ETHICS IN GLOBAL HEALTH:
BEYOND HIPPOCRATES
Scott Loeliger, MD, MS
Mark Stinson Fellowship in Global and Underserved Health
Contra Costa Family Medicine Residency
Evaleen Jones, MD
Child Family Health International (CFHI)
Stanford University Medical School
TUFH INTERNATIONAL CONFERENCE
Bogota, Colombia
30 September, 2008
OBJECTIVES
• Review the historical context of ethics within medical
training and practice.
• Understand the place of ethics within the “new” medical
professionalism.
• Incorporate the concepts of ethical behavior and practice
into service learning activities.
• Encourage open discussion about current controversies
and new generation focus on global health work.
Historical Perspectives
• Hippocratic Oath
• (4th Century BC)
• The Declaration of
Alma Ata (1978)
• Universal Declaration • Declaration of Helsinki
of Human Rights
(1948)
• The New Hippocratic
Oath (1966)
(1964-2004)
• Millennium
Development Goals
(2000)
Ethical Principles
• Primum non Nocerum to Primum non Tacere.
• Physician Charter on Medical Professionalism.
• Healing in the context of Social Justice.
• Residents with Skills – Helpful or Dangerous?
Physician Charter
American Board of Internal Medicine Foundation, the American
College of Physicians Foundation, and the European Federation of
Internal Medicine
1. Primacy of patient welfare: Stresses altruistic
dedication to the well-being of the individual
patient.
2. Patient autonomy: Urges physicians to
facilitate patient involvement in treatment
decisions.
3. Social justice: Calls upon physicians to work
actively toward equitable societal distribution of
health care resources.
Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6. [PMID:
11827500]
The Physician Charter:
• Physician Charter Construct for Medical Professionalism
Social justice
Patient
Autonomy
MP
Erika Shimahra, Master’s of Education, Stanford University, 2006
Patient
Welfare
Embedding Ethics in Residency
• Formal learning and didactics.
• Pre-experience preparation.
• Consideration of ethics in underserved local
•
•
communities.
Understanding complexities of global realities,
institutions, processes and programs.
Self- study and self-reflection.
Models of Service
or
Service Learning
• Short term clinical work combined with tourism.
• Attachment to clinical research project.
• Longer term work with NGO’s or Universities.
• Advisor/Teacher or Medical Corps?
Conflicts in Conscience
• All done in the name of Hippocrates is not right.
• Physician centered paradigm can distort true
health improvements.
• Resource poor areas require careful attention to
appropriate strategies.
• Attention to the Immediate versus the
Sustainable.
THE BRAIN DRAIN
• We are going there, who’s coming here?
• Raised expectations without means to
correct health manpower deficiencies.
• True professional exchanges, joining the
growing global debate (Global Health
Workforce Alliance).
Primary Care and the Medical
Home
Do They Want What We Want
• Translating “Ours” to “Theirs.”
• While working in health care, how to attend to social
injustice and underlying factors of poor health.
• Training leaders, followers, co-conspirators or
colleagues?
• Respect for emerging literature and research from
abroad.
NGO CODE OF CONDUCT
• Recently developed (2007-08).
• Included input from APHA, Partners in Health,
Physicians for Human Rights, Save the Children, AMREF,
GHETS, WHO, World Bank and others.
• Most recent consultation in Kampala during March global
forum on human resourses for health.
• Next consultation at APHA meeting in October, 2008
ARTICLES OF NGO CODE OF CONDUCT FOR
HEALTH SYSTEMS STRENGTHENING
I.
NGOs will engage in hiring practices that ensure long-term health system
sustainability.
II.
NGOs will enact employee compensation practices that strengthen the
public sector.
III.
NGOs will pledge to create and maintain human resources training and
support systems that are good for the countries where they work.
IV.
NGOs will minimize the NGO management burden for ministries.
V.
NGOs will support Ministries of Health as they engage with communities.
VI.
NGOs will advocate for policies that promote and support the public
sector.
Ethics and Research
• Global health research may have some ethical
flaws.
• Interventions determined by narrow research
goals may not be sustainable.
• Article 25 of Universal Declaration of Human
Rights.
• WMA and Declaration of Helsinki.
UNDERSERVED HEALTH CARE
• Think Global, Consider Local.
• Incorporate the Experience into Your Future Practice
• Work in Your Milieu to Integrate Service Learning into
the Medical School and Residency Experience.
• In Your Medical Bag:
Stethoscope – Check; Ophthalmoscope-Check;
Sansome Guide – Check; Language Dictionary – Check;
Ethical Guidelines-Check?
CASE SCENARIOS
#1 Filling In – A Little Knowledge is a
Dangerous…
#2 Vertical Projects – We Only Do…
#3 Ignoring Bureaucratic Barriers
#4 NGO/Institutional Short Time Work
Resources
Markle, W, et al. editors. Understanding Global Health.
McGrawHill Medical, 2007, 362pp.
Evert, J., et al. Developing Residency Training in Global
Health: A Guidebook. San Francisco: Global Health
Education Consortium, 2008. 119pp.
O’Neil, E. Awakening Hippocrates: A primer on health,
poverty and global service. AMA, 2006. 502 pp.