 Welcome. All right, so we're trying something a little new, and it's modern technology and all its marvels here. So I'm Eric Hansen, and welcome to our biannual grand round on ethics. And today we welcome Nathaniel Gebhardt, who's actually joining us from Tanzania. And we'll be leading the discussion remotely via Zoom. And then we have Dr. J. Jacobson here with us in person. And so we're going to be doing a little bit of a combined remote and in-person presentation here on ethics and global ophthalmology. So I don't know if all of you have met Dr. Gebhardt, but he is on faculty at OHSU. And he's also been our global fellow this year traveling around extensively and working with our partners internationally. And then Dr. J. Jacobson, if you've been around, you know him well. He is a professor emeritus of infectious disease, as well as medical ethics, and has been a real stalwart partner in our conversations around ethics here in Moran. So I'm going to go ahead and give it over to Nathan first. And then I think if you're here, I can advance the slides with this, and it should work. OK? So if you need to advance, and I'm not doing it, just pop me on the head. Nathan, you should be able to speak. Thank you, Eric. Awesome. Can you guys hear me, Eric? Yes, Nate. All right. Thank you. It's great to be co-presenting with Jane Eric this morning. Mambo from Tanzania. Hopefully the connectivity isn't an issue today. But I'm very excited to be a part of this discussion today. Hopefully we can all learn a lot from each other. When Jay and I were discussing our objectives for our ethics grand rounds, we thought of three main points that we, or goals that we wanted to achieve. One was generate thoughtful discussion on medical ethics, especially within global ophthalmology. Two, share and learn from one another's experiences, encountering global ophthalmology of ethics questions or dilemmas. And three, gain more awareness about the AO's ethical principles and rules. So as I was thinking about this, I've thought a lot about the experiences I've had this year as Moran's global ophthalmology fellow. And a couple of anecdotes came to mind. And hopefully this morning we can share experiences and stories from our own global health work. I'd love to hear your stories and anecdotes about problems, ethical dilemmas, and things of that nature that you've encountered. But anyway, just to get us started, I wanted to share two quick anecdotes with you that really got me thinking about ethical problems in global ophthalmology. And I'm sorry, I apologize for the background noise. Hopefully it's not too distracting. I'm at Hotel Tilapia, the only place that has good Wi-Fi here in London. So the first little anecdote was when I first started my SICS training earlier this year at Silganga in Kathmandu. I was, of course, doing everything I could to be an ethical ophthalmologist working within their training framework and just learning SICS one step at a time with my mentors. But one thing that I didn't realize was that my being there was having some unintended consequences and ripple effects that I couldn't have foreseen. So oftentimes we'd have cases that were scheduled for me. But if there was no case scheduled for me, I'd just be observing the other surgeons doing their SICS cases. But occasionally they would bring me into room and say, oh, hey, we found a case for you. Let's go ahead and do this case together. And I, of course, was really excited to do more cataract surgery cases, so I, of course, would agree. And this happened a few times. And then eventually I came to find out that they were taking some of the residents SICS training cases and giving them to me the visiting global ophthalmology fellow. And of course, that really bothered me. And I asked them not to do that anymore. But it really got me thinking about the fact that even if we're trying to act ethically towards our patients and individuals, our actions having unintended consequences on systems or on other physicians. So that's a problem in global ophthalmology that I don't necessarily have a good answer for. But it's something I've been thinking a lot about. And then the second anecdote I wanted to share with you all was, as I've been working here in Tanzania, I've encountered the situation a lot. How we'll be seeing patients in clinic and patients will specifically say that they want the Mizumu doctor to do their cataract surgery. And it's got me thinking a lot about the idea of my presence here, perhaps undermining patient confidence in the local doctors and their ability to take care of their own patients. Of course, when a patient says that to me, I usually counter that I'm actually here as a burden of the kind of convergence and the same from the point of view. So I present the teacher. But it made me think a lot about treatment with socialism, mindset, or actions that push on modern technology. Do you guys have someone reading this one? We can hear you again. Sorry, what did you say? I think we'll just go to the cases. That sounds good. I'm sorry if I cut it out. Now let's try to go to case one. OK. And I'm going to go ahead with those. And I want you to either signal by raising the icon for your hand or just sort of step in if you want to add things or comment on what we're doing, Nate. So I let the audience. OK, thank you, Jay. Nate has shared, of course, a story about his own experience. And he's brought a couple of cases from the American Academy, which has its own resource collection about ethics. So this is the first one. And as you can see, there's an ophthalmologist, Dr. Z. And you can read that he hasn't performed surgery for about five years. We're not told how many years he did do surgery before that. And he wishes to start operating again. And he's heard that there's a good place to practice ophthalmologic surgery in another country. Next slide. So he's in touch with a surgical instrument company looking for a sponsor and they agree he visits. And when the program in the country he visits asks about his experience, he states something we didn't know before that he's been operating for over 10 years. But you'd recall that there has been an interruption over about the last five. The company agrees to sponsor the visit, but it's contingent on his use of a new instrument, which has not yet been approved in the country that he's going to visit. So he arrives and immediately starts to operate on patients who have advanced cataracts. Next slide. So he's there about a week and performs 50 surgeries. And these are the things that did not happen. So he didn't do a pre-op or post-op assessments, did not secure informed consent. There was no post-operative assessment by another health provider. And his surgery was not supervised by an ophthalmology colleague or other provider skilled in cataract surgery. Next slide. So he gets home and wishes to publish his outcomes using the sponsoring company's equipment. He does publish his results and presents case studies using patient names and testimonials about how doctors he helped them. And he's then paid as a consultant for the surgical company. Next slide. So what I'll tell you is that Nate and I sort of collectively decided and Eric to use that case. And I would just share with you acknowledging that it comes from the AOA. It's pretty egregious. I think that Nate used those terms. So the first thing to say is that I think in clinical practice, it's pretty rare that we encounter a situation where the healthcare provider has, shall I say, consciously broken so many rules. And so this case I think is worth thinking about in a couple of ways. Because time is short. One of the things it does is condense all of those things for us. We get a chance to see them. They are all rules that your academy has developed. But I think it would be naive to imagine someone actually breaking them all. So this is not a hard case in the sense of trying to decide if a rule is broken. But let's go ahead and run that a bit. And then we'll kind of back up a step and think about where do these rules come from? And in a more complicated case, how do we decide if the behavior is appropriate or not? So why don't you tell us what ethical violations Dr. Z is committed, whether intentionally or unintentionally. And that might be a great thing for you to comment on whether you think that he is in fact acting willfully or could you imagine that he's acting unintentionally? And for Nate, it would be great if you just share your name before your comment. So that's the question. What violations may he have committed? I'm gonna ask you, Jay. Can you guys hear me now, by the way? Yes. That's much better, Nate. Sorry to cut out. We're just looking for some comments. Randy has one. Well, there's so many, it's hard to get started, but the fact that he clearly increased his skills. So if it was decided he would do it at the expense of people who don't have the ability to solve it. And I would submit because I know exactly scenarios like this that the competition rate under these circumstances probably horrendous. So there's a huge price that was paid on these people being essentially experimented or trained on that it was being paid for doing this and that a company that was involved was essentially supporting this fraud and in order to get the experience in the country and area and likely indeed these patients, if the one I think of was so very similar to this or very poorly screened, likely they all had dense cataracts, but many likely also had no light perception or had no ability to have return of vision and using their name. I mean, almost every step of these would be in technical violation. I think the hard discussion, the story when we get into the zone where it's the only way people would get provision and chair was appropriately done, but there'd be a positive and there's a variation on this when you're ready. I'd like to get to is in which there are groups and the one I think in particular in India that literally make money out of doing this. They charge people who have lost their surgical privileges or have been told that they should be doing surgery. We'll charge people horrendous amount of money to come and practice on charity patients so that they can try to get a skill set that's better. One I know in particular is India so that they can hopefully reverse and be able to maintain their surgical skills. That happens still like exactly who you can contact and they charge for a week. So I remember it's about $15,000 to go and be able to operate on a group of patients often without some conditions, sometimes just vision as a very significant money making operation. So Nate, I'm sure you heard that and I appreciate when he's talking about it. He's introduced the idea of money which interestingly doesn't feature very prominently in the usual principles that we think about in terms of medical ethics. But clearly it's a motivator, it's an incentive that can be very powerful. And in this particular case if you think about it, money may be behind many of the actions that were taken and the violations that we're seeing. So we'll come back and talk a little bit about that because for example, in our society making money is often seen as a good. We recognize that it's a motivator but let's just use the corporate example. The test of good performance is often about making money much more than about what actions are taken. So let's keep that in mind. And I think Randy's comment in many ways covers several things. If you think about what he said and what he was concerned about, I think he used the word fraud. So that may have to do with the lack of transparency and I'd be interested in knowing whether the rest of you think that fraud was one of the violations here. And also I think Nate in our conversations asked, what's the most egregious thing that you think Dr. Z did or violated? Because as you can see on this slide, he violated all of those rules that are listed. Which one is the most troubling to some of you? I'm gonna just collect a couple others Randy if I may. Yeah, please give your, also please give your name so Nate can hear who's commenting. Why don't you go ahead? I'll get both of you, you first. Yes, please. And I don't know that any particular rule sticks out to be egregious but it's the overarching attitude. There's such a condescending approach and a self-serving attitude here that he's an incorporant sponsors. He looks at this as an opportunity with no negative repercussions to himself. In fact, he's probably doing a lot of harm to his patients. Not giving them full consent. All of that speaks to this attitude just it's entirely self-serving. It's just so dangerous. So I think that's the thing that was supposed to be. So I believe Nate heard you and we heard you. And Nate provided a handout of this extensive list of rules that comes from the Academy. And interestingly, it says on number two, an ophthalmologist's responsibility is to always act in the best interest of the patient. So if you think about it, that's one rule. In many ways it's the rule you're referring to. That's very disturbing because in our world we all have multiple interests at the same time. But it's fascinating that number two on the list of a lot of rules is to put the patient's best interest first. And we'll see if anyone disagrees with you. But I think a lot of his actions could be under that umbrella that he's putting his own interest first. And I remind you that that rule exists for many other people. We actually expect them when you buy a used car. The used car salesman is pretty clearly I would say putting his or her interest first. And that's acceptable within that field. So we'll keep track of that. Anyone else that actually there was another hint previously about a violation or an egregious one here? Can I collect that there? It was on the left, yes. Tyler, I think the moral licensing that he performed to try to convince himself that he was somehow acting ethically is the most egregious thing that he did. Would you repeat that just even for me to hear a little better? What was the rationale or the? No, the moral licensing. So he presumably convinced himself that he was acting ethically by what he did. And I think that was the most egregious thing that he did. Fill that out a little bit. That actually goes back to that idea of intention that we talked about. So there could be two kinds of intention, right? The intention was I know these rules. I'm gonna break all of them and I know that. That's fine. Another one might be that either I misunderstand the rule or I know another rule and I'm acting in concert with that ethically. What do you think is going on? Yeah, I think, I don't know what's going through his head but it seems like how egregious those, how egregiously he broke those ethical principles that he presumably knew as a physician and grew up in as a physician. But at some point in time, he had to essentially convince himself that what he was doing was right. And there was some benefit to either the patient or himself or others. And he fell down that level of convincing himself that he was doing something that was appropriate. And so when you're judging a moral act is it the attention or is it the action? And for him, the action was amoral but the intention may have also been amoral but he could have convinced himself the other way. Let me just see if Nate has a comment back on that. So just the point summary is very, very important is that your, I'm gonna call it an assumption, you may be right, was that he did what he did with the personal belief that what he did was ethical. And we haven't really heard what his argument was for that but that's a little different than some of you does what they do knowing it's wrong. Let's just be really clear. Randy used the word fraud earlier. There are people who defraud but they do it very stealthily because they know it's wrong and they're actually afraid of being accountable for doing the wrong thing. So let me just check with Nate. Nate, any follow up comments on those comments? Thank you, Jay, can you hear me still? I'm so sorry, I just grabbed it out earlier. I'm not sure at what point I was lost but that's a great comment. I think that raises a great question whether our ethics are determined by our intentions or motivations or whether they are determined by the questions. It's kind of going to go into a broader discussion about the foundation and philosophical rules of ethics and a little bit more detail. That's a really great comment. Thank you, Nate. And just so you know, I think we got the gist of what you're saying but there's still a little bit of an interruption in the audio. So I'm gathering that what Nate had to say and I would affirm is what you said is very, very important but it's important to know how we should judge things is does it matter what the intent is? For example, couldn't you excuse this ophthalmologist for a couple of reasons? Let's just start with the first one. Let's say you didn't know the rules that he hadn't read the material from the Academy in the handout that you have today. What would be your judgment at that point? So we'll call that ignorance of the rule. So his intent was his own best guess of what was the right thing to do. He didn't recognize that anything that he was doing ran outside his own judgment of, for example, let's say he was rationalizing that he's 10 years of surgery was a lot of experience and that that might have been more experienced than some of his younger colleagues in a developing country. And so his rationale was, I have more experience than they do, I'm just brushing up. What do you think about, would it justify what he did? Yes, and get your name. Bob, when we send people on outreach trips for Moran, they don't do things surgically in developing countries that they do not do regularly at home. Basic principle, setting aside the academies, quote of ethics, the thing that troubles me most with this is this issue of I'm gonna go do this and it's okay because it's in the developing country. And I have seen this with attending physicians, other programs, I've also seen it in residency training programs and I've been doing international work for the last 25 years. And one program I work with would send residents to what would be an outreach setting for them to do unsupervised surgery, supervised by inadequately trained residents. I have as much trouble with that. But this, the thing that bothers me is that this individual is doing things that are not regularly part of the fabric of what he does day in and day out here. And I think that should be the thing that drives it. So again, Nate, I hope you heard that. It's a very helpful comment, but let's think about the question of did he know the rules? Given your comment, I don't need to doubt that your residents do know the rules before they go. You shared that, you said their expectations. Your comment is especially valuable because you declared not only that there are physicians who do that without following those rules, but there are even other training programs that may do that. So I guess one of the questions and I invite you to think about that. You would be upset, I think, if residents in your own program found a way to do unsupervised procedures while they were in a developing country. But if another program sent residents to do that knowingly, who would you judge as breaking the rules? Would you be judging the resident as acting unethically or the program? Again, your comment first. Yeah, I would hold the program and the individual supervising residents accountable. Residents are just doing what they're asked and they try to get trained by whatever means possible. The program I mentioned, the only surgical experience those residents got doing, the minimum number of cataract surgeries they did was in these outlying areas, which perpetuated a training program that was not adding. So I really appreciate that and we should recall that Dr. Z in this case is not a resident. And one of the questions might be, where do we learn what the rules are? And we won't take more time on that because you already know some of the answers. The answers to the rule questions in your handout, they're very accessible and some of them I think we learn by example, but not by written text, right? So if you train in a program where everyone around you is following these rules, it's understandable that you might come to believe that those are the rules. So just to draw contrast for a moment and maybe we have someone at the table or on Zoom from the private practice community, once they leave training, they may not see those models of behavior and the rules change in medical ethics. So someone who hasn't been doing things for a while might not be as familiar with the rules. I'm gonna just leave it there and let you think about that. How important is it that this doctor knew the rules versus is it even conceivable that he didn't and did all those behaviors? So on Nate's slide, he's inviting you to answer the question, have you witnessed or encountered an ethical dilemma, anything like this or different in doing global health work? And Randy's already shared one story. And in fact, you know as well that is another program, is there a different experience that somebody has encountered doing global epidemiology that troubled you as maybe being an ethical problem? Let's see, behind Randy, do I see, yes, and then we'll go to Randy, yes, please. Hi, I just saved you. Jeff, hi, Nate, thanks for doing that. So if you're well, I would say daily, kind of an hour to hour, half day by half day basis, you are faced with these type of situations. It's really nice and simple to start with an example where you just throw the whole kitchen sink of the meticulous actions to start with, but the reality is much messier. And in general, you have extremely well-intentioned people willing to find the resources, et cetera, to come and help, right? They've got a tool which is surgery or a skill that's empty. Once you're there, for the period of ethical levels that you're faced, one specific example, we're in place, there's a young child, you're less than a year old, and bilateral white cataracts, you're interested in epidemiology infrastructure, and if you don't operate, they will definitely be blinded. If you do operate, they can all likely be marked on your blinds because they don't want them to follow, or come back on this, et cetera. And yet, you're looking into the face of parents and this child knowing that technically you can do it, and you might even have a safe ecosystem within the hospital to do it, but you were now faced with a situation you never could have imagined, and that I would say is the rule, that it very much is at least two to three times a day, you're faced with something that you just couldn't have anticipated. You wouldn't have necessarily read something directly applicable to it, and now you're left to navigate based on what your own kind of moral compass, what your code of ethics is all in the face of, you've got patients sitting in front of you, we're at that moment. I just sort of underlined some of Jeff's comments. Several of them are so important. We'll talk a little bit if we can about solutions. That is, I think we can agree there are lots of problems, ethical issues that arise in global ophthalmology. And the question, I mean, there are a couple of questions that are layered. One is, is this particular doctor's action breaking one or more rules? And we have the rules in front of us, and we can usually answer that question. We are struggling with his intention. And so just to answer an earlier question about how do you decide where your intention is, it's a choice. For example, in law, there's a big difference between first degree murder and manslaughter. And it's very much predicated on intention. Philosophers, especially Aristotle who's written a lot about ethics, argues that intention is almost always close to impossible to determine. That is, if you ask me my intention, I can say lots of things to you, primarily designed to serve my self-interest, but you would have a hard time knowing whether that's true or not. Think about a crime and trying to understand the intention. It's really hard. Aristotle would argue that it's the consequence of the action that makes something wrong or right and not the intention. Other people may disagree, but that's partly an answer to one of the earlier comments about, what do we do about intention? Just last comment, I didn't write you the way in a little bit because I think you may have offered us as many as three ways of thinking about what's right. You could go right to the rules. You might go to other rules, right? People who are religious have no trouble finding a set of rules that guide behavior. And he also used the word, you might use your personal moral compass. So I think that's a great thing to think about even in the case of Dr. Z. But what do you think about solving some of the problems which, as Jeff pointed out, are not as straightforward as some of the rules that we shared here today are? How would you suggest to people they think about meeting some of those ethical challenges? Jay, I got off this blog back on, so I didn't hear the question. Can you read the question? We've been talking at first, people have shared personal experiences and then they've talked a little bit about the fact that these problems are quite common in global epidemiology, including some that are not listed in the rules. So they pose very challenging questions about what do we do when we feel that there's one of these problems? Do you have some thoughts from your experience coming back to us about what strategies you might recommend for a resident who goes very often practicing ophthalmologists and faculty member? Go ahead. Well, I was gonna have a, yeah, I'd actually I'd like to first offer a comment from the chat. So Dr. Chia said, you know, responsibility by all the principles of patient autonomy and beneficence by not participating consent, not being supervised by a precept or an experienced surgeon. I think before solutions, I was wanting to piggyback off something Jay said. A lot of the conversation has been with the ignorance of rules as being an immoral act. But I think what he was getting to with intention versus consequence is there's also an ignorance out there. I think that's where we hugely failed as a global health or international development community for a long time and we're trying to rewrite that ship. And so one way, you know, with this, just like kind of laid out very straightforward actions that violate rules, it becomes easy. But when you start thinking about the subtlety, so much of this actually happens in much more nuanced ways, even now, even amongst partners we probably respect and work with. I think it's important to acknowledge that. So, and then taking back Dr. Z's actions here, which seems so egregious to us had a better outcome. What if what the consequence of his trip in a year or two year was the development of an institution and its rise because of the sponsorship, patients actually got care and they turned out well despite his inadequacies. Was that a better moral act or ethical act than somebody who went with all the intention and the, you know, by the rules and maybe the outcomes weren't by as good? How would you characterize that? So I would just sort of bang what Eric said because he's kind of pre-visioned if I can use that word, something that we'll talk about. So we've talked about a conflict of this between the act and the intention and there's kind of a formulaic way of judging that that is the act is really, really important. We sometimes make a little room for intention to mitigate what's otherwise a pretty strong violation of a rule. But Eric's comment also invites you to realize that even ethicists they really disagree about whether an act is ethically correct or not because you heard him mention that consequences are very important. So I just wanna share with you that that's something that exists as a problem not just for you, not all knowing what the consequences are but it exists in philosophy because you get very different judgments of an action. If you say there's a rule and violating the rule is a per se ethical violation or if the ethical strategy is the consequences should be whatever provides the most good for the greatest number and they can be in conflict. We need to recognize that but it's a very important point. A couple of other comments and we'll go to the next slide. Anyone else who wants to bill on what we've been saying? I'm looking and I wanna be sure. Yes, please. I'm Lauren McCoy. I had to say as well and I think even going into this even earlier is that the due diligence needs to be done by Dr. Z even before he actually gets there, right? He has to just figure out what those rules are, what the needs are, what is the rules that he needs to follow in that country or where he needs to fill these medical licensee has been stepped up in all these countries now because of I think all these providers going in and just thinking that they can use surgery and not have any consequences that happen. And so there's a lot of lines that needs to be done prior to these physicians going in there and also being able to understand what is happening and what his expectations are when he gets there but also his expectations of himself and what he can provide to them, what skills he can offer even if it's an observance of being able just to watch and learn because a lot of times in these countries they're very creative and they're very when they have their resources are very low and so they have to do surgery in a way that you can learn a lot from them. So having expectations of going in and learning from them and not you going in to save the day, scope of practices, what is your scope of practice that you're able to offer them because if you don't have something to offer then you need to stay within that practice to be able to just observe those things. Good intentions, good or bad, like you said, you have to take those under consideration to what you're doing because when there are those poor outcomes that you have with those patients you're putting that for the next person, provider group that wants to come in that is affecting what's happening that they don't want you there or they won't let you come in or they feel like what you have there to offer is not going to be meaningful because of these poor outcomes of patient positions working outside of the scope of practice that they have and being able to know when you should be doing surgery or not doing surgery is because going in and just observing what's happening in those countries before you feel like you need to go in and do something you may just be able to observe and have that possibility of knowing I might not be doing surgery let me just observe what's happening and maybe I can come back another time and offer services because I observe what's happening and this is what they need to do. So just again, and Nate I'll pause in a minute and ask for your follow up but put a lot of excellent points you raised. One of the things that was so interesting in your first part of your comment was the request or the suggestion to someone making a trip to do what you call do diligence and I've just underlined that before you do operations you think a lot about competence and what skills you need and what steps need to be done before, during and after the surgery that's understood as a requirement for being an ophthalmologist. One of the things that we could think is that it's also important that an ophthalmologist literally every day but particularly visiting say a third world country do the diligence you describe and number one look for the rules. I will just tell you that the AMA has a code of ethics and many rules and in survey after survey what we find is that most physicians are not aware of those. So what they're most aware of is what they see and what we see depends on our peer group. So you've already described that there are physicians for example that systematically may violate these rules but if those are the only positions that one knows you might not realize that there were these rules out there. So the first one to be looked for the rules the next one goes back to what Jeff said I think. The rules don't address all of the problems that someone is likely to find. And I think one of the thoughts there is and you do it in your program systematically I hope. I think the residents before they're sent are not only made aware of the rules you have a huge set of resources here of ophthalmologists who have been in those places. So this is kind of an invitation both of the residents to ask but to the ophthalmologists who have this experience to share that including sharing that some of your experiences are actually puzzling that sometimes it's very hard to know what the right thing to do is again remember Eric's comment it depends a lot on how you think about what you're doing but just the process of thinking about it is really helpful and I just really encourage that I think that's part of the development of an excellent clinician as your ophthalmologist and it's never too late for us to think about those complex problems. The last thing I'll say is that you incorporated some of what Eric talked about you talked about knowing the rules but you also cited some consequences that your behavior may affect both patient care which we've heard a lot about but also even the potential training of subsequent physicians. So a lot of really good points. Nate, any follow-up before we move on from here? That's what you may have missed the discussion. I'm channeling my Nate. He agrees wholeheartedly with this conversation and would like to call on first Dr. Warner. How hard do they agree? Thank you, Nate, we heard that. I think one of the ethical violations that we've went from being the most courageous was the consent model. I don't know if this was generally highlighted in prior discussions but informed consent and we've actually had grand rounds about this about informed consent and what does that mean and when is somebody truly informed? And I think this is a huge issue in outreach in general because I think with the cultural differences the language barriers truly providing informed consent to a patient is probably extremely challenging. And I mean, it's hard enough to do with a highly educated person kind of brand I sent her for cataract surgery to truly have something important about what they're gonna be undergoing and kind of that sort of mind-boggling understanding. I don't even imagine how treacherous that must be in the currently early of an outreach camp without even bringing in the issues of coercion. Not coercion in a sort of traditional arm bending sense but in the sense that many patients in outdoor situations may feel that they have no alternatives. And so they don't have risk benefits and alternatives that all explained. So I think that sort of underlying this whole series of ethical violations is a lack of consent because if there's true consent then the issues of undergoing experimental treatments or undergoing surgery by a less trained person and not having pre-op evaluation and not having post-op evaluation that should be covered under informed consent but I'm not sure that that's really possible. That's a really excellent point and it does confront us in I think all of our outreach settings. And I think another really difficult part of that is the expectations culturally and legally around informed consent differ quite drastically in the different locations we go. And so do the question of do you abide by your own and what we have decided here in our medical ethics community or is it appropriate to abide by what you've done in practice there? And that's still a work in progress constant because sometimes it might violate our own personal ethics even though it's not violating the ethics the context we're working within. And Dr. Tayden also had a point. Yeah, as an observer of several outreach camps just to say what Jeff was saying, follow up really well, Bob and me. And I was always really concerned about, for example, from being cornea transplants that were being done, some of these patients come great distances, you know, are brought by family members and the follow up of these people that always bothered me. So I knew that sutures are gonna pop, sutures have to come out, that can, you know, a rejection that's gonna happen here for the transplant. And it was a big ethical thing, especially at the patient who they transplanted perhaps on just one eye but that follow up of these patients that certainly outreach camps. And then just what you were saying like, you know, even if Dr. Z's, even if everything was perfect all his patients were seeing wonderfully after, what he did was wrong. And I just, you know, everything you said was I agree totally with you, but what he did was wrong. And you know, if other people say, well, you know, I'm gonna, you know, he went and got extra training and you know, I'm gonna do what he did. It just, it's even about what he did was just like, bad example, just went wrong. Yeah. Can I have one more? Sure. I love your points. Thank you. And just to take one step further on what Eric and Judith were talking about, right? So we know what important that should be, right? According to us and in another country it could mean something entirely different, right? Okay, Eric pointed out which one do you choose? And then layer on top of that, like we really are trying to get away from exploiting the power dynamic, right? Because nearly anything we say and do be potentially just taken at face value and there is this term and very real term about, you know, this kind of medical or global health colonialism, right? And that power dynamic is so prevalent and yet it's important and perhaps what they're doing just does not conform to what we believe is important and sent in this kind of cultural and relativity. How do you engage your first-time guests? Like where do you plant your flag on? Well, that's, you know, what are the things that we're gonna exchange in this conversation and build this relationship, you know, of trust between each other and yet you may not do anything other than, you know, their informed consent for the next five years just because that's the, you know, that's the situation you're in. So we're gonna go to the next slide in a moment but just to kind of give you some added perspective about that informed consent is actually relatively recent even in the United States. So the practice of medicine for most of our history did not include that and a really good example of that is still going on as attention. If part of informed consent is sharing with people the potential risk of a procedure or a treatment, there are some people who are so frightened by that potential risk that they decline a procedure. Let me just give an extreme example. I think you work in a field where infection and loss of vision are actually quite rare after many of the procedures that you do. Let me just pick a number and say it's 1 in 500 that there would be a serious consequence. Make it large. One in three to 5,000. So again, another procedure, let me use Randy's data and show you how that looks as an issue in informed consent. When you mentioned the risk of blindness somewhere there absolutely is a patient for whom that possibility is a reason not to have the procedure. They exist, they're relatively common. That patient, if not told of that theoretical risk is very likely to agree. So think a little bit about what Eric said. If you judge informed consent from the standpoint of consequences, that's a fascinating problem because it's likely that more patients would refuse vision saving surgery than you would have had consequences if you had required informed consent for everyone. So you're actually training in some cases people denying or giving up the opportunity for improved vision for another value. And again, I think maybe Eric or one of you commented earlier modern medical ethics has about four main values the first on the list and for me the first priority is called autonomy. That's actually the value that drives the argument for informed consent. We have decided actually in about the last 50 years that autonomy is more important than some of the consequences, meaning good consequences that we could get without it. It was the practice that many doctors doing procedures that patients might consider risky or dangerous would either not mention the risk or underweight the risk when they talk about the benefits. We would call that coercion today. That is an unfair disclosure of risks and benefits. 50 years ago, that was an ethical discussion. Yes. Very real for strong, I was back in that period of time. That was not, that was something that some of the older people said you've got a lot of people who aren't gonna have something that would save, but almost for sure save their lives and concern them with surgery. So it is still a discussion. What I'm sharing with you and I think it's really good to think about that in ethics as well as sort of in the OR things change. What was right at one point would not be acceptable now. I will just tell you as an infectious disease physician with people turning down a vaccine because of a false belief is a challenge in the world of autonomy. Are you with me? Is autonomy argues that I remember best interest on your list of rules. The patient says it's in my best interest not to receive this. All of my training tells me that's a wrong decision which could not only be dangerous to them, but maybe it's right. Yeah. Just to appreciate the kind of the dynamic here of things changing but how useful it is to talk about them because at the end of the day, what one hopes is that the rules and behaviors that we follow are acceptable to a lot of careful consideration. And again, global ophthalmology is relatively new. So there's a lot of discovery and some of you have asked that this question which is whose rules do we follow? That is there are rules in the US that's where your academy rules are really grounded but there are both rules and practices in other countries which are very different. I don't have a fast answer for that for you today but it's a very important discussion I think for you to think about within the program when you're sending it. One of the nice things about the program is you have some control over the behaviors at least that you expect whether they will happen or not is another question. But think about Dr. Z a little bit kind of going to a place in a vacuum not having been there before and seeing primarily the potential as one of you said benefits to themselves. Let's look at the next slide. So actually I won't spend much time I'm gonna get made if you want to do the comment because fortunately you provided a handout portion. So none of you would leave today without knowledge of those rules Nace did you want to highlight any of those rules or make some other comments? Jay, I think Eric told me you heard my first anecdote introduction. Just wanted to comment on one other thing someone made the comment that there's always a danger of medical colonialism I'm not sure who that was but I totally agree that's been my experience. What was that? That was Dr. Petty that mentioned that. Oh Dr. Petty and no wonder I agreed with him. So I've been really cognizant of that as I've been working here in Tanzania oftentimes we'll be seeing patients in clinic and a patient will make the comment that they want the Mazungu doctor to do their free for them rather than one of my colleagues in the department. And it always makes me really uncomfortable when someone makes a comment like that and I always try to put myself in the position of being the learner and I explained that I'm here to learn from my colleagues we're doing a skills exchange and they are much better surgeons than I am when it comes to SICS but it has made me think a lot about our complex history with colonialism and I don't want to do anything that could be misconstrued as neocolonialism or white saviorism and it's easy to fall into those sort of traps even inadvertently when there's such a power dynamic I know a couple of commenters have mentioned the power dynamics and the ethical dilemmas those bring so I think that's a really important part of this discussion so thank you for bringing that up Dr. Petty there are a lot of principles and rules on those handouts that we can discuss but I think Jay you wanted to get into some of your broader perspective slides before we close and we're probably running short on time. So that's exactly right and I think that the group actually has summarized for what I would like you to leave with a couple of things one ethical decisions are complicated rules are numerous and require what someone called due diligence discussion and analysis is probably the best way to deal with them and acknowledge that ethical things ethical violations that we think we're making make us really uncomfortable. The best way I think to deal with that is to share that with experienced colleagues and when I come to Moran that's what I think about I think about people who have struggled with these problems and frankly talking to more than one would be a very good idea to find the range of things that people find possible and the last thing I just wanted to say is special thanks to Nate this is very challenging to participate not just remotely but under the technical challenges that you've got so many thanks to you for bringing the cases and helping with the discussion. Yeah I think we're out of time and I would just echo what Jay said we apologize for the technical challenges but kudos for everybody adapting and I think it was still an excellent discussion and maybe so much we're putting together the cases and it generated a lot of conversation and thought for all of us so honestly everybody would kind of bring together what Jay said and what Jeff said is there's a real messiness not only working internationally but also in our own spheres where you have to think of all the things that Dr. Z did it seems so black and white but I'm acting as a reassess on something that's a spectrum and understanding how you fall within that spectrum and how you would navigate where there is maybe a less clear violation but it's still present or underlying and I think then also realizing that you have to acknowledge the messiness to work and to find any way to move forward and I think that's something that is us as in global homology but also in society we're trying to sort out is okay yeah there's a lot of ethical violations and a lot of maybe things have ended up in none perfectly but in that imperfection has come progress and finding where that level of due diligence where that level of intention and consequences where you fall within that so you're willing to actually go and do but still do it in a way that's ethical so that everything just doesn't remain stagnant I think that's a really big challenge for all of us and I hope we can continue to do some thoughts and not bother with the thoughts so thanks Nathan, thanks Jay, thank you guys for engaging in the discussion and I think it's really cool. Thank you.