Questioning the Universality of Medical Ethics: Dilemmas Raised Performing Surgery around the Globe

Performing surgery in the developing world presents unique challenges and dilemmas for the visiting physician from an industrialized country. Language barriers, widespread, profound pathology, and lack of adequate facilities are obvious hurdles. A more subtle problem, though every bit as significant, is that the principles and procedures we routinely utilize at home to uphold ethical standards of care and to aid us in decision-making are often poorly applicable in the developing world. Acknowledging that cultural factors play a primary role in every aspect of their interaction with patients, physicians must scrutinize and even modify the tools they employ when attempting to deliver ethical care in foreign environments.

Over the past two decades, I have routinely taken time from clinical practice to teach, practice, and perform eye surgery in remote locations. I’ve enjoyed the privilege of vastly broadening both my professional skills and global perspective while working with some of the most devoted and selfless health care workers I’ve encountered in my career. From Mongolia to points along the ancient Silk Route, to the deep Himalayas, to Southeast Asia, to sub-Saharan Africa, many of the locations where I’ve worked lack basic facilities including potable water, reliable electricity, and proper sanitation. Nearly all lack what an ophthalmologist considers requisite for even the most basic intraocular surgery: adequate illumination and magnification. If available at all, the precise instrumentation necessary to manipulate tissue within the eye is usually worn or broken due to overuse and repeated repair. Cutting instruments are blunt; forcep tips no longer meet. Disposable equipment acquired through donation is meticulously cleaned and reused far beyond its intended lifespan, and medications are routinely expired or implicitly understood to be the “best available.” Surgical gloves and sutures are resterilized and used as long as possible. Dressings are ingeniously fashioned from material of every imaginable sort. Indeed, resourcefulness and ingenuity are the unique and necessary attributes of doctors and their staff throughout the developing world.

I am always presented with highly advanced pathology when working abroad, due in part to a chronic shortage of trained medical personnel and resources. Whether their ailments are secondary to trauma or to neglected or indolent disease, indigent patients usually seek care only when there is no alternative. The numbers are shocking: According to the most recent World Health Organization estimates, approximately 87 percent of the 314 million visually impaired live in developing countries; roughly 45 million are completely blind.¹ About 85 percent of all visual impairment and 75 percent of blindness could be prevented or cured.² While procedures performed to save or restore sight do not directly save lives, they are nevertheless crucial to survival in subsistence-level societies. A blind person often represents an untenable responsibility for both the family and the community. It is believed that 60 percent to 80 percent of children who become blind in the developing world die within two years.³ A Nepalese proverb conveys the economic reality most concisely: “A blind person has a mouth but no hands.”

In all of medicine, there is a unique burden associated with the decision to perform surgery. This arises, I suspect, from the very nature of an operation’s invasiveness, and is compounded by the unpredictable perils of intraoperative and postoperative complications. In the industrialized world, a surgeon’s decision to operate is not only strongly supported by well-defined ethical principles, but also facilitated by procedural tools that help to ensure the maintenance of these principles in daily practice. The most well-known is perhaps the Hippocratic edict to do no harm. Every graduating medical student is required to recite this commandment and implicitly understands it to be the sine qua non of ethical practice. During the course of training, we are also taught to adhere to our community’s “standard of care,” apply principles of “triage” where there are mass casualties or numerous emergencies requiring prioritization, and obtain “informed consent” prior to performing a procedure. The universality of these fundamental concepts is unquestioned.

So let us set off together on a typical mission, having packed...