CEL6: Culture, ethnicity & bioethics

The following extracts are real descriptions of experiences that UK and US medical students have
encountered whilst on global health electives. They are taken from the work of Peluso et al (2018)
and Monrouxe and Rees (2017).

Case 1 – from students on elective in South Africa

“The patient had great difficulty getting out of bed and had a knee effusion on exam. She had already
seen a nurse at the local clinic for evaluation, and the nurse had referred her to the hospital for X-
rays and further evaluation of the joints. However, the patient had not been able to go because of
lack of money for transport. She would need to pay for two people’s bus fare to the hospital, as she
would not be able to complete the trip alone. We probed to see if there was any way she could
borrow from friends to make the trip, but there did not seem to be funds available. The question
arose – should we just pay the 80 Rand required for her travel?”

This case highlights the issue of economic disparity between visiting elective students from resource-
rich countries and the patients they may meet in resource-poor countries. The bus fares that this
patient needed would be equivalent to about £4 sterling – something that the visiting students could
probably easily afford to donate.

 Do you think they should pay their patient’s travel expenses?

 How do the ethical principles of beneficence (a duty to help our patients if we can) and of
justice (a duty to treat everyone fairly) influence your decision?
 Would you give a bus fare to a patient you saw in a UK GP surgery, who couldn’t afford to go
to hospital for an X-ray? Is your response to this scenario different depending on whether it
arises in the UK or on elective, or is it the same? Can you articulate why?

Case 2- from a student on elective in Pakistan

“I was in Pakistan, and it’s quite… resources are quite limited… I was in the staff room.
Basically, I get a knock on the door and it’s a nurse saying “oh, there’s like parents of the child who’s
developed a rash and we need you to, you know, deal with the matter”. What that meant was,
basically seeing the patient, diagnosing what’s going on and prescribing, or doing any investigations
that I needed to, because there was no other doctors around.
And I felt “oh my god what am I supposed to do in this situation?” So then I just felt that, I just had
to like decline… let the nurse know that basically I can’t do it…
Her response was a bit negative… she was putting a lot of pressure on me because she was saying
“you know, they’re in a very critical situation… and you’re the only person who’s got some sort of
medical knowledge who could actually help.”
So that was a bit of a dilemma for me… when I thought it through, I just stood my stance… the
parents were outside the room and that was extra pressure”

 Do you think the student was right to decline to see the patient without a doctor present to
supervise them? Can you articulate the reasons why you hold this opinion?
 Can you identify any other possible courses of action that the student could have taken?
Would they have been better or worse than declining to see the patient?
 How might cultural differences have influenced this student’s conversation with the nurse,
and the student’s perception of what was happening?
Case 3- from a student on elective in Indonesia
“We saw a 16-year-old girl who was admitted because she overdosed on cough syrup and
benzodiazepines after her boyfriend broke up with her. She was admitted overnight, and I saw her
with the team the next morning on rounds. She was not having any worrisome symptoms from the
medications, so the team was planning to send her home. A visiting medical volunteer asked if the
girl was having any thoughts of hurting or killing herself, and the Indonesian doctors said “we can't
really ask that directly,” indicating that asking patients about suicidal ideation was not culturally
acceptable. She was sent home without anyone taking a thorough psychiatric history.”

 Would it ever be acceptable in the UK for a 16-year-old to be discharged after treatment for
an overdose without anyone asking her about suicidal ideation?
 Does difference on any of the dimensions of culture that we have been looking at in this
unit, or other cultural differences explain any difference in practice between the UK and
Indonesia?
 How would you categorise this student’s response to encountering difference in practice,
according to the advocacy-enquiry quadrants that was described in the lecture and reading?
 Can you use this advocacy-enquiry model to suggest other ways that the visitors could have
approached this situation with the local team?

Case 4 – from a student on elective in Senegal

When I was in Senegal… we were doing circumcision… they kind of realised part way that the local
hadn’t fully worked, and it was horrible, and then they were saying to the kid like “no just be brave…
put up with it” and they were getting quite mean, and I just sat there thinking “maybe it’s a cultural
thing” and in the end I was like… “don’t talk to him like that it’s just not right” and they were like
“what do you mean” I was like “he’s in pain he’s six years old” like “that’s just not funny” and they
were kind of laughing…
I think it’s the language barrier as well. I think at first they thought I was joking. They really laughed,
that was horrible… at first I thought “oh I’ll put it down to cultural differences…” It took ages, and
after about twenty minutes, I was like “this can’t go on any more, this just can’t go on any more, I’ve
got to say something because I can’t put up with it anymore”

 Why might the doctors have carried on with the procedure under these circumstances?
 Do you think continuing with the procedure was bad practice, regardless of cultural context?
Why?
 How might cultural differences or unconscious bias have influenced the doctors’ perception
that it was appropriate to continue with the procedure, and the student’s perception that it
was not?
 In addition to the language barrier that the student identified, how might cultural
differences have made communication between the student and the doctors more difficult?