Ethics in short-term medical volunteerism

More harm than good?

Kishaini Baskararao Aurelne Thian

“Saving our planet, lifting people out of poverty, advancing economic growth – these are one and the same fight.” - Ban Ki-Moon

Over the past decade, there has been an increase in the number of medical students and clinicians undertaking humanitarian aid trips to rural and remote communities in order to provide basic medical access and support to vulnerable communities.[1] For the longest time, medical volunteerism has been focused on developing countries with the aim of providing health access in areas of limited resources to improve health and social outcomes.[2]

However, the increased interest in medical volunteerism has seen a surge in the number of organisations that arrange such humanitarian aid trips and, as a result, such programs and travel plans have become increasingly commercialised. [3] While the various programs retain that initial core principle of giving aid to the vulnerable, we cannot ignore the shift in focus towards less pure intentions. These include boosting one’s curriculum vitae or using these trips as a chance to travel and enjoy oneself. In fact, the recent popularity of medical volunteerism has somewhat created a bandwagon effect; medical students feel obliged to participate for fear of missing out.[4]

So many student volunteers offer their time and money to ‘give back’, and while these intentions are to be applauded, the question must still be asked: are these well-meaning efforts actually improving people’s lives? We will discuss the ethics of short-term medical volunteerism through the four main ethical pillars: beneficence, non-maleficence, justice, and autonomy.

BENEFICENCE

The discussion of beneficence in the context of global health can be rather straightforward since medical volunteerism is, at its heart, based on principles of equity aiming to address the lack of healthcare resources and care available to the less advantaged. In fact, the rising interest in global health has greatly contributed to the popularity of medical volunteerism, especially among medical students.[5] There are many pathways to undertake medical volunteerism. The most commonly discussed are disaster relief or short trips to less developed countries, which are ideally undertaken to improve quality of life and healthcare for vulnerable populations.[6] These easily fall in line with doing good and acting in the patient’s best interest. The sharing of knowledge also has beneficial impacts on the professional development of volunteers. Medical volunteerism is widely encouraged as a learning opportunity for medical professionals, as well as students.[7-9] Placed in different and often challenging clinical scenarios, medical students develop personal, professional, and practical skills; are exposed to diseases would otherwise not encounter in their home country; and are made more aware of the inequities of global health. An exposure to different cultures accentuates the importance of culturally sensitive healthcare practises. These experiences are invaluable for future practice.[10-11] Being exposed to and learning how to practice culturally responsive medicine early on is an extremely valuable skill for medical students. Students are forced to consider how to manage and educate patients on mental health issues, such as depression, in various cultural contexts. This often includes being aware of the stigma and lack of patient knowledge associated with mental health disorders, as well as learning how to address cultural beliefs regarding mental illnesses.[12-16]

Medical volunteerism also benefits the communities who receive this help. Volunteers often bring with them a set of skills, ideas, and expertise that can be shared with local medical staff and community members, who can then integrate these techniques into their own healthcare as they see fit even after these short volunteerism trips have ended. The communities are able to receive healthcare and resources that are not typically available to them.

However, beneficence is not simply to ‘do good’ but also to ‘serve the best interests of the patients and their family’. Despite providing communities with healthcare they may not otherwise have access to, several issues have been raised regarding whether or not these efforts are acting in the community’s best interests. For example, is the care provided by medical volunteers actually empowering these communities, or are they, in fact, pulling resources away from more needed local activities without increasing their capacity?[17-18]

NON-MALEFICENCE

The pillar of non-maleficence refers to ‘doing no harm’[19]. While certainly not an endeavour which actively seeks to ‘do harm’, there have been increasing concerns over the ethics of medical volunteerism.[1] These concerns generally revolve around themes of power imbalances and exploitation, a perpetuation of paternalistic healthcare, cultural insensitivity, a focus on self-serving benefits (e.g., tourism), and even criminal activities.[3,20]

Other ethical concerns and harms have been described; these include vulnerable populations being used as ‘practise’, taking away local jobs and resources from other local activities that may be more necessary. This does little in improving capacity of these populations and only further increases their vulnerability and dependency on foreign aid.[20- 21]

Another concern that has been raised regarding medical volunteerism is the shift in focus towards boosting one’s curriculum vitae. Organisations may utilise medical volunteerism as an opportunity to create an industry for profit. International medical student electives have particularly been criticised for this, wherein student volunteers end up spending more time recreationally than in the clinical setting. The focus is thus less on improving the health outcomes of these populations, and this wastes resources that could be more needed elsewhere.[22- 24]

Further, medical students are often given freer rein to undertake procedures. They may not have the qualifications in their home country to do so independently but may have that responsibility placed upon them due to lesser regulations and resource strain from staff shortages. There may also be the perception that they are there to help a more vulnerable population that requires ‘any help that they can get’. Whether or not they may, in fact, be causing more harm both to the patient and by wasting resources is a major concern.[25]

Volunteers may also unintentionally practice in a way that is culturally inappropriate.[24,26] Culturally inappropriate care results in poorer patient outcomes and the development of negative attitudes towards healthcare. Thus, developing an awareness of one’s own culture, developing the ability to remain non-judgemental, and learning to respond to different attitudes and cultures is important in practicing culturally appropriate medicine.[27,28]

Volunteers therefore need to remember to be aware of one’s own cultures and beliefs and be sensitive, responsive, and respectful towards differences in culture—especially when volunteering in a culture different to one’s own.

JUSTICE

The pillar of justice requires that healthcare professionals ‘seek to equitably distribute the life-enhancing opportunities afforded by health care’.[29] The principle of justice has been described as the moral obligation to act on the basis of fair adjudication between competing claims and is linked to fairness, entitlement, and equality. In healthcare ethics, distributive justice refers to the fair distribution of scarce resources while rights-based justice encompasses respect for people’s rights.[30]

DISTRIBUTIVE JUSTICE

In many underdeveloped settings, certain resources—including medications and treating equipment—are more limited than in a resourced practice setting, presenting several ethical challenges. Clinical resource and staff limitations can often result in the need for challenging decisions to be made regarding triaging patients of the community, with only those deemed most ‘in need’ receiving access to healthcare. [31] Rooted in the ethical principle of justice, triage is a necessary part of every health system whenever there is a mismatch between demand for care and availability of resources, which can be significantly bigger in underdeveloped settings. It is difficult to manage the ethical challenges that come with balancing the welfare of the patient, maintaining efficiency within a short period of time, and providing equitable distribution with special considerations for vulnerable populations.[5] Short-term medical trips can involve having a limited number of medications, surgical apparatus, and aseptic materials (such as gloves and under-pads) brought along. [31] This often limits the number of people that can be helped, especially in terms of minor surgeries/ procedures or when managing chronic conditions like diabetes and hypertension, which often require months-worth of supplies to be distributed during a single trip.[32]

Furthermore, many volunteer groups, especially those with students, often choose to target certain communities—perhaps those deemed safer or more accessible. This alters the equity of care received amongst differing villages in the same country.[33] For example, medical student electives are often restricted to Level 1 and Level 2 countries that are deemed ‘safe’, leaving out the most vulnerable populations and exacerbating the inequity that medical volunteerism aims to resolve. More thought should go into expanding the service capacity of existing resources in a way that is consistent with the context and needs of remote communities.

RIGHTS-BASED JUSTICE

The ethical principle of respect for each person’s rights regarding their own healthcare and to be respectful of cultural differences is pivotal.[30] When volunteering overseas, cultural sensitivity and respecting a

patient’s right to choose, to maintain privacy, and to speak their own truth is a critical component of global health ethics.[5]

The effectiveness of medical volunteerism would have to be decided by all stakeholders, including the treating team volunteers and local community members, with measures to ensure appropriate defences are in place. These measures should also be designed to suit the cultural values of a community or family, as well as have flexibility for the patient’s individual preferences regarding their healthcare. [5,34] There is argument as to whether certain cultural and/or religious beliefs, especially within the Asian community where doctors are regarded as ‘healers’ and ‘gods’, play a role in their preference for an authoritative approach as opposed to a more collaborative one.[35] The concept of rights-based justice often overlaps with the ethical pillar of autonomy, which highlights respecting the rights and preferences of the patient.

AUTONOMY

The pillar of autonomy refers to respecting the right of the (competent, informed) patient to make his or her own decisions.[5,36]

Often, in developed, high-income country settings, the shared healthcare decision making model is adopted, whereby the patient and clinician work together to devise an approach that is often effective and tailored to the patient’s values and preferences. [37] However, in low- to middle-income countries, there is a lack of patient education and understanding regarding what treatment they are receiving and the significance of their medication in the treatment of disease.[38]

Vulnerable populations often require help and likely have lower health literacy. Local healthcare workers and patients are often forced to accept help from these medical volunteers who are likely to have had more training and are equipped with more resources. However, medical students with limited knowledge may have limited roles.[25]

The points raised in the context of medical ethics ultimately lead us to question whether medical volunteerism, if not conducted within well-described ethical guidelines, could possibly be working against the initial agenda of improving global health inequities. Despite the increasingly popular critique on medical volunteerism, the good news is that the increasing discussion of ethics in medical volunteerism means that student volunteers are made more aware of the potential impacts of their actions. We can work towards mediating these ethical issues and, in the near future, allow medical volunteerism to flourish as a means to improving global health.

Although this remains an ethical pillar that is less easily met with short-term medical trips, it is worth keeping in mind that student volunteers can still play an active role in educating patients on different aspects of health care (including nutrition and oral hygiene), which still provides a significant contribution towards patients learning to take control of their own healthcare.

The education of locals is a key element in ensuring sustainable, lasting benefit. However, this will require time that short-term missions often do not have.[39] As the definition requires, patients should be competent and informed of the situation and management plan and this requires upskilling and competency development of local members of the community.[5,39]

CONCLUSION

Foreign medical aid is increasingly seen as our ethical duty as global citizens. As future healthcare workers, it is our duty to alleviate suffering and to protect the health of our worldwide community. The ultimate goal of these medical trips is to provide local residents with greater access to quality healthcare and to reduce the burden of disease. However, to properly achieve this requires recognition that this is a multi-factorial, complex issue and necessary consideration should be done, as addressed in this article.

Kishaini is a Doctor of Medicine student at the University of Western Australia. She is passionate about global health, with particular interest in migrant, refugee, and asylum seeker health, and has been involved in WAMSS’ Interhealth for the last 2 years.

Aurelne Thian is a Doctor of Medicine student at the University of Western Australia. She has an interest in many areas of medicine and global health, particularly in child and paediatrics health.

Correspondence

21829674@student.uwa.edu.au

Acknowledgements

None

Conflicts of Interest

None declared

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