Comprehensive Child and Adolescent Nursing

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Ethical Considerations: Pediatric Short-Term Medical Missions in Developing Countries John S. Murray To cite this article: John S. Murray (2016) Ethical Considerations: Pediatric Short-Term Medical Missions in Developing Countries, Comprehensive Child and Adolescent Nursing, 39:1, 20-29, DOI: 10.3109/01460862.2015.1088595 To link to this article: http://dx.doi.org/10.3109/01460862.2015.1088595

Published online: 15 Oct 2015.

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COMPREHENSIVE CHILD AND ADOLESCENT NURSING 2016, VOL. 39, NO. 1, 20–29 http://dx.doi.org/10.3109/01460862.2015.1088595

Ethical Considerations: Pediatric Short-Term Medical Missions in Developing Countries John S. Murray, PhD, RN, CPNP-PC, CS, FAAN

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School of Professional Studies, Northwestern University, Chicago, Illinois, USA ARTICLE HISTORY

ABSTRACT

For many years pediatric healthcare experts have debated how much benefit was derived by host nations from the well intentioned efforts of Pediatric Short-Term Medical Missions (STMMs). Most of the literature on STMMs, while limited, has focused on frameworks for the delivery of care. Today the focus of these endeavors is on the ethical implications. The purpose of this article is to describe how the focus of STMMs has changed over the past 15 years from delivery of care frameworks to ethical considerations.

Received 17 June 2015 Revised 7 August 2015 Accepted 24 August 2015 KEYWORDS

Developing countries; ethics; pediatrics; short-term medical missions

Short-term medical missions During the 1990s I traveled to developing countries several times a year to provide humanitarian aid in my role as a pediatric healthcare professional in the United States (U.S.) Air Force. One of the issues that was discussed broadly even then is how much benefit was derived by the host nation from these well-intentioned efforts. In fact, in 1999 I published an article that discussed what I thought could be done on these short-term medical mission (STMMs) (e.g. vitamin A supplementation, treatment of intestinal parasites, oral rehydration therapy, etc.) and what interventions may not be so helpful (e.g. treatment of chronic conditions) (Murray, 1999). Most of the literature on STMMs, while limited, has focused on frameworks for the delivery of care. Today the focus of these endeavors is on the ethical implications. The purpose of this article is to describe how the focus of STMMs has changed over the past 15 years from delivery of care frameworks to ethical considerations. STMMs are also referred to as medical missions in the civilian community (Berry, 2014) or military operations other than war and humanitarian and civic assistance operations in the U.S. military (Agazio, 2010; Johnson et al., 2013). The concept of medical missions originated from religious missionary work. It is estimated that upwards of 6,000 STMMs, with thousands of volunteers, occur around the globe annually costing in excess of $250 million (Naujokas, 2013). The top four countries supporting medical missions are the CONTACT John S. Murray © 2016 Taylor & Francis

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20 Chapel Street Unit # A502, Brookline, MA 02446.

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U.S., Canada, United Kingdom, and Australia respectively. Central America and Africa are the recipients of most STMMs (Martiniuk et al., 2012). For the purpose of this article, the focus of STMMs will include those where healthcare providers deliver care benefitting children and not delegations attended by those without health care training. Most STMMs to vulnerable communities in developing countries last weeks to months, and health care is oftentimes provided to 200 to 2,000 patients in makeshift clinics (Berry 2014; Mulvaney & McBeth, 2009; Murray, 1999). Teams generally consist of 6 to 10 healthcare professionals (e.g. nurses, physicians, pharmacists, etc.). The amount of supplies, medications, and teaching materials brought depends on the length of the mission, type of healthcare professionals on the team, and the amount of available funding (Murray, 1999). STMMs are not meant to provide a full spectrum of care, especially where complex, long-term conditions are involved. Instead missions, especially those that predominantly serve children, focus on more acute illnesses which have a higher likelihood of being treated as a result of focused interventions (Martiniuk et al., 2012; Murray, 1999). During STMMs children benefit from interventions such as vitamin A supplementation, single dose therapy for parasitic infections (caused by intestinal helminths and protozoan parasites), oral rehydration therapy, and treatment of selected infectious processes (e.g. otitis media, respiratory infections, etc.) (Haque, 2007; Murray, 1999). These medical missions provide an invaluable learning experience and insight into international healthcare delivery. STMMs undoubtedly offer great value to communities in developing countries. Community members are appreciative of the care provided even for a limited period of time. STMMs not only provide health care services not otherwise readily available in the area, but also serve as an opportunity for healthcare professionals to experience the challenges confronted which are not always evident to the outside world. STMMs are valuable in putting a human face on the health care deficiencies as well as providing hope for the communities that ongoing support may ensue (Bonner et al., 2013; Martiniuk et al., 2012). It is important for healthcare professionals supporting STMMs to acknowledge and remember that while makeshift facilities and poor resources of the host community may be substandard; this is what the local natives have to work with. They are doing the best they can to provide services with what little resources they have available (Mulvaney & McBeth, 2009). While publications over the past 15 years regarding STMMs have been mainly focused on delivery of care frameworks, there is an increasing need to focus on the ethical challenges associated with these endeavors (Crump, Sugarman, & the Working Group on Ethics Guidelines for Global Health Training (WEIGHT), 2010; Hunt et al., 2012; Martiniuk et al., 2012; Sheather, & Shah, 2011). Poverty, illiteracy, lack of health care services and

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medications, and cultural and language differences have the potential to result in exploitation (Emanuel et al., 2004). Ethical guidelines for STMMS remain in their infancy. What procedures exist are based on those used for clinical research in developing countries (Decamp, 2011). The meaning of ethical in context of this article relates to providing care in accordance with principles used to decide what actions are right or wrong based on professional standards. Ethical considerations during STMMs A highly effective way in which to consider ethical issues in the delivery of health care during STMMs is using the four principles of biomedical ethics pioneered by Drs. Thomas Beauchamp and James Childress. The four principles include beneficence, nonmaleficence, autonomy, and justice (Gillon, 1994). Beneficence and non-maleficence

Beneficence refers to the act of providing care that affords the greatest benefit to others which is a fundamental principle of patient advocacy. Non-maleficence means doing no harm to individuals in the course of providing care which is at the core of professional nursing ethics (Beauchamp & Childress, 2009; Gillon, 1994; Lawrence, 2007). It’s important that health care professionals providing care during STMMs balance beneficence and non-maleficence. One of the ethical challenges of STMMs is that those providing care to disadvantaged populations in resource-poor environments oftentimes automatically assume that any type of care provided is good. However, even when the goal of any initiative is to do good, inevitably there is also the risk of causing harm (Gillon, 1994). The ethical principles of beneficence and nonmaleficence require healthcare professionals to consider both the benefits and harms of assistance provided. The objective is always to achieve benefit over harm (Wallace, 2012). There is a paucity of published literature that provides guidance on how to consider the benefits of STMMs. Likewise, there is very little evidence regarding possible harms that may occur as a result of these missions. What is more likely to be noted in the literature are the benefits of STMMs failing to consider even the possibility of harm (Berry, 2014; Decamp, 2007). In fact, STMMs carry the potential to do more harm than good (Berry, 2014). For example, during missions it is very common for dermatological conditions to be treated (e.g. scabies, pediculosis capitis, fungal infections, impetigo, cellulitis, etc.). Head lice are readily treated with Permethrin 1% rinse or Pyrethrin shampoo. However, in order for the intervention to be effective, the entire family must be treated (Murray, 1999). Lindane shampoo is sometimes distributed for lice or in lotion form to treat scabies. Westerners do not think of these treatments as being harmful

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because they are used frequently. However, lindane products can be poisonous if not used properly. Lindane is easily absorbed through the skin. If applied excessively, it can affect the brain and nervous system causing seizures. Oftentimes those individuals receiving care during STMMS are illiterate and unable to read instructions for use. Safe use of the product requires extensive education provided in a language the patient and family understand as well as at an appropriate reading level (Berry, 2014; Murray, 1999). It is highly recommended that instruction provided to parents cover disease communicability, proper administration of medications, and possible complications. If the healthcare provider does not speak the native language of the host country, instructions should be provided by a translator (Murray, 1999). Providing care during STMMs requires the use of empirical information regarding the probabilities of the harms and benefits that may occur from any planned intervention (Bonner et al., 2013; Gillon, 1994). Another potential situation for ethical concerns is treating chronic medical problems during STMMs. While some chronic pediatric illnesses may seem routine, and easily treated in the Western world (e.g. diabetes, hypertension, etc.), healthcare professionals must be prepared to recognize that care of these diseases go beyond the scope of the short term nature of medical missions. There is more potential to do more harm than good since followup medical care and refills of medications may not be readily available. Even if available, families may not have the financial or transportation resources to obtain this care. This same holds true for children who present for care late in the course of their disease (e.g. malnutrition, severe anemia, cancer, and congenital heart disease). Healthcare professionals can potentially help by working with the host country Ministry of Health to determine if there are resources available for the long-term care needed (Murray, 1999; Walk et al., 2011). STMMs should aim to provide interventions that will provide the most benefit for the greatest number of children (Walk et al., 2011). An aspect of STMMs that benefits individuals over time is empowerment— supporting communities to be more in control of their own health as well as health care systems. STMMs should work within the existing health care structures, not in opposition to them. Empowerment is thought to combine the principles of beneficence and respect for autonomy in ways that not only respect but also enhance self-sufficiency (Bonner et al., 2013; Gillon, 1994). Respect for autonomy

Individuals who have autonomy are able to freely make their own decisions based on information provided as well as act upon their choices in regards to their own well-being. As such, there is an agreement on behalf of nurses to respect an individual’s right to determine what is in their best interest (Beauchamp & Childress, 2009). This means that the recipient community

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should be consulted regarding what services are needed during STMMs. Even during STMMs, healthcare providers are required to consult with those they treat even though most patients traveling to clinics do so based on their own decision (Bonner et al., 2013; Decamp, 2011). Confidentiality is another important aspect of respect for autonomy. Many individuals cared for during STMMs fear stigma associated with their illness. Infectious diseases (Courtwright & Turner, 2010) and behavioral health (Murray et al., in press) are two key examples. In the absence of confidentiality, these patients are less likely to seek care. Maintaining confidentiality provides two key elements of care—respect for autonomy and greater likelihood of care. Respecting autonomy also requires being able to communicate with patients. If the STMM provider does not speak the native language, it is critical that an interpreter be readily available (Gillon, 1994). Justice

Justice refers to ensuring that all individuals be treated fairly whereby there is an equal and fair distribution of resources, based on analysis of benefits and burdens of decision (Beauchamp & Childress, 2009; Gillon, 1994). During STMMs there are limited resources available. There is often a shortage of medications; and equipment considered basic to care in developed countries (e.g. disposable gloves, blood pressure cuffs, thermometers, glucometers, etc.) is almost always inaccessible in developing countries. Even simple resources such as pens, pencils, and paper for documentation may not be readily available. It is not uncommon to witness patients die of medical conditions that are treatable. However, STMM healthcare workers must recognize that there is no alternative option when there is a complete absence of resources. Often not all patients can be seen which might raise concerns regarding justice (Bonner et al., 2013; Wall, 2011). Limited time to provide care during STMMs is also an ethical consideration. Healthcare professionals providing care do so for a finite period of time (e.g. weeks to months as previously noted) (Berry 2014; Mulvaney & McBeth, 2009; Murray, 1999). Oftentimes healthcare providers depart the country for home before all patient problems have been addressed. The sheer number of individuals requiring care during STMMs intensifies the problem of limited time. Healthcare providers want to see as many patients as possible, which shortens the amount of time spent with each individual and subsequently may lower the quality of care. However, this is the only method for quantifying the impact of services provided (Wall, 2011). The best approach to distributing health care resources is by meeting the needs of those requiring services the most while maximizing benefit as much as possible. This requires determining how best to care for each patient as well as the community (Figure 1) (Bonner et al., 2013; Gillon, 1994; Wall, 2011).

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Figure 1. Children waiting for care during a STMM in the Philippines. Source: Global Voices. This work is in the public domain. Available at: globalvoicesonline.org.

Recommendations—what makes STMMs ethical Pre-mission planning

There are many complexities associated with STMMs. Healthcare providers delivering services will undoubtedly encounter ethical issues. Decisions will need to be made regarding allocation of resources, treatment of focused medical conditions, and time allotted per patient. These decisions often present unexpectedly in the field when healthcare professionals do not have access to ethics consultants. Therefore, it is imperative that potential ethical challenges be considered prior to the mission when resources are available (Wall, 2011). Pre-mission training and planning affords healthcare providers a wonderful opportunity to discuss the ethical dimensions of STMMs (Hunt et al., 2012;Wall, 2011). There are a number of ways healthcare providers can prepare for STMMs. One of the most valuable tools is to speak with individuals who have prior experience with medical missions. Often these individuals have lessons learned that would be of benefit especially as it relates to ethical dilemmas and methods for solving them. Being familiar with host nation cultural beliefs and practices will be of value in working with patients. Healthcare professionals should also invest the time to learn about the health care facilities they will be using as well as resources available (Wall, 2011). Participants must take the time to determine what infrastructure already exists in the host country and work with the local system to do no harm to local residents and the community. Actions must be critically evaluated to

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ensure that the host country is benefitting from the effort being provided (Wall, 2011). Understanding limitations in advance of medical missions will go a long way in planning for how to best to utilize those resources and recognizing in advance what interventions can be feasibly provided. Recognizing limitations related to resources and staffing will provide a basis for anticipating some ethical situations that may present (Decamp, 2011; Wall, 2011). Guiding principles

Global outreach activities can be productive and beneficial for host countries especially if provided with an ethical framework in mind (Bishop & Litch, 2000; Decamp, 2011). Currently there is increasing focus on ensuring STMMs follow a robust ethical framework in the same way as for international research (Decamp, 2011). Healthcare providers should understand and adhere to ethics and best practice guidelines. For example, Crump and colleagues (2010) offer guidelines regarding ethical challenges that may be faced during international training experiences. The guidelines are considerably helpful as they address the roles and responsibilities of institutions sending individuals to developing countries, the volunteers themselves, as well as the host country. The WEIGHT guidelines can be used by any discipline and activities other than STMMs (e.g. research and education). Some factors to consider include benefits to sending and host institutions, mitigation of adverse outcomes related to the short duration of experiences, proper preparation and supervision of providers of care, and safety. Another helpful ethical framework for STMMs is that provided by Children’s Health International Medical Project of Seattle. Their guidelines were developed in response to wanting to have a model for providing sustainable ethical care in El Salvador. The model consists of seven guiding principles (Suchdev, 2007): (1) Mission: A mission statement provides a framework for addressing the needs of the community during a global health mission. The statement should be regularly reviewed for changes in the way care is delivered. (2) Collaboration: Partnerships with the local community are essential for providing an infrastructure that best meets the needs of the host country. This entails empowering communities to provide some of the services needed. (3) Education: Learning about the needs of the host country, infrastructure present, and supplies available should take place well before the medical mission. Teaching host country providers helps to increase

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(4)

(5)

(6)

(7)

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their knowledge base as well as provides them with new skills. Following missions, healthcare professionals should share their experiences in order to expand the state of the science as it relates to providing care in developing countries. Service: The best way to maximize the benefit of missions is to focus on priorities identified by the local community. Care can be provided in a much more focused approach with these goals in mind. Listing needs also helps in determining the type and amount of supplies that may be needed for the trip. Teamwork: In order to gain the greatest benefit for the local community, it is best to bring a variety of healthcare professionals (e.g. nurses, physicians, laboratory technicians, pharmacists, etc.) who can provide their expertise to address the most important needs. It is also helpful to work with healthcare providers in the host country since they will be providing continuing care at the end of the mission. Sustainability: Providing the greatest benefit to developing nations is done by creating sustainable projects that can be continued by the local community and built upon during future missions. This empowers the community as well as shows commitment to an ongoing partnership. Evaluation: To determine if the community’s priorities are being met, it’s important that an evaluation mechanism be in place to measure progress and improve upon future missions. This could be as simple as meeting with the local community, host country healthcare providers or health committees in the developing country and asking for feedback to using a structure-process– outcome approach.

Conclusions The frequency and type of STMMs is expected to only increase in the future. While frameworks for delivering care have been discussed to some extent, greater attention is needed on understanding the most common types of ethical problems encountered during medical missions. Limited resources, healthcare personnel, and time, coupled with language and cultural barriers have the potential to result in ethical dilemmas. This article broadly highlights some potential areas of ethical concern during STMMs as well as suggests some frameworks for delivery of care in a principled manner. Additional dialogue is needed to continue to address ethical issues during STMMs as well as explore what interventions others have found to be effective in dealing with concerns when they present.

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Acknowledgment The author gratefully acknowledges the support and encouragement of Dr. Sarah Rodriguez, Global Health Studies program at Northwestern University.

Declaration of interest

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This manuscript has not been published elsewhere and has not been submitted simultaneously for publication elsewhere. The author has no conflicts of interest, financial or otherwise, to disclose.

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Ethical considerations: pediatric short-term medical missions in developing countries.

For many years pediatric healthcare experts have debated how much benefit was derived by host nations from the well intentioned efforts of Pediatric S...
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