Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether medical ethics allow you to deny a brutal dictator, named "Fozzie," an experimental treatment.
Is it ethical for the doctor to refuse to provide the experimental treatment to Fozzie?
Yes: 52%
No: 48%
Would your answer change if Fozzie makes credible threats against the doctor's life if treatment is not provided?
Yes: 25%
No: 75%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt from his book, Who Says You're Dead? Medical & Ethical Dilemmas for the Curious & Concerned:
The leaders of developing nations, both dictators and those democratically elected, have a long history of traveling to wealthy Western countries for medical care. The result is that the world's leading democracies often play medical host to the planet's most brutal rulers. In 2012, Ethiopian strongman Meles Zenawi died while undergoing treatment in Belgium.
That same year, Saudi Crown Prince Nayef received cancer treatments in Cleveland and later died in Geneva, Switzerland. Spain played host to dying Gabonese dictator Omar Bongo in 2009 and Angolan strongman José Eduardo dos Santos in 2017, while Germany has welcomed Kazakh despot Nursultan Nazarbayev for regular medical checkups. Professor Ian Taylor, an expert on African politics, has noted that of the ten African heads of state to die of natural causes between 2000 and 2015, all received foreign medical care and eight died abroad. Many of these nations have deplorable human rights records, and their populations have highly limited access to healthcare of any meaningful quality.
Possibly the most famous case occurred when President Jimmy Carter allowed the former shah of Iran to undergo surgery at New York Hospital in Manhattan in 1979. Carter's decision, widely criticized at home and internationally, led to the notorious Iranian hostage crisis.
Surprisingly, the bioethics community has remained relatively silent on this subject. As a general principle, medical ethics favors that healthcare be delivered apolitically. When Bahrain placed medical professionals, such as nurse Rula Al-Saffar, on trial for providing emergency first aid to antigovernment protesters in 2011, numerous international medical associations condemned the government's actions. Similarly, physicians' groups have criticized the targeting of doctors by all sides in the Syrian civil war. However, such efforts to keep medicine apolitical make it difficult for these same organizations to raise their voices when dictators seek treatment abroad. Although a few commentators have suggested rules requiring world leaders to receive healthcare in their own nations, these efforts remain quixotic.
Just because the U.S. government has given Fozzie a visa, however, does not mean that Steven Strange, MD, has an ethical obligation to treat him. In fact, physicians generally have no obligation to treat anyone with whom they do not already have an established relationship. (One might argue that such a relationship was created when Strange initially agreed to enroll Fozzie into the protocol, but as treatment has not yet started, this is debatable.)
Patients are turned away from potentially life-saving experimental therapies all the time -- often as a result of circumstances beyond their control, such as that a study reaches its enrollment limit.
Unlike Fozzie, these individuals often die without ever even learning that such studies are ongoing. Strange may wish to take into account the broader impact of rejecting Fozzie as a patient. The result may be the further politicization of medicine and could make it more difficult for groups such as the World Health Organization and the International Council of Nurses to protest the treatment of physicians abroad. Or the refusal may serve as a statement that draws public attention to the plight of the victims of human rights abuses under Fozzie's dictatorship.
Yet physicians are often constrained in any efforts to publicize their refusals: dictators generally want their medical treatment kept secret, and confidentiality laws prevent doctors from publicizing such requests without permission. The truth is that the public has very little idea of how many problematic leaders seek medical care in their countries. Doctors may be refusing to provide care to such autocrats all of the time. There is no way of knowing. Yet just because the public is unlikely to learn of Strange's decision does not diminish its ethical components.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases: