This article analyzes the ethical considerations involved in focusing a global health effort on a single patient. The specific case considered is “Funds for Felix”, in which money was raised by students for a patient encountered by the UCLA Global Medical Training trip to Nicaragua in December of 2010. As the leader of the UCLA campus branch of Global Medical Training, I approach this case from a broader, organizational perspective. Although the Global Medical Training at UCLA leadership body was enthusiastic about the Funds for Felix project, we wondered about the potential ethical concerns that arise from devoting so many resources to an individual. Ultimately, the approach taken for the Funds for Felix project was extremely successful. This was due to several factors, including the transparency with which the project was conducted, the involvement of Nicaraguan mentors, and the students’ altruistic motivations. Given the rising awareness of global health issues, the relevant ethical questions of the Funds for Felix project are salient for any student or physician in the field of global health.
Introduction to GMT and Felix
Global Medical Training (GMT), founded in 2003 by Dr. Wilbur Johnson, is an international medical volunteer organization with the mission of giving undergraduate students the opportunity to observe and participate in medical clinics in Central American countries. GMT at UCLA, which has been operating as an undergraduate-run campus branch since 2008, organizes and prepares students for three such trips each year. After each trip, students return brimming with anecdotes about their patients. Although most trippers are pre-meds with substantial clinical volunteering experience, something about travelling to an unfamiliar location heightens their sense of observation. After being limited to volunteer work in sterile hospital environments, their trip abroad often sparks a new interest in global health and a greater appreciation for primary care. However, two students returned from the GMT at UCLA Trip to Nicaragua in 2010 with a distinct goal. As can be seen in “Funds for Felix: A Global Collaborative Effort to Restore One Patient’s Vision”, . Poorva Vaidya and William Temple were spurred to action by their encounter with the patient Felix, whom they met on a home visit. Despite his youth (Felix is twenty-three years old), he was depressed, unresponsive, and weak. A genetic retinal disorder left him nearly blind, and unable to work, go to school, or do almost anything independently. Furthermore, his routine hospital visits alone drained nearly 50% of his family’s income. Viewing Felix as a peer, Poorva and William were unwilling to accept the dismal prognosis that he faced. They planned to raise money to offset his extensive healthcare costs, with the ultimate goal of placing Felix in a position to support himself. Though clearly altruistic, raising money for an individual patient raises issues about sustainable global health service. While it is crucial to consider the potential arguments against the Funds for Felix project, these pitfalls were largely avoided in the actual execution of the project. This is primarily due to the transparency with the project was conducted, the involvement of Nicaraguan mentors, and most of all, William and Poorva’s underlying motivations.
After returning to the United States, Poorva and William approached me about storing the money they planned to raise for Felix with GMT at UCLA. As finance officer of GMT at the time, I explained the project to the GMT Officer Board, who greeted the proposition enthusiastically. In addition to storing the money, the officer board voted to host several fundraisers, with all profits going to Funds for Felix, as the project came to be called. Although GMT at UCLA keeps a running list of monetary goals, such as buying a set of blood pressure cuffs, fundraisers are generally not held for a specific purpose. Furthermore, fundraising events are not major sources of revenue for GMT at UCLA, and serve primarily as publicity events for the club. Since the money was going towards a specific and direct cause, Funds for Felix appealed to our desire to produce a tangible result, and it was also beneficial from an advertising perspective. A clear goal, such as “fund three doctor visits for Felix” made the money seem more productive than a general promise of “funding medical donations”. Thus, GMT at UCLA came to provide several resources for the Funds for Felix project.
Potential Ethical Dilemmas Associated With Funds for Felix
William and Poorva had no problem soliciting donations from friends and family. They quickly reached their goal of $1000, with money still coming in. I never questioned this outpouring of generosity, until I approached the Undergraduate Students Association (USAC) accounting department about obtaining tax deductions for donors to the “Funds For Felix” project. Well aware of the effect Felix’s story generally has on people, I was confident that USAC would readily agree to provide umbrella tax deductibility for Felix donations. I shared the story with an intently listening employee in the accounting department, assured of a positive response. Despite expressing her personal interest in the project, the employee informed me that unfortunately, Funds for Felix could not receive tax-deductible status. The simple reason is that the money would be going directly to an individual. Though disappointed, I initially dismissed this as a bureaucratic idiosyncrasy that had no moral relevance to the Felix project. As I thought more, I wondered if there might be some merit to this reasoning. Superficially, raising money for Felix appears to violate Global Medical Training’s mission of promoting a sustainable future for the countries in which we volunteer. GMT emphasizes public health education and preventative care, and employs physicians that are native to Central America. Just as treating the disease is considered preferable to treating symptoms, the best way to utilize charitable donations and services is to address the root problems of the issue, rather than the individual manifestations. Felix’s story is somewhat unusual, in terms of his youth and the rarity of his condition. However, he is one of millions lacking access to simple healthcare in Central America. Thus, giving money to a single patient appears to facilitate dependence on foreign aid. The Funds for Felix project ultimately raised approximately $1300, which is more than enough to cover GMT at UCLA’s operational expenses, and is almost five times the approximate amount that GMT at UCLA spends on general medical donations for GMT clinics each year. Thus, this amount of money is significant in terms of GMT at UCLA’s cash flow. We all felt good about the tangible results of giving to Felix, but supporting an individual arguably does little to promote the greater good in Nicaragua. Self-indulgence is one of the greatest dangers of charitable work. As the economist Tim Harford argues in his famous argument against charity, “The scattershot approach [giving small amounts to multiple causes, such as Funds for Felix] simply proves that we’re more interested in feeling good than doing good. Charity Is Selfish” . While the motives for donating resources to Felix are altruistic, our satisfaction with the neatness of the project was resoundingly selfish.
How “Funds for Felix” Fulfills the “Ethical Imperative of Global Health Service”
In his essay entitled “The Ethical Imperative of Global Health Service”, Dr. Edward O’Neil Jr. argues that global health service is a duty for all health professionals, but especially medical students and young physicians . Most of the undergraduates who are willing to give up their precious school beak and devote significant time and money to a GMT trip are likely to understand embody this view. However, how does this relate to the individual patient on our trips? In clinic, we strive to internalize the code of professionalism and ethics that the Nicaraguan doctors set forth for us. The most recent American Medical Association’s ethics report on the Doctor/Patient relationship explains, “Within the patient-physician relationship, a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount” . As undergraduates, Poorva and William do not yet have the skills to treat Felix themselves. Since they could not provide him with the standard of medical care they wished for him, they mobilized what resources they did have- their family, friends, and the UCLA community. The professional acceptability of this gesture is apparent in the enthusiasm with which doctors in both United States and Nicaragua greeted the project. The various specialists in the United States that William contacted (ophthalmologists and neurologists) were all supportive; some even offered to provide pro bono medical services to Felix. However, it seems unlikely that a group of physicians would have undertaken this type of project to raise funds for a patient. While physicians can be generous with their professional skills and resources, the Funds for Felix project was born out of William and Poorva’s unique position as undergraduates, unable to help Felix medically, but motivated to do whatever they could.
At the height of the Funds for Felix campaign, William and Poorva were hit with a surprising addition to Felix’s medical story. At their initial home visit, Felix had told the GMT team that the loss of his eyesight was due to physical assault during a robbery. An MRI scan that was only possible due to Funds for Felix funding revealed that Felix had lied about his condition. Although the assault had happened and had no doubt exacerbated his condition, the truth was that he was suffering from a genetic disorder that causes progressive retinal detachment. When confronted about the discrepancy in his story, Felix admitted that he thought GMT would be less likely to help him if he had a progressive disorder . Importantly, William and Poorva were not deterred by the revelation of Felix’s dishonesty. Instead, they took this news as a reason to intensify their efforts. As Dr. Johnson explained, “If a doctor turned away patients who distort or are, in other ways, less than totally honest, that doctor would, in fact, be seeing few patients… It is the doctor’s job to uncover the true facts, remain relatively nonjudgmental, and proceed to do that which is medically of most benefit for the patient” . Although William and Poorva are only students, they applied the ethical standards of a doctor-patient relationship to their relationship with Felix. This aspect of the story is useful for assessing the criticism that charity is ultimately selfish. Poorva and William were hurt by the disclosure of Felix’s true medical record, but they chose to brush aside their own personal feelings in favor of Felix’s best interests.
The specific plan that was formulated for using the “Funds for Felix” money counters the criticism that donating to the individual is not a sustainable approach to global health service. The Funds for Felix contingent were well aware that sending a large lump sum to Felix would be irresponsible, and even potentially dangerous for Felix and his family. Collaboration was a critical aspect of developing a plan that would provide the maximum benefit to Felix, while still working towards the goal of helping him achieve independence. This plan was created with input from the following parties in addition to William and Poorva: Felix and his family, physicians from the United States and Nicaragua, and the GMT at UCLA officer board. By enlisting a range of people with different expertise, William and Poorva ensured that the money would be put to the best possible use. Dr. Angelica Torrentes’ involvement throughout the process was particularly important. As a native Nicaraguan, she was more aware of the social and economic subtleties of Felix’s situation than any of the undergraduates from the United States. For example, the logistics of physically getting money to Felix turned out to be somewhat complicated, and required her knowledge of the Nicaraguan banking system and public transportation. Dr. Angelica was also able to counsel William and Poorva on the best way to explain the monetary situation to Felix. As Dr. O’Neil Jr. explains in Awkakening Hippocrates, humanitarian efforts by foreigners are often marred by a failure to understand the actual needs of the particular patient or population . William and Poorva avoided this problem by involving Dr. Torrentes and other Nicaraguan doctors to provide cultural context for their efforts. This teamwork resulted in a plan that will allow Felix the funds to attend braille school, train for potential jobs, receive the necessary extensive medical care, and support himself until he is self-sufficient. In an interview about Funds for Felix, Dr. Johnson explained, “I consider this to be a small, but very significant aspect of one version of sustainability” .
Finally, the transparency with which “Funds for Felix” was conducted was a critical logistic element in the success of the project. Although the exact details have evolved, the goals were always simple: provide the patient Felix with money for medical care, and help him find suitable job training and employment. Every donor was aware of these goals, and gave their money with the understanding that it would be going to help this specific individual. Despite GMT’s involvement with the project, the Funds for Felix money was always kept distinct from general GMT donations. In this way, the Funds for Felix project avoided the ethical problems associated with using donated money for purposes other than what the donor intended.
It is easy to dismiss these concerns due to the small scale of our operations. However, as future members global community of healthcare professions, the decisions we make now might someday translate into policy choices on a much larger scale. Furthermore, as the trend of undergraduate and medical student involvement in global health continues, this issue will become more prominent. The issue of extra care for individuals has already become relevant in the field of clinical research, where ethicists hotly debate how to approach the issue of extra health care for individual members of clinical trials .
How to approach a similar project in the future is a salient issue for the leaders of other medical volunteer organizations. From a strictly organizational perspective, the pros outweigh the minor cons of utilizing club resources. A campaign such as Funds for Felix provides an excellent publicity opportunity by providing a unique story to interest prospective members, and showcasing the immense dedication and passion that GMT members espouse. The moral perspectives on this type of project are more complex. Good intentions are important, but an organized and culturally aware logistic approach is essential for success. Due to the overall success of the Funds for Felix project, similar projects have sprouted on other GMT trips. By following William and Poorva’s example, these other students can hope to positively represent the future generation of medical professionals in global health service.
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