Diabetes, Disclosure and DNR: A Glimpse into the Ethics of Maltese Medical Practice

Malta is a picturesque landscape with a cosmopolitan culture that arises from years of intermingling between locals and invading civilizations. From the lesser known giants of prehistory who dotted the landscape with temples to now forgotten deities to the Phoenicians, Turks, French and British conquerors to what is now an independent republic and proud member of the European Union (EU). For my month-long elective in general internal medicine, the most insightful experiences I had were through encounters with the Maltese people who remained staunchly proud of their country and its colorful history. The application process for an elective is succinctly explained on the Malta Medical Students’ Association’s (MMSA) website (http://mmsa.org.mt/electives/). As a member of the International Federation of Medical Students’ Associations (IFMSA), they also accept applications for the medical exchange program. An exchange arranged by either avenue will include an option for shared housing. For my elective, we were six people from around the world in a three bedroom, two bathroom apartment located walking distance from the hospital. The MMSA arranges fantastic social programs including weekend trips to Gozo and a traditional meal of rabbit stew. Malta is a focal point for many international travelers, guaranteeing an interesting exchange of ideas with individuals from different countries and varied healthcare systems. My elective focused largely on endocrinology and diabetology. Through numerous encounters in wards and in outpatient clinics, I saw a full range of diabetics; from a perfectly controlled mother to a 20-year-old man who already suffered from retinopathy due to a mere five years of neglect. I discovered that the disease has massive impact on quality of life, completely changing schedules and easily becoming the focal point of one’s routine. The response of people to the disease can largely impact its course. There were patients who accepted their diagnosis and strived to turn it into a manageable part of their life. Others experienced difficulty and were instead beset by complications. I saw a 14-year-old girl admitted for diabetic ketoacidosis after juggling her insulin to try and lose weight. I realized that at the center of the disease was the necessity for family support. However, support did not always simply mean assisting with the insulin and the management of the disease. For example, parents of children with type 1 diabetes took a leading role in assessing and administering insulin, but this sometimes led to familial strife that resulted in patients rebelling against their diagnosis. The troublesome part was that on top of all the usual issues children experience growing up, the consequences of ignoring diabetes were devastating and often life changing. During rounds in the ward, one of the house officers whispered to me, “She has cancer.” Turning back to the smiling 87-year-old woman, I wondered how she seemed to be at peace with her diagnosis. Her family, however, looked painfully ill and was clearly disturbed. As my consultant spoke with the woman, she continued to smile, gazing over to me till our eyes met. I realized then that she had no idea of her diagnosis. As our entourage left the room, the woman’s daughter came out and spoke at length with the consultant in Maltese, tears streaming down her face. The house officer later explained to me that, although it may seem strange to a foreigner, in Malta elderly patients are often not informed of their terminal diagnoses, especially cancers, as it would trouble them in their last days. How far this rule extended, and which diseases it included, I was unable to ascertain but its ramifications were troubling. Speaking to fellow students in general surgery, I heard of similar stories, where patients were informed they were having surgery for an ‘infection’ but were in fact undergoing cancer resections. Especially where metastases were concerned, patients were often ill aware and uninformed. This was by no means the rule, nor the exception, and I am unable to comment on its frequency. The cases I did witness were deeply and morally troubling, although that is not to say that I did not see the merits in some of the arguments. I think the greater question relates to how medical systems relate to each other and how we as a profession push forward our ethical responsibilities and what value systems are being used to create these frameworks. For us in Canada, the guiding principle would be the individual’s right to access information and determine the course of treatment. In Malta, a highly familial and community-based culture, the support of the family is more important and may override the individual’s wishes. In these different outlooks, neither is more right than the other; it is in their application that one must carefully consider the sequelae. The central question is how we as an international medical community can reconcile with diverse ideologies when they are seemingly in conflict. While the culture was at times community-based, at other times it was strongly hierarchical. The system, while based on the British design, clearly demarcated the difference in responsibility and relative power between students, house officers, residents and consultants. This hierarchy was reflected in interactions with the patient, where consultants led interviews and others responded to their instructions. For me, the power of the physician was palpable in one particular encounter. We visited an elderly demented woman who had suffered a CVA. I heard that unfortunately she had not been put on appropriate medications, despite being at risk, and had suffered a debilitating stroke, which limited her movement, speech, and cognitive capacities. As we left the bed, I noticed that the doctor wrote clearly in her chart: Do Not Resuscitate. I inquired as to how the decision could be made unilaterally, without consultation to the family. I was informed that decisions as to patient care remained the responsibility of the doctor and that the family would be notified but had no real role to play in passing the judgment. My experience in Malta was largely beneficial and educational. I experienced many patient encounters and was offered extensive teaching sessions by my consultant and the firm. It was eye-opening to study in a system that was so similar, but yet different and to appreciate the nuances of hospital-based care. I appreciate the hard work and support of the professors who offered their time to teach me, as well as the University of Malta and the University of Alberta for affording me an opportunity to further my education through international exposure.