A Medical Student in the Tropics Part 1
After finishing your first year of medical school, you are eager to put your knowledge into practice and to help in an under-resourced setting, you decide to volunteer at an urban clinic in a tropical country. You have never been to this country, and are intrigued by their culture and would love the opportunity to learn a new language. The clinic administrator seems eager to have you come and serve the local community’s health needs as they are understaffed. What should you consider before you decide to go?
1. Ethics of care
The ethics of care dictates that you should consider all possible positive and negative impacts of your decision when working especially with those who can become vulnerable to our decisions. You should carefully consider how a visit to this country might affect the host community. Here are some questions to consider:
- What kind of training might be necessary to address the health needs of the community you are entering?
- How might your actions make the community more or less vulnerable?
- The country has an established medical system; however, students within the same cohort as you are not permitted to practice. How do you respond to this?
2. Non-Maleficence/Beneficence
In working in any kind of clinical setting, whether at home or abroad, your first priority according to this principle is to do good without doing any harm. However, you are also obligated to help patients in the hospital and may feel that your training has provided you with the necessary skills to at least help patients with mild medical complaints. Some questions to consider:
- What are the potential benefits and harms to providing basic care to patients? Consider possible barriers to providing care e.g. lack of training in tropical medicine, variations in therapeutic nomenclature, and communication.
- How does your training contribute to these potential benefits and harms?
3. Justice
When justice is held as the most important consideration, resources are distributed equally to all individuals who are similarly situated. In this case justice would favour allocating the available medical resources (trained physicians) to all patients equally because they are similarly situated. Some questions to consider:
- Assuming that all patients are “similarly situated”; does your presence ensure that the community is receiving balanced health care?
- What are the long-term implications on the distribution of health services i.e. once you have left?
A Medical Student in the Tropics Part 2
You decide to go and upon arrival, you find that the staffing shortage at the clinic is more severe than the administrator described; there is a desperate and immediate need for patient care. Your passion for serving vulnerable populations pushes you to lend a hand. You start by assessing the patients and recommending treatments. You feel satisfied with your work, but can’t shake the nagging feeling that due to your lack of thorough medical knowledge you may have misdiagnosed some patients or offered the wrong treatment. Nevertheless, compared to the other foreign students, who performed surgeries (and bragged about doing so), you think that what you did was not harmful. You feel your services were beneficial to the clinic and its patients; but was it the right thing to do?
1. Ethics of care
The ethics of care dictates that you should consider all possible positive and negative impacts of your decision when working especially with those who can become vulnerable to our decisions. This theory would suggest you also consider how your services may have caused harm to the community. Some questions to consider:
- Have your services made patients more vulnerable to continued health problems?
- What implications do your services have on the continuity of patient care?
- What immediate benefits does the community experience due to your actions? Compare these to the possible harms that you identified above.
2. Non-Maleficence/Beneficence
In working in any kind of clinical setting, whether at home or abroad, your first priority according to this principle is to do good without doing any harm. Some questions to consider:
- What implications does your volunteering have on the work of other clinic staff?
- Assuming you misdiagnosed a patient or provided incorrect treatment, what implications does this have on the relationship between the community and the hospital?
3. Justice
When justice is held as the most important consideration, resources are distributed equally to all individuals who are similarly situated. In this situation, health care/health services are the resource to be distributed equally. Some questions to consider:
- Following your actions, are the inherent harms of the medical profession equally distributed amongst the community?
- Have your actions resulted in the equal distribution of health care within the community?
4. Autonomy
Autonomy talks about how individuals know what’s best for themselves and how we should not act in a way that compromise their agency. Some questions to consider:
- What is your responsibility to the patients/community? Should they be informed of your level of medical training?
- Does your level of medical training alter the quality of health care the community want?
Academic Resources (7):
Becker, H. S., B. Geer, et al. (1961). Boys in White: Student Culture in Medical School. Chicago, University of Chicago Press.
Betancourt, J.R. et al. Cultural Competence and Health Care Disparities: Key Perspectives and Trends. Health Affairs. 24(2): 499-505.
Evert, Jessica, Chris Stewart, Kevin Chan, Melanie Rosenberg, Tom Hall, et. al (2008). Developing Residency Training in Global Health: A Guidebook; Chapter 3: Ethics for Global Health Programming 23-35. San Francisco: Global Health Education Consortium. 119 pp.
Gibson, D. and M. Zhong (2005). “Intercultural communication competence in the healthcare context.” International Journal of Intercultural Relations 29(5): 621-634.
Kumagai, A. K. and M. Lypson (2009). “Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education.” Academic Medicine 84(6): 782-787.
Seear, M. (2007). An Introduction to International Health. Toronto, Canadian Scholars’ Press.
Shah, S. and T. Wu (2008). “The Medical Student Global Health Experience: Professionalism and Ethical Implications.” Medical Ethics 34: 375-378.
Non-Academic Resources (5)
Louie, D. and S. Dharamsi. (2009). “Creating Global Doctors.” The Lancet Student, from http://www.thelancetstudent.com/2008/04/14/creating-global-doctors/.
Orbinski, J. (2008). An Imperfect Offering. Toronto, Doubleday Canada.
Reed, P. (2007). Triage: Dr. James Orbinski’s Humanitarian Dilemma, National Film Board of Canada.
Remen, R. (2000). “Helping, Fixing, Serving.” iJourney.org, from http://www.ijourney.org/?tid=127.
Schimmelpfennig, S. (2010). “Would you hire a doctor or a contractor whose work was never evaluated?” Good Intentions Are Not Enough, from http://informationincontext.typepad.com/good_intentions_are_not_e/2010/01/the-importance-of-evaluations.html.
Total (12)
Evert, Jessica, Chris Stewart, Kevin Chan, Melanie Rosenberg, Tom Hall, et. al (2008). Developing Residency Training in Global Health: A Guidebook; Chapter 3: Ethics for Global Health Programming 23-35. San Francisco: Global Health Education Consortium. 119 pp.
