When context-relevant guidelines are missing
In parallel with the effort to promote cost-effective interventions, advanced treatment methods are also being introduced in Ethiopia to prolong the lives of severely ill patients.
Systematic and well-planned implementation of new techniques and interventions in tertiary care are challenged by international collaboration or aid. The latter may include donation of hospital equipment, where use and maintenance will require thorough training for healthcare workers.
One example is dialysis treatment for patients with renal failure, which is now being offered on a very limited scale in countries like Ethiopia. Few low-income countries have conducted high-level and transparent priority setting processes, or developed locally appropriate and context-relevant guidelines for treatment of chronic renal failure (10). Studies show that dialysis treatment causes a catastrophic health expenditures for many families in low-income countries, even when the treatment takes place in public hospitals (10). Many acquire debt that they never manage to repay, sell land or seeds, or use savings they had set aside for their children's education. In South Africa, dialysis treatment was shown to be distributed unfairly when the allocation of this limited resource was left to clinicians without access to guidelines or regulations. Older, white men had a far greater chance of receiving dialysis than others with a similar medical indication (11). The study led to development of explicit priority-setting criteria for dialysis treatment in South Africa.
In our study, we found that very few doctors in Ethiopia had access to guidelines to help them prioritise whom they should treat, who should undergo surgery first, and who should receive the last bed in the intensive care unit or be admitted to an overcrowded ward. The vast majority adopted a strategy in which resources were distributed based on a first come first served strategy (5).
During a collaborative project to educate intensive care providers in Ethiopia, it emerged that lack of guidelines was making it particularly difficult to make decisions regarding restricting life-sustaining treatment. A few hospitals in larger Ethiopian cities have, in a very short period of time, acquired equipment that can help keep seriously ill or injured patients alive due to use of respirators, chemotherapy or advanced surgery.
At present no legislation or clinical ethics committees exist to assist clinicians in making such decisions. Many physicians are afraid of being accused of performing euthanasia. The newly established clinical ethics committee at Black Lion Hospital has, along with two of the authors (Ole Fritjof Norheim and Ingrid Miljeteig), prepared a draft guideline for restriction of life-sustaining treatment that take account of the economic, cultural, religious and legal context in which the guidelines will be used. The proposal is now out for local hearing in the hospital (see Box 1).
In aiming to do good, technical equipment and new opportunities are often presented as positive contributions to improve health in resource-constrained settings. Our experience, as external collaborators (in academia and healthcare institutions), suggests that stimulating and contributing to ethical debate is an important responsibility. When resources are limited, there will always be dilemmas regarding who should have priority, and when it may be unethical to provide health services. This type of capacity building must be recognised as being of equal value to donation of equipment or training in the use of these.
How can we facilitate this type of competence without contributing to what has been described as moral imperialism or colonialism (12)? In academic discussions criticism is often directed at ethics projects originating from the USA and Europe. Too often, these do not relate to the local values and the sociocultural context in which the teaching of healthcare workers takes place.