OTROS INGRESOS

A guideline is a statement, a rule, an outline or direction, designed to help others determine a course of action. In this dissertation, I have attempted to ground guidelines for making ethical decisions and addressing ethical dilemmas around unsolicited information in the clinical context in a combination of the philosophy of Ubuntu and the communicative system developed from the Yoruba concept of oot _{. This aim was achieved in different chapters. In} this first chapter, I introduced the problem statement to be addressed. In the second chapter, I attempted a conceptual clarification of terms. In this chapter, I adopted a definition of unsolicited information as a finding (or piece of information) – anticipatable or unanticipatable – with or without clinical or personal significance about a subject, discovered in the process of a systematic and methodic analysis of data for findings related to the aim and objectives of the test or procedure. I equally clarified how this term is employed in this dissertation, following the precedence in literature. In this dissertation, this term refers to a piece of information or a finding about which there is pressing and real ethical uncertainty as to whether to disclose or not to disclose.

Following this clarification, I identified different contexts in which such unsolicited information may arise, as well as highlighted the physician (or more broadly health professional)-patient context, as my principal context of interest. I defined the physician- patient relationship or context as a context or relationship in which a physician or health professional takes an affirmative action in a patient‟s case by either examining, diagnosing, treating or agreeing to do so. Once the physician enters into a relationship in any of the preceding ways, a legal contract is formed in which the health professional owes a duty to that patient to continue to treat or properly terminate the relationship by mutual consent. Some of the duties in a health professional/patient relationship include: the duty to rescue; the duty of care; the duty to uphold respect for persons; a fiduciary duty; and a justice duty. In the rest of this first chapter, I highlighted some ethical issues that can act against a physician‟s ability to fulfill these duties, or create ethical, as well as legal, dilemmas for the health profession or physician.

In the third chapter, I defined an ethical dilemma as a puzzling circumstances in which moral obligations demand or appear to demand that a person adopts each of two or more alternatives but incompatible actions, such that the person cannot perform all the required

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actions. I also highlighted the different types of dilemmas. All moral dilemmas pose some difficulties for agents; some are resolvable and are called apparent dilemmas, while others are not resolvable and are called real dilemmas. Healthcare professionals are often taught to analyse real ethical dilemmas by applying principlism. Principlism, I explained, is a pluralistic approach to moral decision-making based on four key principles of autonomy, beneficence, non-maleficence and justice. This pluralistic approach is the ethical foundation of modern clinical and research practices. However, principlism has certain limitations. When principles conflict, it is often difficult to manage such conflicts without a foundational principle, when they occur. Additionally, empirical studies equally exist to refute principlism‟s claim to universal applicability or common morality. Other studies have highlighted the limits of current medical ethics framework, specifically principlism, for managing culturally/religiously nuanced clinical contexts, or contexts where health professionals and patients are motivated by different religious or cultural values. Furthermore, I pointed out in this chapter that principlism reflects the core values of the dominant Western culture from which it emerged – independence, individualism, and autonomy. But such an autonomy, individual-centered outlook to life cannot be integrated in contexts which emphasize community, connectedness, togetherness and so on.

Hence, there is a need to supplement principlism by developing alternative frameworks based on other (non-Western) models of decision-making. These frameworks must accommodate other patients who make decisions using different models of decision-making, and should also foster theoretical diversity (in decision-making within the clinical context) which is needed to manage ethical dilemmas around unsolicited information in a variety of clinical contexts.

In the fourth chapter, I introduced an alternative ethical theory developed around a tradition other than the Western model, and that is specifically, based on the ideas, practices and beliefs salient amongst many cultures in sub-Saharan Africa. In this chapter, I highlighted a theoretical formulation of Ubuntu that encompasses the common themes which run across existing, and sometimes competing, interpretations of the same. In addition, I also highlighted in this chapter that this theoretical formulation can serve as supplement to current Western frameworks, contribute towards theoretical diversity, and can be useful for addressing ethical dilemmas around unsolicited information in a variety of clinical contexts. Ubuntu defines a morally right action as one that honours the capacity to relate communally, reduces discord or promotes friendly relationships with others, and in which the physical world (horizontal line)

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and the spiritual world (the vertical line) are fundamentally united. This definition is a result of a systematic review of the ethical literature on Ubuntu. I justified the use of this methodological approach in that is likely to increase methodological transparency, reduce bias and ensure thoroughness.

Although the theoretical formulation which I highlighted in the fourth chapter is useful , it does not make specific reference to communicative ethics. In the first section of the fifth chapter, I therefore supplemented the theoretical formulation of this ethical theory by introducing a communicative system based on the Yoruba concept of oot _{. A combination of} this communicative ethics modelled around the Yoruba concept of oot _{and the theoretical} formulation of Ubuntu, properly constitute the African Ethics which I apply and defend in this dissertation.

By grounding the ultimate moral rule in what connects, rather than separates, individuals, I showed that this ethical theory is a better alternative guideline for justifying or addressing loss of values, such as the value of confidentiality in Case Two. Based on this ultimate moral principle, disclosure (of H‟s serostatus) to W is mandated and justified, even if this might likely entail the violation of H‟s right to confidentiality. Maintaining H‟s right to confidentiality is not likely, or is less likely, to lead to a situation where H becomes a true object and subject of harmonious relationships, since others cannot appropriately care for him.

I acknowledge here that applying guidelines requires judgment. In the introductory case and Case One, I showed how ethical judgments, in dilemmas regarding information, can also incorporate the views and values of patients without revealing the truth of the information. Unlike previous suggestions for invoking therapeutic privilege or considering ethical dilemmas around non/disclosure which do not make any essential reference to how one can also incorporate the values of the patient, I introduced – based on the African ethics I defend – a communicative ethics for making decisions about non/disclosure in a way that does not rely only on the health professional‟s discretion but also fosters the shared decision-making capacity of the patient.

This communicative ethics begins with engagement. The goal of engagement is to get a proper understanding of a patient‟s values and views, as well as to include those views and values in the decision-making process. Sometimes disclosure may be mandated, following a patient‟s responses in a friendly conversation, but at other times disclosure may be ill-

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advised. In these cases, I showed how a physician can avoid lying to a patient, in the event that non-disclosure is mandated, by focusing on the strategy of paltering. I defined paltering as a deliberate act of withholding the relevant truth by stating other truths. This, I noted, is my preferred non-disclosure strategy and is not inconsistent in itself with the value of honesty that is prized by the African ethics I apply and defend in this dissertation. This ethics eschews lying, since this is an inappropriate way of relating with others; it is not other-regarding; is a devaluation of oneself to the level of an eranko (animal); and finally, it entails a failure to exhibit the virtue of honesty. Paltering is a justifiable way of avoiding lies and deception, as well as preventing harm to a patient, especially when disclosure is medically contraindicated. Although the African ethics I apply in this dissertation offers a compelling alternative to extant models of decision-making within the clinical context, the mere fact that patients, doctors, systems and communities have varying value systems reveals that no situation, such as the cases discussed in this dissertation, can ever be definitively addressed to the satisfaction of all concerned. In order for this to be possible, an over-arching value system is needed, which is currently not available; and given the overwhelming call for multiculturalism and theoretical diversity in clinical ethics support system, a monopoly by a single theory on normative guideline for ethical decision-making in clinical care is not desirable.

The African Ethics I defend in this dissertation possesses an under-emphasized value that can significantly contribute towards achieving theoretical diversity in clinical care. It also provides exposure to lesser known models of truth-telling from other regions of the world such as sub-Saharan societies. I recommend that future studies should focus on properly integrating this ethics into medical ethics curricula and codes. I am optimistic that if this alternative model is incorporated into current medical ethics codes and curricula, it will significantly enhance clinical decision-making, as well as health professional/patient communication. Although I have defended the view that the non-disclosure strategy I propose, paltering, may be justified following an African ethical framework, I encourage future studies to focus on developing other practical approaches – in addition to the one I propose in this dissertation – for employing paltering (and other non-disclosure strategies) in concrete contexts, so that it does not become a device for avoiding truth-telling merely because it is convenient to do so. Future studies should also focus on studying these and other ethical dilemmas using other ethical frameworks. I am optimistic that this would contribute to

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the theoretical diversity needed to address real ethical contexts where stakeholders are influenced by different beliefs and values.