ETHICS IN GLOBAL HEALTH: BEYOND HIPPOCRATES

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ETHICS IN GLOBAL HEALTHBEYOND HIPPOCRATES
Scott Loeliger, MD, MS Mark Stinson Fellowship in
Global and Underserved Health Contra Costa Family
Medicine Residency Evaleen Jones, MD Child
Family Health International (CFHI) Stanford
University Medical School TUFH INTERNATIONAL
CONFERENCE Bogota, Colombia 30 September,
2008
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OBJECTIVES

• Review the historical context of ethics within
  medical training and practice.
• Understand the place of ethics within the new
  medical professionalism.
• Incorporate the concepts of ethical behavior and
  practice into service learning activities.
• Encourage open discussion about current
  controversies and new generation focus on global
  health work.

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Historical Perspectives

• Hippocratic Oath
• (4th Century BC)
• Universal Declaration of Human Rights (1948)
• The New Hippocratic Oath (1966)
• The Declaration of Alma Ata (1978)
• Declaration of Helsinki (1964-2004)
• Millennium Development Goals (2000)

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Ethical Principles

• Primum non Nocerum to Primum non Tacere.
• Physician Charter on Medical Professionalism.
• Healing in the context of Social Justice.
• Residents with Skills Helpful or Dangerous?

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Physician CharterAmerican Board of Internal
Medicine Foundation, the American College of
Physicians Foundation, and the European
Federation of Internal Medicine
1. Primacy of patient welfare Stresses
altruistic dedication to the well-being of the
individual patient. 2. Patient autonomy Urges
physicians to facilitate patient involvement in
treatment decisions. 3. Social justice Calls
upon physicians to work actively toward equitable
societal distribution of health care resources.
Medical professionalism in the new millennium
a physician charter. Ann Intern Med.
2002136243-6. PMID 11827500
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• The Physician Charter
• Physician Charter Construct for Medical
  Professionalism

Social justice
MP
Patient Autonomy
Patient Welfare
Erika Shimahra, Masters of Education, Stanford
University, 2006
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Embedding Ethics in Residency

• Formal learning and didactics.
• Pre-experience preparation.
• Consideration of ethics in underserved local
  communities.
• Understanding complexities of global realities,
  institutions, processes and programs.
• Self- study and self-reflection.

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Models of ServiceorService Learning

• Short term clinical work combined with tourism.
• Attachment to clinical research project.
• Longer term work with NGOs or Universities.
• Advisor/Teacher or Medical Corps?

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Conflicts in Conscience

• All done in the name of Hippocrates is not right.
• Physician centered paradigm can distort true
  health improvements.
• Resource poor areas require careful attention to
  appropriate strategies.
• Attention to the Immediate versus the
  Sustainable.

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THE BRAIN DRAIN

• We are going there, whos coming here?
• Raised expectations without means to correct
  health manpower deficiencies.
• True professional exchanges, joining the growing
  global debate (Global Health Workforce Alliance).

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Primary Care and the Medical HomeDo They Want
What We Want

• Translating Ours to Theirs.
• While working in health care, how to attend to
  social injustice and underlying factors of poor
  health.
• Training leaders, followers, co-conspirators or
  colleagues?
• Respect for emerging literature and research from
  abroad.

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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

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ARTICLES OF NGO CODE OF CONDUCT FOR HEALTH
SYSTEMS STRENGTHENING

• I. 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.

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Ethics and Research

• Global health research may have some ethical
  flaws.
• Interventions determined by narrow research goals
  may not be sustainable.
• Article 25 of Universal Declaration of Human
  Rights.
• WMA and Declaration of Helsinki.

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UNDERSERVED HEALTH CARE

• Think Global, Consider Local.
• Incorporate the Experience into Your Future
  Practice
• Work in Your Milieu to Integrate Service Learning
  into the Medical School and Residency Experience.
• In Your Medical Bag
• Stethoscope Check Ophthalmoscope-Check
  Sansome Guide Check Language Dictionary
  Check Ethical Guidelines-Check?

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CASE SCENARIOS

• 1 Filling In A Little Knowledge is a
• Dangerous
• 2 Vertical Projects We Only Do
• 3 Ignoring Bureaucratic Barriers
• 4 NGO/Institutional Short Time Work

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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.
• ONeil, E. Awakening Hippocrates A primer on
  health, poverty and global service. AMA, 2006.
  502 pp.