Ethics/residents' perspectiveEthical Challenges and Considerations of Short-Term International Medical Initiatives: An Excursion to Ghana as a Case Study
Introduction
Medical students, physicians, nongovernmental organizations, and military personnel have participated in short-term international medical initiatives for decades. The increased ease of transport and interest in international endeavors have only served to increase the numbers of people traveling and locations visited. In fact, by 2004, 22.3% of US medical students had completed an international educational experience,1 and by 2008, 47% of accredited MD-granting medical schools had established initiatives, centers, institutes, or offices of global health.2 Furthermore, the field of emergency medicine has also seen a recent burgeoning of international interest, research, and collaborations accompanying the development and recognition of the specialty in more than 30 nations.3, 4, 5, 6, 7 Ethical quandaries frequently pervade the practice of medicine in the developing world by visiting medical personnel and are exacerbated by factors inherent in what are frequently brief stays. Efforts to discuss the ethical challenges of short-term international medical assistance thus far have been relatively sparse. This article will focus on the ethical subtleties that underlie our well-intentioned actions abroad, through the lens of a recent excursion to the eastern region of Ghana. Examples of ethical challenges that will be explored in the following pages include the difficulties of obtaining consent and administering appropriate medical interventions in the setting of language and cultural differences, the challenges of using limited or “substandard” medication or equipment in austere resource-poor environments, the possibility for harm when treatments are provided without opportunity for follow-up, the normative importance of pursuing sustainable projects, and the risks of allowing amateurs or trainees to practice medicine without the same oversight they would have within the United States.
Suchdev et al8 put forth a model for sustainable short-term international medical trips that identifies the following 7 areas of focus: developing a clear mission, collaborating with the local community, educating travelers and the local community, making the commitment to serve the needs of the community, engaging in teamwork, having sustained capacity building, and developing a mechanism of periodic evaluation. Building on the model by Suchdev et al,8 this article provides further detail and additional guidelines that should be considered before each international medical initiative, including effective communication and cultural sensitivity, contextually relevant use of resources and triage, the avoidance of chronic care medicine and elective surgery without appropriate follow-up, a focus on sustainability, and the importance of humility and oversight.
Section snippets
Principles of Biomedical Ethics
In any conversation concerning biomedical ethics, it is important to recognize 4 major principles: respect for persons, beneficence, nonmaleficence, and justice. These principles derive from “a set of moral norms that bind all [morally serious] persons in all places.”9 They serve as the basis for US federal regulations governing the treatment of human subjects, as well as for internationally recognized documents, including the Belmont Report, the Declaration of Helsinki, and the Council for
Culture and Language
Communication breakdowns and cultural differences are ubiquitous. Indeed, there are more than 46 million people in the United States who do not speak English as their primary language; this population is less likely to receive the care they need, is less likely to be compliant with treatment regimens, is at greater risk of experiencing medical errors, and has been the subject of recent calls for research to more rigorously understand how language affects care.11 Similarly, participants in
Conclusion
Increasing numbers of people are participating in short-term international medical initiatives. These efforts have been successful in providing much-needed medical services to populations with little to no access to health care. These well-intentioned participants face significant ethical challenges and are still without a systematic and practical ethics framework to address these issues.34 This article seeks to contribute to the discourse through examining 5 major ethical considerations and
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section editor: Debra E. Houry, MD, MPH
Supervisng editors: Suzanne L. Lippert, MD, MS; Donald M. Yealy, MD
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported in part by a grant from the University of Virginia Medical Alumni Association; funding also received from the University of Virginia School of Medicine.
Publication date: Available online August 21, 2009.
Reprints not available from the author.