Page 37 - 59peadiatric-surgery-speciality8-14_opt

CHAPTER 13

Ethics of Paediatric Surgery in Africa

Daniel Sidler Benedict C. Nwomeh
Sharon King Peter F. Omonzejele

Introduction somebody, not nobody—a doer, deciding, not being
A paediatric surgeon not only has the responsibility to care for the decided for, self-directed and not acted upon by external
young and developing patient but equally has the duty to counsel and nature or by other men.
care for the concerned parents—and sometimes their broader family
members, who all live within a very specific cultural milieu with its This is in stark contrast to the African philosophy of Ubuntu, which
value systems and demands. Besides surgical skills, therefore, a pae- basically says that one’s humanity is dependent on the appreciation,
diatric surgeon needs to be aware of the psychological, cultural, and preservation, and affirmation of the other person’s humanity, as was
ethical issues involved with the care of patients and their families. At well expressed by Dzobo in 1992 : “We are, therefore I am, and since
3
times, this can be quite challenging. I am, therefore we are.”
Paediatric surgery has a long and interesting history of profound Before we go into the discussions of what constitutes African ethics,
concern with providing quality of care and the many potential ethical we need to clarify the use of that term in this context. The entire African
dilemmas encountered. Old traditions as well as new technological continent cannot be said to have identical cultural ethics. However,
developments can present with a quagmire of ethical dilemmas, and ethical themes and values are similar “in their essentials, as African
modern paediatric surgeons should be aware of these issues and have cultures, metaphysics, attitudes are at least very similar”. For the
4
the cognitive and emotional maturity as well as the skills to carry out purpose of this chapter, the generalisation to African ethics based on
their duties in the most professional manner. similar African cultures is therefore acceptable. This applies with the
This chapter can only be a very short introduction to some important exception of North Africa, where cultures and ethics are more in line
ethical issues, concentrating on the often neglected African aspects. with Islamic injunctions.
History African ethics (also known as African traditional ethics) is communal
in outlook; it defines moral precepts and values that Africans abide by
Historically, the Hippocratic Oath defined the ethical principles guiding
consciously or unconsciously in their day-to-day living. Those moral
medicine, instructing physicians to use their knowledge and skills for
precepts are defined and founded on communal values. Hence, Africans
the benefit and protection of their patients. Over the years, a collab-
have the saying that “one can only dance well when one dances in
orative process has evolved, incorporating ethical principles of patient
line with the drum beat of the community”. This means that what is
autonomy, respect for persons, nonmaleficence, beneficence, and jus-
1
tice. In this model, the physician contributes medical knowledge, skill, considered good or bad is what the community considers as such. For
instance, amongst the Esan people of southern South Nigeria, ebeme
and judgment; the patient or patient advocate personally evaluates the
and agbonsi (the good and worthy life) are understood in terms of the
potential benefits and risks inherent in the proposed treatment.
communal good. This means that the realisation and actualisation of the
Western medical ethics may be traced to guidelines on the duty
self is expected to be through and within the community and not outside
of physicians in antiquity, such as the Hippocratic Oath and early
of the community.
rabbinic and Christian teachings. From the medieval and early modern
However, this does not mean that the self is suppressed in favour
period, the field is indebted to such Muslim physicians as Ishaq bin Ali
of the community. Rather, it means that in the actualisation of the self,
Rahawi, who wrote the Conduct of a Physician, the first book dedicated
the community should and indeed must be taken into consideration. As
to medical ethics, and al-Razi; Jewish thinkers such as Maimonides;
a result, community recognition and appreciation are highly important
Roman Catholic scholastic thinkers such as Thomas Aquinas; and the
in African communities, and a member cannot be recognised by the
case-oriented analysis (casuistry) of Catholic moral theology. These
community if his or her moral values are personal and subjective and at
intellectual traditions still continue today in Catholic, Islamic, and
variance with those of the community. This is important, as “morality in
Jewish medical ethics.
African traditional thought is essentially interpersonal and social, with
In modern times, five main reasons have been constitutive for
a basis in human well-being”.
5
the birth of a discipline of biomedical ethics expressed succinctly by
2
Isaiah Berlin : African ethics is based on a communal and utilitarian foundation.
In traditional African societies, the good aims for greater benefits to
the generality of the community, and is therefore not based on religious
I wish my life and decisions to depend on myself, not on or divine injunctions as such. “The gods may only be relevant when it
external forces of whatever kind. I wish to be the instru- comes to the use of divination and application of sanctions, that is, if
ment of my own, not other men’s act of will. I wish to a member of the society errs against the norms of the society and he
be a subject, not an object; to be moved by reasons, by is unrepentant”. This belief implies that the consequences of one’s
6
conscious purposes which are my own, not by causes actions rather than the alignment of such action with his or her religious
which affect me, as it were, from outside. I wish to be faith determine praiseworthiness from a community perspective.