Response: why not at least try?

Working in a low- or middle-income country (LMIC) brings several challenges, like dealing with limited resources, language barriers, and sometimes a harsh climate. One of the hardest challenges, however, is dealing with different cultural and moral values. For three years I worked in a district hospital in Zimbabwe. I remember a ninety-year-old woman who was brought to the hospital by her family. She had been admitted several times over the last weeks. After careful examination, I did not find new developments. I discussed the situation with her, together with the nurse in charge and the family. We discovered that the family was not comfortable with taking care of the woman at home, which I could easily understand considering the care difficulties the family was facing in such a limited resource setting. The sister in charge, however, was extremely upset after the consultation. How could the family be so inhumane, unwilling to take care of their mother and grandmother after she had raised the family?

I realized that my Western worldview influenced the way I thought about taking care of family members. Working in Zimbabwe opened my mind to the fact that moral values are different across the globe. It has given me the richness of knowing those differences and keeping the best of both worlds. I learned that there is more than one truth when talking about topics like time, family relations, life and death, respecting elderly people, and the amount of information that is given to patients.

Just as a tropical doctor abroad learns to deal with limited resources along the way, he or she will also get more experienced in dealing with different moral values. The difference between these two challenges is that the latter touches your own personality. It’s more difficult to deal with a lack of informed consent, for reasons that you do not understand from your own perspective, than to deal with a lack of resources. Getting to know more about the people, the way they think and the background of their moral values, helps to understand why they make certain decisions different from what we expect.

As an outsider, I realized that I was the one who had chosen to work in a cross-cultural setting. Most people I worked with in Zimbabwe did not choose to work with me. It helped me to respect the local cultural and moral opinions. Working together brought opportunities to show and share something of the values I was raised with. Trying to truly understand the difference in background and learning from experienced local nurses taught me the local views and helped me to prepare patients for their theatre procedures.

Compared to other LMICs, people in Zimbabwe do have a relatively high education level. The local way of asking for informed consent was to ask patients to place a signature (or a cross if no signature was available) for agreement to undergo a certain procedure. I don’t believe all patients fully understood the implications of their signature. Despite the relatively high education level, I don’t think they had enough understanding of medicine to be able to interpret risks and consequences. This means the depth of the informed consent is definitely not the same as we are used to in the Netherlands. However, that does not mean we should not try to find ways of communicating indication, procedure, and risk with patients and their relatives in a way that connects with their knowledge and beliefs, to make sure the main issues are being communicated. The fact that we do not fully succeed does not mean we should not try. It is certainly not a waste of time, if not just because of the patients’ right to information, then because of our own values as a surgeon to inform our patients before we take them to theatre.

Just as we can learn from the families that are used to taking care of their relatives, the different way of dealing with informed consent in LMICs helps us reflect on our own system in the Netherlands. Of course, the majority of patients want to know exactly what will happen and what might go wrong. But not all patients are helped by the detailed way we share the risks of complications these days. Is it really helpful to explain that the risk of complications is 1/1000 for a procedure if not performing the procedure is not an option? I think we should be willing to take some of the responsibility on our own shoulders, since informed consent can be used as an easy way of burdening our patients with it. However, we should continue trying to inform our patients prior to procedures in the best way possible, depending on circumstances like medical situation, education level and cultural background.