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Ethics of Paediatric Surgery in Africa 77
Western-Style Medical Ethics diagnosis, prognosis, treatment options, etc. A patient’s role, on the
Let us first look at the Western style of medical ethics and at the five other hand, is to inform his or her physician about values and prefer-
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important constitutive points and discuss how we could apply these ences concerning treatment”. The assumption here seems to be that
principles to an African context: all value-judgements should be the patient’s responsibility. Such an
assumption, however, is illusionary because value-free information is
1. growth of the middle class with its new value system of individual- 10
ism, utilitarianism, and a culture of consumerism; impossible to attain.
More important are five consequences of this informative model.
2. disenchantment of the world, leading to a decline of a reliance on (1) It impoverishes the patient-physician relationship by discouraging
myths, religions, and ideologies, leading to an increased rational and doctors from empathising with their patients because such empathy
practical approach to life;
is considered undesirable and might negatively influence the doctor’s
3. increased influence of feminism, giving rights to women; professional attitude. (2) It stops any discussion between the patient
4. fragmentation of society into different spheres, such as human and doctor from the beginning, preventing doctors from questioning
rights, morality, religion, politics, jurisdiction, family, school, etc. as perceived strange and irrational patient treatment demands and
well as the super-specialisation within medicine; and preferences. (3) It prohibits physicians from sharing their acquired
personal experiences and moral beliefs. (4) It completely misinterprets
5. new belief or ideology of a technoscientific progress into utopia.
patients’ preferences as ready-made and given; it does not acknowledge
Such faith in a utopia achievable by technoscientific progress
or allow patient preferences to develop or to be adjusted during the
boosted the scientific enterprise enormously. Such scientific discoveries
course of illness and therapy. (5) It deals with the patient-doctor
were not only embraced with enthusiasm, but created an equal amount
relationship and their respective preferences and attitudes as if there
of controversy. Medical progress (e.g., haemodialysis becoming
were no overall, encompassing societal good to be considered; it
possible with the development of the arteriovenous shunt, or techniques
completely ignores that both patient and doctor have their preferences
of cardiopulmonary resuscitation), together with the perennial problem
imprinted by society and need them to be adjusted from time to time by
of limited resources, raised a set of very difficult considerations, such
the overall good of society.
as who should live, who should die, and who should decide?
Paternalism, as the opposite of the informative model, often
Such positive development was not without serious abuse of
involves some form of interference with or refusal to conform to
physician power, as is highlighted by the Tuskegee study. One of US
patients’ preferences. “Paternalism, then, is the intentional overriding
president Bill Clinton’s more convincing apologies in recent times
of one person’s known preferences or actions by another person, where
was that made on 16 May 1997, for the infamous Tuskegee Syphilis
the person who overrides justifies the action by the goal of benefitting
Study. From 1932 to 1972, hundreds of poor black farm workers
or avoiding harm to the person whose will is overridden.”
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with syphilis were deliberately left untreated, with the supposed goal
Within the African context, paternalism has hardly been contested.
of studying the natural history of the disease. Participants received
It is still common and easy for physicians to ignore and neglect patient
free food and transportation to encourage them to join a study they
autonomy. Apart from the cultural divide and lack of exposure to each
were told was aimed at curing their “bad blood”. In fact, government
other’s value systems, there is an underlying assumption that medical
officials went to inordinate lengths over the decades to ensure that
knowledge and technology could be too complex to understand for
these men received no treatment at all, even after the discovery of
patients in general, and African patients in particular. Patients easily
penicillin. It is inexplicable that such a study went on for more than
develop unrealistic expectations of modern medicine and adopt a
40 years (1930–1970), even after a treatment for syphilis was found.
cowed role, trusting their doctors’ expertise unconditionally.
It is unlikely, even after the Nuremberg Code and the Universal
We suggest that the dichotomy between autonomy and paternalism
Declaration of Human Rights (1948), that people would be safe from
be abandoned altogether to favour a model of deliberation wherein
unethical research practices.
patient and physician interact, share and finally make the decision
Recent research on male circumcision as a prevention of human
together. Both parties ought to accept moral responsibility to arrive
immunodeficiency virus (HIV) (3 randomised controlled trials (RCTs)
at a decision. Such a solution is more than just the consensus of two
in South Africa, Kenya, and Uganda) requires assessment of the
positions and suits the African context and philosophy of Ubuntu. The
research outcome for the female partners of those men who were HIV
deliberation model points to the urgent need for democratisation of
positive at the time of circumcision, to realise that a Tuskegee could
Western medicine and its institutions.
be repeated. It has been suggested that the female partners of the
Giving informed consent for a procedure on a child has its own set
HIV-infected men who were circumcised had not been informed that
of problems. It is morally advisable, if a child has the cognitive and
they were part of a study. The outcome of the study as reported by
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Dr. Wawer, showed that the HIV incidence of those female partners emotional maturity to understand the situation, that his or her assent
should be sought as well as the consent of the parents or legal proxy.
increased by 60% over a period of two years.
Parents, however, do not have the right to refuse or give consent
Informed Consent to surgical procedures if doing so would be detrimental or of no
In the Western world, a specific style of conversation between the immediate benefit to the child. Paediatric surgeons should be familiar
patient and doctor has developed whereby the patient is encouraged with each country’s individual legislation.
to take a more active, informed position within the decision-making The ethical justification of informed consent is respect for the
process. Some physicians, however, still point out that they can solve patient’s and family’s autonomy and for the right of the patient or proxy
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all difficult questions without discussing them with the patient or the to make informed decisions. Informed consent is, therefore, one of our
patient’s proxy by relying solely on their own professional expertise. main duties as paediatric surgeons, and this usually means obtaining
It is important, however, to be aware that professional expertise is not parental consent.
without value judgements. Therefore, the physician-patient relation- Informed consent includes a three-tier cascade, each step presupposing
ship has been described as an often-conflicting power dichotomy. An the previous one.
extreme on the side of patient autonomy denies any room for physician 1. Determination of the patient’s competence to give consent:
decision making. Such an extreme approach had been called the infor- Competence is a prerequisite to be able to give informed consent.
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mative, or engineering, model of the patient-physician relationship, A competent patient needs to be able to grasp the essentials of what
whereby the “physician’s role is to disclose factual information about is explained, to think rationally and logically, and to come to an