This post is part of a series of discussions about ethical dilemmas in global health, with responses from one global health leader in the Global South and one in the Global North. Please leave us your feedback in the comments section below, and send us ethical dilemmas you would like to see discussed.
Compiled by Dr. Majid Sadigh, Trefz Family Endowed Chair in Global Health at WCHN and Director of Global Health at UVMLCOM, and edited by Mitra Sadigh, Editor of Global Health Diaries.
A wide range of ethical dilemmas is integral to global health experiences. Please comment on the following scenarios:
How should we screen potential program participants for what we perceive to be potential limitations to cultural integration? For example, should a history of depression or other psychiatric disease be exclusion to participation? Is it fair to exclude a highly motivated candidate based on our biases?
Dr. Winter: I recommend screening candidates for at-risk limitations and having frank discussions with them regarding their motivation and capacity to function in a culturally complex environment. If concerns remain, I would be in favor of risk assessment by a mental health expert, the candidate’s own psychiatrist or mental health specialist if possible. If the candidate is then cleared, I recommend putting together an explicit plan for how they can seek support and assistance while in the field. Although this seems somewhat intrusive, it comes down to a matter of their personal safety and potentially that of our other participants or their hosts.
Dr. Kalyesubula: I think the screening tool for participants should be standardized, and a candidate excluded from participation once considered not fit unless the host institution is briefed, ready, and able to give special attention to such a candidate.
Due to the shortage of medical personnel, global health elective participants often find themselves left unsupervised with patients. This situation is compounded by the fact that participants coming from the Global North may be viewed as more experienced or knowledgeable, and may lead to involuntary engagement in an activity that participants are not trained for. What are the possible solutions?
Dr. Winter: As part of pre-departure orientation, participants must be prepared for these situations and counseled not to act beyond their knowledge, training, or comfort level.
Dr. Kalyesubula: Global health partnerships should ideally have a knowledgeable coordinator/resource medical person who is willing to step in when such scenarios arise. If finances allow, a key person should fill this role in every collaboration. Alternatively, candidates can be paired with doctors-in-training along with the attending to help reduce the likelihood of such scenarios.
The program coordinators should also be selective when sending candidates to different wards and specialities. Students should always be advised not to exceed their limits and to maintain the same ethical standards in place at home. Global health teams should teach students some key basic skills based on their level of training to help minimize such scenarios.
Many women’s health issues are driven by cultural and social forces that global health participants may or may not be aware of, and some of which they may be encountering for the first time. Take for example, (1) a chaotic OB/GYN ward where multiple patients are delivering on the floor unattended, (2) a patient is dying from massive bleeding due to lack of blood transfusion, or (3) a patient has an infection from a self-induced abortion, or finally (4) a patient seeks treatment for a fistula she has been suffering from for several years. How do we help participants deal with these issues, reconcile associated cultural differences, and manage their emotional reactions?
Dr. Winter: While pre-departure discussion groups and scenario training may help attenuate the emotional response, there also needs to be an opportunity for venting, reflection, and self-examination of emotional response in real time in the field as outlined in the response to the previous question.
Dr. Kalyesubula: Proper preparation and orientation are key components of managing these issues, along with careful selection of candidates, as participants need to be able to handle such shocks of life that they are likely to encounter. These unfortunate scenarios are not due to cultural reasons, but rather a mere lack of resources. No one culturally or socially accepts this kind of treatment; it is just the circumstances. Advocacy should be played on the part of all concerned parties.
Many global health participants sometimes feel overwhelmed by the variety of challenges they face. How do we differentiate between those who need further encouragement and support, and those who are simply not fit for global health?
Dr. Winter: I don’t think that we presently have the tools to make this determination. The best we can do is use our existing tools including reflections, interviews, and evaluations by observers as discussed elsewhere. When there is sufficient concern that action such as removal from a clinical site is contemplated, the Director of Global Health should convene a committee of faculty involved in program administration to review the available evidence and come to a consensus conclusion. In order to avoid any appearance of bias or lack of due process, such a decision should not be made by a single individual.
Dr. Kalyesubula: Strict selection criteria as well as regular feedback sessions can help make this differentiation.