The Power of Community Participation in Improving the Health of Older Persons During COVID-19: The Case of Rwanda

### **Ethical Challenges with Decision-Making in Elder Care in Ethiopia**

#### **Kirubel Manyazewal Mussie1, Mirgissa Kaba2, Jenny Setchell3, and Bernice Simone Elger1,4**

<sup>1</sup> Institute for Biomedical Ethics, University of Basel, Switzerland

2School of Public Health, Addis Ababa University, Ethiopia

3School of Health and Rehabilitation Sciences, The University of Queensland, Australia

#### 4Centre for Legal Medicine, University of Geneva, Switzerland

Ethical decision-making is an important discussion in the area of elder care. This is a qualitative exploratory study based on interviews conducted between March and November 2021 with 20 older adults (aged 60 and above) and 26 health professionals in Ethiopia. The first ethical challenge was lack of informed consent as health professionals do not provide all the needed medical information and explanation to older patients due to reasons such as lack of time to explain because of high patient load, health professional lack of knowledge and ethical conduct, and thinking older patients might become frustrated and/or refuse treatment if they knew the truth about their health condition. The second ethical challenge was dealing with family involvement. Families and relatives of older patients often greatly influence the treatment plans of older patients and sometimes override decisions made by the older patients themselves or health professionals.

Thirdly, there were ethical challenges resulting from value conflicts between health professionals and older patients. Health professionals often experienced a dilemma between benefiting the patients and respecting their autonomous decisions informed by their cultural and religious beliefs. Furthermore, health professionals had ethical dilemmas with prioritizing older COVID patients in the face of resource scarcity. These findings add more knowledge on the ethical challenges and considerations in elder care in low- and middle-income countries. This study also implies that health professionals dealing with tensions between the health needs of older people, culture, and resource scarcity need more comprehensive geriatric education, ethics training, and ethical guidelines.

Kirubel Manyazewal Mussie1, Mirgissa Kaba2, Jenny Setchell3, and Bernice Simone Elger1,4

1 Institute for Biomedical Ethics, University of Basel, Switzerland

2 School of Public Health, Addis Ababa University, Ethiopia

3 School of Health and Rehabilitation Sciences, The University of Queensland, Australia

4 Centre for Legal Medicine, University of Geneva, Switzerland

#### Methods



#### Results

1. Lack of informed consent

"They don't give us time, they don't even listen. What is the use if you don't explain things very well?" O.Ad.

2. Family over-involvement

"The family decides at the end" H.Pro. "Usually, you treat the family more than the older patient" H.Pro.

3. Value conflict between H.Pro and O.Ad

"They don't listen sometimes. For ex, they skip medication when they are fasting and say no when you tell them not to." H.Pro. "I just pray to God. There is nothing that helps" O.Ad.

#### 4. Priority setting during COVID-19

"Our machines cannot be for all, so we sometimes use age to give priority. I will definitely lean towards saving the younger patient. The older has lived until now, at least." H.Pro.

#### Implications



#### Acknowledgements

#### Background




