Coping with healthcare ethical issues in Cameroon

Abstract

Introduction: The Most healthcare professionals (HCPs) face numerous ethical challenges while performing their tasks, regardless of clinical ethics support structures (CESS) in many health facilities. There has been little research on CESS in Africa. This study sought to determine how often Cameroonian HCPs in the Southwest Region (SWR) faced ethical issues, how many health institutions have CESS and whether those with no CESS are willing to have one created.

Method: From December 2022 to June 2023, a cross-sectional study of 469 nurses and physicians working in the SWR was conducted. Descriptive statistics and the chi-squared test were used. The threshold for statistical significance was p < 0.05.

Results: Of the 466 respondents who answered the question about encountering ethical issues, 177 said they encountered them once a month, whereas 217 reported encountering them weekly. Of the 464 responses to the questions about the CESS, 172 (37.1%) agreed that there was one in their health facility. Where there was no CESS, 255 out of 292 respondents (87.3%) expressed their willingness for one to be established.

Conclusions: SWR nurses and physicians regularly face ethical issues, and they are willing that CESS be established in their hospitals to assist them in resolving complex ethical problems. The Ministry of Public Health is requested to support such initiatives.

Key words: clinical ethics support structures, ethical dilemmas, healthcare workers, Southwest Region Cameroon.

Introduction

Ethical issues arise daily as healthcare professionals (HCPs) carry out their clinical duties. While physicians, nurses and midwives encounter ethical dilemmas regularly, health administrators and hospital porters may also encounter ethical issues when engaged in patient matters.^[1] Concerns about privacy, autonomy, truth-telling, surrogate decision-making, fairness, no maleficence, beneficence, and informed consent are common contributing factors to ethical issues in healthcare settings.^[1] We present two hypothetical cases below to illustrate how ethical issues may present in clinical settings.

Case 1

Mike, 40 years old, is a rural hospital physician in Northwest Cameroon who serves as the sole doctor for a community of approximately 15,000 people. Martha, 80 years, was taken to Mike’s hospital by her relatives after complaining of extreme pain in her lower abdomen. Mike quickly examines Martha, performs ultrasonography, and reveals that she requires an urgent appendectomy. Martha is advised that she should undergo surgery, but she bluntly refuses. Martha’s relatives are notified of her condition and refusal to undergo surgery. Both Mike’s and Martha’s relatives try to persuade Martha to accept, but she stays adamantly resistant.

Case 2

Miranda works as a hospital porter in a hospital in the Cameroonian city of Douala. Miranda has been tasked with transferring a fragile 28-year-old patient to the ward. Following a consultation with the patient, the physician requested her admittance to the ward. The physician provides the patient’s medical records to Miranda and instructs her to present it to the ward’s chief nurse when she arrives. While transferring the patient, the records fall from the file, and when she picks them up, she realizes that the patient has HIV/AIDS. Two days later, Miranda and one of her coworkers walked by the patient and one of her relatives, who were seated outside. Miranda notified her colleague immediately following their passing that the patient has HIV.

Miranda’s disclosure of confidential patient information to a colleague, who is not directly involved in the patient’s treatment, presents an ethical issue as it is imperative to maintain confidentiality. Like Miranda, sometimes HCPs may carry out acts that are unethical while interacting with patients, for example, a midwife could insult a pregnant woman if she doesn’t push strongly during labour, a member of the medical team could make jokes about a patient’s body type while operating on them, or a nursing assistant could decide to take a bribe and prioritise patients who come later when sending them to see a doctor. All these represent unethical practices that occur quite frequently in hospital settings that need to be addressed. The simple solution here is for the HCPs to refrain from such unethical practices. HCPs must treat patients with compassion, respect, and dignity. They must also refrain from exchanging medical information with those not directly involved in the patient’s care.

Now, let us consider Mike’s situation: while he must save Martha as HCP, Martha is not willing to undergo surgery. This raises an ethical dilemma, with the situation being more complex than in the previous case. Mike must not base his decision solely on Martha’s medical condition, although the standard practice is to manage patients’ illnesses to facilitate their recovery. He should additionally consider the patient’s best interests as well as any relevant contextual circumstances, such as beliefs, that may be influencing the patient’s decision.

Knowledge of clinical ethics could aid HCPs such as Mike in concluding what to do when they encounter such ethical dilemmas. Clinical ethics is a practical and structured approach for assisting HCPs in recognizing, examining, and resolving such ethical issues that emerge in clinical settings.^[2] While some hospitals have clinical ethics support structures (CESS) that could assist HCPs in resolving complex ethical issues, others do not. HCPs in hospitals without CESS must rely on their intuition or collaborate with their supervisors and/or colleagues to come up with a resolution when such ethical cases arise. 

How to address such issues with the available structures is critical for every health institution. Resolutions are difficult when responsibilities are unclear.^[3] CESS exist in most hospitals in advanced nations in the form of clinical ethics committees.^[4]

Other types of CESS includes moral case deliberations (MCDs) and individual clinical ethics consultants.^[5] A MCD involves a skilled facilitator with professionals, including expert ethics consultants, patients, and families, providing a discussion forum for ethical dilemmas.^[6,7]

Research on CESS in Africa is very sparse. In Cameroon, ethics committees such as the National Ethics Committee and Institutional Review Boards (IRBs) focus on training HCPs and other scholars on informed consent and other topics related to conducting studies involving human subjects^[8] with minimal attention to clinical ethics or CESS. No research has been conducted in Cameroon to assess the processes used by HCPs to address clinical ethical issues.

The purpose of our study was to identify the methods by which Cameroonian HCPs handle ethical challenges and whether the training they received helped them resolve the issues they faced. Additionally, we aimed to determine whether HCPs were willing to accept the creation of CESS within their hospitals.

Method

A cross-sectional questionnaire study using convenience sampling was conducted among physicians and nurses practicing in the southwest region (SWR) of Cameroon (an English-speaking region with a population of approximately 1.2 million).^[9] 

All physicians and nurses who were actively engaged in healthcare practice within the SWR and had been practicing for at least a year were considered eligible for participation.

We modified questionnaires employed in studies on medical ethics in developing countries.^[10-13] The final instrument contained six sections. We considered the fifth and sixth sections of the questionnaire (a full version is available upon request). Between December 2022 and June 2023, the surveys were handed to hospital administrators, who then placed them at a designated area in the hospital for their staff members to collect, complete, and return at their convenience. Then weekly follow-up visits were conducted to collect the completed questionnaires. The overall completion rate was 32.5% (469/1491).

The data were entered into a Microsoft Excel 2013 spreadsheet and cleaned. Descriptive analyses were performed on the entire dataset. Using the chi-squared test or Fisher’s exact test, a comparison of responses on frequency of ethical problems encountered and the type of health facility was carried out. A p-value <0.05 was considered to indicate statistical significance. The data were analysed using SPSS version 27 software.

Ethical considerations

This study was approved by the Regional Delegation of Public Health, SWR, and the institutional review board of the Faculty of Health Sciences, University of Buea. Written informed consent was obtained from all participants, and no personally identifiable information was collected.

Results

Baseline characteristics

Of 469 participants, nurses accounted for 89.8% (79.6% female), while 10.2% (60.4% male) were physicians. Most respondents were within the 30–39-year age group. Two hundred and fifty-six (54.6%) participants were affiliated to public health facilities (HFs), while 82 (17.5%) were based in Faith HFs (Table 1).

	Physicians n (%)	Nurses n (%)	Total n (%)
Gender
Female	19 (39.6)	335 (79.6)	354 (75.5)
Male	29 (60.4)	81 (19.2)	110 (23.6)
Did not specify their gender	-	5 (1.2)	5 (1.1)
Type of Health Facility
Faith-based	7 (14.6)	75 (17.8)	82 (17.5)
Private	10 (20.8)	121 (28.7)	131 (27.9)
Public	31 (64.6)	125 (53.4)	256 (54.6)
Age group (years)
20 – 29	18 (37.5)	132 (31.4)	150 (32.0)
30 – 39	25 (52.1)	200 (47.5)	225 (48.0)
40 – 49	4 (8.3)	69 (16.4)	73 (15.6)
50 +	1 (2.1)	20 (4.8)	21 (4.4)
Time in service ( years)
1 – 5	32 (66.7)	216 (51.3)	248 (52.9)
6 – 10	11 (22.9)	125 (29.7)	136 (29)
11 +	5 (10.4)	80 (19)	85 (18.1)
Religion
Christian	45 (93.8)	407(96.7)	452 (96.4)
Muslim	1 (2.1)	9 (2.1)	10 (2.1)
Pagan	2 (4.2)	5 (1.2)	7 (1.5)
Total	48 (10.2)	421 (89.8)	469 (100)

Medical ethics training

Four hundred and forty-nine (95.7%) of 496 respondents participated in medical ethics courses. More physicians compared to nurses (43.8% vs 30.9%) received over 10-hour training sessions. Overall, most HCPs (40.5%) received 1-5 hours of training (Table 2). Two-thirds of the respondents said the training was adequate. Nurses reported significantly greater satisfaction with the training than physicians (71% vs. 43.2%, p<0.01).

Table 2. Training on medical ethics 

Furthermore, over two-thirds of all the respondents confirmed that the training helped them identify and cope with ethical issues. More nurses than physicians significantly agreed (78.6% vs. 66.7%, p = 0.02) with this question.

Ethical issues

Almost half (46.6%) of the HCPs experienced ethical issues weekly and about 177 (38%) monthly (Table 3). Significant differences were found between the type of health facilities (public vs faith-based) encountering ethical issues (p = 0.02). 

Table 3. Frequency of ethical issues

	How often do you experience an ethical issue in your practice? (N=466).					How often do you find an answer to your question on the ethical issue? (N=448).
	Frequently (once every week)	Occasional (once every month)	Rarely (once every year)	Never	p- value	Frequently (> 75% of the time)	Often (50% to 75% of the time)	Occasional (25% to 50% of the time)	Rarely (<25% of the time)	Never	p- value
Profession
Physicians	25 (52.1)	18 (37.5)	5 (10.4)	-	0.76	11 (22.9)	16 (33.3)	13 (27.1)	8 (16.7)	-	0.39
Nurses	192 (51.9)	159 (38.0)	55 (13.2)	12 (2.9)		85 (21.3)	91 (22.8)	141 (35.3)	79 (19.8)	4 (1.0)
Type of facility
Public	110  (43.3)	95 (37.4)	41 (16.1)	8 (3.1)	0.02	40 (16.5)	65 (26.7)	82 (33.7)	55 (22.6)	1 (0.4)	<0.01
Faith-based	46 (56.1)	25 (30.5)	11  (13.4)	-		31 (38.3)	13 (16.0)	27 (33.3)	9 (11.1)	1 (1.2)
Private	61 (46.9)	57  (43.8)	8 (6.2)	4  (3.1)		25 (20.2)	29 (23.4)	45 (36.3)	23 (18.5)	2 (1.6)
Total	217 (46.6)	177  (38.0)	60 (12.9)	12 (2.6)		96 (21.4)	107 (23.9)	154 (34.4)	87 (19.4)	4 (0.9)

*Never responses excluded from p-value calculation

Senior colleagues (51.4%) were the mostly consulted by the HCPs when faced with ethical issues, then department heads (40.7%). Only 12.9% of the HCPs approached ethics committee (Figure 1).

Figure 1. Consultation preference of HCPs when faced with ethical problems.

Table 1. Demographic characteristics of study participants

Clinical ethics support structures (CESS)

The existence of a CESS in their hospital was reported by 172 (37.1%) respondents; 235 (50.6%) did not have, and 57 (12.3%) did not know. Among those with CESS, 91 (52.9%) were from public HFs, 36 (20.9%) were from faith-based HFs, and 45 (26.2%) from private HFs. Of respondents with CESS, 116 (72.0%) were satisfied with the role of the committee, while 45 (28.0%) were not. Respondents from the faith-based HFs were the most satisfied with their ethics committee. While those without CESS, 87.3% were willing for CESS establishment. Of those willing, all physicians and most nurses responded positively.

Discussion

Medical ethics training

A working knowledge of medical ethics would help HCPs manage ethical dilemmas. Our study revealed that nearly all HCPs had received some medical ethics training, and most medical training institutions in the SWRs offered ethics courses. The fact that more than 80% of HCPs seek further training in medical ethics highlights the necessity for ethics training, given that most receive fewer than ten teaching hours.

Clinical ethics support structures (CESS)

The finding that many HCPs experience ethical issues very frequently and some were unable to answer their ethical dilemmas indicates the necessity for the establishment of more CESS in health facilities in the SWRs.

The fact that only a third agreed that a CESS existed in their institution is not surprising and reflects a similar situation in most parts of Africa and other underdeveloped nations.^[14] Among those with CESS, two-thirds of the respondents were satisfied with it. However, in a qualitative study carried out at the Uganda Cancer Institute, most participants thought informal mechanisms for debating clinical ethical issues lacked expertise and advised that clinical ethics committees be created.^[15]

The observation that a large percentage of HCPs whose hospital had a CESS expressed satisfaction with the role indicates that the establishment of a CESS throughout the SWR may be well received.

This study is the first to document the prevalence of ethical issues encountered by HCPs in the SWRs of Cameroon, as well as their management challenges. Our study’s limitations include the inability to capture in depth our participants’ thoughts and feelings and further explore responses; social desirability bias; and the study’s limited geographic scope, making it difficult to generalise results. Notwithstanding these constraints, the findings of this study should aid public health authorities across Cameroon in implementing actions targeted at establishing CESS.

Conclusion

This study demonstrates that HCPs in Cameroon’s SWR regularly face ethical issues, and they need clinical ethics structures to be put in place to address ethical problems.

Conflict of interest:  Nil

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