AMA Journal of Ethics^®

Abstract

Changes made in 2017 to the World Medical Association Physician’s Pledge strive to keep in step with geopolitical trends by addressing respect for patients’ dignity and autonomy and respect among colleagues. Health professions students should continue to proactively insist on patient care, research, and advocacy efforts that uphold human rights and the principles of beneficence, nonmaleficence, justice, and respect for autonomy regardless of a patient’s origins or locale. US students should enter clinical encounters, both domestically and abroad, with cultural humility but should hold institutions accountable for ethical violations committed or observed during immersion experiences. As part of global and cultural humility, students should also remain cognizant of their privileged position as international observers.

Physician’s Pledge and Immersion Experiences

In October 2017, the World Medical Association (WMA) General Assembly made key changes to its Physician’s Pledge. To the 2006 declaration addressing human rights and civil liberties, it added language on respect for the autonomy and dignity of the patient and a clause about respect between colleagues.¹ These additions are timely in light of the global ascendance of authoritarianism and the concomitant rise in human rights abuses over the past decade.² Then- WMA President Yoshitake Yokokura stated that the additions focus “more on important ethical principles not in the current version and not expressed explicitly.”¹ Students of the health professions from across the globe should use these additions to the WMA Physician’s Pledge as a robust foundation for their individual efforts in providing local patient care and conducting research when participating in international immersion programs.

How the pledge is interpreted will vary based on individual and geopolitical context, especially with respect to the infrastructure in which health care is provided. Regardless of location, all health professions students should insist on considering patients’ autonomy, human rights, and civil liberties as vital aspects of clinical encounters, professional decision making, and patients’ health and well-being. For students from the United States, this commitment means international patient care should not differ from provision of domestic standard of care with exceptions for local differences in resource limitations and respect for cultural diversity. Offering professional and ethical care of a high standard irrespective of international borders is a crucial opportunity to master, model, and advance culturally appropriate care. The opportunity to do so is also a privilege—one that should be considered, protected, and, most importantly, used to prevent the erosion of human rights and civil liberties. Toward that end, students should prioritize participation in advocacy and research that upholds and reinforces the values of the WMA Physician’s Pledge.

Respecting Patients’ Autonomy and Dignity

The WMA General Assembly added the line “I WILL RESPECT the autonomy and dignity of my patient” to its 2017 Physician’s Pledge.³ Addition of this ethical principle was made in the context of a regress in global human rights over the past decade.⁴ Consolidation of local political and global economic power in several large authoritarian nations⁵ has contributed to this relapse, and the rise of ethnocentric nationalism also plays a role.⁶ The addition to the Physician’s Pledge suggests awareness of these changes and strengthens the profession’s commitment to providing a global high standard of patient care. While the global medical community has paid significant attention to Ebola in the Democratic Republic of Congo, Zika in Latin America, and air pollution in many industrial and industrializing countries, less medical attention has been devoted to the concomitant suffering of civilians, journalists, and activists in Syria, Yemen, Afghanistan, Myanmar, Russia, Guatemala, and China. Proactive involvement in crises affecting human rights and civil liberties directly relates to respect for autonomy and dignity and should accompany attention to traditional health issues. Professional groups such as Physicians for Human Rights provide a framework for physician involvement in advocacy and research that addresses this gap.⁷

The WMA Physician’s Pledge rightly discourages use of health professions expertise to violate human rights and civil liberties.³ Passive avoidance, though, is a poor excuse for beneficence. Such a practice is akin to limiting health care to secondary and tertiary prevention. Our efforts should not just not violate human rights and civil liberties but should proactively support the use of medical knowledge to protect and advance them.

Fulfilling the Updated WMA Physician’s Pledge

Clinical work abroad. Respect for patient autonomy and beneficence are not like visas, limited to certain passports and forbidden from crossing certain borders. As presumably universal ethical principles, they transcend borders. As such, domestic advances in human rights and civil rights should provide momentum for international health progress. US students should express the intention of following, and should model their behavior on, the Physician’s Pledge when learning in international settings. In clinical encounters overseas, students should treat patients with the same respect, afford them the same autonomy, and abide by other ethical principles that they would draw upon when practicing in their own country. Domestic standards vary internationally, and students can refer to the Hippocratic Oath,⁸ the Physician’s Pledge,³ and the Universal Declaration of Human Rights⁹ for guidance.

Practical application of these principles can seem daunting to students, so we offer some suggestions. Students should decline to participate in so-called medical tourism—a term suggesting that international patients are mere objects of education or even entertainment for leisure travelers—or programs that do not conform to the standards outlined above, and they should also discourage others from doing so. When abroad and involved in patient care, students should respectfully elicit and consider perspectives of their host-community colleagues and supervisors on ethical issues, recognizing that cultural differences and resource limitations can inject ethical complexity into clinical encounters and community or colleague interactions. Additionally, students should conscientiously note the promulgated policies and actual practices of their host organizations.

Without fail, patients’ human rights and civil liberties should be integral parts of clinical encounters and professional decision making. Taking these into account means (1) ensuring adequate translation services, (2) guaranteeing respect for autonomy and informed consent, and (3) demanding institutional accountability. Learning opportunities that do not observe these standards should be identified as unethical, interrogated from an ethics perspective, and improved for the better as soon as possible.

Transparency, accountability, and cultural humility are also important. Students should seek to clarify their role in international immersion experiences before departure, upon arrival, and in each encounter. Bidirectional accountability between institutions should be established to ensure that expectations are appropriate. Expressing global and cultural humility and responsibly and skillfully responding to ethical pluralism are essential skills for health professionals, especially those practicing in global settings. If conducted justly, international health care work can be an enriching training experience for all stakeholders.

Advocacy and research. The scope and focus of student research outside students’ countries of training is underinvestigated. Anecdotally, since students often work as research assistants under host-nation or home-institution mentorship and oversight, their global health research has predominantly focused on understanding and preventing disease, and their ability to direct a research agenda is limited. Some students seek participation in research on global health education, infrastructure, and access. The possibility of partnering with willing mentors who engage in research that can inform human rights advocacy, global health ethics, and global health care policy and that can contribute to illuminating neglected topics is readily overlooked. Informed, pertinent, and cooperative inquiry not only is consistent with the WMA’s Physician’s Pledge to respect colleagues and share knowledge and expertise but also might be a way for international medical students to contribute to upholding human rights and civil liberties when outside their home countries.

As with patient care, students can advocate for—and should only participate in—research that adheres to the standards mentioned above and the World Health Organization’s Code of Conduct for Responsible Research.¹⁰ When conducted ethically, student scholarship can catalyze conversations, shape dialogue, and build evidence that supports local patients and host-nation clinicians as well as human rights and civil liberties. Fruits of collaborative research should be a foundation for advocacy. As has been argued in the United States, collecting evidence is the most scientific way to approach advocacy, and blocking evidence building has been employed to obstruct progressive policy formation and implementation.¹¹

Conclusion

Recent additions to the WMA Physician’s Pledge clarify ethical duties of health professions students and clinicians and provide explicit support for all patients’ dignity and autonomy. These additions should be reinforced by clinicians’ promoting human rights and civil liberties. Specifically, health professions students everywhere should act both domestically and internationally to express respect for patient autonomy, uphold beneficence, defend justice, and practice cultural humility. In domestic and international settings, to the safest extent possible, students should use their voices to hold institutions accountable for violations to human rights or civil liberties that undermine respect for patients’ dignity and autonomy.