Monday, June 23, 2014

A Tiny Ethical Dilemma



A Tiny Ethical Dilemma

Life is not always so simple. Black and white moral choices. Do they even exist in such stark, contrasting colours? Seems like there are a quite a few shades of grey when it comes to ethics.  Fifty shades if you believe a certain author…

Clients old and young crammed into our clinic waiting area. Those healthy enough hung around the perimeter avoiding the sweaty, hot central node of sick bodies, nudging their way past mothers with babies strapped to their back and elderly grandparents resting against the wall grasping their walking sticks while sitting on the benches. Somehow there was an order although at the time it was difficult to conceive any sort of queue existed among the impatient patients.

My door cracked open as I sat opposite a sick client reviewing her history. “Oh, sorry,” Madam H said unapologetically. Her eyes flicked to her medical book and back to me expectantly as she pushed the door open further and shoved her book under my nose for an inspection of her lab results. She was ready for her prescription.

“Ok. Thank you,” I said, trying not to sound to exasperated. Mrs G. sat motionless and silent, suspended in animation until my intruder finished intruding on our private interview. “I will look at your labs and write the prescription after I finish with her.” I indicated Mrs G.

Madam H gave a satisfied nod and backed out, closing the door on our privacy once more. “So, you were saying you have vaginal itching but that the discharge does not have a smell….” I picked up where I’d left off in our original conversation. Amazingly, Mrs G seemed unperturbed and jumped back into a detailed description of her ailments for the past eight years.

“Yes, doctor. When I take medicine it goes but then it always comes back.”

“Any pain associated with the discharges?” I probed further into her history trying to ascertain her underlying fears and preconceptions about the problem.

“Yes, doctor, here,” she pointed to her lower abdomen.

“What is the pain like?”

She was silent a moment, trying to come up with a suitable analogy. In those brief seconds, another knock on my consultation door alerted me to the next interruption. It’s amazing I manage to get any outpatient consults done some days.

“Doc?” Nurse A poked her head into my consult room. “There’s another doctor who says he wants to talk to you.”

“Ok. After I finish here,” I nodded to Mrs G. and gave her a small nod. “Just tell him to wait and I’ll come.”

Within a few minutes, I completed my interview and examination of Mrs G. and had sent her on her way to the laboratory. I strolled out of my office and looked around. “That guy,” the nurse pointed out an average-looking middle-aged Cameroonian male standing near the doorway. He spotted me even before I could introduce myself.

“Doctor?” he held out his hand in greeting.

“Yes, I’m the doctor,” I replied hesitantly. I wondered what he could want from me. I didn’t recognise him. Why was he here? What did he want?

“Doctor, I’m happy to meet you.”

“Happy to meet you too,” I shook his hand but remained standing out in the doorway.

“Doctor, I want to talk to you.”

“Oh?” I glanced around at all the patients who were giving me less-than-patient curious stares. “I still have a lot of people to see…” I shrugged.

“It’ll only be a minute. Can we…” he indicated a more private corner, “…talk together just for a minute?”

I hesitated. There were so many people to see. Many had been waiting several hours. They were sick and didn’t feel good. Most were hungry because they had come without taking breakfast. It wasn’t fair to make them wait just because another professional colleague that I didn’t even know decided now was convenient for him to visit me.

“It will only take a minute,” he pressed his case persistently.

At last I relented. “Ok, come back here.” I indicated the bench where we do our dressing changes and injections. “Agbor, Natalie,” I called out.

The patient shouldered her purse and hurried to enter my consult room. “Have a seat inside,” I indicated the chair. “I’m coming.”

I returned my attention to my unknown, physician visitor. We sat across from each other.

“Doctor, I wanted to meet you…”

“And now you have,” I smiled.

He gave a wane smile in return. “Doctor, I work at the ___ hospital.”

“Oh?”

“Yes. I wanted to meet you so that maybe we could work together – collaborate – refer each other patients.” He paused frequently as he struggled to fish out the correct words to get his point across clearly yet subtly.

I listened. I wasn’t sure I understood his agenda yet.

“You know, doctor, I’ve been to ___ country.”

“Oh,” I nodded. I wasn’t sure why he was sharing his foreign travels with me. I’d been to other countries outside Cameroon too.

He continued. “You know, I studied many additional things.”

“Ok.”

“I’ve had training in gynaecological procedures.” He paused waiting for the light bulb to click in my mind. It didn’t.

“Knowing how to manage gynaecological problems in women is a good thing.” I filled the pause.

“You see, doctor,” he resumed his explanation, “I have additional training in how to manage bleeding in women, like after a miscarriage.”

“Like a dilation and curettage?” The light bulb was beginning to turn on.

“Yes, I can do D&Cs.” He was pleased I seemed to understand him now. He paused again.

I waited for him to continue. I wanted him to verbalise the point of his visit more clearly and confirm what I was beginning to suspect.

“Well, you see, doctor, like yourself, I have training in helping take care of women. I can help them. Sometimes you see women who come here for an echography.”

“True.”

“Sometimes they come for an echo and they don’t want it.”

“You mean, when we confirm that a woman is pregnant but she doesn’t want to be pregnant?”

He nodded.

“I can help them. You can send them to me.”

I now understood my colleague’s visit. He was soliciting referrals for dilation and curettage (D&C) for patients who came and wanted an early abortion.

“I am trained in that way.”

The light bulb was fully illuminated in my brain. I understood his request perfectly.

For now, I didn’t have any cases to refer to him. Thankfully, most women recognise that we are a church-based mission hospital and a D&C to abort an unwanted pregnancy is not possible at such a health institution. And yet, sometimes we do diagnose a pregnancy and the dilemma arises: what to do?

Does one refer a young lady to a doctor who can perform a D&C relatively safely and in antiseptic conditions in a hospital? Does one council and pray with this woman and hope that she abandons all thoughts of ridding herself of the pregnancy? Does one refuse to discuss anything outside of maintaining the pregnancy and pray she doesn’t go in secret for an abortion under unsanitary conditions by unqualified people with no training that masquerade as “doctors”?

I have seen some horrible complications of abortions done in shady clinics and even homes by unqualified persons. Sometimes the reason for a woman seeking an abortion can be quite compelling. Losing a job. Being thrown out of the house onto the streets to fend alone. Sent home to the village in shame while forced to abandon hope of a higher education. Pregnancy because of rape and incest. The list is long and complicated and heart-rending.  I once had a young woman of the age of 16 or 17 dragged by her auntie to the clinic – auntie demanding an echo to determine if her niece was pregnant or not. In the privacy of the exam room, the girl fell down on her knees and with clasped hands begged me, tears streaming down her dusty face, to please write that she was not pregnant. She’d had sex with a man in order to obtain money for her brother in prison. If she was found out pregnant, her family would throw her out and she would never be able to finish her education. Intense times. With little resources (not even a positive pregnancy test), she’d gone for a “backyard abortion” and yet she was terrified that the ultrasound might show she was pregnant.


Choices are not always so clear. Fuzziness lies on the edges. Greyscale predominates over defined black and white. To refer or not to refer?