We walked into the clinic of our nongovernmental organisation to find a young man sprawled on the floor face down and crying in pain. We were told that Velu (name changed), an Irula tribal from a village about six km from the clinic, had been fetching water from the well when he had felt a sharp pain in his abdomen, cried out and fainted. He regained consciousness in a few minutes and was brought to the clinic in severe distress. He was gasping for breath and said every deep inhalation was making the pain in his abdomen worse. Even the slightest movement elicited severe pain. The look on his face was of anxiety and fear. His abdomen was rigid; this was the protective mechanism of nature whereby any damaging process taking place inside is walled off, and movements are restricted as much as possible to limit damage. His blood pressure was 70 / 0 mmHg and his pulse was fast and thready. These were indications that his condition was serious. Most likely there was a puncture in either the stomach or small intestine, leading to spillage of its contents into the abdominal cavity.

We started treatment with intravenous fluids to raise Velu’s blood pressure, preparing him for transfer to a tertiary care centre for immediate exploratory surgery and correction of the defect. He was in severe pain and begged us to send him to the hospital as fast as possible. We spoke to his brother who had accompanied him and asked him to inform his family. In a few minutes, his brother returned with a request to send the patient back home as they were not interested in going to the tertiary hospital.

Here was a robust young man with a potentially treatable condition, whose family chose not to pursue the treatment suggested by us. We tried explaining the gravity of the situation, the need for immediate referral and probably an emergency, life-saving surgery. The family wanted to take their son home and treat him with traditional medicine. We spoke to the brother, the father, the head of the tribe, and the village health worker (trained by our organisation) and pleaded, threatened and even ordered them but nothing worked. And while all this was happening Velu’s pain was worsening.

We knew that the stories of relatives or neighbours being overwhelmed by the unfamiliar and possibly unfriendly environment of the tertiary hospital often deter marginalised people from seeking healthcare. So we offered to escort them to the tertiary hospital and stay with them till proper treatment was initiated. Even this did not make a difference.

We felt strongly that since Velu, a mentally competent adult, was eager to get treatment, he should be sent to the tertiary centre. But that would mean going against the wishes of his family, whose support he would ultimately need for any follow-up and continued care. Moreover, in the tertiary centre they would not admit a patient without a relative in attendance. A consenting adult who is in dire need of specialised medical attention was being denied it by uninformed but well meaning relatives. Should we allow this to happen? Important ethical principles were being violated. The patient’s autonomy was not given voice and the best treatment was being rejected. We were in a quandary.

After much deliberation, we came to a decision. In marginalised communities such as the Irula tribes, social cohesion is strong. Placing our faith in the benefits of this cohesion, we let the family take Velu back home to his village, after clearly explaining the diagnosis and the possible consequences of refusing our recommended treatment. We documented the case as “discharged against medical advice”. At the time of discharge, his blood pressure was still low and he was in an unstable condition.

It did not need much expertise to diagnose an acute abdomen in Velu and to know that he needed immediate referral. To our mind, only a surgeon’s scalpel could have set the problem right. At the very least he needed to be seen by a surgeon and possibly get an ultrasound scan to rule out any dangerous complication. But this did not happen and Velu was taken home.

While the four pillars of ethics: autonomy, beneficence, non-maleficence, and justice are useful to guide us in most of our clinical practice situations, there are gray areas such as these where the practice of ethics becomes fluid. Had Velu not belonged to a marginalised community, with its own reservations and apprehensions about modern healthcare, this situation may not have arisen.

We visited Velu at his home the same evening. A faith healer had been summoned and after her ministrations, the young man had made a dramatic recovery. This made us wonder if this had been a self-limiting form of acute abdomen, an exaggerated response to some form of milder abdominal condition, or whether it was truly a paranormal healing experience. The next day Velu walked into the clinic and thanked us for our care. Behind him were his father, mother, brother and wife. He shyly told us, “I want my wife to have her pregnancy check up with you.”

What exactly happened to Velu and the reasons for his almost miraculous recovery are fit subjects for a separate paper. However, the episode leads to a number of questions related to ethics and the interaction between alternative cultural / belief systems:

• At what point does non-maleficence within the framework of modern medicine need to give in to autonomy, especially when the alternatives chosen are systems of healing that we do not understand?
• At what point does our responsibility towards the patient stop – even if they refuse our form of treatment?
• What is our obligation to interact with, and create openings for, interaction with practitioners of other systems of medicine?
• How does one respond to a subsequent event of a similar nature given that the clinic and the community have had a certain experience?

We are still not sure whether we could have done things any differently, and this case remains a continuing ethical puzzle for us.