Can our health professionals practice ethically in an unethical environment?
By: Moses Mulumba
A few weeks back we lost Dr. Margaret Mungherera and a lot has been said and written about her. I had a privilege to severally interact with her and our last interaction was on a radio talk show discussing the law and medical practice. I also had a reflection with one of her psychiatric colleagues who indicated that he will never forget the day Mungherera asked him if it was possible for health professionals to practice ethically in a highly unethical environment. This is a question worth our collective rumination.
Ethics, as a principle, is concerned with moral principles, values and standards of conduct. It is not a preserve of any discipline, but is a multi-disciplinary and inter-disciplinary with contributions from various fields including philosophy, religious studies, law and several other disciplines.
In medical practice, the duty to act ethically lies at the very origins of the profession. It is indeed striking that the Hippocratic Oath includes more on ethics of the physician’s conduct than on the science of efficiency that a health professional should apply.
In clinical settings, it is expected that health professionals are technically sound with all required competencies. It is also an expectation that while they are practicing medicine and dealing with patients, attendants, relatives of patients, they practice ethical behavior with relevant competencies. As such, they have to be guided by principles such as patient autonomy, confidentiality, informed consent, human rights, equity and justice. These same principles must be extended to health policy making, implementation and monitoring of health programs.
These ethical principles seem to make a huge assumption that the environment in which the health professionals work is supportive of ethical practice. This assumption extends to availability of all the required resources in sufficient amounts and also assumes a sound governance structure for delivery of health services.
One can also read an assumption of responsive and empowered recipients of the care and minimal interruption to delivery of healthcare by external factors like politics, religion, and economic policies such as the neoliberalism approaches.
There is equally an assumption of a strong State exercising its regulatory function in all facets of healthcare delivery. An environment lacking in these assumptions could be what Mungherera described as a highly unethical environment.
In my own experience, we have gaps in our healthcare delivery environment and these have in many cases severely affected ethical delivery of health care. First, our health system continues to work with resources below what is required. Even when this could be attributed to our low tax base, there is no indication that the health sector in progressively being resourced.
For instance, while the budget to road and energy has increased from 18.7% to 23% of the total budget; that of health has stagnated at 8%.
It is also striking that even when the total general government budget has increased, the government’s allocation to the health sector has not matched these increases. In fact, the government’s allocation to the health sector has been declining.
Any visible growth in the health budget has been mainly driven by increased external support. The overall development assistance to government generally declined from 25% in FY 2010/11 to 18% in FY 2014/15, yet this assistance to health increased from 14%-42% in the same period. This for me is a serious ethical issue posed by those setting priorities in the national cake allocations.