Professionalism, Medical Ethics, and Medical Mission Trips

1. Professionalism, Medical Ethics, and Medical Mission Trips Diane W. Davis MD, MATS Dublin Ear, Nose and Throat Associates Richard L. Elliott MD, PhD, FAPA Professor and Director. Professionalism and Medical Ethics Mercer University School of Medicine

3. Ethics and Cultural Understanding Not just about the “do’s and don’ts” but a positive opportunity to see yourself and your profession in the mirror of another culture.

4. Who am I and who are we as a team? Our own culture of biomedicine Previous mission experience? Ethics background? Faith background? Reasons for going on trip?

5. What are your goals for the trip? Learn medicine Learn about another system of care Learn culture Help patients Learn cooperation among healthcare providers

6. Professionalism and ethics in medicine:Principles for medical mission trips • Primacy of patient welfare Non-maleficence, beneficence, altruism • Patient autonomy Is this valued in all cultures? • Social justice Allocation of risks/resources Medical professionalism in the new millenium: A physician charter. Ann Int Med 2002: 136:243-46

7. Beneficence How do we choose among different kinds of “good” in a short-term trip? • Less vs more severe conditions to treat • Acute vs chronic conditions • Respectful education of local practitioners and patients

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

9. First do no harmnon-maleficence 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 TEST Will local medical community want you to return?

10. 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 in other cultures? • Who makes decisions? Informed consent process. • What is basis for decision? Patients’ individual medical interests only or interests of community

11. Ethical issues Is a little care by trainees on the mission staff better than no care? Should we practice care on trips we would find unacceptable at home? Should students give care without the same supervision and consent they would have at home?

12. Other considerations Protecting the public? Conserving resources? Protecting the existing health care system? Effects of medical decision on family, community, other doctors?

13. Most Important Ethical Principle R – E – S – P – E – C – T To respect, one must try to understand

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

15. The Spirit Catches You and You Fall Down • What was the “illness”? • What was the treatment? • Should Lia have been taken from her parents? • What is the standard of care in her case? • What could have been done differently?

16. The Explanatory Models Approach • What do you call this problem? • What do you believe is the cause of this problem? • Why do you think it started when it did? • What do you think this problem does inside your body? • What do you think the sickness does? How does it work? • How serious is it? Will it have a long or short course? • What do you most fear about this condition? • What treatment is needed? • What do you most fear about the treatment? • Are there any positive elements of this sickness?

17. Language Barriers translators vs cultural brokers

18. REMEMBER! Before going on the elective, ensure that you, your advisors, and the local supervisors have communicated accurately regarding your training and competencies. When in-country, do not misrepresent your training status. You may be nervous about completing certain tasks. Always ask for help or supervision when necessary. If you have the requisite training, it is appropriate to attempt it on your elective. Short-term electives abroad are NOT a chance to practice unsupervised tasks or procedures for which you lack training!

19. WHAT DO YOU LEAVE BEHIND? • No acute care that requires an unavailable follow-up care • Do only what you’d do if at home • Inappropriate short-term care can lead to unrealistic future expectations. • Who gets credit or blame? – local sponsors. • Be sure they’re glad you came!

20. Robotic trans-Axillary Thyroid Surgery R. A. T. S.

21. Just my “sinus” 79 y/o F c/o drainage and “sinus,” never mentioning her throat. Nasal endoscopies shows a little swelling and clear mucus, sinus CT was normal. After 6 physician visits, an office flexible laryngoscopy finally showed a tumor in the larynx. Look beyond the patient’s own self-diagnosis and understanding of the illness.

22. 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?”

23. Is a little 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. • Can/should we inform patients of our limitations?

24. 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)

25. 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)