Image source: http://www.savethechildren.org/site/apps/nlnet/content2.aspx?c=8rKLIXMGIpI4E&b=8943305&ct=14066953&notoc=1

Humanitarian aid programs exist in two different structures: horizontal programs and vertical programs. Horizontal aid programs aim to strengthen health systems to treat multiple diseases, while vertical aid programs utilize outside agencies to target a specific disease. Much debate surrounds the two different approaches to humanitarian aid.

“Case 8.2 Ethics and Humanitarian Aid: Vertical Aid Programs”  discusses a vertical approach to treating cholera in a refugee camp in South Sudan. However, due to the limited resources in the nearby hospital, individuals visit Dr. Asadour’s, physician with a Canadian NGO, temporary work station seeking out care for other illnesses and diseases. Thus, the case poses the following ethical dilemma: Should Dr. Asadour use his resources to treat all individuals despite their disease, or should Dr. Asadour follow the mandate and only treat individuals suffering from cholera?

Due to the nature of the situation, Dr. Asadour ought to continue the vertical approach to aid. Of all disease outbreaks in refugee camps, diarrheal diseases, such as cholera, generate the highest mortality rate (Connolly et al., 2004). In addition, the World Health Organization states, “Cholera is an acute diarrheal disease that can kill within hours if left untreated,” (World Health Organization, 2014). Furthermore, when not treated quickly, a cholera infection can lead to kidney failure, coma, shock from dehydration, and of course death (Mayo Clinic, 2014). Thus, cholera causes a great deal of suffering in a population, especially in refugee camps. Fortunately, however, simple treatment for symptoms of cholera exist. For example, oral rehydration salts successfully treat up to eighty percent of cases of cholera (World Health Organization, 2014). Therefore, Dr. Asadour possess the ability to reduce the suffering of eighty percent of the population who may end up dead from untreated cholera. Thus, on the basis of the principles of nonmaleficence and beneficence, Dr. Asadour ought to admit only patients infected with cholera.

Furthermore, the case explains that Dr. Asadour cannot always determine the cause of an individual’s suffering upon entrance into the medical tent. As a result, he may admit patients who have a different disease. At this point, an additional ethical dilemma arises. Dr. Asadour can either treat the individual or send him or her to the local hospital. Based on emotional state of the refugees, as articulated as frightened, Dr. Asadour ought to treat the patients whom he misdiagnoses during “intake” to minimize harm. For instance, since the refugees traveled unknown distances, admittance into a medical facility would provide the refugees with  hope. Therefore, by discharging patients without cholera, Dr. Asadour would be negatively impacting both their physical well-being and mental well-being. Thus, treating all admitted patients, with the initial screening process of cholera patients only, serves as the most ethical course of action.

Moreover, implementing a horizontal approach to aid could have potentially prevented the aforementioned ethical dilemmas. The sustainability of horizontal aid programs sets up the area for greater success and less suffering in the future instead of dependence from vertical aid. Nonetheless, since Dr. Asadour already traveled to South Sudan and set up his clinic, he ought to continue treating patients as previously outlined.

Connolly, M. A., Gayer, M., Ryan, M. J., Salama, P., Spiegel, P., & Heymann, D. L. (2004). Communicable diseases in complex emergencies: Impact and challenges. The Lancet, 364(9449), 1974-1983. doi: 10.1016/S0140-6736(04)17481-3

Mayo Clinic. (2014, April 5). Cholera. Retrieved from http://www.mayoclinic.org/diseases-conditions/cholera/basics/complications/con-20031469

World Health Organization. (2014, February). Cholera. Retrieved October, 2014, from http://www.who.int/mediacentre/factsheets/fs107/en/

In “Why Doctors Should Intervene”, Terrance Ackerman discusses various constraints on autonomy. For example, he explains how mental and social constraints have the ability to impede autonomous behavior. In class, we have debated over the relationship between incompetence and a lack of autonomy. However, we have not discussed in depth another constraint mentioned by Ackerman: physical constraints.

Ackerman states, “There are physical constraints- confinement in prison is an example- where internal or external circumstances bodily prevent a person from deliberating adequately or acting on life plans,” (1985). Thus, imprisonment removes not only the freedom from an individual but also the autonomy as well, which poses ethical questions. For instance, pregnant prisoners experience morally unjust treatment. A recent study published a “report card” for various components of medical care for pregnant prisoners. According to the scoring in the report, thirty-right states failed prenatal care, thirty-one states do not have a policy to hold the institution accountable without adequate justification, and forty states have laws that may allow shackling during labor (The Rebecca Project for Human Rights, 2010). Although all of the aforementioned statistics present ethical issues, the use of shackles strikes me the most.

http://www.theguardian.com/commentisfree/2012/jun/06/women-born-free-give-birth-in-chains

To begin with, as illustrated, the use of restraints during labor appears extremely painful. One woman explains how she had deep cuts from the shackling during labor and delivery (Law, 2015). In addition, shackles, especially waist chains, limit a physician’s ability to assess the condition of the mother and the baby, which puts both individuals at risk. Furthermore, restraints can limit mobility, which will interfere with vaginal delivery or slow down the process of an emergency cesarean section. Thus, institutions are violating the principle of nonmaleficence by causing additional harm or additional risk of harm to the patients.

Moreover, one can argue the role of a lack of freedom in the diminished autonomy. For example, since the women committed a crime and lost their freedom, then they do not have the right of autonomy. Although status affects autonomy, such as a minor, the status of an imprisoned person should not override the status of a human being. Human beings posses a high moral status that enable them to make autonomous decisions. However, by removing the autonomy of the pregnant prisoners, then the institutions are treating them as less than human.

Furthermore, institutions and physicians usually make their decisions about autonomy based on competency and understanding. For instance, physicians may deem an individual with a mental disease as incompetent, so a proxy will make the medical decisions for him or her. In the case of the pregnant prisoners, however, competency does not seem to matter. Although the women have the mental capacity to make their decisions about prenatal care and the labor and delivery process, they do not have the opportunity to do so. Therefore, the typical criteria for determining competency does not apply to prisoners either, which one cannot morally justify.

Moreover, Ackerman articulates that doctors should intervene in certain situations, including those with physical constraints. However, as illustrated above, physicians should not impede on the autonomous behavior of incarcerated pregnant patients, for it results in morally unjustifiable treatment of the women.

Ackerman, T. F. (1982). Why Doctors Should Intervene. The Hastings Center Report, 12(4), 14-17. Retrieved March 26, 2015, from http://www.jstor.org/stable/10.2307/3560762?ref=no-x-route:368d91fb989e22ecddae6d166c31991c

Law, V. (2015, February 13). Giving birth while shackled may be illegal, but mothers still have to endure it. Retrieved March 26, 2015, from http%3A%2F%2Fwww.theguardian.com%2Fus-news%2F2015%2Ffeb%2F13%2Fmothers-prison-illegal-shackled-while-giving-birth

The Rebecca Project for Human Rights. (2010). Mothers behind bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant and parenting women and the effect on their children. National Women’s Law Center.

(Image source: http://www.cbc.ca/news/canada/compassionate-homicide-the-law-and-robert-latimer-1.972561)

Society agrees upon nonmaleficence, the avoidance of causation of harm, as a fundamental principle of biomedical ethics (Beauchamp and Childress 13). For example, the idea of “do not kill” guides many in everyday actions. However, society has specified the aforementioned principle to include exceptions, such as “in the case of self defense”. Case 6.3 with Robert Latimer and his daughter Tracy exemplify another specification on the idea of “do not kill”, for Robert argues not to kill an individual unless in the best interest of the individual. For example, “Robert’s defence was that his act was “mercy killing” and that he had acted only to relieve his daughter’s continued and inevitable suffering,” (Thomas, Waluchow, and Gedge 222-223). Thus, he killed Tracy to protect her from a future life of pain. As a result, the judicial system classified this case as a “compassionate homicide”. The term “compassionate homicide” seems oxymoronical, for the principle of maleficence typically does not align with beneficence. For instance, beneficence would not justify an act of killing. However, the idea of “compassionate homicide” argues that beneficence, a connotation for acts of kindness and mercy (Thomas, Waluchow, and Gedge 202), promotes nonmaleficence. Thus, perhaps one principle of biomedical ethics can outweigh another principle.

(Image source: http://becuo.com/uneven-balance-scale)

Nonetheless, this case highlights many other ethical issues as well. For example, as an individual with cerebral palsy, the murder of Tracy challenges the rights of the disabled. The text articulates the slippery slope with regard to parallel scenarios, such as the withdrawal of life-support and physician-assisted suicide. However, the permissible violation of the fundamental right to life for people with disabilities can lead to the slippery slope of others further specifying “do not kill” to include other groups, such as the terminally ill. Thus, the judicial system opened up a frightening path for discrimination. In addition, this case questions the role of a medical proxy for an individual who cannot competently make a decision for himself or herself, because Robert made the medical decisions for Tracy. In Robert’s decision to end Tracy’s life, he acted on an extension of his duty to decide the treatment in the best interest of Tracy. As previously mentioned, Robert claimed that he killed Tracy to free her from future pain and suffering. However, his justification relies on an assumption that Tracy did not want to experience pain and preferred to die. The judicial system, for the context of this case, cannot assume that Tracy would have expressed the aforementioned desires. Unfortunately, however, the media influences individuals’ beliefs. For instance, news stations broadcasted the story of Brittany Maynard, a woman diagnosed with a brain tumor and only six months to live (Maynard). As a result of her poor projected quality of life, Maynard chose to undergo “death with dignity” and end her life instead of living in pain (Maynard). Thus, one can understand Robert’s justification for the “compassionate homicide” due to the influence, but Tracy could not express the sentiment of preferring a high quality of life rather than life at all like Maynard. Therefore, society and the judicial system should not justify the violation of “do no harm” and nonmaleficence on an influenced assumption of beneficence.

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford U, 2013. Print.

Maynard, Brittany. “My Right to Death with Dignity at 29.” CNN. Cable News Network, 02 Nov. 2014. Web. 26 Feb. 2015. <http://www.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity/>.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. New York: Broadview, 2014. Print.

          Informed consent requires the voluntary authorization for an action based on the complete understanding of such action. Thus, one cannot perform a treatment or intervention on another without gaining permission to do so. However, O’Neill articulates that limitations to informed consent exist. For example, incompetent patients, public health interventions, personal information, and vulnerable populations do not require informed consent in order to proceed with an ethical practice (O’Neill 2003). Although some of the aforementioned exceptions, such as public health interventions, do not warrant informed consent for an ethical practice, other limitations, such as vulnerable populations, should require informed consent.

          To begin with, public health interventions ignore the necessity to obtain informed consent, for they act on the principles of beneficence and nonmaleficence. For instance, vaccinations induce protection against a disease. Thus, by vaccinating a population, the risk of contracting a disease decreases. Unfortunately, many individuals in the United States are refusing to vaccinate their children against measles. Consequently, the prevalence of measles in the United States has greatly increased, as illustrated in Figure 1. Epidemiologists have traced the source of the outbreak to an individual in an amusement park in California (Centers for Disease Control and Prevention 2015). The source, an unvaccinated traveler, visited the amusement park while infectious (Centers for Disease Control and Prevention 2015). As a result of the abundance of unvaccinated individuals in the United States and the highly contagious characteristic of measles, herd immunity did not protect the seven-hundred individuals from the disease (Centers for Disease Control and Prevention 2015). Furthermore, the disease will likely spread to additional people in the United States, because individuals are refusing vaccinations against measles. Thus, the autonomy to give informed consent for an intervention does not adhere to the principle of nonmaleficence, for the unvaccinated individuals are causing harm to others. Therefore, public health officials should mandate the immunization of all individuals against the disease without requiring informed consent.

Figure 1.

Prevalence of measles in the United States.

    Although vaccinations support O’Neill’s claim of limitations of informed consent, prisoners challenge her idea of vulnerable populations. For example, O’Neill explains that individuals under duress have the capacity to consent but the inability to refuse (O’Neill 2003). However, ethical practices can still occur despite the lack of informed consent (O’Neill 2003). Unfortunately, history does not display ethical behavior towards prisoners. For instance, during the Nuremberg Trials, Nazis performed experiments on the prisoners without their consent (Emanuel  2003). For example, Nazis infected prisoners with malaria to test antimalarial drugs, placed prisoners in low-pressure tanks to analyze length of survival with little oxygen, and burned prisoners with phosphorus bombs to examine consequent wounds (Emanuel  2003). Although the Nazis were performing the experiments for the amelioration of society, the principle of beneficence does not apply. Therefore, the Nazis were not engaging in ethical behavior. Moreover, modern scientists have generally accepted the Nuremberg Trials as unethical practices. However, based on O’Neill’s explanation of the lack of requirement for informed consent of prisoners, society cannot prevent experiments such as the aforementioned examples from occurring again. Although prisoners do not have freedom, they should not lose the autonomy over their own bodies; prisoners should give informed consent as well.

          Thus, limitations of informed consent may exist, as illustrated with the public health interventions. However, treatment towards prisoners without informed consent does not equate ethical practice. Therefore, the context of the exception influences the limitation of informed consent and categorizes it as ethical or unethical.

Centers for Disease Control and Prevention. “Measles Cases and Outbreaks.” Centers for Disease Control and Prevention. February 02, 2015. Accessed February 02, 2015. http://www.cdc.gov/measles/cases-outbreaks.html.

O’Neill, O. “Some Limits of Informed Consent.” Journal of Medical Ethics 29, no. 1 (2003): 4-7. doi:10.1136/jme.29.1.4.