Ethics in Global Health Practice
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DiscussionAid.docx
Discussion Aid Template
Case: FAIRNESS AND EQUITY IN THE PROVISION OF ANTI-RETROVIRAL
THERAPY: SOME REFLECTIONS FROM LESOTHO
(RUSSELL AMSTRONG)
· In Southern African Region HIV epidemic is a societal issue of enormous magnitude
· Number of people in immediate need of ART continues to significantly exceed health systems capacity to provide it
· Approaches to the complex rationing dilemma have evolved in different directions
· Contains 4 countries with the highest HIV prevalence globally: Lesotho-23.2%, Botswana: 23.1%, Swaziland: 26.1%, and South Africa: 18.1%. In 2007 there were about 5.7 million HIV-Positive individuals in South Africa alone
· Despite a massive effort to scale-up public sector access to ART in the region, the need for treatment continues to exceed these countries capacity to provide it
· Progress is limited by challenges such as inadequate PHC systems, besides lack of skilled labor to deliver plus monitor treatment programs
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Ethical Issues |
Relevant Ethical Concept(s) |
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1. Insufficient effective rationing tool, which champions the number of individuals who meet the suggested eligibility to exceed spaces available for treatment. Besides is indirect and implicitly favors those who are informed, can afford it, are in the proximity to facilities |
Patient selection process designed to put the ‘right’ patients on ART through a process of clinical and non-clinical screening and eligibility determination. It should be a formal, explicit eligibility criteria developed through a structured, inclusive, transparent process of deliberation, besides publicly accessible process for applying the criteria and for deliberating on expectations |
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2. Unfairness with respect to patients who were very ill and unable to participate in adherence counselling or even to provide consent to be tested for HIV
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Fairness as a structured, formalized selection process |
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3. Inequity in receiving ART due to lack of monies to travel to the hospital to enroll in the program, besides being unable to pay for the nominal user fee for outpatient provision services.
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All individuals should have equal chances to receive treatment. |
Actor with Decision-Making Authority: healthcare team
Please consider the responsibilities of the actor and the constraints they face. The purpose of these considerations is to identify courses of action that the actor might reasonably be expected to undertake: that is, courses of action that are both consistent with their responsibilities as a public health professional and realistic given the degree of authority they have.
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Responsibilities |
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1. Using patient selection process designed to put the ‘right’ patients on ART through a process of clinical and non-clinical screening and eligibility determination. 2. Ascertaining that all individuals have equal chances to receive treatment. 3. Applying fairness as a structured, formalized selection process, including patients who were very ill and unable to participate in adherence counselling or even to provide consent to be tested for HIV |
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Constraints |
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1. Lack of more pragmatic tools are required to enable health care teams to more fully understand the ethical dimensions of what they do in ways that enlighten and empower them to develop creative, context-specific approaches to the difficult task they face.
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Available Course of Action:
1) Address the limitation between the model selection processes and criteria proposed at the international level and the specific practice of patient selection.
2) Examine and address whether the balance between the public health objective of a well-administered treatment program, and an individual’s entitlement to the means to preserve life and health with only the minimal necessary restrictions, is correctly proportioned.
3) Institute more pragmatic tools to enable health care teams to more fully understand the ethical dimensions of what they do in ways that enlighten and empower them to develop creative, context-specific approaches to the difficult task they face.
