Lynn McIntyre MD MHSc FRCPC is Professor in the Department of Community Health Sciences, and Research Coordinator for the Public Health and Preventive Medicine program, at the University of Calgary, Alberta
I am sitting on a balcony in Mwanza, Tanzania looking out on Lake Victoria. This is the second public health and preventive medicine residency elective I have done here.
My institution, like many other North American universities, embraces global health educational opportunities and supports these experiences by covering some or all of residents’ travel expenses and facilitating contact with potential host institutions.
The Canadian Association of Interns and Residents supports global health electives as well and outlines institutional responsibilities related to resident participation. Their guidelines state that Postgraduate Medical Education Offices should offer residents predeparture training to address health, safety and “ethical challenges”; to designate a contact person; and to provide clear expectations. I have been thinking about these "ethical challenges" in addition to how sending institutions define their own responsibilities, not only towards their residents, but with regard to host institutions. Clearly, institutional arrangements transcend program and individual traineeship levels; however, at their core is an ethical obligation to engage in a relationship of mutual and reciprocal benefit.
But what does reciprocity mean in the context of resident-level global health electives, and what do egalitarian partnerships look like?
The Golden Rule
The “Golden Rule,” also known as the “ethics of reciprocity,” is a moral principle and a test of consistency that ensures that one’s actions are in harmony with moral beliefs. The Golden Rule is infringed when one acts in a given way towards another and yet is unwilling to be treated that way oneself.
The literal interpretation of the Golden Rule states that one ought to “treat others as one wants to be treated.” For example, as physicians, we are expected to treat our patients with dignity and respect; in return, we expect that our patients will treat us the same way.
Following this rule, sending institutions should be willing to receive residents from host intuitions. In this context, sending institutions could ensure reciprocity if they implemented a “send one, get one” policy of resident exchange. However, this does not happen.
Although many medical schools do have processes that permit foreign residents to do electives in a partner institution, structural mechanisms such as most-favoured nation policies, licensing board requirements and prohibitive tuition fees work to systematically exclude residents from low- and middle-income countries from accessing the same global health experience that I have enjoyed. In addition, there is a moral concern that a “send one, get one” policy might perpetuate “brain drain."
Still, ensuring a bidirectional transit of residents would literally satisfy the issue of reciprocity. Sending institutions that choose to work towards a “send one, get one” policy could focus on removing barriers for foreign residents, such as prohibitive costs of travel and administrative hurdles, such as licensing requirements.
The literal interpretation of the Golden Rule may, however, lead to irrational conclusions. For example, physicians ask patients personal questions, but we do not expect patients to do the same. We are doing something to our patients that we wouldn’t want them to do to us; therefore, we are not consistent in our behaviour under the literal rule. This is of course absurd; we need to ask our patients personal questions because these questions will help us reach a diagnosis.
The flaw in the literal interpretation of the Golden Rule lies in the different situations of physicians and patients, which must be taken into consideration when testing for reciprocity. The proper question to ask is whether we physicians would be willing to answer personal questions if we were in the same situation as our patients, and of course we would if we knew that these questions would assist in diagnosis. This nuance of the Golden Rule is called the “present attitude” test, which asks if we are willing for the same thing be done to us in the same situation.
It is important to note that in the “present attitude” test the individual (or institution) whose behaviour is tested for reciprocity is not only in the “same shoes” at the receiving end of the action, but also has the knowledge of consequences of that action. This knowledge of what the actual consequences of our actions are is an essential component of the “present attitude” test. It is not until we have learned all the facts (and acknowledged our reaction to those facts) that we are in a position to determine whether we would be willing to receive the same actions in the same circumstances.
In the context of sending and host institutions, situations differ. Host institutions are often resource poor, and sending institutions are usually resource rich. The present attitude test asks sending institutions to ask whether, were they in the same situation as the host institution, they would still be willing to receive residents from institutions from higher-income countries? Would they take residents who did not speak the language; who took precious preceptor time away from busy clinics; whose skills were unknown; who might affect patient safety? And what capacity would be required by a host institution to inform, implement, and monitor policies that the sending institution has codified in its decisions about accepting host institution residents for global electives?
Furthermore, host institutions may be less likely to have sufficient resources to monitor and document the benefits and potential harms that residents bring, and may consequently lack the knowledge to make an informed decision on whether and under what circumstances they should receive trainees. Moreover, even if they had such information; they may hesitate to approach the sending institution for fear of disrupting the relationship and jeopardizing other beneficial institutional arrangements.
The challenge for sending institutions, therefore, is to think about reciprocity in these terms. The Golden Rule helps guide behaviours toward others. It encourages sending institutions to take greater effort to know, understand and inform the receiving host. Only with that understanding will terms of reciprocity be meaningfully enacted.
The authors would like to acknowledge Dr. Richard Musto for the endless stimulating conversations that inspired the conception of this manuscript.