AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. January 2017, Volume 19, Number 1: 8-15.
doi: 10.1001/journalofethics.2017.19.01.ecas1-1701.

Ethics Case

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Saving the Starfish: Physicians’ Roles in Responding to Human Rights Abuses in Global Health Practice

As a matter of medical ethics, physicians must advocate for their vulnerable patients and medical schools should offer training in advocacy and activism.

Commentary by Monir Moniruzzaman, PhD

Abstract

This paper examines how an overseas medical student can improve the life of a kamlari, an indentured servant girl in Nepal. I argue that physicians and students should not only provide care for the health and well-being of patients but also act to ameliorate the suffering of their patients, particularly when patients’ social, cultural, economic, and political vulnerabilities overshadow their immediate clinical needs. I also address the point that medical schools need to offer courses on health advocacy and activism in order to promote health equity and social justice for all.

Case

Kathy, a medical student, traveled to Kathmandu, Nepal, during her fourth year for a global health elective. While in the clinic, the attending physician, a local Nepalese doctor, instructed her to examine a female patient while he spoke with her chaperone.

Through an interpreter, Kathy interviewed a 12-year-old girl named Laxmi who was holding her forearm wrapped in a shawl. The girl said her injury occurred when her “mistress” hit her with a stick as punishment for not cleaning the pots thoroughly enough. On examination of the wrist, Kathy noted bruising over the back of the wrist associated with significant point tenderness. She suspected a wrist fracture due to blunt force trauma.

Kathy asked the interpreter about the consequences to child abusers. He explained that nothing could be done, because Laxmi was owned by the person who abused her. He went on to tell Kathy about the local custom of kamlaris. In the 1950s, when migrants occupied their land and filed ownership papers, the Tharu people lost their ancestral farms. In exchange for allowing the Tharu people to keep their farms, the new owners demanded the Tharu families’ young daughters as house servants. These indentured daughters are called kamlaris and those who own them are referred to as “masters” and “mistresses.”

Laxmi told Kathy and the interpreter that she missed her parents and wanted to go home. She was fed only scraps from her owners’ plates. And she was concerned for her safety because a girl from her village had been repeatedly raped by the junior master and then sent home in shame when she became pregnant. Laxmi had also seen a news story about a kamlari named Srijana who had been burned to death.

Kathy asked the interpreter if kamlaris were able to leave the owners’ homes. The interpreter explained that the distance from Kathmandu to the country farms was too great for the girls to travel on their own. He also explained that, although the kamlaris system had been outlawed in 2006, the laws were not enforced for wealthy landowners. Unless Laxmi willingly left her owners, there was nothing they could do to stop the abuse. Kathy wondered what more physicians could do about these kinds of situations.

Commentary

We all can contribute to making positive change in this world, as the following story illustrates.

A young man is walking along the ocean and sees a beach on which thousands and thousands of starfish have washed ashore. Further along he sees an old man, walking slowly and stopping often, picking up one starfish after another and tossing each one gently into the ocean. “Why are you throwing starfish into the ocean?” he asks. “Because the sun is up and the tide is going out and if I don’t throw them further in they will die.” “But, old man, don’t you realize there are miles and miles of the beach and starfish all along it! You can’t possibly save them all, you can’t even save one-tenth of them. In fact, even if you work all day, your efforts won’t make any difference at all.” The old man listened calmly and then bent down to pick up another starfish and threw it into the sea. “It made a difference to that one” [1].

Sick and injured people can be like starfish on the beach. Physicians are in a unique position to act like the older man who returns some starfish to the water by caring for sick and injured people and maybe helping to improve their lives. Physicians’ roles are not limited to delivering health care for vulnerable people, but also involve advocating for their patients [2], especially when patients’ clinical and social sufferings are intertwined. The American Medical Association’s “Declaration of Professional Responsibility” reinforces these obligations, noting that physicians should “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” [3].

What does patient advocacy entail? Rudolf Vichow notes, “Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction” [4]. Paul Farmer explains that the poor are at higher risk of contracting diseases and are also less likely to have access to care; therefore, he urges physicians to make a preferential option for the poor, which means to serve the sick and work for their physical survival [5]. Noting that poverty, inadequate education, powerless positions, and insecure and toxic environments negatively impact health across the globe, Farmer and John R. Stone argue that physicians have a major responsibility to eliminate the “structural violence” of social inequalities [5, 6] “that greatly shorten lives and wreak so much suffering” [6]. Farmer defines structural violence as a form of social injustice that is silently built into social structures and institutions that systematically foster human rights abuses and extreme suffering [5]. His research shows how structural violence contributes to the plagues of tuberculosis and HIV/AIDS among the global poor, reducing both their access and adherence to effective therapy [5]. One example of structural violence is the lack of insurance coverage in the US prior to the implementation of the Affordable Care Act; the Kaiser Family Foundation notes that nearly 50 million Americans lived without health insurance in 2009, and 90 percent of them belonged to low- or moderate-income families [7]. Eugene C. Rich and colleagues argue that the role of physicians is to address the needs and concerns of the people who are most vulnerable; weakened by illness and injury; or distraught by the prospect of a loved one’s suffering, death, or disability [8].

All of these physicians argue that advocacy must be an integral part of medical practice and medical professionalism. Yet others challenge the scope of advocacy in medical practice by noting, “Advocacy must remain an occasional and optional avocation in academic medicine, not a universal and mandatory commitment” [9]. My position is that physicians cannot act as bystanders to the violence, inequality, and injustice around us but rather must advocate for health care of the impoverished populations whose socioeconomic conditions, such as food insecurity, inadequate housing, or domestic violence, impair their health directly. Physicians can also advocate for structural, political, and educational changes that would ameliorate patients’ suffering. In other words, physicians cannot escape advocacy in their professional pursuits and should occasionally engage in activism as public individuals.

Consistent with this scholarship, in analyzing Kathy’s case, I argue that physicians, residents, and students ought to take an active role in providing for the health and well-being of patients. They have professional and ethical responsibilities to stand against the injustice to and suffering of their patients, even in culturally complex and sensitive situations—particularly when patients’ social, cultural, economic, and political vulnerabilities overshadow their immediate clinical needs. Physicians can do this by adopting the multilevel approach that I explain below in analyzing the case.

Duties of a Physician

As the health care worker caring for Laxmi, Kathy has several duties. First, she must examine Laxmi’s wrist injury and offer her medical care. However, medical care alone is not sufficient to improve the life of Laxmi, who faces violence and suffering because of her status as an indentured servant. Kathy needs to assess the abuse Laxmi has suffered in order to determine her course of action. Kathy could discover that Laxmi has been subject to more extensive violence, injury, or abuse, i.e., sexually transmitted infections, pregnancy risks, and trauma. Kathy also needs to inquire what would be the possible consequences, under kamlaris, if Laxmi were to run away and get caught. What would be her position in her village if she returns to her parents?

Kathy then must ask Laxmi through the interpreter whether she is willing to leave her owner and return home. If Laxmi answers in the affirmative, Kathy should actively support her decision in order to protect her from further abuse and to improve her overall health and well-being. If Laxmi responds in the negative (which is unlikely, as Laxmi already asked to go home), Kathy may suspect that Laxmi’s choice is coerced. In such a scenario, Kathy should understand Laxmi’s point of view but reason with her to act as her advocate and persuade her to put together a plan of action (e.g., developing a safety plan, reporting the crime, or suggesting that Laxmi contact the trafficking advocacy groups by giving out their phone numbers [10]). Either way, Kathy should act in Laxmi’s best interests, which is to protect her from long-lasting harm.

A challenge for Kathy is that her actions could inadvertently create a life-threatening situation for Laxmi. The owner could learn and reveal that Laxmi is trying to leave, putting her at risk for further violence and abuse. Kathy must assess the situation carefully. If she believes the potential risks are minimal for Laxmi, Kathy should directly intervene and assist Laxmi in returning home. If the risks outweigh the benefits, Kathy should still assist Laxmi but minimize Laxmi’s risks by taking the multifaceted approach that I suggest below. In that case, it is important that Kathy not assist Laxmi on her own; rather, she needs to seek other professional and institutional support. Kathy could collaborate with Laxmi’s family, the clinic where she was treated, and local nongovernmental organizations.

Family. Kathy can try to contact Laxmi’s family by asking Laxmi for the telephone numbers and mailing addresses of her parents, relatives, or neighbors. If Kathy or designated staff can reach Laxmi’s parents, she can inform them of Laxmi’s injury and her decision as well as convey her own concerns to them. Laxmi’s parents may ask for support from Kathy due to their lower socioeconomic status. Kathy can offer them advice, and she can connect them with legal officers and social workers who may be available and affordable for them. If Kathy is unable to reach Laxmi’s parents, she should act for the beneficence of the child, the primary ethical guideline in pediatrics [11], by reaching out to others.

Clinic. Kathy should consult with the attending physician, explaining to him Laxmi’s injury and abuse, and seeking his advice on how to assist the patient. She should explain to the attending physician that the patient wants to leave her owner’s home and that Kathy would like to support this desire to ensure the health and safety of the patient. It is important that Kathy be careful in approaching the attending physician, since he has already heard the chaperon’s side of events. Kathy can review the case with other colleagues to evaluate how to handle the situation efficiently. Kathy can possibly meet with the hospital administrators and ask them to provide funds or transportation and support Laxmi by publicly using the authority of the institution to condemn the abusive kamlari system.

Nongovernmental organizations. One might argue that, as an outsider, or on behalf of the institution for which she works, Kathy should not intervene in this localized and complicated practice of bonded slavery. Regardless, Kathy is obliged to protect Laxmi from the consequences of abuse that adversely affect Laxmi’s health. Therefore, Kathy, office staff, or hospital representatives can seek further collective assistance from governmental and nongovernmental organizations, such as Change Nepal [12], Forum for Protection of People’s Rights Nepal [13], and Nepal’s Common Forum for Kamlari Freedom [14]. These groups offer a range of legal, social, and personal support to the victims of human trafficking, domestic violence, and child abuse. As physicians are generally well respected in many societies, Kathy would be influential in connecting Laxmi with groups that may help to set her free.

Advocacy and Activism: Training in Medical School

It is likely that Kathy has not received any formal training in health activism, since few medical schools or residency programs have advocacy electives [15]. As there is no prescribed form of activism that is applicable to every situation, I urge that medical schools should teach their students to denounce everyday violence, inequality, and injustice, and take action to reduce health care disparities and advocate for impoverished populations. Students need to learn in their clinical practice that their professional duties extend to protecting vulnerable people [3], particularly when patients’ medical and social suffering is entwined. In addition, medical schools need to motivate their students’ commitment to take action for social justice and to become powerful agents of change. These aims can be achieved through course development, case studies, community engagement, critical reflection, problem-solving skills, volunteer opportunities, and firsthand training, particularly in cross-cultural settings [6]. For example, if Kathy had received training on how to serve impoverished populations, intervene in their sociomedical realities, act collectively, build collaborations and coalitions with relevant groups, and participate in taking action for social change—particularly in international settings—she would have the knowledge and skills to better protect Laxmi’s health and well-being.

Although some training in cross-cultural awareness and communication is often offered as part of health professionals’ training, addressing horrendous health disparities in our world today is complex and can be hard to integrate into health profession curricula. These disparities are caused by multiple forms of structural violence, including slavery, racism, sexism, gender inequality, poverty, war, and political violence [16]. Most clinicians are well aware that social factors deeply affect health, but they are not always trained to address these pressing social factors when treating patients, as Farmer notes [17]. For this reason, he and others ask: Should cultural competency training be replaced by “structural competency” training [16, 17]? Or do we need to offer training in navigating both structural inequality and cross-cultural complexities of global and international health encounters? Either way, clinicians need to study the social and cultural origins of poor clinical outcomes and learn how to promote health equity and social justice, a skill set that should be included in health professionals’ training.

Conclusion

Kathy alone cannot put an end to the local practice of kamlari during her brief visit to Nepal, but she can make a profound difference in Laxmi’s life by serving as her advocate. By collaborating with Nepalese colleagues and NGO actors, for example, Kathy might also help to rescue other kamlari girls and free them from abuse. In this way, Kathy can model how physicians can treat the sick, reduce their suffering, and speak out against injustice to them.



References

  1. The starfish story. http://www.esc16.net/users/0020/FACES/Starfish%20Story.pdf. Accessed November 18, 2016.
  2. Dharamsi S, Ho A, Spadafora SM, Woolard R. The physician as health advocate: translating the quest for social responsibility into medical education and practice. Acad Med. 2011;86(9):1108-1113.
  3. American Medical Association. Declaration of professional responsibility: medicine’s social contract with humanity. https://www.cms.org/uploads/Declaration-of-Professional-Responsibility.pdf. Adopted December 4, 2001:2. Accessed November 18, 2016.
  4. Virchow RLK. Collected Essays on Public Health and Epidemiology. Sagamore Beach, MA: Science History Publications; 1985:217.
  5. Farmer P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, CA: University of California Press; 2005.
  6. Stone JR. Saving and ignoring lives: physicians’ obligations to address root social influences on health-moral justifications and educational implications. Camb Q Healthc Ethics. 2010;19(4):497.
  7. Kaiser Family Foundation. The uninsured: a primer: key facts about Americans without health insurance. http://www.statecoverage.org/files/KFF-UninsuredPrimer.pdf. Published December 2010.
  8. Rich EC, Sessums LL, Dennis LB, Moran WP, Liebow M. Clinicians and healthcare advocacy: what comes next? In: Sessums LL, Dennis L, Liebow M, Moran W, Rich E, eds. Health Care Advocacy: A Guide for Busy Clinicians. New York, NY: Springer; 2011:113-124.
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  12. Change Nepal website. http://www.changenepal.org.np/. Accessed November 21, 2016.
  13. Forum for the Protection of People’s Rights Nepal. Asia Foundation. http://asiafoundation.org/projects/forum-for-the-protection-of-peoples-rights-nepal/. Accessed November 21, 2016.
  14. No clear route out of servitude for indentured girls. Irin. June 20, 2011. http://www.irinnews.org/feature/2011/06/20/no-clear-route-out-servitude-indentured-girls. Accessed November 21, 2016.
  15. Croft D, Jay SJ, Meslin EM, Gaffney MM, Odell JD. Perspective: is it time for advocacy training in medical education? Acad Med. 2012;87(9):1165-1170.
  16. Willen S, Kohler A. Cultural competence and its discontents. In: Brown PJ, Closser S, eds. Understanding and Applying Medical Anthropology: Biosocial and Cultural Approaches. 3rd ed. Walnut Creek, CA: Left Coast Press; 2016:353-362.
  17. Farmer P, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical practice. In: Brown PJ, Closser S, eds. Understanding and Applying Medical Anthropology: Biosocial and Cultural Approaches. 3rd ed. Walnut Creek, CA: Left Coast Press; 2016:336-343.

Monir Moniruzzaman, PhD, is an assistant professor in the Department of Anthropology and Center for Ethics and Humanities in the Life Sciences at Michigan State University in East Lansing, where he regularly teaches the course, Social Contexts of Clinical Decision. His research examines human organ trafficking through the narratives of kidney and liver sellers from Bangladesh and has been published in major journals, presented at the US Congress Human Rights Commission, and transformed into art exhibits.

Advocacy by Physicians for Patients and for Social Change, September 2014

Advocate as a Doctor or Advocate as a Citizen?, September 2014

The AMA Code of Medical Ethics’ Opinion on Physician Advocacy, September 2014

An Intergenerational Conversation about Frustrations, Lessons, and Hope in Physician Activism, May 2015

A Call to Service: Social Justice Is a Public Health Issue, September 2014

Caring for the Trafficked Patient: Ethical Challenges and Recommendations for Health Care Professionals, January 2017

Human Rights and Advocacy: An Integral Part of Medical Education and Practice, January 2004

Physician Involvement with Politics—Obligation or Avocation?, November 2011

Physicians and Political Advocacy, October 2011

Physicians’ Social Responsibility, September 2014

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.