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• Response to e letter
  Delan Devakumar
  Published on: 15 October 2008
• Is "acceptance" really an unethical form of negligence?
  Raymond V Downing
  Published on: 10 September 2008

• Published on: 15 October 2008

  Response to e letter

  • Delan Devakumar, Doctor in Public Health

  In response to your comments:

  Ethics is about choices, but I do not agree that health care workers do not have choices. The choices available to us are obviously very varied. Some may well be able to change the number of nurses in a hospital (or have the ability to lobby for that kind of change). Alternatively in your cancer example, your choice may be just to turn the patient or to provide a cushion. The...

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  In response to your comments:

  Ethics is about choices, but I do not agree that health care workers do not have choices. The choices available to us are obviously very varied. Some may well be able to change the number of nurses in a hospital (or have the ability to lobby for that kind of change). Alternatively in your cancer example, your choice may be just to turn the patient or to provide a cushion. The constraints are mental as well as physical and the Kenyan doctors you mention who are “working to improve the standard of care”, I would say are working against the constraints. The constraints could be teaching/learning about pressure sores. It is also not necessarily the individual doctors who are at fault but that a social and structural change and shift of thinking are needed to improve the situation in Africa. I am certainly not saying that Kenyan doctors, or any other group, are unethical and I think it over simplistic to categorize in this way. We make hundreds of decisions with a wide scale of ethics. A number of experiences in this article actually relate to European doctors working overseas. It is also not that practices in the UK are better than those in other parts of the world. Some are, some aren’t; most are just different. Accepting the status quo occurs everywhere but the situations tend to be much worse in the developing world. Not washing your hands between patients occurs every day in the NHS, but as there are generally less serious diseases and the patients are usually better able to cope, so the problems caused are comparatively less. The scenario is much worse if your infectious disease is cholera and your patient is a malnourished infant for example. I entirely agree that intensive care has a very small contribution to worldwide infant mortality. The point of that paragraph was that our target should be an IMR of a developed country but to get there is unrealistic due to the very high costs of intensive care. The role of the rich world certainly is important. This does not take up a large proportion of the essay because it is not primarily about this issue. I know it is easy to sit here and pass judgment, but are all practices/behaviours acceptable just because they occur in a society? I think there are universal standards that we, in admittedly very different ways, should be striving to achieve.

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  Conflict of Interest:
  None declared.

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• Published on: 10 September 2008

  Is "acceptance" really an unethical form of negligence?

  • Raymond V Downing, MD, Chair, Family Medicine

  If I understand ethics correctly, it has to do with "oughts" - what we should do, or ought to do. This assumes that we have a choice. It is not unethical to "let" someone die of a highly aggressive cancer of unknown etiology, for example; we have no choice in the matter. We do have a choice on whether to perform a 1st trimester abortion on demand, or whether to pull the plug on Karen Quinlan. Ethics implies choice. Delan...

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  If I understand ethics correctly, it has to do with "oughts" - what we should do, or ought to do. This assumes that we have a choice. It is not unethical to "let" someone die of a highly aggressive cancer of unknown etiology, for example; we have no choice in the matter. We do have a choice on whether to perform a 1st trimester abortion on demand, or whether to pull the plug on Karen Quinlan. Ethics implies choice. Delan Devakumar suggests that doctors in developing countries have a choice to either "accept the way things are and work within the constraints" or "always be battling against the constraints." He suggests the second is the more ethical choice. Now I cannot control how many nurses our district hospital has (no matter how much I "battle against the constraints"), nor the lack of transport and roads to get people to the hospital, nor the 50% of Kenyans that live on less than a dollar a day, nor the poor morale that often results from working in overworked understaffed facilities. Do I really have a choice in these fundamental matters? If I decide – or rather so many excellent Kenyan doctors decide – to "work within the constraints", why does that come on the unethical side? The ethical Kenyan doctors I know who are "working within the constraints" are working to improve the standard of care. To me, the unethical choice is to leave. Of course there are ethical reasons for why things are bad in Africa, there are choices – but only a minority of these choices are local. Yes, there is corruption locally, and there has been in Kenya a palpable change in this regarding health care since the 2003 election. But where is the equivalent palpable change in the world economy that is stacked in favor of the North? The author mentions this ethical issue, but only in passing: "It is equally not acceptable for the industrialised world to contribute to these disadvantages both directly—for example, through the sale of arms—and indirectly, by keeping countries impoverished through various biased directives and embargoes." In fact, for those who accept the 4 principles of bioethics (and who assume them to be universal), the 4th is distributive justice. The fundamental ethical problem in Africa is not unethical doctors who "work within the constraints". I can appreciate that the author is troubled by what he sees here. But his proposals seem very much to be only the good intentions he mentions at the end. What do intensive care units have to do with child mortality? And he may have "longed for the much-maligned British social services", but would they really do a better job than the "traditional practices [which] in the main have a positive cohesive effect on society"?

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  Conflict of Interest:
  None declared.

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