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ETHICS IN GLOBAL HEALTH: BEYOND HIPPOCRATES Scott Loeliger, MD, MS Mark Stinson Fellowship in Global and Underserved Health Contra Costa Family Medicine.

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Presentation on theme: "ETHICS IN GLOBAL HEALTH: BEYOND HIPPOCRATES Scott Loeliger, MD, MS Mark Stinson Fellowship in Global and Underserved Health Contra Costa Family Medicine."— Presentation transcript:

1 ETHICS IN GLOBAL HEALTH: BEYOND HIPPOCRATES Scott Loeliger, MD, MS Mark Stinson Fellowship in Global and Underserved Health Contra Costa Family Medicine Residency Evaleen Jones, MD Child Family Health International (CFHI) Stanford University Medical School TUFH INTERNATIONAL CONFERENCE Bogota, Colombia 30 September, 2008

2 OBJECTIVES Review the historical context of ethics within medical training and practice. Review the historical context of ethics within medical training and practice. Understand the place of ethics within the new medical professionalism. Understand the place of ethics within the new medical professionalism. Incorporate the concepts of ethical behavior and practice into service learning activities. Incorporate the concepts of ethical behavior and practice into service learning activities. Encourage open discussion about current controversies and new generation focus on global health work. Encourage open discussion about current controversies and new generation focus on global health work.

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4 Historical Perspectives Hippocratic Oath Hippocratic Oath (4 th Century BC) (4 th Century BC) Universal Declaration of Human Rights (1948) Universal Declaration of Human Rights (1948) The New Hippocratic Oath (1966) The New Hippocratic Oath (1966) The Declaration of Alma Ata (1978) The Declaration of Alma Ata (1978) Declaration of Helsinki ( ) Declaration of Helsinki ( ) Millennium Development Goals (2000) Millennium Development Goals (2000)

5 Ethical Principles Primum non Nocerum to Primum non Tacere. Primum non Nocerum to Primum non Tacere. Physician Charter on Medical Professionalism. Physician Charter on Medical Professionalism. Healing in the context of Social Justice. Healing in the context of Social Justice. Residents with Skills – Helpful or Dangerous? Residents with Skills – Helpful or Dangerous?

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7 1. Primacy of patient welfare: Stresses altruistic dedication to the well-being of the individual patient. 2. Patient autonomy: Urges physicians to facilitate patient involvement in treatment decisions. 3. Social justice: Calls upon physicians to work actively toward equitable societal distribution of health care resources. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136: [PMID: ] Physician Charter American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine

8 The Physician Charter: Physician Charter Construct for Medical Professionalism Physician Charter Construct for Medical Professionalism Social justice Patient Autonomy Patient Welfare MP Erika Shimahra, Masters of Education, Stanford University, 2006

9 Embedding Ethics in Residency Formal learning and didactics. Formal learning and didactics. Pre-experience preparation. Pre-experience preparation. Consideration of ethics in underserved local communities. Consideration of ethics in underserved local communities. Understanding complexities of global realities, institutions, processes and programs. Understanding complexities of global realities, institutions, processes and programs. Self- study and self-reflection. Self- study and self-reflection.

10 Models of Service or Service Learning Short term clinical work combined with tourism. Short term clinical work combined with tourism. Attachment to clinical research project. Attachment to clinical research project. Longer term work with NGOs or Universities. Longer term work with NGOs or Universities. Advisor/Teacher or Medical Corps? Advisor/Teacher or Medical Corps?

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12 Conflicts in Conscience All done in the name of Hippocrates is not right. All done in the name of Hippocrates is not right. Physician centered paradigm can distort true health improvements. Physician centered paradigm can distort true health improvements. Resource poor areas require careful attention to appropriate strategies. Resource poor areas require careful attention to appropriate strategies. Attention to the Immediate versus the Sustainable. Attention to the Immediate versus the Sustainable.

13 THE BRAIN DRAIN We are going there, whos coming here? We are going there, whos coming here? Raised expectations without means to correct health manpower deficiencies. Raised expectations without means to correct health manpower deficiencies. True professional exchanges, joining the growing global debate (Global Health Workforce Alliance). True professional exchanges, joining the growing global debate (Global Health Workforce Alliance).

14 Primary Care and the Medical Home Do They Want What We Want Translating Ours to Theirs. Translating Ours to Theirs. While working in health care, how to attend to social injustice and underlying factors of poor health. While working in health care, how to attend to social injustice and underlying factors of poor health. Training leaders, followers, co-conspirators or colleagues? Training leaders, followers, co-conspirators or colleagues? Respect for emerging literature and research from abroad. Respect for emerging literature and research from abroad.

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16 NGO CODE OF CONDUCT Recently developed ( ). Included input from APHA, Partners in Health, Physicians for Human Rights, Save the Children, AMREF, GHETS, WHO, World Bank and others. Most recent consultation in Kampala during March global forum on human resourses for health. Next consultation at APHA meeting in October, 2008

17 ARTICLES OF NGO CODE OF CONDUCT FOR HEALTH SYSTEMS STRENGTHENING 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 will 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.

18 Ethics and Research Global health research may have some ethical flaws. Global health research may have some ethical flaws. Interventions determined by narrow research goals may not be sustainable. Interventions determined by narrow research goals may not be sustainable. Article 25 of Universal Declaration of Human Rights. Article 25 of Universal Declaration of Human Rights. WMA and Declaration of Helsinki. WMA and Declaration of Helsinki.

19 UNDERSERVED HEALTH CARE Think Global, Consider Local. Think Global, Consider Local. Incorporate the Experience into Your Future Practice Incorporate the Experience into Your Future Practice Work in Your Milieu to Integrate Service Learning into the Medical School and Residency Experience. Work in Your Milieu to Integrate Service Learning into the Medical School and Residency Experience. In Your Medical Bag: In Your Medical Bag: Stethoscope – Check; Ophthalmoscope-Check; Sansome Guide – Check; Language Dictionary – Check; Ethical Guidelines-Check? Stethoscope – Check; Ophthalmoscope-Check; Sansome Guide – Check; Language Dictionary – Check; Ethical Guidelines-Check?

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21 CASE SCENARIOS #1 Filling In – A Little Knowledge is a Dangerous… Dangerous… #2 Vertical Projects – We Only Do… #3 Ignoring Bureaucratic Barriers #4 NGO/Institutional Short Time Work

22 Resources Markle, W, et al. editors. Understanding Global Health. McGrawHill Medical, 2007, 362pp. Evert, J., et al. Developing Residency Training in Global Health: A Guidebook. San Francisco: Global Health Education Consortium, pp. ONeil, E. Awakening Hippocrates: A primer on health, poverty and global service. AMA, pp.


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