AMA Journal of Ethics^®

Abstract

Opportunities to study and practice health-related professions internationally offer transformative benefits for patients, educators, and students. Institutions and educators should model ethical behavior and set examples for global health trainees. Toward this end, it is imperative that universities engaging in international immersion experiences ensure that principles of respect, beneficence, and justice are upheld.

Case

A medical school in the United States has recently started advertising what it calls a “global health immersion” program to prospective applicants. The program partners with a free clinic in a South American country and is tremendously popular, often regarded by students as one of the best experiences of their medical school careers and as one of the College of Medicine’s best experiential learning offerings.

Although the program attracts abundant positive attention for the College of Medicine, the partner clinic struggles to meet the health needs of local community members and is always short on supplies. Housing and teaching students from the United States requires resources and efforts by local clinicians and residents. Increasing numbers of students and faculty returning from recent trips have expressed concern not only for patients but also for local clinicians who work with limited resources—electricity and clean water, for example—that are stretched even more thinly by their presence.

The College of Medicine provides small scholarships from donors who subsidize US students’ cost to travel to the partner site. Money from these sources has never been used to compensate local people for their on-site mentorship or administrative support or to contribute to the clinic’s costs of caring for local people. Nor have students from the local clinic population who are interested in medicine ever been invited to participate in any College of Medicine programs in the United States. Students and faculty continue to express concern about the hardships their trips seem to impose on locals at the partner site and about what seems like a lack of reciprocity on the part of the College of Medicine to return the favor by offering comparable educational opportunities to its international clinic partners. Students and faculty have begun questioning the goals of the “medical mission,” how those goals get defined, and by whom.

Commentary

As our world becomes more interconnected and interdependent, short-term experiences in global health (STEGHs) during educational degree programs are increasing in popularity across health professional fields.^1,2,3 STEGHs are defined as international experiences that are usually short in duration (1-30 days) and incorporate elements such as clinical care, public health education, research, or public health practice.¹ The benefits of STEGHs are well documented in the literature and mainly focus on the positive experiences of students at all levels of clinical and public health education, including medical residents.^4,5 STEGHs not only aim to prepare students for longer-term opportunities abroad, but also strive to prepare them to work with underserved populations at home.^2,4 However, attention has also been drawn to student culpability in ethical violations—ranging from cultural insensitivity to potentially life-threatening omissions—during STEGHs.² Examples of such unethical behavior include students overstepping their capabilities in practicing medicine abroad and students undermining local professionals.^2,6,7,8

In contrast to ethical concerns regarding student behavior, the case above illustrates an institutional-level ethical concern. The manner in which the international program was designed and implemented by the College of Medicine resulted in benefits for its students and for its own reputation at the expense of the host community. Although alarming, such failures of ethical global health practice in training programs are likely not all that unusual. Possible reasons for these violations include the lack of awareness or willful neglect of ethical principles in global health, conflicts of interest among individuals and institutions based in both sending and host communities, and a lack of accountability to ensure that ethical principles are upheld.⁹ Accordingly, institutions and educators should model ethical behavior for global health trainees and follow ethical guidelines for STEGHs.

Goals and Guidelines

Goals of STEGHs should be determined through a collaborative effort between the sending and host institutions.^3,10 Intentions of all stakeholders—including sending and host institutions, students, faculty, staff, patients, sponsors or donors, and others—need to be examined when setting goals of international educational experiences. Ethical dimensions of the learning experience should also be discussed. The Association of American Medical Colleges,¹¹ the Working Group on Ethics Guidelines for Global Health Training,¹² and others¹ have published guidelines for community engagement, internships or experiential learning abroad, and electives. These published principles and guidelines call for:

1. Gathering input from partner institutions about directing and implementing projects;
2. Evaluating educational, community, and health outcomes;
3. Motivating sustainability and continuity of programs;
4. Maintaining transparency in how students are prepared for their experiences;
5. Committing to reciprocity and mutual benefit;
6. Nourishing opportunities for program participants to connect and collaborate over time;
7. Confirming that the program does not drain resources from local operations;
8. Maintaining program compliance with local cultural, political, and financial norms.

STEGHs that have a primary objective of exposing students and faculty from high-income areas to challenges faced in low- and middle-income areas should ask how they improve the health of the host population.^13,14 Additionally, STEGHs should be asking: How (and by whom) should ethics and justice questions about offering educational opportunities to relatively well-funded students in underresourced areas be identified, articulated, and addressed?

Ethics in Program Development

It is the duty of all individuals and institutions to uphold ethical principles in STEGHs at the program development stage and throughout the partnership. As discussed above, there are several published guidelines on ethical codes of conduct with respect to STEGHs^1,11,12; principles that guide biomedical research ethics can also be useful in articulating partnership goals and identifying ethical concerns. The Belmont Report, a governing reference for institutional review boards, was published in 1979 in response to serious ethical lapses.^15,16 The Belmont Report’s explicit focus on respect for persons, beneficence, nonmaleficence, and justice can serve as a model for developing ethical guidelines for STEGHs.   

Respect for persons. STEGH trainees will observe significant disparities in resources that can influence power dynamics in a partnership.^10,17 Partners with fewer resources tend to have diminished autonomy and power. Wealthier institutions have ethical responsibilities to acknowledge and ameliorate these vulnerabilities. Key stakeholders should clearly identify relevant disparities to ensure that open communication can occur and to try to minimize harms from powers imbalances.

Beneficence. While sending institutions benefit from learners’ opportunities, benefits for host institutions are less often considered.¹³ Host institutions can benefit from STEGHs through exchanges that develop more opportunities for host faculty members’ professional development, host student engagement, and more support for research and program development opportunities. Ensuring that resource disparities are identified and ameliorated will allow programs to maximize mutual benefits.

Nonmaleficence. After identifying resource disparities and agreeing upon how to ameliorate them, collaborating institutions should ensure that students are never put in a position in which they would be expected to work beyond their capabilities,⁸ that students understand their limitations and communicate these limitations to the host institution, and that expectations for student conduct are clarified. Furthermore, STEGHs should compensate host faculty equitably for mentoring students from sending institutions, whether through financial or nonfinancial means. Finally, sending institutions should never undermine the authority of local professionals.^13,18,19

Justice. Although every effort should be made to ensure that STEGHs provide equal benefits for the sending and host institution,¹⁸ it is possible that each institution will not have the same experience of the partnership. Thus, it can be helpful for both institutions to agree upon criteria according to which they would deem a partnership equitable. This kind of agreement could take the form of financial reimbursement, curriculum development or implementation, clinical services, or other compensation.

When ethical concerns about a new or continuing partnership arise, they should be articulated to the office that supports the STEGH program and, if necessary, to higher administrators in the university. Without accountability, it is possible that even well-intentioned programs could miss important considerations in educational program development or management. Ethical concerns need to be addressed immediately at each level of program administration, including at the individual level, program level, and institutional level.

What Should the College of Medicine Do?

We propose the following short- and long-term recommendations to ensure that the program in the case above is conducted ethically.

Short-term. The College of Medicine should initiate communication with the host institution to identify the STEGH program burdens and benefits for both parties^12,15,18 and then address and resolve any shortcomings in the equitable sharing of those burdens and benefits. Collaborators should also clarify the goals and objectives of the STEGH,^12,15,18 which should be not only mutually beneficial but also compatible. The phrase medical mission used by students and faculty at the College of Medicine implies that the program will achieve better health for locals. Both the College of Medicine and the host institution should acknowledge that the college’s interest in educating its students (through exposure to the host community) could conflict with health interests of local patients. The College of Medicine should clarify to STEGH students that the purpose of their trip is educational, not clinical-service oriented. Furthermore, the College of Medicine must ensure student understanding of shared goals in the partnership and dispel commonly held misconceptions, especially the view that people living in poverty benefit from any health care even if it is inadequate.²⁰ Because STEGHs are collaborative educational initiatives, expectations regarding program goals, student learning objectives, and the limits of students’ participation in caregiving must be clearly articulated and agreed upon by program leaders and communicated to all faculty and students at both sending and hosting institutions.

Long-term. The College of Medicine should cultivate a culture of knowledge sharing in which both institutions share challenges and solutions, actively pursue bidirectional exchanges, and agree upon mutually desired outcomes when seeking future international partnerships. The College of Medicine should incorporate a process for reviewing whether the STEGH has been or is being implemented ethically. Finally, the institution should advocate for accountability processes for STEGHs at all US-based programs.

Conclusion

The College of Medicine in the case would benefit from STEGHs designed and evaluated in an ethical and collaborative manner. Ensuring that institutions adhere to ethical principles in global health will increase the likelihood of achieving the goals not only for better global health education but also for more sustainable and substantial health care for underserved patients.