Appendix B
Ethical Issues in Foreign Health Workforce Assistance Programs

Presentation to the IOM Committee on December 2, 2004

Daniel Wikler, Ph.D.

Department of Population and International Health

Harvard School of Public Health

INTRODUCTION

Daniel Wikler is a professor of ethics in the Department of Population and International Health at Harvard School of Public Health. His presentation was designed to articulate ideas that were put forth during the course of the two-day meeting of the Committee on the Options for Overseas Placement of U.S. Health Professionals. He spoke about moral and logistical issues involved with sending U.S. health professionals overseas. These issues involved more questions than answers mainly because the ethical rules, guidelines, criteria, and evaluation would all depend on how the program is structured. Dr. Wikler began his presentation by describing two categories of ethical questions.

TESTIMONY

What I am doing here is more articulating ideas that have been in the air for a couple of days, rather than laying down any startling new ideas. First of all, wouldn’t it be nice if we could say that the idea of a volunteer corps going all the way to Africa or to another very poor, struggling country to help with PEPFAR, help with relief of AIDS, doesn’t need an ethical justification, doesn’t need an ethics talk? If ever there was something that was obviously, self-evidently justified, this is it. It would be nice, but it is not true. So here are two categories of ethical questions. There are many more, but time doesn’t allow.

The first has to do with questions that face this committee. They are



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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Appendix B Ethical Issues in Foreign Health Workforce Assistance Programs Presentation to the IOM Committee on December 2, 2004 Daniel Wikler, Ph.D. Department of Population and International Health Harvard School of Public Health INTRODUCTION Daniel Wikler is a professor of ethics in the Department of Population and International Health at Harvard School of Public Health. His presentation was designed to articulate ideas that were put forth during the course of the two-day meeting of the Committee on the Options for Overseas Placement of U.S. Health Professionals. He spoke about moral and logistical issues involved with sending U.S. health professionals overseas. These issues involved more questions than answers mainly because the ethical rules, guidelines, criteria, and evaluation would all depend on how the program is structured. Dr. Wikler began his presentation by describing two categories of ethical questions. TESTIMONY What I am doing here is more articulating ideas that have been in the air for a couple of days, rather than laying down any startling new ideas. First of all, wouldn’t it be nice if we could say that the idea of a volunteer corps going all the way to Africa or to another very poor, struggling country to help with PEPFAR, help with relief of AIDS, doesn’t need an ethical justification, doesn’t need an ethics talk? If ever there was something that was obviously, self-evidently justified, this is it. It would be nice, but it is not true. So here are two categories of ethical questions. There are many more, but time doesn’t allow. The first has to do with questions that face this committee. They are

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS questions in the design of the program. I don’t think you can talk about ethical criteria unless you have some idea of what the program is. I have to confess, after two days, I really don’t know what the program is meant to be. I have a feeling that I know where the committee is going. I have a feeling that [the funding organizations] had something else in mind. So what results, we will see. I was thinking, what are the models? One model is the groups that do the emergency humanitarian intervention. There is an earthquake, and 75 aid groups all show up. They start pointing fingers at each other saying “We’re the only sincere people here. You don’t know what you are doing. You are just trying to increase your donations.” They start fighting over who gets credit for what. Nothing is coordinated. There are major lapses. No one is keeping score. There is no one in charge, so there is no overall plan to make sure that all the bases are covered. So what have you got? You have some really wonderful agencies that do wonderful work and try to keep tabs on each other as best they can. Their work is complicated by all kinds of other players who run around doing their own thing, sometimes tripping up the activities of the best agencies. So that is not so great. It is not the model for this, obviously, partly because it is a very flawed model, and the better agencies all know it and they are trying to do something about it. But also these are very short-term interventions. As soon as you get things fixed up and stabilized, you are off to the next emergency. They happen because, usually, there has been a total breakdown. The model for PEPFAR, of course, is totally different. You are basically thinking about stable regimes, with tragically stable or long-term patterns of suffering, and, presumably, one is there for the long haul. So that is not the right model. What is the better model? Number two is what is already happening. We have heard for two days that there are a lot of people over there, a lot of Americans over there, working for different agencies, doing good work—God’s work, as one might say. And bless them. But this is sort of a bouquet of individual initiatives. Again, there is no one keeping score. There is no one in charge, no one who is trying to say, “Yes, we have covered all the main bases here,” or, “I know you came over and you want to do this, but the real need is over here. Would you please do that?” There is nobody to report to and nobody to check off the needs and so on. So that is what is there. Now, it is possible that what the [funders of PEPFAR] have in mind is that they would be something like that. Actually, what I heard was something less than that. They just want to encourage lots more of the shoots to come up.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS The third one, which would be just great, would be to say, no, what we are really talking about here is how to prevent the complete breakdown of health systems, focusing on HIV/AIDS, but obviously with ramifications for other serious diseases. We are looking at the medium to long term. We want to make sure that the PEPFAR intervention is actually one that would enhance the other work, so we want to integrate PEPFAR with the other stuff that is happening. Either PEPFAR would be the integrator or ask WHO to play that role, or some other agency. The emphasis, being on the long term, would be on training. Moreover, there might be other aspects to intervention, beyond the focus on AIDS that this would also dovetail with. That would just be wonderful. But I don’t know what you are planning. The ethical rules, the ethical guidelines, the criteria, evaluation, and so on would all depend on which one of these you had in mind. Let’s look at some big-scale issues having to do with equity. These are not questions that face the individual volunteer. They face the people who are planning the system. We have this odd situation in which the United States is now talking about sending over planeloads of volunteers, and they will wave in the window to all those physicians coming from those very countries on their way to better jobs in the United States. What do you call this? You have volunteers, and you have brain drain. What happens when these are happening simultaneously? I have just listed two views here. I am not going to endorse one of them. One would say that this is a sign of a serious inequity. It basically says that the fact that Africa is emptying out its health systems, both nurses and doctors, and they are coming to places like the United States is in part the fault of the rich countries. Why is that? Because we have jobs, in the state mental hospitals and less desirable jobs in general, that these people are filling—not always, but often. Why are they going empty? Why is it that people have to recruit abroad? Because those jobs aren’t adequately recruited for or funded or whatever. We are producing lots of doctors, but our doctors have almost total discretion over where they practice, and we are not making those jobs attractive enough to lure them there. So we sort of create a magnet, and sure enough, it draws people toward it. They are coming from these places where what we are offering is much better than what they would otherwise face. To that extent, the brain drain is partly our fault. So it is an inequity. What it amounts to is a huge subsidy by the very poorest countries of the very richest. The NHS saves a caboodle by hiring the graduates of the Aga Khan medical school’s nursing academy. The way it was described to me was that on graduation day, the nurses file out with their diplomas and there are tables set up with the Germans and the British and so on. They can take their pick. We don’t recruit. We are not that gross. But there is complicity, too.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS The other point of view, obviously, is that we didn’t bring these people here. The way the world system works is, individuals get to go where they want. They choose to come here, which is not irrational. Since we don’t recruit these doctors, we don’t owe anybody any compensation. It is not a wrong that is done to them. What hangs on this? If you have done a wrong to another country, you owe them something, basically. One question I would put to the committee is, Do you want to take a position on this? Do you want to address the fact that you are contemplating a volunteer corps at the same time that the very places that the volunteers would go to are sending their experts here and to England and so on? If you don’t address this, it seems to me that there is a blind spot in the report. It is a little bit other-worldly. That is the context in which this is being contemplated. At least to address it would show that you thought about it. I would think that would be a good idea. Then not only to address it, but to say what you actually think about it, which means debating it, would be even better. So what should one say? Here are, again, three views, without any endorsement. The first one would say, keep your volunteers until we solve the brain-drain problem. Maybe we won’t need volunteers if we could just keep the people we have. Help us with that. Help us raise the salaries so that people can earn a decent living, while providing medical care under unpleasant circumstances. Also don’t make it so easy for them to come, and also fund your own system better so that you don’t create these openings. That one says, think twice before you engage in this volunteer effort. The second view says, no, no, no, these are happening simultaneously, but they are otherwise unrelated. As a matter of fact, you could use the volunteers to help stem the brain drain, for example, by establishing long-term collegial relationships through twinning and so on. That might actually make it a more viable career to stay in some of these countries. Also we could say that by providing the volunteers, we are partly compensating the countries for the subsidy that they are giving us by sending us their medical graduates. The third one, which is sort of allied to the third view about what this program is about, is to say, yes, there are equity issues here, and there is a solution to the equity issues, which is that the United States will help go to the root causes of the brain drain and the critical lack of qualified personnel by shoring up the health systems. This PEPFAR effort is a step in that direction. But that means, of course, it has to be coordinated with and supplemented by other steps. This is pretty obvious. One kind of ethical consideration is, is there anything that you might do in setting up a volunteer corps that would actually make things worse? Of course there is. There is a question about displacing the trade of existing practitioners. We know that food aid some-

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS times, even in humanitarian emergencies, has the net effect of increasing starvation, because when you give away food to people even in emergencies, neighboring farmers can’t sell their produce. So, after a while, they will stop growing it, and the amount of food available may be actually less. So with emergency food supplies, there is this kind of effect. Do we know whether this will occur with the use of volunteers? Some emergency intervention agencies now insist that you never give away food. You charge for it, even if some people have to starve because they can’t afford it, because it is too dangerous to do the opposite. What about this? Is it possible that coming in with a vertical program, an AIDS-oriented program, would have the effect, since it is going to be well-funded, even though these may be volunteers, of drawing people away from primary care and from other kinds of treatment, which, in fact, may be more cost effective? After all, you don’t really cure any AIDS patients. It is very expensive, year after year, and very labor intensive. Presumably, the people who are going to be drawn into this were not just idling. They were very busy before they would be drawn into it. What were they doing? Is what they are doing dispensable? Is it less cost effective than what they would be doing with the AIDS program, or are they just coming over because it is better-funded and offers all kinds of other opportunities? So that is a problem. Finally, there is the question about abandonment. If PEPFAR comes in and people get antiretrovirals for a few years, and then the party is over and all the Americans go home—they have had a great experience, and they will never forget it. So good for them, but how about the people who were left behind? You could say, look, they would have died earlier if Americans hadn’t come. But is that really the goal? Is that the only possibility? If there are other possibilities, then how does one exercise a responsible choice? Let me switch over now, briefly, to some ethical issues facing volunteers. I don’t think any of these will come as a surprise to you. First of all, having to do with selection of beneficiaries, setting priorities—there is an old distinction in moral philosophy between perfect and imperfect obligations. Perfect obligations are ones that you incur to specific individuals. I borrow your book; I owe you the book. If I give your book to somebody else who needs it or wants it, that doesn’t fulfill my obligation. But there are imperfect obligations, like charity. I have an obligation to be charitable, but no one has a specific claim on my charity. I can more or less pick my beneficiary. Which is it? What is PEPFAR? Is it the exercise of a perfect or an imperfect obligation? One of the differences might be that if it is imperfect, then any amount of good you do is fine; it is great. Right now, for example, we heard from all these programs that are selecting sites, that are going over; they are all doing good. Could you go to them and say, “I don’t think you are a very upstanding outfit, because there is another place where you

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS could have done even more good, and you didn’t go there.” You wouldn’t think of saying that. It is amazing that they did as much as they did, and bravo for them. PEPFAR, though, is a different order of magnitude here. I assume that we are talking about a larger and certainly more official governmental organization. So does it have an obligation, then, to select according to equity criteria as opposed to just treating whoever they want to treat, for whatever reasons? If they want to be equitable, they have to decide what would be equitable. In situations like this—I think this is a criticism that has been made in regard to the WHO three-by-five program—this unremitting emphasis on the number of people treated basically blots out all equity considerations. If your only goal is to treat as many people as you can, then you will treat the people who are easiest to treat, easiest to get to. It means that you want your dollars, which will always be scarce, to go as far as they can. That means if somebody can pay for themselves, you treat them for sure, because then you can use that money to treat somebody else. If somebody is out in the sticks and you have to bring some of these city doctors out there, then they go without treatment. If males are free to come into the clinic, but the females are basically locked up in the house, and it would be a big to-do if you wanted to go out there and combat this, so what if you have 70 percent males in your patient list? So that is a question: To what extent should the volunteers go over there with a set of scruples, equity considerations, and an insistence that these are the rules that they have to play by? There are rules, or at least we hope there are. There are aspirations anyway. Should that be brought over to that environment? You may find that there are some people there who share the same view about what equity is, and there are some who don’t. In some countries, for example, small children just are not seen as important, whereas here sometimes they are seen as more important, and certainly with men and women. The fact that there is such stigma attached to AIDS means that this very disease marks somebody as less than worthy, as long as it is openly admitted that they have it. These are the questions about expertise. Obviously, we are setting up a situation in which the American may go over with many more years of training, better training, than the host physician has. Then what do you do? One hears often a plea for deference, for not trying to lord it over the host, and so on. There is a lot to be said for that. But on the next slide, what I have is basically an extended argument made to me by an African colleague, whom I respect very, very much. What he is trying to say, if you can read through this, is: Be nice. Don’t make them feel bad. But don’t, don’t cede your ground. You are there to raise the standards. Never lose sight of

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS that. Do everything you can to dance around the fact that you know and they don’t know, but don’t give up. If it doesn’t work the first time, try it again. He had various strategies for doing it. What the volunteers go there for and what PEPFAR is [there] for may be somewhat different. As we heard before, there are all kinds of motives for people to go over. If they have different motives, we don’t know what they will do when they get there. Should there be limits on what they do? Should we say that we don’t really care what else they do, as long as they do their treating, and if they are there to do something else, go for it? Or should you say, look, we are there for AIDS; the rest of the stuff you can do on some other trip to Africa? With public–private partnerships, you have the additional consideration that some of your private partners may have commercial motives. They may be pursuing those. They may be using your cover as a way of legitimizing them. So what do you do about that? It is a chronic problem, of course. Finally, I was wondering whether it would be useful for the committee to say that there should be some ethical constraints, some ground rules that govern basically all aspects of the program. It is very hard to draw these things up without being vapid. The ideal is something that is general enough so that you don’t come up with immediate counter-examples, but specific enough so that it has some actual force. A few times, somebody actually achieves these. Just thinking this through with some colleagues, here are a few candidates. I am not necessarily endorsing any of these, and certainly not this set of six. But they are examples of what these rules could look like: Benefit to the host country is the fundamental criterion of adequacy. Capacity-building over the medium and long term is the primary goal. The work of a PEPFAR volunteer corps should be coordinated with other initiatives to allocate resources rationally. Needs are defined by host countries. Standard of care is defined by the needs of the host country. Volunteers should respect hosts values but must be governed by their own values, including equity in selection of patients. I think when one comes up with the magic formula, something that has the right degree of bite and generality, it is very, very useful, because it gives you a benchmark against which later infractions or deviations can be held to account.