Freshman Seminar University of Massachusetts- Boston March 9, 2017

Ethical & Cross-Cultural Considerations in Global Health Education Joyce A. Sackey, M.D., FACP Dean for Multicultural Affairs and Global Health Associate Professor, Departments of Medicine & Public Health and Community Medicine Tufts University School of Medicine

Tufts Around The Globe

Educational Benefits of Participating in a Global Health Experience Service opportunity Become part of the solution to inequities in global health Personal growth Learning opportunity Health systems other than US Cultural competency through immersion Spectrum of diseases otherwise not encountered during medical school

Global Engagement: TUSM’s Approach  Hallmarks- A passion for excellence, active citizenship, and a deep commitment to addressing global health disparities. Time-tested, community-centered approach to problem solving and finding locally- driven solutions Empowering global partners to work directly with their communities to find innovative, transformative and sustainable solutions

Special Focus: Resource-limited Settings What Types of Ethical and Cross-cultural Issues Arise When Working in International Settings? Special Focus: Resource-limited Settings

Ethical Considerations Patients Host institution Sending institution- Tufts Personal safety

Sending Institution Primary purpose of experience is global health learning (service to a lesser extent). Tufts ambassador Tufts professionalism standards Communication with Tufts mentor and other administrators

Host Community Community-centric Cultural humility Consider local needs and priorities Cultural humility Be open to listen and learn from all sources Be mindful of burden on host Unintended consequences Solidarity Importance of establishing relationships

Patients Right to appropriate care Privacy Informed consent Confidentiality Cultural sensitivity Communication skills

Common Themes Allocation of scarce resources. Reconciling the provision of care within a particular cultural context and our notion of “standard of care.” Balancing educational and training needs and patient care.

Core Guiding Principle Primum non nocere- First, do no harm

Case Discussion A rural hospital in a resource-limited setting with a new “neonatal intensive care unit.” A mixed health care team, consisting of local professionals (permanent) and volunteers (short-term), including students. The patient- a baby born prematurely and requiring “intensive” care in the new NICU. Resource in question: Oxygen.

Framework for Resolving Ethical Dilemmas What is the problem or dilemma? What are the facts and issues? What are the values at stake? Are the values and preferences of different stakeholders (e.g. patient vs. health care provider) at variance or in conflict? What ethical principles are at stake? What practical issues need to be addressed? Principles of Biomedical Ethics, Beauchamp, Childress, 6th Ed

Four Key Principles of Health Care Ethics Beneficence Doing good for a patient Respect for autonomy The patient’s right to decision-making regarding his/her body Non-maleficence “Primum non nocere”- First do no harm Justice Protecting one’s patient from exploitation and discrimination Principles of Biomedical Ethics. Beauchamp, Childress, 6th Ed.

A ten year old boy presents hours after an unprovoked dog bite Case Discussion 2 A ten year old boy presents hours after an unprovoked dog bite Health care team is concerned about a possible risk of exposure to rabies, a condition that carries with it a high mortality rate The boy does not have access to anti-rabies immunoglobulin at the location, and the visiting team contemplates obtaining an emergency supply from the US (at a considerable cost)

Summary Primum non nocere- First, do no harm Adopt an attitude of cultural humility Learn first, do later Be community-centric in your approach Strive to understand the values at stake (or at odds) when facing an ethical tension Use a win-win strategy to resolve conflicts

Social justice and Advocacy Your final ethical responsibility is to share what you have learned. Bear witness!