ABSTRACT

The dawn of globalization has produced the need for doctors who are prepared to facilitate communities regardless of their ethical constraints. Medical ethics is an integral component of undergraduate training and has gradually affirmed that different ethical issues are encountered by doctors within rural settings and urban areas. There is a strong need to acknowledge that ethics varies as we move not only from urban or rural settings, but also as we move across different regions, countries, and continents. There have been various studies conducted in different regions of the world to highlight the presence of different ethical issues arising in various settings. This review aims to highlight common ethical issues faced by general practitioners in rural settings as various regions have different customs which influence their decision-making skills and the patient’s relationship with their practitioner. This gives rise to the necessary task of providing training for doctors so that they are better equipped to handle these challenging scenarios in primary healthcare domains to facilitate optimal healthcare for patients from diverse backgrounds in different settings ethically and professionally.

Keywords:

Ethics, professionalism, training, doctors, rural, general practitioners, patient care.

Review

Ethics is one of the founding pillars of medical practice with roots embedded deep in the Hippocratic Oath dating back to 400 BC. It is a term that includes the study of morals and the specific moral choices that are made.¹ Ethics is the principles of conduct that distinguish between what is acceptable and unacceptable behavior which makes it an essential part of the practice of medicine since the time of Socrates and Plato and was in fact one of the integral components of training medical graduates; due to which it gained recognition as a trait without which a doctor is deemed incomplete.² Hippocrates was not only a philosopher but a visionary who considered healing to be a scientific art and thus gave us the divine Hippocratic Oath with the sentence “First of all, do no harm.”³

The World Health Organization has described health to be “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”⁴ This state of complete health is only attainable if each individual involved is discharging their duty in a manner that is ethical and justified towards achieving this goal. Ethics is a very important part of medical education so without doubt we need to restructure our teaching practices to ensure we are preparing doctors who are self-directed learners and have an in-depth approach to analyze data and apply their knowledge in different scenarios and situations. Ethical issues faced by the medical students, due to regional diversity may influence their perceptions along with their working environment. To make the teaching of ethics more effective and relevant it is important to acknowledge the ethical problems of the relevant region. Research suggests that when a health care professional trained in urban settings provides healthcare to patients in rural settings, they are faced with numerous encounters due to which they face problems convincing patients to be compliant with their prescribed mode of treatment. This has given rise to the need to highlight literature that reflects the ethical dilemmas of low-density population areas with limited healthcare resources.⁵

Rural settings are strong tight-knit communities that present healthcare providers with unique challenges such as shared decision making, overlapping personal and professional relations, and gender-defined roles of men and women. Being distant from better-facilitated hospitals patients are hesitant to discuss stigmatizing illnesses with their physicians.⁶ Geographically isolated there is a higher incidence of prevailing ethical issues novel to practitioners trained in urban settings.⁷ With the advent of new innovations in medicine a variety of ethical issues are faced by healthcare professionals in different settings involving their own personal values, the values of the institution, and the ethical, legal, and cultural values of society.⁸

It has been seen through research those various ethical problems arising in different regions of the world need handling in different ways. When problems faced by Native Americans were analyzed it was found that due to the influence of various ethnic origins and isolation from the U.S. and trauma faced by them in history during colonization; competent healthcare providers were needed to deal with their specific issues.⁶ In a research based on the Old Order Amish, a religious subpopulation found in the United States various ethical issues were encountered as their code of living Ordnung included rejection of technology posing hurdles in solving their medical problems.⁹ A research paper based on the ethical perspectives of rural, suburban, and urban physicians in Georgia also revealed that scarce resources, poverty, access to specialty care, and cultural apprehensions gave rise to different ethical issues.

Among the different ethical issues experienced by rural physicians is also tolerating inadequate fellow physicians; as due to the close-knit small community at times it is a better prospect than having no doctor at all.¹⁰ A research study comprising of Indonesian and Dutch medical students revealed that problems such as euthanasia, privacy, and confidentiality did not cause ethical issues in Indonesia where euthanasia was illegal but the Dutch encountered ethical issues when faced with these situations.¹¹ Another research regarding ethical problems present in rural areas of Indonesia revealed that scarce healthcare facilities and limitations to healthcare availability gave rise to various ethical issues concerning lack of privacy, consent, and limited facilities and resources.¹² Furthermore, a research paper on health ethics in six South-East Asia Region countries such as Bangladesh, Indonesia, India, Nepal, Myanmar, and Sri Lanka highlighted ethical issues arising due to a lack of patients’ informed consent and resources not allowing patients to get specialty health treatment. Issues related to medical termination of pregnancy, and female foeticide were also present in India due to illegal abortions and the influence of different ethnicities and multiple gods on medical treatments.¹³ Another paper based in India recognized ethical issues arising due to a socio-cultural gap and lack of professional challenges.¹⁴ Though some cultural values might be similar between rural communities even then each community is unique requiring the health care providers to be sensitive towards their values and behaviors or otherwise face ethical issues.¹⁵

Asia is not only the largest continent but in fact the most populous due to which it is the home to a diverse variety of distinctive cultures, philosophies, and lifestyles. These diverse lifestyles have norms with are drastically different from ways of living in different regions or even continents. These complex social norms create unique issues between the healthcare provider and the patient. Previous research has shown that Asians in general deem it important to maintain relationships with families and their communities.¹⁶ They have also been found to be intolerant of any view that opposes their beliefs and traditions as opposed to the views of people in the West.¹⁷ Pakistan, a part of Asia is home to multi-ethnicities each with its own traditions and beliefs. While rural areas might have a smaller population residing in a particular setting compared to urban areas yet, 62.84% of Pakistan’s population lives in rural areas as reported in 2020 by the World Bank Collection of Development Indicators. These rural areas have their own distinct communities with age-old traditions and philosophies and their particular belief systems.¹⁸

Pakistan is a predominantly Muslim country; religion along with family and community values govern how life is lived leading to divergence in ethical issues being faced by practitioners in rural practice.¹⁰ Rural communities believe in ghosts, use taweez, or go to shrines for fulfillment of their healthcare needs. There are people who are very superstitious and even offer money and food to their spiritual leaders if their wishes are fulfilled or the disease is cured.¹⁸ At times, women are denied treatment as they are said to be under the influence of a ghost or black magic even though they might be victims of horrors such as acid attacks, domestic and sexual violence, genital mutilation, rape, and burns. Therefore, women in general are targets of denied healthcare; leading to health hazards that can be fatal.⁴ Pakistan’s 70% population resides in rural areas where violence against women is more prevalent.¹⁹ The issue at times is that remote rural communities are home to many ostracized populations who in fact lack integration into the sources of societal power such as expert knowledge and financial resources. These rural communities give rise to unique issues as the patient population has it is particular traditions and beliefs that give birth to different patient-provider relationships and reformed therapeutic limitations that pose the tough challenge of preservation of patient autonomy and privacy.²⁰

Medical ethics is entwined with religious and social beliefs of the particular setting or community thus the ethics curriculum needs to encompass ethical issues relative to areas of Pakistan.²¹ There is a need to discover the relevant cultural bioethics of rural areas which reflects their challenges and limited healthcare facilities that are available to them just as urban bioethics focuses on the overpopulated areas and the problems that occur.⁵ The environment where a person works constructs their ethical and moral behavior. It is based on the commitments and the expectations that arise due to the profession the doctors have embraced and what society expects of them. Though this is not a standardized phenomenon the critical and sensitive issues which arise in different cultural contexts regarding the doctors’ professional conduct pose a contest to the teaching and then practice of ethics in different parts of the world.²¹

Ethics has been long a part of undergraduate medical and dental education in Pakistan. The MBBS curriculum which was last revised in 2022 by Pakistan Medical and Dental Council (PMDC) erstwhile Pakistan Medical Commission, also allocated 50 hours to ethics in the subject-based curriculum whereas 2 weeks were given in the system-based curriculum.²² Ethics, in the form of didatic lectures is delivered to students in medical schools with the help of resources and books. But the agony of the situation is that these resources give a general idea of ethics and problems faced which are generally based on Western ethics and hardly cover topics relevant to ethical issues faced by doctors in Pakistan or in rural areas. The new graduate or practitioner when working in rural areas faces ethical problems which were previously not discussed in the taught curriculum. To make the ethical curriculum more effective and relevant it is important to acknowledge the ethical problems as perceived by them, because cultural and regional diversity may influence their perception along with their working environment.

It has been seen that medical practitioners working at primary-level institutions faced ethical issues more frequently including patient’s privacy, their self-respect, and the protection of the patients’ personal information as compared to doctors practicing at secondary and tertiary level institutions or urban settings.⁸ Previous research has recommended that there is a need to focus on issues faced by general practitioners in different settings and locations.²⁰ It has been seen that it is more challenging to obtain informed consent and adhere to ethical rights in settings where the patients are part of a relatively low socio-economic group. Further adding to the challenge is that there is a gap in the level of trust the patients have in their healthcare provider in these rural settings regarding different issues. The communication limitations faced by the general practitioner while dealing with patients with low educational exposure lead to situations that could be tackled more appropriately if the doctors were prepared for a spontaneous response.⁴ The general practitioner who practices in rural settings is exposed to unique challenges which at times give rise to situations that may not coincide with ethical norms in different settings but are realistic in the rural settings, as tradition or culture influences them. Diversity in ethical issues in various settings has resulted in the need for such problems to be identified so that they can be utilized by policymakers to train medical students to be better equipped to tackle these challenges while working in rural settings

Conclusion

The present review highlights the need to identify major ethical issues faced by doctors in rural settings that may be different from those of the urban settings in which future doctors are being trained. This calls for designing courses on ethics for health professionals which encompasses everyday regular, practical clinical ethical issues and the real problems faced by patients and their health care providers in less developed areas. Healthcare providers need to be trained to identify these situations and act promptly instead of just learning ethics they caught on from their seniors in an otherwise “hidden curriculum.” This exposure to ethical problems can be helpful in resolving issues arising due to diversity leading to better healthcare delivery to vulnerable patients in rural settings.

List of Abbreviations

Not applicable.

Conflict of interest

None to declare.

Grant support and financial disclosure

None to disclose.

Ethical approval

Not applicable.

Authors’ contributions

SC: Conception and design of study, acquisition of data, drafting of the manuscript with critical intellectual input.

ZHT: Acquisition of data, drafting of the manuscript.

ALL AUTHORS: Approval of the final version of the manuscript to be published.

Authors’ Details

Zunaira Haris Tarar¹, Saima Chaudhry²

1. MHPE Student, University of Health Sciences, Lahore, Pakistan
2. Director Centre for Health Professionals Development and Lifelong Learning, The University of Lahore, Lahore, Pakistan.

References

1. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17–28. https://doi.org/10.1159/000509119
2. Shamim MS, Zubairi NA, Sayed MH, Gazzaz ZJ. Innovation in ethics and professionalism course: early experience with portfolio-workbook. J Pak Med Assoc [Internet]. 2016;66(9):1149–53.
3. Indla V, Radhika M. Hippocratic oath: losing relevance in today’s world? Indian J Psychiatry. 2019;61(Suppl 4):S773–S5. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_140_19
4. Shafique S, Bhattacharyya DS, Anwar I, Adams A. Right to health and social justice in Bangladesh: ethical dilemmas and obligations of state and non-state actors to ensure health for urban poor. BMC Med Ethics. 2018;19(Suppl 1):61–9. https://doi.org/10.1186/s12910-018-0285-2
5. Klugman C, Nelson W, Anderson-Shaw L, Gelfond J. A survey of rural ethics teaching in North American allopathic and osteopathic medical schools. Voices Bioeth. 2014;1(2014-2015):1–6. https://doi.org/10.7916/vib.v1i.6484
6. Tom L. Training doctoral clinical psychology students for practice in rural communities in Hawai ‘i: ethical dilemmas and the role of culture. Chicago, IL: Argosy University; 2018.
7. Rajiah K, Venaktaraman R. The effect of demographic and social factors on the decision-making of community pharmacists in ethical dilemmas. JRPP. 2019;8(3):174–7. https://doi.org/10.4103/jrpp.JRPP_19_15
8. Grosek Š, Kučan R, Grošelj J, Oražem M, Grošelj U, Erčulj V, et al. The first nationwide study on facing and solving ethical dilemmas among healthcare professionals in Slovenia. PLoS One. 2020;15(7):1–20. https://doi.org/10.1371/journal.pone.0235509
9. Conlin WE. Ethical considerations for treating the old order Amish. Ethics behav. 2021;31(6):419–32. https://doi.org/10.1080/10508422.2020.1805614
10. Wickersham DPA MEE, Sumner MD JR. The ethics of place: differences in ethical perspectives among urban, suburban, and rural physicians in Georgia. JHE. 2015;11(2):5. https://doi.org/10.18785/ojhe.1102.05
11. Muhaimin A, Willems DL, Utarini A, Hoogsteyns M. What do students perceive as ethical problems? A comparative study of Dutch and Indonesian medical students in clinical training. ABR. 2019;11(4):391–408. https://doi.org/10.1007/s41649-019-00101-6
12. Wicaksono RB, Ferine M, Lestari DWD, Hidayah AN, Muhaimin A. Experience of Indonesian medical students of ethical issues during their clinical clerkship in a rural setting. J Med Ethics Hist Med. 2021;14(6):1–8. https://doi.org/10.18502/jmehm.v14i6.6750
13. World Health Organization Regional Office for South East Asia. Comprehensive guidelines for prevention and control of Dengue and Dengue Haemorrhagic Fever: revised and expanded edition. New Delhi, India: World Health Organization. 2011
14. Goel S, Angeli F, Singla N, Ruwaard D. Measuring the reasons that discourage medical students from working in rural areas: development and validation of a new instrument. Medicine. 2018;97(2):e9448. https://doi.org/10.1097/MD.0000000000009448
15. O’Connor N. Health care ethics. J Fam Pract. 1994;38(6):569–70
16. Chandratilake M, McAleer S, Gibson J. Cultural similarities and differences in medical professionalism: a multi‐region study. Med Educ. 2012;46(3):257–66. https://doi.org/10.1111/j.1365-2923.2011.04153.x
17. Shamim MS, Baig L, Torda A, Balasooriya C. Culture and ethics in medical education: the Asian perspective. J Pak Med Assoc. 2018;68(3):444–6
18. Farooq A, Kayani PDAK. Prevalence of superstitions and other supernaturals in rural Punjab: a sociological perspective. J South Asia Stud. 2020;27(2):1–10
19. Huda S, Kamal A. Assessing demographics-based differences in attitude toward honor killings. J Interpers Violence. 2022;37(5-6):NP3224–NP41. https://doi.org/10.1177/0886260520927499
20. Erwin C, Aultman J, Harter T, Illes J, Kogan RCJ. Rural and remote communities: unique ethical issues in the COVID-19 pandemic. AJOB. 2020;20(7):117–20. https://doi.org/10.1080/15265161.2020.1764139
21. Shamim MS, Torda A, Baig LA, Zubairi N, Balasooriya C. Systematic development and refinement of a contextually relevant strategy for undergraduate medical ethics education: a qualitative study. BMC Med Educ. 2021;21(9):1–12. https://doi.org/10.1186/s12909-020-02425-6
22. Pakistan Medical Commission. Guidelines for curriculum of MBBS’, (Revised). 2022. 13–4 pp. Available from: https://www.pmc.gov.pk/Documents/Examinations/Guidelines%20for%20Undergraduate%20Medical%20Education%20Curriculum%20(MBBS).pdf