium • A 30 yo man was seen in a jail in an isolated community. There were no other psychiatrists within 60 miles. He was on lithium for severe manic-depressive illness and was starting to become manic again. I was asked to restart him on lithium, which requires close monitoring, but had no access to a lab.

6. What are we going to do today? Review professionalism What can we say about professionalism and medical ethics on medical mission trips? Understanding (medical) illness in another culture

7. Professionalism and ethics in medicinePrinciples for medical Mission Trips • Primacy of patient welfare • Non-maleficence, beneficence, altruism • Effects on patients, culture, health care system • Patient autonomy • Is this valued in all cultures? • Social justice (allocation of risks/resources) • Should training “costs” be greater on poor? • Medical professionalism in the new millenium: A physician charter. Ann Int Med 2002;136:243-46

8. Professionalism and ethics in medicineResponsibilities • Competence • Confidentiality • Relationship boundaries • Improve quality of care • Just distribution of resources • Honesty • Access to care • Scientific knowledge • Conflicts of interest • Professional organizations

9. Professionalism and ethics in medicineResponsibilities • Competence • What can you do? • Honesty • Your title, credentials, expertise • Confidentiality • Photographs, social media • Relationship boundaries • Gifts?

10. Professionalism and ethics in medicineResponsibilities • Improve quality of care • How does trip affect long-term health care? • Access to care (including follow-up care) • Just distribution of resources • Scientific knowledge (vs cultural beliefs?) • Conflicts of interest (care vs training?) • Professional organizations

11. Jane, an American medical resident, is doing a 6-week rotation in a hospital clinic in the Middle East. During her stay, she and another medical resident, Ryan, have become friends. They live in the same apartment complex and walk to the hospital together. Jane invites Ryan to dinner at her apartment. From: Ethical challenges in global health training. http://ethicsandglobalhealth.org/index.shtml

12. Did Jane make a mistake by having a male colleague over to dinner despite local customs? • No – Jane and Ryan are both Americans and it was after hours • No – Jane didn’t know customs and wasn’t accountable • Yes – Jane violated norms and jeopardized her safety • Yes – It was Jane’s responsibility to learn about local norms

13. After learning of the customs, what should Jane do? • Make her dissatisfaction with the norms known and empower local women • Keep quiet to avoid offending local population • Discuss with advisors, including local advisors • Not worry – it was after hours on her “own time”

14. Jasmine is a 3rd year medical student spending a month in a training program in Central America. She learns that the resident she was to work with will be away for a week. Her local supervisor says this will be a great opportunity for her to practice independently “in the the real world.” Jasmine has just finished seeing a patient, who calls Jasmine "doctor.”

15. Should Jasmine explain she is not a doctor? • No. This happens even in developed countries, so Jasmine has no reason to correct the patient. • No. Her local supervisor wants her to diagnose and treat patients independently, so in fact, Jasmine IS acting as the patient’s doctor. • Yes. Jasmine is not a doctor. Respecting this patient requires that he be aware of her level of training and competence. • Jasmine should ask her local supervisor. If he wants her to represent herself as a doctor, then she should. If not, she should not.

16. After discussing this with her local supervisor and with her advisor at home, everyone agrees that Jasmine should correct patients if they call her "doctor."  Jasmine remains concerned, however, that she might be performing some tasks that she is not ready for and would not be permitted to do at home. For example, she was asked to perform a thoracentesis; she had observed but never been trained how to do this procedure.

17. What should Jasmine do? • If Jasmine feels uncomfortable with a task, she has a responsibility at least to ask for assistance and supervision. • Jasmine should perform no task for which she does not feel 100% competent – even if it is a blood draw. • Jasmine is a guest, and the hospital is critically understaffed. She should try to perform any task she is asked to do. • So long as local medical students do it, Jasmine should feel comfortable doing so.

18. Jasmine is ready to return home after her elective rotation. She realizes how much she has learned about the local community, herself, and the global practice of medicine. As she prepares for her flight, she begins to fill out her post-elective evaluation form, which asks what advice she would offer to future medical students preparing for their elective rotations.

19. Jeffrey is a student volunteering in East Asia. He is trained in blood drawing, and part of his job involves screening individuals for hepatitis and HIV prior to blood donation. If the testing returns positive for either condition, he informs the individual that they cannot donate blood. Jeffrey is unsure what to do when a person asks about her blood testing. His own culture values truth telling for relevant information, particularly when directly asked. Thus he feels compelled to tell this woman of her HIV and hepatitis status. As she might rarely see a health care worker, it might be the only chance for her to learn her HIV and/or hepatitis status. However, in Jeffery’s training, he was told to simply inform potential donors who have evidence of infection with HIV or hepatitis that they are "not a match".

20. What should Jeffrey do? • Tell the person about her HIV status; she has a right to know and Jeffrey has a duty to tell. • Refuse to disclose the HIV or hepatitis status; no treatment is available in this area anyway. • Tell the person that she was "not a match," and move on. • Excuse himself from the situation, at least temporarily, and seek advice from his local advisor.

21. Jeffrey proceeds to ask his local advisor about what to do. Dr. Zao informs Jeffrey that, in this cultural setting, telling an individual that he or she is "not a match" is interpreted as being informed of an HIV and/or hepatitis B diagnosis. Speaking about these diseases is often not done in public. Individuals do know, however, to return to the local clinic to pursue further testing and treatment. Later in the day, Jeffrey observes Dr. Zao from a distance sitting with an individual, telling her about her HIV diagnosis. Jeffrey is surprised. He just learned that the truth can be expressed differently in different cultures. Now, however, he has just witnessed Dr. Zao directly tell an individual of her diagnosis.

22. What might explain what Jeffrey saw? • Sometimes, "who" delivers the news matters. Dr. Zao is a trusted local and thus might be able to deliver news that a trainee ought not. • Not everyone in a community necessarily holds the same belief about speaking the "truth" directly. Dr. Zao knows that this woman accepts speaking about "HIV" directly. • HIV is such an important diagnosis that Dr. Zao probably had some reason for violating the general norm she just discussed with Jeffrey.

23. Invigorated by his new understanding of this community, Jeffrey proceeds to his previously planned educational session with a group of community members about HIV infection and safer sex practices. The community members seem upset during the discussion of male circumcision. Jeffrey is confused. On the one hand, he feels compelled that individuals in the community need "the whole truth" – including male circumcision. Not doing so seems dishonest. On the other hand, he realizes that reaching the community might require a different method.

24. What should Jeffrey do? • Jeffrey should not change his teaching method. This community needs “the whole truth” about HIV. • Jeffrey should offer an “acceptable” class to the community, then insert his health messages after they have been in attendance. • Jeffrey should avoid teaching about objectionable facts, such as male circumcision, altogether. • Jeffrey should first meet with a few locals whom he knows well and have an open conversation about how collaborative educational aims could be accomplished.

25. Three Cases I was a GMO working in an ER when a 30 –ish Korean man, was brought in. He had accidentally driven his car off the end of a ferry, killing his wife and child. He was distraught and was admitted to the hospital. But the next morning he asked to leave, insisted he was not suicidal. His friends said he would apologize to all his friends, return to Korea to apologize to family, and commit ritual suicide.

26. A woman with a belly mass A woman presents to your team with abdominal pain and swelling, is found to have a 45 pound mass. What do you do? What questions would you like to ask before making a decision? How would you go about asking?

27. The Spirit Catches You and You Fall Down • What was the “illness”? • What was the treatment? • Should Lia have been taken from her parents? • Should doctors have given substandard care? • What could have been done differently?

28. The Explanatory Models Approach • What do you call this problem? • What do you believe is the cause of this problem? • What course do you expect it to take? How serious is it? • What do you think this problem does inside your body? • How does it affect your body and your mind? • What do you most fear about this condition? • What do you most fear about the treatment?

29. Culture and Medical Mission Trips • What can you learn from the people of Cambodia? • Can you develop a different perspective on U.S. health care? On how people from different cultures within the U.S. might want to be treated? • What sort of questions might you have for you Cambodian colleagues, patients, and families?

30. Questions?

31. Culture and Medical Missions • “You catch the spirit and fall down”

32. What are your goals for the trip? • Learn medicine • Learn culture • Traditional medicine • Faith • Learn about another system of care • Help patients

33. What might be other considerations? Protecting the public? Conserving resources? Protecting the existing health care system? Effects of medical decision on family, community, other doctors?

34. Autonomy • Every patient of adult years and sound mind has a right to decide what shall be done with his own body • How does this work elsewhere? • Who makes decisions? • What is basis for decision? • Patients medical interests? • Interests of community

35. First do no harm What kinds of harm might we do on trips? Medical harm to patient Harm to reputation of local practitioners Squandering local resources Harm to reputation of mission team Will local doctors want you back?

36. Beneficence • How do we choose among different kinds of “good?” • Less vs more severe conditions to treat • Acute vs chronic conditions • Conditions where opportunity to educate local practitioners might learn more?

37. Social Justice Is it better to spend money on medical trips, or to invest in better water? Education of farming methods?

38. Ethical issues • Is a little care by less well-trained mission staff better than no care? • Should we practice care on trips we would find unacceptable at home? • Lithium in jail • Older medications in public clinics in Arizona • Should we train students without the same supervision and consent we would have at home?

39. Most Important Ethical Principle Respect To respect, one must try to understand

40. Understanding Cultural Views of Illness What do you call the problem? What do you think has caused the problem? Why do you think it started when it did? What does the sickness do? (How does it work – pathophysiology, spirits, . . .) What do you think will happen? (prognosis) What treatment is needed? What problems does sickness cause? What are positive elements of sickness? (seizures and divine visitation) What worries you most about this?

41. Interpreters and Understanding Text translators vs cultural brokers

42. Goals • What’s different about medical ethics on mission trips? • Beneficence - What should you do? • Nonmaleficence - What shouldn’t you do?

43. Case • Neuropathic pain, new medicine not on WHO list, helps, can’t sustain

44. What are your goals for the trip? • Learn medicine • Learn culture • Traditional medicine • Faith • Learn about another system of care • Help patients

45. What should you avoid? • Primum non nocere • For patients • For local practitioners • We want to strengthen through education, not undermine • For system of care • Avoid treatments that overwhelm aftercare services • Test – will local doctors want you back?

46. How might ethical principles differ? • Autonomy less important • Primum non nocere

47. Phil, a 3rd year medical student, thought he would shadow surgeons, but, on his first day, he was given a white coat and told to introduce himself as “Dr. Denton.” He saw patients by himself and, with his fairly fluent Spanish gained their consent for surgical procedures. In the OR, after a brief introduction to suturing and sterile technique, Phil was asked to prep patients before surgery and suture incisions afterward. The surgeons were usually out of the room while he performed these functions. At first, Phil was thrilled to be getting such experience at so early a stage in his training. In the U.S., that kind of responsibility was usually reserved for 2nd and 3rd year surgery residents. But after a patient he had prepped for surgery returned with a wound infection, Phil 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 U.S.. 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?”

48. Is a little is better than nothing? • Should physicians and students exceed their training when providing care to those in need? • Emergencies, no other resources, yes! • Non-emergencies, no other resources, look at risk-benefits. We listen to questions from friends and families about other specialty concerns, give advice (e.g., about questions to ask), study and practice new techniques • Can/should we inform patients of our limitations?

49. Principles of Medical Ethics • Autonomy • Right of self-determination • How does it apply in non-western cultures? • Non-maleficence (primum non nocere) • First of all, do no harm • Harm to patient? System? • Beneficence • Doing good • For patient, system • Social justice • Access to care, wise use of resources

50. “My First Consideration” • THE HEALTH OF MY PATIENT will be my first consideration