Updated: Sep 5, 2019
What are the ethical implications of purposely designing a less effective treatment for resource-limited settings?
There are four main principles of healthcare ethics, these are: autonomy-the right of patients to make their own decisions regarding their health choices; beneficence –health care providers must do all they can in terms of procedures and treatments to benefit the patient; non-maleficence – consider whether other people or society can be harmed by the decisions; and justice-fairness in all medical decisions.We can apply these four principles to cervical cancer treatment in that patients should be given the right to decide whether or not to undergo treatment, the treatment must be the very best that can be done for the patient within the settings, the treatment should not intentionally harm the patient or society and all patients should have fair access to treatments.
In most high-income countries, the Loop Electrosurgical Excision Procedure (LEEP) is the preferred mode of treatment for identified early stage cervical cancer and pre-cancer lesions. In resource-limited settings there are particular obstacles that prevent access to this option. Although LEEP is highly efficacious in treating such lesions, it is expensive to procure the equipment necessary for this procedure. It also requires a constant supply of electricity, which cannot be taken as a given in many low resource settings. Sophisticated technologies such as LEEP also require significant up-front capital investments by governments or local clinics as well as clinicians who have the proper training to operate the technology. As such, an ideal treatment for cervical cancer would be cheap, portable, independent of constant electricity, easy-to-use AND would treat lesions up to 5mm deep. When providing treatment, health practitioners need to be mindful that they are not compromising fragile muscle tissue in the process of eliminating the cancer for when the integrity of the cervical muscle is compromised, it could lead to complicated births or even preterm births in the future. Currently, cryotherapy is the most popular treatment option in most low income countries. This involves application of high pressure N2O gas to the surface of the cervix to freeze cells to death. Even though cryotherapy is inexpensive, does not require electricity and is effective for surface lesions, it is less effective for pre- cancerous cells that extend deeper in the cervical tissue since the N2O gas only penetrates to about 5mm in depth. The storage tanks used for the gas are bulky and heavy, making them difficult to transport. Additionally, N2O gas is not always available and is sometimes replaced with less effective CO2 gas which only penetrates about 3mm in depth into the cervix. It is however important to remember that access to care, albeit less effective, is better than no care at all as long as the principles of healthcare ethics mentioned above are not violated.
Several other treatment techniques, including ethanol ablation, photothermal therapy, etc, are being developed to make treatment for cervical cancer more effective and accessible. The issue at hand is that many of these alternative therapies in their quest to make a low cost treatment alternative may decrease the effectiveness of the treatment. The ethics of this intervention scheme needs to be carefully considered. Is it ethically justifiable that effort and resources are being diverted into providing an inferior treatment option for people in lower income countries?
We can first examine this decision from a utilitarian perspective. To a utilitarian, the decision would be ethically justified if it increased utility of the treatment within the target population. For this case, we can consider the number of people successfully treated for cervical cancer using LEEP alternatives such as cryotherapy or ethanol ablation. Even though they may not be as efficacious as LEEP, they still offer a treatment option and cryotherapy has been found to destroy abnormal tissue in 77% to 96% of cases which still manages to treat a large proportion of women. This is better than the alternative of having no treatment options and treating zero women. If other alternatives such ethanol ablation improves on the efficacy of cryotherapy and adds additional benefits it is ethically justified to invest in development of these alternative treatment options. Given that ethanol ablation does not require electricity to be performed, is a highly portable treatment mechanism, and costs a fraction of LEEP, there is strong reason to believe that it will have exceedingly greater access to screen-positive patients in lower income countries than LEEP could.
There is also the ethical implications regarding human right to health. It is unethical to design an inferior treatment just because a patient resides in a low-resource setting. The goal should always be to provide top-notch medical treatment to all patients and to always keep patients’ best interest in mind. However, there exists a trade-off considering the fact that there isn’t good health infrastructure in most low-resource settings. In order to treat people as soon as possible, it is better to focus on providing treatment so that the incidences of that disease decrease. While focusing on fighting illness is important, in the long run working on bettering health clinics and infrastructure may be beneficial. If we focus on infrastructure rather than specific treatments, the treatments used in high- resource settings could easily be integrated into low-resource settings. This could also be done based on the disease. So, for more critical diseases scientists should work on treatments for low-resource settings, while for other less serious diseases money should be put towards bettering infrastructure.
How does increasing access to screening and early detection change the constraints for successful treatment?
The high portability, low cost, and simple design of the POCkeT cColposcope works to increase the access to cervical cancer screening. Increasing access to screening and early detection and treatment significantly increases cervical cancer survival rate. This is because it takes about 8 to 10 years for abnormal cervix cells to progress to cancer. In the early pre-cancerous stages, the abnormal lesions exist on the surface of the cervix and can be treated by simple removal of the surface of the cervix through excision or ablation. However, at later stages, the cancer progresses deeper into the cervix, the uterus and then eventually metastasizes to other parts of the body. When it spreads to the uterus, treatment is still possible but with more radical means, usually total hysterectomy, a complete removal of the female reproductive system, rendering the patient barren. Should the cancer metastasize to other parts of the body, radiation, chemotherapy and surgery need to be performed. These may be even less available in low resource settings and at this stage the patients’ chances of survival are significantly lower. Hence increased access to screening with allow for cervical pre-cancer detection at early stages and simplifies the constraints from those needed for more invasive procedures.
Examples in shift in treatment constraints from late stage cancer to early stage pre- cancers are outlined below: