As a student one does not appreciate the importance of bioethics. The subject seems to be yet another obstacle, in a long list of obstacles, that would get between you and studying the pathophysiology of some rare copper-retaining disorder. It was only during my community service year that I realised the importance of this subject.
The undergraduate exposure to bioethics was double-edged: it provided a useful framework for decision-making but, with that, illuminated all the grey areas and potential ethical pitfalls of rural healthcare. I remember being involved in a resuscitation of an elderly woman. I was struck by the seemingly apathetic attitude of the local staff to the procedure versus the frantic attempts of the university-trained staff to save the life. There seemed to be a constant rift between my university training and the rural way of life.
The first I heard of the MPS Bioethics Competition was through the WITS medical students council. Two thoughts flashed through my mind: first was the challenge of writing 5,000 words on the frustrations I experienced trying to take Western healthcare into rural Africa and, second, five great ways to spend the R5,000 prize money.
At this point you may be confused as to what I was doing back at WITS after completing my community service. The answer is that I completed BSc Physiotherapy in 2005 and returned to WITS in 2008 for the Graduate Entry Medical Programme. Sucker for punishment or continuing professional development: we’ll see in two years’ time.
The toughest part of any essay is deciding what to write about. The brief given for the competition was rather vague – “5,000 words on the problem of dual loyalty” – but the topic I picked is an African approach to the problem of dual loyalty. This sprung from my frustrations experienced in rural KZN and an attempt to understand my patients better.
The bioethics field, despite globalisation, is dominated by Anglo-American thought and ideas.1 With a history of colonisation by Western countries, these thoughts and ideas have shaped the development of the African continent; but there remains a difference in the thinking between Africans and Westerners – and it is the difference The bioethics field, despite globalisation, is dominated by Anglo-American thought between communitarian and individualist thought.
This difference revolves around the relative value of the individual within a community. The individual is central to moral concern in an individualist approach; in communitarian thought, however, importance is placed on the community as well as the individual. On the African continent, communitarianism, also known as Ubuntu, is described in the following maxim: “Umuntu ngumuntu ngabantu.” Translated, this means: “I am because we are.” I have come to realise that the frustration I experienced in rural South Africa was the result of trying to interpret a communitarian way of life through an individualistic pair of eyes.
The definition of dual loyalty is: “The clinical role conflict between professional duties to a patient and the interests of a third party.”2 To understand dual loyalty from an African point of view, we need to apply a communitarian point of view to the definition.
Firstly, who is the patient in an African setting? This is not just the patient presenting to the doctor, but extends to include the community that the patient is from. This is because the individual and community are inseparable. The HIV/AIDS epidemic illustrates this concept with the sick patient surrounded by a sick community; AIDS orphans, child-headed households and loss of the community’s workforce.
Secondly, who is a third party? This is a party which is not part of the community that the presenting patient is from. This third party would have to have a separate existence to that of the patients. Examples of such third parties are governments, distant communities or corporations.
Thirdly, what are the professional duties of the health professional? These professional duties would have the same scope as that of the patient in an Ubuntu community. It is important to note that Ubuntu is also a spiritual concept.3 Members of an Ubuntu community strive to be honourable ancestors and the path to being a good ancestor is living an honourable life.
How does this difference in points of view affect the practice of healthcare in an Ubuntu setting? There is no need to rewrite the bioethics principles (autonomy, beneficence, non-maleficence and justice) as these widely-accepted principles are congruent with values held by an Ubuntu community.
The important lesson to be learned is an appreciation of the differences between Western and Ubuntu thought. The crucial difference revolves around the understanding of who the individual is in relation to society. When dealing with problems of dual loyalty in an Ubuntu setting one should remember that patients are not just the people presenting with illness; third parties are parties that exist independently of the patient and, by acting honourably, the health professional is on his/her way to becoming a venerable ancestor.
Access Kyle’s essay at www.sajbl.org.za.