Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper

Matthew DeCamp; Lisa Soleymani Lehmann; Pooja Jaeel; Carrie Horwitch

doi:10.7326/M17-3361

Position Papers |1 May 2018

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper Free

Matthew DeCamp, MD, PhD; Lisa Soleymani Lehmann, MD, PhD; Pooja Jaeel, MD; Carrie Horwitch, MD, MPH; for the ACP Ethics, Professionalism and Human Rights Committee *

Article, Author, and Disclosure Information

This article was published at Annals.org on 27 March 2018.

* This paper, written by Matthew DeCamp, MD, PhD; Lisa Soleymani Lehmann, MD, PhD; Pooja Jaeel, MD; and Carrie A. Horwitch, MD, MPH, was developed for the ACP Ethics, Professionalism and Human Rights Committee. Members of the 2017–2018 ACP Ethics, Professionalism and Human Rights Committee at the time the paper was approved by the Committee were Thomas A. Bledsoe, MD† (Chair); Omar T. Atiq, MD† (Vice Chair); John R. Ball, MD, JD†; John B. Bundrick, MD†; Ricky Z. Cui†; Douglas M. DeLong, MD†; Lydia S. Dugdale, MD†; Jack Ende, MD†; Susan Thompson Hingle, MD†; Lauris C. Kaldjian, MD, PhD†; Lisa Soleymani Lehmann, MD, PhD‡; Susan Lou, MD†; Paul S. Mueller, MD, MPH†; and Sima Suhas Pendharkar, MD, MPH†. Approved by the ACP Board of Regents on 18 November 2017.

† Nonauthor contributor.

‡ Author.

Johns Hopkins University, Baltimore, Maryland (M.D.)
Veterans Health Administration, Washington, DC, and Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (L.S.L.)
University of California, San Diego, La Jolla, California (P.J.)
Virginia Mason Medical Center, Seattle, Washington (C.H.)
Disclaimer: The views expressed in this manuscript do not necessarily reflect the views of the National Center for Ethics in Health Care, the Department of Veterans Affairs, or Harvard University.
Acknowledgment: The authors and the EPHRC thank peer reviewers Michele Barry, MD, John A. Crump, MBChB, MD, Marion Danis, MD, Ana S. Iltis, PhD, Tracy L. Rabin, MD, MS, and the many leadership and journal reviewers of the paper for helpful comments on drafts; Sean Lena for research assistance; and Lois Snyder Sulmasy, JD, and Kathy Wynkoop of the ACP Center for Ethics and Professionalism.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3361.
Requests for Single Reprints: Lois Snyder Sulmasy, JD, American College of Physicians, Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, lsnyder@acponline.org.
Current Author Addresses: Dr. DeCamp: Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205.
Dr. Lehmann: National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Avenue, NW, Washington, DC 20420.
Dr. Jaeel: Internal Medicine Residency Training Program, University of California–San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093.
Dr. Horwitch: Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA 98101.
Author Contributions: Conception and design: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Analysis and interpretation of the data: M. DeCamp, L.S. Lehmann, P. Jaeel.
Drafting of the article: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Critical revision of the article for important intellectual content: M. DeCamp, L.S. Lehmann, C. Horwitch.
Final approval of the article: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Collection and assembly of data: M. DeCamp, L.S. Lehmann.

Abstract

This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.

Ethics resources and best practice guidelines for short-term global health clinical care experiences focus on medical trainees and training programs (1–8). There is a need to translate guidelines and apply ethical principles from the American College of Physicians (ACP) Ethics Manual to practicing physicians engaged in global health activities (9) in nontraining capacities.

The Ethics Manual (10) notes, “Physicians have an important role to play in promoting health and human rights and addressing social inequities. This includes caring for vulnerable populations.” This is true both locally and globally. Over the past 2 decades, global health activities involving medical trainees (11–13) and practicing physicians (14–16) have expanded, with hundreds of millions of dollars in direct expenditures (4, 17, 18). With potential benefits of global health participation (19–23), including the potential to influence how and where physicians practice at home (for example, in underserved settings [13, 24–27]), come ethical challenges. These include respecting different cultural norms, avoiding unintended harms, protecting privacy, working within one's scope of practice, and managing resource constraints and priority setting (28). Evidence of positive long-term health effects has been lacking (29, 30), except in long-term, sustainable partnerships (31).

The term “short-term experience in global health” (STEGH) (12) as used here covers a range of clinical care and educational activities and is intentionally broad. “Short-term” refers to activities lasting a few days to several months. “Global health” could technically include any health-related activity anywhere in the world. This position paper follows others that have noted that global health typically emphasizes vulnerable populations in underserved settings (9). As used here, “experiences in global health” refers to circumstances where physicians from high-income countries travel to low- or middle-income countries or to underserved areas in high-income countries. Comprehensive review of ethical challenges is beyond the scope of this paper; for example, ethical challenges in international research is a rich and distinct field. This paper focuses on STEGHs, but these positions could also inform career global health work (32) or local activities in underserved settings.

Methods

This position paper was developed on behalf of the ACP Ethics, Professionalism and Human Rights Committee (EPHRC). Committee members, staff, and authors abide by the ACP's conflict-of-interest policy and procedures (www.acponline.org/about-acp/who-we-are/acp-conflict-of-interest-policy-and-procedures), and appointment to and procedures of the EPHRC are governed by the ACP's bylaws (www.acponline.org/about-acp/who-we-are/acp-bylaws). After an environmental assessment to determine the scope of issues and literature reviews, the EPHRC evaluated and discussed several drafts of the paper. The paper was then reviewed by members of the ACP Board of Governors, Board of Regents, Council of Resident/Fellow Members, Council of Student Members, and other committees and experts. The paper was revised on the basis of comments from these groups and individuals. The ACP Board of Regents reviewed and approved the paper on 18 November 2017.

Positions

Position 1: Physicians' primary ethical obligation in short-term global health experiences is to improve the health and well-being of the individuals and communities they visit.

A physician's primary ethical obligation is to the welfare of individual patients, not his or her own interests (10). The principles of beneficence and nonmaleficence (“do no harm”) apply in the short-term global health setting. Evidence suggests the potential for unintended but real harms (22, 33–42) (see the Table for vignettes).

Table. Case Scenarios

Best practice guidelines (2, 6) and recent literature (12) no longer consider short-term global health work as pure altruism or “something that is better than nothing” (43). Instead, STEGHs must demonstrate real benefit to the local community, with a goal of sustainability. Benefits could be short-term (such as relief of suffering or provision of needed medications or health care services) or long-term (such as treating to cure certain medical or surgical problems; educating local health care professionals; building health care infrastructure; or increasing awareness of global health inequalities that motivates long-term, sustainable change).

A few general recommendations can be made with regard to obligations of beneficence and nonmaleficence. First, the benefits of STEGHs should be “desired by and the interventions acceptable to” the local community (10) (Table [position 1, scenario B]). Short-term experiences in global health may involve physicians at different levels of training or students. Expected benefits must be balanced with potential risks on the basis of participant experience and training level. Because the STEGH participant cannot always determine what is most beneficial abroad, humility about one's knowledge and expertise is an important component of beneficence (44).

Second, beneficence requires adherence to existing ethical standards. For example, the dilemma of whether to use expired medicines sometimes arises in this context (Table [position 1, scenario A]). Existing guidelines from the World Health Organization usually prohibit such use, citing unintended harms and an ethical double standard (45), although some prescription drugs may retain potency after the manufacturer's expiration date (46).

Third, physicians should not exceed their scope of practice, even though local regulations may be less restrictive in other countries. When the need is urgent enough to raise consideration of exceeding one's scope, careful forethought and informed consent (47) are required at a minimum. Medical students, residents, and postgraduate trainees should not exceed their level of training. Local licensing requirements must be adhered to.

Finally, physicians' actions should not detract from local clinicians and resources. Supporting the local community may foster long-term, sustainable change (Table [position 1, scenario B]).

Patient and community welfare has primacy, but that does not mean that educational benefit for physician participants does not matter ethically. However, STEGHs can occur in contexts of power imbalance for historical, political, resource, and other reasons. Special efforts may be required to ensure unequivocal focus on benefits to the community as decided by the community (see position 3).

Position 2: The ethical principle of justice requires partnering with local leaders to ensure that the potential burdens participants can place on local communities abroad are minimized and preparing for limited material resources.

Justice requires that physicians “seek to equitably distribute the life-enhancing opportunities afforded by health care” (10). In many STEGH settings, certain material resources may be far more limited than in physicians' usual practice settings (Table [position 2]), presenting ethical challenges. Clinical resource limitations may be the most obvious, but ensuring that physician participants do not burden the host site is equally important. Examples of potential burdens include tangible costs (such as licensure; lodging; food; transportation; care in the event of acute illness, such as travelers' diarrhea; or measures to protect the physical safety of physician volunteers) and intangible ones (for example, causing local practitioners to shift their time and efforts toward the visiting team or expanding or supplanting their usual obligations).

Managing such burdens requires first recognizing them. Volunteers may lack knowledge of local circumstances, necessitating partnership with local community leaders. The full cost to local communities should be calculated and reimbursed (2). Protecting the safety of physician volunteers (such as during travel or using personal protective equipment) may require actions on the part of the local community, the organization, and the volunteer, but financial responsibility rests with the organizations that send volunteers. Although organizations typically provide reimbursement, individual physicians must be cognizant of potential burdens created by their presence (Table [position 2, scenario A]), take steps to minimize them, and report them to the sending organization. Responsibility for medical care of physician participants, including medical evacuation if necessary, rests with the sending organization.

Ensuring just distribution of limited resources is another possible ethical challenge. This may occur for many resources, such as diagnostics, therapeutics, and personal protective equipment. Managing ethical tensions among the welfare of the individual patient, efficiency, and equitable distribution with special concern for vulnerable patients is challenging. The best balance should be decided among all stakeholders, with appropriate deference to local community values (Table [position 2, scenario B]) and in advance rather than during an individual patient encounter when possible (10).

Position 3: The ethical principle of respect for persons, including being sensitive to and respectful of cultural differences, is essential to short-term global medical experiences.

Physicians are obligated to provide culturally sensitive care that does not presume the correctness of any one culture's view (the physician's or the patient's) (10). Global health clinical activities in unfamiliar or underserved settings may make cultural differences more evident (Table [position 3]).

Cultural sensitivity respects individual and community choice, privacy, and truth telling. Respect is also a critical component of global health ethics frameworks that emphasize solidarity (collective obligations based on social reciprocity) (48, 49). Local communities may place greater importance on STEGHs as expressions of solidarity than on the tangible benefits they provide (50, 51).

Respect for persons is important in its own right; physicians must demonstrate not only cultural competence but also cultural humility (10). This entails being respectful of different cultural views about the role of medicine in society and its goals. At the same time, certain values may transcend cultures, and being abroad does not reduce their importance. For example, physicians abroad should respect individual patient choice, privacy, and confidentiality by not sharing images or other personal health information without consent, including on social media (52, 53).

Respect also helps facilitate the obligations stated in positions 1 and 2. By humbly respecting cultural differences, STEGH physicians can help mitigate power imbalances between local communities and sending organizations (which may have more financial resources) or between volunteer physicians and local communities (who may perceive the volunteer team as inherently “better” physicians). Either could inappropriately influence decisions about mutual benefit and fair resource allocation. One way to fulfill these obligations is to partner with local community members (and other overlapping global health efforts if applicable [54]) before, during, and after STEGHs (55, 56).

Respectful partnership helps ensure that efforts are consistent with community values and self-identified needs (position 1), which increases the likelihood of lasting benefit (Table [position 3, scenario B]). Finally, partnership reveals burdens on the host through ongoing dialogue (some burdens may not be readily apparent to STEGH participants) and is also necessary for difficult discussions about fair resource allocation (position 2).

The physician's general orientation abroad should be one of a humble visitor who is respectful of cultural differences. However, physicians should not shirk their ethical duties and are “not required to violate fundamental personal values, standards of medical care or ethical practice, or the law” (10). For example, radical differences in how some cultures treat persons of different genders may cause a physician to wonder whether to conform, tolerate the treatment, try to change it, or even leave. Potential differences of such gravity must be elucidated and explored in advance of STEGHs. When such differences do occur, physicians should reach out to trusted mentors and peers in their home country, at the sponsoring organization, or in the local community to learn how best to respond.

Position 4: Predeparture preparation is itself an ethical obligation. It should incorporate preparation for logistical and ethical aspects of STEGHs, including the potential for ethical challenges and moral distress.

Many ethical guidelines and recommendations exist for STEGHs (2, 4, 6, 12, 28, 57–60). Predeparture training has been (61) and continues to be (62) ethically necessary to help physicians avoid some of the ethical pitfalls of short-term global health work (63).

Organizations that sponsor or support STEGHs may be primarily responsible for predeparture training. It should be tailored to the community where the experience will occur. Recommended topics include logistics (such as immunizations and predeparture medical screening, travel insurance, and appropriate licensure); planning for adequate supervision (especially for trainees); personal safety (such as road and travel safety or personal protective equipment needs); and, where applicable, malaria prophylaxis or health information needed to stay well while abroad. Education in local health and health system issues, history, culture, language, and ethics is also essential (64, 65).

Physicians should explicitly prepare for the possibility of ethical dilemmas and moral distress before, during, and after STEGHs (22, 66–68). Moral distress can occur if physicians are unable to act in ways that are consistent with ethics and their professional values or if they feel complicit in a moral wrong (Table [position 4, scenario A]). Moral distress is frequently accompanied by a sense of powerlessness, which can lead to deprofessionalization, burnout, decreased quality of care, or lasting negative emotions (69).

Organizations sponsoring or supporting STEGHs should prepare physicians for the ethical challenges they are likely to encounter and should formally debrief the experience afterward (70) (Table [position 4, scenario B]). Individually, physicians can develop and apply strategies for moral resilience. Physicians should have a mentor in their home country (who may also be a fellow traveler) and in the local community to discuss ethical concerns before, during, and after the STEGH and may find moral resilience strategies (71, 72) helpful. For example, regularly assessing one's emotions and actions surrounding the experience of ethical challenges abroad, documenting them in a journal, and sharing them with peers could help build moral resilience (72). Mobile technology and increased connectivity make this possible in real time.

Self-paced online resources on a range of global health topics allow participants to supplement organizational preparation (73–75). More specific ethics preparation (76–79) and book-length manuals (80) are also available. Although many resources focus on medical trainees (medical students, residents, and fellows), “trainee” should be interpreted broadly. Any STEGH participant with limited global health experience should, for the sake of humility, consider themselves a trainee.

In the future, predeparture training for STEGHs should be improved to target seasoned clinicians and evaluate the effect of training and training method on participant knowledge, skills, attitudes, and beliefs, as well as the long-term sustainability and effectiveness of short-term programs (81). Greater attention to monitoring and managing ethical challenges for all STEGH participants, including partners abroad, is also needed.

Position 5: Physicians should participate with organizations whose STEGHs are consistent with ethics and professionalism as exemplified in these positions.

Physicians who engage with organizations that sponsor short-term global health work may not be in the best position to influence decisions about such issues as benefits or resource allocation. Nevertheless, by choosing organizations that sponsor ethical STEGHs, physicians can maintain their professional integrity, serve underserved populations, and indirectly influence how short-term global efforts are organized.

No single checklist exists for physicians to use in guiding their choice, although some have been proposed for medical trainees (82). Best practice guidelines and resources can help physicians articulate questions to ask before committing to a particular organization that sponsors STEGHs. Physicians are obligated to report problematic STEGH practices to the administrative leadership of the organization sponsoring the trip (and, if necessary, to medical licensing bodies when applicable). For-profit global medical volunteer or tourism organizations may require special scrutiny because of the tension between profit margins and maximal benefit to communities abroad.

Although STEGHs with long-standing partnerships with host communities and organizations abroad are preferred, there is no “one-size-fits-all” approach to ethics in STEGHs. For example, natural disasters or severe pandemics may pose additional or different ethical challenges. Therefore, evaluation must also be sensitive to local context and needs. Short-term experiences in global health may initially not be fully sustainable (due to uncertain funding, local political circumstances, or other factors), but they may lead to sustainable, partnered efforts in the future or be ethically justified by short-term benefits, such as relief of suffering in areas of violence or humanitarian crises. In contrast, more can reasonably be expected in terms of positive effect, capacity building, and sustainability from a program that has operated for several years in the same location.

Evaluation is therefore itself an ethical obligation. Organizations that sponsor STEGHs should evaluate their effect, and physicians should choose organizations that are committed to evaluation. Progress toward the goals described in these positions requires evaluation timelines and benchmarks that create accountability for STEGHs. These should include process measures (such as the number of patients seen or local community involvement), outcome measures (for example, local health outcomes, capacity built, or relationships developed), and full cost accounting. Ideally, evaluations should be designed and conducted by or with the local community.

Conclusion

Physicians who participate in STEGHs have ethical duties and special obligations to advocate for sustainable, mutual benefit; a fair and equitable distribution of resources; and partnership with and respect for the individuals and communities they serve. These principles inform physician decision making surrounding short-term experiences and can positively influence how STEGHs are done. By adhering to these principles, physicians can help maintain trust in a profession committed to protecting patient well-being and improving health equity at home and abroad.

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This article was published at Annals.org on 27 March 2018.

† Nonauthor contributor.

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4 Comments

Chester B Good, N Randall Kolb, Lindsay Nakaishi, Mark Meyer

UPMC Helath Plan, UPMC Family Medicine Global Health Track

April 19, 2018

Ethical Obiligations are Important, but should not Dissuade Physicians from Participation in Short-term Global Health Experiences

The Position Paper of the American College of Physicians (and associated editorial) on ethical obligations regarding short-term experiences in global health (STEGH) is timely and appropriate (1,2). However, as physicians deeply involved in a clinic in Honduras (Shoulder to Shoulder Pittsburgh/San Jose,www.shouldertoshoulderpgh.org) which serves as a STEGH site for medical trainees and practicing physicians, we are concerned these guidelines might overly discourage participating in STEGH.
All five of the core positions from the ACP are explicated and embedded in a well-established, evidence-based medical-community development strategy known as Community Oriented Primary Care (COPC) (3). The COPC model revolves around the community’s resources and needs. As each community is unique, this framework requires engagement with the community before developing programs, and informs proper development over time. The COPC model facilitates defining the community’s health priorities. It sustainably and ethically addresses disparities.
Our partnership began 18 years ago with a small Honduran community whose health priorities were gleaned after more than 30 hours of direct discussion with community leaders during our initial two-week brigade. We have returned to the same community with medical teams at least twice a year since, applied the COPC model and built a water purification system, feeding program for undernourished children, and a locally run healthcare clinic with 8000 patient visits annually. Currently, University of Pittsburgh medical trainee STEGH participants use COPC to collaborate with local partners to address preventative well child care, chronic disease management, and mental health. We have sought to be thoughtful and deliberative in our program development and to be consistent with the ethical obligations of STEGH. However, it took many years to get to where we are today, and it has been a learning process. The position paper should serve as a guide for STEGH programs to follow, but should not discourage those seeking to enter a relationship with global health partners.
Finally, we would posit that the position paper ignores one important aspect of the ethics of STEGH- that is, where STEGH is combined with faith based medical service. We understand the attractiveness of the arrangement (particularly since much of our funding comes from local churches). However, we believe that combining these efforts together raises another tier of potential conflicts of interest. As such, we have carefully avoided combining medical brigades with religious brigades in our Honduran partner village to reduce the risk of any perception of quid pro quo care relationships.

1. DeCamp M, Lehmann LS, Jaeel P, Hortwitch; ACP Ethics, Professionalism and Human Rights Committee. Ethical obligations regarding short-term global health clinical experiences: an American College of Physicians position paper. Ann Intern Med. 2018. [Epub ahead of print]. doi:10.7326/M17-3361
2. Farquhar C, Nduati RW, Wasserheit JN: Ethical obligations in short-term global health clinical experiences: the devil is in the details. Ann Intern Med. 2018 [Epub ahead of print]. doi:10.7326/M18-0566
3. Gofin J, Gofin R, and Stimpson JP. Community-oriented primary care (COPC) and the Affordable Care Act: An opportunity to meet the demands of an evolving health care system. J Prim Care & Comm Health. 2015;6:128-133.

Dr. Mitch Brinks, Dr. Justin Denny, Dr. Sara Schwanke Khilji

The Oregon Health & Science University, Global Southeast Asia, Oregon Health & Science University, Portland, Oregon, USA

April 27, 2018

Ethical Standards Supporting Quality STEGH: A Case Study in Myanmar

We applaud the recent publication by Dr. Decamp and colleagues, “Ethical Obligations Regarding Short-Term Global Health Clinical Experiences (STEGHs): An American College of Physicians Position Paper” . While Western ethical frameworks may not be generalizable globally , DeCamp et al. address an important gap regarding ethical considerations in clinical international health experiences for physicians .

In their editorial, Farquhar et al. ask how physicians can determine which organizations meet ethical standards. Until objective measures are developed, we must rely on organizations to share information from their experience with STEGHs. As such, we offer a brief summary of the authors’ experience developing a collaboration between Mandalay Eye Hospital (Myanmar), Tipitaka Eye Hospital (Myanmar), and the Casey Eye Institute (CEI) (U.S.A.), to evaluate alignment with ACP positions for STEGHs.

Position 1. The partnership’s mission statement, “Reducing preventable blindness in Southeast Asia through education, research, and delivery of care” and linked goals and objectives clarify for participating physicians their ethical obligation to, first and foremost, improve the well-being of the host community. STEGHs meet host, partner, and oversight body ethical standards; monitoring care outcomes is required.

Position 2. The partnership develops strategies in concert with informed and representative local health leaders, with the fundamental goal of achieving leaders’ long-term vision. Comprehensive, coordinated discussions and regularly scheduled process evaluations are integral to each program. Consultation with oversight organizations, relevant NGOs, and scientific guidelines ensures equitable, sustainable, and effective programs.

Position 3. Myanmar leaders supervise program monitoring and advise best cultural practices. Regular bidirectional visits enhance understanding and essential in-person communication. Consistent site visits strengthen program identity and help local partners invest themselves, providing balanced leadership.

Position 4. Preparations include individual, group, and cultural liaison discussions of potential logistical and ethical challenges. During STEGHs, support is readily available from both the hosting and sending site. Post-visit debriefs evaluate and address distressing challenges and improve preparation for future teams.

References:

DeCamp M, Soleymani Lehmann L, Jaeel P, Horwitch C. Ethical obligations regarding short-term global health clinical experiences: An American College of Physicians position paper. Ann Int Med 2018 Mar 27 [epub ahead of print].
2 Stonington S, Ratanakul P. Is there a global bioethics? End-of-life in Thailand and the case for local difference. PLoS Med 3(10):e439.
3 Farquhar C, Nduati RW, Wasserheit JN. Ethical obligations in short-term global health clinical experiences: The devil is in the details. Ann Int Med 2018 Mar 27 [epub ahead of print].

Riley G. Jones MD MSc MSc

Global Health Fellow, University of Florida

May 24, 2018

Ethics in global health- the definitions matter

I read the ACP position paper on ethics in short-term global health clinical experiences by DeChamp and colleagues (1) with much enthusiasm. While the authors do a decent service in putting forth a set of guidelines, I was disappointed to see their assertion that “global health… emphasizes vulnerable populations in underserved settings” and then goes on to cite Koplan et al. (3) before going on to say, “As used here, ‘experiences in global health’ refers to circumstances where physicians from high-income countries travel to low- or middle-income countries or to underserved areas in high-income countries”. The authors seem to have misunderstood the definition put forth by Koplan et al. who don’t emphasize vulnerable populations or underserved settings but instead “emphasizes transnational health issues, determinants, and solutions.” Though important to minimize neo-colonialism in these experiences, the loss of perspective engendered by the rich-poor assumption, as opposed to the broader Koplan definition, fails to recognize the interplay of multiple power imbalances and, for example, the not inconsequential influence that a less-than-benevolent host government may have over the visiting practitioner and communities. Although “global health” has become vernacular for re-branded tropical medicine, medical missions, or low-resource medicine, the discipline is certainly larger than that. Tackling issues such as pharmaceutical evergreening, TRIPS Plus, the opioid epidemic, climate change, viral sovereignty, the political exploitation of natural disasters, resource conflicts, healthcare infrastructure rebuilding in fragile & post-conflict states, rape as a weapon of war, drone warfare, or the global refugee surge do not fit well into an ethics discussion that misunderstands the discipline of global health as the juxta-socioeconomic aspect of medical voluntourism. The Koplan et al. definition has been widely accepted partly because of its effectiveness at differentiating global health from other disciplines such as international health, public health, or tropical medicine. The distinction does matter to practice beyond the academic discourse- an incomplete understanding of what is global health, and what is only a part of it, can ultimately undermine careful efforts to practice equitably and ethically.
While the ethical positions are welcomed, proper representation of the referenced definition and discipline of global health, even without a comprehensive review of the ethical challenges inherent in global health, is important. This is true not only when considering the influence which the ACP Position Paper is likely to carry, but also to better equip practitioners for engaging patients and communities in constrained environments with multiple stakeholders.

Riley G. Jones, MD, MSc, MSc
Global Health Fellow, University of Florida
Gainesville, Florida

Disclosures: the author has disclosed no conflicts of interest

References:
1. DeChamp M, Lehmann LS, Jaeel P, Horwitch C; ACP Ethics, Professionalism, and Human Rights Committee. Ethical obligations regarding short-term global health clinical experiences: an American College of Physicians position paper. Ann Intern Med. 168(9):651-657. [PMID:29582076] doi: 10.7326/M17-3361.
2. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993-5. [PMID:19493564] doi:10.1016/S0140-6736(09)60332-9.
3. Medecins Sans Frontieres. MSF History. Accessed at http://www.msf.org/en/msf-history on 23 May 2018.

Matthew DeCamp, MD, PhD, Lisa Soleymani Lehmann, MD, PhD, Pooja Jaeel, MD, and Carrie A. Horwitch, MD, MPH

Johns Hopkins, VA Washington, DC, Harvard, UCSD

June 20, 2018

Author's Response

IN RESPONSE: We are grateful for the comments generated by American College of Physicians (ACP) Position Paper on Ethical Obligations Regarding Short-Term Global Health Clinical Experiences.
We applaud Dr. Brinks and colleagues for their work in Myanmar and appreciate its relationship to the ACP’s positions. We agree that organizations have an ethical obligation of transparency to share sufficient information with physicians to aid their decision-making about participation. While we currently lack rigorous, objective metrics, we hope this changes over time. For example, a tool for evaluating a short-term global health program was developed – with input from the local community – to assess costs, health impact, and sustainability (among other parameters).(1) Evaluative efforts should be supported and expanded to include measures relevant to all five ACP positions.
Dr. Good and colleagues worry that the ACP positions might dissuade physician participation in global health. Our intent is not to dissuade but to encourage physician participation in programs that meet basic ethical obligations. The flexibility intended by our statement that “there is no ’one-size-fits-all’ approach to ethics” would likely apply to the program maturation Dr. Good et al. describe in Honduras. Still, we emphasize that programs should progress based upon timelines and benchmarks described in the ACP positions. We also agree with Dr. Good et. al that organizations should be transparent regarding their mission and funding. Potential conflicts of interest need to be identified and should not interfere with appropriate medical care by volunteers.
Dr. Jones is concerned that we misunderstood Koplan et al.’s definition of global health and thus fail to recognize certain multifaceted ethical issues in global health work. Koplan et al.’s complex definition also states that global health prioritizes “achieving equity in health for all people worldwide” and shares with public and international health a “concentration on poorer, vulnerable, and underserved populations.”(2) The position paper did not propose a comprehensive theory of global health ethics. Circumscribing our definition allowed us to focus on short-term experiences in global health (STEGHS) and medical care delivery within the broader domain of global health. This is an area where ACP and its Ethics, Professionalism, and Human Rights Committee have relevant expertise (with additional input from the International Council and Volunteerism Committee). Nevertheless we agree that recognition of factors such as power imbalances, armed conflict, and governance concerns are important components of predeparture preparation.
1. Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res. 2008;8:121. [PMID: 18518997] doi:10.1186/1472-6963-8-121
2. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993-5. [PMID: 19493564] doi:10.1016/S0140 -6736(09)60332-9.

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Position Papers |1 May 2018

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper Free

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