ETHICS IN GLOBAL HEALTH:ETHICS IN GLOBAL HEALTH:BEYOND HIPPOCRATESBEYOND HIPPOCRATES

Scott Loeliger, MD, MSMark Stinson Fellowship in Global and Underserved HealthContra Costa Family Medicine Residency

Evaleen Jones, MD Child Family Health International (CFHI) Stanford University Medical School

TUFH INTERNATIONAL CONFERENCEBogota, Colombia

30 September, 2008

OBJECTIVESOBJECTIVES

• Review the historical context of ethics within Review the historical context of ethics within medical training and practice.medical training and practice.

• Understand the place of ethics within the “new” Understand the place of ethics within the “new” medical professionalism. medical professionalism.

• Incorporate the concepts of ethical behavior and Incorporate the concepts of ethical behavior and practice into service learning activities.practice into service learning activities.

• Encourage open discussion about current Encourage open discussion about current controversies and new generation focus on global controversies and new generation focus on global health work.health work.

Historical PerspectivesHistorical Perspectives

Ethical PrinciplesEthical Principles

• Primum non Nocerum to Primum non Tacere.Primum non Nocerum to Primum non Tacere.

• Physician Charter on Medical Professionalism.Physician Charter on Medical Professionalism.

• Healing in the context of Social Justice.Healing in the context of Social Justice.

• Residents with Skills – Helpful or Dangerous?Residents with Skills – Helpful or Dangerous?

1. 1. Primacy of patient welfare:Primacy of patient welfare: Stresses Stresses altruistic dedication to the well-being of the altruistic dedication to the well-being of the individual patient. individual patient.

2. 2. Patient autonomy:Patient autonomy: Urges physicians to Urges physicians to facilitate patient involvement in treatment facilitate patient involvement in treatment decisions. decisions.

3. 3. Social justice: Social justice: Calls upon physicians to Calls upon physicians to work actively toward equitable societal work actively toward equitable societal distribution of health care resources. distribution of health care resources.

Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6. [PMID: 11827500]

Physician CharterPhysician CharterAmerican Board of Internal Medicine Foundation, the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the American College of Physicians Foundation, and the

European Federation of Internal MedicineEuropean Federation of Internal Medicine

The Physician Charter:• Physician Charter Construct for Medical ProfessionalismPhysician Charter Construct for Medical Professionalism

Social justice

PatientAutonomy

PatientWelfare

MP

Erika Shimahra, Master’s of Education, Stanford University, 2006

Embedding Ethics in Embedding Ethics in ResidencyResidency

• Formal learning and didactics.Formal learning and didactics.

• Pre-experience preparation.Pre-experience preparation.

• Consideration of ethics in underserved Consideration of ethics in underserved local communities.local communities.

• Understanding complexities of global Understanding complexities of global realities, institutions, processes and realities, institutions, processes and programs.programs.

• Self- study and self-reflection.Self- study and self-reflection.

Models of ServiceModels of Serviceoror

Service LearningService Learning

• Short term clinical work combined with Short term clinical work combined with tourism.tourism.

• Attachment to clinical research project.Attachment to clinical research project.

• Longer term work with NGO’s or Universities.Longer term work with NGO’s or Universities.

• Advisor/Teacher or Medical Corps?Advisor/Teacher or Medical Corps?

Conflicts in ConscienceConflicts in Conscience

• All done in the name of Hippocrates is not right.All done in the name of Hippocrates is not right.

• Physician centered paradigm can distort true Physician centered paradigm can distort true health improvements.health improvements.

• Resource poor areas require careful attention Resource poor areas require careful attention to appropriate strategies.to appropriate strategies.

• Attention to the Immediate versus the Attention to the Immediate versus the Sustainable.Sustainable.

THE BRAIN DRAINTHE BRAIN DRAIN

• We are going there, who’s coming We are going there, who’s coming here?here?

• Raised expectations without means to Raised expectations without means to correct health manpower deficiencies.correct health manpower deficiencies.

• True professional exchanges, joining True professional exchanges, joining the growing global debate (Global the growing global debate (Global Health Workforce Alliance). Health Workforce Alliance).

Primary Care and the Medical Primary Care and the Medical HomeHome

Do They Want What We WantDo They Want What We Want

• Translating “Ours” to “Theirs.”Translating “Ours” to “Theirs.”

• While working in health care, how to attend to While working in health care, how to attend to social injustice and underlying factors of poor social injustice and underlying factors of poor health.health.

• Training leaders, followers, co-conspirators or Training leaders, followers, co-conspirators or colleagues?colleagues?

• Respect for emerging literature and research from Respect for emerging literature and research from abroad.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

STRENGTHENINGI. 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 ResearchEthics and Research

• Global health research may have some Global health research may have some ethical flaws.ethical flaws.

• Interventions determined by narrow Interventions determined by narrow research goals may not be sustainable.research goals may not be sustainable.

• Article 25 of Universal Declaration of Article 25 of Universal Declaration of Human Rights.Human Rights.

• WMA and Declaration of Helsinki.WMA and Declaration of Helsinki.

UNDERSERVED HEALTH UNDERSERVED HEALTH CARECARE

• Think Global, Consider Local.Think Global, Consider Local.

• Incorporate the Experience into Your Future Incorporate the Experience into Your Future PracticePractice

• Work in Your Milieu to Integrate Service Learning Work in Your Milieu to Integrate Service Learning into the Medical School and Residency Experience.into the Medical School and Residency Experience.

• In Your Medical Bag:In Your Medical Bag: Stethoscope – Check; Ophthalmoscope-Check; Stethoscope – Check; Ophthalmoscope-Check;

Sansome Guide – Check; Language Dictionary – Sansome Guide – Check; Language Dictionary – Check; Ethical Guidelines-Check?Check; Ethical Guidelines-Check?

CASE SCENARIOSCASE SCENARIOS

#1 Filling In – A Little Knowledge is a#1 Filling In – A Little Knowledge is a

Dangerous…Dangerous…

#2 Vertical Projects – We Only Do…#2 Vertical Projects – We Only Do…

#3 Ignoring Bureaucratic Barriers #3 Ignoring Bureaucratic Barriers

#4 NGO/Institutional Short Time Work #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.