Ethics of Electives. TEN Award ~ Kate Milne - Runner up

by Ruth Price on 22 Sep 2016

Can a UK medical student ethically justify a medical elective in a developing country?

Volunteering overseas has increased greatly since the 1970s resulting in the emergence of a new sector of the travel industry often referred to as “voluntourism”. The altruism that motivates this behaviour is applaudable but the nature of such projects has been heavily criticised for a lack of sustainability and the detrimental effects to the development of impoverished countries. For instance, building projects deprive much more qualified local workers of much needed jobs and orphanages may be disrupted by the presence of individuals who only stay for short periods. Additionally, it could be argued that this intervention is culturally insensitive and perpetuates the idea of western centred idealism. The organisation Volunteer Services Overseas (VSO) who look to recruit experienced individuals suitable for projects running for at least a year, recommend that individuals interested in volunteering especially for short lengths of time are better off travelling. They argue that the only real beneficiaries are the travel companies who they accuse of exploiting both the volunteers and host communities(1).

The popularity of international medical electives has rocketed over a similar time frame and whilst there is an obvious difference between “Volutourism” and a medical student with at least several years of training embarking on overseas elective, it is just as important to consider the impact on the host country. The benefit to the individual student is undeniable with data gathered from post-elective questionnaires in Canada and the US highlighting the positive effect on students’ skills, attitudes, and knowledge of tropical and global health issues (2, 3). However, there is very limited research and evidence documenting the effect on the host community.

The unsustainable nature of the short time period, with most electives lasting for 8-10 weeks, is not the only reason for concern; medical students may lack appropriate training for the conditions they encounter and it is likely their knowledge of the local language will be rudimentary. It is worth considering that one of the most well established aid providing NGOs, Médecins Sans Frontières (MSF), requires doctors to have completed training up to ST-2 as a minimum and to have a diploma in tropical medicine or infectious disease from one of their recognised providers.

This problem could be circumvented by adherence to the GMC which requires all students and doctors to work ‘within the limits of their competence’(4) but difficult situations and inadequate support in poorly staffed and under resourced hospitals may result in students endorsing unsuitable treatment decisions. Nearly half of medical trainees surveyed at Ottawa Hospital, Canada reported being asked to act beyond their competency with either emotional or hierarchical pressure to do so (5). This is reinforced by an overestimation of a student’s ability by local care workers and the different structures encountered in worldwide healthcare systems. A survey conducted in a Soloman islands hospital during 2005 reported the majority of healthcare workers thought it was acceptable for elective students to diagnose, prescribe and carry out practical procedures unsupervised. They were unaware that this would not be the norm in the UK (6). If we assume that similar beliefs are held by patients their ability to consent, already hindered by languages barriers, to an overseas student being involved in their care is further impaired. These factors may lead to unethical practice on vulnerable patients, no matter how unintentional.

Furthermore, medical students’ desire to improve their skills is at odds with the duty to act within their competencies, with 94% of students reporting hopes to improve their clinical skills (7). On a more anecdotal level a colleague of mine stated that performing a lumbar puncture was one of the main goals of his elective. Worryingly this exploitation of patients extends beyond undergraduates; Obstetrics trainees visit countries explicitly to gain more experience in breach vaginal births, allowing them to offer a safer alternative to an elective Caesarean section to patients upon their return home. This dichotomy is not exclusive to international electives, with students and doctors arguably “using” patients worldwide for educational gain, but is more problematic in this context due to the lack of resources and supervision available and as the patients have little option other than to accept.

The issue of patient consent to students opens discussion on a broader area- the cultural differences between medical practice around the world. The movement away from paternalism in developed countries has not be seen worldwide. This is accompanied by vastly different beliefs regarding privacy, consent, and treatment e.g. the provision of analgesia in childbirth. Medical students are presented with the dilemma of cultural relativism: is it insensitive to advocate the ethical and medical standards of their home country when abroad.

This variance in attitude combined with the differences in patient and disease demographic and in resources encountered overseas, weakens the applicability of knowledge and skills gained by students perhaps rendering the elective educationally redundant in modern medical training.

There are ways to reduce the risk of unintentional harm to patients. Pre-departure schemes, such as that run by the University of Toronto, allow students to discuss the ethical dilemmas that they may face (8). Internet resources provided by the GMC, the BMA and websites such as Responsible electives provide a less formal means of achieving this. The provision of formal contracts and guidelines for all parties involved may further this. And long term relationships between first world institutions and partners in a developing country can have a huge benefit. This can be achieved sustainably by the collaboration of multiple western medical schools as modelled by the Friends Consortium of Moi University Faculty of Health Sciences, Kenya. Such efforts are likely to increase the understanding of the role of an elective student in host institutions (9). More support from local staff will improve the elective students’ experience providing greater encouragement to individuals to return as qualified specialists who are then in the position to deliver training and to support local practitioners. This is likely to provide a more lasting positive effect for the local community.

References

1. Ward L, You're better off backpacking- VSO warns about the perils of 'voluntourism'.The Guardian Tuesday 14th August 2007 http://www.theguardian.com/uk/2007/aug/14/students.charitablegiving [Accessed 7 Dec 2013]

2. Stys D, Hopman W, Carpenter J. What is the value of global health electives during medical school? Med Teach. 2013;35(3):209-18.

3. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med. 2003;78(3):342-7.

4. GMC. Duties of a doctor. Available from http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp [Acessed 7 Dec 2013]

5. Petrosoniak A, McCarthy A, Varpio L: International health electives: thematic results of student and professional interviews. Med Ed. 2010, 44: 7-10.1111/j.1365-2923.2009.03536.x. 10.1111/j.1365-2923.2009.03536.x

6. Radstone SJ. Practising on the poor? Healthcare workers' beliefs about the role of medical students during their elective. J Med Ethics. 2005;31(2):109-10.

7. Gilbert BJ, Miller C, Corrick F, Watson RA. Should trainee doctors use the developing world to gain clinical experience? The annual Varsity Medical Debate - London, Friday 20th January, 2012. Philos Ethics Humanit Med. 2013;8:1.

8. Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA: International experience, electives and volunteerism in surgical training: a survey of resident interest. J Am Coll Surg. 2007, 205: 162-8. 10.1016/j.jamcollsurg.2007.02.049

9. Oman K, Khwa-Otsyula B, Majoor G, Einterz R, Wasteson A. Working collaboratively to support medical education in developing countries: the case of the Friends of Moi University Faculty of Health Sciences. Educ Health (Abingdon). 2007;20(1):12.

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