Abstract
There is growing interest in the area of global health by obstetricians-gynecologists. As more of these physicians become involved in this important and exciting undertaking, the physicians are potentially exposed to situations in which they may have to deal with ethical questions that they may not have previously considered. Some of the principles which frame the ethical problems that obstetricians-gynecologists may encounter include autonomy, beneficence, nonmaleficence and justice. We believe that exposure to ethical principles and study of cases involving ethical issues will be of benefit to the physicians and their patients, and that this exposure takes place before these doctors are placed in the environments and circumstances they might face as they travel to distant locations.
Introduction
Large disparities exist globally in obstetric and gynecological health care for women. Developing countries accounted for 99% of the estimated 358,000 global maternal deaths in 2008, 1 as well as 86% of new cervical cancer cases. 2 Many of the most pressing obstetric and gynecological health complications in the developing world are highly treatable and often preventable with access to quality obstetrics and gynecologic health car. 3 Increased globalization has led to an increase in resource and information sharing across national boundaries. Efforts to expand access to quality obstetric and gynecological care worldwide are underway in many ways. Obstetrician-gynecologists are responding to the need for improved healthcare by giving their time and resources to under-served populations across the globe. However, these efforts may raise ethical issues that need to be considered carefully. Many doctors have not received any ethically-focused training on how to work in under-resourced environments (see “Conclusion” section for recommendations). It may be difficult for a physician who has not received proper guidance to understand the complexities of such situations. Potentially, issues such as the lack of accountability between visiting physicians and the communities they are serving, institutional corruption, inadequate physical resources in the context of gaping needs and cultural differences may contribute to the provision of health care that does not fully meet the physician's ethical obligations to his or her patients.
Ethical considerations for the obstetrician-gynecologist considering making contributions to global health women's health issues include the principles of autonomy, beneficence, nonmaleficence, and justice. To address the issues surrounding obstetrics and gynecologic global health ethics is to recognize that providing healthcare is often a complicated process. One must constantly examine the context for each patient in light of the fundamental concepts of medical ethics. Obstetrics and gynecology patients must also be treated with considerations around the cultural values and expectations of each community with which a physician interacts. The principle of autonomy dictates that each patient, no matter where in the world, must be invited to fully participate in her own care. Beneficence requires that a patient's good be considered above all else. All interventions must be examined within the concept of nonmaleficence. Even the best intentions are misplaced when a medical intervention results in harm that could have been avoided had one considered the complete cultural context where one is providing care. Finally, one cannot hope to participate fully in healthcare on a global scale without understanding the ethical concept of justice and recognizing the importance of this principle in light of the cultural practices and institutional corruption that may contribute to global health disparities.
Autonomy
Autonomy is defined in The Value of Life by John Harris as “strictly speaking, ‘self-government’, and people are said to be autonomous to the extent to which they are able to control their own lives… by the exercise of their own faculties.” 4 This principle requires that a physician afford each patient the opportunity to decide how and when he or she will or will not receive medical care. It is from a respect for individual autonomy that the idea of consent for care was identified. “Consent implies a fiduciary relationship which assumes that the patient's good is to be done and assumes that patient's consent because they fully (or as fully as possible) understand not only what it is that is to be done (the means) but also the ultimate goal (or end) of doing it.” 5
One might be quick to consider a disregard for a patient's consent for care as a thing of the past. It may seem that the world has learned from such highly publicized ethical missteps as the use of human subjects for experimentation that resulted in the Nuremberg trials or denial of treatment to the subjects of the Tuskagee Syphilis Study. However, in July 2010 a New York newspaper 6 reported about a campaign for female sterilization in Uzbekistan. The 24-year-old subject of the story is one of hundreds of Uzbek women who were reportedly sterilized without giving consent to the operation. The Uzbekistan story is similar to what transpired in Peru. It was reported 7 that authorities in Peru used material enticement to persuade poor and undereducated women to undergo sterilization in the 1990s. In this case the surgeries were done in less than desirable conditions, resulting in infection, injury and even death for many of the women. In these situations, the actions of the doctors, without the knowledge or consent of their patients, violated the autonomy of the patients. Women were forced into sterilization as it was deemed necessary by their government, rather than as a result of each woman's informed decision for her own body's treatment. Autonomy is a core ethical principle that needs to be considered when involved in caring for global health patients.
Beneficence
Beneficence, in medical ethics, encompasses the idea that a doctor should work solely to promote the highest benefit for the patient. 8 This seems intuitive; the whole practice of medicine exists to promote the health and well-being of individuals and societies. Unfortunately, though, the desire to do good can often be misguided. When providing care in an under-resourced area, one might be tempted to consider his or her own suggestions as the unconditioned best for each patient. Under this circumstance, a physician must understand and avoid the danger of paternalism. According to Loewy 5 paternalism, “often arises out of a sense of responsibility in which the paternalist's claim to greater knowledge, foresight, wisdom or experience is the ostensible excuse.” The danger of paternalism is especially relevant when considering global health. Too often, doctors and healthcare professionals from the developed world may suppose that they know what ‘good’ their patients in the developing world require, even when their patients may have different desires and expectations. However, a physician's desire to do good must be balanced with an inherent respect for the autonomy of the patient. “The act of profession requires us to pursue our patient's ‘good’; respect for others requires that we define that ‘good’ on that other's terms. A respect for autonomy presupposes a sense of beneficence.” 5 This illustrates well why it is so important that a physician seek to understand the cultural beliefs and practices present within any population with which he or she works. Not only this, but the physician must also work diligently to educate his or her patients with regard to their current state of health and any interventions that might be deemed necessary. This may require the assistance of multi-lingual individuals who know the culture and are able to communicate both with the patient and the obstetrician-gynecologist regarding each patient's desires and expectations.
Nonmalficence
Some would argue that the most famous line of the Hippocratic oath is Primum non nocere; “First, do no harm.” This fundamental concept, known otherwise as nonmaleficence, requires that a physician, whenever acting or choosing not to act, must consider whether the benefits of an intervention will outweigh the harm that may be caused. 9 The principle of nonmaleficence is crucially important to consider alongside autonomy, and it would seem to go hand in hand with beneficence.
Consider the following situations in global health. In response to infertility cases in developed countries, a new trend is emerging. According to the London newspaper The Guardian, 10 couples are outsourcing pregnancy surrogacy to India. Although this practice provides families with an opportunity to have a child through a surrogate at a lower cost, one must consider the harm this might cause. Thus far there are no regulations in place for any part of the process. Does the harm that this process may cause to the surrogate mother outweigh the benefit of a couple gaining a child? Indian culture has not yet fully embraced the idea. Many women who are choosing to be surrogates because of the financial opportunity are in turn facing rejection by their family and community. Consider also the effect this may have on Indian society. With women in India being used as cheap surrogates by women in wealthier countries, childbearing could become a commodity sold to the lowest bidder. The ethical principle of nonmalfiasance needs to be considered in this context to weigh both sides of the infertility/fertility equation.
Another situation 11 in which one must weigh benefits against harm regards treatment for infertility in the developing world. Through the work of Dr. Ian Cooke and others, “Low Cost IVF Foundation” is finding ways to lower the cost of IVF treatment to make this therapy more accessible to the poorest areas of the world. When confronted with an issue such as this, it is important that a physician consider not only the benefit that might come to an impoverished family through low-cost IVF treatment, but also any possible harm. What burden might availability of this service put on poor families who are desperate for children? At this time, the IVF procedure cannot guarantee the desired results. Even a relatively small amount of money is a lot to spend on a procedure that cannot promise an outcome. These families may also have no way to ensure that they will have the means to take care of the child should the procedure be successful. Thus, while at first glance it seems highly altruistic to provide a means for poor couples struggling with infertility to conceive via IVF, a physician who encounters a similar situation is required to weight the benefits against the harm.
Justice
Justice must be included in the consideration of global health medical ethics. Most people would consider health care a basic need. Timko, recalling philosopher John Rawls, discusses justice in health care as fair treatment. “Each person gets what one ‘needs’ while being required to contribute ‘fairly’ to the community's well-being.” 9 Issues of justice often go well beyond the basic availability of healthcare. In light of the disparities that exist in access to and quality of obstetric and gynecological care worldwide, the ethical principle of justice is especially relevant to this discussion. Though many areas of the world have limited access at best, complications are often present that cause even greater stratification between those who have access and those who do not.
For example, in Afghanistan, women are by and large a neglected and forgotten segment of society. Poverty, malnutrition, and limited resources contribute to what is nearly the worst maternal mortality rate in the world. In 2008, the country witnessed 1400 deaths per 100,000 live births. In the United States, that number was 24 in 100,000. 1 One of the barriers to healthcare that women in Afghanistan face involves the lack of education about their own health needs. Many do not know the danger signs of complications in pregnancy. Even when women do recognize their need for care, a lack of transportation makes it very hard for a woman in distress to get to one of the few available healthcare facilities. Once they arrive, the care is minimal and resources are limited. 12
Afghanistan's present cultural conventions dictate that men are not allowed to treat women. “There are still men who would rather have their wives die than have a male doctor treat them,” says one of the only trained (male) gynecologists in Southern Afghanistan. 12 However, under the Taliban women were for many years (and are still in some areas of the country) banned from education. It is difficult to find women with enough training to provide the care many women need. As a result, women continue to suffer without access to much needed care. As this situation demonstrates, it is important to be aware of the circumstances that are involved in the just distribution of healthcare throughout a community. The presence of injustice is often a complicated mixture of societal prejudice, institutional corruption and lack of resources, among many other things. The responsible and ethically trained obstetrician-gynecologist needs be able to examine global health situations relating to the ethical principle of justice in light of this complex mixture.
Conclusion
We believe that it is only when the ethical concepts reviewed here are thoughtfully and fully considered will physicians be able to positively contribute to the effort to lessen global health disparities in obstetrics and gynecology. We recommend that a standardized global health ethics curriculum become a required part of all obstetrics and gynecologic programs in which physicians are sent to serve in global health sites. The disparities that exist on a global scale can also be seen within our local communities. All physicians, no matter where they plan on practicing medicine, will benefit from a fuller examination of medical ethics in the context of our global society. We also recommend that any organization provides obstetrics and gynecologic care to underserved populations, locally and globally, require healthcare and non-medical staff to participate in ethical case studies before participating in global healthcare work. It is now timely for our obstetrics and gynecology community to develop more concrete ethical guidelines and educational standards that will prepare physicians to participate most effectively in increasing the health of our global society. At a minimum, we recommend that the physicians to be exposed to subjects such as a historical overview, general ethical principles, principles of professional medical conduct, principles of research conduct and issues that pertain specifically to global health.
Disclosure
Author(s) have provided signed confirmations to the publisher of their compliance with all applicable legal and ethical obligations in respect to declaration of conflicts of interest, funding, authorship and contributorship, and compliance with ethical requirements in respect to treatment of human and animal test subjects. If this article contains identifiable human subject(s) author(s) were required to supply signed patient consent prior to publication. Author(s) have confirmed that the published article is unique and not under consideration nor published by any other publication and that they have consent to reproduce any copyrighted material. The peer reviewers declared no conflicts of interest.