Local Attitudes, Moral Obligation, Customary Obedience and Other Cultural Practices: Their Influence on the Process of Gaining Informed Consent for Surgery in a Tertiary Institution in a Developing Country

Abstract

The process of obtaining informed consent in a teaching hospital in a developing country (e.g. Nigeria) is shaped by factors which, to the Western world, may be seen to be anti-autonomous: autonomy being one of the pillars of an ideal informed consent. However, the mix of cultural bioethics and local moral obligation in the face of communal tradition ensures a mutually acceptable informed consent process. Paternalism is indeed encouraged by the patients who prefer to see the doctor as all-powerful and all-knowing, and this is buttressed by the cultural practice of customary obedience to those 'above you': either in age or social rank. The local moral obligation reassures the patients that those in authority will always look after others placed in their care without recourse to lengthy discussions or signed documentation, while the communal traditions ensure that the designated head of a family unit has the honor and sole responsibility of assenting and consenting to an operation to be carried out on a younger, or female, member of the family. Indeed it is to only a few educated patients that the informed consent process is deemed a shield against litigation by the doctors. This paper later addresses the need for physicians to update their knowledge on the process of informed consent through the attendance of biomedical ethics courses, which should highlight socio-cultural practices that may make this process different from the Western concept, but perfectly acceptable in this setting.

Surgeons' opinions and practice of informed consent in Nigeria

“…This also explains why, at the time of this study, most of the surgeons had practised for less than 5 years. However, since the residents are the ‘lieutenants of consultants’13 and they do most of the informed consent, the information in this report can be taken to be a true reflection of the status quo. More research is needed on informed consent in Nigeria to explore the usefulness or otherwise of multimedia tools, customised consent forms and some suggestions that have been raised in this study.…”

“…One explanation for this might be that those who would refuse consent to surgery do not come to the hospital in the first place so that the degree of non-consent as measured in the hospital environment is probably under-reported as a measure of the true incidence in the community or population. In a study by Irabor and Omonzejele, 6/19 surgeons sampled had witnessed a patient refusing to give consent at the outpatient clinic 13. In the majority of those who declined surgery, the surgeons could not identify what might be responsible for their refusal.…”

Causes, Spectrum and Effects of Surgical Child Abuse and Neglect in a Nigerian City

“…The importance of counselling cannot be overemphasized because these categories of parents cooperated and signed the informed consent; haven been adequately counselled by the nurses, doctors and especially the social workers. Moreover, majority of the parents, except the 27 (9.6%) who discharged the children against medical advice and were lost to follow-up, cooperated after counselling as previous researchers also noted 1,2 . The social workers' department efforts at organizing counselling sessions and home visits for every case of registered child abuse were rewarded when many fathers who abandoned their wives with the babies were reunited and many abandoned children rehabilitated.…”

“…Therefore, they are completely reliant on the parents and caregivers for the quality of health care services received, particularly in developing countries. 1,2 Unlike what obtains in developed countries, government policies in many developing countries including Nigeria do not protect children against several forms of child abuse [3][4][5] . Many children have fallen victims because they were left at the mercy of their parents or caregivers.…”

Medical Education: Meeting the Challenge of Implementing Primary Health Care in Sub-Saharan Africa

“…The considerable cultural heterogeneity among Africans requires an understanding of how different beliefs and practices influence illness, and how differences across cultures influence attitudes to illness: for example, understanding who makes the decisions in the family, the role of women in decision making, belief in the notion that illness is due to fate, the importance given to spiritual and other forms of healing and religious taboos, and the ideations that exist about death and dying. The doctor should be able to exercise a nonjudgmental approach to community-specific norms of behavior, such as "bride price," which prevents women in certain African cultures from giving informed consent for interventional procedures, 22 and social stigmas attached to illness such as HIV infection. Evidence indicates that the ability of health services to deal effectively with diverse cultural and social conditions reduces inequity in health care and improves health outcomes.…”