Mini Review

Medical Ethics and Pandemics in a Low- and Middle-Income Country-what is the Fate of the Health Worker who Render Neurosurgical Services? - The Nigeria Example?

Eghosa Morgan^1,2*, Charles Esekhaigbe³, Ezemwenghian Morgan⁴, Poluyi Edward⁵, and Ikwuegbuenyi Chibuikem⁵

¹Clinical Neurology, Observer in Neurology-Oncology, Master Neurosciences, Comprehensive Cancer Centre, Clínica de Occidente, Santiago de Cali, Colombia

²Medical Doctor, Emergency and hospital rooms, Clínica de Occidente, Santiago de Cali, Colombia

³Internist, Universidad Fundación San Martín. Clínica de Occidente. Santiago de Cali, Colombia

⁴Internist, Universidad Fundación San Martín. Clínica de Occidente. Santiago de Cali, Colombia

⁵Internist, Universidad Fundación San Martín. Clínica de Occidente. Santiago de Cali, Colombia

Submission: October 10, 2020; Published: November 11, 2020

*Corresponding author: Eghosa Morgan, Department of Surgery, Ambrose Alli University Ekpoma, Nigeria

How to cite this article: Eghosa M, Charles E, Ezemwenghian M, Poluyi E, Ikwuegbuenyi C. Medical Ethics and Pandemics in a Low- and Middle-Income Country-what is the Fate of the Health Worker who Render Neurosurgical Services? - The Nigeria Example?. Open Access J Neurol Neurosurg 2020; 14(4): 555891.DOI: 10.19080/OAJNN.2020.14.555891.

Abstract

The world is currently facing ravaging pandemic of novel coronavirus with imminent collapse of health services, economic activities and widespread loss of lives with surgical services somewhat on the suspense. The low- and middle-income countries are faced with huge infrastructure deficit, poor or non-existing efficient and effective health care services and a rampaging situation of brain drain of trained health care providers to the developed world leaving a huge gap on health care delivery which is presently been compounded by coronavirus. Medical ethics guide the practice of neurosurgery and it bring the core of morality in the practice of safe health care delivery culminating in better surgical outcome. These health workers who are surgeons have the responsibility to ensure they, their families and community are safe within a morally acceptable precinct while in the forefront of service delivery in this pandemic, but there exists a situation where neurosurgeons are being asked to ensure ethical standards without the adequate tools as commonly seen in poor countries. There must be a balance between ensuring ethical standards are followed and also ensuring that those in frontline are safe from being a victim of the societal failure. Infrastructural deficit in the low- and middle-income countries like Nigeria have direct correlation with the level of corruption in the polity. A recent publication by Bloomberg [1] highlighted the level of neglect, infrastructural deficit in which the article deride Nigeria leaders are being trapped in their countries with no standard health facilities and have nowhere to run to as many nations facing the coronavirus pandemic have barred them from accessing their health facilities with embargo on land, water and air travels.

Keywords: Ethics; Health workers, Politics; Fate

Introduction

Medical ethics have been described in various ways to mean morality in the practice of medicine [2]. There is no other time that the practice and emphasis on medical ethics is best taught and understood than this global novel coronavirus (COVID-19) pandemic. Ethics has two branches: normative and non- normative ethics. Normative ethics answers the question, what one has to do for a given moral dilemma [2]. Non- normative ethics simply describes how people reason and act in moral situations, without commenting on the inherent rightness of their actions and this non-normative ethical teaching bring into the fore the problem faced by health care workers in infrastructure deficient low- and middle-income countries. The application of these principles to health care delivery becomes a huge burden in face of global pandemic by ensuring safety for first line providers some of which are neurosurgeons who will attend to neurosurgical emergencies in coronavirus patient. Though medical ethics seeks to define, analyze and guide decision-making in medical practices in view of the moral issues that confront both health care provider the neurosurgeon and the health care providers and patients [2].

The foundation of medical ethics dates back to fifth century BC when Hippocrates codified his musings on how a doctor should behave in the Oath of Hippocrates which has evolved over the last century. 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 [1]. Four basic principles are commonly associated with medical ethics in this modern era [3].

Principilism

This refers to the four pillar of bioethics Autonomy, nonmaleficence, beneficence and justice [1]. Other aspect of bioethics includes dignity and honesty of patient and caregivers (7). 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 disease [1,3]. However, the autonomy of a patient during pandemic is called into question as overall public safety may override individual and this is a poser to health institutions and neurosurgeons during this pandemic.

Non maleficence

Primum, non noncore (Above all do no harm). Every neurosurgical treatment has an inherent risk and benefit, with risk more to the patient and caregiver during pandemic such as the COVID-19. 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 harm2 than ignore such as neurosurgical procedures are risky and therefore need all the important tools to be available before been commenced, so the question arisesshould neurosurgeons in low and middle income countries who are likened to battle field soldier do more harm to themselves or patient by providing care without adequate safety materials? Nigeria has been in the forefront of fighting this scourge with past and present government paying little or no attention to health care delivery. Bloomberg in their recent article likened the Nigeria situation to those whose ineptitude have caught up with them as they have no option to continue their medical tourism in view of global restriction on movement [1].

Beneficience

It refers to performing acts of kindness and charity even in the face of challenges such as this pose by COVID-19. The intent should be for care or prevention. Quieta non-movere (don’t fix it if it ain’t broke) such as the intervention that are unnecessary, thus ethical yardstick should be that, the benefit should outweigh the risk of neurosurgical intervention. Such neurosurgeons render charity in the face of paucity of safety gadget and needed facilities to carter for patients.

Justice

Justice refers to what is fair or deserved, or what someone is entitled to or benefit well deserved. 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 [2]. 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. It is only fair that they are at liberty to make choice in ensuring justice and fair play in applying medical knowledge and safety to carter for patients. Government in low and middle countries across the 3rd world with Nigeria not being an exception have had reckless attitude towards investing in health care services with politicians looting the commonwealth of the people to seek medical tourism in the developed countries leaving ghost facilities at the mercy of poorly equipped neurosurgical units. Should neurosurgeons abandon their responsibilities due to the simple reason of lack of safety materials and tools to work in this global pandemic, the answer to this could be an affirmative yes as it is justice to be fair and cause no harm to the patient, to themselves, their families and the community. The fate of neurosurgeons in Nigeria and other lowand middle-income countries lies in the application of the tenets of medical ethical. Politics has consequences and decision made by politicians has direct effect on health care delivery and justice demand people should not be sent to war without weapons to attack the enemy. The coronavirus pandemic has been likened to the 3rd world war and the army to fight this invisible enemy are the heath care worker who must make the right decision for the safety of all including [4].

Few questions do arise – does this country have modus of operandi in protecting health workers during global pandemic? If health workers refuse to attend to this patient, are there fundamental human right breach. These above questions leave gaps in application of medical ethics during pandemic and this leaves the health care worker a gap to protect themselves in the face of failures of government in this low- and middle-income countries.

Conclusion

Health care worker such as the neurosurgeon in the low- and middle-income countries fate lies in the clear understanding and application of ethical principles within the best of what is available and provided during pandemic. They have a moral duty not only to care for the patients but to protect the immediate community and the country by determining where, when or how to intervened with the limited resources and materials as the battle against the COVID-19 rages.

References

1. DulueMbachu (2020) Trapped by Coronavirus, Nigeria’s elites faces squalid hospitals. Bloomberg Africa on Twitter.
2. Dimitrios Panagopoulos (2018) Ethical Issues in Pediatric Neurosurgery Practice: The Neurosurgical Point of View. Biomed J SciTech Res 10(4): 804-806.
3. Beauchamps TL, Childress JF(2001) Principle of Biomedical ethics (5^th edition).
4. Udo Schuklenk (2001) Health care professionals are under no ethical obligation to treat COVID-19 patients. Journal of Medical Ethics.