1. Ethical Dilemmas in Medical Missions Dennis Sullivan, MD, MA (Ethics)Director, Center for BioethicsCedarville University Center Website: www.cedarville.edu/bioethicsEmail: sullivan@cedarville.edu

2. ““The rules are the same, but the context is different.” • Objectives: • To review the major principles of modern biomedical ethics • To provide a historical context for these rules • To consider how these principles may need modification in a cross-cultural context

3. Medical Principlism

4. Medical Principlism1 • 2400 years of normative medical practice • Exemplified by the Hippocratic Oath (400 B.C.) • Four Rules: • Beneficence • Non-Maleficence • Distributive Justice • Autonomy 1Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2013.

5. Beneficence • H: “I will apply treatment for the benefit of the sick according to my ability and judgment.” • Always acting in the best interest of a patient

6. Non-Maleficence • H: “I will keep them from harm and injustice.” • “Primum non nocere:” • First, do no harm • (L. version first said by Galen) • Two specific prohibitions: • no assisted suicide • no abortion

7. Distributive Justice • Treat everyone the same, regardless of… • H: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief, and in particular of sexual relations with both male and female persons, be they free or slaves.” • Remarkable in a Greek society where women and slaves had no rights.

8. Autonomy • The fourth dictum of medical principlism • Never even implied in the Oath, but very important today • Gives rise to the idea of informed consent

9. Other Aspects • Professionalism • Medicine is a high calling • The oath is akin to ordination • Confidentiality • Keeping medical information private • H: “What I may see or hear in the course of treatment or even outside of the treatment in regard to the life of men, which on no account ought to be spread abroad, I will keep to myself, holding such things shameful to be spoken about.”

10. Non-Maleficence and its Discontents

11. “Abortion is always wrong” • Medical ethics seminar in New Delhi, India • Roopa: Pro-life (adopted an abandoned baby girl) • But had trouble when I said I would refuse to refer a patient for abortion

12. “Euthanasia is always wrong” • New Delhi conference: physicians not willing to terminate life support • “Always wrong” • It is euthanasia • According to these Christian physicians • In fact, withdrawal of futile treatments is quite ethical (with strict qualifications)

13. Autonomy and its Limitations

14. The Culture of Autonomy • Western idea • From Immanuel Kant and the Enlightenment • Patients are willing and able to make their own decisions • Implies a strong degree of individualism • Not always true of developing cultures!

15. Examples • “Don’t tell my wife she has cancer” • Common request by a loving African husband • In fact, she is illiterate and probably cannot comprehend the facts • More sinister: • 22 year old man with gangrene of left foot • Needed amputation, consent by parents and him • Blocked by village chief • Confidentiality • Story of pastor with AIDS • With tears: “I only cheated on my wife one time!” • I spent over an hour, promising not to discuss his infidelity with anyone

16. Distributive Justice and its Barriers

17. The Dilemma of Gender Inequality • Women have few rights (in the Western sense) • AIDS, FGM, and poverty add to the gender disparity • Few women recognize the disparity • We cannot correct these disparities at the bedside • A clinician must accept these things and live within the system

18. The Problem of Polygamy • Long-standing cultural practice • Koran: up to four wives (though may be over-interpreted by Christians) • May be more related to folk Islam than high Islam

19. A Unique Problem: VVF • In Africa, 4th wife is often very young (12-14) • Belief that this will give an older man vigor • Pregnancy: “children having children” • CPD  ischemic damage to anterior vaginal wall • VVF  constant leaking • Women then abandoned, stigmatized • Repair of VVF is a ministry opportunity

20. Perfectionism, Paternalism, and Other Woes

21. Living with Limitations • How much do we practice Western medicine? • Example of AAA in patient with Marfan’s Syndrome • Decided not to operate (for the greater good) • Paternalism • Not our habit • But given the lack of education, may be the best policy • Resource limitations • Frustrating • Can be a big cause of overwork and burnout

22. Summary • Four Rules: • Beneficence • Non-Maleficence • Distributive Justice • Autonomy • Other aspects • Professionalism • Confidentiality Remember: “The rules are the same, but the context is different.”

23. Ethical Dilemmas in Medical Missions Dennis Sullivan, MD, MA (Ethics)Director, Center for BioethicsCedarville University Center Website: www.cedarville.edu/bioethicsEmail: sullivan@cedarville.edu