A new vision for bioethics training in global health

Abstract

Global health education and training is in high demand. Institutions and organisations, particularly in high-income countries, are responding by offering diverse learning opportunities that range from applied international field research or care experiences of varying durations to certificates, masters, and doctoral degrees. Pre-departure preparation is essential to successful international experiences.1DeCamp M Lehmann L Jaeel P Horwitch C Ethical obligations regarding short-term global health clinical experiences.Ann Intern Med. 2018; 169: 589-590Crossref Scopus (1) Google Scholar, 2Purkey E Hollaar G Developing consensus for postgraduate global health electives: definitions, pre-departure training and post-return debriefing.BMC Med Educ. 2016; 16: 159Crossref PubMed Scopus (20) Google Scholar Ethics—understood as the study of why we do what we do, who we are, what is good, how to do good, etc—is arguably the foundation of all pre-departure preparation. The language and concepts of ethics provide lenses through which trainees can understand global health work and their experiences abroad. Because of different cultural norms and resource constraints, distressing situations often arise. However, despite increased attention to and greater availability of global health ethics training over the past decade,3Rahim A Knights Nee Jones F Fyfe M Alagarajah J Baraitser P Preparing students for the ethical challenges on international health electives: a systematic review of the literature on educational interventions.Med Teach. 2016; 38: 911-920Crossref Scopus (20) Google Scholar ethics is not always part of pre-departure training,4Kalbarczyk A Nagourney E Martin NA Chen V Hansoti B Are you ready? A systematic review of pre-departure resources for global health electives.BMC Med Educ. 2019; 19: 166Crossref Scopus (15) Google Scholar and few attempts have been made to assess the effect of ethics training on programme outcomes. At this critical juncture, we think it is important to champion a renewed positive vision for global health ethics training. The first element of this vision involves reconnecting global health research ethics, which can be narrowly understood to involve only issues of institutional review boards or research ethics committees, with broader clinical and other ethics. Attention to international clinical research from the late 1990s until today has resulted in real moral progress. This specialisation, however, might have inadvertently contributed to bifurcating issues of research ethics from other issues in global health training.5DeCamp M Scrutinizing global short-term medical outreach.Hastings Cent Rep. 2007; 37: 21-23Crossref PubMed Scopus (77) Google Scholar, 6Crump JA Sugarman J Ethical considerations for short-term experiences by trainees in global health.JAMA. 2008; 300: 1456-1458Crossref PubMed Scopus (155) Google Scholar This bifurcation is problematic. For one, separating research ethics issues from the others is inconsistent with the lived experience of global health trainees.7Manabe YC Jacob S Thomas D et al.Resurrecting the triple threat: academic social responsibility in the context of global health research.Clin Infect Dis. 2009; 48: 1420-1422Crossref PubMed Scopus (17) Google Scholar As part of preparing trainees for the US National Institutes of Health Fogarty Global Health Program for Fellows and Scholars over the past 5 years, we have observed that the challenges that the programme reports do not always fit neatly into research, clinical, or public health ethics spheres. For example, should a licensed physician who is primarily abroad while doing a research study fill in for a local physician where the study is occurring who is on vacation? Or, when a visiting researcher or trainee abroad observes practices that are perceived to be substandard (eg, infection control) or inappropriate (eg, bribery), what is the obligation to report the practices versus maintaining presence as an observer? Or, when working in settings of scarcity where research programmes have more resources than traditional clinical ones, how should a trainee apportion resources? More importantly, by potentially short-circuiting ethical reasoning within a single ethics domain, the bifurcated approach could result in missed opportunities for transformative learning, practical problem solving, and moral development about broader social issues. For example, how a trainee manages cultural differences in informed consent is not simply about what the approved protocol said; the issue is more about managing complex ethical challenges within a broader cultural environment that is unfamiliar and where fundamental norms might differ. A notable exception to the separation of research and clinical-based or care-based ethics in global health might be the ancillary care debate (ie, whether providing care to research participants is morally required when that care is outside the research's scope and might not otherwise be provided because of resource limitations8Richardson HS Eyal N Campbell JI Haberer JE When ancillary care clashes with study aims.N Engl J Med. 2017; 377: 1213-1215Crossref Scopus (5) Google Scholar). The rich ethics discussion around this issue should be a model for global health ethics training. The second element of this vision is grounding concepts of introspection, humility and solidarity.9Pinto AD Upshur RE Global health ethics for students.Dev World Bioeth. 2009; 9: 1-10Crossref PubMed Scopus (142) Google Scholar Asking questions of introspection (eg, why am I here?), humility (eg, what are my limits?), and solidarity (eg, how do my actions show unity among people?) are crucial to moral reflection. Although evident in best practice guidelines,10Crump J Sugarman J Ethics and best practice guidelines for training experiences in global health.Am J Trop Med Hyg. 2010; 83: 1178-1182Crossref PubMed Scopus (308) Google Scholar these concepts not only complement classical principles of beneficence, respect, and justice, but also are essential for properly interpreting them. For instance, only if one approaches issues of community benefit, choice, and justice from the standpoint of humility about one's knowledge of that community, can obligations of beneficence, respect, and justice be truly fulfilled. Global health pre-departure training at all levels should begin with concepts of introspection, humility, and solidarity, and never stray far from them. Thirdly, ethics training should, from the outset, be designed and implemented by the communities where global health training programs occur, or at least in collaboration with them. What would ethics training look like if designed by individuals and communities who have been victims of imperialism, colonial rule, and marginalisation in trade and other global policies? Would the same issues or bioethics principles be deemed important in this more global vision?11DeCamp M Rodriguez J Hecht S Barry M Sugarman J An ethics curriculum for short-term global health trainees.Global Health. 2013; 9: 5Crossref PubMed Scopus (38) Google Scholar, 12Manabe YC Katabira E Brough R Coutinho A Sewankambo N Merry C Developing independent investigators for clinical research relevant for Africa.Health Res Policy Sys. 2011; 9: 44Crossref Scopus (21) Google Scholar The differences would be illuminating. The fourth element is to recognise the important role of mentors in supporting trainees' ethical decision making. Trainees learn through mentors as role models, which is arguably more important than formal curricula. Moreover, mentors frequently have a wealth of experience in translating ethical principles into their real-world application. Increased effort that is focused on training mentors in ethics as compared to trainees could therefore be necessary and helpful. Meaningful mentorship requires mentors at home and abroad who are in frequent contact and develop real relationships with mentees before, during, and after training programmes. Our vision is not meant to replace existing ethics guidelines, but is instead meant to ensure their proper application and to encourage further development led by the people most affected by them.1DeCamp M Lehmann L Jaeel P Horwitch C Ethical obligations regarding short-term global health clinical experiences.Ann Intern Med. 2018; 169: 589-590Crossref Scopus (1) Google Scholar, 7Manabe YC Jacob S Thomas D et al.Resurrecting the triple threat: academic social responsibility in the context of global health research.Clin Infect Dis. 2009; 48: 1420-1422Crossref PubMed Scopus (17) Google Scholar Nor will requiring continuous effort before, during and after global health training programmes be easy. By broadening the ethics of global health to re-integrate research, clinical, and public health ethics, we hope to cultivate in all of us a moral imagination and capability for ethical reflection that will catalyse global health training to achieve its main goal: tangible improvements in global public health. We declare no competing interests. This work was supported by National Institutes of Health Fogarty International Centre (NIH/FIC) grants D43TW009340 and R25TW009730 . NKS is a principal investigator for grants that support bioethics and research capacity building (NIH/FIC grant NURTURE D43TW010132 and a Wellcome Trust/DFID DELTAS grant DEL-15-011/07742/Z/15/Z). YCM is supported by the NIH/FIC grants D43TW010132 , D43TW009771 .