Case Analysis

Introduction

Surgery plays an important role in healthcare across the world. A population that
lacks surgical treatment is likely to experience an increase in both morbidity and mortality.
This is usually the case for low-income countries with limited resources. In such places,
patients that require surgical services sometimes have to rely on short-term medical
volunteers from abroad on short-term medical missions. Since such teams only stay for a
short time and are, therefore, not able to provide postoperative services to patients that they
perform surgeries on, there is real possibility that their services may end up doing more harm
than good. This paper examines a specific case that represented an ethical dilemma for a
surgery team that was on a medical mission in central Africa. The team was faced with the
dilemma of performing a surgical operation on a JJ, a boy with cleft lip and palate. Both
performing and not performing the surgery has benefits and drawbacks. This paper examines
issues related to this ethical dilemma that the surgery team and presents a solution to the
dilemma. The solution presented, performing the surgery and then training local medical staff
to provide postoperative care and other similar services, is not only relevant to the specific
case in the case study but also to the wider short-term medical mission operations.

Background

Short-term medical mission (STMM) is the practice whereby health professionals
from developed countries go to developing countries to provide medical services that
populations in the local areas may not be able to access due to reasons such as cost and lack
of enough trained health professionals (McLennan, 2014). Often, these missions serve rural
or poor communities for free or for a small fee. Motivation for the medical professionals who
volunteer for such missions include desire to use one’s knowledge, skills, and experience to

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help the poor (McLennan, 2014). Others are motivated by educational factors, such as
opportunity to gain more medical experience that such missions provide. Recent times have
seen dramatic growth of STMMs due to, among other factors, increased awareness about
inadequate or poor healthcare services in developing countries and improved global travel
and communication (McLennan, 2014).

In addition to offering important healthcare services to populations that would
otherwise have difficulties accessing them, such medical missions have been found to
increase international responsibility, improve social awareness, and the networks ties formed
through missions can help improve future health of the served communities through training
and other forms of skills development for local healthcare professionals (McLennan, 2014).

Despite these potential benefits, STMM has significant limitations. Some of these
limitations have the potential of causing harm to served communities. For instance, some
studies have found that lack of familiarity of the patient population can have negative impact
on the effectiveness of the services that visiting teams provide to local populations
(McLennan, 2014). Language barriers have also been found to have the potential of causing
harm to the patients. As this case study has revealed, the other major limitation of STMM that
has the potential of causing patient harm is lack of time. The medical teams are usually
available for a very short time, often a few weeks. Such a short time does not allow patients
that they serve adequate follow-up treatment and visits. Without follow-up treatment, some
patients may experience worse health outcomes than they would have otherwise experienced
had they not been treated by the visiting medical team.

Apart from the general ethical issues that STMM teams face, there are also complex
ethical questions that they have to grapple with in their daily practice. The case study presents
one such ethical issue. In the case study, the visiting surgical mission team from the U.S. is

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faced with two options, both of which have significant benefits and drawbacks as well. The
first option is to provide JJ with cleft lip and palate repair. The benefit of this option is that JJ
may have improved quality of life. The drawback is that such surgery requires postoperative
care which, for reasons such as cost and availability of trained professionals nearby, JJ may
not be able to obtain and may, therefore, end up developing complications which in turn may
lead to morbidity. Due to these risks, the visiting surgical team have the second option of not
providing JJ with cleft lip and palate repair. This second option is also not ideal as patients
who have undergone surgery have better quality of life than patients who had not received
surgical services.

Given the many perspectives that providing surgical services to JJ can be viewed and
interpreted, the ethical question presented in the case study can be considered to be a complex
ethical question. Unlike simple ethical questions which have simple clear-cut answers,
complex ethical questions require proper analysis of the data that is relevant to the ethical
concern at hand and the use of multiple perspectives (Elder & Paul, 2010). Such an analysis
is important because of existence of multiple viewpoints from which a given event can be
viewed and interpreted (Elder & Paul, 2010).

Alternatives

The visiting surgical team operated on JJ out of belief that the benefits of the
operation outweighed its possible risks. The alternative that the team had was to deny JJ cleft
lip and palate repair services. While at first look such a decision appears callous, it is actually
a viable alternative when one considers JJ’s circumstances. JJ comes from a low-income
family in rural central Africa. The cleft lip and palate repair could only be successful in the
long run if he had access to postoperative care. Without the postoperative care, JJ risked
developing complications that would leave him in a worse situation than he was before the

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operation. Due to geographical and financial barriers, there was high possibility that JJ might
not access the postoperative care that he needed. Thus, due to problems associated with
difficulty of getting continuity of care, the visiting surgical team had the alternative of not
providing JJ with cleft and palate repair services.

Another alternative that the visiting medical team had was to offer JJ cleft lip and
palate repair services and then train local medical personnel so that they get the knowledge
and skills needed to offer JJ adequate postoperative care.

Proposed Solution

A major ethical concern that has been raised with regards to STMM operations is lack
of adequate postoperative care as well as patient follow-up care (Meidl et al., 2017). In the
case study under analysis, this was the main ethical concern that was raised. The visiting
surgery team did a great job of providing poor residents of the community with free cleft lip
and palate repairs. However, they did not plan for follow-up and postoperative care. Due to
lack of such plan, some of the patients that had been operated on such as JJ did not
experience the expected improvement in their condition. In fact, they were put in a position
where they risked experiencing morbidity. Thus, the most appropriate solution for the case
study is one that addresses the ethical concern of lack of planning for follow-up and
postoperative care.

A solution that addresses the ethical concern raised would foster sustainability of the
services that the visiting surgical team provided to the local community. A sustainable
intervention helps to build the local capacity of health professionals to treat the patients after
the visiting team has left (Koch, Meara & Wall, 2019). Thus, the visiting team should spend a
portion of their time training local healthcare professionals such that by the time the visiting

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team leaves, the local health professionals would be able to competently provide
postoperative care and other forms of care that patients that had been operated on such as JJ
need.

Leaving without transferring to the local team skills needed to sustain the health
services that the visiting team offered will not help in improving the overall state of local
public health in any meaningful manner (Almeida et al., 2018). In fact, it risks leading to poor
clinical outcomes for the patients as the case of JJ shows. Thus, for STMMs to have long-
term success there is need for the visiting teams to train local medical staff.

Recommendations

Training local medical teams so that they are able to continue providing surgical
services that the visiting medical team was offering to the local community is the ideal
solution to the ethical concern raised in the case study. The training should be thorough
enough to allow local teams to provide surgical and postoperative care independent of the
supervision of the visiting teams. Without thorough training of the local teams, there is risk
that the local, poorly trained teams may cause harm to their patients. The thorough training
required may not be achieved within the short time that the visiting surgical team will be
around.

However, through repeated visits by the surgical mission, local health personnel have
a real chance of acquiring all the skills that they need to competently provide patients from
the local community with the services that the visiting medical professionals offer.
Additionally, the missions can sponsor a few members of local medical teams to train abroad
so that they are able to acquire skills that are not locally available, such as speech therapy.

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References

Almeida, J. P., Velásquez, C., Karekezi, C., Marigil, M., Hodaie, M., Rutka, J. T., &
Bernstein, M. (2018). Global neurosurgery: models for international surgical
education and collaboration at one university. Neurosurgical focus, 45(4), E5.

Elder, L., & Paul, R. (2010). Critical Thinking: Ethical Reasoning as Essential to Fairminded
Critical Thinking, Part IV. Journal of Developmental Education, 34(1), 36-37.

Koch, R., Meara, J. G., & Wall, A. E. (2019). How should we decide whether and when some
care is better than no care? AMA journal of ethics, 21(9), 729-734.

Meidl, K. A., Meidl, J. M., Meidl, L. R., & Meidl, E. J. (2017). Effects of short–term medical
mission trips to Chiapas, Mexico, on the religiosity of the missionaries. The Linacre
Quarterly, 84(2), 115-129.

McLennan, S. (2014). Medical voluntourism in Honduras: ‘Helping the poor? Progress in
Development Studies, 14(2), 163-179.