In the thirty-odd years I have worked with torture survivors, I have heard countless versions of the following story. When Azad* was a 22- year-old university student in his home country, he participated in a public demonstration, criticizing the government’s financial cuts to social programs important to his minority group. He and many other demonstrators were apprehended and brought to a crowded holding centre. They slept on the floor, had limited access to a dirty toilet, and were given a cup of water with a small amount of non-nutritious food twice a day. Azad was taken for interrogation on three occasions. He was accused of having links to terrorist organizations outside the country, and of spreading seditious ideas (his interrogators had found political leaflets in his backpack). They demanded the names of organizers. While being questioned he was struck repeatedly on his back and thighs with police batons, and on the third occasion they beat the soles of his feet. Afterwards he could not ...continue reading →
Ewan C Goligher MD is an Intensivist at Toronto Western Hospital and a doctoral student in the Department of Physiology at the University of Toronto, Toronto, Ontario
Stephen W Hwang MD MPH is a General Internist at St. Michael’s Hospital and Professor of Medicine in the Department of Medicine at the University of Toronto, Toronto, Ontario.
The writing is on the wall. Physician-assisted death is very likely to soon be legal in Canada. Although legal decisions cannot put to rest ethical controversy, the winds of public opinion have shifted considerably, and policy changes will probably gain rapid and widespread acceptance in Canadian society. Requests for assisted death will become more frequent. Canadian physicians, of whom only a minority have indicated a willingness to provide or administer lethal doses of the drugs at their disposal, will therefore be faced with the serious personal ethical challenge of deciding whether to honour such requests and whether to refer patients to physicians willing to accommodate such requests. ...continue reading →
Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK
Taking your nine year old to climb Mont Blanc (altitude 4810m), seeking the record for the youngest ascent, is high risk on a mountain where about 100 people die each year. At what point on the scale of encouragement-to-achieve do we stray into the red zone? Take a look at this clip from ABC News in the US showing Paul Sweeney and his two children aged eleven and nine climbing in the snow and, watch as one child, then another, slip off the mountain. The children were unhurt but the mayor of St Gervais les Bains, which includes Mont Blanc, was highly critical. While there are non-medical questions about who controls the wilderness and when we should intervene when adult behaviour puts others, such as the rescue services, at risk, there are other deeper ethical questions when children are involved.
An underage athlete was also one of the main medical stories at the Commonwealth Games. Chika Amalaha, a 16year old female Nigerian weight lifter was stripped of her gold medal when, according to the BBC, amiloride and hydrochlorothiazide, both prohibited as diuretics and masking agents, were identified in her urine sample.
While this clearly transgresses the ethical and legal boundaries, and is particularly serious when it involves a minor, other sporting situations involving children are less clear. To achieve excellence in sport requires immense commitment with intensive skills training from a young age. Children are vulnerable and may well not be making informed decisions for themselves so, although we are generally impressed by outstanding underage performance, we might also sometimes feel uncomfortable.
Other random Commonwealth Games medical thoughts- while I marvelled at English diving sensations Victoria Vincent (13) and Matthew Dixon (14), on the 10m board, I wondered if repetitive diving risks damaging the developing brain. I have no idea if there is significant impact on striking the water. (Perhaps someone might respond.)
In boxing, blood streaming from cuts made dramatic, if rather unsavoury, television. Amateur boxing has shed head protection making head clashes more likely. Head gear may not reduce repetitive impact but it will reduce potential blood injury. Medicine struggles with boxing. It is difficult to defend a sport where the ultimate aim is to inflict direct injury but the sport is generally well regulated and undoubtedly benefits many young men and women. There is no body contact in squash but the ball is a perfect fit for the orbit and I was impressed with the eye protection worn by squash players in those amazing externally transparent courts. Good sports medicine should be in the background. If it is makes headlines, it usually means there is something wrong so we should acknowledge the outstanding work of the host medical team since among the non-stories were a well contained potential outbreak of gastroenteritis and an Ebola virus scare.
On Monday, as the athletes left the airport in a swirl of bagpipes, we gathered in another part of Glasgow for a memorial service celebrating the life of Professor Stewart Hillis, a cardiologist and one of pioneers of Sport and Exercise Medicine. Long-time Scotland Team doctor, he contributed much to soccer, including introducing cardiovascular screening of referees, worked enthusiastically with UEFA and FIFA medical committees, and was a close friend and confidante of many soccer legends, including Sir Alex Ferguson who gave one of the eulogies. In his academic role, he was a key to introducing the BSc and MSc in sport and exercise medicine to the University, and educating a generation in sport and exercise medicine, many of whom worked on the Games and some of whom came in their team kit. His was a life spent in the service of others – a witty, inspirational, and incredibly committed professional, and a wonderful colleague and friend.
Last week I was fortunate enough to be invited to a great workshop, organized by the CMA’s Public Health division, aimed at developing a unified policy and advocacy platform for humanitarian medicine. As the background reading material pointed out, many Canadian physicians are interested in participating in humanitarian medicine initiatives and work or volunteer abroad at different stages of their life and career. The problem is that many such activities are ad hoc, not optimally planned, fragmented, and undertaken without due consideration of their impact. The CMA hopes to co-ordinate efforts in Canada to explore and delineate best practices, and to optimize the way that global health activities are coordinated among NGOs, physicians, residents and medical students.
I’ve had some experience with developing guidelines for best practice during short term experiences in global health. In 2010 I was part of a group led by Jeremy Sugarman, professor of bioethics and medicine at Johns Hopkins, and John Crump, a professor at Duke’s Global Health Institute, that produced the first Open Access guidelines on Ethics and best practice guidelines for training experiences in global health. The first decade of the new century saw an explosion of global health programs that would send students and graduates for short term experiences, usually from a developed country to a less developed country (without much traffic in the other direction). To quote Sugarman, we now have a “stunning prevalence of initiatives covering a broad range of activities, institutions, and countries”, offered by “Governmental, Non-‐governmental, Religious, Humanitarian relief, Academic and Professional [organizations].”
In the early 1990s, as a medical student in Johannesburg, South Africa, I spent some clinical rotations in Baragwanath Hospital in Soweto. There I met many foreign medical students (mainly German and British) who came to get 'developing world experience' (mostly of performing surgery that they would not get to perform at home). If they were keen and hung around long enough sooner or later they’d get to do an appendectomy, or a circumcision, or excise a lipoma the size of a baseball. Ethically sound behavior? Mmmm. Not so much.
But it isn't just students. Trained physicians from wealthy countries also go to less well developed areas to offer their skills. Historically the pattern was for physicians to pack up their lives and go to live and work in an under-served area for many years. Yet in the last few decades the ease with which air travel and temporary accommodation can be arranged has changed this pattern. Now the opportunity exists for physicians to keep their ‘developed world lives’ relatively intact while taking a short trip to ‘do good’ somewhere else.
Do they do good? That's the million dollar question. While they may be motivated by good intentions there is no clear evidence that such activities are beneficial in an enduring way to the host countries. An oft-quoted paper points out that there IS benefit for physician who goes abroad for the brief stint, both for that physician personally and for his/her home country (because such people are more likely to work in under-served areas back home in their future careers). Trainers from leading humanitarian organizations acknowledge that one thing we DO know for sure is that there is always some harm that comes from even the most well-intentioned of humanitarian missions (see list of resources below).
Some of the ethical considerations and potential negative consequences of short term global health experiences were outlined in an influential 2008 JAMA article. The cynical term ‘voluntourism’ is perhaps a realistic descriptor of such activities, given their clear benefit for the traveler and much less clear benefit for the receiving community.
I think there is a particular difficulty for many who are fired up by the noble desire to ‘do good’ or ‘make a difference’ to stop and think about potential negative consequences of their well-intentioned behavior. Because how could giving up one’s time for the good of others be bad? Yet it is probably ‘placebo’ at best as some have argued “don’t go”. But realistically, without some Icelandic volcanic ash scenario in which all airplanes out of North America and Europe are grounded, physicians will continue to go abroad on global health ‘missions’. The only thing that we can do is increase awareness of ethical concerns, encourage physicians and students to think about scenarios ahead of time and endeavor to educate, educate, educate…. in the hope that the harm done by people going on global health experiences and humanitarian missions can be minimized.
The CMA meeting’s participants were top notch, representing all the main stakeholders leading the way in humanitarian activities and global health electives in Canada and some international players, perhaps with the notable exception of experts from countries who receive medical humanitarian missions and voluntourists. The CMA will produce an official report at the end of the process. In the mean time here are some educational and support tools that may be helpful to those who are thinking of going abroad to ‘do good’ in a medical way.
The Johns Hopkins Berman Institute of Bioethics collaborated with the Stanford Center for Innovation in Global Health to produce an excellent case based online course on Ethical Challenges in Short-Term Global Health Training. [This course is based on the guidelines on Ethics and best practice guidelines for training experiences in global health I mentioned earlier; it is widely understood that case studies are the best tools to teach applied ethics…best for pre-departure training, but also useful as an in-field resource and to assist debrief after return.]
HumEthNet, a website that developed out of empirical research on the ethical dilemmas faced by humanitarian healthcare professionals working in humanitarian crises, disasters or areas of extreme poverty.
The McGill Humanitarian Studies initiative, which offers the Canadian Disaster and Humanitarian Response Training Programs that range from an introductory course to an advanced program that includes simulation training.
The 53rd week, a non-profit organization that aims to maximize the benefits derived from short-term volunteer initiatives using innovation, education, and research.