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Individual Rights and International Justice

by JAMES DWYER

When health care workers migrate from poor countries to rich countries, they are exercising an

important human right and helping rich countries fulfill obligations of social justice. They are also, however,

creating problems of social justice in the countries they leave. Solving these problems requires balancing

social needs against individual rights and studying the relationship of social justice to international justice.

In New Zealand, the United Kingdom, Australia,the United States, and Canada, over 20 percentof practicing physicians are foreign medical grad-

uates. Many of these physicians emigrated from low-and middle-income countries that struggle under rel-atively high burdens of disease. Jamaica, Haiti, Pak-istan, India, Ghana, South Africa, and Uganda, forexample, have lost more than 10 percent of their

James Dwyer, "What's Wrong with the Global Migration of HealthCare Professionals? Individual Rights and International Justice,"Hastings Center Report 37, no. 5 (2007): 36-43.

practicing physicians. For some countries, the losshas been much more dramatic. Since Zambia gainedits independence, it has graduated about five hun-dred physicians. Only sixty still practice in the coun-try.' The migration of nurses follows a roughly simi-lar pattern. The United Kingdom, the United States,and Canada have imported large numbers of nursesfrom the Philippines, India, the Caribbean, andAfrica. Some of the nurses were actively recruited byhospitals and health care systems. Others availedthemselves of informal networks of migration.

Although this global migration benefits the desti-nation countries, it seems terribly unfair. Some of the

36 HASTINGS CENTER RFPSRT Septernber- October 2007

wealthiest and healthiest societies arepulling health care professionals frompoorer and sicker countries, leavingthem with substantially fewer healthcare workers to attend to enormoushealth needs. Canada, for example,where the average life expectancy isseventy-nine years, is attracting nursesfrom South Africa, where the averagelife expectancy is forty-nine years. Inthe usual flow of medical migration,the source countries lose a lot: highlyneeded and skilled personnel, publicinvestments in education and train-ing, and leadership and social capital.But they also gain. Workers who goabroad often send home remittances.Health care professionals who areworking abroad sometimes help todevelop transnational connectionsand partnerships. And if health careprofessionals return home to practice,they bring with them enhanced skillsand new ideas. To understand theethical aspects of this global migra-tion, it's tempting to try to add up allthe gains and losses in order to arriveat a net balance.

But I think that's the wrong way toproceed. Although the consequencesare undoubtedly important, weshould not assume at the outset thatjustice is to be understood on an ac-counting or business model. I want tobegin with the question of whetherhealth care workers have a right toemigrate. This discussion will lead toquestions about social and, eventually,international justice and the complexrelationship between them. I shallconclude by considering a few exam-ples of fundamental changes that,while respecting individual rights,would move us closer to ideals of re-sponsibility, social justice, and inter-national justice.

The Migration of Health CareWorkers

irst, a few indicators and studiesin order to provide a better de-

scription of the migration of healthcare workers. One measurement ofmedical migration is the percentageof physicians practicing in a particular

country who are graduates of foreignmedical schools. The five highest per-centages are found in wealthy, Eng-lish-speaking countries: in NewZealand, 35 percent of physiciansgraduated from foreign medicalschools; in the United Kingdom, 28percent; in Australia, 27 percent; inthe United States, 25 percent; and inCanada, 23 percent.2

Of course, not all of these foreignmedical graduates are from develop-ing countries. There are physiciansfrom Ireland practicing in the UnitedKingdom; physicians from the Unit-ed Kingdom practicing in Australia;and physicians from Canada practic-ing in the United States. But a sub-stantial number come from low- and

middle-income countries with rela-tively high burdens of disease. In theUnited States, for example, over 60percent of immigrant physicianscome from low- or middle-incomecountries. Over forty thousand arefrom India, over seventeen thousandfrom the Philippines, and almost tenthousand from Pakistan.

As impressive as these numbersare, an even better indicator of theproblem is the emigration factor-that is, the percentage of physicianswho have left the country where theywent to medical school.3 Many coun-tries in different global regions havelost well over 10 percent of theirphysicians. In the Indian subconti-nent, Sri Lanka has lost 28 percent ofits physicians, Pakistan 12 percent,and India 11 percent. In theCaribbean, Jamaica has lost 41 per-cent, Haiti 35 percent, and the Do-minican Republic 17 percent. In

September-October 2007

Africa, Ghana has lost 30 percent,South Africa 19 percent, Ethiopia 15percent, Uganda 14 percent, Nigeria12 percent, and Sudan 11 percent.South Africa is a complex case. Whilemany South African physicians haveleft to practice in more developedcountries, many physicians fromother African countries have beendrawn to practice in South Africa.

In most wealthy countries, the per-centage of nurses who are foreign-trained is not as high as it is for physi-cians. For example, about 10 percentof the nurses in the United Kingdomare foreign-trained, compared to 28percent of the physicians. 4 But the sit-uation is changing. In the last tenyears, the proportion of foreign-

trained nurses among newly regis-tered nurses has risen dramatically. In2001, more foreign-trained nursesthan British-trained nurses registeredin the United Kingdom. Many ofthese newly registered nurses are fromthe Philippines, India, South Africa,and other African countries.

For many hospitals and health caresystems, the out-migration of nurseshas become unmanageable. At onehospital in Malawi, 60 percent of theregistered nurses emigrated during athree-year period.6 In Ghana, 50 per-cent of the registered nurses have leftduring the last ten years. 7 In thePhilippines, about 70 percent of nurs-ing graduates move abroad, wherethey can earn 10 to 20 times more.Although nursing schools have ex-panded in the Philippines, and thecountry counts on remittances as partof its development plan, it now has

HASTINGS CENTER REPORT 37

For many hospitals and health care

Ssystems, the out-migration of nurses

has become unmanageable. At one

hospital in Malawi, 60 percent of the

registered nurses emigrated during a

three-year period.

about thirty thousand vacant nursingpositions."

In most source countries, three orfour migrations are taking place si-multaneously, compounding the ac-cess problems. Health care workersare moving from rural areas to urbanareas and from the public sector tothe private sector (the latter due inpart to structural adjustment policiesthat have forced countries to curtailpublic expenditures).9 There are evenreports, though no hard data, thatwell-funded NGOs are hiring healthcare workers away from the publicsystem. Thus, the overall shortage ofhealth care workers tends to be feltmost acutely by the most disadvan-taged groups-those in rural areasand those that depend on the publicsystem. In South Africa, for example,the outflow of nurses has been partic-ularly detrimental to the public sec-tor.10

Many factors are pulling healthcare professionals to more developedcountries: higher salaries, better work-ing conditions, more training oppor-tunities, relatively stable political con-ditions, beliefs about merit, andhopes for the future. These factorscombine with the dominance of Eng-lish in science, the standardization ofhealth care, and the effects of colo-nialism. All these factors work withina labor market that is more globalthan ever. The resulting migration isnot surprising, but it does raise deepethical questions.

Rights and Responsibilities

T he first ethical issue to address iswhether people have a right to

emigrate. I believe they do because ofwhat it protects people against, whatit allows people to do, and how it isrelated to other rights and concerns.Consider some widely accepted basicrights. People have a right to securityagainst genocide, slavery, arbitrary ar-rest, torture, and persecution. Theyalso have a right of conscience that al-lows freedom of religion, politicalopinion, and a range of beliefs. Andthey have a right to marry and prac-

38 HASTINGS CENTER REPORT

tice an occupation. All of these arehuman rights, which puts them in aspecial subclass of rights. The right toemigrate serves to reinforce theserights and to protect people whenthese rights are violated or in danger.If people are allowed to leave, thenthey can seek asylum or residenceelsewhere. Recognizing the right toemigrate would justifiably limit thepower that governments have overpeople and allow people more free-dom of movement to pursue theirgoals and help their families.

Article 13 of the Universal Decla-ration of Human Rights of 1948 tellsus that the right to emigrate is itself ahuman right. I'm not sure that thereis a principled, nonpragmatic way todelineate the subclass of humanrights," but whether the right to em-igrate is a human right or not, it iscertainly an important right. Still, likeall rights, it needs to be specified,qualified, and balanced against otherrights and concerns. Even the Univer-sal Declaration of Human Rights,which includes an expansive list ofrights, recognizes that people haveduties to the community and thatrights may be limited based on "thejust requirements of morality, publicorder and general welfare" (Article29).

The right to emigrate should bequalified by and balanced against thesocial responsibility of health careprofessionals. One basis of this re-sponsibility is the public investmentthat society makes in the educationand training of health care profession-als. This investment takes manyforms: state schools, state subsidies,tax regulations, loans, research grants,public hospitals and clinics, patientsto learn on, cadavers to dissect, teach-ers who have been publicly educated,and so on. But establishing responsi-bility is not only about identifyingand tracing public resources. It's alsoabout delineating the legitimate struc-ture of social institutions. In my view,it is right for a social system to en-courage people to develop and exer-cise their abilities in ways that con-tribute to the social good.12 Some de-

gree of responsibility may be embed-ded in the structure of a legitimate so-cial order.

The need for qualifying the rightto emigrate arises when a sizeablenumber of people take advantage ofthe social order to develop abilities,but then use those abilities to benefitpeople in other societies that arewealthier and healthier. The issue hereis not about forcing people to developabilities and then to exercise them in aprescribed way. People are free not tostudy; they are free not to exercisetheir skills; they are even free to leavea society. But at least in many circum-stances, when people choose to ac-quire professional skills and rely onpublic resources and institutions toachieve that goal, they also acquiresome social responsibilities.

Putting social responsibility intopractice requires balance and judg-ment. A society could justifiably re-quire that health care professionalscomplete a substantial period of pub-lic service before they emigrate, oreven before they graduate. It couldalso justifiably require a payment ifhealth care professionals want to emi-grate before practicing for a numberof years. Moderate and reasonableschemes qualify, but do not violate,the right to emigrate.

We should also think about thedestination countries. Does recogniz-ing a right to emigrate entail a duty toaccept immigrants? Some rights doentail correlative duties, but others donot. If I have a right not to be tor-tured, then other people have a dutynot to torture me. But if I have a rightto marry, it does not follow that any-one has a duty to marry me. I wouldput the right to emigrate in the sec-ond category. People have a right toleave their country, but no particularcountry has a duty to take them in.(The right to asylum seems to belongin the first category, however: peoplehave a right to seek asylum, and if theclaim is reasonable, the country wherethey have sought asylum has a duty totake them in.)

Overall, it makes ethical sense torecognize both that people have a

September- October 2007

qualified right to emigrate and thatstates have a qualified right to regu-late immigration. A country's right toregulate immigration does not de-pend on the appropriateness of cur-rent national boundaries, which maybe quite contingent and arbitrary. It isbased on the need for defined territo-ries that allow peoples to form repre-sentative governments, maintain justpolitical institutions, deal more effec-tively with social problems, and takemore responsibility for the naturalenvironment.' 3 The problem of med-ical migration does not arise becausethe destination countries are trying torestrict immigration, but becausethey are restricting immigration in ahighly selective way. They seem onlytoo willing to accept highly qualifiedhealth care workers while trying tokeep out less skilled workers. It is thisapproach to immigration that raisesissues of justice.

Social Justice andResponsibility

efore taking up the issue of inter-national justice, I want to consid-

er the migration of health care work-ers from the perspective of social jus-tice-the justice of arrangements andstructures within a society. Lackingspace for a detailed account of socialjustice, I will note just a few basic fea-tures of social justice that help illumi-nate the problem of medical migra-tion. I believe a just society would (1)respect rights and foster responsibili-ties, (2) help people meet basic needs,and (3) give some priority to the leastadvantaged.

We have already discussed how thefirst feature is relevant to the problemof global migration, but the secondand third features need a little furtherexplanation. The intuition behind thesecond is that a society that could butdoes not work to help people meetbasic needs (for nutrition and safety,for example) seems unjust, even cruel."Basic needs" is a vague concept, ofcourse. Sometimes we know whethersomething is a basic need, but some-times we do not; and in my own view,

there is no easy, context-free way tospecify basic needs, especially thosethat concern health care. I may"need" a very expensive, rare, andtechnical treatment (extracorporealoxygenation, for example) in order tolive. From an individual point ofview, this treatment may seem like abasic need because it is the only wayto sustain life. But from a social pointof view-taking into account popula-tion needs, cost-effectiveness, and op-portunity costs-we may not want tocount this need as basic.

The idea behind the third featureis that a society that favors and de-votes more and more resources togroups that are already better offseems unjust. Such a society seems tobe organized according to power rela-tions, not norms of justice. Talk

about priority is also vague, of course:sometimes we know who the disad-vantaged groups are, how much pri-ority they should be given, and whatcount as important social goods, andsometimes we do not.

The vagueness in my descriptionof social justice is a merit, given mypurpose. I want to avoid a protractedargument about the exact features ofjustice, and I want to connect myconclusions with a range of views-for example, the view that we shouldmaximize the benefit to the least ad-vantaged, as well as views that balancethis priority against the overall good.Hence, I tried to describe social jus-tice only with that amount of preci-sion that will help me illuminatesome important aspects of medicalmigration.

Now, consider how the destina-tion countries make use of medicalmigration. Often, they use immigranthealth care workers to serve under-served populations: to work as gener-


al practitioners in rural areas, to staffhospitals in inner cities, to serve inthe prison health system, and so on.The Canadian provinces of Albertaand Saskatchewan, for example, haverecruited foreign physicians to prac-tice in rural areas.14 The United Statesaccepts many foreign medical gradu-ates to work as residents at teachinghospitals that serve inner cities. Manyof these residency positions are infields like pediatrics and internalmedicine, not dermatology and or-thopedic surgery, and many of theforeign graduates who accept thesepositions end up staying in the Unit-ed States.

The destination countries are notto be faulted for trying to meet thehealth care needs of disadvantagedgroups. Indeed, this effort is congru-

ent with the goals of meeting people'sbasic needs and giving some priorityto those who are disadvantaged,which I have just noted are features ofsocial justice. The ethical problemconcerns the origin of the medicalstaffing shortfall and the response toit. The shortfall stems, in part, fromthe fact that those in the health careprofession in destination countrieshave relatively little sense of social re-sponsibility. Physicians would ratherpractice dermatology in the suburbsthan pediatrics in the inner city. Andthe profession does not take responsi-bility for the distribution of physi-cians within society (in terms ofplaces and specialties).

Politicians and planners respondto the distribution problem by focus-ing on solutions that are quick,cheap, and market-based, such as im-porting foreign health care workers.But importing foreign workers tomeet national health care needs takesmeasures that are international in


In most source countries, three or

four migrations are taking place

simultaneously, all influencing each other.

scope to solve a problem of social re-sponsibility and social justice. It pitsthe interests of relatively disadvan-taged groups in wealthier societiesagainst the interests of people in low-and middle-income countries. This isnot an inevitable tragedy, but a social-ly constructed problem.

The destination countries also useimmigrant health care workers to ad-dress overall shortages. The UnitedStates, for example, is experiencing ashortage of nurses. The present short-fall is about one hundred thousandless than the demand. Because of thelimited supply of American nurses,the relatively low rates of retention,and the aging population, the short-fall in 2020 could be as high as eighthundred thousand.15 Some estimatesalso project shortages in the supply ofphysicians, at least in specialties likefamily practice and geriatrics.

Addressing overall shortages ofhealth workers also meets a popula-tion's basic health care needs, which iscongruent with social justice. But it isimportant to consider various ways ofresponding to the perceived shortagesand to examine critically the assump-tions behind the perception. Import-ing nurses is one possible measure.The destination countries could alsoexpand their nursing schools, raise thesalaries of nursing faculty, recruitmore people into these schools, andtry to retain more nurses who are al-ready in the work force. These coun-tries could even try to make the pro-fession of nursing more attractive totheir own citizens by increasing nurs-es' pay, improving their work condi-tions, increasing their autonomy, andaccording them more respect. This re-sponse would require a long-termview and a willingness to make funda-mental changes.

Or the destination countries couldtake a more radical step and criticallyexamine the very idea of a shortage.After all, compared to most countries,they have no shortage of health careprofessionals. The United Kingdomhas one physician for about everythree hundred people, whereas Ghanahas one physician for about every fif-


teen thousand people.16 But even inabsolute terms, the idea of a shortageassumes too much. In an ethicalanalysis, making some distinction be-tween real needs and market demandsis important. The projected shortagesare based on market demands, but thereal needs are for conditions that sus-tain good health and responses thatameliorate or palliate ill health.

Within a wealthy country, healtheconomists have noted a pretty clearcorrelation between the number ofdoctors and the expenditures forhealth care, but they have not seen aclear correlation between the numberof doctors and measures of popula-tion health. More may not be better,especially if we consider the opportu-nity costs. If health and justice are im-portant goals, and opportunity costscount, then a society might not needmore physicians. It might need in-stead a different mix and distributionof physicians, or a different kind ofhealth care system, or it might need tofocus attention on the social determi-nants of health (rather than on simplyresponding to health needs after theyarise).

The bottom line is that destinationcountries are using immigrant healthcare professionals to address real prob-lems of social justice, but by relyingon these skilled workers, and by notconsidering other options, they aremaking it more difficult for thesource countries to address healthneeds and care for the disadvantagedin their own societies. This way of ad-dressing social justice in wealthycountries is undermining social jus-tice in poorer countries. It is this com-plex relationship that gives rise to thedeepest problem of international jus-tice.

International Justice andResponsibility

O ne approach to the issue of in-ternational justice takes a cos-

mopolitan view. It discounts the im-portance of national boundaries, em-phasizes human need, and appliesprinciples of social justice globally.

The contrasting approach embodies apolitical view. It gives more weight tonational boundaries, focuses less di-rectly on individual need, and empha-sizes background conditions that en-courage just societies. 17

The cosmopolitan approach unde-niably has a certain intuitive appeal. Itseems morally important to try to ex-tend features of social justice to theworld as a whole, and it seems moral-ly salient to consider basic humanneeds in all countries and to givesome priority to the least advantagedin the world. The cosmopolitan ap-proach also illuminates some of theethical concerns with global medicalmigration. People need social condi-tions that promote and sustain goodhealth and social responses that ame-liorate or palliate ill health. Clearly,basic health needs matter in a waythat some goods do not. I am relative-ly unconcerned about the migrationof basketball players to North Ameri-ca. Many of the best players in theworld leave their countries to work inthe National Basketball Association,drawn by the high salaries, the socialprestige, and the opportunity to de-velop and test their skills. But physi-cians and nurses are different frombasketball players in ethically signifi-cant ways.

The focus on basic need may alsohelp to explain why some medical mi-grations are more morally troublingthan others. I am troubled by the em-igration of 30 percent of Ghana'sphysicians because life expectancy inGhana is about fifty-seven years. I amless troubled by medical migrationout of Ireland. About 40 percent ofIrish physicians have emigrated, yet inspite of this high rate, life expectancyin Ireland is about seventy-six years.Of course, the high rate of Irish med-ical emigration still raises questionsabout international fairness, postcolo-nial exploitation, and national poli-cies, but the questions lack the moralsalience and urgency that they havewhen we think about Ghana. Com-parative need, even between peoplewho live in different societies, seemsto make a moral difference, at least to


some degree and in some contexts.Even the underserved groups in thedestination countries are better offthan many or most people in thesource countries. The rural areas ofCanada, for example, have bettermeasures of population health thanSouth Africa as a whole, and muchbetter measures than the disadvan-taged areas in South Africa. And thatfactors into my moral judgment.

The implications of the cos-mopolitan approach for global med-ical migration are not difficult to sortout. A cosmopolitan approach thatextends the features of social justicethat I sketched demands that we takeinto account the interests and per-spectives of the least advantagedgroups. This concern with the leastadvantaged is missing from account-ing models of international justicethat simply tally up the average gainsand losses in the respective countries.Balance sheets that try to calculatewhat a source country loses and whatit gains in remittances and partner-ships tend to ignore the distribution.The least advantaged in the sourcecountries are often left behind be-cause the remittances rarely benefitthem, and the out-migrations under-mine the public sector on which theydepend. The private gains do notcompensate fairly for the public loss-es.

Similarly, the political approachalso has a certain intuitive moral ap-peal. It sometimes makes moral senseto give some weight to nationalboundaries while trying to create in-ternational frameworks and condi-tions that foster internally just soci-eties. This approach can also help toarticulate what's troubling about thecurrent forms of medical migration.As I said before, I believe that each so-ciety should be ordered so as to at-tend to basic needs and give some pri-ority to the least advantaged in soci-ety. But the international system ofmedical migration makes achievingthese aspects of social justice harderand more expensive for poor coun-tries, and easier and less expensive forrich countries. That's what seems so

unfair, even morally perverse: the in-ternational system tends to under-mine social justice in the neediestcountries.

But now a complication. Considerthe migration of manufacturing capi-tal. Suppose a company decides toshift its manufacturing base from arelatively rich country (with highlabor costs) to a relatively poor coun-try (with low labor costs). This shiftmay benefit workers in the poorcountry and consumers in manycountries, but it will probably hurtworking class people in the rich coun-try. In a way, the shift makes it harderor more expensive for the rich coun-try to achieve features of social jus-tice--especially if jobs are outsourcedto countries that lack labor unions

son to think it would work any betterin the international case.

In the domestic case, in order toachieve a just social order, societyneeds to attend to the background in-stitutions and conditions in whichmarkets operate. The features of jus-tice that one desires help to specifywhat the social conditions should be.For example, John Rawls desires a so-cial order that works to secure equalliberties, to ensure fair value of politi-cal liberty, to promote fair equality ofopportunity, and to improve the situ-ation of the least advantaged. But cer-tain conditions are needed to approx-imate fair value of political libertyand fair equality of opportunity. Hewrites:

The destination countries are not to

be faulted for trying to meet the

health care needs of disadvantaged

groups. The ethical problem concerns the

origin of the medical staffing shortfall and

the response to it.

and ignore safety regulations and pol-lution standards. In this sense, then,this example is analogous to that ofmedical migration out of poor coun-tries. But it may not be similarlyproblematic. What it really points tois the need to look more comprehen-sively, from the point of view of jus-tice, at international transactions andconditions.

In the international realm, wecould work to create conditions thatensure a free market-in this case, afree labor market-and simply acceptas fair whatever results. But it wouldbe a mistake to emphasize markets,contracts, and procedural justicewhile ignoring the importance ofbackground institutions and norms.This approach has not worked well inthe domestic case, and there's no rea-


A free market system must be setwithin a framework of politicaland legal institutions that adjustthe long-run trend of economicforces so as to prevent excessiveconcentrations of property andwealth, especially those likely tolead to political domination. Soci-ety must also establish, amongother things, equal opportunitiesof education for all regardless offamily income."8

If market forces are not embedded inappropriate institutions and inequali-ties of goods are not kept within ap-propriate limits, they result in politi-cal domination and gross inequalitiesin opportunities.

I have a similar concern about in-ternational transactions. 19 Interna-tional institutions and conditionsshould promote justice at two levels.


They should promote just relationsbetween societies in matters like theuse of force, the protection of the en-vironment, and other areas. But theyshould also promote the developmentof internally just societies (with dueregard for different reasonable ways ofordering society). I suggested beforethat just social orders strive to helppeople meet basic needs and givesome priority to the disadvantaged.But the unregulated migration ofhealth care workers tends to under-mine those worthy aims. To try to mi-cromanage every international trans-action would be foolish, but to pro-fess concern about social justice while

strict the public sector, skewed distri-butions of health care workers withincountries and within specialties, un-questioned assumptions about short-ages, a reliance on global labor mar-kets, and international norms thatmake social justice harder to achieve.If those are the constraints, then myanswer is, Not much. All we can do istinker around the edges of the prob-lem: for example, we can ask publicagencies to follow codes of recruit-ment, which private agencies willprobably ignore.

But if we are willing to considermore fundamental changes, thenthere are many ideas worth exploring.

The right to emigrate needs to be

qualified by and balanced against the

social responsibility of health care

professionals.

ignoring international conditions thatimpede its realization is naive, evenhypocritical. Thus, both the cos-mopolitan and the political approach-es point toward similar conclusionsabout the problem of medical migra-tion, in spite of their important dif-ferences.

Ways of Responding

T he migration of health care work-ers from developing to developed

countries, now in its fifth decade, hasbeen as enduring as it has been signif-icant. So what can be done about it?This is the question that people oftenask when I give talks about medicalmigration. Different people ask it indifferent ways-some with great con-cern, and others with an air of cyni-cism or defiance. Sometimes thequestion is a challenge to formulate asolution that leaves everything elsethe same: an unlimited right to emi-grate, low levels of social responsibili-ty (in both source and destinationcountries), an emphasis on trainingfirst-world doctors, policies that re-


First, given the current internationalpolitical climate, the source countriesmay want to consider some responsesthat they could undertake themselves.For example, they could require sub-stantial social commitments frompeople who are educated as healthcare professionals. They could alsofocus more attention and resources ontraining community health workers.

This second idea, in particular, isworth exploring. In many sourcecountries, a significant number ofpeople suffer health problems becausethey lack adequate nutrition, safewater, good sanitation, and very basicmedical care. Blindness, for example,is sometimes caused by biologicalconditions that cannot be prevented.In a few of these cases, the only treat-ment may be a cornea transplant,which requires highly trained oph-thalmologists and a complex medicalinfrastructure. But almost 4 percentof all blindness is caused by (latestage) trachoma, an infection trans-mitted by flies found in communitieswith unsanitary living conditions.20Preventing blindness from trachoma

does not require board-certified oph-thalmologists and cornea banks. It re-quires political will, appropriate socialorganization, and community healthworkers.

Focusing attention on communityhealth workers may allow sourcecountries both to promote basichealth and to reduce health dispari-ties. Community health workers mustunderstand something about scienceand causal mechanisms, but theymust understand more about socialconditions and interventions. To beeffective, they need a command of thelocal language, a lot of local knowl-edge, a variety of skills, and the trustof the people they are working with.Because local languages, knowledge,and skills are not easily transferred,community health workers are lesslikely to emigrate. By contrast, manymedical and nursing students learnknowledge and skills that are stan-dardized, abstract, transferable, andrefined for secondary and tertiarycare. In his article on medical migra-tion, Fitzhugh Mullan notes that"many medical schools in source na-tions are influenced by the 'Westernaspirations' of their students, so thattheir training programs are not wellaligned with local patterns of diseaseand levels of technology. The result isthat graduates can be dissatisfied withopportunities in their own countries,inappropriately trained for local prob-lems, and inclined to seek placementabroad."21

Of course, the destination coun-tries have a greater responsibility totake action. They could address themaldistributions of health care profes-sionals, in terms of locations and spe-cialties, in their own countries. Theycould call into question assumptionsabout shortages and think about waysto promote conditions that fosterhealth. They could even think abouthow to set fair limits and meaningfulconditions on the expansion of med-ical consumption.

The destination countries couldalso work with other countries to ad-dress the problem of internationaljustice. To begin, they could enter


into cooperative agreements withsource countries. But the ultimategoal should be to create internationalnorms and institutions that embedmarket forces in ways that promote,rather than undermine, efforts toachieve social justice.

The responses I have outlined herewould aim to encourage social re-sponsibility while upholding a rightto emigrate, and would promote so-cial justice in ways more compatiblewith international justice. All ofthem, however, would require funda-mental changes in the way we thinkabout the problems, organize socialinstitutions, and regulate interactionsbetween societies. They require thatwe take a long-term view of humanresources, take ethical concerns moreseriously, and develop political will.

Acknowledgments

I am grateful to Peter Sy for conver-sations that furthered my thinkingabout these issues.

References

1. J. Johnson, "Stopping Africa's MedicalBrain Drain," British Medical Journal 331(2005): 3.

2. All these statistics are from E Mullan,"The Metrics of the Physician Brain Drain,"New England Journal of Medicine 353(2005): 1810-18. I have rounded off his fig-ures to the nearest whole number. The fol-lowing statistics about physicians are alsofrom this excellent study.

3. As Mullan notes, these figures under-state the problem. They are based on physi-

cians who are practicing in the UnitedKingdom, Australia, the United States, andCanada. They do not include physicianswho left to practice in other countries andphysicians who are not working as physi-cians. A physician from Sri Lanka who ispracticing in New Zealand is not included,for example. A physician from Haiti work-ing as a lab tech in the United States is alsonot included.

4. The estimates for nurses range fromabout 8 percent to 14 percent. See, for ex-ample, S. Glover et al., Migration: An Eco-nomic and Social Analysis (London: HomeOffice, 2001).

5. J. Buchan and J. Sochalski, "The Mi-gration of Nurses: Trends and Policies," Bul-letin of the World Health Organization 82,no. 8 (2004): 587-94.

6. Buchan and Sochalski, "The Migra-tion of Nurses," 588.

7. C. Nullis-Kapp, "Efforts Under Wayto Stem the 'Brain Drain' of Doctors andNurses," Bulletin of the World Health Orga-nization 83, no. 2 (2005): 84-85.

8. S. Bach, "International Migration ofHealth Workers: Labour and Social Issues,"working paper written for the InternationalLabour Office, 4.

9. See N. Daniels, "Equity and Popula-tion Health: Toward a Broader BioethicsAgenda," Hastings Center Report 36, no. 4(2006): 30-31.

10. See Bach, "International Migrationof Health Workers," 14.

11. John Rawls thinks there is. See J.Rawls, The Law of Peoples (Cambridge,Mass.: Harvard University Press, 1999), 78-80.

12. This is one of the key ideas behindRawls's difference principle. See Justice asFairness: A Restatement (Cambridge, Mass.:Harvard University Press, 2001), 61-79.

13. For a more detailed discussion of theright to regulate immigration and the socialresponsibility for immigrants, see J. Dwyer,"Illegal Immigrants, Health Care, and So-cial Responsibility," Hastings Center Report34, no. 1 (2004): 34-41.

14. Bach, "International Migration ofHealth Workers," 5; P. Bundred and C.Levitt, "Medical Migration: Who Are theReal Losers?" The Lancet 356 (2000): 245-46.

15. Bach, "International Migration ofHealth Workers," 6.

16. Nullis-Kapp, "Efforts Under Way,"85.

17. For a discussion of these two ap-proaches, see J. Dwyer, "Global Health andJustice" Bioethics 19, nos. 5-6 (2005): 460-75.

18. Rawls, Justice as Fairness, 44. Otherthinkers have also emphasized the need toembed economic forces within civil and po-litical society. See M. Walzer, "The Civil So-ciety Argument," in Theorizing Citizenship,ed. R. Beiner (Albany, N.Y.: State Universi-ty of New York Press, 1995), 165. See alsoK. Polanyi, The Great Transformation(Boston, Mass.: Beacon Press, 1957), 57.

19. So does Rawls: "Unless fair back-ground conditions exist and are maintainedover time from one generation to the next,market transactions will not remain fair,and unjustified inequalities among peopleswill gradually develop. These backgroundconditions and all that they involve have arole analogous to that of the basic structurein domestic society." Rawls, The Law ofPeo-ples, 42.

20. J. Ngondi et al., "The Epidemiologyof Trachoma in Eastern Equatoria andUpper Nile States, Southern Sudan," Bul-letin of the World Health Organization 83,no. 12 (2005): 904.

21. Mullan, "The Metrics of the Physi-cian Brain Drain," 1816.

HASTINGS CENTER REPORT 43Septe mber- October 2007

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TITLE: What’s Wrong with the Global Migration of Health CareProfessionals? Individual Rights and International Justice

SOURCE: Hastings Cent Rep 37 no5 S/O 2007

The magazine publisher is the copyright holder of this article and itis reproduced with permission. Further reproduction of this article inviolation of the copyright is prohibited. To contact the publisher:http://www.thehastingscenter.org/

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