AMA Journal of Ethics^®

A large international nongovernmental organization (INGO) health project shutters its doors in sub-Saharan Africa, with no advance notice, leaving chaos in its wake. Key health stakeholders in the local community, including the Ministry of Health, are completely caught by surprise, and the questions (and recriminations) begin to mount: Who will treat the people formerly served by this INGO health project? Which organizations will provide jobs to the local health care workers, formerly earning above-market wages, who have been abruptly handed their walking papers? How could this lack of foresight by the INGO have occurred in the first place? Who is minding the shop, ensuring that the local health system is functional in the face of this pull-out?

This all-too-common scenario underscores the need for discussions about the ethics of INGO behavior in the context of global health and development [1]. This essay addresses the need for professional rules of conduct in the field of global health, drawing parallels to the related topic of professional conduct in medicine, and proffers a set of solutions to address these issues in the field. Given the dramatic rise of interest among physicians and medical students in global health service, such guidelines are critical to ethical and appropriate practice.

Professional Conduct in Medicine

The topic of professional conduct is well-traveled terrain in the medical literature. Some of these discussions focus on the delineation of the hierarchies and roles of health care professionals within health care organizations. Other normative discussions center on demarcating ethical from unethical clinician behavior. Certain professional boundaries are clear-cut, like a third rail that a physician or medical student should never touch (e.g., engaging in romantic relationships with patients), while other boundaries are murky. Consider, for example, whether a physician should provide personal funds so a patient can afford to buy medication [2] or how to ensure that medical students provide more benefit than harm during their short-term global health trips [3]. These discussions highlight the critical importance of establishing (and adhering to) core principles and codes of conduct in clinical medicine. Examples include discussion of the patient-physician relationship in the American Medical Association Code of Medical Ethics, which stipulates, “The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups…” [4]. Another oft-cited example is Beauchamp and Childress’s seminal work, Principles of Biomedical Ethics, which articulates four main principles of ethics in medicine—respect for autonomy, nonmaleficence, beneficence, and justice—and rules for engaging patients—veracity, privacy, confidentiality, and fidelity [5].

Professionalism in Global Health

A similar need exists at a macro-level for focused discussions about professional conduct in the field of global health, especially for INGOs working in global health and development. Global health is public or population health on a global scale. Public health is itself an amalgamation of fields; as one former World Health Organization leader put it, “public health assembles and then tries valiantly to assimilate a wide variety of disciplinary perspectives, from economists, political scientists, social and behavioral scientists, health systems analysts, and a range of medical practitioners” [6]. In 2009, Koplan et al. accommodated the aforementioned amalgamation of viewpoints in defining global health as

an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care [7].

Professional rules of conduct in global health are a worthwhile topic, first of all, because INGOs are so numerous. While not all INGOs are health-focused, many work to mitigate the effects of the social determinants of health in society and thus contribute to positive change in population health. Because of the enormous size and scope of their collective activities—all ostensibly pointing towards the public good—there is a need to articulate principles of ethical behavior for INGOs working in global health. Also, similar to the primacy in biomedical ethics of the integrity of the patient-physician relationship, it is crucial to ensure that INGOs working in global health are accountable to the communities they are serving according to their mission statements. Two of the authors of this essay have witnessed firsthand how this INGO-community trust can be violated in the absence of relevant rules of conduct. We recently operated a health program in Juba, South Sudan and saw many expensive INGO-purchased Toyota Land Cruisers dotting the landscape (no doubt the residue of a massive, rapid influx of foreign aid into the country), standing out in sharp relief against the abject human poverty we saw in the streets of this city. While hardly naive, we wondered aloud how the INGO community could so ostentatiously put its interests ahead of those of the poor and disenfranchised whom they had been asked to serve.

Toward a Pragmatic Framework to Define Professional Conduct in Global Health

Given the multidisciplinary nature of the field, it is appropriate to consider inter- and intra-professional conduct in global health. The good news is that several global initiatives have begun thinking through these topics. For example, the INGO Accountability Charter—comprising large INGO members such as Care and Oxfam—requires its members to report on several domains of accountability, such as “respect for human rights” (how the organization “advances” human rights), “ethical fundraising,” “diversity/inclusion,” and “professional management” (including how well it evaluates its own performance) [8]. Similarly, the Global Standard Project, composed of several large networks of civil society organizations (CSOs), is currently working towards a unified global standard for CSO accountability that will synthesize existing codes of conduct for organizations working in the field [9]. The World Association of Non-Governmental Organizations (WANGO) has developed its Code of Ethics and Conduct to guide good management practices for NGOs [10]. In the global humanitarian space, in 2014, Groupe URD, HAP International, People In Aid, and the Sphere Project promulgated nine “core humanitarian standards” [11] to guide ethical practices among humanitarian response organizations globally:

Humanitarian response is appropriate and relevant….
Humanitarian response is effective and timely….
Humanitarian response strengthens local capacities and avoids negative effects….
Humanitarian response is based on communication, participation and feedback….
Complaints are welcomed and addressed….
Humanitarian response is coordinated and complementary….
Humanitarian actors continuously learn and improve….
Staff are supported to do their job effectively, and are treated fairly and equitably….
Resources are managed and used responsibly for their intended purpose [11].

The themes underlying these initiatives—transparency, sustainability, equity—can all contribute to professional standards for organizations working in the broader field of global health. Had such principles been developed (and adopted), perhaps the INGO fiasco described at the beginning of this essay could have been averted—a rational exit strategy for the INGO could have been developed early on (sustainability), other INGOs or government agencies could have planned well ahead of time to address the gap in service provision left behind and strengthened the health care delivery system in the local area (transparency), and the local health care workers could have been paid market wages (equity). Downstream efforts to adhere to these principles in the delivery of global health programs will undoubtedly enhance the positive impacts of INGOs on communities’ health, make it possible to identify best practices for the field, and help organizations both understand and adhere to these principles.

Conclusions

As physicians and medical students increasingly work in global health, the onus is on all of us in the field to safeguard the covenant between health-focused INGOs and the communities they serve. Professional codes of conduct represent an important first step in promoting good practices and rejecting ethically dubious ones. The ideal guiding principles for INGOs in global health will focus on communities, prioritizing communities’ wants and needs over the INGO’s. Perhaps not coincidentally, these guiding principles are not dissimilar from Beauchamp and Childress’s seminal principles of physician-patient relationships: autonomy, nonmaleficence, beneficence, and justice [4].