Ethics and Medicine

Throughout medical school and residency, we are constantly taught those ‘basic’ ethical principles in medicine.  Those principles of Justice, Beneficence, Nonmaleficence, and Autonomy are grinded into our head every year for our in service exam so that by the time it’s time to take your boards, you might actually remember each specific definition.  Big words, but basic principles . . . do what is best for your patient; respect their decisions for care; and most importantly EQUAL CARE TO ALL. 

I have found myself needing to approach these principles in a very different way during my time down here.  The patient care is actually quite basic.  At times I feel like I’m still in medical school, just pretending I’m a doctor as much of the care I provide necessitates some type of macgyvering capabilities.  Using foley catheters for bartholin’s abscesses (I’m not sure if that is the correct way to pluralize); cutting up gauze instead of q-tips for cancer screening; diagnosing and treating all of our different vaginal infections by smell and sight (which is also one of the great joys of being a gynecologist) . . . I think you get the point.  [Although, I still can't do a c section with a paper clip].

For the most part, the simplicity of this program has not been too challenging from an ethical standpoint.  You see something abnormal, you take it off . . . plain and simple.  [I have had some concerns regarding the business aspect of the program, but that is a completely different blog].

What is killing me is the concept of justice.  The fact that I know many of these patients could be getting better care in the United States makes me feel like I’m doing something wrong.  Today, I saw a 32 year old who I suspect may have an early cervical cancer (and her exam is somewhat skewed as we are in fibroid country).  She still wants to have children . . . so what to do?  [In case if I had not mentioned, the pathology specimens go to the patients to take to a pathologist in port au prince if they can afford it . . . thus far, no one has opted to take it to the big city].  Tell her I suspect she has cancer and needs a hysterectomy just by the appearance?  . . . Do an aggressive LEEP and just hope that everything has been removed? 

I explained to her my thoughts, gave her the option of doing either, but strongly recommended that if she has the LEEP performed, to have the specimen taken to a pathologist in port au prince.  Luckily, she agreed.  

I realize, just writing it down, the whole sequence of events seems quite easy.  But what you are forgetting is that there is no insurance here . . . the patients have to pay for everything.  You think twice before ordering a test.  If I had every patient do what is considered the standard of care in the states, they would all go bankrupt.  You need to decide what is 100% essential to taking the care of the patient.  Everything is so skewed.  Even though that in my heart, I feel that this is the right thing to do, a part of me feels guilty that it is necessary for her to pay for a pathologic evaluation.  

Although those basic principles of medical ethics are the same wherever you go, various places provide different challenges in their application.  I guess it’s good that I question myself on a daily basis as to how best to practice these concepts (much better than the alternative!)