Ethical problems in cancer treatment in developing countries

and what can be done

Abkenova A., Yedillov Z.,Aidynbek Z., Orynbay A.,Uzak S.

Abstract
This article is the examination of the ethical issues resulting in cancer treatment in middle and
low income countries. Specifically, the study will touch upon the issues of tobacco production,
late stage diagnosis, genetic predisposition, public condemnation and the available solutions to
this problem that can be acted upon both on the systematic and one-time basis when little
democratic institutions are available. There is a trend in developing countries for governments to
be more interested in the financial benefit of the immediate income source, rather than potential
increase of pressure on the health-care system and future generations. Though, some
difficulties are conditioned by the lifestyle choices overall, refuse of them is impossible in the
light of given socio-economical circumstances, calling upon certain measurements from a third
party and raising issues on resource allocations.

Introduction
Cancer, being one of the main challenges in medicine, presents a huge interest in terms of
research, treatment development and screening equipment [1]. However, the complexity of the
care and diagnosis give rise to a number of ethical entanglements involving the management of
access to treatment, elimination of risk factors, social stigmatization and preventive practices
which only aggravates with ascending socio-economic inequality.
​
The International Agency for Research on Cancer (IARC) in 1997 and Woods et al. in 2005 did
thorough evaluations and found conclusive evidence of socio-economic disparities in cancer
survival for the majority of malignancies [2,3]. Especially significant correlation value was for
malignancies of the breast, colon, bladder, and corpus uteri, all of which have relatively
successful prevention if diagnosed early [4]. The aforementioned reason is why the given article
will mostly view the issues in the context of low and middle income countries, and in Kazakhstan
in particular.

Tobacco and legislation abuse

Ethical challenges in cancer treatment are those that oppose to cancer treatment or prevention,
manifest equally right or rational options [5]. One of the most problematic examples is tobacco
production. The leading cause of cancer is well-reported to be regular smoking and considered
to be a leading cause of preventable death (8 million death cases yearly) and the most
frequently diagnosed cancer, which is lung cancer [6,7]. A number of studies consistently
demonstrate a positive association between most of the cancer types and regular tobacco
inhale[8]. Additional moral strain constitutes second-smokers or passive smokers that are
exceeding the number of active ones – 1.3 billion and compiles 1.2 million death annually [9].
80% of smokers are accounted for developing countries’ population, and that is where the
problem unfolds in all the complexity. Transnational companies that are gaining a substantial
profit from the tobacco production in countries like China, India, Brazil and from its distribution
and sell in Nauru( 52.1%), Kiribati(52%), Myanmar(45.5%), Chile (44.7%) etc [10,11]. As a
result they obtain one of the most powerful lobbies that not only will prevent any anti-tobacco
legislation, but also will be targeting the product to a more and more specific groups, by
associating the habit with liberal values and hiding information of its health consequences,
which explains the increase in women and child smoke rates [12]. Usually the institutions that
can oppose to such gigantic power are not strong enough, while the governments hold very little
interest from declining such financial resources. The most famous case is The Philip Morris
International that is the largest tobacco company in the world with branches in 180 countries,
that was accused of international cigarette smuggling, founding faux research facility to change
scientific discourse and executing controversial targeting strategies to young people [13].
In Kazakhstan, with every 5th person employing tobacco abuse (20.8%) the incidence of lung
cancer decreases by 2-10 percent each year. However, the distribution of lung cancer death
cases is uneven [14]. According to a study by Bersimbaev and Bulgakova, the north and
north-eastern regions of Kazakhstan are high in radon concentration in the air. Radon is the
second-reason of the lung cancer, and it increases its oncogenic effect by 2-10 times with
tobacco usage [15].

Late stage patients

The ethical difficulties linked with terminal cancer care are complicated, especially when it
comes to palliative care and end-of-life options [16]. Palliative care plays an important part in the
treatment of patients with terminal cancer, seeking to ease discomfort, symptoms, and provide
emotional support. According to Rietjens et al. research published in BMC Medical Ethics,
palliative care is critical in meeting the holistic requirements of terminal cancer patients,
emphasizing the importance of patient-centered care and protecting human dignity throughout
the end-of-life phase [17] . However, various ethical issues arise in this situation, most notably
the equitable distribution of resources and access to palliative care services. Due to a lack of
resources, difficult decisions must be made about how to use those resources, frequently
creating moral quandaries where some patients may not receive the best care possible because
of discrepancies in wealth [18]. A study by Khan et al. (2022) that was published in PubMed
Central (PMC) of the National Library of Medicine draws attention to the urgent problem of
resource allocation and the moral ramifications of prioritizing treatments based on financial
reasons [19]. Accessing palliative treatment can be a difficult challenge for patients with very
advanced disease who are struggling financially.
 Stigmatization of the breast cancer
There are lots of stigma around certain kinds of cancer that might be uncomfortable to
acknowledge in some cultures, the most prominent examples of which is a breast cancer.
Breast cancer is an imposing wellbeing concern around the world, and the number of cases per
capita correlates with countries’ gross domestic product in an unobvious way, with diagnoses
being three times more in high-income countries [20]. However, it doesn’t apply to the mortality
statistics, where the leading countries are those with low socioeconomic level, which invites
people to debate the factors contributing to that [21]. While the aforementioned economical
basis is undeniable, another strong force is cultural. In the case
Stigma could be a complex social phenomenon that envelops negative demeanor, beliefs, and
generalizations encompassing a specific condition or gather of people. Within the case of breast
cancer, disgrace frequently shows as misguided judgments, fear, and segregation against those
influenced. It is estimated that 8.7% of the breast cancer survivors report moderate and high
stigma levels [22].
The shame encompassing breast cancer not as it were influences the passionate and mental
well-being of people living with the infection but also hampers endeavors in anticipation, early
detection, and effective treatment. It makes obstructions to open discourse, disheartens people
from looking for timely medical care, and propagates societal taboos surrounding breast health.
In addition, the negative views about breast cancer may make it harder for people to get the
help they need. This can make them feel more alone and can make their life less sustained [23].

Genetic predisposition
The body of knowledge is consistently increasing on the genetic, lifestyle associated,
epidemiological risk factors essential in solving cancer issues. Though being born with inherited
objectionable genes doesn't mean that a person will definitely get cancer, they do increase the
probability of developing tumor and developing it at younger age [24]. It is possible that inherited
genetic alterations account for up to 10% of all malignancies and can be a substantial factor in
the cases of breast, ovarian, colorectal etc. cancers [25,26].
These days, personalized medicine is commencing to modify medical decision-making to a
patient’s risk of disease. However, with these developments of screening procedures, a rise in
ethical questions in the primary and secondary prevention of cancers has also started. For
instance, in Astana, these screening programs are shown to reduce certain cancer incidences
and mortality up to by 50%–60% [27]. The main concerns are whether it should be voluntary or
mandatory and who should have control over the results, balancing the patient's right to know
about their genetic predisposition with the potential psychological and social consequences and
resource allocations on what groups gets to know the information for free or waived price [28].
 Methodology
This review's goal is to pinpoint ethical issues with cancer therapy, examine them, and consider
potential remedies. We want to obtain a thorough grasp of the ethical difficulties that are
encountered in cancer therapy and identify potential solutions by examining the literature
available.
To achieve a thorough examination of the material, this review will adopt a systematic
methodology. By employing a systematic review methodology, we aim to minimize bias and
provide an objective synthesis of the available evidence.
To find pertinent research and sources, a thorough literature search will be carried out. Using
relevant keywords and MeSH phrases, electronic databases such as Core, Google Scholar, and
PubMed will be thoroughly searched [29]. In addition, gray literature sources, conference
proceedings, and relevant organizational websites will be investigated to ensure inclusion of all
relevant information.

Findings
When it comes to the prevention of aforementioned issues, the solutions for the most part are
well-known. However, almost all of them requires the through reformation that can take decades
as the matter concerning the tradition is as early as 5000 BC. Because it requires systematic
approach that can be achieved only by the hands of the government, the political regime of the
countries plays a crucial role, which inevitably leads to the paradox: for stroke prevention
country has to be rich or democratic, but if it were to be democratic, they did not have to
struggle with most of the ethical issues.
The fundamental components of a national tobacco control policy are the same for every
country in the globe; the only variations are in how they are tailored to each nation's specific
circumstances. The WHO Framework Convention on Tobacco Control (FCTC) treaty was
adopted in 2003 as the single largest effort to reduce tobacco use in the world. However,
compliance with the WHO FCTC treaty is still difficult and problematic in many nations,
especially those in developing ones [30]. Policies that restrict who can buy tobacco products,
how and where they can be purchased, where and when they can be used (such as smoke-free
laws in restaurants, bars, and other public places), as well as restrictions on advertising and
mandatory health warnings on packages, can all be used as policy-level measures to prevent
smoking [31]. More than 100 studies have demonstrated that increased cigarette costs, for
instance, result in considerable drops in smoking, particularly among young and those with
lower incomes as shown in Figure 1 with the case of Chile [32]. Laws prohibiting smoking in
public places and regulating advertising have also been beneficial [33].
 Figure 1. Cigarette Price and Youth Smoking Prevalence

A comprehensive and fair palliative care support system is a practical answer to the ethical
issue of the just economic disadvantage in treating patients with extremely advanced disease.
In order to guarantee that all terminal cancer patients, regardless of their financial situation,
have equal access to palliative care treatments, policy frameworks should place a high priority
on resource allocation. It is possible to build cooperative efforts between healthcare facilities,
public agencies, and non-governmental organizations to create financial support programs that
are especially geared to patients from economically disadvantaged backgrounds [34]. The
promotion of an ethically aware approach to end-of-life care also requires that healthcare
professionals have the tools necessary for ethical decision-making in order to traverse the
difficulties of resource allocation [35].
However, first and foremost, the main focus has to be on prevention and decrease the number
of cases of late stage cancers. Addressing the moral issue of late stage diagnosis requires
expanding access to screening programs, especially in rural regions, eliminating regulatory
burdens [36].
The best solution in addressing the breast cancer stigmatization is educating the public on the
misconceptions about the ways womb, ovarian, vaginal, cervical, vulval and prostate cancers
develop and teach urologists and gynecologists not to interfere in their patients' life. Public
awareness campaigns help dispel misconceptions and myths about breast cancer and provide
accurate information about breast cancer and its treatments. These campaigns also aim to
reduce the stigma associated with breast cancer by promoting empathy, understanding, and
support for those affected by breast cancer [37]. Another important factor to consider is
belonging to a social group. Creating support groups and peer networks for breast cancer
survivors can provide a safe space for individuals to share their experiences and seek emotional
support to combat isolation [38]. These groups help reduce stigma by encouraging a sense of
community and empowerment among survivors. Educating health care workers to be more
sensitive and empathetic when working with breast cancer patients can help reduce stigma.
Health care providers play an important role in shaping patients' experiences and perceptions of
illness, and their supportive and compassionate approach can help combat stigma. Again, most
of them require some financial allocation and a lot of time to bring about social change. But if
implemented, it could save millions of people with this disease from improved quality of life,
increased social support and reduced psychological distress [39].
The National Breast Cancer Foundation trained over 4,000 volunteers and delivered life-saving
services to over 74,000 women on breast self-awareness techniques and helped lots of women
detect breast cancer at the early stages and get treatment without feeling ashamed [40].
The complicated ethical problem of genetic predisposition in cancer therapy calls for an
all-encompassing strategy. By educating people about the advantages and disadvantages of
genetic testing, the potential effects of the results, and the available preventative treatments,
genetic counseling can assist people in making educated decisions about genetic testing and
screening. When dealing with the psychological effects of genetic testing, people frequently find
assistance from the counselors themselves [41].
Patients and clinics/hospitals must sign a legal contract that would be supported by informed
consent for genetic testing in order to ensure that patients are aware of the potential risks and
benefits of testing as well as the implications of the results [42].
The question of access remains to be a matter of debate, but one thing is clear: efforts should
be made to ensure equitable access to genetic testing and screening, particularly for individuals
with limited access to healthcare or financial resources.

Conclusions and Limitations

Cancer treatment research advances shed light on ethical concerns that are worsened by low
socio-economical status. They call mostly for systematic and long-term solutions like
enlightenment and ensuring access to diagnosing and treatment equipment, however the case
of tobacco prevention will have the effect immediately after the legislation as the examples of
others countries has shown. Almost all the issues were the matter of consequentialism and the
long, though not direct effect of certain policy actions, cultural reinforcement and the very
existence of the knowledge itself as with genetic counselling. Though, the case of terminal
cancer patients are the question of deontological predicament and raises the question of when
does the doctor have the right to pull off the life support.
The limitations of the study were the restricted number of problems covered, whereas there are
also the issues of voluntary withdrawal from the treatment, resource allocation during a
pandemic and the changing ethical codex in general. Also, the limitation by the literature might
create narrow perspective of the situation and not touch upon the less popular angles.
The cancer have important ethical ramifications that should be carefully considered. In resolving
these ethical issues, the values of beneficence, non-maleficence, fairness, and autonomy are
essential. Policies and screening processes should work to protect individuals, guarantee equal
access, and respect their right to privacy. To minimize unnecessary pressure and potential
harm, the ethical, economic, and social ramifications of establishing new screening programs
must also be properly assessed.
In conclusion, a comprehensive strategy is needed to address the moral concerns raised by
cancer therapy in middle and low-income nations. It entails taking tobacco production into
account, enhancing early detection, addressing genetic predisposition, and coming up with
remedies that are compatible with the socioeconomic conditions of these nations. Individual
well-being should be given top priority in ethical decision-making, and fairness and access to
healthcare should also be promoted.

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