The need for Global Health Ethics

Most clinicians are familiar with the traditional view of clinical ethics. As outlined by Beauchamp and Childress , clinical interactions should be guided by the principles of beneficence, non-maleficence, justice, and respect for autonomy. Increasingly, physicians around the world are being asked to move beyond a case based approach to ethics and to contribute to global health by engaging with research, policy development and clinical care in low-resource countries where both inequities and disparities in health care are great. Global health was once seen as the realm of public health specialists and missionaries, but the increasingly complex policy, training and clinical aspects of problems in health care require an appropriate response from physician leaders . Whether one is a physician in a high income country seeking to engage in global health projects, or a physician in a low income setting navigating conflicting clinical, educational, research and policy needs, global health issues are increasingly part of the physician’s portfolio and provides the opportunity to improve the quality of health systems.

Global health ethics is a relatively new area of concern for caregivers and academics, offering a lens and a guide for Obstetrician/Gynecologists who wish to engage globally. In their review of “prominent theories and relevant topics” in global health ethics, Stapleton et al. propose a definition of the field: “global health ethics is a term that is used to conceptualize the process of applying moral value to health issues that are typically characterized by a global level effect or require action coordinated at a global level” . Moving from the general to the specific, they see two ethical considerations as foundational: “1) what is the moral significance of health and 2) what is the moral significance of boundaries?” With regard to the first they note, “health has special moral importance; therefore, health inequalities are also morally significant…Health justice is principally concerned with reducing unfair and avoidable health inequalities…” They then go to examine the moral significance of geopolitical boundaries. The authors distinguish “cosmopolitan” and “anti-cosmopolitan” approaches to this issue. Cosmopolitans claim that “every person is a ‘world citizen’ and thus boundaries have no moral relevance; on the other hand, anti-cosmopolitans argue that “morality is ‘local’ and specific to cultures.”.

Benatar and colleagues created a foundation for the field of global health ethics by laying out “a rationale for mutual caring” that described the need and promise of global health ethics. Noting that the “rapidly expanding global economy has failed to reduce poverty and improve health for all”. They suggested that bioethics, as an interdisciplinary field, “could make a contribution toward improving health globally,” by embracing “widely shared and foundational values.” For them global health ethics offers the possibility of improving health by creating an interdisciplinary space that examines the contexts of global health, promotes shared values (including empathy, generosity and solidarity), and promotes transformational approaches to governance. By introducing a normative approach to global health care, asking care workers to be ‘committed and engaged in identifying global wrongs related to health and seeking to have them redressed’ , they – wittingly or unwittingly — created the difficult challenge of establishing common values for improving global health.

The high rates of maternal and early neonatal mortality are a persistent global wrong. When maternal mortality was first identified as a neglected epidemic in 1985 , the global health community responded in myriad ways that have significantly reduced but have not yet “solved” the problem. The first WHO estimates of maternal mortality in 1990, suggested that more than 500,000 maternal deaths were occurring globally every year . An unacceptable high global maternal mortality ratio of 395 per 100,000 live births was dwarfed by the ratio in sub Saharan Africa of 987/100,000. The most recent estimates from 2015 demonstrate a maternal mortality ratio of 216 and in sub-Saharan Africa a ratio of 546 . Ratios within a country, however, vary widely when stratified by socioeconomic status . Although all pregnancies are at risk, access to care is better for women in higher socioeconomic brackets. Infant mortality has decreased during this time. As infant mortality decreases, the proportion of infant deaths from early neonatal causes increases . Perinatal mortality rates in women with preeclampsia are exceedingly high .

Global estimates of maternal mortality levels and associated perinatal mortality are not granular, relying heavily on survey data with large confidence intervals . Community-based investigations of maternal mortality consistently identify maternal deaths that have gone unrecognized by the health system. In Ghana the reproductive age mortality surveys have determined that maternal mortality is underestimated by up to 50% . Compared with high income countries where preventable maternal and early neonatal mortality have been virtually eliminated, these persistent inequities present a global health ethical dilemma that has yet to be solved.

Efforts to address this ethical challenge face a number of predictable problems. In Global Health Ethics: Key Issues, the World Health Organization describes three ethical challenges that are central to the work of global health: access, cultural relativity, and research . The authors of the report point out that “health in low-resource countries is often compromised by social determinants, such as poverty, malnutrition, poor education, unhealthy living conditions, and lack of access,” a problem exacerbated by a “brain drain” that creates a shortage of health professionals in resource-poor countries. They go on to explain the challenge of cultural relativity: Are ethical standards universal? Or are they rooted in local culture, a product of values unique to each society? While the protection of human rights is a noble goal, the danger of ethical imperialism is ever present . International research presents the third ethical challenge of global health. Low and middle income countries (LMICs) are increasingly attractive sites for clinical research because costs are low and the population offers “naïve bodies,” that is, persons who are not already taking drugs for depression, hypertension, cholesterol control and the like . The coming of the drug industry may be a boon to local economies, but this type of research presents special problems, including the difficulty of obtaining truly informed consent and lack of post-trial access to the medications and therapies being tested .

The first step in responding to problems of access and research must be finding ways to address the central challenge of cultural relativity: finding common values for international and interdisciplinary teams working to improve health. The Elmina Declaration on Human Resources for Health outlines a practical way to approach this challenge . The Elmina Declaration provides a moral foundation for local or global partnerships that seek to improve access to clinical care and to design appropriate research while addressing the cultural context. The Declaration consists of a Charter for Collaboration that lays out concepts and principles for guiding the development of partnerships that respects the interests and perspectives of all partners (see Table 1 ). The Charter was created to guide human capacity partnership projects between the government and universities in Ghana and the University of Michigan, and serves as a model for the ethical conduct of academic global health projects in both high income low/middle income countries (LMICs) . The process used to guide and assist global health academic partnerships stemmed from a prior on-going collaboration that has produced over 140 OBGYNs trained in Ghana who stayed in Ghana to practice .

The Sustainable Development Goal (SDG) framework has made the elimination of maternal and early neonatal by 2030 a priority , establishing the elimination as morally significant, without regard for political boundaries, adopting a “cosmopolitan” approach while still demanding interventions that are culturally appropriate. It is important to remember, however, that maternal and early neonatal morality are among a long list of topics related to human reproduction that demand a response from those concerned with global health, including:

• •
  

  The elimination of in-utero exposures to elevated glucose levels, teratogens and toxins;

  
  
• •
  

  The provision of health care and education to young girls;

  
  
• •
  

  The provision of sex education to adolescent boys and girls;

  
  
• •
  

  Access to family planning and abortion and post abortion services;

  
  
• •
  

  Provision of resources for the prevention, diagnosis and treatment of sexually transmitted diseases;

  
  
• •
  

  Early diagnosis of pregnancy, and prompt diagnosis and resolution of pregnancy complications in all trimesters of pregnancy and postpartum;

  
  
• •
  

  The prevention of obstetric fistula, and repair of both obstetric and iatrogenic fistula;

  
  
• •
  

  The development of a comprehensive approach to major women’s health issues such as infertility, cancer prevention and treatment, management of menopause and pelvic organ prolapse.

Because all of these issues are subject to cultural, religious, political influences, careful and ethically informed deliberation is a necessary part of the creation of policy and decision making regarding the just allocation of resources.

In each of these areas of reproductive health, a global health ethics lens calls our attention to the fact that care as usual is insufficient, intervention is necessary, and interventions must be done with a finely tuned sensitivity to local understandings of the moral dimensions of health and health care. Interventions are needed, but these interventions must be locally situated – organizationally and culturally. The challenge is to intervene in a respectful way, to honor local culture and to be aware that any intervention brings with it its own set of cultural assumptions. Our focus here is on the ethical issues associated with the current SDG to eliminate preventable maternal and neonatal mortality in LMICs, but what we learn in this one area provides a template for responding the other pressing needs in reproductive care.

The challenge of designing respectful interventions for responding to the problem of maternal and neonatal mortality is nicely illustrated in the tensions identified by Miller et al. in their contrast between maternity care systems that offer “too little too late” (TLTL – a problem of LMICs) and those that offer ‘too much too soon’ (TMTS – a problem of high income countries). The solution to TLTL is not TMTS. Recognizing problems on both ends of this continuum is the first step toward collaborative interventions, where the strengths and weaknesses of all parties are acknowledged and respected, while at the same time, obtaining the levels of health outcomes that everyone in the world has a right to expect, a variation on the classic imperative of medical ethics: primum non nocere .

What has been the global response thus far?

Attempts to reduce maternal mortality have been broad and comprehensive and cannot be adequately covered in this discussion. However, the response can be described in broad strokes with reference to past and current interventions and the gaps that remain. Early in the Safe Motherhood initiative, attempts to solve the problem assumed incorrectly that prenatal care and traditional birth attendant training could reduce maternal mortality . It was soon realized that this was insufficient for responding to at-risk pregnancies, and that only through the provision of skilled emergency obstetric care could maternal deaths be averted. The millennium development goal framework initiated prior to 2000 provided clear priorities for the reduction of maternal and neonatal and child mortality. Effective efforts within this framework focused on basic and comprehensive emergency obstetric and neonatal care, and training midwives and other health workers . The components of basic emergency obstetric care include the provision of 1) antibiotics to prevent puerperal infection; 2) anticonvulsants for treatment of eclampsia and preeclampsia; 3) uterotonic drugs (e.g., oxytoxics, misoprostol) administered for postpartum hemorrhage; 4) manual removal of the placenta; 5) assisted or instrumental vaginal delivery; 6) removal of retained products of conception; and 7) neonatal resuscitation. Comprehensive emergency obstetric and newborn care also includes blood transfusions, surgery (e.g., cesarean section), neonatal intubation and advanced resuscitation (intubation and respirator available). Using a cost analysis model to study effectiveness and cost effectiveness of obstetric surgical procedures, it has recently been shown that cesarean delivery and probably also obstetric forceps-assisted vaginal delivery are associated with increased years life saved (YLS) and reduced disability adjusted life years (DALY’S) .

Task sharing or shifting was introduced as an alternative to physician provided care, especially in the case of providing cesarean sections for obstructed labor as well as training in other singular complications. A recent meta-analysis compared controlled, nonrandomized trials of outcomes from cesarean deliveries determined that there were no differences in maternal and perinatal deaths, but clinical officers had a higher incidence of wound dehiscence and wound infections . The non-randomization in these trials makes the conclusions difficult to evaluate.

A great emphasis has been place on midwifery skills. The recent Lancet series presented the importance of midwifery in the reduction of maternal and neonatal mortality. One important conclusion is that application of the evidence would indicate that midwives could avert more than 80% of maternal and newborn deaths, including stillbirths . Midwifery therefore has a pivotal, yet widely neglected, part to play in accelerating progress to end preventable mortality of women and children.

What has been the global response thus far?

Attempts to reduce maternal mortality have been broad and comprehensive and cannot be adequately covered in this discussion. However, the response can be described in broad strokes with reference to past and current interventions and the gaps that remain. Early in the Safe Motherhood initiative, attempts to solve the problem assumed incorrectly that prenatal care and traditional birth attendant training could reduce maternal mortality . It was soon realized that this was insufficient for responding to at-risk pregnancies, and that only through the provision of skilled emergency obstetric care could maternal deaths be averted. The millennium development goal framework initiated prior to 2000 provided clear priorities for the reduction of maternal and neonatal and child mortality. Effective efforts within this framework focused on basic and comprehensive emergency obstetric and neonatal care, and training midwives and other health workers . The components of basic emergency obstetric care include the provision of 1) antibiotics to prevent puerperal infection; 2) anticonvulsants for treatment of eclampsia and preeclampsia; 3) uterotonic drugs (e.g., oxytoxics, misoprostol) administered for postpartum hemorrhage; 4) manual removal of the placenta; 5) assisted or instrumental vaginal delivery; 6) removal of retained products of conception; and 7) neonatal resuscitation. Comprehensive emergency obstetric and newborn care also includes blood transfusions, surgery (e.g., cesarean section), neonatal intubation and advanced resuscitation (intubation and respirator available). Using a cost analysis model to study effectiveness and cost effectiveness of obstetric surgical procedures, it has recently been shown that cesarean delivery and probably also obstetric forceps-assisted vaginal delivery are associated with increased years life saved (YLS) and reduced disability adjusted life years (DALY’S) .

Task sharing or shifting was introduced as an alternative to physician provided care, especially in the case of providing cesarean sections for obstructed labor as well as training in other singular complications. A recent meta-analysis compared controlled, nonrandomized trials of outcomes from cesarean deliveries determined that there were no differences in maternal and perinatal deaths, but clinical officers had a higher incidence of wound dehiscence and wound infections . The non-randomization in these trials makes the conclusions difficult to evaluate.

A great emphasis has been place on midwifery skills. The recent Lancet series presented the importance of midwifery in the reduction of maternal and neonatal mortality. One important conclusion is that application of the evidence would indicate that midwives could avert more than 80% of maternal and newborn deaths, including stillbirths . Midwifery therefore has a pivotal, yet widely neglected, part to play in accelerating progress to end preventable mortality of women and children.