11.3: ETHICAL DECISION-MAKING IN GLOBAL HEALTH: WHEN CULTURES CLASH

Disclaimer: This case is a critical analysis of a topic that most readers will view as an act of gender-based violence. A critical analysis of the subject requires reviewing it from several different perspectives, not all of which are disapproving of the subject. Although the subject is discussed from varying perspectives, the authors are in no way supportive of the practice.

Acknowledgement:

We gratefully acknowledge the assistance of Rachel Purdy, PharmD 2019, for her assistance with reviewing and editing this case.

Introduction

Pharmacists planning to serve on a short-term medical mission trip often prepare by reviewing the pathophysiology and treatment for diseases they do not normally see as part of their usual practice. Being clinically prepared to serve on a mission trip is vital, but so is preparing for cultural situations that will be new and maybe disturbing.

This case discusses the practice of surgically altering the external female genitalia as part of a cultural or religious practice. Most in the Global North, including the WHO, refer to this practice as female genital mutilation (FGM). The term “mutilation” may be problematic because it suggests that harm is intentionally inflicted, and not all cultures see the practice as intentionally harmful. Consequently, this case study uses the term female genital cutting (FGC). Regardless of terminology, the WHO indicates that FGC creates risks for both short-term and long-term adverse consequences including pain, excessive bleeding, fever, infection, dyspareunia, difficult childbirth, and psychological problems.1

FGC is practiced primarily in a wide swath across Africa from the Atlantic Coast to the Horn of Africa and is highly variable in where it is practiced, how it is practiced, and who practices it.2 Although prevalence is highest in Somalia, Egypt, Sudan, Mali, Guinea and Sierra Leone, all with rates >80%, different regional, ethnic, or tribal groups within and between countries may differ widely in how (or even if) they practice FGC.2Although most countries in which FGC is practiced are majority Muslim, the practice is not limited to (or required by) Islam. While the practice is widespread in sub-Saharan Africa, it may also occur in immigrant communities in Europe, North America and Australia.

In most countries, girls are cut before 15 years of age and often below the age of five. In other regions, the event may not happen until shortly prior to, or even after, marriage. There is great variability in who performs the procedure. For example, in Senegal, nearly all FGC is performed by traditional practitioners, while in Egypt, nearly 80% is performed by trained health personnel.2

Although the WHO describes FGC as a violation of women’s human rights,3 in communities where it is practiced, FGC is often seen as providing a sense of identity within the culture and is a purifying rite that signals a girl is of good moral character.4,5 Although Westerners often believe the practice is intended to inhibit female sexual pleasure or preserve female virginity, women who have undergone the procedure often disagree.6-8

Case Scenario

You have arrived in Mali, West Africa on your first medical mission trip. Your medical team consists of two physicians (one of whom serves as your medical director), a physician assistant, a pharmacist (you), one of your pharmacy student interns, and a nurse. The village has not only welcomed your team to the village but has treated you as honored guests. Over the weeks, the clinic your team has worked in has been highly successful and you have treated nearly 120 patients for malaria and various other tropical diseases.

One evening, your team is invited to an enormous village celebration with feasting and dancing. As you are enjoying yourself, one of your team members quietly comes up to you and tells you the celebration is to honor a village girl who will undergo FGC in the morning.

Your team gathers back at your bunk house to discuss the situation and what you all should do. Frankly, most of you are angry with your medical director for not informing you beforehand this was a situation the team could possibly find itself in. The team is divided as to what to do. However, it is clear to all team members that they are working in a culture that they do not understand.

In the end, the team cannot come to any agreement about what to do. You go to bed for the night and try in vain to get some sleep under your bed net. The next morning, you go to clinic as usual and try to act like nothing has happened.

Author Commentary

Usually, the role of the pharmacist on a global health mission trip is to ensure the smooth running of the pharmacy, consult with team members on drug therapy decision making, and to counsel patients on their medicines. But there will be times when no one on the team is adequately prepared to deal with situations that may arise. Providers’ clinical education may not include adequate cultural humility training, leading to providers making negative judgments about the community they serve. Consequently, all team members, including pharmacists, should be able to negotiate these cultural differences and adopt a process for ethical decision making when cultural differences may impair patient care.

Practicing global health or volunteering for a medical mission trip to a medically underserved region can be a life-changing experience. Volunteers often gain a deeper understanding of themselves and their place in the world. They also come to recognize that what we think of as normal in the US is not always considered normal somewhere else. As a result, any actions taken (or not taken) may not be the same as what you would do in the usual course of your pharmacy practice in an American setting. The case presents an extreme practice situation which most Americans would certainly not see as normal. However, the process of working through and identifying an ethical response will be similar no matter if the cultural divide is about FGC or if the patient refuses drug therapy due to a belief that his illness is caused by evil spirits.

Patient Approaches and Opportunities

Ethical analysis requires time and reflection. The gut instincts that we experience around complex and controversial situations are more likely related to our moral system than an ethical framework. Purtilo presents a formalized scheme called the Six-Step Ethical Decision-Making Process, to take a situation apart, organize your thoughts, and come to an ethical decision.10 The process includes the following steps:

Step 1: Gather Relevant Information

Factors that may help the team decide a course of action may include:

• How does the local community view FGC? This is part of getting the story straight. Best practices in global health make it a requirement to understand the community the team serves in. Proposing solutions before we even understand what may or may not even be a problem is bad practice. Cultural practices need to be understood within their own contexts, and not compared to an outsider’s perspective on that culture so as to denigrate it. Cultures don’t exist to make observers or visitors feel better, they exist to provide those who live within them a set of cultural rules, values, behaviors, and practices that make daily life in that culture possible. So, if one can see past one’s own cultural biases (e.g. FGC is barbaric) it becomes possible to see (if not necessarily agree with or understand) that FGC may assist women to live within the culture they inhabit.
• Why do cultures practice FGC? If we can see the practice through the eye of the local community, we learn that it is not the parents’ intention to mutilate their daughters, nor is it necessarily the result of living in a deeply patriarchal society. Rather, FGC is often seen as a proper, socially acceptable, cultural expectation that is thought to be purifying.
• Are there existing interventions that have been shown to be helpful? If the decision is made to intervene, gathering needed information will require knowing what experts have found to be helpful. Making clinical recommendations that are not evidence-based is unprofessional. So is making cultural recommendations that are not evidence-based. Ending FGC involves changing cultures, not just educating villagers about the harms of a long-standing practice. Although cultures do change (e.g., cigarette smoking in public in the US is now prohibited) they may change slowly and from the bottom up, not from a top down program. One thing is clear – if an intervention is to have any hope of success, it must be focused as a community change effort. The most effective work appears to have been done by a non-governmental organization called Tostan working in West Africa.11

Step 2: Identify Type(s) of Ethical Problem(s) Occurring

After collecting relevant information, it is critical to determine what type(s) of ethical problem(s) are occurring in your particular situation. There are four types of ethical problems:

• Ethical distress occurring due to an existing barrier to acting on an obvious solution;
• Ethical distress occurring because two or more solutions are possible; however, value is lost if only one solution was acted upon;
• Dilemma of justice occurring because resources or benefits are not distributed fairly; and
• Locus of authority ethical problem occurring because someone other than yourself holds the power to decide and act.

A situation may result in more than one ethical problem. However, this FGC case is a good illustration of a locus of authority ethical problem.

Step 3: Use Ethical Approaches and Tools to Analyze the Problem

During their training, most health professionals were provided some basic tools to evaluate and proceed when faced with an ethical situation, but when faced with the cultural divide posed by FGC, these tools may not be sufficient.

Consider the Pharmacist’s Code of Ethics provided by APhA.12 The Code discusses the covenantal relationships with the patient but since a young woman about to undergo FGC is not actually the pharmacist’s patient, much of the Code does not readily apply. The eight principles listed are the desirable characteristics that American society desires from a pharmacist practicing in the US. Could or should the Code be applied to an individual who is not your patient and who is not residing in the US?

Next, consider the ethical principles of autonomy, beneficence, non-maleficence, and justice that most practitioners are familiar with. Since Westerners may frequently believe FGC impairs a woman’s sexual pleasure, perhaps the best ethical argument against it is justice. However, ethnographic studies of the sexual experiences of women who have undergone FGC found that some women continue to have a satisfying sex life while others think the Western world’s emphasis on sexual pleasure and orgasm is misguided.5,13

Step 4: Explore the Practical Alternatives

Up until this step, you have had the opportunity to decide what you should do. The next step is to take all the information and tools and determine what you can do in this situation. This step encourages brainstorming of all possible actions and non-actions. It is important to not oversimplify the possible actions. One option to prevent tunnel vision is to bring those who should be involved in this decision to the table to make sure all perspectives are represented in the alternatives. Please keep in mind that non-action is a form of decision. Doing nothing should be considered as a possible alternative.

Steps 5 & 6: Complete Action and Evaluate

Once an action/non-action is taken, take time to engage in personal reflection. Conduct an evaluation of how effective your process was in helping the team to come to a decision. Determine what the outcome of your action was. This is important for personal and professional growth. Additionally, lessons learned may be passed to other healthcare providers and educators.

Important Resources

References

• Female Genital Mutilation. World Health Organization 2018. Available at: http://www.who.int/en/news-room/fact-sheets/detail/female-genital-mutilation. Accessed August 17, 2018
• Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change. UNICEF 2013. Available at: https://www.unicef.org/publications/index_69875.html. Accessed August 17, 2018
• Female Genital Mutilation. World Health Organization Sixty-First World Health Assembly. 2008. Available at http://apps.who.int/iris/bitstream/handle/10665/23532/A61_R16-en.pdf;jsessionid=99305740E5F244925F996B1406F6C2C7?sequence=1. Accessed August 17, 2018
• Gruenbaum E. Honorable mutilation? Changing responses to female genital cutting in Sudan. In Anthropology and Public Health – Bridging Differences in Culture and Society. Hahn RA, Inhorn MC eds. 2nd Ed. 2009 Oxford Press. New York, New York
• Gruenbaum E. Sexuality. In The female circumcision controversy – an anthropological perspective. 2001. The University of Pennsylvania Press. Philadelphia, PA.
• Shell-Duncan B, Hernlund Y. Are there “stages of change” in the practice of female genital cutting?: Qualitative research findings from Senegal and The Gambia. African J Reprod Health 2006;10(2):57-71.
• Hernlund Y, Shell-Duncan B. Contingency, Context, and Change: Negotiating Female Genital Cutting in The Gambia and Senegal. Africa Today. 2007;53(4):43-57.
• Boddy J. Gender Crusades: The female circumcision controversy in cultural perspective. In Transcultural Bodies – Female Genital Cutting in Global Context. Hernlund Y, Shell-Duncan B. eds. 2007 Rutgers University Press. New Brunswick, New Jersey.
• WHO guidelines on the management of health complications from female genital mutilation. World Health Organization 2016. Available from: http://www.who.int/reproductivehealth/topics/fgm/management-health-complications-fgm/en/. Accessed August 22, 2018.
• Purtilo R. Ethical Dimensions in the Health Professions. Philadelphia: Saunders; 1999.
• Tostan – Dignity for All. Available from: https://www.tostan.org/. Accessed August 21, 2018.
• Code of Ethics for Pharmacists. American Pharmacists Association. 1974 Available at: https://www.pharmacist.com/code-ethics. Accessed August 21, 2018.
• Ahmadu F. Ain’t I a Woman Too? Challenging Myths of Sexual Dysfunction in Circumcised Women. In Transcultural Bodies – Female Genital Cutting in Global Context. Hernlund Y, Shell-Duncan B. eds. 2007 Rutgers University Press. New Brunswick, New Jersey.