the ethics of electives

Electives Presentation

Jonny CurrieBristol

Why do we do electives?

Overseas electives Different cultural and

organisational setting See diseases rare in UK

Personal development Travel Experience different

medico-social context

A tale of two electives…

Adams and Sheather, 2001. Elective Ethics. sBMJ 9; p.305-356.

Medical tourism Self-serving

Raise unmet expectations

Ineffective

Impose burdens on local health facilities

Inappropriate

If under colonialism natural resources and human labour were exploited;

Are western societies now using under-developed nature of developing countries as training grounds for their own teachers and other professionals?

Are medical electives the new neo-colonialism?

Are medical electives the new neo-colonialism?

Practising ethics Ambassadors abroad

Discomfort about suddenly being expected to “see patients”

Poor supervision

Limited resources Huge health needs

Justifies acting role of doctor?

Practising ethics Patients have right to know are being cared by

students

Ethics of intervening

Legal ground

Moral boundaries

Risk to the poor – benefit to the rich Medical students profit from

international elective experience and practise within USA/Europe

benefits in training transferred to patients in developed world

burden of harm is placed on the population in the developing world and most benefit is accrued by patients in developed nations

exploitation might emerge

The Elective Industry Parallels to Gap Year industry

Diverse organisations

Simplistic definition of development

The Elective IndustrySPW is a true development organization. We will not send you on an exotic holiday where you can also indulge in a little teaching, or environmental work. You willknow that if you participate in one of our programmes you will be helping to make a real difference - not only for your CV, but for the people you are working with.

Original emphasis, Student Partnership Worldwide, 2002

Does the idea of travel to far off destinations appeal to you? How about the adventure of joining an expedition into the world’s greatest mountain ranges? And I expect you’d like to help a disadvantaged community and acquire new skills while working on an aid project . . . . At the same time you’re probably thinking about how your Gap Year will fit into the broader picture, will it be something to impress future employers and how will it look on your CV?

Venture Co., 2002, p. 1

Incorrect representation of ‘developing world’

Limited critical engagement allows students to confirm their presumptions, with added authority of ‘experience’

Fatalistic faith in the ‘luck of the draw’

‘Lotto logic’

Outgoing reflections of students

What the gap year industry lacks is a pedagogy for social justice

The route to internationalisation?

Authors question whether electives enable students to meet requirements of globalisation

Comprehensive programme of international health teaching

Preaching to the converted

Edwards et al, 2004. Understanding global health issues: are international medical electives the answer?

Curricula for change WHO qualities of ‘5 star

doctor’ Community oriented Reconciling individual and

community needs Initiating actions on behalf of

community

Tomorrow’s Doctors: Public health medicine

prominent in curriculum Health promotion; illness prevention; Assessment and targeting of

population needs Awareness of environmental

and social factors in disease

International Health electives Karolinska Institute,

Sweden

Global Multiculturalism Track, Massachusetts, USA

University College London, UK

Health Systems Developing countries face

severe health workforce shortages

4 million health workers needed to fill gap (World Health Organisation)

NGOs can lure qualified people from Ministry of Health and into private sector

Parallel health systems NGOs can high more staff

at higher salaries Can acquire specialised

equipment Or create idealised projects

serving one limited population in a geographic area

Result is a fragmented and inequitable health system

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 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.

Funding Electives operate in

context of inequality

Consider how you spend your money

Ethics of funding?

What can you do? Before you leave:

think what you hope to gain and what you are capable of doing

question medical school on when to ask for help and what to do when not forthcoming

knowledge and skills of health context

Broad learning on determinants of disease

What can you do? Once you’re there:

discuss with supervisor what is expected and how you can be most helpful

offer something in return relevant research

On return: future student or research

exchanges Reflect on experience Develop global

understanding

Final remarks We live in a global

economy; surely we should practise global medicine?

One-way process

Strive to minimise the risk: benefit ratio

Essential reading

UCL Elective Pack

Available at:http://student.bmj.com/international/elective_pack.php

Improving health for the world’s poor: what can health professionals do?

http://www.bma.org.uk/ap.nsf/content/Improvinghealth

Global Health education

http://www.medsin.org

http://globalhealthedu.org/Pages/default.aspx

Websiteshttp://student.bmj.com/international/electivenpack.php

http://www.bma.org.uk/ap.nsf/content/Improvinghealth

http://www.medsin.org

http://globalhealthedu.org/Pages/default.aspx