some reflections on ethics, technology, medicine, and a real life story from extreme poor Africa

June 18, 2010

My father pastors a congregation in rural Swaziland. Their biggest task is looking after the victims of HIV & AIDS in a home-based care program. Earlier this week he wrote a story on the use of technology in this extremely poor area of Africa, where even running water and electricity is a luxury most people don’t have access to.

Ons of the things I do somewhat on the sideline is working in ethics at the University of Pretoria. Over the past few weeks I was part of a team teaching Engineering Ethics (I’ve been part of this for a number of years now), and I marked a number of papers in Christian Ethics and Health care. From this ethical perspective, I’d like to make a few remarks, to point out some of the complexities raised by the story. I’d suggest you first read this.

One of the complex questions we try to bring to the attention of Engineering students on their way to make a life in the field of technology, is the problem of the weakening between the causal link of an action, and the possible negative outcomes. This raises the question of who are to be held responsible in the case that something went wrong.

On the other hand, in ethics and medicine we tend to focus on doctor-patient relations, and all kinds of potential models for how medicine should be applied or understood, while the reality of Africa is that there simply isn’t doctors available for people, many times not adequate medicine available, and difficulty in accessing medical facilities from rural areas. The questions concerning medicine and ethics in areas of poverty might by much less about what to do with the doctor that messed up an operation, than about what to do about a system which doesn’t allocate enough doctors to the poor (or doctors who prefer not working with the poor).

Now, some questions and reflections surfacing out of the above and the story.

If I ever visited a doctor, who looked at my medical record, and took out his phone to check the name of something written there, and in reference to some random google hit (which didn’t get to number one on google because the South African board of medicine thought it should be there) would tell be what I should do in future, I’d be really unhappy. But in this case we’d probably be OK with the act (or maybe you wouldn’t, but then I’d get to that in a moment). But lets say that the answer found from google was wrong? Now, I’d agree that chances are almost nothing, but what if it were? Who’d be responsible? If it was my hypothetical doctor, we’d surely say he’s responsible, since he was supposed to have access to the right journals and textbooks. But what if it was my father the missionary, pastor and theologian? Is he responsible? Can we hold wikipedia responsible if incorrect information was found on there site (assuming he got the info from a wikipedia site), which lead to wrong advice given in this situation, and possible worsening of the patients condition? How does the fact that there is a total lack of doctors in this specific area affect our thinking? The fact that we live in a system where it’s simply not possible that a doctor or nurse would see this lady of her family to make sure that they have all the correct information.

More complex, is the questions concerning the photos. What if the pharmacist would make a wrong judgment on the photo, and prescribe something which would worsen the wound? Would he be responsible? What if he refused to look at the photos? Would he then be responsible for not giving advice? What about all the millions of trained doctors that isn’t giving advice even electronically? Can the fact that distant advice is possible become a hindering factor in making sure that adequate doctors are sent to these poor areas? Can new possibilities in applying medicine distance interfaces become a further reason for not getting doctors into the areas which need them most? And what about the story told by comment no. 4 about doctors being trained to use advanced technology, and now refusing to work in areas where this technology isn’t available. Could the wonders of modern medical science become yet another worsening effect for the health of the poor of society?

Reflecting on the layers of complexity in the decisions that need to be made in this situation should obviously bring out the importance of context, and be a reminder that certain answers we give in our comfortable developed existence, simply cannot hold in other contexts. Furthermore, it’s a reminder that in times of crisis, we change our perceptions of right and wrong. Few of us would rely on the methods described above in our daily medical care, but in the extreme crisis the people of rural Swaziland are finding themselves with HIV & AIDS, these same processes become life-giving beyond our imagination. But furthermore this story brings out the absolute injustice of medical care, where the rich have access to the most amazing possibilities thanks to technology, while the poor don’t have access to the most basic of medical attention.

And as you read this thanks to the same technology that delivered the pictures to the pharmacist, and gave the answer to my father, technology becomes the tool focusing our attention on the injustice mentioned above, and the question is forced down: Who should now take responsibility for this injustice? And what is our responsibility when technology make us aware of injustice in the world?

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