DERMATOETHICS
CONSULTATION
Short-term international volunteerism in dermatology: Ethical considerations Benjamin K. Stoff, MD,a,b and Josette R. McMichael, MDa Atlanta, Georgia
CASE SCENARIO Dr Goodheart is a general dermatologist in the United States who has signed up for a 3-week international volunteer trip to an underserved area. Her trip is coordinated by a reputable organization that partners with a local health care system and sends dermatologists to this site 2 to 3 times per year. Dr Goodheart brings along a box of sample-sized tubes (15 g) of topical steroids of various potencies that were donated by a pharmaceutical company and approved for use by the partnering health care organization. Upon arrival at the clinic site, she pairs up with a local primary care provider to evaluate patients. The first patient they encounter is a 7-year-old boy with moderate to severe atopic dermatitis. Although topical steroids are available and relatively inexpensive at the local pharmacy, his family cannot afford them. In addition, the health care system does not have sufficient means to dispense free medication under normal circumstances. In addition to providing basic education about atopic dermatitis to the boy and his family, Dr Goodheart and her colleague should: A. Give half of the topical steroid samples to the boy B. Give a few samples of topical steroid to the boy. Advise the family to return to the clinic when the next volunteer dermatologist arrives in 4 to 6 months C. Give 1 sample of topical steroid to the boy. Go to the local pharmacy and buy a year-long supply of topical steroids to donate to the boy D. Do not give any topical steroid samples to the boy
lobal health, a union of public and international health, refers to research and service aimed at promoting equality in health worldwide.1 The bioethical rationale for global health stems from the concept of social justice, which advocates for fair access to resources and shared responsibility for burdens across all members of society.2 Specifically, the cosmopolitan view of social justice suggests that country of origin is not an ethically justifiable basis for exclusion of certain people from a just allotment of medical resources.2 According to this perspective, the obligation to promote health should not be constrained by national boundaries.2
G
One means of ostensibly promoting global health is through short-term international medical volunteerism. The growing popularity of this work is reflected in the numerous organizations coordinating trips for health care providers, and an impressive 50% of accredited medical schools in the United States offering formal experiences in global health for students.3 In principle, short-term international medical volunteer work advances the tenets of global health by promoting patient care, education, and health infrastructure in underserved communities. However, it also has the capacity to work against health equity and the empowerment of local health
From the Department of Dermatology,a Emory University School of Medicine, and the Emory Center for Ethics,b Atlanta. Funding source: None. Conflicts of interest: None declared. Reprint requests: Benjamin K. Stoff, MD, Department of Dermatology, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA 30312. E-mail: [email protected].
J Am Acad Dermatol 2014;71:822-5. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.03.026
822
J AM ACAD DERMATOL
Stoff and McMichael 823
VOLUME 71, NUMBER 4
Table I. Ethical principles to guide global short-term medical volunteer trips* Guideline
Create a statement of common purpose Establish a collaborative partnership
Ensure fairness in site selection
Commit to benefits of social value
Engage in bidirectional educational initiatives targeting the local community and team members
Build the capacity of and work within the limits of local health care infrastructure Evaluate program outcomes
Engage in frequent ethical review
Example
Promotion of global health equity through an expression of mutual caring and the relief of suffering Formulate goals for the trip through open, mutual input from volunteers and representatives of host site well in advance of the trip Make transparent the rationale for a project at a given site and include ethically relevant features, including perceived medical need, efficiency of resource impact, and safety for volunteers and patients Allow representatives of the local community to determine the desirability and feasibility of the service work to be performed In collaboration with local health care providers, create a series of interactive lectures and other educational materials targeting local health care providers and covering commonly encountered diseases in their community Donate resources to establish a high-speed Internet connection and telemedicine capacity at the host site For an educational goal, measure durable gains in knowledge; for a patient care goal, measure long-term responses to treatment After working with local health care leaders to define guiding principles and benchmarks, periodically seek external, independent review (eg, from a member of a different volunteer organization) of goals and deliverables for adherence to these principles
*Adapted from DeCamp.3
care systems in a number of ways.3,4 For example, the short duration and intermittent nature of this work often does not allow for sufficient patient follow-up to determine the safety and efficacy of interventions. Volunteers, particularly trainees, may also be tempted to practice beyond their scope of competency or below accepted standards of care in their home communities. Even when the volunteer or coordinating organization covers travel expenses, volunteer visits may expend host community resources (including time, logistical support, and culturally mandated hospitality) that could be better allocated to other purposes. Conflicting cultural and ethical norms may also interfere with the effective provision of health care. Perhaps most important, short-term medical volunteer work may unintentionally subvert the local health care system and alienate local providers. For these reasons and others, ethicists in the field of global health have proposed guidelines for carrying out short-term international medical volunteer work in a morally sound manner3 (Table I). The scenario presented here highlights 2 important ethical considerations in international medical aid work. The first involves fair allocation of limited
medical resources, an extension of the bioethical notion of distributive justice.2 Experts in the field point to 4 general principles guiding allocation in this context5: 1. Considering potential recipients equally (eg, a lottery system or first come, first served) 2. Giving priority to the worst off (eg, sickest first or youngest first) 3. Maximizing utility (eg, saving the most lives or reducing the most morbidity overall) 4. Promoting social value (eg, treating valued members of society ahead of others) Each principle has advantages and disadvantages. For example, an allocation system based on first come, first served seems equitable in theory but, in practice, tends to favor those with sufficient means to travel quickly and wait for long periods of time.5 Therefore, some experts suggest that the ideal allocation system for scarce medical resources should draw upon a combination of several principles.5 A second theme of global health ethics prompted by the scenario is sustainability. In order to advance
824 Stoff and McMichael
health equity and empower local health care systems, the benefit of short-term medical aid work must be durable, continuing well beyond an isolated visit by volunteers.4 In addition, the interventions must be feasible within the constraints of the local health care system and, ideally, carried out in collaboration with local health care providers.4 If not, the local health care system may be undermined and local providers marginalized. Sustainability poses a particular challenge when the local disease burden is composed of chronic conditions.4 Indeed, many of the most common and burdensome skin diseases worldwide, including atopic dermatitis, are chronic.6 In this context, volunteers may be tempted to circumvent the local health care system with one-time donations of
ANALYSIS OF CASE SCENARIO Choice (A), in which the volunteer gives half of the supply of topical steroids to the boy, is flawed for several reasons. First, it does not conform to principles for just distribution of limited resources. Such a large allotment exceeds the patient’s fair share. Although the boy has moderate to severe disease, it is impossible to know at this point whether he will be worst off among patients evaluated by the volunteer team. Depleting half of the supply of topical steroids quickly limits the utility of the intervention overall. For instance, the volunteer may encounter other patients with acute dermatitis who will not require long-term treatment but will benefit greatly from a small supply of topical steroid samples. Finally, although young children are presumably valued by the host society, others patients, such as young adults whose ability to work is limited by skin disease, may be valued more highly. Choice (A) also raises concerns about sustainability. This amount of medication will last the patient longer than the other choices above. However, it does not address his need for a reliable means of obtaining more topical steroids, given the chronic nature of atopic dermatitis. Choice (C) appears desirable at first glance, because a single sample of topical steroid could represent a just allotment, and purchasing a yearlong supply of topical steroids from the local pharmacy may be well within the means of the volunteer and her organization. However, it constitutes a workaround of the local health care system. As such, it may have untoward
J AM ACAD DERMATOL
OCTOBER 2014
limited amounts of medication.4 However, this practice may have undesired effects. For example, it may inadvertently mask infrastructural problems related to local formularies that could be brought to the attention of the ministry of health. Donations by volunteers may also lead to unrealistic expectations on the part of local health care providers and patients that volunteers will always provide medications that are needed by the community. According to the World Health Organization (WHO), ‘‘.[M]edicine donations are neither a long-term solution to underfunded health systems nor a solution to the lack of access to medicines in poor countries—especially for diseases that require lifelong treatment or large numbers of treatments.’’7
effects, including diverting the attention of the local health administration from the ongoing needs of patients, creating untenable expectations of volunteers, and marginalizing local health care providers. Giving a few samples to the boy and recommending follow-up when the next volunteer group arrives, as in choice (B), may be reasonable. Donating several samples, rather than 1 tube or half of the supply, seems justified for a patient with moderate to severe disease but would not substantially deplete the stock of donated medication. Although this amount will certainly not last 4 to 6 months, it may enable the boy and his family to learn how to use topical steroids appropriately and provide temporary relief. Nonetheless, this choice may be viewed as a workaround, because it fails to address the need for the local health care system to reliably accommodate indigent patients with chronic skin diseases. At first glance, choice (D) may seem objectionable. Withholding appropriate treatment from a patient with moderate to severe disease appears to violate the duty of health care professionals to provide standard treatment if it is available. However, extenuating circumstances of short-term medical aid work, such as limited donations and highly constrained local health care systems, may compel a volunteer to consider this option. It is imperative that volunteers not bypass the local health care system and that donations of medicine comply with standards set forth by the WHO.7 Indeed, the decision not to intervene fully is perhaps the most difficult
J AM ACAD DERMATOL VOLUME 71, NUMBER 4
one a volunteer faces.4 However, in this context, the more appropriate use of a limited supply of topical steroids may be for patients with acute dermatitis who cannot otherwise access topical steroids. Of course, electing to withhold topical
Bottom line Short-term international medical service work has the potential to promote global health equity and empower local health care systems. To achieve this end, it is vital to understand the capabilities, needs, and expectations of local health care providers. Coordinating organizations and individual volunteers must conduct this work in an ethically sound manner, as outlined in Table I. Scarce resources should be allocated in accordance with appropriate principles, and care for individual patients must be delivered within the constraints local health care systems to be sustainable. At times, this may mean using therapeutic strategies that deviate from standard practices in the volunteer’s home health care system and making difficult choices among several seemingly undesirable courses of action. Volunteer organizations must also exercise caution in donating limited medications to manage chronic diseases and should comply with
Stoff and McMichael 825
steroid samples from the boy in this case would not come at the expense of other essential elements of the treatment plan, such as education about care of dry skin and the itch/scratch cycle.
guidelines put forth by authoritative bodies, such as the WHO. REFERENCES 1. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al. Towards a common definition of global health. Lancet 2009;373:1993-5. 2. Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press; 2009. 3. DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum 2011;23:91-103. 4. Wall AE. Ethics for international medicine: a practical guide for aid workers in developing countries. Hanover (NH): Dartmouth College Press; 2012. 5. Persad G, Wertheimer A, Emanuel EJ. Principles for allocation of scarce medical interventions. Lancet 2009;373:423-31. 6. Hay RJ, Johns NE, Williams HC, Bolliger IW, Dellavalle RP, Margolis DJ, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol 2014;134:1527-34. 7. World Health Organization web site. Guidelines for medicine donations - revised 2010. Available at: http://www.who.int/ selection_medicines/emergencies/guidelines_medicine_donations/ en/. Accessed February 7, 2014.
CONSULTATION
Short-term international volunteerism in dermatology: Ethical considerations Benjamin K. Stoff, MD,a,b and Josette R. McMichael, MDa Atlanta, Georgia
CASE SCENARIO Dr Goodheart is a general dermatologist in the United States who has signed up for a 3-week international volunteer trip to an underserved area. Her trip is coordinated by a reputable organization that partners with a local health care system and sends dermatologists to this site 2 to 3 times per year. Dr Goodheart brings along a box of sample-sized tubes (15 g) of topical steroids of various potencies that were donated by a pharmaceutical company and approved for use by the partnering health care organization. Upon arrival at the clinic site, she pairs up with a local primary care provider to evaluate patients. The first patient they encounter is a 7-year-old boy with moderate to severe atopic dermatitis. Although topical steroids are available and relatively inexpensive at the local pharmacy, his family cannot afford them. In addition, the health care system does not have sufficient means to dispense free medication under normal circumstances. In addition to providing basic education about atopic dermatitis to the boy and his family, Dr Goodheart and her colleague should: A. Give half of the topical steroid samples to the boy B. Give a few samples of topical steroid to the boy. Advise the family to return to the clinic when the next volunteer dermatologist arrives in 4 to 6 months C. Give 1 sample of topical steroid to the boy. Go to the local pharmacy and buy a year-long supply of topical steroids to donate to the boy D. Do not give any topical steroid samples to the boy
lobal health, a union of public and international health, refers to research and service aimed at promoting equality in health worldwide.1 The bioethical rationale for global health stems from the concept of social justice, which advocates for fair access to resources and shared responsibility for burdens across all members of society.2 Specifically, the cosmopolitan view of social justice suggests that country of origin is not an ethically justifiable basis for exclusion of certain people from a just allotment of medical resources.2 According to this perspective, the obligation to promote health should not be constrained by national boundaries.2
G
One means of ostensibly promoting global health is through short-term international medical volunteerism. The growing popularity of this work is reflected in the numerous organizations coordinating trips for health care providers, and an impressive 50% of accredited medical schools in the United States offering formal experiences in global health for students.3 In principle, short-term international medical volunteer work advances the tenets of global health by promoting patient care, education, and health infrastructure in underserved communities. However, it also has the capacity to work against health equity and the empowerment of local health
From the Department of Dermatology,a Emory University School of Medicine, and the Emory Center for Ethics,b Atlanta. Funding source: None. Conflicts of interest: None declared. Reprint requests: Benjamin K. Stoff, MD, Department of Dermatology, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA 30312. E-mail: [email protected].
J Am Acad Dermatol 2014;71:822-5. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.03.026
822
J AM ACAD DERMATOL
Stoff and McMichael 823
VOLUME 71, NUMBER 4
Table I. Ethical principles to guide global short-term medical volunteer trips* Guideline
Create a statement of common purpose Establish a collaborative partnership
Ensure fairness in site selection
Commit to benefits of social value
Engage in bidirectional educational initiatives targeting the local community and team members
Build the capacity of and work within the limits of local health care infrastructure Evaluate program outcomes
Engage in frequent ethical review
Example
Promotion of global health equity through an expression of mutual caring and the relief of suffering Formulate goals for the trip through open, mutual input from volunteers and representatives of host site well in advance of the trip Make transparent the rationale for a project at a given site and include ethically relevant features, including perceived medical need, efficiency of resource impact, and safety for volunteers and patients Allow representatives of the local community to determine the desirability and feasibility of the service work to be performed In collaboration with local health care providers, create a series of interactive lectures and other educational materials targeting local health care providers and covering commonly encountered diseases in their community Donate resources to establish a high-speed Internet connection and telemedicine capacity at the host site For an educational goal, measure durable gains in knowledge; for a patient care goal, measure long-term responses to treatment After working with local health care leaders to define guiding principles and benchmarks, periodically seek external, independent review (eg, from a member of a different volunteer organization) of goals and deliverables for adherence to these principles
*Adapted from DeCamp.3
care systems in a number of ways.3,4 For example, the short duration and intermittent nature of this work often does not allow for sufficient patient follow-up to determine the safety and efficacy of interventions. Volunteers, particularly trainees, may also be tempted to practice beyond their scope of competency or below accepted standards of care in their home communities. Even when the volunteer or coordinating organization covers travel expenses, volunteer visits may expend host community resources (including time, logistical support, and culturally mandated hospitality) that could be better allocated to other purposes. Conflicting cultural and ethical norms may also interfere with the effective provision of health care. Perhaps most important, short-term medical volunteer work may unintentionally subvert the local health care system and alienate local providers. For these reasons and others, ethicists in the field of global health have proposed guidelines for carrying out short-term international medical volunteer work in a morally sound manner3 (Table I). The scenario presented here highlights 2 important ethical considerations in international medical aid work. The first involves fair allocation of limited
medical resources, an extension of the bioethical notion of distributive justice.2 Experts in the field point to 4 general principles guiding allocation in this context5: 1. Considering potential recipients equally (eg, a lottery system or first come, first served) 2. Giving priority to the worst off (eg, sickest first or youngest first) 3. Maximizing utility (eg, saving the most lives or reducing the most morbidity overall) 4. Promoting social value (eg, treating valued members of society ahead of others) Each principle has advantages and disadvantages. For example, an allocation system based on first come, first served seems equitable in theory but, in practice, tends to favor those with sufficient means to travel quickly and wait for long periods of time.5 Therefore, some experts suggest that the ideal allocation system for scarce medical resources should draw upon a combination of several principles.5 A second theme of global health ethics prompted by the scenario is sustainability. In order to advance
824 Stoff and McMichael
health equity and empower local health care systems, the benefit of short-term medical aid work must be durable, continuing well beyond an isolated visit by volunteers.4 In addition, the interventions must be feasible within the constraints of the local health care system and, ideally, carried out in collaboration with local health care providers.4 If not, the local health care system may be undermined and local providers marginalized. Sustainability poses a particular challenge when the local disease burden is composed of chronic conditions.4 Indeed, many of the most common and burdensome skin diseases worldwide, including atopic dermatitis, are chronic.6 In this context, volunteers may be tempted to circumvent the local health care system with one-time donations of
ANALYSIS OF CASE SCENARIO Choice (A), in which the volunteer gives half of the supply of topical steroids to the boy, is flawed for several reasons. First, it does not conform to principles for just distribution of limited resources. Such a large allotment exceeds the patient’s fair share. Although the boy has moderate to severe disease, it is impossible to know at this point whether he will be worst off among patients evaluated by the volunteer team. Depleting half of the supply of topical steroids quickly limits the utility of the intervention overall. For instance, the volunteer may encounter other patients with acute dermatitis who will not require long-term treatment but will benefit greatly from a small supply of topical steroid samples. Finally, although young children are presumably valued by the host society, others patients, such as young adults whose ability to work is limited by skin disease, may be valued more highly. Choice (A) also raises concerns about sustainability. This amount of medication will last the patient longer than the other choices above. However, it does not address his need for a reliable means of obtaining more topical steroids, given the chronic nature of atopic dermatitis. Choice (C) appears desirable at first glance, because a single sample of topical steroid could represent a just allotment, and purchasing a yearlong supply of topical steroids from the local pharmacy may be well within the means of the volunteer and her organization. However, it constitutes a workaround of the local health care system. As such, it may have untoward
J AM ACAD DERMATOL
OCTOBER 2014
limited amounts of medication.4 However, this practice may have undesired effects. For example, it may inadvertently mask infrastructural problems related to local formularies that could be brought to the attention of the ministry of health. Donations by volunteers may also lead to unrealistic expectations on the part of local health care providers and patients that volunteers will always provide medications that are needed by the community. According to the World Health Organization (WHO), ‘‘.[M]edicine donations are neither a long-term solution to underfunded health systems nor a solution to the lack of access to medicines in poor countries—especially for diseases that require lifelong treatment or large numbers of treatments.’’7
effects, including diverting the attention of the local health administration from the ongoing needs of patients, creating untenable expectations of volunteers, and marginalizing local health care providers. Giving a few samples to the boy and recommending follow-up when the next volunteer group arrives, as in choice (B), may be reasonable. Donating several samples, rather than 1 tube or half of the supply, seems justified for a patient with moderate to severe disease but would not substantially deplete the stock of donated medication. Although this amount will certainly not last 4 to 6 months, it may enable the boy and his family to learn how to use topical steroids appropriately and provide temporary relief. Nonetheless, this choice may be viewed as a workaround, because it fails to address the need for the local health care system to reliably accommodate indigent patients with chronic skin diseases. At first glance, choice (D) may seem objectionable. Withholding appropriate treatment from a patient with moderate to severe disease appears to violate the duty of health care professionals to provide standard treatment if it is available. However, extenuating circumstances of short-term medical aid work, such as limited donations and highly constrained local health care systems, may compel a volunteer to consider this option. It is imperative that volunteers not bypass the local health care system and that donations of medicine comply with standards set forth by the WHO.7 Indeed, the decision not to intervene fully is perhaps the most difficult
J AM ACAD DERMATOL VOLUME 71, NUMBER 4
one a volunteer faces.4 However, in this context, the more appropriate use of a limited supply of topical steroids may be for patients with acute dermatitis who cannot otherwise access topical steroids. Of course, electing to withhold topical
Bottom line Short-term international medical service work has the potential to promote global health equity and empower local health care systems. To achieve this end, it is vital to understand the capabilities, needs, and expectations of local health care providers. Coordinating organizations and individual volunteers must conduct this work in an ethically sound manner, as outlined in Table I. Scarce resources should be allocated in accordance with appropriate principles, and care for individual patients must be delivered within the constraints local health care systems to be sustainable. At times, this may mean using therapeutic strategies that deviate from standard practices in the volunteer’s home health care system and making difficult choices among several seemingly undesirable courses of action. Volunteer organizations must also exercise caution in donating limited medications to manage chronic diseases and should comply with
Stoff and McMichael 825
steroid samples from the boy in this case would not come at the expense of other essential elements of the treatment plan, such as education about care of dry skin and the itch/scratch cycle.
guidelines put forth by authoritative bodies, such as the WHO. REFERENCES 1. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al. Towards a common definition of global health. Lancet 2009;373:1993-5. 2. Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press; 2009. 3. DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum 2011;23:91-103. 4. Wall AE. Ethics for international medicine: a practical guide for aid workers in developing countries. Hanover (NH): Dartmouth College Press; 2012. 5. Persad G, Wertheimer A, Emanuel EJ. Principles for allocation of scarce medical interventions. Lancet 2009;373:423-31. 6. Hay RJ, Johns NE, Williams HC, Bolliger IW, Dellavalle RP, Margolis DJ, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol 2014;134:1527-34. 7. World Health Organization web site. Guidelines for medicine donations - revised 2010. Available at: http://www.who.int/ selection_medicines/emergencies/guidelines_medicine_donations/ en/. Accessed February 7, 2014.
