Setting: An office in the department of global health at a large North American university

Scenario: The associate dean of global health at a North American university is meeting in her office with a second-year medical student who recently completed an international elective in West Africa. The student requested the meeting because he has felt troubled and had difficulty focusing on his coursework since returning home.

The student explains that these feelings mainly stem from the many differences he noticed in the way healthcare is delivered in West Africa in comparison to his home country. For example, he witnessed several patients with terminal illnesses suffering in crowded hospital wards without privacy or analgesic medications. The student remains distressed by the memory of the discomfort and perceived lack of dignity available to these patients.

The medical student also relates how he was taken aback by the limited therapeutic options offered to patients with serious illnesses or poor prognoses during his elective. Whereas his training emphasizes pursuing any available worthwhile intervention, the medical student found that local physicians oftentimes do not attempt any form of treatment for these patients. In one instance, he proposed several treatment options for a patient with advanced pulmonary disease, all of which were rejected by local hospital physicians as being impractical, costly, or futile.

Finally, the medical student explains that he observed many patients deferring to their physicians on important medical decisions, with little effort being made by hospital staff to ensure that patients and their families are informed about their condition and the implications of treatment. The student also observed hospital staff performing procedures and administering medications without seeking the patient’s consent.

The medical student describes how he has felt isolated since returning home and that no one around him can relate to his experiences. He concludes by saying that he has a strong desire to be involved in humanitarian healthcare in the future, but feels disempowered about the root causes of the situations that he experienced and what he can do about them. The associate dean must now decide how she can best support and guide this student. The situation also prompts her to reflect on whether there are ways that the university’s international elective program could be adapted to better prepare students prior to electives, and support them during the elective and following their return.

Analysis: Apply this case to the Humanitarian Healthcare Ethics Analysis Tool (HHEAT). The HHEAT  is intended to facilitate discussion and deliberation for those involved in ethically challenging situations and will assist humanitarian healthcare workers in implementing well-considered decisions.  The six steps are designed to help you or your team structure reflection and deliberation on the ethical dilemma presented in the case study. You may skip questions that appear less relevant to the issue or explore dimensions pertinent to the context but not listed in the tool.

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Disclaimer: Case studies in the Student Case Study Series are based on the reflections of healthcare students on ethical challenges experienced in humanitarian health care contexts. While the stories presented in the cases draw on real events and the accounts of real persons, many stories are composites in which similar experiences are woven together. In all of the stories, details such as names, dates, locations, career and life stage, gender, and profession have been changed, obscured, or omitted. Any resemblance the stories may bear to actual persons, places, and events is co-incidental.

While the stories often aim to show what the protagonist is thinking or feeling, the Humanitarian Healthcare Ethics Research Group’s intent as the stories’ author is not to suggest that the values and assumptions held by a story’s protagonist are those of all or many students engaged in humanitarian healthcare learning experiences. Similarly, the values, opinions and actions of a protagonist or other actors in a story should not be understood to reflect those of, or be endorsed by, the Humanitarian Healthcare Ethics Research Group.

How to cite: Humanitarian Healthcare Ethics. 2014. Student Case Study Series: Root Causes of Differences in Healthcare Delivery between Countries. www.humanitarianhealthethics.net.

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