1Department of surgery, Ambrose Alli University, Nigeria
2 Department of Surgery, Irrua Specialist Teaching Hospital, Nigeria
3 Department of Orthopaedic and Traumatology, Irrua Specialist Teaching Hospital, Nigeria
4 Department of Orthopaedic and Traumatology, Ambrose Alli University, Nigeria
Submission: January 28, 2020; Published: February 19, 2020
*Corresponding author: E Morgan, Department of Surgery, Neurosurgeon, Neurosurgery unit, Ambrose Alli University/Irrua Specialist Teaching Hospital, Nigeria
How to cite this article: Eghosa M, Gerald C A, Chima O, Ezemwenghian A M. Ethics and Challenges in the Practice of Neurosurgery in the Rural
Setting- Irrua Specialist Teaching Hospital Experience. Open Access J Neurol Neurosurg. 2020; 13(1): 555852.
Ethical issues have been at front burner of medical practice. It has guide the practice of neurosurgery, with the rural settings not been an exception to the application of the basic moral tenets which form the core value of ethics. This ethical principle guides the safe practice of neurosurgery in view of its sophisticated rigorous training and practice schedule aiming to protect the interest of the patients and the neurosurgeon. Our review looks through a literature search of medical ethics as it is applicable to the practice of neurosurgery.
Ethics has been defined in various ways with morality as it concerned the practice of medicine. It encompasses the various approaches to understanding and examining moral behavior. The study of ethics can be broadly divided into two areas normative and non- normative ethics. Normative ethics answers the question, what one has to do for a given moral dilemma. Non- normative ethics simply describes how people reason and act in moral situations, without commenting on the inherent rightness of their actions. The application of these principles to health care cum neurosurgery is quite new and evolving. It seeks to define, analyze and guide decision-making in medicine, as it relates to the moral issues that confront both health care providers and patients .
There is perhaps no other area of medicine that is faced with the challenges of ethics like neurosurgery. These challenges are worse for the neurosurgeon practicing in the rural area . The neurosurgeon working in the rural environment is faced with many challenges in addition with other general problems facing those in the cities. Some of this issue includes low manpower,
there is paucity of neurosurgeon and other healthcare workers in the rural setting this poses huge ethical challenges. Other special issues include social, cultural problem, religious belief, poverty, illiteracy and lack of health equipment [2,3]. The neurosurgeon alone has the training and education to operate on the organ that constitutes the locus of human consciousness, emotion and intelligence . With the advancement in technology, there has being increase accuracy in neurosurgical diagnosis due to the relative availability of computerized tomography scan, Magnetic resonance imaging, and equipment for image-guided equipment aiding ease and safe access to the skull and the spine. It is not is infrequent for the neurosurgeon to approach cases with a high risk of death or neurological deficit . The neurosurgeon is also faced with other ethical challenges in management of some cases like congenital anomaly, neurotrauma in the face of absent family relatives, quality of life and end life issues, making decision with profound ethical, spiritual and religious consequences [1,6]. The root of bioethics date back to fifth century BC when Hippocrates codified his musings on how a doctor should behave in the Oath of Hippocrates. The modern resurgence of bioethics occurred in the
late 1940s. The Doctors Trails in Nuremberg from 1946 to 1947
resulted in the formulation of the Nuremberg, outlining a list of
requirements for the ethical conduct of human- subject research.
This has been largely replaced by the World Medical Federation’s
Declaration of Helsinki .
This refers to the four pillar of bioethics Autonomy, non-maleficence,
beneficence and justice . Other aspect of bioethics
includes dignity and honesty . Autonomy- there is a shift from
beneficent paternalism to Autonomy. It is the act and willingness
of a patient taking decision in their health care. It forms the core
of informed consent. For there to be autonomy, patient should be
well informed of the benefit, risks and possible alternatives to
management of a given neurosurgical pathology . The acronym
PARQA (procedure, alternative, risk, Question, and Advanced life
plan) can be used for adequate patient counselling .
Primum, non-noncore (Above all do no harm). Every medical
intervention with neurosurgical procedure inclusive has an inherent
risk, neurosurgery is even associated with more risk. Arthur
Bloom-Field after an iatrogenic tragedy pleaded that every hospital
should have a plaque in the physicians and students entrance
stating there are some patients whom we cannot help, there are
none whom we cannot harm. It is better to communicate non maleficence
in term of undue risk of harm or intent to harm [1,8].
It refers to the act of doing well or performing acts of kindness
and charity. The intent should be for care or prevention. Quieta
non-movere (don’t fix it if it ain’t broke) i.e. intervention that are
unnecessary, thus ethical yardstick should be that, the benefit
should out ways the risk of intervention.
Justice is described as what is fair or deserved, or what one
is entitled to. Distributive justice ‘refers to fair, equitable, and appropriate
distribution determined by justified norms that structure
the terms of social co-operation. The allocation and rationing
of health-care resources at all levels and priority setting in the
health- care institutions are issues in which the principle of justice
plays a role . This is a key component of bioethics and it guide
the conscience in the application of knowledge of ethics in the
ensuring fairness to all parties concerned in the care Other ethical
principles includes- dignity- the neurosurgeon is to treat this
patient / client, and relatives with utmost respect. There should
as be dignity in every affairs of the neurosurgery, with colleagues
and other members of the health team. The neurosurgeon is expected
to be honesty to his patient in all deals and to maintain
Neurosurgery is the surgical specialty that treats diseases
and disorders of the brain and spinal cord . Rural and low-resource
societies have diminished capacity to carter for neurosurgical
patients due to lack of infrastructure, healthcare investment,
and training programs for health care practitioners  Irrua demographically
is a rural community located in Edo Central Local
Government area of Edo State whose people major occupation is
subsistence agriculture. It hosts a federal teaching hospital which
serves primarily people of irrua and adjoining rural communities.
Most neurosurgical patients in the rural setting are neurotrauma
patient , some who might be unconscious, and this
affects patient’s autonomy, a common scenario at Irrua. The neurosurgeon
might act in this scenario based on the local law of the
area. The autonomy of these rural patients is also affected by socio-
cultural factors, example gender inequality. Some female of
legal age might refuse autonomy to themselves and transfers it to
the male fold, who might not be acting in the patient’s best interest.
It might be a source of conflict of interest. Religion is also a
major issue, some religious beliefs are against some basic medical
principle, and it might hinder consent. For instance, the belief
in incarnation might prevent consent to removal of body tissue
for diagnosis (premortem) or postmortem. There is also in some
instances when individuals transfer his / her right of autonomy
to his or her religious leader and spouse or seeks their approval
before exercising it. Illiteracy is also a major challenge in the rural
settings, this prevents or makes the transfer, flow and dissemination
of information difficult. This thus affect patients’ autonomy.
The neurosurgeon in the rural area is faced with challenges
like lack, or shortage of well-trained manpower. There is also lack
or shortage of up to date neurosurgical equipment. This reduces
the safety of neurosurgical procedures when compared with the
cities. The neurosurgeon is face with the ethical challenge of to
refer or manage, bearing in minder the challenges of transferring
this patient like in emergency condition.
Futility can also bring controversy between patient and the
neurosurgeon. When a neurosurgery deicide not to go ahead with
a surgery due to its outcome which the patient or relatives think
contrary and vice versa. Another aspect is in the withholding or
withdrawing life support. Another challenge is in continuation of
treatment in patients with financial constraint or lack law health
insurance. This is very common in rural area with low socio-economic
status. The resource of the neurosurgeon might not be able
to care for all this cases.
The neurosurgeon in the rural setting is also faced with the
challenge of being just in rendering his services. Faced with the
issue of shortage , he might have to take a decision of continuing
service in management for a patient with a poor prognosis and
not taking in a new patient with better prognosis and vice versa.
Also, due to low manpower might have to decide either to go for
further training and leaving his patients or continue patient and at
the expense of further training .
Neurosurgery practice in the rural setting is associated with
many ethical issues. These ethical issues arise as a result of the
peculiarities of neurosurgery and also of the rural environment.
The neurosurgeon or surgeon working in the rural areas should
familiarize himself with these ethical challenges and driveways of
taking care of them.