May 13 Michele Barry (School of Medicine)
“Ethics of Global Medicine: Dilemmas Faced by Medical Students and Researchers Who Go to Work in Low Resource Countries”
Professor Barry discussed four different case studies with us. The first dealt with a female volunteer being asked to conform to cultural norms about the proper role of women in the host community. The second focused on a medical student who discovers he is expected to work alone in an underserved community without supervision or full training. The third dealt with a student who was unable to complete her research in a foreign community and felt badly about having accepted her host’s hospitality for several weeks. The fourth focused on what a student abroad should do when he realizes that workers in the area are not properly adhering to the requirement to obtain informed consent from the patient.
What did you think of these case studies? Professor Barry mentioned that Africa has 4% of medical workers but 25% of the need – how are we to balance concerns surrounding student volunteerism abroad with the great need they are trying to meet?
I thought that the case studies we discussed were interesting, not only because they presented worthwhile ethical dilemmas, but also because they were plausible scenarios that I could imagine would crop up fairly frequently in the realm of global medicine.
However, I would’ve liked it if Professor Barry had talked a little bit more about some of the standout cases she has faced with her students, and explained more fully why she has the ethical standards she does on these issues.
I thought that Professor Siegel’s comment in class about where the threshold is for how much the “average” American abroad will tolerate conforming away from Western customs was especially interesting. This threshold is undoubtedly different for everyone, and thus it seems extremely important for the host programs to have very clear guidelines for student behavior overseas. The students go abroad representing their funding source/their organization and will be obligated to conform to the guidelines set forward by said organization (otherwise they wouldn’t choose to go on the trip).
I agree with Kyle above. Although Dr. Barry did hint at some of the reasons why she has developed some of the ethical standards on the issues discussed, I wanted her to be a little more explicit. I found one thing to be interesting in particular. She said that such programs have to be very much reciprocal, but reciprocal to whom? There seemed to be a focus on how foreign students should behave given the ethical dilemmas they are in. But I wonder, do these programs ever formally record the reactions domestic citizens have when they interact with international students/volunteers? There could have been a women’s movement in Borneo that might have agreed with Janet…Maybe Argentines in rural areas preferred Genes line of work more than the other alternatives they have? How does this change the ethical situation?
The first case study about cultural norms very much reminded me of an issue that Colonel Sheffield raised in the second lecture of the quarter. In the military case, the soldiers were not allowed by order to interfere with what they would consider ethically wrong, while in the health care case, visitors were asked to conform to foreign cultural values. It is interesting to note how varied these two perspectives are (one must resist to impress one’s ethics upon a situation, and another must forcibly conform to another society’s ethics), but they share the fact that they find it necessary to, if only temporarily and outwardly, align oneself ethically and behaviorally to another culture.
The second case Professor Barry spoke about really hit home with me. I spent the past summer working in Tanzania and, while my experiences were not nearly as traumatic, I ran into similar problems. I intended to help with fundraising and grant proposal writing for a small NGO and suddenly found myself the organization’s only hope for funding. I had never written a proposal before, never even properly seen one being written, but because I was educated, from the US and, frankly, because I was white, it was assumed that I could make everything better. Many of my colleagues working at nearby clinics noticed similar expectations.
Obviously, in my situation people’s lives weren’t at stake in the same way Professor Barry’s med student encountered. Both circumstances, though, stem from the myth that not only can Westerners make miracles happen, but also that, because of the resources we have, we have a responsibility to, even when it’s beyond our ability or knowledge. I’m not going to discuss here whether or not we have a duty to help developing countries–that’s a much more complicated question, but I do believe that when we are in situations like this our first duty is to ourselves. There is certainly a chance that we can do some good, but it is very unlikely that we will change the world directly in such a small setting. As such, we need to be sure the good we are doing doesn’t cause greater harm to ourselves. There’s a difference between stretching our comfort zone and traumatizing ourselves. The farther we step outside of our scope of understanding, the more we flirt with that line, especially in a medical situation where decisions can mean life or death. One of the most important things about working in difficult situations is knowing when to say, “I can’t do this alone. I’ve had enough.”
There seems to be a stigma to saying that, as if it means we’re not strong enough or too spoiled by our fortune. Maybe. But while the impulse to go save the world is a wonderful one (I have it, too), there’s nothing wrong with first taking care of ourselves.
Without sounding cruel I do not see much more of a solution to many of these solutions besides that of if they want our help we are going to do things our way. If we want help and are going to these countries to learn then we can do things their way. With that said in many of these countries life is difficult, and bad things happen. Yes the value of a life should still be the same but this is not America, students must understand this before they embark. Students will encounter a lot of responsibility while there, which while good practice for a future career, may be difficult to handle. However this is the life of a doctor, they have to make life or death decisions. Things will not always be easy, thats life, and these native populations certainly understand that. We all will find ourselves in situations that are less than perfect but it is essential to make due with what on has. All you can do is do your best, and stay true, everything else is our of your hands.
I found the case studies that Professor Barry presented particularly worthwhile in grounding such a multi-dimensional discussion in realistic, concrete examples. The overarching problem presented in each case was a difference in the expectations of a student versus the host organization or culture — sometimes overestimating or underestimating the amount of control each could have on the volunteer situation. In contrast to Colin’s comment, it seems to me that on balance, the emphasis should be on doing things “their” way. If the priority of volunteers is really to deal with the issues in the communities they are working in, and if we as a western society are truly going to meet the needs of a suffering countries, we are going to have to stretch. Obviously, it is necessary for students to set ethical boundaries of what they will and will not be willing to do. One possible example is to bow to cultural traditions within reason (so long as they do not restrict the volunteer’s ability to do his/her work) and to adhere to a “do no harm” guiding principle and not agree to perform medical procedures where a lack of experience could lead to unnecessary risk for a patient’s health. However, with these or other guidelines in place, the emphasis for volunteers should be meeting any and ALL of the needs in their host community.
I want to follow up on some threads from Sylie’s and Julia’s comments. I am somewhat uncomfortable with Julia’s idea that international volunteers should “bow to cultural traditions[...]so long as they do not restrict the volunteer’s ability to do his/her work” (I took this to be her elaboration of what “within reason” really amounts to). I don’t know if I agree that the decision should always be so clear-cut: I think that when helping people in underserved communities necessitates a violation of a volunteer’s personal values or norms, that volunteer needs to weigh the value she places in helping people in that community against the negative value of violating others of her normative commitments (e.g. by acquiescing to personal interactions structured by gendered power asymmetries). This is kind of obvious, and I probably agree with Julia that in most cases the value of providing medical service (e.g.) to people who wouldn’t get it otherwise outweighs personal qualms about cultural norms. But I don’t think this trend holds universally. Following Sylvie, I agree with Prof. Siegel that everyone will have his or her own ‘threshold’, and that the important thing is that cultural expectations be outlined in advance.
The cases she presented were all very interesting. Regarding the last one on informed consent, I think that if the student is truly concerned about the patients actually being informed of their rights, then he should make this known to the local research directors ASAP, so that if there’s a need to not use the data of those patients, then not much data would have been lost. He should not wait until the middle of the process to voice his concerns.
I really enjoyed Professor Barry’s talk and that she encouraged our participation through case scenarios. In most of the cases I felt that there was no “right answer” and that the individual within the context would have to come to their own conclusions. I know how I might act in a given situation, but without every detail of context it is hard to determine what someone else should do, let alone what is “ethical.” From all the cases, however, I think we can take away the point that it is always best to talk over ethical issues with friends/supervisors etc. in order to find out exactly what’s at stake in our decisions and to ensure that our actions are in alignment with the particular circumstances as well as our own personal values.
I was really interested in Professor Barry’s talk, especially because I have an interest in working in international medicine. Many of the controversies she brought up were really important, but not necessarily things we would automatically think of. I think she did a really good job of making it clear that there wasn’t really a distinctly right or wrong answer. Her case studies really made me think about what my boundaries and limits are.
I greatly appreciated the change in format that Dr. Barry offered. The specificity in the examples was a wonderful way to get past the initial, largely unhelpful, reactions to real ethical dilemmas. I remember some of the responses were stressing the importance of informed consent, transparency and the value of human life, but because Dr. Barry brought examples from real life we were able to progress past these true but mostly useless pieces of advice. Obviously everything should be transparent, and people should know everything about what they’re getting into, but real life rarely works that way. I enjoyed the way this talk showed that difficult ethical decisions are difficult, and not because one may lack the appropriate technical know-how as in a difficult mathematical problem, which in hindsight becomes clear, but simply because there is no clear answer at all to be had.
I agree with the comments made by Dixon and Melissa. Professor Barry offered an interesting mix of self-reflection and application that made for more dialogue and interaction. I think it’s very important to encourage that type of back-and-forth communication. Also, I liked how subtle conversations on various identities were brought into each other scenarios and I deeply agree with Dr. Barry’s overall assessment about the level of expertise and understanding necessary to conduct work in areas with little to no resources. It can’t simply be seen as a chance to go out and learn the techniques or experiment with them just because the people one would be serving are separate from our reality here at Stanford.
I liked the format of the talk this time, students having more opportunity to speak up. We couldn’t hear more from the speaker herself of course, but the class felt more like a relaxing discussion session rather than a stiff lecture.
It was interesting to see that ethical questions may rise from any trivial situations, such as feeling sorry for your host overseas. Also, I was glad that doctors and would-be-doctors are trying to better their approach towards various moral dilemmas,constantly taking into account the welfare of the patients.
In practicing medicine overseas, I hope medical students ore doctors do not make a mistake of enforcing American values an practices. Unless it imposes an urgent and serious risk on the life of the patient, the culture of the host country must be respected, no reason what.
I also appreciated the break in form that Dr. Barry bright us. I tend to think of ethics as a separate entity that can be possessed, but Dr. Barry’s conversational format was a good reminder that ethics exist as a tension between multiple points of resistance in the social context. In the case study about the woman who struggled with reciprocating her host’s hospitality, the idea of the Great White Hope that Dr. Barry brought up immediately came to mind. If the medical student was the first to go work in this clinic abroad, this response may not be entirely unexpected.
I found Dr. Barry’s talk very interesting. I had never before considered the ethical debates surrounding the practice of international medicine in third world countries. The case studies were scenarios I had not encountered before. I think to balance the concerns of student volunteerism with the needs they are trying to meet a certain level of preparation should be achieved prior to trips. Maybe simply sharing experiences in a manner similar to the talk.
The case studies that were brought up in Dr. Barry’s talk were interesting, but clearly on some level biased. I found the direction or purpose of her talk was slightly diluted by the format, where she lost control of the discussion once or twice as audience members went off on unrelated tangents.
On the ethical issues brought up, I feel they tie in more neatly to larger discussion on culture and multiculturalism.
I also found Dr. Barry’s talk interesting and compelling. I agree with others who expressed concern, in class and in the comments, over the practice of going abroad as part of medical school “because they let you do more over there.” I’m really worried that underqualified medical students might offset local resources that would otherwise be directed towards effective medical treatment. This is, of course, a worry with all overseas aid.
I wonder how the medical case differs from broader development or health aid internationally?