Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position PaperFREE
This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.
Ethics resources and best practice guidelines for short-term global health clinical care experiences focus on medical trainees and training programs (1–8). There is a need to translate guidelines and apply ethical principles from the American College of Physicians (ACP) Ethics Manual to practicing physicians engaged in global health activities (9) in nontraining capacities.
The Ethics Manual (10) notes, “Physicians have an important role to play in promoting health and human rights and addressing social inequities. This includes caring for vulnerable populations.” This is true both locally and globally. Over the past 2 decades, global health activities involving medical trainees (11–13) and practicing physicians (14–16) have expanded, with hundreds of millions of dollars in direct expenditures (4, 17, 18). With potential benefits of global health participation (19–23), including the potential to influence how and where physicians practice at home (for example, in underserved settings [13, 24–27]), come ethical challenges. These include respecting different cultural norms, avoiding unintended harms, protecting privacy, working within one's scope of practice, and managing resource constraints and priority setting (28). Evidence of positive long-term health effects has been lacking (29, 30), except in long-term, sustainable partnerships (31).
The term “short-term experience in global health” (STEGH) (12) as used here covers a range of clinical care and educational activities and is intentionally broad. “Short-term” refers to activities lasting a few days to several months. “Global health” could technically include any health-related activity anywhere in the world. This position paper follows others that have noted that global health typically emphasizes vulnerable populations in underserved settings (9). As used here, “experiences in global health” refers to circumstances where physicians from high-income countries travel to low- or middle-income countries or to underserved areas in high-income countries. Comprehensive review of ethical challenges is beyond the scope of this paper; for example, ethical challenges in international research is a rich and distinct field. This paper focuses on STEGHs, but these positions could also inform career global health work (32) or local activities in underserved settings.
This position paper was developed on behalf of the ACP Ethics, Professionalism and Human Rights Committee (EPHRC). Committee members, staff, and authors abide by the ACP's conflict-of-interest policy and procedures (www.acponline.org/about-acp/who-we-are/acp-conflict-of-interest-policy-and-procedures), and appointment to and procedures of the EPHRC are governed by the ACP's bylaws (www.acponline.org/about-acp/who-we-are/acp-bylaws). After an environmental assessment to determine the scope of issues and literature reviews, the EPHRC evaluated and discussed several drafts of the paper. The paper was then reviewed by members of the ACP Board of Governors, Board of Regents, Council of Resident/Fellow Members, Council of Student Members, and other committees and experts. The paper was revised on the basis of comments from these groups and individuals. The ACP Board of Regents reviewed and approved the paper on 18 November 2017.
Position 1: Physicians' primary ethical obligation in short-term global health experiences is to improve the health and well-being of the individuals and communities they visit.
A physician's primary ethical obligation is to the welfare of individual patients, not his or her own interests (10). The principles of beneficence and nonmaleficence (“do no harm”) apply in the short-term global health setting. Evidence suggests the potential for unintended but real harms (22, 33–42) (see the Table for vignettes).
Best practice guidelines (2, 6) and recent literature (12) no longer consider short-term global health work as pure altruism or “something that is better than nothing” (43). Instead, STEGHs must demonstrate real benefit to the local community, with a goal of sustainability. Benefits could be short-term (such as relief of suffering or provision of needed medications or health care services) or long-term (such as treating to cure certain medical or surgical problems; educating local health care professionals; building health care infrastructure; or increasing awareness of global health inequalities that motivates long-term, sustainable change).
A few general recommendations can be made with regard to obligations of beneficence and nonmaleficence. First, the benefits of STEGHs should be “desired by and the interventions acceptable to” the local community (10) (Table [position 1, scenario B]). Short-term experiences in global health may involve physicians at different levels of training or students. Expected benefits must be balanced with potential risks on the basis of participant experience and training level. Because the STEGH participant cannot always determine what is most beneficial abroad, humility about one's knowledge and expertise is an important component of beneficence (44).
Second, beneficence requires adherence to existing ethical standards. For example, the dilemma of whether to use expired medicines sometimes arises in this context (Table [position 1, scenario A]). Existing guidelines from the World Health Organization usually prohibit such use, citing unintended harms and an ethical double standard (45), although some prescription drugs may retain potency after the manufacturer's expiration date (46).
Third, physicians should not exceed their scope of practice, even though local regulations may be less restrictive in other countries. When the need is urgent enough to raise consideration of exceeding one's scope, careful forethought and informed consent (47) are required at a minimum. Medical students, residents, and postgraduate trainees should not exceed their level of training. Local licensing requirements must be adhered to.
Finally, physicians' actions should not detract from local clinicians and resources. Supporting the local community may foster long-term, sustainable change (Table [position 1, scenario B]).
Patient and community welfare has primacy, but that does not mean that educational benefit for physician participants does not matter ethically. However, STEGHs can occur in contexts of power imbalance for historical, political, resource, and other reasons. Special efforts may be required to ensure unequivocal focus on benefits to the community as decided by the community (see position 3).
Position 2: The ethical principle of justice requires partnering with local leaders to ensure that the potential burdens participants can place on local communities abroad are minimized and preparing for limited material resources.
Justice requires that physicians “seek to equitably distribute the life-enhancing opportunities afforded by health care” (10). In many STEGH settings, certain material resources may be far more limited than in physicians' usual practice settings (Table [position 2]), presenting ethical challenges. Clinical resource limitations may be the most obvious, but ensuring that physician participants do not burden the host site is equally important. Examples of potential burdens include tangible costs (such as licensure; lodging; food; transportation; care in the event of acute illness, such as travelers' diarrhea; or measures to protect the physical safety of physician volunteers) and intangible ones (for example, causing local practitioners to shift their time and efforts toward the visiting team or expanding or supplanting their usual obligations).
Managing such burdens requires first recognizing them. Volunteers may lack knowledge of local circumstances, necessitating partnership with local community leaders. The full cost to local communities should be calculated and reimbursed (2). Protecting the safety of physician volunteers (such as during travel or using personal protective equipment) may require actions on the part of the local community, the organization, and the volunteer, but financial responsibility rests with the organizations that send volunteers. Although organizations typically provide reimbursement, individual physicians must be cognizant of potential burdens created by their presence (Table [position 2, scenario A]), take steps to minimize them, and report them to the sending organization. Responsibility for medical care of physician participants, including medical evacuation if necessary, rests with the sending organization.
Ensuring just distribution of limited resources is another possible ethical challenge. This may occur for many resources, such as diagnostics, therapeutics, and personal protective equipment. Managing ethical tensions among the welfare of the individual patient, efficiency, and equitable distribution with special concern for vulnerable patients is challenging. The best balance should be decided among all stakeholders, with appropriate deference to local community values (Table [position 2, scenario B]) and in advance rather than during an individual patient encounter when possible (10).
Position 3: The ethical principle of respect for persons, including being sensitive to and respectful of cultural differences, is essential to short-term global medical experiences.
Physicians are obligated to provide culturally sensitive care that does not presume the correctness of any one culture's view (the physician's or the patient's) (10). Global health clinical activities in unfamiliar or underserved settings may make cultural differences more evident (Table [position 3]).
Cultural sensitivity respects individual and community choice, privacy, and truth telling. Respect is also a critical component of global health ethics frameworks that emphasize solidarity (collective obligations based on social reciprocity) (48, 49). Local communities may place greater importance on STEGHs as expressions of solidarity than on the tangible benefits they provide (50, 51).
Respect for persons is important in its own right; physicians must demonstrate not only cultural competence but also cultural humility (10). This entails being respectful of different cultural views about the role of medicine in society and its goals. At the same time, certain values may transcend cultures, and being abroad does not reduce their importance. For example, physicians abroad should respect individual patient choice, privacy, and confidentiality by not sharing images or other personal health information without consent, including on social media (52, 53).
Respect also helps facilitate the obligations stated in positions 1 and 2. By humbly respecting cultural differences, STEGH physicians can help mitigate power imbalances between local communities and sending organizations (which may have more financial resources) or between volunteer physicians and local communities (who may perceive the volunteer team as inherently “better” physicians). Either could inappropriately influence decisions about mutual benefit and fair resource allocation. One way to fulfill these obligations is to partner with local community members (and other overlapping global health efforts if applicable ) before, during, and after STEGHs (55, 56).
Respectful partnership helps ensure that efforts are consistent with community values and self-identified needs (position 1), which increases the likelihood of lasting benefit (Table [position 3, scenario B]). Finally, partnership reveals burdens on the host through ongoing dialogue (some burdens may not be readily apparent to STEGH participants) and is also necessary for difficult discussions about fair resource allocation (position 2).
The physician's general orientation abroad should be one of a humble visitor who is respectful of cultural differences. However, physicians should not shirk their ethical duties and are “not required to violate fundamental personal values, standards of medical care or ethical practice, or the law” (10). For example, radical differences in how some cultures treat persons of different genders may cause a physician to wonder whether to conform, tolerate the treatment, try to change it, or even leave. Potential differences of such gravity must be elucidated and explored in advance of STEGHs. When such differences do occur, physicians should reach out to trusted mentors and peers in their home country, at the sponsoring organization, or in the local community to learn how best to respond.
Position 4: Predeparture preparation is itself an ethical obligation. It should incorporate preparation for logistical and ethical aspects of STEGHs, including the potential for ethical challenges and moral distress.
Many ethical guidelines and recommendations exist for STEGHs (2, 4, 6, 12, 28, 57–60). Predeparture training has been (61) and continues to be (62) ethically necessary to help physicians avoid some of the ethical pitfalls of short-term global health work (63).
Organizations that sponsor or support STEGHs may be primarily responsible for predeparture training. It should be tailored to the community where the experience will occur. Recommended topics include logistics (such as immunizations and predeparture medical screening, travel insurance, and appropriate licensure); planning for adequate supervision (especially for trainees); personal safety (such as road and travel safety or personal protective equipment needs); and, where applicable, malaria prophylaxis or health information needed to stay well while abroad. Education in local health and health system issues, history, culture, language, and ethics is also essential (64, 65).
Physicians should explicitly prepare for the possibility of ethical dilemmas and moral distress before, during, and after STEGHs (22, 66–68). Moral distress can occur if physicians are unable to act in ways that are consistent with ethics and their professional values or if they feel complicit in a moral wrong (Table [position 4, scenario A]). Moral distress is frequently accompanied by a sense of powerlessness, which can lead to deprofessionalization, burnout, decreased quality of care, or lasting negative emotions (69).
Organizations sponsoring or supporting STEGHs should prepare physicians for the ethical challenges they are likely to encounter and should formally debrief the experience afterward (70) (Table [position 4, scenario B]). Individually, physicians can develop and apply strategies for moral resilience. Physicians should have a mentor in their home country (who may also be a fellow traveler) and in the local community to discuss ethical concerns before, during, and after the STEGH and may find moral resilience strategies (71, 72) helpful. For example, regularly assessing one's emotions and actions surrounding the experience of ethical challenges abroad, documenting them in a journal, and sharing them with peers could help build moral resilience (72). Mobile technology and increased connectivity make this possible in real time.
Self-paced online resources on a range of global health topics allow participants to supplement organizational preparation (73–75). More specific ethics preparation (76–79) and book-length manuals (80) are also available. Although many resources focus on medical trainees (medical students, residents, and fellows), “trainee” should be interpreted broadly. Any STEGH participant with limited global health experience should, for the sake of humility, consider themselves a trainee.
In the future, predeparture training for STEGHs should be improved to target seasoned clinicians and evaluate the effect of training and training method on participant knowledge, skills, attitudes, and beliefs, as well as the long-term sustainability and effectiveness of short-term programs (81). Greater attention to monitoring and managing ethical challenges for all STEGH participants, including partners abroad, is also needed.
Position 5: Physicians should participate with organizations whose STEGHs are consistent with ethics and professionalism as exemplified in these positions.
Physicians who engage with organizations that sponsor short-term global health work may not be in the best position to influence decisions about such issues as benefits or resource allocation. Nevertheless, by choosing organizations that sponsor ethical STEGHs, physicians can maintain their professional integrity, serve underserved populations, and indirectly influence how short-term global efforts are organized.
No single checklist exists for physicians to use in guiding their choice, although some have been proposed for medical trainees (82). Best practice guidelines and resources can help physicians articulate questions to ask before committing to a particular organization that sponsors STEGHs. Physicians are obligated to report problematic STEGH practices to the administrative leadership of the organization sponsoring the trip (and, if necessary, to medical licensing bodies when applicable). For-profit global medical volunteer or tourism organizations may require special scrutiny because of the tension between profit margins and maximal benefit to communities abroad.
Although STEGHs with long-standing partnerships with host communities and organizations abroad are preferred, there is no “one-size-fits-all” approach to ethics in STEGHs. For example, natural disasters or severe pandemics may pose additional or different ethical challenges. Therefore, evaluation must also be sensitive to local context and needs. Short-term experiences in global health may initially not be fully sustainable (due to uncertain funding, local political circumstances, or other factors), but they may lead to sustainable, partnered efforts in the future or be ethically justified by short-term benefits, such as relief of suffering in areas of violence or humanitarian crises. In contrast, more can reasonably be expected in terms of positive effect, capacity building, and sustainability from a program that has operated for several years in the same location.
Evaluation is therefore itself an ethical obligation. Organizations that sponsor STEGHs should evaluate their effect, and physicians should choose organizations that are committed to evaluation. Progress toward the goals described in these positions requires evaluation timelines and benchmarks that create accountability for STEGHs. These should include process measures (such as the number of patients seen or local community involvement), outcome measures (for example, local health outcomes, capacity built, or relationships developed), and full cost accounting. Ideally, evaluations should be designed and conducted by or with the local community.
Physicians who participate in STEGHs have ethical duties and special obligations to advocate for sustainable, mutual benefit; a fair and equitable distribution of resources; and partnership with and respect for the individuals and communities they serve. These principles inform physician decision making surrounding short-term experiences and can positively influence how STEGHs are done. By adhering to these principles, physicians can help maintain trust in a profession committed to protecting patient well-being and improving health equity at home and abroad.
- 1. Evert J, Drain P, Hall T. Developing Global Health Programming: A Guidebook for Medical and Professional Schools. 2nd ed. San Francisco: Global Health Education Collaborations Pr; 2014. Accessed at www.cfhi.org/sites/files/files/pages/developingglobalhealthprogramming_0.pdf on 20 July 2017. Google Scholar
Crump JA, Sugarman J; Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg. 2010;83:1178-82. [PMID: 21118918] doi:10.4269/ajtmh.2010.10-0527 CrossrefMedlineGoogle Scholar
Stone GS, Olson KR. The ethics of medical volunteerism. Med Clin North Am. 2016;100:237-46. [PMID: 26900110] doi:10.1016/j.mcna.2015.09.001 CrossrefMedlineGoogle Scholar
Lasker JN. Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. 1st ed. Ithaca, NY: Cornell Univ Pr; 2016. Google Scholar
Lahey T. Perspective: a proposed medical school curriculum to help students recognize and resolve ethical issues of global health outreach work. Acad Med. 2012;87:210-5. [PMID: 22189876] doi:10.1097/ACM.0b013e31823f3fb1 CrossrefMedlineGoogle Scholar
- 6. World Medical Association. WMA statement on ethical considerations in global medical electives. 17 February 2017. Accessed at www.wma.net/policies-post/wma-statement-on-ethical-considerations-in-global-medical-electives on 31 January 2017. Google Scholar
Roche SD, Ketheeswaran P, Wirtz VJ. International short-term medical missions: a systematic review of recommended practices. Int J Public Health. 2017;62:31-42. [PMID: 27592359] doi:10.1007/s00038-016-0889-6 CrossrefMedlineGoogle Scholar
Wilson JW, Merry SP, Franz WB. Rules of engagement: the principles of underserved global health volunteerism. Am J Med. 2012;125:612-7. [PMID: 22502955] doi:10.1016/j.amjmed.2012.01.008 CrossrefMedlineGoogle Scholar
Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993-5. [PMID: 19493564] doi:10.1016/S0140-6736(09)60332-9 CrossrefMedlineGoogle Scholar
Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156:73-104. [PMID: 22213573]. doi:10.7326/0003-4819-156-1-201201031-00001 LinkGoogle Scholar
- 11. Association of American Medical Colleges. Medical School Graduation Questionnaire: 2016 All Schools Summary Report. 2016. Accessed at www.aamc.org/download/464412/data/2016gqallschoolssummaryreport.pdf on 21 February 2018. Google Scholar
Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond medical “missions” to impact-driven short-term experiences in global health (STEGHs): ethical principles to optimize community benefit and learner experience. Acad Med. 2016;91:633-8. [PMID: 26630608] doi:10.1097/ACM.0000000000001009 CrossrefMedlineGoogle Scholar
Nelson B, Izadnegahdar R, Hall L, Lee PT. Global health fellowships: a national, cross-disciplinary survey of US training opportunities. J Grad Med Educ. 2012;4:184-9. [PMID: 23730439] doi:10.4300/JGME-D-11-00214.1 CrossrefMedlineGoogle Scholar
Greysen SR, Richards AK, Coupet S, Desai MM, Padela AI. Global health experiences of U.S. physicians: a mixed methods survey of clinician-researchers and health policy leaders. Global Health. 2013;9:19. [PMID: 23663501] doi:10.1186/1744-8603-9-19 CrossrefMedlineGoogle Scholar
Caldron PH, Impens A, Pavlova M, Groot W. Demographic profile of physician participants in short-term medical missions. BMC Health Serv Res. 2016;16:682. [PMID: 27927193] CrossrefMedlineGoogle Scholar
Merson MH. University engagement in global health. N Engl J Med. 2014;370:1676-8. [PMID: 24785204] doi:10.1056/NEJMp1401124 CrossrefMedlineGoogle Scholar
Caldron PH, Impens A, Pavlova M, Groot W. Economic assessment of US physician participation in short-term medical missions. Global Health. 2016;12:45. [PMID: 27549787] doi:10.1186/s12992-016-0183-7 CrossrefMedlineGoogle Scholar
Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res. 2008;8:121. [PMID: 18518997] doi:10.1186/1472-6963-8-121 CrossrefMedlineGoogle Scholar
Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med. 2003;78:342-7. [PMID: 12634222] CrossrefMedlineGoogle Scholar
Mutchnick IS, Moyer CA, Stern DT. Expanding the boundaries of medical education: evidence for cross-cultural exchanges. Acad Med. 2003;78:S1-5. [PMID: 14557080] CrossrefMedlineGoogle Scholar
Dowell J, Merrylees N. Electives: isn't it time for a change? Med Educ. 2009;43:121-6. [PMID: 19161481] doi:10.1111/j.1365-2923.2008.03253.x CrossrefMedlineGoogle Scholar
Abedini NC, Gruppen LD, Kolars JC, Kumagai AK. Understanding the effects of short-term international service-learning trips on medical students. Acad Med. 2012;87:820-8. [PMID: 22534591] doi:10.1097/ACM.0b013e31825396d8 CrossrefMedlineGoogle Scholar
Kumwenda B, Royan D, Ringsell P, Dowell J. Western medical students' experiences on clinical electives in sub-Saharan Africa. Med Educ. 2014;48:593-603. [PMID: 24807435] doi:10.1111/medu.12477 CrossrefMedlineGoogle Scholar
Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University's internal medicine residency program. Am J Trop Med Hyg. 1999;61:1019-23. [PMID: 10674689] CrossrefMedlineGoogle Scholar
McKinley DW, Williams SR, Norcini JJ, Anderson MB. International exchange programs and U.S. medical schools. Acad Med. 2008;83:S53-7. [PMID: 18820502] doi:10.1097/ACM.0b013e318183e351 CrossrefMedlineGoogle Scholar
Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Fam Med. 2004;36:412-6. [PMID: 15181553] MedlineGoogle Scholar
Shaywitz DA, Ausiello DA. Global health: a chance for Western physicians to give—and receive. Am J Med. 2002;113:354-7. [PMID: 12361834] CrossrefMedlineGoogle Scholar
Waal AE. Ethics for International Medicine: A Practical Guide for Aid Workers in Developing Countries. Hanover, NH: Dartmouth; 2012. Google Scholar
Sykes KJ. Short-term medical service trips: a systematic review of the evidence. Am J Public Health. 2014;104:e38-48. [PMID: 24832401] doi:10.2105/AJPH.2014.301983 CrossrefMedlineGoogle Scholar
Caldron PH, Impens A, Pavlova M, Groot W. A systematic review of social, economic and diplomatic aspects of short-term medical missions. BMC Health Serv Res. 2015;15:380. [PMID: 26373298] doi:10.1186/s12913-015-0980-3 CrossrefMedlineGoogle Scholar
Einterz RM, Kimaiyo S, Mengech HN, Khwa-Otsyula BO, Esamai F, Quigley F, et al. Responding to the HIV pandemic: the power of an academic medical partnership. Acad Med. 2007;82:812-8. [PMID: 17762264] CrossrefMedlineGoogle Scholar
Loh LC, Chae SR, Heckman JE, Rhee DS. Ethical considerations of physician career involvement in global health work: a framework. J Bioeth Inq. 2015;12:129-36. [PMID: 25672614] doi:10.1007/s11673-014-9591-7 CrossrefMedlineGoogle Scholar
Montgomery LM. Short-term medical missions: enhancing or eroding health? Missiology: An International Review. 1993;21:333-41. CrossrefGoogle Scholar
DeCamp M. Scrutinizing global short-term medical outreach. Hastings Cent Rep. 2007;37:21-3. [PMID: 18179101] CrossrefMedlineGoogle Scholar
Roberts M. A piece of my mind. Duffle bag medicine. JAMA. 2006;295:1491-2. [PMID: 16595744] CrossrefMedlineGoogle Scholar
Wolfberg AJ. Volunteering overseas—lessons from surgical brigades. N Engl J Med. 2006;354:443-5. [PMID: 16452555] CrossrefMedlineGoogle Scholar
Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008;300:1456-8. [PMID: 18812538] doi:10.1001/jama.300.12.1456 CrossrefMedlineGoogle Scholar
Provenzano AM, Graber LK, Elansary M, Khoshnood K, Rastegar A, Barry M. Short-term global health research projects by US medical students: ethical challenges for partnerships. Am J Trop Med Hyg. 2010;83:211-4. [PMID: 20682858] doi:10.4269/ajtmh.2010.09-0692 CrossrefMedlineGoogle Scholar
Ott BB, Olson RM. Ethical issues of medical missions: the clinicians' view. HEC Forum. 2011;23:105-13. [PMID: 21598049] doi:10.1007/s10730-011-9154-9 CrossrefMedlineGoogle Scholar
Al-Samarrai T. Adrift in Africa: a US medical resident on an elective abroad. Health Aff (Millwood). 2011;30:525-8. [PMID: 21383372] doi:10.1377/hlthaff.2010.0842 CrossrefMedlineGoogle Scholar
Asgary R, Junck E. New trends of short-term humanitarian medical volunteerism: professional and ethical considerations. J Med Ethics. 2013;39:625-31. [PMID: 23236086] doi:10.1136/medethics-2011-100488 CrossrefMedlineGoogle Scholar
Creaton A. Embodying the three Rs in Fiji. N Engl J Med. 2016;375:1820-1. [PMID: 27959658] CrossrefMedlineGoogle Scholar
DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum. 2011;23:91-103. [PMID: 21604023] doi:10.1007/s10730-011-9152-y CrossrefMedlineGoogle Scholar
Pinto AD, Upshur RE. Global health ethics for students. Dev World Bioeth. 2009;9:1-10. [PMID: 19302567] doi:10.1111/j.1471-8847.2007.00209.x CrossrefMedlineGoogle Scholar
- 45. World Health Organization. Guidelines for Medicine Donations. 3rd ed. Geneva: World Health Organization; 2011. Accessed at www.who.int/selection_medicines/emergencies/guidelines_medicine_donations/en on 20 July 2017. Google Scholar
Cantrell L, Suchard JR, Wu A, Gerona RR. Stability of active ingredients in long-expired prescription medications [Letter]. Arch Intern Med. 2012;172:1685-7. [PMID: 23045150] CrossrefMedlineGoogle Scholar
Hunt MR, Schwartz L, Fraser V. “How far do you go and where are the issues surrounding that?” Dilemmas at the boundaries of clinical competency in humanitarian health work. Prehosp Disaster Med. 2013;28:502-8. [PMID: 23890475] doi:10.1017/S1049023X13008698 CrossrefMedlineGoogle Scholar
Baker R. Bioethics and human rights: a historical perspective. Camb Q Healthc Ethics. 2001;10:241-52. [PMID: 11414180] CrossrefMedlineGoogle Scholar
Benatar SR, Daar AS, Singer PA. Global health challenges: the need for an expanded discourse on bioethics. PLoS Med. 2005;2:e143. [PMID: 16033302] CrossrefMedlineGoogle Scholar
DeCamp M, Enumah S, O'Neill D, Sugarman J. Perceptions of a short-term medical programme in the Dominican Republic: voices of care recipients. Glob Public Health. 2014;9:411-25. [PMID: 24617943] doi:10.1080/17441692.2014.893368 CrossrefMedlineGoogle Scholar
Kung TH, Richardson ET, Mabud TS, Heaney CA, Jones E, Evert J. Host community perspectives on trainees participating in short-term experiences in global health. Med Educ. 2016;50:1122-30. [PMID: 27762010] doi:10.1111/medu.13106 CrossrefMedlineGoogle Scholar
Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM; American College of Physicians Ethics, Professionalism and Human Rights Committee. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158:620-7. [PMID: 23579867] doi:10.7326/0003-4819-158-8-201304160-00100 LinkGoogle Scholar
- 53. Hayward A. Medical missions: there is no HIPAA in Haiti? Student Doctor Network. 24 October 2012. Accessed at www.studentdoctor.net/2012/10/medical-missions-there-is-no-hipaa-in-haiti on 31 January 2017. Google Scholar
Fisher QA, Fisher G. The case for collaboration among humanitarian surgical programs in low resource countries. Anesth Analg. 2014;118:448-53. [PMID: 24445642] doi:10.1213/ANE.0000000000000053 CrossrefMedlineGoogle Scholar
Mitchell KB, Balumuka D, Kotecha V, Said SA, Chandika A. Short-term surgical missions: joining hands with local providers to ensure sustainability. S Afr J Surg. 2012;50:2. [PMID: 22353311] MedlineGoogle Scholar
Loh LC, Cherniak W, Dreifuss BA, Dacso MM, Lin HC, Evert J. Short term global health experiences and local partnership models: a framework. Global Health. 2015;11:50. [PMID: 26684302] doi:10.1186/s12992-015-0135-7 CrossrefMedlineGoogle Scholar
White M, Evert J. Developing ethical awareness in global health: four cases for medical educators. Dev World Bioeth. 2014;14:111-6. [PMID: 23025791] doi:10.1111/dewb.12000 CrossrefMedlineGoogle Scholar
- 58. AmeriCares. Medical Outreach: Best Practices Study. A Literature Review. 1st ed. May 2013. Accessed at http://medicaloutreach.americares.org/wp-content/uploads/Americares-MedOutreachPracticesStudy-Lit-Review-Final.pdf on 20 July 2017. Google Scholar
- 59. International Medical Corps. International Medical Corps code of conduct and ethics. February 2016. Accessed at https://secure.ethicspoint.com/domain/media/en/gui/29929/code.pdf on 20 July 2017. Google Scholar
- 60. Medical Teams International. Team Code of Ethics and Conduct. Accessed at www.medicalteams.org/docs/default-source/Volunteer-Materials/team_code_of_ethics_and_conduct.pdf?sfvrsn=2 on 21 February 2018. Google Scholar
Imperato PJ. A Third World international health elective for U.S. medical students. The 16-year experience of the State University of New York, Health Science Center at Brooklyn. J Community Health. 1996;21:241-68. [PMID: 8842888] CrossrefMedlineGoogle Scholar
Purkey E, Hollaar G. Developing consensus for postgraduate global health electives: definitions, pre-departure training and post-return debriefing. BMC Med Educ. 2016;16:159. [PMID: 27259965] doi:10.1186/s12909-016-0675-4 CrossrefMedlineGoogle Scholar
Anderson KC, Slatnik MA, Pereira I, Cheung E, Xu K, Brewer TF. Are we there yet? Preparing Canadian medical students for global health electives. Acad Med. 2012;87:206-9. [PMID: 22189881] doi:10.1097/ACM.0b013e31823e23d4 CrossrefMedlineGoogle Scholar
Jogerst K, Callender B, Adams V, Evert J, Fields E, Hall T, et al. Identifying interprofessional global health competencies for 21st-century health professionals. Ann Glob Health. 2015;81:239-47. [PMID: 26088089] doi:10.1016/j.aogh.2015.03.006 CrossrefMedlineGoogle Scholar
Khan OA, Guerrant R, Sanders J, Carpenter C, Spottswood M, Jones DS, et al. Global health education in U.S. medical schools. BMC Med Educ. 2013;13:3. [PMID: 23331630] doi:10.1186/1472-6920-13-3 CrossrefMedlineGoogle Scholar
Dell EM, Varpio L, Petrosoniak A, Gajaria A, McMcarthy AE. The ethics and safety of medical student global health electives. Int J Med Educ. 2014;5:63-72. [PMID: 25341214] doi:10.5116/ijme.5334.8051 CrossrefMedlineGoogle Scholar
Elit L, Hunt M, Redwood-Campbell L, Ranford J, Adelson N, Schwartz L. Ethical issues encountered by medical students during international health electives. Med Educ. 2011;45:704-11. [PMID: 21649703] doi:10.1111/j.1365-2923.2011.03936.x CrossrefMedlineGoogle Scholar
Harrison JD, Logar T, Le P, Glass M. What are the ethical issues facing global-health trainees working overseas? A multi-professional qualitative study. Healthcare (Basel). 2016;4. [PMID: 27417631] doi:10.3390/healthcare4030043 CrossrefMedlineGoogle Scholar
Hamric A. A case study of moral distress. J Hosp Palliat Nurs. 2014;16:457-63. CrossrefGoogle Scholar
Bender A, Walker P. The obligation of debriefing in global health education. Med Teach. 2013;35:e1027-34. [PMID: 23102161] doi:10.3109/0142159X.2012.733449 CrossrefMedlineGoogle Scholar
Leppin AL, Bora PR, Tilburt JC, Gionfriddo MR, Zeballos-Palacios C, Dulohery MM, et al. The efficacy of resiliency training programs: a systematic review and meta-analysis of randomized trials. PLoS One. 2014;9:e111420. [PMID: 25347713] doi:10.1371/journal.pone.0111420 CrossrefMedlineGoogle Scholar
- 72. Finklestein C. Improving physician resiliency. American Medical Association Steps Forward. Accessed at www.stepsforward.org/modules/improving-physician-resilience on 20 July 2017. Google Scholar
- 73. Unite for Sight. Certificate for global health. 2015. Accessed at www.uniteforsight.org/global-health-university/enroll on 20 July 2017. Google Scholar
- 74. Boston University. The Practitioner's Guide to Global Health. Accessed at www.edx.org/course/practitioners-guide-global-health-bux-globalhealthx on 20 July 2017. Google Scholar
- 75. Consortium of Universities for Global Health. Global health training modules. Accessed at www.cugh.org/resources/educational-modules on 20 July 2017. Google Scholar
- 76. University of Minnesota. Global Ambassadors for Patient Safety toolkit. Accessed at www.healthcareers.umn.edu/courses-and-events/online-workshops/global-ambassadors-patient-safety on 20 July 2017. Google Scholar
DeCamp M, Rodriguez J, Hecht S, Barry M, Sugarman J. An ethics curriculum for short-term global health trainees. Global Health. 2013;9:5. [PMID: 23410089] doi:10.1186/1744-8603-9-5 CrossrefMedlineGoogle Scholar
Elansary M, Kallem S, Peluso M, Thomas J, Rabin T. Global health clinical ethics. MedEdPORTAL Publ. 2015;11:10232. doi:10.15766/mep_2374-8265.10232 CrossrefGoogle Scholar
Logar T, Le P, Harrison JD, Glass M. Teaching corner: “first do no harm”: teaching global health ethics to medical trainees through experiential learning. J Bioeth Inq. 2015;12:69-78. [PMID: 25648122] doi:10.1007/s11673-014-9603-7 CrossrefMedlineGoogle Scholar
Arya AN, eds. Preparing for International Health Experiences: A Practical Guide. New York: Routledge; 2017. Google Scholar
Rahim A, Knights Née Jones F, Fyfe M, Alagarajah J, Baraitser P. Preparing students for the ethical challenges on international health electives: a systematic review of the literature on educational interventions. Med Teach. 2016;38:911-20. [PMID: 26841123] doi:10.3109/0142159X.2015.1132832 CrossrefMedlineGoogle Scholar
- 82. Child Family Health International; Medsin-UK. Choosing an international elective: a roadmap for your decision. 2017. Accessed at www.choosinganelective.org on 20 July 2017. Google Scholar
Author, Article, and Disclosure Information
Johns Hopkins University, Baltimore, Maryland (M.D.)
Veterans Health Administration, Washington, DC, and Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (L.S.L.)
University of California, San Diego, La Jolla, California (P.J.)
Virginia Mason Medical Center, Seattle, Washington (C.H.)
Disclaimer: The views expressed in this manuscript do not necessarily reflect the views of the National Center for Ethics in Health Care, the Department of Veterans Affairs, or Harvard University.
Acknowledgment: The authors and the EPHRC thank peer reviewers Michele Barry, MD, John A. Crump, MBChB, MD, Marion Danis, MD, Ana S. Iltis, PhD, Tracy L. Rabin, MD, MS, and the many leadership and journal reviewers of the paper for helpful comments on drafts; Sean Lena for research assistance; and Lois Snyder Sulmasy, JD, and Kathy Wynkoop of the ACP Center for Ethics and Professionalism.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3361.
Corresponding Author: Lois Snyder Sulmasy, JD, American College of Physicians, Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected]
Current Author Addresses: Dr. DeCamp: Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205.
Dr. Lehmann: National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Avenue, NW, Washington, DC 20420.
Dr. Jaeel: Internal Medicine Residency Training Program, University of California–San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093.
Dr. Horwitch: Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA 98101.
Author Contributions: Conception and design: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Analysis and interpretation of the data: M. DeCamp, L.S. Lehmann, P. Jaeel.
Drafting of the article: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Critical revision of the article for important intellectual content: M. DeCamp, L.S. Lehmann, C. Horwitch.
Final approval of the article: M. DeCamp, L.S. Lehmann, P. Jaeel, C. Horwitch.
Collection and assembly of data: M. DeCamp, L.S. Lehmann.
This article was published at Annals.org on 27 March 2018.
* This paper, written by Matthew DeCamp, MD, PhD; Lisa Soleymani Lehmann, MD, PhD; Pooja Jaeel, MD; and Carrie A. Horwitch, MD, MPH, was developed for the ACP Ethics, Professionalism and Human Rights Committee. Members of the 2017–2018 ACP Ethics, Professionalism and Human Rights Committee at the time the paper was approved by the Committee were Thomas A. Bledsoe, MD† (Chair); Omar T. Atiq, MD† (Vice Chair); John R. Ball, MD, JD†; John B. Bundrick, MD†; Ricky Z. Cui†; Douglas M. DeLong, MD†; Lydia S. Dugdale, MD†; Jack Ende, MD†; Susan Thompson Hingle, MD†; Lauris C. Kaldjian, MD, PhD†; Lisa Soleymani Lehmann, MD, PhD‡; Susan Lou, MD†; Paul S. Mueller, MD, MPH†; and Sima Suhas Pendharkar, MD, MPH†. Approved by the ACP Board of Regents on 18 November 2017.
† Nonauthor contributor.