Health Management, Ethics and Research Module: 8.  Ethical Dilemmas in Health Service Delivery

Lemlem, a Health Extension Practitioner at Laelay Michew kebele, Central Zone, Tigray Regional State, is approached by Hailemariam, the son of Ato Gebregziabher, a well known Gena player in his locality. Hailemariam asks Lemlem to provide him with some paracetamol tablets because of pain in his knees. In fact Hailemariam doesn’t have any pain, but he is trying to accumulate enough tablets to commit suicide. He has also bought additional tablets at a market and asked another Health Extension Practitioner for even more tablets. Sometime later Hailemariam swallowed all the tablets at one time and for a while he was very ill, near to death. Hailemariam didn’t die and when he recovered he didn’t want others in the community to discover that he had attempted suicide. He began to spread rumours that Lemlem, the Health Extension Practitioner, was incompetent and had prescribed medication that she does not know how to use and that she had harmed him.

Although this is quite a complicated situation, and hopefully you will never be faced with such a difficult case, people in the community may make false accusations against you. For poor Lemlem the dilemma is something like this: she has done nothing wrong at all. She has prescribed some painkilling tablets with the best of intentions when Hailemariam pretended to have some pains. It is Hailemariam who has deceived her, but then gone on to accuse her, falsely, of being an incompetent practitioner. If she does not defend herself then her position in the community may be damaged. People might believe Hailemariam and start to think that she is not very good at her job. But how can she defend herself while still being professional and ethical in relation to her relationship with her patient Hailemariam?

Can Lemlem’s ethical principles help her in this situation? Perhaps there are principles of justice involved? Lemlem is certainly in the right and should have the opportunity to defend herself against these charges. But defending herself might harm her patient. If she successfully wins her struggle against Hailemariam he might lose face in the community and feel that he has to try to commit suicide again. He does sound as though he is very troubled. He has deep psychological problems and has already tried to kill himself - and now he’s making trouble for Lemlem. Lemlem doesn’t want to harm him (nonmaleficence), but she also feels that she should keep her job and continue to help lots of people in the community (beneficence).

Ali has been a soldier for the last five years. He’s now returned to his rural village and started to help his father on their farm. He’s a strong and handsome man and soon starts to see a new girlfriend Kedija. Ali comes to the Health Post and shows the Health Extension Practitioner, Workinesh, the results of his recent HIV test – which is positive. Workinesh also has information through her work that neither Kedija nor Ali have asked for, or been given any, condoms. What should Workinesh do?

Almost anything that Workinesh does actively will risk breaking confidentiality. But doing nothing will potentially harm one of her patients, Kedija. If she doesn’t warn Kedija that Ali is HIV positive then Kedija might become infected and become seriously ill and even die (Figure 8.2). Several ethical principles are at stake here including trust, confidentiality and autonomy. Nobody can force Kedija or Ali to act in a particular way because they each have their own autonomy.

Figure 8.2  Who has HIV/AIDS? From the outside it isn’t possible to tell who has been infected with this sexually transmitted virus. (Photo: Carrie Teicher)

Tadelech is a member of your local community. She is usually a strong woman who is a good mother to her seven children and an active member of the community. Recently she has become seriously ill with a chest infection that has turned into pneumonia. Although the Health Extension Practitioner, Hadas, has tried to convince her that she needs to go to hospital, Tadelech is determined to stay in her own home.

Hadas is in a difficult position. Of course Tadelech should be able to decide about her own health and her own body – this is the basic ethical value of autonomy. But the healthworker knows that without proper treatment she might die and then all Tadelech’s children would suffer. Indeed the whole community would lose one of their important members.

Imagine that you are a Health Extension Practitioner in a rural area and you are planning to conduct a vaccination campaign and also a malaria control campaign. Both are necessary to improve the health of your local community, but there are only limited human resources available and it is not possible to do both of these campaigns immediately.

In this situation you need to decide: should you continue with the malaria campaign or the vaccination campaign, or share your resources in some way between both campaigns? There may be ethical principles that you can use to help you make your decision. Both campaigns may be beneficial for members of the community (beneficence), and none of the decisions seem to involve potential breaches of confidentiality. You may need to gather more information about the situation in order to be helped to make the correct decision.

Jemila, a Health Extension Practitioner who is working at one of the Health Posts in Gambella Regional State, attends Ato Ojul’s family. When she visited Ato Ojul’s family she found that W/ro Hawa, the wife of Ato Ojul, is very depressed and tearful. Jemila tried to reassure her but Hawa was not willing to tell her the reason why she was depressed and crying. Later in the course of their discussion, Hawa told Jemila that she is HIV positive and that she is worried what will happen to her because of the stigmatising effect of HIV. If people in the wider community find out that she is HIV positive she fears that she will be an outcast and treated badly.

This is a complicated situation for Jemila to cope with, but there are some ethical principles that she can use to help her. Firstly, Hawa is her patient and must not be harmed by anything that Jemila does now or in the future. She must reassure Hawa about total confidentiality and establish a situation of trust between the two of them. Hawa’s status is safe with Jemila and she can get treatment for her HIV without anyone else being aware.

Leila, a Health Extension Practitioner, works in a Health Post within the Southern Nations, Nationalities and People’s Region (SNNPR) and provides community health services including family planning support. One Friday she had made a visit to Ato Olano’s family to discuss family planning issues with Ato Olano’s wife, W/ro Abebech. When she finished her discussion, Ato Olano’s oldest daughter, Bekelech (aged 15), came over to Leila and talked about something that was obviously worrying her. She confided in Leila that she has started a loving relationship with Wajo, a student, over the last six months. She says that she really likes him a lot. However she has not started sexual relations, but she has been thinking about it. She is wondering if she could start taking birth control pills. Bekelech also explained that her parents do not know anything about this relationship. She says her mother would be very upset if she knew about it, and asked that this information should not be told to her parents. At the doorway on the way out Abebech and Olano ask Leila what their daughter has been talking about with her.

Although this is a potentially difficult situation for Leila to deal with, this is a common problem and Leila will be able to use some ethical principles to work out the way that she should act in these circumstances. There is definitely a conflict of ethical principles involved in this situation. Ato Olano and his wife Abebech need to be sure that Leila, their healthcare worker, will always tell the truth. Truthfulness is a very important part of all health work. However, Bekelech has been discussing issues that she wants to keep secret from her parents who might be angry. Confidentiality should be expected of all health workers. If Leila tells Bekelech’s parents about the content of the discussion then this is a clear breach of confidentiality whatever the age of the client. Bekelech is exhibiting her own autonomy that is separate from that of her parents.

Amarech is providing antenatal care for W/ro Alemach, wife of Ato Feleke. Alemach is 26 weeks pregnant. This is her third pregnancy and the previous two deliveries were safe. When W/ro Alemach comes to the Health Post for her appointment, she complains of a burning sensation during urination and a yellowish discharge from her birth canal. Amarech has told W/ro Alemach that this is almost certainly caused by an infection acquired by sexual intercourse. She asks W/ro Alemach to tell the truth if she has had extra-marital sex because this might be the source of infection and the cause of her symptoms. W/ro Alemach eventually admits that she has had an affair with Ato Tadesse, a well-known community member, who is the likely source of the infection. Her husband does not know about the extra-marital relationship and she does not want him to know. She is certain her husband is the father of the child she is carrying. She asks Amarech to provide treatment for her infection and not to tell her husband about her situation.