Clinical ethics dilemmas in a low-income setting - a national survey among physicians in Ethiopia.

BACKGROUND: Ethical dilemmas are part of medicine, but the type of challenges, the frequency of their occurrence and the nuances in the difficulties have not been systematically studied in low-income settings. The objective of this paper was to map out the ethical dilemmas from the perspective of Ethiopian physicians working in public hospitals. METHOD: A national survey of physicians from 49 public hospitals using stratified, multi-stage sampling was conducted in six of the 11 regions in Ethiopia. Descriptive statistics were used and the responses to the open-ended question "If you have experienced any ethical dilemma, can you please describe a dilemma you have encountered in your own words?" were analyzed using a template analysis process. RESULTS: A total of 587 physicians responded (response rate 91,7%), and 565 met the inclusion criteria. Twelve of 24 specified ethically challenging situations were reported to be experienced often or sometimes by more than 50% of the physicians. The most frequently reported challenge concerned resource distribution: 93% agreed that they often or sometimes had to make difficult choices due to resource limitation, and 83% often or sometimes encountered difficulties because patients were unable to pay for the preferred course of treatment. Other frequently reported difficulties were doubts about doing good or harming the patient, relating to conflicting views, concern for family welfare, disclosure issues and caring for patients not able to consent. Few reported dilemmas related to end-of-life issues. The 200 responses to the open-ended question mirrored the quantitative results. DISCUSSION: Ethiopian physicians report ethical challenges related more to bedside rationing and fairness concerns than futility discussions and conflicts about autonomy as described in studies from high-income countries. In addition to the high report of experienced challenges, gravity of the dilemmas that are present in their narratives are striking. Recognition of the everyday experiences of physicians in low-income settings should prompt the development of ethics teaching and support mechanisms, discussion of ethical guidelines as well as increase our focus on how to improve the grave resource scarcity they describe.

Bedside Rationing Under Resource Constraints-A National Survey of Ethiopian Physicians' Use of Criteria for Priority Setting.

In low-income settings resource constraints force clinicians to make harsh choices. We examine the criteria Ethiopian physicians use in their bedside rationing decisions through a national survey at 49 public hospitals in Ethiopia. Substantial variation in weight given to different criteria were reported by the 587 participating physicians (response rate 91.7%). Young age, primary prevention, or the patient being the family's economic provider increased likelihood of offering treatment to a patient, while small expected benefit or low chance of success diminished likelihood. More than 50% of responding physicians were indifferent to patient's position in society, unhealthy behavior, and residence, while they varied widely in weight they gave to patient's poverty, ability to work, and old age. While the majority of Ethiopian physicians reported allocation of resources that was compatible with national priorities, more contested criteria were also frequently reported. This might affect distributional justice and equity in health care access.

Financial risk protection at the bedside: How Ethiopian physicians try to minimize out-of-pocket health expenditures.

BACKGROUND: Out-of-pocket health expenditures can pose major financial risks, create access-barriers and drive patients and families into poverty. Little is known about physicians' role in financial protection of patients and families at the bedside in low-income settings and how they perceive their roles and duties when treating patients in a health care system requiring high out-of-pocket costs. OBJECTIVE: Assess physicians' concerns regarding financial welfare of patients and their families and analyze physicians' experiences in reducing catastrophic health expenditures for patients in Ethiopia. METHOD: A national survey was conducted among physicians at 49 public hospitals in six regions in Ethiopia. Descriptive statistics were used. RESULTS: Totally 587 physicians responded (response rate 91%) and 565 filled the inclusion criteria. Health care costs driving people into financial crisis and poverty were witnessed by 82% of respondants, and 88% reported that costs for the patient are important when deciding to use or not use an intervention. Several strategies to save costs for patients were used: 37-79% of physicians were doing this daily or weekly through limiting prescription of drugs, limiting radiologic studies, ultrasound and lab tests, providing second best treatments, and avoiding admission or initiating early discharge. Overall, 75% of the physicians reported that ongoing and future costs to patients influenced their decisions to a greater extent than concerns for preserving hospital resources. CONCLUSION: In Ethiopia, a low-income country aiming to move towards universal health coverage, physicians view themselves as both stewards of public resources, patient advocates and financial protectors of patients and their families. Their high concern for family welfare should be acknowledged and the economic and ethical implications of this practice must be further explored.

A survey of Ethiopian physicians' experiences of bedside rationing: extensive resource scarcity, tough decisions and adverse consequences.

BACKGROUND: Resource scarcity in health care is a universal challenge. In high-income settings, bedside rationing is commonly discussed and debated as a means to addressing scarcity. However, little is known about physicians' experiences in resource-limited contexts in low- income countries. Here we describe physicians' experiences regarding scarcity of resources, bedside rationing, use of various strategies to save resources, and perceptions of the consequences of rationing in Ethiopia. METHODS: A national survey was conducted amongst physicians from 49 public hospitals using stratified, multi-stage sampling in six regions. All physicians in the selected hospitals were invited to respond to a self-administered questionnaire. Data were weighted and analyzed using descriptive statistics. RESULTS: In total, 587 physicians responded (91% response rate). The majority had experienced system-wide shortages of various types of medical services. The services most frequently reported to be in short supply, either daily or weekly, were access to surgery, specialist and intensive care units, drug prescriptions and admission to hospital (52, 49, 46, 47 and 46% respectively). The most common rationing strategies used daily or weekly were limiting laboratory tests, hospital drugs, radiological investigations and providing second best treatment (47, 47, 47 and 39% respectively). Availability of institutional or national guidelines for whom to see and treat first was lacking. Almost all respondents had witnessed different adverse consequences of resource scarcity; 54% reported seeing patients who, in their estimation, had died due to resource scarcity. Almost 9 out of 10 physicians were so troubled by limited resources that they often regretted their choice of profession. CONCLUSION: This study provides the first glimpses of the untold story of resource shortage and bedside rationing in Ethiopia. Physicians encounter numerous dilemmas due to resource scarcity, and they report they lack adequate guidance for how to handle them. The consequences for patients and the professionals are substantial.