Navigating Ethical Tensions in Global Health Practice Debjani Mukherjee, Ph.D. Director, Donnelley Ethics Program, Rehabilitation Institute of Chicago Associate Professor, Northwestern University Feinberg School of Medicine

Kolkata

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Core Principles of Biomedical Ethics  Beneficence: providing benefit and balancing risks to bring forth the best results  Respect for Autonomy: fostering self- determination and respecting individual differences  Nonmaleficence: doing no harm  Justice: upholding concepts of fairness and equity  Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed. New York: Oxford University Press;

“Global Health Ethics”  Four concepts in addition to Respect for Autonomy, Beneficence, Nonmaleficence and Justice  Humility  Introspection  Solidarity  Social Justice  Pinto, A.D. & Upshur, R.E. (2007). Global Health Ethics for Students. Developing World Bioethics. Vol 9 (1)

Global Health Training: Best Practices (Crump & Sugarman, 2010)  Sending and Host institutions  Sponsors  Trainees  The authors have 14 recommendations for trainees including  Demonstrate cultural competency and engage in appropriate discussions about different perspectives and approaches  Take measures to ensure personal safety and health

International health electives: thematic results…(Petrosoniak et al, 2010)  Ethical implications exist  IHE’s may include a component of medical tourism  Awareness of medical tourism is often variable

Ethical issues encountered by medical students (Elit et al, 2011)  1. Uncertainty about how best to help  2. Perceptions of Western medical students as different  3. Moving beyond one’s scope of practice  4. Navigating different cultures of medicine  5. Unilateral capacity building

Examples/Cases

 Ethical Challenges in Short-Term Global Health Training  Ten Cases  Developing Cultural Understanding  Ensuring Personal Safety  Exceeding Level of Training  Ensuring Sustainable and Appropriate Benefits  Addressing "Ancillary Benefits"  Recognizing Burdens  Shifting Resources  Telling the "Truth"  Selecting a Research Project  Understanding Informed Consent for Research

Example: Privacy  1) differences in norms of spatial privacy  2) western practices can feel intrusive  3) privacy and trust are inextricably linked  4) norms of disclosure also affect the researcher  “Ethics-as-Process” approach  Mukherjee, D. (2008), Privacy and intrusion in ethnographic health research, in Brinda Jegatheesan (ed.) Access, a Zone of Comprehension, and Intrusion (Advances in Program Evaluation, Volume 12), Emerald Group Publishing Limited, pp.83-96

Questions for Students Prior to Global Health Work (Pinto and Upshur, 2007)  6. Where are the weaknesses of your plan, specifically?  7. Is the work feasible, cost-effective, necessary, focused and justified?  8. Will it work to undermine disparity, or actually contribute to it? Will there be a net benefit to the community?  9. What do you hope to bring back to your community, and whom will you share it with?  Is you work sustainable, and if not, will this leave a negative impact?

Questions for Students Prior to Global Health Work (Pinto and Upshur, 2007)  1. Why do you hope to do this work?  2.What are your objectives, both personal and structural, short and long-term?  3. What are the benefits and who will receive them, and what are the costs and who will bear them?  4. In the context of very limited resources for global health needs, is your elective justified? What exists close- by?  5. What do you need to do to prepare for your elective, both practical and personal?

Ethics and emotion: Plutchik's wheel en.wikipedia.org/wiki/Contrasting_and_categorization_of_emotions

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