Difficult trade-offs are often necessary in low-income areas where health care is paid for out of pocket, with both families and health workers often facing distressing choices, according to an article published in the Journal of Medical Ethics.

Worldwide each year, approximately 2.6 million newborns die within their first month of life. Most of these deaths are preventable and most occur in low-income and middle-income countries.

Kristine Husoy Onarheim MD, PhD, of the Department of Global Public Health and Primary Care at the University of Bergen, in Bergen, Norway, and colleagues used a 7-step ethical analysis to explore real-life situations faced by families and health workers in Ethiopia. They analyzed the trade-offs that had to be made between the overall financial well-being of the family and the acceptability of limiting treatment for an ill newborn to protect the family against financial risk.

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In their study, the authors examined both available evidence and ethical issues involved in such trade-offs. The authors discuss 3 principles involved in these decisions: the greater benefit principle, which gives priority to interventions with greater health benefits, the worse-off principle, which gives priority to patients who are worse off initially, and the financial risk protection principle, which prefers interventions that protect against high out-of-pocket expenses. The World Health Organization recommends that these principles be carefully balanced.

The authors considered the case of a 2-day old infant who was brought to a clinic by her father, a daily laborer. She had not taken to breastfeeding and appeared to be in respiratory distress. The healthcare worker suspected she had neonatal sepsis, but the clinic was not equipped to handle the intravenous antibiotics the infant needed, and the healthcare worker told the father that the child should be taken to the hospital. The father was distressed about the cost of the antibiotics and worried that if he sold his seeds to pay for the infant’s care, his other children would go hungry as a consequence. If he did not, the infant would die.

The 7-step ethical analysis involves determining what the ethical dilemma and alternative actions are; what we know about the outcomes of the alternatives; what the laws, rules, or guidelines that regulate the decision are; who the stakeholders are; what the stakeholder’s potential burdens and benefits are; where there are conflicts of interest; and what the values and principles at stake are.

The authors conclude that if we ignore non-health factors and their effects in a real-life priority setting — in particular the health and welfare of the poor — this neglect may perpetuate and strengthen the failure to address underlying structural issues that form health and development.


Onarheim KH, Norheim OF, Miljeteig I. Newborn health benefits or financial risk protection? An ethical analysis of a real-life dilemma in a setting without universal health coverage [published online March 30, 2018]. J Med Ethics. doi: 10.1136/medethics-2017-104438.