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Jul. 09, 2003 - The scene is high drama. The young and handsome doctors are kneeling in the dust, with profusely sweating hands submissively locked behind their heads. Gun-toting rebels surround them. They each feel the cold hardness of a loaded gun’s barrel at their temple. The bullet-riddled bodies of insurgents scattered on the ground fortify their fear. They know that their lives hang in the balance. Kovac and Carter wait on their knees in the African dirt, to see if the balance of life will tip in their favor. They are a long way from the frenetic, yet familiar rhythm of Chicago’s County General ER. They are in Kisangani, Democratic Republic of Congo.

Kovac and Carter are in this situation as humanitarian aid volunteers on a vaccination campaign. They travel in a country that has been disseminated by many warring factions. Carter discovers quickly that Kisnagani is not a friendly environment for a trustfund dilettante. Kovac, on the other hand, lost his family in war-torn Croatia. He has lived through the carnage of a war fueled by senseless prejudice and hate. The ethical dilemmas that these young doctors face in the County General’s ER are fairly standard. Issues such as informed consent and termination of life support turn on autonomy, the keystone of contemporary American bioethics. Autonomy, or self-determination, however, is a rich man’s bioethical issue. In order to assess the ethical behavior of Kovac and Carter, as they await their destiny the Congo dust, it is first necessary to understand the milieu in which Western humanitarian aid workers carry out their mission.

The UN and many non-governmental organizations (NGO)’s carry out humanitarian aid efforts all over the world. Following are the names and purpose of the most commonly known organizations. The International Red Cross/Red Crescent aims to assist the world's most vulnerable people. Oxfam International works with and in 100+ countries to find lasting solutions to poverty, suffering and injustice. Médecins Sans Frontières (MSF) is an international humanitarian aid organization that provides emergency medical assistance to populations in danger in more than 80 countries. Amnesty International’s mission is to undertake research and action focused on preventing and ending grave abuses of the rights to physical and mental integrity, freedom of conscience and expression, and freedom from discrimination, within the context of its work to promote all human rights. Catholic Relief Services (CRS) helps people affected by both complex, or "man-made", emergencies (wars, etc.) and natural disasters like earthquakes, floods and droughts.

Each of these organizations has a distinct mission, yet the nuance of the differences is often lost on the indigenous people who are the recipients of the aid. That is due to several factors. The first is the political stance of the NGO. Some of these organizations “witness” the atrocities that they see. As part of their mission, they feel that it is incumbent upon them to inform and educate the rest of the world about violations of human rights, abuse and oppression. Other organizations will not witness. They consider their function to be exclusive intellectual, professional and material assistance. They are politically agnostic. A third type of humanitarian care provider is government whose desire is to bandage the wounds of civilians after a declaration and engagement of war. This is currently the case with the United States Government in Iraq.

As a result of these complexities, it is not difficult to understand why the indigenous people’s trust for these organizations may be negligible. Workers are accused of being government spies. They are the victims of kidnapping, torture and death. Another recent, and fatal, development is that rebel forces also have little regard for international symbols of neutrality, such as the ubiquitous Red Cross. The protection historically offered humanitarian workers by the 1949 Fourth Geneva Convention has been deemed impotent by some warring factions who do not consider themselves bound by any law other than their own. As a result, participating as a volunteer is very dangerous. There are hundreds of documented deaths of humanitarian aid workers. The NGO’s make it very clear to potential volunteers and workers that their tenure in a less developed and/or unstable nation is potentially dangerous.

In the case of the Congo, where Kovac and Carter are serving, border issues, control of resources and assertion of power has provoked the constant warfare. The conflict, regarded as Africa's First World War, involves many factions, including various African countries, rebel groups and non-African nations with an interest in the outcome of the fighting. After half a decade of conflict the Congolese people live in constant fear and depravation, without medicine and basic needs. “Every aspect of life has been disrupted.” The physically and emotionally battered people of this Republic are wary and weary.

There are many complexities regarding the behavior, perception and security of Western humanitarian workers in less developed nations. An important consideration is that the will of humans to adapt in order to live is magnificent. The Congolese who have survived the war have done so by being acutely aware of the ethos of a culture engaged in civil war. Maintaining the fine line between life and death requires the skill of a surgeon and an acute sense of environment. Any outside influence, such as a humanitarian aid worker with little or no acclamation to the mechanics and nuance of surviving in a country of conflict, can create havoc and leave the indigenous imperiled. Médecins Sans Frontières implores their staff to be sensitive: It is critical that you, as an MSF volunteer, respect the views of local health care professionals, however divergent from your own. Remember that they have lived through the same trauma as the patients, and it is they who will remain there long after you are gone.

So, this is the environment in which Kovac and Carter practiced medicine. They were faced with a dearth of supplies and facilities, diseases like polio, which they had previously only read about, and a fatalistic doctor/patient community. The cultural change for Carter, fresh off the plane from Chicago, was considerable. His first medical case was a rebel, a victim of a gunshot wound. The bullet tore through muscle, artery and bone. As Carter worked, his audience included the French speaking brothers-in-arms who brought their fallen comrade to Carter for treatment. Assisting Carter was medical staff experienced in the ways of Congolese medicine. One doctor counsels Carter that the rebel is a Red Cross category four: a "waste of resources". As a novitiate, however, Carter carries on. He attempts to pound life back into the man. Carter sees him as a patient, not a rebel.

Kovac’s medical scene is well-directed and hones in on the sinister nature of the Congolese war and the resultant pressures under which the doctors must provide care. One moment, in a makeshift Tiki bar, Kovac is enjoying an intimate moment of dance with a beautiful woman. A Willie Nelson song drones from out of a jukebox. The moment of peace is shattered with the fierce blast of a bomb and an intense flash of light. Then, a moment of silence and stillness like that of the dead. The eerie quiet is broken by the piercing cry of a youngster. Chaos ensues with screaming, the staccato of gunfire and the hasty preparation of an OR to treat the girl with the piercing cry. She will loose her leg. As the skirmish creeps closer to the OR, Kovac stays focused on the girl and refuses to be distracted by the other medical team members’ imploration to stop the amputation and leave the patient. They successfully complete the operation and everyone safely evacuates.

The episode culminates where this essay started, with the doctors, on their knees, in the dust. The violent situation in which they find themselves mirrors an actual event. Healthcare workers from IMC were held at gunpoint, during a vaccination campaign in the Congo. Rebels stormed the village, looking for opposition rebels. Gun blast ensued and rebels lay dead in the dust. Unlike the IMC workers, however, our ER doctors were spared. Why? Perhaps it is because the man who held the gun to Carter’s head was the brother of the patient that Carter tried so hard to save. Perhaps that is why Kovac was spared as well. Kovac and Carter were sensitive to the needs of the Congolese. They provided treatment as partners with their patients, not paternalistic do-gooders. However, ER is a television show. The IMC, UN and other NGO fatalities are not fiction. The dead are beacons of light whose work and dedication should be honored, emulated
and remembered.


The ethical question of whether Kovac and Carter endangered themselves, their patients or the villagers is easily answered. They acted within the ethical and professional guidelines by completing treatment and evacuating without abandoning their patients. The AMA's Council on Ethical and Judicial Affairs currently is developing a report on physicians' obligation to treat under personal risk. This report likely will be presented to the AMA's House of Delegates, for vote, in December 2003. The AMA's current policy reflects a certain level of obligation "We the members of the world community of physicians solemnly commit ourselves to: … Apply our knowledge and skills when needed, though doing so may put us at risk."

The larger ethical issue is that faced by thought and financial leaders in rich Western nations. Powerful decision-makers and influencers in government, corporate, medical and bioethics communities can take a page from an unlikely book. Cultural icons such as Bono and Carlos Santana have given enormous resource and visibility to the economic and healthcare issues faced by less developed nations. NBC’s ER, showed maturity and used restraint in the script, directing and acting. They educated, and entertained, their audience. More of the same in the next season would be welcome.

i. Advice and insight, based on experience, scholarship and humanity provided by:
Renee Fox, Ph.D. Annenberg Professor Emerita of the social Sciences, Department of Sociology, Senior Fellow, Center for Bioethics, University of Pennsylvania. Dr. Fox, a prolific author, is also an active member of the Medecins Sans Frontiers, which was awarded the Nobel Prize for Peace and has done extensive research on the medical, social and cultural dilemmas encountered by MSF.

ii. Maryknoll Rev. Dr. Peter LeJacq, MM. Fr. LeJacq is a driving force behind Touching Tanzania, a unique collaboration of the Maryknoll Missioners; Weill Cornell Medical College; and the Tanzanian government $21.4 million Bugando University College of Health Sciences, a combined medical, nursing, dental and pharmacy school which will graduate 175 medical professionals per year. Fr. Peter has served at Bugando Medical Center since 1987 states, "Never before have the Catholic Church, an African government and an Ivy League Medical School teamed up to create a medical school in a Third World country."

iii. Doctors Without Borders

iv. Information for each organization obtained from the respective websites.

v. http://www.reliefweb.int/symposium/PayingUltimatePrice97-01.html

vi. Catholic Relief Services www.catholicrelief.org AMA's current Declaration of Professional Responsibility