Moral Landscape

The need for clinical ethics in guiding healthcare professionals in their decision-making processes is heightened in complex fields such as surgical oncology. Life-threatening diseases like cancer not only impairs quality of life of patients as they are exposed to multiple treatment regimens, but they encounter uncertainty in their daily lives as they navigate the healthcare terrain. Physicians have a crucial role to play in these situations. Drawing from my experience dealing with complex cancers whilst working in Pakistan and United Kingdom, I seek to illustrate the similarities and differences between the healthcare systems of the two countries highlighting ethical challenges heightened in this field.

How does one make informed consent from patients truly ‘informed’ in the Pakistani context where family continues to remain at the center of decision-making? Families often request physicians to not tell patients about their diagnosis and treatment believing that they are in the best position to decide for the patient. Some may also argue that they do so in order to protect the patient’s emotional well-being. This contradicts respecting patient autonomy, a fundamental principle of modern medical ethics. In the UK, patients have better access to resources and information therefore the discussion remains patient-centric, resulting in shared decision-making. Differences in culture and level of education have an impact on the process of informed consent. Therefore, the onus lies with the physician to tailor their approaches to best suit patients’ requirements so that they remain the center of care.

In Pakistan, physicians struggle with providing healthcare. In low and middle income countries, resource constraints pose additional burdens on physicians. Certain cancers require specialized surgical equipment, and specific expertise, beyond the reach of majority of the population due to high costs. Limited resources along with a huge patient load necessitates fair and transparent processes for equitable access to care. Physicians also have to contend with the moral burnout experienced that can result from making these life-altering decisions for their patients.

The risk of moral distress also increases when physicians have nothing to offer but comfort care to patients who can no longer benefit from any treatment. What should physicians offer to patients who have exhausted all treatment options? While the UK has made significant progress in integrating palliative care into the healthcare system, Pakistan is lagging far behind. Surgical oncologists over here do not have the luxury of relying upon a specialized palliative care service. They have to initiate and sustain these difficult conversations with terminal patients themselves.

The practice of surgical oncology requires an additional sensitivity since it creates ethical challenges unique to it, shaped inevitably by existing cultural and socioeconomic pressures. A special commitment and extra care is required to ensure better decision-making for patients, to preserve their dignity and ultimately minimize their suffering.