It was a cold Friday morning in Amsterdam, the picturesque canal houses reflecting in the waterways, a thin sheet of fallen golden leaves covering the cobblestone roads. More and more people made their way into the Rode Hoed, a refurbished 16th-century church, that today would house ethicists, lawyers, doctors, and med students. The discussion of the day revolved around the ethical dilemmas in global health and the necessary changes in resources, research and rights to create a universal level playing field.
Understanding that “We cannot escape ethical dilemmas” was the guiding thought throughout the day: realising that by working in the (global) health sector, choices have to be made that often cause ethical dilemmas. This can be related to the distribution of medical, human or financial resources, or by looking at the obligations in research, the social responsibility within data-driven medicine, or lastly the importance of the right to health, allowing for available, accessible, acceptable health care of high quality.
There are ethical dilemmas at all levels of health care, exacerbated by the inequitable distribution of resources. Differences between countries, such as life expectancy, limited health budgets, temporal or continuous physical shortages of resources such as donor organs all lead to the challenge of meeting the medical need for all (Krütli, Rosemann, Törnblom, & Smieszek, 2016). There are structural, financial and social causes that further this divide between countries.
On this topic, Dr Kluge said: “When resources are limited, and the demand exceeds the supply, then allocation becomes a problem” (2007). He believes the discussion should not revolve purely around the material senses of healthcare resources, but also the human aspect, the nature, role and moral status of the healthcare professions and how this has implications on the ultimate allocation. He suggests three models: the Hippocratic model is based on the idea that the effort of the physician should be directed towards the best interest of his/her patient. This is very much a “hands-on” level and demonstrates that the allocation issues arise because of individual need. The second model he suggests is the Social model, in which social considerations are highly relevant as healthcare occurs in a social setting. However, this means that more than one individual has a need and that competing needs will have to be balanced. Lastly, the business model is suggested; wherein the physicians are seen as professionals and therefore have a right to give some weight to entrepreneurial considerations. However, these entrepreneurial concerns should be balanced with individual and social obligations (Kluge, 2007).
The further interplay between human and financial resources was one of the main items of discussion at NVTG. Dr Ann Phoya addressed these health challenges, specific to her situation in Malawi. Her main statement, that “removing financial barriers without proper staffing levels does not ensure access” was vital to understand the balance that needs to be struck in managing these limited resources. Adequate human resources are needed as a work overload can lead to poorer quality of care. The provision of good/quality patient care and avoiding harm is the cornerstone of ethical practice.
The road to better medical care is paved by healthcare data. The analysis of health outcomes and techniques guides the way to more value-based healthcare, and as data technology becomes cheaper and more widely available - it has the potential to help many more people. However, while big-data technology may wear the mask of a social neutraliser or offer a solution to levelling the healthcare discrepancies, it also carries the potential to create deeper divisions between countries.
These divisions are created on the basis of the theory of “knowledge gap” - “people who already have better information are also better at getting more information, even if that information is in theory universal and available to all.” (Tufekci, 2018). This pattern is seen in all sorts of fields, and the lesson is universal; the increase in inequality is not purely between those that can and cannot afford these new methods, but also amongst those that can take advantage of them and those that cannot (Tufecki, 2018). We, therefore, find a solution that maintains this universal access, yet promotes availability, acceptability and understanding of these new methods early on in all regions. With ever-increasing data-driven medicine, this accessibility is increasing. With simple-to-use mobile apps, such as Teamscope, it allows for the collection of data for clinical studies even in offline or remote areas, increasing the reach of such new methods.
However, with power also comes great responsibility and obligations. These ultimately aim to increase knowledge for the public good, through help or research as well as increase the responsibility of the healthcare workers. For example, for clinical trials, the obligations are threefold. During the pre-trial stage: responsiveness and community engagement is essential in providing effective local care or research. During the trial, the researchers must provide a high standard of care and ancillary care. Lastly, post-trial responsibility requires continuous access to the proven effective treatment, transitioning to care and capacity strengthening.
The latest techniques and methods provided through research have the potential to lead to better health outcomes - and over time, to become cheaper and more accessible.
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Case Informed Consent – South Sudan
"A 17-year old woman is brought in at the labour ward by her sister. She is gravida 1 [=her first pregnancy], full term and presenting with severe (antepartum) blood loss. The ultrasound shows a placenta praevia [=the placenta is growing at the lowest part of the womb and covering all or part of the opening to the cervix], which is an absolute maternal indication for a caesarean section. The woman refuses an immediate caesarean section because she wants to have permission from a male family member for the intervention. It is a local habit in South Sudan that women are not allowed to make decisions about interventions or blood transfusions by themselves. Despite the medical team insisting on an immediate caesarean, the woman refuses the operation without the permission of her husband. Even when the medical team explains that she and her baby’s life are at risk and the bleeding could be fatal for both of them. However, the baby’s heart rate is still stable, and the bleeding is not life-threatening at that moment."
(Case study from South Sudan - with permission from Prof. Dr J (Hans).J.M. Van Delden)
The refusal of a caesarian section in the face of obvious tragic maternal and perinatal consequences is an ethical and legal dilemma with which many developing countries are continuously struggling. The underlying societal issues guiding the decision often encounter resistance from the medical obligation to save lives.
The discrepancy comes about from the conflict between two ethical standpoints. On the one side, the core guiding principle is human dignity. We must respect the right, protect the right and fulfil the right of every person and their individual decision. However, on the other side, the Dutch medical oath (2003) pledges every doctor to “practise the art of medicine as well as [they] can for the benefit of [their] fellow man. [They] will take care of the ill, promote health and relieve suffering.” This leads them to try their utmost to help people, convince them of the necessity of a medical intervention to ultimately save their life. Doctors should aim to further the availability, accessibility, acceptability and quality of health care.
The woman in the case was lucky however as “The operation is postponed, and her sister brings her uncle who can give permission. After half an hour, the uncle gives his permission, and the caesarean is performed. Both mother and baby are doing well after the caesarean.”
With the emergence of data driven medicine, the ethical dilemma now not only encompasses a person’s physical rights towards treatment, but also the right of their data usage.” . With increased data collection, privacy, confidentiality, and control of data is now an area of significant concern. There must be a balance between an individual’s desire for privacy and their desire for good evidence to drive healthcare, which may sometimes conflict. Mobile apps and wearable devices create new opportunities for personalised health (tailored care for the needs of the patient) while at the same time large volumes of their data are created, shared, and sold (Kostkova, 2016).
Therefore, a responsible way to collect big (open) data for healthcare while at the same time respecting the patients' privacy and confidentiality needs to be developed. This will require public engagement and a dialogue between the public, private sector and policymakers to understand the data usage for research and thus the public good. It demands clarity and transparency such as regulation, enforcement and information for the public understanding. New regulatory frameworks, data structures and big data analytics should aim to deliver solutions that benefit individuals, practitioners and healthcare professionals at all levels while operating under licensed registries for safe personal data storage and analytics. Lastly, training and education, for both citizens and healthcare professionals should enable future work to incorporate ethical skills within the best computing systems. (Kostkova, 2016) This will be the only way to respect and protect the individuals right while at the same time staying true to the responsibility of making healthcare more available, accessible and acceptable.
The future of (mobile) resources, research and rights depend upon an equitable distribution, a socially obligated method of research and a focus on the rights to health and privacy. This goes beyond simple fairness. This is what a healthy society looks like.
A big thank you to the team at NVTG for organising this event, in particular to all the speakers and a special thank you to Prof. Dr. J.J.M. Van Delden for providing his presentation for the creation of this article. Thank you also to the team at Teamscope - it was a great event.