Bioethics and Moral Hazard in Short-Term International Medical Training 2 February 2013 Carolyn Smith-Morris, Ph.D., M.S., LPC Associate Professor, Medical Anthropology Southern Methodist University
Suchdev, P., K. Ahrens, E. Click, L. Macklin, D. Evangelista, E. Graham (2007). A Model for Sustainable Short-Term International Medical Trips. Ambulatory Pediatrics 7(4): 317-320. Ethical Challenges of International Health Work Self-serving Raising unmet expectations Ineffective Imposing burdens on local health facilities Inappropriate providing value for visitors but without meeting the local community s needs sending volunteer practitioners and trainees who do not have appropriate language or medical training or accountability providing temporary, short-term therapies that fail to address root causes providing culturally irrelevant or disparaging care and leave behind medical waste failing to follow current standards of health care delivery (continuity, access) or public health programs (equity, sustainability)
Principles of Biomedical Ethics a Western philosophical construct 1. Respect for autonomous persons 2. Justice 3. Nonmaleficence 4. Beneficence
Challenges to Ethical Care Culture and Language Communication breakdowns and cultural differences are ubiquitous Less likely to receive care Less likely to be compliant Greater risk of experiencing medical errors Respect for autonomous individuals requires providers to acknowledge and honor a patient s ability to consent for treatment. Jesus, J.E. (2010). Ethical Challenges and Considerations of Short-Term International Medical Initiatives: An Excursion to Ghana as a Case Study. Annals of Emergency Medicine 55(1): 17-22.
Challenges to Ethical Care Lack of Adequate Time, Resources Triage identifying medical needs and likelihood of benefit. The principle of justice obligates medical personnel to consider the medical utility and prospect of success as factors in the decisions about how to allocate resources The Utilitarian Approach To do the most good for the most people To offer the best possible care (for the community? for the individual?) with available medications and equipment
Challenges to Ethical Care Chronic Care and Elective Surgery Nonmaleficence requires physicians to consider what care should not be offered. Without the ability to provide long-term follow-up care, avoid chronic care medication and elective surgery. (Jesus 2010: 19)
Challenges to Ethical Care Sustainability * A rational and beneficent approach to serving communities in the developing world should involve teaching and training community members and local health care workers.
Challenges to Ethical Care Delivery of Care by Nonlicensed Personnel and the Need for Oversight The principle of respect for autonomous persons requires the protection of populations with diminished autonomy All personnel and administrators must have the humility to recognize their limitations, and tailor their actions accordingly.
Global Health Ethics for Students 1. Humility 2. Introspection 3. Solidarity Medical Tourism can undermine existing health care and cause harm to local systems and (power) structures. 4. Social Justice Ultimately, global health should be concerned with health inequity seen in the world. Work to align your goals with those of the community. Be aware of one s own privilege Pinto, A.D. and R.E.G. Upshur (2007). Global Health Ethics for Students. Developing World Bioethics 1471-8847 (online)
Additional Resources Crump, J.A. and J. Sugarman (2008). Ethical Considerations for Short-Term Experiences by Trainees in Global Health. JAMA 300(12): 1456-1458. Decamp, M. (2007). Scrutinizing Global Short-Term Medical Outreach. Hastings Center Report 37(6): 21-23. Drain, P.K., A. Primack, D.D. Hunt, W.W. Fawzi, K.K. Holmes and P. Gardner (2007). Global Health in Medical Education: A Call for More Training and Opportunities. Academic Medicine 82(3): 226-230. Shah, S. and T. Wu (2008). The Medical Student Global Health Experience: Professionalism and Ethical Implications. Journal of Medical Ethics 34: 375-378. CONTACT INFORMATION: Carolyn Smith-Morris, smithmor@smu.edu, AND OF INTEREST: Physicians for Human Rights (2010). Hospital Staff Upholds International Medical Ethics During Unrest in Bangkok: A Briefing Paper by PHR. Beagan, B.L. (2003). Teaching Social and Cultural Awareness to Medical Students: It s All Very Nice to Talk about It in Theory, But Ultimately It Makes No Difference. Academic Medicine 78(6): 605-614.
Why do you hope to do this work? Questions for Students Prior to Global Health Work (Handout) What are your objectives, both personal and structural, short and long-term? What are the benefits and who will receive them, and what are the costs, and who will bear them? In the context of very limited institutional and societal resources for global health needs, is your elective justified? What alternatives exist, or how can the justification for this allocation of resources be improved? What do you need to do to prepare for your elective, both practical and personal? Where are the weaknesses in your plan, specifically? Is the work feasible, cost-effective, necessary, focused, and justified? Will it work to undermine disparity in the host community, or will it contribute to disparity? Will there be a net benefit to the community? What do you hope to bring back to your own community or institution? Is your work sustainable locally? If not, will this program or your group s presence leave any negative impacts or potential unjustified disruption? Adapted From: A.D. Pinto and R.E.G. Upshur (2007). Global Health Ethics for Students. Developing World Bioethics 1471-8731 (online).