In many countries worldwide, especially in Sub-Saharan Africa, a shortage of physicians limits the provision of lifesaving interventions. One existing strategy to increase the number of physicians in areas of critical shortage is conditioning medical school scholarships on a precommitment to work in medically underserved areas later. Current practice is usually to demand only one year of service for each year of funded studies. We show the effectiveness of scholarships conditional on such precommitment for increasing physician supplies in underserved areas. (...) Then we defend these scholarships against ethical worries that they constitute slavery contracts; rely on involuntary, biased, or unauthorized early consent by a young signatory; put excessive strains on signed commitments; give rise to domination; and raise suspicion of slavery contracts. Importantly, we find that scholarships involving far longer commitment than current practice allows would also withstand these worries. Policymakers should consider introducing conditional scholarships, including long-term versions, as a means to increasing the supply of physicians to medically underserved areas. (shrink)

ZusammenfassungIm gesundheitspolitischen Kontext werden die internationale Rekrutierung und Migration von Ärztinnen, Ärzten und Personal in Gesundheitsfachberufen seit langem diskutiert. Diese Studie untersucht die thematischen Schwerpunkte dieser Debatten um ethische Aspekte der internationalen Rekrutierung in der Public Health Literatur mit Peer Review. Unser Artikel diskutiert, welche Implikationen für gesundheitspolitische Maßnahmen bezogen auf gesundheitliche Ungleichheiten diese fachspezifischen akademischen Diskussionen aufwerfen. Wir erstellten eine qualitative Übersichtsarbeit basierend auf Literaturrecherchen zu fachspezifischen internationalen Studien mit Schwerpunkt auf theoriebasierten und qualitativen Forschungsdesigns in den Datenbanken PubMed (...) und Web of Science. In die Analyse einbezogene Artikel wurden mit der Critical Appraisal Skills Program Checkliste für qualitative Forschung bewertet und anhand eines thematischen Inhaltsanalyseverfahrens auf gemeinsame Muster untersucht und kodiert. 17 Artikel wurden in die Analyse einbezogen. Diese Artikel befassten sich mehrheitlich entweder mit Pflegeberufen oder mit Ärztinnen bzw. Ärzten, und wurden verfasst aus Perspektiven des globalen Nordens. Die thematische Inhaltsanalyse ergab, dass ethische Aspekte generell zusammen mit einer allgemeinen Übersicht über Gesundheitssysteme und Ungleichheiten zwischen Ländern genannt wurden und Migration zwischen Ländern stärker im Fokus stand als Migration innerhalb einzelner Landesgrenzen. Vorgeschlagene Lösungsansätze in der Public Health Literatur sind meist ökonomischer Natur und stellen globale Finanzausgleiche zwischen Ländern oder nationale Verbesserung von Arbeitsbedingungen zur Diskussion. Möglichkeiten der Evaluation solcher Lösungen werden selten vertieft. Insgesamt fokussiert diese fachspezifische Diskussion mehrheitlich auf einen systemischen Ansatz und problematisiert die Migration von Personal in Gesundheitsfachberufen sowie von Ärztinnen und Ärzten. Unsere Ergebnisse deuten darauf hin, dass die akademische Forschung im gesundheitswissenschaftlichen und medizinischen Feld derzeit nur Vorschläge für politische Maßnahmen formuliert, die nicht grundsätzlich die globale Ordnung der Gesundheitssysteme in Frage stellen. Die Diskussion scheint daher geeignet zu sein, ein Bewusstsein für Benachteiligungen zu schaffen, ohne diese radikal beseitigen zu wollen. Eine vertiefte Auseinandersetzung mit Aspekten von Gender, Ethnizität und übergeordneten intersektionalen Bedingungen sowie Auswirkungen für und von internationaler Rekrutierung und Migration könnte die Diskussion schärfen. (shrink)

There is a consensus that the effects of medical brain drain, especially in the Sub-Saharan African countries, ought to be perceived as more than a simple misfortune. Temporary restrictions on the emigration of health workers from the region is one of the already existing policy measures to tackle the issue—while such a restrictive measure brings about the need for quite a justificatory work. A recent normative contribution to the debate by Gillian Brock provides a fruitful starting point. In the first (...) step of her defence of emigration restrictions, Brock provides three reasons why skilled workers themselves would hold responsibilities to assist with respect to vital needs of their compatriots. These are fair reciprocity, duty to support vital institutions, and attending to the unintended harmful consequences of one’s actions. While the first two are explained and also largely discussed in the literature, the third requires an explication on how and on which basis skilled workers would have a responsibility as such. In this article, I offer a vulnerability approach with its dependency aspect that may account for why the health workers in underserved contexts would have a responsibility to attend to the unintended side effects of their actions that may lead to a vital risk of harm for the population. I discuss HIV/AIDS care in Zimbabwe as a case in point in order to show that local health workers may have responsibilities to assist the population who are vulnerable to their mobility. (shrink)

Some bioethicists and political philosophers argue that rich states should restrict the immigration of health workers from poor countries in order to prevent harm to people in these countries. In this essay, I argue that restrictions on the immigration of health workers are unjust, even if this immigration results in bad health outcomes for people in poor countries. I contend that negative duties to refrain from interfering with the occupational liberties of health workers outweighs rich states' positive duties to prevent (...) harm to people in sending countries. Furthermore, I defend this claim against the objection that health workers in poor countries acquire special duties to their compatriots that render them liable to coercive interference. (shrink)

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of (...) MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy. (shrink)

Many organisations in rich countries actively recruit health workers from poor countries. Critics object to this recruitment on the grounds that it has harmful consequences and that it encourages health workers to violate obligations to their compatriots. Against these critics, I argue that the active recruitment of health workers from low-income countries is morally permissible. The available evidence suggests that the emigration of health workers does not in general have harmful effects on health outcomes. In addition, health workers can immigrate (...) to rich countries and also satisfy their obligations to their compatriots. It is consequently unjustified to blame or sanction organisations that actively recruit health workers. (shrink)

Catholic end-of-life ethics does not contain a principle that prohibits the excessive use of medical treatment for declining and dying patients. This article fills this lacuna by exploring and developing the principle of unreasonable means. Unreasonable means are present when the burdens to the patient and community far outpace the benefits to the patient and when the use of such means directly or indirectly limits another patient’s access to ordinary means. Unreasonable means reinforce the redistribution of limited medical resources from (...) the poor to the wealthy and from the global south to the global north. The principle of unreasonable means guides individual patients and medical proxies to preferentially opt for the morally ordinary medical needs of others before the patient’s own extraordinary medical needs. The principle underscores the need for patients and proxies to incorporate justice and the common good into end-of-life decisions. (shrink)

There is a recent interest in the ethics of high-skilled worker emigration through which the limitations of the right to exit are discussed. Insightful arguments have been made in favour of the emigration restrictions on skilled workers in order to tackle the deprivations in developing countries. However, there is still a need for clarification on how we can understand, discuss and implement limitations of a right from a normative perspective. Significantly, how we understand the limitation of a right might determine (...) how we approach such limitations – both in terms of the process of assessing the limitations and in terms of their implications. In this paper, I identify two distinct ways to understand limitations of the right to exit with respect to losses associated with health worker emigration, while also pointing to their implications for restrictive policies: as a matter of scope, and as a matter of weight or emergency, which requires a compensatory scheme for the individual right holders. While the emergency restrictions seem to be a point of convergence in the literature, what defines an emergency and the nature of the compensation still warrant exploration. To that end, I also discuss from a normative perspective what might constitute a public emergency that would give states a prima facie prerogative to regulate temporary limitations on the exercise of the right to exit. In addition, I briefly introduce the implications of emergency restrictions, with a particular focus on compensatory schemes for individual right holders. (shrink)

One of the ways to address the effects of skilled worker emigration is to restrict the movement of skilled workers. However, even if skilled workers have responsibilities to assist their compatriots, what if other parties, such as affluent countries or source country governments, do not fulfil their fair share of responsibilities? This discussion raises an interesting problem about how to think of individual responsibilities under partial compliance where other agents (including affluent countries, developing states, or other individuals) do not fulfil (...) their fair share of responsibilities. What is fair to expect from them? Taking health worker emigration as a case in point, I discuss whether the individual health workers’ fair share of responsibilities to address basic health care needs decreases or increases when the other parties do not fulfil their share. First, I review the responsibilities that different stakeholders may hold. Second, I argue that there are strong reasons against increasing or decreasing health workers’ fair share of responsibilities in a situation of partial compliance. I also argue that it is unfair for non-complier states to enforce health workers to fulfil their fair share or take up the slack. (shrink)

Some bioethicists and political philosophers argue that rich states should restrict the immigration of health workers from poor countries in order to prevent harm to people in these countries. In this essay, I argue that restrictions on the immigration of health workers are unjust, even if this immigration results in bad health outcomes for people in poor countries. I contend that negative duties to refrain from interfering with the occupational liberties of health workers outweighs rich states' positive duties to prevent (...) harm to people in sending countries. Furthermore, I defend this claim against the objection that health workers in poor countries acquire special duties to their compatriots that render them liable to coercive interference. (shrink)

Clinical Ethics, Ahead of Print. The migration of health-care professionals has often produced morally charged discussions among ethicists, politicians, and policy makers in the migrant-sending and migrant-receiving countries because of its devastating effects on the health of those left behind in the countries of origin.This movement of skilled professionals – their decision to leaving their countries of origin in search of better work environments – has created a phenomenon that has been described as brain drain. Although the migration of health (...) workers continue to bring prosperity to millions of people around the world, they have also evoked hopelessness in many more people. Thus, questions of global justice manifest themselves when it comes to the matters of brain drain and the just distribution of health and healthcare professionals. (shrink)