Linköping Studies in Arts and Sciences No. 792 CTE No. 19 FACULTY OF ARTS AND SCIENCES The Ethics of Bilateral Linköping Studies in Arts and Sciences No. 792, CTE No. 19, 2020 Department of Culture and Society Labor Agreements for Nurses Linköping University SE-581 83 Linköping, Sweden Perspectives from the Philippines Klein R. Fernandez www.liu.se The Ethics Bilateral of Labor Agreements for Nurses Klein R. Fernandez 2020 ! Studies in Arts and Sciences No. 792, CTE No. 19 The Ethics of Bilateral Labor Agreements for Nurses Perspectives from the Philippines Klein R. Fernandez National School of Public Health, Universidade Nova de Lisboa, Lisbon, Portugal Universidade de Evora, Evora, Portugal Centre for Applied Ethics, Department of Culture and Society Faculty of Arts and Sciences, Linköpings universitet SE-581 83 Linköping, Sweden Linköping 2020 ! Studies in Arts and Sciences No. 792, CTE No. 19 The Faculty of Arts & Sciences provides education and research in humanities, social- and behavioural science, law, art disciplines and thematic science. The Faculty conducts research and offers postgraduate and doctoral programs both in individual disciplines and in interdisciplinary themes. This thesis comes from the Centre for Applied Ethics of the Department of Culture and Society (IKOS). Jointly, they publish the series Linköping Studies in Arts and Sciences. The PHOENIX Erasmus Mundus Joint Doctoral Program (PHOENIX EMJDP) Dynamics of Health and Welfare is managed by a consortium of universities composed of Universidade de Evora (UE), L'École des Hautes Études en Sciences Sociales (EHESS), Linköpings universitet (LiU), and the National School of Public Health, Universidade Nova de Lisboa (ENSP/UNL). The Ph.D. Program is designed for future careers in teaching, research, private and public management in national and international contexts. It is interdisciplinary with an explicit and solid basis in social sciences and humanities; thematically, theoretically, methodologically, and empirically. It includes philosophy and ethics, history, cultural, socio-economic, and political studies, epidemiology, demography, health economics and organization, health communication, evaluation techniques, etc. in humanities and social sciences. PHOENIX JDP integrates theory and practice in courses, seminars, research, and mandatory internships. Distributed by: CTE – Department of Culture and Society ISSN 0282-9800 ISBN: 978-91-7929-797-8 © Klein Fernandez, 2020 Printed in Sweden by LiU-tryck, Linkoping, Sweden, 2020 Cover picture: Christian Joy Brosas Abstract The dissertation "The Ethics of Bilateral Labor Agreement for Global Nurses - Perspectives from the Philippines" is written in the research area of applied ethics and examines ethical aspects of labor migration in the specific area of healthcare, with the Philippines as an example. The central questions for the dissertation are the ethical issues of nurse migration in the Philippine context. These ethical concerns give rise to how the responsibility for such migration governance should be understood and designed. More specifically, the issue of responsibility is discussed in relation to the Philippine Government, and its counterpart foreign governments, for their use of the bilateral labor agreement (BLA) as a policy measure to manage the migration of nurses. The thesis draws on from empirical studies of Filipino nurses’ massive emigration and how this mobility affects individuals and the Philippine society. Historical description of the emergence of healthcare professionals as export products in the Philippines are also consulted. The country’s colonial history is described, and its relevance to today’s migration pattern is analyzed. Based upon the empirical data on past and present Filipino health worker emigration, identified ethical implications are examined. Among these are the rights of individuals and the division of responsibilities between origin and destination countries in order to address the ethical implications the BLAs give rise to. In the theoretical part of the work, key elements from John Rawls’ theories of justice (1971, 1993, 2001) are used to identify conditions of a crafting public policy that, ideally, should be met in agreement with the members of a liberal society. Thereafter, the ideal model of a BLA is constructed based on the main principles of justice. The model is used to examine the extent to which, if at all, the existing BLAs between the Philippines and countries like Japan and Germany can be considered as ethically defensible instruments for managing the emigration of nurses. Finally, a discussion on how such agreements should be designed to be ethically defensible is offered. Key words: Nurse migration, ethics of migration, Rawls’ theory of justice, bilateral labor agreements i Avhandlingen ”The Ethics of Bilateral Labor Agreement for Global Nurses – Perspectives from the Philippines ” är författad inom forskningsområdet tillämpad etik och undersöker etiska aspekter av kompetensmigration inom det specifika området vård och omsorg, med Filippinerna som ett exempel. De mest centrala frågorna för avhandlingen är vilka etiska frågor som kompetensmigration inom området vård och omsorg i en Filippinsk kontext ger upphov till liksom hur ansvaret för sådan migration bör förstås och utformas. Mer konkret diskuteras ansvarsfrågan i relation till den Filippinska statens bruk av bilaterala avtal avseende Filippinska sjuksköterskor. Studien tar sin utgångspunkt i empiriska studier av massutvandringen av Filippinska sjuksköterskor och hur denna mobilitet påverkar enskilda individer liksom det Filippinska samhället. Den deskriptiva delen rymmer även en historisk beskrivning av framväxten av ”vårdpersonal som en exportprodukt” i Filippinerna. Landets koloniala historia skildras och relevansen därav för dagens migrationsflöde analyseras. Ur den inledande empiri-fokuserade delen extraheras ett antal frågor av etisk karaktär. Dessa rör primärt de rättigheter och skyldigheter liksom ansvar och ansvarsfördelning för de identifierade etiska implikationerna av rådande kompetensmigration. I en teoretisk, analytisk del av arbetet, används centrala element ur John Rawls teorier om rättvisa (1971, 1993, 2001) för att identifiera villkor som, idealt, bör vara uppfyllda i avtal som rör medborgare. Därefter tillämpas den ideala modellen på rådande bilaterala avtal gällande arbetskraftsutvandring inom vårdsektorn. Modellen och används för att undersöka i vilken grad, om alls, som de befintliga bilaterala avtalen som Filippinerna har utverkat med länder som Japan och Tyskland kan anses vara etiskt försvarbara instrument för att kontrollera flödet av arbetskraft inom vårdsektorn. Avslutningsvis diskuteras hur sådana avtal skulle behöva utformas för att vara etiskt försvarbara. ii Acknowledgement My dissertation is a by-product of collaborative work with several scholars, professors, and friends who came across my path while on this long journey. I have a lengthy list of people that can fill in every space of this page. I am forever indebted to all of your professionalism, generosity, and kindness. Daghang salamat! I am grateful to have Dr. Elin Palm as my main supervisor for many reasons. Since I started in 2016, I have fully trusted your wisdom and academic guidance. You were with me from laying the philosophical foundation of my public health-oriented research and building together, brick by brick, the Rawlsian blueprint of my dissertation in applied ethics. Challenging myself to take up the field that is unknown to me is a tough journey, but I can never emphasize more than enough of the kind of patience you have shown in supervising someone from a different academic discipline. My heartfelt gratitude also goes to my secondary supervisor, Professor Alexandre Abrantes. I value so much your technical and theoretical insights on global health governance. I would also like to thank Professor Ines Fronteira and Professor Gilles Dussault for imparting their professional expertise while taking their course on Human Resources for Health. I am forever appreciative of my seminar discussants, Dr. Henrik Lerner of Ersta Hogskola and Dr. Jonathan Joseffsson of the Department of Thematic Studies, for sparing time and stretching enough patience in reading through my manuscripts. I am so indebted to your clear and thorough theoretical insights in furthering the focus of my ethical framework on John Rawls. My sincerest appreciation also extends to the academic staff of the Centre for Applied Ethics for their generous insights. It feels great to belong in a department peopled with rocKstars. Professor Göran Collste would always have the time to read my drafts and drop by my office to discuss strategies to move forward. Dr. Yusuf Yusekdag, Dr. Johanna Romare, Dr. Erik Gustavvson, and Dr. Lars Lindblom for sharing your opinions during the regular CTE series. To Professor Emeriti Ingemar Nordin and Anders Norgren for generously sharing their wisdom in philosophy. Monica Wise always accommodates my queries and extends help whenever I am confused with the Swedish language, customs, and tradition. Thanks also to the fellow Ph.D. students and professors who took part in the annual seminar at Nordic Research School of Ethics. I am particularly thankful to Professor Janna Hallamaa and Professor Susanne Wigorts Yngvesson for throwing challenging questions and sharing constructive opinions that shape my research work's direction during its earlier stage of writing. To my internship supervisor, Dr. Asa Knack