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Poverty... The Challenge of Medical Ethics

Chimaraoke Nnamani

Governor of Enugu State

ebeano@ebeano.org

SHOCKER…

… Dismay this God, that I be placed in the bottom line where

desire goes without getting, where need is never

compelled to be filled… where the might of

those who have further blights my

chances…

Stand Against Poverty

Ernst Wendell, 1987

THE VOW

… whatever houses I may visit, I will come for the benefit

of the sick, remaining free of all intentional injustice,

of all mischief, and in particular of sexual

relations with both male and female

persons, be they free or slaves…

Doctors’ Hippocratic Oath, since 460 B.C.

2005 edition of Annual Guest Lecture of the Institute of Child Health (ICH), University of Nigeria Teaching Hospital (UNTH), Enugu, Thursday, March 17, 2005, Conference Hall, Protea Nike Lake Resort, Enugu

DEDICATION

The poor who cannot fit into the

exorbitant bills of our medical practicioners.

Our immediate assemblage today, and the thrust of inquiry as we will currently mount on the issue on table has come of our resounding era of sobriety, which rides the persistent demand placed on me by the Director and Consultant Paediatrician, Dr. Beckie Tagbo, of this Institute of Child Health.

Indeed, I recall that a year ago, there was this request and the attendant push to get me involved. As was always the case, I naturally consigned it to the normal flash in the pan of requests, which usually constituted a prelude to complicated prayers for patronage.

I had then placed it among the retinue of requests to give talks which, at present, have to wait for our high commitment to elevating the infrastructure base of this State. Of course, in our own prioritisation, the foundation of the State has to be laid on the enabling environment offered by modem infrastructure and clear direction of development. This, we believe, shall offer the convenient operational base for various enterprises of which the mutation, swelling and harvesting of ideas, shall not be the least.

That decision to set the stage first was not actually going to be altered, and I did not see any immediate need to alter until this last passionate letter arrived from Dr. Tagbo. Initially, I was torn between the prevailing resolute adherence to our set goal and the awe of her Biblical refrain, typifying herself/unit as the Syrophoenician woman. She (Mark 7, vs. 24 - 30) ...pleaded with faith and although the blessings were for others, went home filled... as her sick daughter was revived by the healing power of Christ.

And who am I, to be likened to the Lord, who teaches us mercy and who shows us in His Commandments that we must elect ...to do unto others as we shall expect others to do unto us?

Tagbo really got me, because the key underlining principle of our profession, as we shall examine presently, is to seek to realise the happiness _f he/she who is in need. And for a professional of her standing to liken her case to that of Syropheoncian woman, I must give in, because the evidence of desire has been unquestionably taken to higher points.

At this juncture of settling in response to her spirited call, I faced the challenge of outlining the topic, which the Institute of Child Health deems necessary, urgent and prevailing to table before professionals and the general public, in this edition of annual lecture.

Of course, the issue of ethics has remained a debate with both pundits and laymen. From generation to generation and century after century, it was a subject that engaged the best of minds, the harebrained, the avant-garde, aristocracy and even the untutored. But whichever way it turned out, as in history, the props on which actions and other enterprises of men stood, usually got explained in the values forming motives or inspirations of individuals and groups.

But in the case of medical professionals as well as the ancillary practitioners, our immediate environment is such that besides the straining demands posed by ethical requirements, there arises a seeming intractable situation of social erosion corroding man's faith in himself as in his overall environment. That social erosion, which had previously compelled a segregation of the erstwhile society into the have and the have-not, has evolved into an all encompassing negation of environmental stability, due mainly to unpredictable modern economic and social indices.

In a way, this seems to limit the conceptual fangs of ethics as it undermines the rectitude of character, which ordinarily sweetens inter-personal and intergroup relations. Put differently, the challenge posed by this erosion of faith in individual comportment has made its way to the foundation of orderly behaviour as may be required of individuals or group. And in the case of medical professionals and practitioners, the pervading fang of lack, greased by a large pool of an ignorant populace, leaves a tempting situation of the crocodile which has presented its underbelly. Quite ripe for the plucking, you may say.

In the words of lexicographers, ethics simply means...the morality of conduct... conforming with an accepted standard of behaviour, (Webster's..., p.324, 1994). This, in a case of general inquiry, depicts the subject as posed as having been pre-defined and the import adequately communicated. The word morality, on its own comes from a Latin word, mores, which corresponds or is seen as representative of agreed standard.

Ethics, on its own, has its roots in ethika, a Greek word originating from ethos, which means ... embodied character with roots in customs, traditions and leadership injunctions. While these formed the foundations for Western moral philosophy, which were grounded in the various formal sciences (mathematics and logic); empirical sciences (chemistry and physics) and the behavourial sciences (psychology, sociology, etc.), there remained, for the universe, an overriding need for a meeting point between cultural contradictions and human absurdities in the rigorous environment.

Early philosophers, Kings and other public affairs analysts were firmly agreed on the need to put in check the excesses of human freedom. The Egyptian/Sumerian civilisations had to systemize ethics (Ptahhotep), to enforce a code of human conduct aimed at obtaining obligations from one to the other. In China, Confucius broadened what was moral code, while earlier Greek philosophers, from Pythagoras (6th Century B.C) developed moral principles from an archaic religion called Orphism and concluded that sound moral standing can only thrive in an enlightened intellectual mind committed to perpetual scholarship.

Understandably, these generations of ethical positions conceptualised ethical injunctions as aiming at three results - prudence (admonition of moral obligations), pleasure (compelled to determine pleasure between the immediate and future gains) and power (attenuation or blunting of such harmful competitive edges which knew no obligation other than to self), whose part is strewn with the urge for unfair drive.

Of course, we are aware that these major early schools have been challenged, modified or elaborated on. From the Socratic school, we already have the hedge thrusts of Cynics (who advance self control as the ultimate behaviour), Cyrenaics (who urge universal pleasure - hedonism - as the foundation of proper behaviour), Megarians (who urge logical inquiry as the ultimate good) and the Platonists (who urge intellect and will, i.e. wisdom and courage, as the foundation which can temper emotion and induce self control).

Further to these, Roman leadership character elbowed its way and advanced Stoicism as the hinge on which control of human excesses, especially in relation with others, could be hung. Initially conceptualised as independence of hunger for material, it rode the common refrain, endure and renounce, .. fortitude in the face of hardship. It hardly ever affected the imperial thirst of Roman gladiators, who sought to conquer the world, bequeath their social, political and economic order.

Although Stoics did not commit adherence to the need of living up to the injunction of any deity, basic Christian ethics, as later formulated by Saints Augustine and Thomas Aquinas, arguably pandered to this position of self denial, but this time, for rewards in the life hereafter. Hinged on man's dependence on God, these philosophers posited that ultimate human character should be exemplified in faith, mercy, martyrdom, forgiveness, asceticism and non-erotic love.

Each of these underlined the high point of moral conduct deriving from the need to be restrained from the excesses of human material desire. This goes further to confirm that through the ages, the goal of cultures had been to achieve conformity in the urges

which propelled man to actions in exploitation of the unwary, the weak, the poor and the uninformed.

Against the backdrop of the foregoing evolution of documentation of ethical principles, the medical profession had naturally drawn its strength from the firm belief that its entire aim is to do good. Father of Medicine, Hippocrates 460 - 377 B. C urged vehemently.. .as for disease, make a habit of two things; to help and not to harm; to keep patients from harm and injustice.

About 2000 years ago, Indian Physician/philosopher, Caraka Samhita, also urged.. ..day and night, however you may he engaged, you shall live for the relief of the patient with all your heart and soul. You shall not desert the patient even for the sake of your life and living. Second Century imperial China worked a decree that medicine should be practiced with virtue and health. Its major physicians/philosophers admonished that ...a great physician should not pay attention to status, wealth or age...he should meet everyone on equal ground.

Of course, the story is endless, as more philosophers and physicians have had to drive the point hard that virtue should underlie the practice. This has now compelled me to invite you to an understanding of the word virtue. According to Webster's, (p.II00), it is the ...quality held to be of great moral value... the power to do good.

Again in history, professionals and other practitioners have had strong test cases to determine if they were alive to the admonition of the old philosophers/physicians, but in each case, the compelling environment had left the values on which they were assessed. During the Bubonic plague of the 1300s, right through the 1980s when the first cases of HIV / AIDS pandemic dared civilisation, it remained a robust but inconclusive argument that the medical practitioner should stay and treat, risk infection and death, or flee.

Whichever way, the foundation of our modern ethics had been strengthened by the 19th Century British physician, Thomas Percival, in Professional conduct of physicians, which summed its values thus: ...inspire the minds of their patients with gratitude, respect and confidence. He was indeed underscored by the University of Pennsylvania physician, Benjamin Rush, who affirmed in 1805 that every physician must posses the virtues of generosity, honesty, piety and service to the poor.

The negation of these in the late 19th century America was so intense that when the American Medical Association (AMA) was founded, it minced no words in disclaiming as unprofessional such avaricious practices which caused the lowering of the esteem of medical practice in that age. It therefore had as its basic principles, dedication to provision of competent medical services, with compassion and respect for human dignity... contributing to improvement of the community.

The Canadian Medical Association (CMA) was to follow with the thrust for respect, responsibility and dedication... to human life.

From the 1970s, American philosopher, Tom Beauchamp and theologian, James Childress, evolved the principlism values anchored on autonomy of the patient and medical practitioner, beneficence (helping people as the primary goal), non-malificience (refraining from harming people) and justice (distributing burdens and benefits fairly).

I can guess that you know why I have taken this long trip into ethical history. Of course, Nigeria, you know, has followed dutifully in the trend since her journey through colonialism suffices an unbroken thread stringing from Europe and lately America, where the higher motivation of updated technology define the fine implements of practice.

But even as that is the case, our practice, relating with our evolved culture and national coalition presents a clear picture of a profession mired in the same struggle to wriggle out from the quagmire of economic despondence and social blight. Indeed, this is our take-off point.

You remember that as far back as 2000 years ago, Sun Simiao had admonished that the medical professional should pay no attention to wealth, status or age. You also remember, in our immediate environment, that social despondence has long crept into what looks like perpetual impoverishment for some members of our society. Also, the cyclical nature of boom and burst - presented in every generation - of our economy has long built in a nightmare, rebutting earlier positions of social standing and certain flight from poverty. Against that background, poverty, which is the lot of the greater number, can pose an effective challenge to an enterprise, either by its way of limiting the potentialities or in confusing the decimals, which ought to enunciate growth and development.

To get this point clearly understood, we may have to go back to a conceptualisation of the word. It is simply put as deficiency or inadequate supply, by the Webster's. In this sense, it is against the monastic inclination to renunciation of the right to own ... Today, universal definition of poverty is couched on the researches of Elizabeth Wilkins.. .the income of a community which in subdivision among families and kindred, is less than 40 per cent of the norm. These, according to her, manifest more in poor infrastructure, poor health, poor nutrition, poor self esteem, low hygienic standards, low intellectual development and lack of capacity to articulate social, economic and political environment and low per capita income.

In our parlance, the above signifies an absence of food on the table, absence of the good things of life and absence of such environmental factors that can remedy us from the dilemma.

Elsewhere, I have had to seek an understanding of poverty from the local South East social attitude. This has yielded for me an appreciation of the dangerous trend to which a feeling of poverty can reduce a man or woman who may have perceived lack as having come from God. When our local folk hold the view that the poor is onye chi gbara nkiti (whom the God has ignored) as against the rich or well-to-do seen as onye chi goziri, (whom the God has blessed), we are confronted by a contradiction in belief which ought to argue for equality before God. Perhaps, we are not alone in this.

In the North West zones of Gusau and Ikarra, wealth is called wadata, meaning well being, which stands alongside kwnanciyar hankali, security and raffin ashiri, meaning independence or self sufficiency. These stand against talaka - the poor, who is politically consigned to his level with little chances of ever crossing to the well-being-border. In the South West, poverty comes in such phases as igbe aye ti ko derun, meaning ill being, which ultimately results in igbe aye ti ko dara, meaning ill quality of life. These are distinguished from igbe aye to derun (well being) leading to igbe aye to dara (good quality of life).

Reaction to or response of the individual to poverty understandably differs from culture to culture, but one clear point of distinctive action can be represented in ways these are viewed among the rural and the urban poor. Indeed, the manifestation of poverty in the urban areas can be frightful. First, its severe pang induces such social vices as crime, prostitution, gambling, alcoholism, vandalism, thuggery and other anti-social vices, which promote tension and instability.

Basically, the urban poor are known to exhibit the characteristics of lack of good food, potable water, inability to pay for adequate health care, lack in good supply of electricity and lately, inability to send children to school. Some of these characteristics of urban poverty are never the lots of the well-to-do class - the gainfully employed and business class.

In the rural areas, the poor or well-to-do may not need electricity to survive as against the technician in the urban area who will be put out of business and directly into poverty over an enduring short supply of electricity. Relatedly, the village farmer who has enough food may not bother about hunger even as he worries about the market behaviour of his commodity, which if it fails, forces on him the inability to pay for medical services and send children to school.

I cannot pretend to be unaware that many of you here, ensconced in the comfort of your practices, never bothered about the surging trend of poverty, which, in a regressive fashion, has corroded a large section of our population. Initially, I had marveled at the sheer volume of it but I have come to reconcile with the fact that such public policy programmes which never sought a scientific eradication or reduction in poverty ought to get the results we have had since 1971.

At the moment, the report of the Human Development Index posted Nigeria as holding 18th bottom position of poverty as the 154th of 172 in development assessment. That is to confirm that about 87 per cent of the population or 93 million of the 120 million citizens are viciously gripped by the cold hand of poverty, as in 1999. This, as we now know, did an uninterrupted, if not aided journey from 26 per cent in 1964, 28. 1 per cent in 1980, 46. 3 per cent in 1995 to 65. 5 per cent in 1996. I am aware that it is currently contested that Nigerians had not been that despairing. However, our objective condition, when placed side-by-side with such criteria for assessment, pre-1999, easily revealed a situation of blight and squalor which must be confronted without delay. At least, we did not need to be enlightened on the quality and regularity of electricity available per square kilometre. We could easily guess the quality and possibilities presented by available medical care per community. We needed not be tutored on the availability and reliability of security of life and property per square kilometre. Our chances of getting timely justice in the event of injury were well known to us. And the rate of children dropping out of school, when placed alongside the quality available, was equally clear.

But remember, the Eastern Nigerian economy, which swung into full but modern drive along with today's Asia Tigers, had attained a phenomenal 24. 8 per cent growth rate (and about the fastest growing economy in the sub-Sahara) in 1964.

What we had at hand was a savage retardation, which altered all goals and objectives in every facet of life, including the medical profession, up till 1999.

But today, are we not confronted more by the flight of reason, underpinning professional and moral rectitude, if we easily succumb to the lures of clawing viciously at whatever is at sight to get ourselves wriggled out to a comfortable distance? In other words, the professional demands made of us have stood between the devil and the deep blue sea. Here is the medical practitioner who, savaged by the threat of poverty, stares at the totally ignorant and uninformed poor, without hope if he fails to access quality health care, in the face of a seeming greed of doctors, nurses and physiotherapists.

Again, the soft underbelly of the crocodile has presented itself.

Let us return to the history of Christian ethics as it affects medical practicioners. From early Christian/Jewish philosophy, it was … render unto Caesar the Caesar’s, and to God, God’s… Matthew 22 vs. 21. in Luke 10. vs. 27, it rings out, again, … Love your neighbour as yourself… and enemies.

In examining medical ethics of our generation, can we conveniently say that the medical doctor who diverted the patient to his personal clinic where there are virtually no tools of practice – just to earn the consultancy fee – loves his neighbour or has rendered what is Caesar’s to Casesar? What about the nurse whose training and practice is clearly defined venturing into duties of the physician, a thing more complex and established in a long period of training?

Of course, it is not new to any person in this esteemed audience that a non-doctor as the lab scientist now embarks on treatment of patients, just because he is privileged to understand the behaviour of such viruses and bacteria for which the patient could have been referred for scientific analysis!

In a way, public affairs analysts have situated these anomalies as arising from the failure of medical doctors to maintain a high degree of integrity, of which the patient is compelled to be receptive to any view suggestive of a way out of the abnormality of his/her situation. But even as the patient places him/herself at the mercy of the medical practitioner, the tendency to act in ways that turn off the faith in them heightens.

My worry, at this juncture, is that if for any reason we are forced to drag the modem-day medical practitioner into the courts of Caraka Sumhita of 2000-year-ago India or the 2nd Century Chinese physicians, we will all be largely condemned. Even our own Hypocrates, on whose domineering code we stand certified to practice as doctors, we can hardly claim, as he decreed, that….as for disease, we have made a habit of two things; to help and not to harm; to keep patients from harm and injustice.

The complaints are no longer inaudible. They put money first; they are arrogant and act condescendingly to patients; they are impatient with the patients; they abuse patients of the opposite sex; you spend all day trying to see a doctor; are the ways they are viewed in many quarters.

Besides, other health workers such as administration staff, revenue clerks and records officers, among others, are also reported to have conducted themselves in ways that clearly undermined the compassion and integrity (virtue) of medical practices. Many are specifically accused of nonchalant attitude to patients, aggression to patients, negligence of duty, abandonment of duty, taking advantage of patients' ignorance, abuse of confidentiality, sexual abuse of female patients, etc. The list can be longer.

But if we shudder at these unbecoming conducts of supposedly health workers, whose lack of deep training we can excuse, where do we place the well educated and fully conscientised pharmacist who knowingly gives out fake, expired and sub-standard drugs; treats patients as if he is a medical doctor and diverts patients to private pharmacies for the material gains of it?

Again, we must remember that these professionals have as the kernel of their oath of practice, that fundamental restraining affirmation: I will consider the welfare of humanity and relief of human suffering my primary concerns.. .assure optimal drug therapy outcomes for the patients I serve.

In the same solemn manner, the nurses make the Florence Nightingale pledge, pass… life in purity...abstain from whatever is deleterious and mischievous...to maintain and elevate the standard of...profession...to the welfare of those committed to (my) care.

The nurse is not alone. The laboratory scientist pledges to apply...skills only with the utmost respect for the well-being of humanity, the earth and all its species... will not permit considerations of.. .material advancement to intervene... Here is the dilemma of ethics. The question we may pose here is this: Are we still guided by the ethics of our profession. . . by our oaths of office? Are we still working to stand by our patients as admonished by Sun Simino. ..even at the expense of our life and living?

It is possible that we can, at this moment, cleave the points as may arise from these questions to the predictable disposition of the downtrodden, who obviously, is the victim of a long and sustained perverse medical practices. At this juncture, I wish to re-invite you to the reaction or responses of the various classes of the poor, who are harangued in this unbecoming negation of practices.

Elsewhere in the recent past, we did hold that given the background that each man's economic status means an explicit interpretation of how blessed he appears he is, it has become the rule rather than the exception that among the rural poor, who cannot afford reliable and exorbitant medical care, God or hope in God, is just the answer.

Lately, as we can see, the refrains that. ..our God is not a poor God; the promises of financial reward for believers in Christ, and such others, only confirm the determination of the ubiquitous pastor and man of God to proffer a solution where dubious and avaricious medical practices negate long established principles of medical treatment of cases... with compassion and love.

Indeed, failure of practices of late have clearly compelled the needy to seek succor where they ought not have gone and the responses have followed the known patterns of either resigning to faith or hitting back at the system.

Rural blight, standing side-by-side with urban squalor, as I urged in one other talk I embarked on, harbours some social factors, which condition the people to respond the various ways they do. Curiously, the one is never acting in negation of the other but each, finds value and locality sensibility to the confounding scenario. The words are fate and defiance for the benefit of the rural and urban poor, respectively.

And what would you expect of the deeply poor who cannot stand the barking of the imperious medical doctor or the all-knowing, avaricious pharmacist, nurse, laboratory scientist and maternity matron, who would not suffer the hapless, timorous creature, who cannot even hazard the sky-high medical bills? The ultimate response of God dey offers hope, at least.

At this heightening of blight and recession of hope, they moan;

Nwanne m e bezina,

na Chukwu no nso,

Nwanne m e bezina,

na Chukwu no nso;

Ihe na e me gi e bezina,

na chukwu no nso,

E bezina,

na Chukwu no nso!

(My brethren, do not despair, because our God will not abandon us).

So, when it is so confounding and there are no explanations, the village folk denounce the threat of poverty, blight and lack of reliable medical care, chanting their confidence in the Almighty:

Chim lee, n 'idi nma a,

Ngi n'eme mu ogoo,

Chim lee, n 'idi nma a;

ihe i kwuru ga erne e!

Chim lee n 'idi nma a,

Agbata obi nwa ogbenye,

Chim lee n'idi nma,

Ihe 0 soro gi 0 mee!

(My Almighty God, you are good; I will give you all praises; because you have decreed what will happen.)

And to really solidify the truism of God's supremacy, especially in surmounting the hurdles of ill health, which medical professionals are not prepared to treat, the mral folk yell further:

He is a miracle working God,

He is a miracle-working God,

He's the Alpha,

and Omega,

He's a miracle-working God.

This response in equanimity or submission to faith alone reveals the rural folk or predominantly mechanical societies as electing to leave it all for God. And who else will come to their rescue when they cannot meet up with the sharp practices of sudden wealth seekers in the medical profession? Only God!

The singular rust in faith of the rural poor stands as the basic behaviour acceptable to a people not given to challenging the social order. That is not the case with the usually mobile and repeatedly incensed urban poor who cultivate the rebellious tendencies exhibited in poignant diffidence, deviance, diffidence and periodic preference for showdown.

Of course, the city people, especially the inhabitants of the tough, down town neighbourhoods, would not reject that He is a miracle working God. But they will insist that much as the doctor-powers-that-be would not terminate their suffering, they have the Almighty on the side of their army.

In many cases, they thunder at the medical elite and the system, which pretend to perfection as God that:

If Jesus says yes,

nobody can say no!

Sometimes, they fail to mask their irritation at the failure of leadership to increase or realise their hopes by snarling:

Ka anyi jee zigara ha ozi,

ozi oma,

k'anyi gwa ha na chi anyi ka nma!

K'anyijee zigara ha ozi,

ozi oma,

k'anyigwa ha na chi anyi ka nma!

(We must go and make it clear to them that our God is better than theirs).

But what reveals the extreme tendency of the urban folk to stoutly urge the superiority of God to medical practitioners is in the song;

Jesus na you be Oga,

Jesus na you be Oga;

Every other god na so so wayo,

Jesus na you be Oga!

Of course, I do not share in the position of the urban and rural poor that both the rich and mighty are not equally desirous of the blessing of the Lord. In fact, even the doctors and the other medical people here hope that in their imperious stead, their own

enemies should come to grief while they triumph.

Personally, I view this scenario of resignation to fate and the attendant defiance as variously expressed by the poor who cannot afford expensive medical attention as an abnormality. This is not arguing that hope and faith, cannot be any panacea for debilities. I am deeply worried that it is soon turning into what a very large section of our society can afford in terms of keeping good health and well being.

It is scarier that we have come by an army of skillful public speakers, pastors, men of God and even diviners who cash in on this development for material gains. Such have also presented situations of needless defiance of secular, scientific, solutions to matters as threatening as even terminal, but treatable, illnesses.

On our part, we have elected to put the best in place for the consolidation of real modern medical practices in Enugu State. Our medical school, which is nearing completion, is slated to serve as the best training institution of its kind in Nigeria. It is designed with full facility for scholarship and practices, as its en suite hostel structure will turn out as the first ever in Sub-Sahara.

However, such cases as the consultant whose first contact with a child of one of my staff led to another consultation in a private clinic, and eventual treatment in the government/public hospital - all at the exorbitant private hospital billing - will always pose a problem of ethics.

We recognise the challenge of infrastructure and good pay to ethics. We recognise the demand of policy cohesion on the part of government. We equally appreciate the limitations imposed on our practitioners by the circumstances of our reconfiguring economy since the travesty of old political and economic values. But should the medical professional trade off the power to do good as posited by Sun over 2000 years ago for the shifty nature of the immediate environment? The answer is no, and a vehement one for that matter.

On that note, we hold firmly to the values which proclaimed, since centuries of the past, that moral principles cannot be negated and medical practices cannot be reduced to the trade of the sojourner who is soon gone after he has been made.

We hold that view, affirming further that the challenge to true practitioners lies in the urge, practice, preaching and extension of that which avails scientific treatment of all cases for all classes. And if no one is left in the lurch - the materially downtrodden and the high and mighty - being equal or proportionate contributors to the growth and development of their societies, we shall hum home as we normally do in Enugu State,

To God Be The Glory.

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