Traditions and Trust Medical Ethics in the African Context

The tension between Western and African approaches to healthcare poses an important question: what should medical ethics look like for Nigerians, and for Africans more broadly?

The core tenet of the Hippocratic oath, the pledge taken by all new physicians at the start of their practice, is distilled into the first rule of medical ethics: primum non nocere—first, do no harm. But the history of Western medicine, and its ethics, which took root from the philosophies of ancient Greece, has been riddled with records of the medical profession failing to uphold this standard.

Over centuries, what has become standardized medicine was developed along the line of these philosophies, and when formally instituted in Africa, orthodox medicine was laced with the bitter pill of colonization, and Western ideologies about medical ethics.

As modern medical practices improved globally, medical ethics have slowly evolved to suit a new world where patients are generally better informed, and more aware of their power and autonomy. But in Africa, medical ethics cannot improve without acknowledgment of the core failure of Western medical models applied on the continent, which excluded and even eradicated African methods, and ideals, of healthcare.

In Nigeria, society is divided along class and education. Around the world, these key indices affect both access to quality healthcare and how populations interact with health workers. Individuals with less education are often unable to properly advocate for their own health interests, a situation that is worsened by markers like gender and age. The legacy of colonization, and its philosophies, plays an important role in perpetuating the current situation.

By the end of the twentieth century, more medical training centres were being established in African countries, but only Nigeria and Côte d’Ivoire had more than ten medical schools in-country. Despite the paucity of schools, these pioneer institutions paved the way for professionalized health systems that were administered by Africans, to Africans. They also had significant drawbacks.

For example, before independence, the only medical school in Nigeria was University College Ibadan. Established in the 1940s, the training curriculum at University College Ibadan was designed to mirror the United Kingdom’s, to ensure that medical graduates from the institution were qualified to practice as physicians in Nigeria and in the UK. One impact of this was that it introduced standardized practice to patients. This was positive, as prior to the college’s establishment, Yaba Medical School was the only Nigerian institution that provided medical training, and it granted a lower-quality diploma to its graduates.

As the first institution of its kind, University College Ibadan became the template for the next generation of medical training in Nigeria. However, the system was not without flaws. Transplanting an educational model that worked in the very different British setting without modifying it to suit its new Nigerian environment left gaps. Perhaps even worse, existing defects in the model were carried over too. All of the benefits of standardized medicine were offset by the lack of consideration for how these new practices and practitioners would fit into the Nigerian context.

Despite its shortcomings, including under-regulated and, thus, potentially harmful interventions, traditional medicine in Nigeria still appeals to many. This is because traditional medicine is practiced by those with the skill and assertiveness that comes from a deep understanding of their community’s psyche. Practitioners administer interventions that fit the pre-existing ideals of the communities they work in. One major reason for the dissonance between traditional and Western medicine in Nigeria is that both were inseparable from the religions and core convictions of their originators. Traditional medicine incorporated the rituals and cleansings from traditional beliefs, while Christian ideas underpinned twentieth-century medical ethics. A great chasm formed when Western medicine arrived on the continent, and without being revised first to fit pre-existing approaches to healthcare, African communities suffered as a result of that dissonance.

This tension between Western and African approaches to healthcare poses an important question: what should medical ethics look like for Nigerians, and for Africans more broadly?

WHO CHOOSES WHAT IS NEXT?

The realities of publicly funded hospitals across the continent do not foster an environment where the best of care can be practiced, especially in those that care for poorer patients. The vital rapport between a physician and a patient, needed to institute standard medical ethics, and create more positive experience for the patient, is difficult to achieve. Dr. Koyenikan, a paediatrician working in Ondo town, cited the heavy patient burden as an important reason for this. According to Dr. Koyenikan: ‘A [typical] outpatient clinic that runs for about three hours has one physician to 30 patients. Which means six minutes per patient. This is not enough time to meticulously assess, explain a diagnosis and answer questions the patient may have, especially if it is the patient’s first visit.’

Despite these challenges, Dr. Koyenikan explained, ‘to circumvent putting [patients] in this disadvantaged position, I, as a care provider try my possible best to still ensure an adequate one-on-one session. However, with the patient load, this will mean longer working hours for me, or even working over-time.’ Ultimately, medical practitioners understand that the challenges they face are systemic. The greatest hindrance, Dr. Koyenikan said, ‘is the low-quality healthcare [system] that increases the burden of diseases, and the inadequate manpower, as these invariably up the patient load, hence the cycle continues.’

This situation is not new: even after the establishment of University College Ibadan, the output of physicians in Nigeria remained low. Into the 1960s, 20 years after University College Ibadan was founded, the patient burden remained too high to be met by the supply of new and available doctors. In a 2016 speech, Kelsey Harrison, a retired University of Ibadan professor, detailed the start of his medical career at Ibadan where he was ‘one of only three house officers [medical interns] in the 107-bed department of obstetrics and gynaecology…[handling] about 3000 deliveries every year, many complicated’. This problem continues. Today, Nigeria has only 0.4 doctors for every 1,000 patients, well below the World Health Organization’s (WHO) standards of at least one doctor for every 1,000 patients.

Despite all of the secrecy surrounding traditional medicine, it remains a practice that is available to all, with each region and tribe in Nigeria having its own form. Nigerian patients who resort to homeopathic remedies like herbal medicines (or tinctures and ointments) are often influenced by their own socio-economic class and level of education. The way that these factors intersect informs the health-seeking behaviour of people in a complex way.

A higher level of education has been shown to correspond with a belief that traditional medicine has some harmful side effects, making such individuals less inclined to use traditional medicine. Conversely, poorer Nigerians are more likely to be of a lower educational level, and are less aware of the poisonous effects of some traditional medicines. Patients are made even more vulnerable by African belief systems that postulate supernatural forces are responsible for disease.

Many Nigerians face a difficult choice—either rely on traditional medicine, which is often cheaper and more accessible, especially for rural Nigerians, or attempt to find a solution with Western medicine (but revert to traditional medicine when the costs of continuing western-style treatment become too great). Even richer and better-educated Nigerians are susceptible to the latter choice, as the cost of managing long-term chronic diseases through Western practices can cripple their finances. Out-of-pocket spending accounts for 79.6 per cent of all healthcare spending in Nigeria, and this figure is notable when compared with other West African countries like Ghana or Côte d’Ivoire at 37.7 per cent and 39.4 per cent respectively. It indicates a significant problem, one where most patients have to shoulder their medical bills themselves. And these costs are often able to cause catastrophic health payment (defined as spending that prevents a household from buying essential, non-medical goods and services). In 16.4 per cent of households in Nigeria, healthcare costs of just 10 per cent of total household expenditure are able to cause catastrophic health spending. For 13.7 per cent of households, the threshold is 40 per cent of household expenditure, further illustrating the inequities in accessing healthcare.

It is difficult to determine how vulnerable individuals fare within traditional systems that are largely unregulated. The All-Nigerian Homeopathic Medical Association (ANHMA) was established in 1980, but alternative medicine’s integration into general clinical practice was disfavoured by established orthodox medical institutions in Nigeria. There are traditional practices, like the use of herbal remedies containing heavy metals in amounts beyond the margins of safety, or unstandardized surgical interventions that are often harmful to people. Yet traditional medicine’s greatest strength is that same informality that puts patients at ease when discussing their health challenges.

Amid recent talk by the federal government about defunding the mandatory internship year—compulsory for newly graduated doctors, and typically completed ahead of youth service—morale among healthcare workers is lower, even for the provision of routine health services. To improve patient-doctor relations, there needs to be an environment that ingrains medical ethics into interactions from the start. Major steps in the education of doctors are required, but there is also a need for infrastructure development, proper funding and advocacy. Who carries out this advocacy is just as important as what is being advocated for.

To be the best advocates for their own welfare, patients need to be informed, with ethical education offered alongside health education. Nigeria is heavy-handed regarding respecting authority, to the detriment of vulnerable individuals. This will be the first barrier to breakthrough. Equally important is making patients aware of how they should expect to be treated by health workers, and providing avenues to lodge complaints. The proven effectiveness of models of regular health information on infectious diseases that commonly affect Africans could be combined with the strengths of traditional medicine for this purpose.

ACCOUNTABILITY FOR REASONABLENESS

An important factor in the process of delivering ethical healthcare services is the concept of ‘accountability for reasonableness’ which emerged in the late 1990s.It is a conceptual framework developed by the American political philosopher and medical ethicist, Norman Daniels, to combat dire healthcare inequalities across social and cultural lines. The framework theorises that the best approach to ensuring equitable healthcare is by creating a system that is publicly available for critique by the communities on the receiving end of health interventions.

Following its success in the United States, accountability for reasonableness was woven into the processes that deliver healthcare to Africans. Many of the health services built on this idea were funded through donor organizations like the WHO, the International Monetary Fund (IMF) and others, specifically when combatting HIV/AIDS in the continent.

While accountability for reasonableness proved efficient initially, it began to fail when patients started absconding from treatment. More than a quarter of patients who initially made regular clinic visits eventually died, because they stopped using their drugs due to logistics, compounding inaccessibility, and the unfamiliarity and impracticability of western health programs within their own worldview. These were all failures that the framework’s supposed predilection for publicly audited decision-making could have avoided. However, the framework relies on the assumption of a society where each individual is in a position where they have equal power, and say in decision making, even decisions implemented by global bodies like the WHO or the IMF. This model blocks out the reality of many vulnerable individuals in African communities who have less bargaining power like children, the poor and people with lower levels of education.

The individual-centric basis of healthcare, especially healthcare equity, could be described as the primary failure of this Western framework, and the structures built on it. The introduction of Western medicine in Africa meant that the rights of the individual were forced into pre-eminence within African cultures, like that of the Igbo or the Yoruba, who generally believe a village is required to take care of the vulnerable, and that each individual has a responsibility to that village. Most African institutions that have tried to follow the path of western medicine have run into this problem.

The ethical concerns of Western countries differ greatly from those in Africa, but the conceptual framework that African health systems were built on during colonialism favour these Western ideals.

At the end of the Second World War, Britain was put in a state of reflection on its policies around public life. This contributed to many of the new health legislations the country has made in the last 50 years. These legislative shifts centred on issues like euthanasia, the voluntary termination of pregnancy, and the patient’s right to be informed about terminal illnesses or medical decisions that affect their own health. If the British ethical framework had to be revisited to suit the UK’s changing beliefs, how much more is that revision needed in Nigeria, where the framework never fit?

Fostering more discussion about legalization and easy access to practices like euthanasia, abortion, and birth control might be difficult in Nigeria’s largely conservative society. But revisions to ethics and legislation are necessary. They are required to ensure that justice exists in the health system, and that the Nigerian government carries out its responsibility to the people it governs. This includes ensuring that justice exists in delivering resources and equitable healthcare.

In 2020, the United Nations Secretary General, António Guterres, remarked on health and social inequalities made even more evident by the pandemic. ‘We need to make a new global deal to ensure that power, wealth and opportunities are shared more broadly and fairly at an international level,’ he said. In African countries, it is equally important that, on the national level, we draft a new deal that favours the continent’s unique ideals and psyche.

A FUTURE AWAKENING?

Given that Nigeria’s cultural landscape is changing along with the information age, we may soon witness awakening from the spell of colonization’s influence on African healthcare. We may begin to see what the Hippocratic oath, meaning justice for all patients, looks like in a specifically Nigerian context. As a country, Nigeria might become ready to scrap the entire medical philosophy that it unwillingly inherited.

Doing so should involve a critical evaluation of Nigeria’s own systems of belief and cultural practices before building ethical frameworks on them. Achieving consensus within a non-homogenous society like Nigeria’s will undoubtedly be challenging, but the resulting system would be designed in Nigeria’s own interest.

Very few countries have been able to achieve such a standard in their own cultural climate, even in more homogenous societies. The task ahead involves a restructuring. More investment should be directed to the health system to create a more conducive environment for beneficial patient-health worker relations. Recognizing, and possibly renouncing, colonial ideas about medical training will perhaps be the hardest challenge, given the persistence of those ideas in post-colonial Africa. But our own intellectual frameworks and cultural markers about care and communal wellbeing have value and are indispensable in creating a health system that works for us

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