Under-recognised ethical dilemmas of diabetes care in resource-poor settings
Saurav Basu, Nandini Sharma
Published online: June 16, 2018
Ineffective diabetes management results in suboptimal glycaemic control and adverse health outcomes. In resource-poor settings, a combination of high burden of medication nonadherence in patients and therapeutic inertia amongst clinicians is largely attributed to the failure to achieve glycaemic targets in diabetic populations. The potential health risks from intensification of medical therapy for aggressive lowering of glucose levels in Type 2 diabetes patients represents an ethical dilemma between averting risk from overtreatment and preventing future harm from raised blood glucose levels. However, the ethical dilemmas experienced by clinicians in most of the developing world when contemplating prescription of additional oral hypoglycaemic agents or initiating insulin have received little attention from the medical community. Such ethical dilemmas unique to resource-poor settings often emerge from poor availability of drugs, diagnostics and physician consultation time for diabetic patients. Furthermore, existing evidence-based guidelines for diabetes management assume a standard of care which is lacking in such settings. This often compels the developing world clinicians when confronted with such diabetes-related ethical dilemmas to rely solely on their clinical judgement which could be ethically unjust and medically prone to error. Newer research needs to generate evidence to develop best practice guidelines for optimal therapeutic outcomes, while acknowledging the reality of limited healthcare services available in resource-poor settings.
Optimal glycaemic control as a therapeutic outcome is essential for delaying the onset and progression of microvascular and macrovascular complications in diabetes patients (1). Diabetes complications are associated with premature mortality, reduced quality of life and enormous economic costs. Measurement of glycated hemoglobin (HbA1c) is considered the gold standard for assessment of glycaemic control in diabetics with a value of <7% usually considered as good control (2). Large scale studies have found poor glycaemic control to be a major public health problem, especially in the developing world. The A1chieve study reported a mean HbA1c of 9.2% in a large cohort of 20,554 diabetes patients in India (3). A facility-based study in Kerala among 1200 diabetics undergoing treatment reported HbA1c > 9% in 45% patients (4). The lack of effective diabetes management resulting in poor glycaemic control in a diabetic population is suggestive of a high prevalence of nonadherence to medication intake and therapeutic inertia. Medication non-adherence occurs when the patient’s medication intake does not correspond to agreed recommendations from a healthcare provider, a major problem in chronic diseases which require lifelong medication intake (5), as in diabetes mellitus (DM). Therapeutic or clinical inertia is the failure to intensify the treatment of a diabetic patient who is not at his/her HbA1c goal as per standard guidelines (3). For instance, the American Association of Clinical Endocrinologists (AACE) 2016 guidelines recommend intensification of anti-diabetic therapy every 3 months, culminating in initiation of insulin on failure to achieve the HbA1c target (6). However, intensification of therapy is associated with health risks to patients which cannot be always predicted. In this regard, the ethical dilemma encountered by clinicians when considering intensification of therapy in Type 2 DM patients in attempting to balance their desire to achieve glycemic targets promptly with the need for averting risk to the patient from overtreatment (non-maleficence) has been previously reported in the context of the developed world (7). Yet, the ethical dilemmas which mediate the widespread clinical inertia in resource constrained settings of the developing world have received little attention from the medical community.
Clinicians when treating diabetic patients with suboptimal glycaemic control while also lacking social support and financial protection may experience a dilemma in strictly advocating insulin therapy, considering the difficulty in its acquisition and safety during regular application (8). The ethical challenge of balancing desire for beneficence (improved glycemic control) while avoiding harm (inadequate therapy, hypoglycaemic episodes) to patients is well established. Some other related ethical dilemmas also emerge when considering intensification of medical therapy in patients who are at risk of medication non-adherence. Patients lacking financial resources can struggle to meet their anti-diabetic medicinal requirements especially in dysfunctional healthcare systems (5, 9, 10). Medication non-adherence in these vulnerable populations may also occur on adding new generation oral hypoglycaemic agents to the patient regimen that are unavailable through government supply or when lacking inexpensive generic equivalents. Moreover, any intensification of therapy prior to correction of preexisting medication non-adherence involves the risk of further lowering adherence due to issues with drug acquisition and factors like increased regimen complexity (11). However, in high patient load and resource-poor settings, a correct assessment of medication adherence in chronic diseases like diabetes can be challenging for the clinician due to the shorter time available for patient consultation. Furthermore, patients often tend to over-report their levels of medication adherence due to self-desirability bias (12). The clinician considering all scenarios may continue with existing treatment while awaiting improved glycaemic outcomes from an anticipated improvement in medication adherence and lifestyle modifications. Such a clinical decision is apparently consistent with the non-maleficence principle which prioritises patient non-harm over beneficence. However, paradoxically the deliberate decision of opting for therapeutic inertia in a poorly controlled diabetic may aggravate an earlier onset of diabetic complications, endangering the physician’s ethical compliance with the non-maleficence principle.
In an alternative situation, the diabetic patient may express unwillingness to accept the intensified medical therapy recommended by the clinician. Patients may lack the necessary self-efficacy for conforming to an insulin regimen due to their fear of pain, side effects, nervousness about correct application, and the drug costs. Such patient-directed clinical inertia involves the ethical challenge of respecting patient autonomy and also upholding the clinician’s duty towards advancing beneficence.
Another possibility involves the inability of the physician to confidently identify the presence of clinical inertia in the poorly glycaemic controlled diabetic patient. This can occur when health facilities lack an HbA1c testing facility, or when patients irregularly test plasma glucose levels, or fail to self-monitor blood glucose due to inability to afford a glucometer and recurring cost of strips which precludes valid glycaemic control assessment. The physician preference for a conservative approach favouring non-maleficence over an uncertain beneficence is observed in these situations.
It could also be argued that most of these ethical dilemmas are ultimately an outcome of resource deprivation of the public health system, especially primary healthcare, leading to a denial of justice for diabetic patients dependent on it. We do realise that the achievement of a system of universal health coverage which ensures high quality diabetes care in the outpatient setting, inclusive of drugs and diagnostics, can largely eliminate diabetes related ethical dilemmas encountered by the clinician in existing resource-poor settings. The global NCD targets for 2025 are also directed towards enhancing the affordability, availability and assured delivery of essential medicines, counselling and basic technologies required for control of diabetes, cardiovascular diseases and stroke (13). The incorporation of e-Health and m-Health components for easing clinical decision making for healthcare providers in remote areas and promoting health education in patients can also facilitate the achievement of these targets.
There exist additional ethical dilemmas in diabetes care in resource-poor settings which relate to patient diet and lifestyle management. The challenge of selecting a healthy, culturally appropriate and affordable dietary plan for a largely poor, semi-literate and culturally diverse population can be daunting even for a skillful dietician. Similarly, recommendations of physical exercise can remain unmet due to lack of sufficient open recreational spaces or in the presence of sociocultural resistance against these health practices among younger women in certain orthodox communities (14). Conventional strategies for effective diabetes management overlook the enormity of such sociocultural, socioeconomic and environmental challenges which are pervasive over much of the developing world (15).
In conclusion, both overt and subtle ethical dilemmas influence diabetes management by the clinician. Existing evidence-based guidelines for diabetes management assume a standard of care which is lacking in much of the developing world and thereby inadequate for ameliorating the ethical dilemmas arising during diabetes care in these settings. This increases the clinician’s vulnerability towards exercising his or her clinical judgement which could be ethically unjust and medically prone to error. Newer research needs to prioritise the focus in generating evidence for developing best practice guidelines to achieve optimal therapeutic outcomes while acknowledging the realities of the limited public healthcare services and the socioeconomic vulnerability of diabetic populations living in these resource-poor settings.
Sources of support: Nil
Conflicts of interest: None declared.
- Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diabetes. 2008 Apr;26(2):77-82.
- American Diabetic Association. Glycemic Targets. Diabetes Care. 2017 Jan 1;40(Supplement 1):S48-S56.
- Mohan V, Shah S, Saboo B. Current glycemic status and diabetes related complications among type 2 diabetes patients in India: data from the A1chieve study. J Assoc Physicians India. 2013;61(Suppl. 1):12-15.
- P Suresh Kumar, AM Sandhya. A study on the glycemic, lipid and blood pressure control of type 2 diabetes patients of Kerala. Diabetes Metab Syndr. 2017 Oct-Dec;11(4):231-35.
- Sabatâe E. Adherence to long-term therapies: evidence for action. 1st ed. Geneva: World Health Organization; 2003.
- Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm — 2016 executive summary. Endocr Pract. 2016 Jan; 22(1):84-113.
- Khunti K, Davies MJ. Clinical inertia versus overtreatment in glycaemic management. Lancet Diabetes Endocrinol. 2018 Apr;6(4):266-8.
- Bal A. Diabetes: ethical, social and economic aspects. Issues Med Ethics. 2000 Jul-Sep; 8(3):77-8.
- Basu S, Khobragade M, Kumar A, Raut DK. Medical adherence and its predictors in diabetes mellitus patients attending government hospitals in the Indian capital, Delhi, 2013: A cross sectional study. Int J Diabetes Dev Ctries 2015;35 Suppl 2:95.
- Sankar UV, Lipska K, Mini GK, Sarma PS, Thankappan KR. The adherence to medications in diabetic patients in rural Kerala, India. Asia Pac J Public Health. 2015 Mar;27:NP513-23.
- Odegard PS, Gray SL. Barriers to medication adherence in poorly controlled diabetes mellitus. Diabetes Educ. 2008Jul-Aug;34(4):692. -7.
- Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin Epidemiol. 2011 Mar;64(3):255 – 7. discussion 258 – 63.
- WHO. Noncommunicable diseases: Campaign for action – meeting the NCD targets [cited 2018 Apr 15]. Available from: http://www.who.int/beat-ncds/take-action/targets/en/
- Advika TS, Idiculla J, Kumari S J. Exercise in patients with Type 2 diabetes: Facilitators and barriers – A qualitative study. J Family Med Prim Care. 2017 Apr-Jun;6(2):288-92.
- Basu S, Garg S. The barriers and challenges toward addressing the social and cultural factors influencing diabetes self-management in Indian populations. J Soc Health Diabetes. 2017;5(2):71-6.