Hey party people,
So I’ve decided to scrap the whole “I’m gonna do this chronologically!”
scheme of blogging (at least for this trip) and try my hand at discussing
different topics I’ve seen. The one at
hand? As I promised a while ago, what
I’ve picked up from being around the hospital (whether shadowing or listening
to people). As medical ethics is how I
roll, Part 1 of these reflections will touch on issues like informed consent
and the like. Maybe some of it’s
influenced from med lit I’ve been reading here (I’ve finished two Atul Gawande
books in my stay here… party, party, party).
Part 2 covers the experience I had mentioned in the last note: a visit
to a rural clinic. So without further
ado…
On my first day shadowing in the hospital, I followed around a Korean
expatriate as he did his rounds. Most of
the cases we saw were some form of strep-pneumonia or tuberculosis. There was an interesting diabetes patient…
instead of being obese, like you’d find in the West, he was incredibly
emaciated. Apparently, his form of
diabetes did not allow intake of any blood sugar, leading to no fat
deposits. Honestly, I’m not sure if I
completely understand the physiological cause, though from what I have learned,
many Bangladeshis get diabetes because of how they organize their
mealtimes. Most eat dinner late at
night, causing their blood sugar to spike, and then for the release of glucagon
at night (which releases sugar stores rather than promoting its uptake). Then there was the man whose legs were
paralyzed… because of Chicken pox. To
think that such a treatable disease would lead to such devastating effects is unthinkable to an American, but this
patient had come in too late to see physicians regarding treatment. What was it that delayed him? Thinking that he could wait it out and get
better? Financial burden? Who is to say?
It’s also interesting to note how religious conflict happens in patient
care, though not in a direct manner.
Rather, these battles are fought on how the religions can influence life
outlook. As opposed to the U.S., where
doctors may have to talk at length with families about continuing treatment,
physicians have to fight families for the care of their patients, against a
sort of “Enshallah”(if God wills) passivity.
For example, when a grandmother came in suffering from some form of
asthmatic attack, her relatives wanted to bring her home and let her die, even
though she could easily receive treatment for her condition. Thus, he had to tell them again and again
that she could be treated, even pleading with the family for just 24 hours of
treatment. While part of this may be the Enshallah attitude, I also wonder if
the level of pain people experience here, and the lack of relief from that
pain, encourages a more palliative outlook on medical situations as a
whole. If you contract a disease, and up
until now all you have known is that nothing can solve it, why prolong the
disease in a hospital setting? But from
our perspective, we see a puzzle that can easily be solved given enough time
and effort… or at least, this is the hope of the medical professional.
On the note of families, patient autonomy advocates would be appalled
at what can happen in medical decisions.
For most women, when asked regarding a treatment decision, will not give
an answer at all, but rather, turn to their husbands for their opinions. His decision is what stands, not hers. If that’s how it is in other areas of life,
why not medicine? Yet does the woman
have a conception of ownership of her body, such that she should be making the
decisions, rather than allowing them to be made for her? Even joint decision making would be a step in
the right direction, in my mind, as it would give both parties a voice. At the same time, the decision of a hospital
or doctor can make all the difference.
As I taught biology class about a basic way to approach bioethics
(principlism), one girl brought up how some small Indian hospitals refuse to
deliver baby girls, and that the physician automatically asks the father about
abortion if ultrasounds indicate the baby is a girl. The very fact that the physician chose to ask
the father rather than the mother speaks volumes as to the position women hold
in this area of the world
And then there are questions of patient understanding. With a language barrier and a lack of patient
understanding as to what treatments do, physicians find the degree of informed
consent their patients possess difficult to gauge. If they are not informed enough, does one
take on a paternalistic role, and if so, how does one amend this image? You want to treat the patient as best you
can, yet you want to ensure patients voice their treatment options from a
knowledgeable standpoint. Perhaps the
degree of informed consent one might aspire toward only comes with further
education on both sides:: of the doctor in language and communication skills,
and of the patient in general knowledge of medical practice.
The standards for such things as informed consent obviously differ from
nation to nation. So what do you do when
you have professionals from England, Germany, New Zealand, America, and the
Netherlands all serving in the same facility?
Should each go off of their own understanding of patient care, a standard
of the host country, or should there be some generalized “international”
medical ethics code in place for them to follow when issues arise? The first option would appear to lead to too
different forms of care, e.g., for a patient teetering on the edge of life and
death for the third or fourth time, with little hope of survival, would
patients go to an American whose system trains doctors to always “fight” for
the patient, or to a Dutchman whose system encourages more palliative measures. If possible, operation under that nation’s
standards would be optimal, though if none exists, and international standard
should be implemented. Which, of course,
requires even more education on behalf of all physicians choosing to serve in
the country.
Even without ethical questions, difficulties in care can surface. I followed a team of a pediatrician, a
physical therapist, a surgeon, and a nurse from four different nations try to
figure out what was best for a toddler who had broken his femur. How would we set it best? Well, according to another surgeon from a
fifth country that was phoned, the leg should be put into traction. However, questions of the best way to do this
arose due to different approaches from a medical perspective (which type of
tape do we use to hold the leg in place, and how should it be applied?), from a
nationality perspective (the toddler happened to be a foreigner as well, so how
should care be given if there is likelihood of transfer to another hospital?),
and from simply a lack of resources (the only formal traction equipment in our
possession was for adults). Using a mix
of ingenuity, a textbook on hand, tape, and a weight made from a 7-UP bottle,
the traction was set in place for the child.
Such situations thrill me at their complexity, as one has to determine
the proper care to be given both social and logistical variables. The Korean physician also discussed with me
how he had created a makeshift cauterizer from another metallic piece of equipment,
and how he had prepared an injection to save a patient’s life that he had only
read about previously. Is it right to
test things on patients like this under limited time and resources? When a patient’s life is in the balance, is
it better to let the patient go and die peacefully, or to try all that one can
with all that one has to save the patient, not knowing if the treatment or
technique will ultimately work? I know
this sort of thing is not uncommon; the final chapter of Gawande’s Better discusses his experience in rural
India, and how physicians must engage creative techniques to address everything
from ulcers to brain hemorrhaging. And
according to his work, some of these physicians’ ingenuity has led to better
methods than their Western counterparts.
I would rather err on the side of saving the patient, though I would
pray that God would give me the assurance and ingenuity to know what to do when
such moments arise in practice.
This one’s already really long, so I split the rural clinic visit into
a separate chunk. Love you people!
In Christ,
MJW
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