Canadian Bioethics Society Pre-Conference 2009 - Global Health and Ethical Responsibility

A) Guest Speaker: Dr. James Dwyer, Center for Bioethics and Humanities, State University of New York

Using life expectancy figures and maternal mortality rates as indicators, Dr. Dwyer offered a brief overview of the spectrum of health prospects around the world. He contrasted data from Canada, the U.S., and African countries, including Sierra Leone, which sits at the bottom the UN's Human Development Index. Dr. Dwyer explored the link between the disparity in health standards and the concept of justice, which he then correlated to ethical responsibility. He suggested "responsiveness" as a better term to describe the close engagement with development dynamics that Western countries should embrace.

B) Workshops and Discussion: Summary of Participants' Comments

Theme 1: Research (moderated by Geneviève Dubois-Flynn and Solomon Benatar)

• There is a need for more transparency when explaining to local, often vulnerable, populations the aims and protocols of clinical trials conducted in developing countries.
• Defining vulnerability (who is vulnerable? to what? at what time?) remains a subjective function of incomplete perspectives on the part of researchers.
• While African cultures look backward in time, value tradition and elders, and generally are more accepting of health limitations, the Western outlook is more preoccupied with the future and improvements in quality of life. This puts an asymmetrical premium on research.
• The Spring 2009 issue of the Journal of Law, Medicine & Ethics (Volume 37, Issue 1) explores the theme of vulnerability in biomedical research.
• Local populations are often interested in trials because they generate economic activity, employment, improvements in infrastructure, and "donations" of equipment, as much as wider access to medication and/or hope for a cure.
• An ethical dilemma occurs when "Big Pharma" is testing for a condition or disease that is not what afflicts the local population the most.
• Even when approved by regulatory bodies such as the FDA, clinical trials with non-similar cohort sizes and control groups, where comparatively more subjects are given placebos in developing countries, suffer from serious ethical flaws.

Theme 2: Medical Work Abroad (moderated by Matthew Hunt and Lisa Schwartz)

• Medical electives are increasingly popular with Canada's medical students. Some schools have well-established relationships with medical facilities abroad, but others leave students to organize their own work experience.
• Medical students and local patients would benefit from more solid relationships with healthcare facilities abroad. Medical schools/programs should send members of faculty on site and, when feasible, make modest investments in equipment, to develop productive, long-term collaborations before trainees begin their postings.
• Because of the lack of qualified medical personnel in most developing countries, medical students are often asked to provide diagnoses and perform procedures that are beyond their level of training.
• Doctors, nurses, and other accredited medical personnel are also asked to provide medical assistance that requires expertise outside their respective field or specialty.
• As professionals with codes of ethics and some years of experience, doctors and nurses are better equipped to deal with the ethical challenges and medical consequences of their decision to accept, or refuse, to intervene in emergency situations.
• When they return from a medical elective in a developing country, students often feel isolated because few of their peers and faculty have experienced similar work conditions and wrestled with the ethical dilemmas that come with having to perform, often unsupervised, beyond their level of training and expertise.
• Medical personnel who volunteer to work in developing countries would benefit from a more systematic and comprehensive pre-departure orientation. For each destination country, this should include a historical background, an overview of cultural and customary practices, an assessment of the current political situation, demographics, and information on the healthcare system.
• Upon their return from medical work abroad, many doctors and nurses also feel a need for a better organized post-experience debriefing.
• Improvements at both the pre-departure and return points should be implemented through the establishment of a database built from the information provided by medical personnel in return surveys. It should be searchable with multiple terms (e.g. country, specialty, hospital) and updated regularly. This would increase knowledge transfer and lower anxiety levels.
• New medical volunteers should be paired (perhaps through email introductions) with former ones who could act as mentors and answer questions about the country, work environment, patient population, or other.
• Researchers at the McMaster Qualitative Health Research Group are interviewing returning medical personnel as part of an ongoing survey. Preliminary findings show that doctors, nurses, and other medical personnel who volunteer with Médecins Sans Frontières (MSF) often have also worked in Canada's remote communities, serving aboriginal populations.

© Marie-Jo Proulx, 2009