ETHICS IN GLOBAL HEALTH: BEYOND HIPPOCRATES

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. • Understand the place of ethics within the “new” medical professionalism. • 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.

4. Historical Perspectives • Hippocratic Oath • (4th Century BC) • Universal Declaration of Human Rights (1948) • The New Hippocratic Oath (1966) • The Declaration of Alma Ata (1978) • Declaration of Helsinki (1964-2004) • Millennium Development Goals (2000)

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

7. Physician CharterAmerican Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine 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;136:243-6. [PMID: 11827500]

8. The Physician Charter: • Physician Charter Construct for Medical Professionalism Social justice MP Patient Autonomy Patient Welfare Erika Shimahra, Master’s of Education, Stanford University, 2006

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

10. Models of ServiceorService Learning • Short term clinical work combined with tourism. • Attachment to clinical research project. • Longer term work with NGO’s or Universities. • Advisor/Teacher or Medical Corps?

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

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

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

16. NGO CODE OF CONDUCT • Recently developed (2007-08). • 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. • Interventions determined by narrow research goals may not be sustainable. • Article 25 of Universal Declaration of Human Rights. • WMA and Declaration of Helsinki.

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

21. CASE SCENARIOS #1 Filling In – A Little Knowledge is a 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, 2008. 119pp. O’Neil, E. Awakening Hippocrates: A primer on health, poverty and global service. AMA, 2006. 502 pp.