Medical Volunteering: An Ethical Debate

(By Roxanne Leung, Queen’s University)


 

Students often desire to embark on volunteer trips to foreign countries, driven by . The prospect of dedicating a season to broaden your perspective on life in a new culture while meeting some of the practical, social, or spiritual needs identified is inspiring to many. Such was the case for me; In my second year of my undergraduate studies  I decided to join a medical aid volunteering team that regularly visited the province of Yunnan in South China.

International medical volunteering is an opportunity that allows trained healthcare professionals to lend their time and expertise to address global health care needs. Not-for-profit humanitarian aid groups such as Médecins Sans Frontières are widely known and appreciated for their international relief efforts and non-partisan responses to public health emergencies. The extensive toll of the most recent Ebola outbreak in West Africa is another example of both the impact and sacrifice of medical aid workers and the need for the international community to continue to provide public health and medical support.

For the course of my trip, I accompanied a roster of surgeons, nurses, pharmacists, therapists, and other health care professionals. Our team was able to provide fully covered surgical procedures and post-op care at a local hospital through fundraising activities. Many of the patients came from surrounding villages outside the city, and common clinical cases were severe burns, contractions, and cleft lip and palettes. Managing these injuries and disabilities was extremely difficult, and their quality of life and level of independence were often severely diminished because villagers could not afford medical care provided by local doctors.

In my capacity as the team photographer and IT coordinator, I was able to observe almost every case that the team took on. Officially, I helped manage patient records and photographed pre- and post-op conditions. Unofficially, I was like a fly on the surgical room wall, able to candidly capture images that told a story of the team’s efforts. There is one case that stands out to me in particular. There a patient, in his mid-twenties, presented with two congenital facial tumors: one that covered the left half of his cheek, ear, jaw, and mouth and almost doubled the size of his face and a second, smaller tumor above his right eye. Despite careful planning by a three surgeons, complications that could not have been anticipated arose and the patient was left in critical condition after two aggressive procedures. Fortunately, the three surgeons on the team specialized in plastics, ophthalmology, and cardiology; it was agreed that the procedure was not beyond the scope of their expertise. During a consultation with the surgeons, he was fully informed of the risks and provided his consent. He explained that in the village where he lived, he was socially marginalized due to his appearances, unable to find work, and willing to accept the risks if it meant the possibility of a better life. It was the first time that I felt the necessity of preparedness to address dilemmas and complications respectfully, compassionately, and with prudence and humility so intensely.

The first stage of the procedure was the removal of the tumour above his right eye. The ophthalmologist discovered the root of the tumour stemmed from the optic nerve, but successfully removed it without damaging the patient’s vision.

The second stage was significantly more complex. Since tumours are highly vascularized, the blood vessels within the tumour had to be individually cauterized at the same time the tissue was being cut away in order to reduce the amount of blood loss. Extra caution had to be exercised to differentiate tumour tissue from blood vessels, nerve fibres, and facial muscles. The laborious procedure had to be done slowly and with precision.

Vital signs were constantly monitored to keep an eye on the patient’s stability, and after a few hours the anesthetists began to doubt the accuracy of the local hospital’s equipment due to occasionally inconsistent readings. However, they continued the procedure. As the hours wore on the patient’s blood pressure, heart rate, and core temperatures steadily decreased due to the blood loss.

Around the sixth hour blood transfusions became a necessity to compensate for heavy blood loss.

At around the seventh hour, the tumor was finally removed.

Through it all, his blood pressure remained at a critically low point and his core temperature refused to increase, so the surgical team focused their efforts on stabilizing him. They asked local hospital staff for sterile heat blankets and prescribed him calcium to increase the heart rate and bicarbonate to clear the acidosis in his blood. Unfortunately sterile heat blankets were not available and there was an unexpected delay in acquiring the medications from the hospital’s pharmacy since the procedure was not being performed by local hospital staff. To improvise, the nurses filled bottles with hot water, wrapped them in sterile cloth, and placed them next to the patient’s body and they submerged IV tubes and blood transfusions in pans filled with warm water.

At one point, the patient developed an allergic reaction to medication that was given, and later his vitals had become so low that the surgeons began performing resuscitation maneuvers.

In the last few hours, there was desperation amid the chaos as everyone did what he or she could to revive him while the vitals obstinately declined. Dozens of blood transfusions and our own medical supplies were mostly depleted in the process. Almost 12 hours after the start of the procedure, the patient’s vital signs slowly began to improve. He was transferred to the intensive care unit, and there came an immense sigh of relief the next morning when we learned he had remained stable throughout the night. Though it was slow and painful, he proceeded to gain a full recovery and was eventually discharged from the hospital. Within a few months, he sent the team a picture of himself at his new job.

In the aftermath, much was debated and discussed during the team debriefing. Was it worth it to invest so much manpower and supplies on one severe case when our resources could have made an impact on a greater number of simpler cases? Would expending all our resources have been worthwhile if the procedure had been unsuccessful? Would we still have continued if we had anticipated the complications? Many recognized that the consequential perspective and “what ifs” did not provide a framework for decision making in future cases. Others argued about the ethics of providing a different standard of care based on the country. Still others saw that the challenges they faced were similar to ones they encountered in North America, though the context was significantly different.

I realized that there is no prescriptive checklist, and ethical decisions have to be examined case by case. Simply collecting informed consent and ensuring sufficient expertise is not enough; preparedness must be examined to address as many conceivable risks as possible. However, predetermined risks are only estimations and not all factors may be taken into account. This is a reality that is applicable even “back home”; medical professionals are often required to make numerous judgment calls under time constraints with limited information and unexpected complications. The decision to treat this patient was borne out of compassion for his suffering and ostracization from society. It was respect that treated him with dignity and allowed him to choose. It was prudence that made it feasible to give him our medical care. And it requires humility to recognize that the outcomes never was or will be entirely under our control.

However, this highlights the gravity and depth of responsibility all the more, as the impact has the potential to be tremendously good or harmful. The repercussions of reckless decision making on individuals and between organizations could significantly impede the work that caring individuals set out to accomplish.

Out of my own experience with medical volunteering, I have learned that while much can be done to improve the lives of others, it is important to be mindful of the responsibility this entails. Teams need to be vigilant in using sound ethical frameworks to guide medical decisions. At the same time, human judgment is never omniscient or perfect. This has impressed upon me a sobering understanding of and a greater appreciation for those who dedicate time out of their lives to serve others in the medical field.

 

By: Roxanne Leung

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