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

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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White kid in Swaziland

I grew up in the southern part of a small country called Swaziland. It has less than a million people living in it, and most on them living in the north. My father was a pastor in a black congregation there. The people of Swaziland are poor, as is general for the most of Africa. We lived in a 600m2 house owned by the church, across the street my father’s black collegue was living in a much smaller house with his family.

I have many good memories from this place. Typical child stuff – playing, climbing trees, riding bicycle. But I also remember the black congregations in which my father was working. I remember the singing, and even today still remember some of the songs, and recognize them in black congretions in Mamelodi when I visit. I remember the ways in which they collected the meagre amount of money on a Sunday, with singing and dancing.

But I never had black friends in Swaziland. Well, apparently I had as a very small kid according to my parents, but I can’t remember them. My friends were white. Blacks were the other. They played by themselves. We played by ourselves. When we had birthday parties, it was the white kids from the small white community in South Africa, and the white kids that we went to school with in Piet Retief, the white town on the other side of the border.

I do remember some of the black collegues my father had, with some of them I can remember not really noticing colour. Not caring to be touched by them. Easily talking to them. Especially Baba Gama, who always checked to see if I could recognize his voice when he was calling and I would answer. I remember black people sharing the table with us at our home, and we with them at conferences. I had much of the inter-culture experience that kids of missionaries have. I treasure that.

But I know this: the black people living across the street, the black people in town, even the black congregants, I weren’t looking at them as equals. I don’t know if I were racist at this stage of my life, but I definitely had a sense than the black people among whom I were living weren’t “on the same level”.

small town church

Most of my city friends will see my hometown, Piet Retief, as a small town. They think it small that I grew up in a town with basically one primary school, and one highschool (of course, this is a lot more complex because of the Apartheid destinction between the town and the township). Usually I see this as small myself, after 6 years in Pretoria.

But for the first 10 years of my live I grew up in an area which was really rural, in the town Nhlangano in the southers part of Swaziland. And the percentage of Afrikaner people in around the area is especially small. On Sunday I had the opportunity to preach in the small church in which I grew up. 14 people attended (excluding my family). No, not because they heard who was preaching, this is hoe attendance generally look. We stand outside and talk up to about 9:00, and then someone would say that they think everyone who is coming is here, and we will go in.

The debate is not between organ and band, since they use no instruments, I had to start singing, and then the rest will follow, but I must say this: these people really sing! The service was short, since we only sang two songs, I didn’t so a full liturgy, and I generally preach short. Afterwards they have coffee and tea, with LOTS of cake and stuff.

I must add this. The 14 people attending have all been members of the congregation when we moved away 14 years ago, except for the new kids that was born and the those that got marries into the community, one or two woman, but I just met the one. No one gets allowed into the community, you have to be born or married into the community to be a part.

Parts of what I’ve seen looks very romantic: the informal setting, everyone knowing everyone else, everyone staying behind for tea even though there is no Sunday school keeping them there. Parts of this would probably be part of how some people would see the ideal church, sometimes I would include myself with these “some people”. The little church is also a warning. Because they are so part of each other, that they don’t make room for those on the outside, that they don’t welcome the stranger. This is also a warning for the emerging conversation (see this comment on a previous post on someone’s experience of Solomon’s Porch).