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Human Resources for Global Health: Ethical Questions and A Few Bibliographical Items Samia Hurst, Nir Eyal, and Dan Wikler I. Ten Ethical Questions in Human Resources for Global Health This brief survey presents ethical and philosophical questions about the crisis in human resources for health. They may arise when considering related ethical dilemmas of practice, policy and law, as we plan to do in the 2012 Harvard-Geneva-Brocher summer seminar. This list is merely illustrative, and not all of these questions will be addressed at the seminar. It seeks to be provocative and stimulate thoughts, not to define an agenda. We welcome additional items. 1. When do destination countries do “enough” to mitigate incoming migration? We are in the midst of a global crisis in human resources for health that exacerbates critical shortages in the health systems of some of the world’s poorest and least healthy populations. What steps are called for on the part of the governments of the wealthy countries to which medical workers trained in developing countries wish to migrate? For human trafficking in women and involuntary labor, zero tolerance is the appropriate standard, but it would make less sense for voluntary medical migration. Brain drain that degrades the health systems of the source countries needs to be discouraged, but responsibility for this is diffused among many recipient nations, each with distinctive needs and historical responsibilities. Moreover, some medical migration would be permissible even in an ideally just world. How, then, to determine each recipient country’s responsibilities for mitigating the cumulative public health problem? 2. Obligations of states to their own citizens Vs. to others: Doctors and nurses from developing countries might help the United States to reduce its high costs of health care and to extend access to care to more of its citizens, and “out-sourcing” care by funding medical tourism in some cases might have these advantages as well. Even as these measures enable America to live up to its responsibilities to its citizens, however, they may undermine efforts by developing countries to serve their populations. How should the US – and any nation similarly situated – resolve the moral conflicts involved in setting priorities among the needs of its citizens and the vulnerable citizens of other countries? 3. Doctors’ liberties Vs. patients’ health: In many countries, the profession of medicine has been successful in defending its prerogatives: high salaries, free choice of specialization and location of work, and high barriers against competition. In some others, doctors earn ordinary salaries and work where and how they are told. Which of these is closer to the ideal? This question becomes particularly urgent when there seems to be a direct trade-off 1 between doctors’ liberties and unmet population health needs. Insofar as the Global Code on International Recruitment of Health Personnel prioritizes health workers’ personal liberties, is it based on universal norms and human rights? Or is it a doctor-friendly document that perpetuates privileges that other workers could only dream about? 4. Balancing source country sovereignty and patients’ health: A global response to the crisis in human resources for health will proceed in the context of a complex web of national, bilateral and international agreements and expectations, and in the wake of a history of national interactions, both benign and predatory. Donors might expect considerable latitude in decisions on how their aid should be used for training health workers who are likely to stay. Countries in need may assert the prerogatives of national sovereignty in determining policies in health, health education, and employment. Should relieving the burden of disease take highest priority? Or is national sovereignty the first principle of all international cooperation, even if and where it seems to be a barrier to effective relief? 5. What are source-country medical schools permitted/obligated to do to stem the outward tide? May medical and nursing schools in poorer countries require applicants for fellowships to agree to remain in the country for decades after graduation? Can they require commitments to substantial periods of service in underserved rural areas within the country? If formal commitment and overt coercion are not permissible, then what of the alleged “emotional blackmail” of exposing students to populations of patients who direly need them, or expressing disdain for elite medical practice during lectures? Would it be permissible to try to “capture” trainees by deliberately omitting to train them for skills needed for practice in well-served settings, and less important elsewhere? Can there be any moral objection to basing admissions to medical and nursing schools on factors that predict that the graduate will not emigrate, such as rural origin? What if bad marks predict tendency to stay? 6. The Standard of Care: Developing countries often face a difficult choice between high standards and broad access to care. The training of white doctors in South Africa under apartheid was comparable to that of their peers in London and Boston, but when the new South African government sought to extend care to all its citizens, the need to train a much larger medical workforce forced difficult choices. Strenuous debates ensued, as medical faculties struggled to maintain their hard-won reputations. At the same time, graduates of the best medical institutions were most likely to obtain desirable posts upon emigration. Can we offer any moral advice for this perennial problem in developing-world health systems? 7. When are compensation mechanisms enough? The Global Code calls on destination countries to compensate source countries for lost workers. On what basis should the amount of compensation be determined? The cost of medical and earlier training? Or expected losses from emigration? Who should pay, and who should be paid? Do private remittances offset these losses? 2 8. Medical training and relative advantage: The Global Code calls on destination countries to try to achieve self-sufficiency in human resources for health. Is this goal of intrinsic value, or is it merely a useful strategy to stem the tide of trained health workers from poorer countries to richer ones? In fact, why shouldn’t some countries develop medical training as an export product? And shouldn’t other countries focus their efforts on what their populations do best, not necessarily on training health workers, if they are willing to pay source countries for trained personnel? 9. Why is medical migration such a special case? Ordinarily, worker recruitment does not give rise to claims to compensation, or veto, for the institution or region left behind. Why is health care service provision in resource-poor settings different? 10. Protecting health Vs. resisting intra-societal wage inequality: One way to increase health worker retention is to provide “carrots” that compete with salaries abroad. This works best if the salaries are increased to levels that seem disproportional to those of other local public workers. Thus the goal of retention runs up against norms of social equality. Moreover, the prospect of such high salaries might induce behavior that would have other undesirable (if unintended) consequences. How should these competing values be balanced? II. Bibliographical Items The following selection is fairly arbitrary and seeks mainly to offer a glimpse into some recent writings on the topic of the Brocher 2012 Summer Academy. 1. On the global health workforce crisis: • Chen LC. Striking the right balance: health workforce retention in remote and rural areas. Bulletin of the World Health Organization. 2010; 88(5). • Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. The Lancet. 2008; 371(9613): 668 - 74. • Frenk, J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fienberg H, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010; 376(9756): 1923-58. • Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low- income countries: a literature review of attraction and retention. BMC Health Serv Res. 2008; 8: 19. • Peñaloza B, Pantoja T, Bastías G, Herrera C, Rada G. Interventions to reduce emigration of health care professionals from low- and middle-income countries. Cochrane Reviews 2011. Issue 9. Art. No. CD007673. 7 September 2011. • Physicians for Human Rights. An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa. 2004 • WHO. The world health report 2006: Working together for health. Geneva: WHO; 2006. 3 • WHO. WHO Global Code of Practice on the International Recruitment of Health Personnel. Geneva; May 2010. • WHO. Increasing access to health workers in remote and rural areas through improved retention. Geneva: WHO; July 2010. • Many pieces in the open access journal Human Resources for Health. 2. On related ethical questions: • Benatar, S. R. (2007). An examination of ethical aspects of migration and recruitment of health care professionals from developing countries. Clinical Ethics 2(1): 2-7. • Cohen IG. Medical Tourism, Access to Health Care, and Global Justice. Virginia Journal of International Law. 2011; 52(1). • Dwyer, J. (2007). What’s wrong with the global migration of health care professionals? Individual rights and international justice. Hastings Cent Rep 37(5): 36-43. • Eyal N, Hurst SA. Coercion in the fight against medical brain drain. In: Shah R, editor. The International Migration of Health Workers: Ethics, Rights and Justice. New York: Palgrave Macmillan; 2010. p. 137-58 • Eyal N, Hurst SA. Physician brain drain: can nothing be done? Public Health Ethics. 2008; 1(2): 180-92 • Kalantri, S. P. (2007). Getting doctors to the villages: will compulsion work? Indian J Med Ethics 4(4): 152-3. • Oberman, K. Can brain drain justify immigration restrictions? Working paper. The hyperlink is to a version updated January 2010.

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