During a humanitarian mission as a resident in 2008, Matthew D. Tadlock, MD, saw a patient with a massive ventral incisional hernia. Previously, the patient had sustained a gunshot wound to the abdomen, which required an exploratory laparotomy.
“To fix his hernia would have likely resulted in more harm than good for the patient,” says Tadlock, now a trauma surgery specialty advisor to the U.S. surgeon general . The clinical team tried to explain this, but the man still begged for them to fix his hernia. “We gave him false hope by visiting his country, and it was quickly dashed after a brief clinic visit,” Tadlock says. “We caused harm to this patient, despite our team’s best intentions.”
Ethical practices for informed consent, truth-telling, error disclosure, triage, and the involvement of the trainee all are somewhat different in the humanitarian surgery environment than in the hospital setting, Tadlock notes. “When evaluating patients for a potential surgery, sometimes the best answer a surgeon can give is ‘No.’ Nothing really prepared me for this,” Tadlock says.
At various meetings and venues over the years, Tadlock found some surgeons measured their impact during humanitarian missions strictly in terms of case numbers. “Some surgeons really focused on their inherent gain, not on the people they were helping, without any thought to the sustainability of their actions,” Tadlock recalls. Often, surgeons made comments such as, “We went to this country and performed X number of operations.”
“This really hit home for me,” Tadlock says. “Some type of premission ethical curriculum preparing residents and novice humanitarian surgeons was needed.” To see what existed, Tadlock and colleagues conducted a literature review of 49 papers.1 “There was a lot of guidance for specific surgical specialties. But we wanted to catalogue it, put it together in one place, and make it easily accessible,” Tadlock reports. Three main areas of controversy were identified:
- Providing surgical care to patients with a dismal prognosis, such as major congenital defects or severe trauma;
- The role of residents during humanitarian missions;
- The role of surgical innovation.
“An innovative use of standard surgical principles may be required to successfully care for your patient,” Tadlock notes.
For elective operations, the benefits must outweigh the risks, and humanitarian surgeons must have a reasonable chance to make the patient better. “However, in the emergency and disaster relief setting, there may be a role for surgical innovation,” Tadlock adds.
The researchers developed a Humanitarian Ethics Curriculum, and administered the course to 18 residents about to embark on a humanitarian mission. “Like anything in life, you will be better at something if you prepare for it. Dealing with ethical dilemmas in the global health and humanitarian setting is no different,” Tadlock says. Later, the residents were asked to describe an ethical dilemma they encountered on the mission. Sixty-one percent of these involved surgical patients. The ethics guidance gives surgeons a resource to review the core bioethical principles of medicine and surgery as these apply to the humanitarian and global health context. It is not just patients who will benefit; surgeons will, too. “They will have the framework to keep their moral bearings when dealing with challenging ethical dilemmas,” Tadlock says.
- McDonald VS, Ignacio RC, Kuettel MA, et al. Practical bioethics for the humanitarian surgeon: The development, implementation and assessment of an ethics curriculum for residents participating in humanitarian missions. J Surg Educ 2019; Dec 27. pii: S1931-7204(19)30888-8. doi: 10.1016/j.jsurg.2019.11.015. [Epub ahead of print].