8. Ethics

Michael Krosin¹

(1)

Department of Orthopedics, Alameda Health System, Oakland, CA, USA

Michael Krosin

Email: mkrosin@alamedahealthsystem.org

Typically, international work will take place in a setting with different resources from one’s home country and in unfamiliar medical and cultural environments. This combination presents ethical considerations one should be aware of prior to embarking and includes patient-centered issues of safety and culture, host country physician issues, host country systems issues, and the special situations of either disaster relief or investigative research.

The foremost priority for any physician is patient safety. Surgery in austere environments that might be standard in one’s home country may ultimately create more harm than good. Lack of certain technologies, implants, and a proper sterile environment may create risks that outweigh the benefits. Overly aggressive treatments, which result in poor outcomes, can create lasting mistrust and erode relationships.

There are situations where proper implants and environments exist and difficult procedures may be done safely. However, the aftercare, particularly in the face of complications, may be absent. The availability of aftercare should play a major consideration as to whether a procedure should be performed.

Lastly, proper record keeping should be prioritized by the visiting surgeon. Every effort should be made to establish an accurate, comprehensible, and accessible medical record. While most country’s records are paper-based, it is a good idea for the visiting surgeon to keep an electronic file of implants and procedures in the event the paper chart is unrecoverable.

Patient autonomy in decision-making and other cross-cultural issues can present unforeseen challenges. Time, patience, and alternative methods of communication should overcome these barriers. It is important to set realistic expectations and clearly define the risks of a procedure, and in turn, it is helpful to have the patient verbalize his understanding. Patient and family expectations of physician paternalism may lead them to minimize the risks and overestimate the benefits of intervention. Cultural expectations may discourage the patient from asking questions or exercising his right to either decline or discuss treatments. The host country physician may also discourage questions. In certain cultures, other family members may decide on behalf of a patient. It is up to the visiting physician to make sure that a standard of informed consent and dialogue commensurate with the surgeon’s own standard is maintained while respecting local culture (Box 8.1).

Box 8.1 Pointers for Informed Consent

Prior to talking with the patient, discuss the consent with the translator, and resolve any issues of understanding or translation.
When possible, use pictures or graphics or electronic devices.
Describe percentages, odds, and risks using locally accessible analogies. In developing countries, there may be a therapeutic misconception that a foreign doctor will not encounter any problems and everything will be “normal” again.
Include the patients’ family in the consent process if appropriate, but be aware that family members may prevent the patient from asking questions.
Pause often and allow plenty of time for questions.
Have the patient repeat back “in their own words” the critical risks, recovery time, immobilization, rehabilitation parameters, and likely deficits of function so that you are sure he understands. Explain that it is important to ask questions and that no question is bad or silly. Let the patient and/or family start by asking questions to get a background understanding even before the consent process begins.