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
Ethical Challenges of
International Health Work
 Self-serving
– providing value for visitors but without meeting
the local community’s needs
 Raising unmet – sending volunteer practitioners and trainees who
expectations
 Ineffective
do not have appropriate language or medical
training or accountability
– providing temporary, short-term therapies that
fail to address root causes
 Imposing
burdens on
local health
facilities
– providing culturally irrelevant or disparaging
care and leave behind medical waste
 Inappropriate – failing to follow current standards of health care
delivery (continuity, access) or public health
programs (equity, sustainability)
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.
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
Medical Tourism
can undermine
existing health care
and cause harm to
local systems and
(power) structures.
2. Introspection
3. Solidarity
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: 375378.
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.
Questions for Students
Prior to Global Health Work
(Handout)
Why do you hope to do this work?
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 14718731 (online).