Questioning the road less travelled

Words by Gowri Shivasabesan

A dirt track connects the town to the vast plains where the nomadic tribes roam. Potholed and bumpy, a journey of 50 kilometers takes at least a few hours by car. The vast majority who use cars are the tourists. They travel to see the Parks – to see the wildlife and the scenery which support the bulk of the country’s economy. They drive in or fly in, and some point in the trip, they inevitably visit the villages to observe a life very different to their own.

The road is also used by the local people, but mainly as a path on which to walk. They walk to school, walk to the river for water, walk the distance to buy whatever needed. These communities are impoverished. They receive help from NGOs and tourists – for education and water access. They are impoverished but proud; proud of their lifestyle which has barely changed for centuries. Proud of their songs, and their customs, and their way of life.

The road holds potential for the area. An improved road could attract more tourists – and more money. It would allow for the efficient transport of food and better nutrition. Service providers could access the area more easily bringing better health access. Put a bus in, and people could look for opportunities further away than walking distance from home.

But the tribes do not want a good road. Because a good road means more people; more people who will disrupt their communities and corrupt their lifestyle. Already they lose young people to the cities and grandchildren return with diluted practices.

Let us say for certain, an NGO knows that fixing this road will mean they can help the community – that they can bring better medical access, reduce their child mortality, and transport teachers from the city.

Do they have a right to build that road if the community does not want it?

Does the country’s government have that right?

Even if they do have that right, should they exercise it?

Does it depend on the number of villagers who are opposed to the road building? Does a few locals’ support give enough justification?

It boils down to whether anyone has the right to interfere in another’s business. Does a “greater good” justify unwanted interference? And if the answer is yes, isn’t that kind of logic which starts us on a slippery slope to half a dozen wars?

Medicine, global health, and development are no strangers to ethical quagmires. There is an overabundance of good intentions gone sour and questions left unanswered. Some are more clear-cut than the others and fortunately, the international community is becoming more aware of these. Evidence-based interventions and transparency are gaining credence, as well as the limitations of simply a good attitude. But there is no prescription or guide for what may be morally right or wrong.

Morals can be tricky. They are individual, but constrained by the law. In some ways, legality protects us – it gives us a clear defined line of what can and cannot be crossed. But these are not uniform; Australian laws do not apply in a different country with different practices. And that’s when the big questions start.

Let’s say community X practices female genital mutilation (FGM). You disagree with the practice, but no-one in the community objects because it is tradition. Do you a) not interfere because it’s their cultural practice b) assist them because you know you can do it in the most safe and sterile way or c) refuse to support the community because you find it is morally and ethically wrong. Clearly this is an over-simplification of complex issues and there are d), e), f)…options (see articles on FGM below). But this is to highlight the kinds of questions that arise. Depending on who you talk to, there may be a right or wrong answer, or there may not be. But if you have never considered such issues before, they can be confronting.

For a profession which is deeply linked to ethics, I have been surprised by the lack of teaching we get. From abortion to end of life care, our decisions as health professionals impact our patients and ourselves. The ethics teaching which I have witnessed tends to be prescriptive; the ethics of medicine are beneficence, non-maleficence, autonomy, and justice – you shall follow these. We are taught the laws and the principles (and can all probably repeat them ad-nauseam for exams!) but rarely explore why. We are taught to be culturally sensitive and this makes the framework less transferable to new contexts. Given the ethical minefield which practicing in our own backyard can be, it is no surprise that working overseas can be akin to wading in a piranha pond.

In a world where more and more medical students and health professionals travel overseas on electives and placements, cultural awareness and personal understanding are critical. We can be confronted by ethical and moral questions which we have never considered. Furthermore, students on electives often experience dilemmas regarding doing procedures under limited supervision, and issues with culture and communication. As a result, pre-departure training (“PDT”) courses are beginning to be recognized as important tools before going overseas (see the below linked articles). They play an essential role in understanding one’s role in global health as well as preparing us for such dilemmas. AMSA Global Health and AMSA Academy are opening an online PDT course soon, which attempts to provide this service to medical students.

Global health interventions face even more questions with serious repercussions. Some of these questions have no correct answers. Perhaps the road should be built, perhaps not. Often the issues are grey and no amount of thinking or arguing will be objectively right. But in an area so fraught with such dilemmas, they should always be discussed. Questions without answers are probably better than answers without questions.

Other reading/resources

http://www.ethics-e-learning.com/ – Answer a series of scenario-based questions, and find out what type of ethical standpoint you use

Articles on PDT
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207171/
http://www.ncbi.nlm.nih.gov/pubmed/25420975

Guide to Working Abroad: https://www.mja.com.au/journal/2011/194/12/guide-working-abroad-australian-medical-students-and-junior-doctors?0=ip_login_no_cache%3D7e2d9b9f79c5196a5cf48b6197a1a23f

FGM
Recently, the Journal of Medical Ethics published an article on FGM – http://jme.bmj.com/content/early/2016/02/21/medethics-2014-102375.abstract
http://www.economist.com/news/international/21700631-rite-passage-ranges-symbolic-awful-where-should-line-be-drawn
http://www.huffingtonpost.com/dan-arel/ethics-journal-offers-ins_b_9308382.html
Internet Encyclopedia of Philosophy: http://www.iep.utm.edu/

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