This essay discusses the potential harms and benefits of short term medical service trips (MSTs), arguing that they should not be considered inherently ethical because they are a charitable act, and can have significant negative impacts on host communities (HCs) and low-income nations as a whole. This is done by evaluating the effects of MSTs through the lens of the four principles of biomedical ethics. While MSTs may empower HCs to make autonomous decisions about healthcare as a result of being less restricted by lack of resources and knowledge, the inherent power imbalance between volunteers and HC patients may undermine the autonomy of patients. Furthermore, while MSTs aim to improve the health of HCs, volunteers often lack the training to do so. MSTs are also not harmless, as their unregulated presence can disrupt local healthcare systems. Additionally, although MSTs often aim to address health inequities, they can result in HCs becoming dependant on outside intervention, further reinforcing global health injustice. Following a discussion of their drawbacks, the essay presents suggestions on how the ethics surrounding MSTs can be addressed.
Short-term medical service trips (MSTs), sometimes referred to as “medical voluntourism,” involve students with minimal to no medical training travelling abroad to gain healthcare experience and improve the health of the host community (HC). MSTs are arranged by charities, for profit businesses, and universities. Over 250 million dollars are spent annually on these trips, and approximately one third of medical graduates in the United States and Canada have completed an MST during their training. MSTs are often marketed to students as both charitable missions and experiential learning opportunities. They are primarily organized by high-income countries, with the destination often being a low or middle-income country. Due to the high disease burden in many low and middle income nations, coupled with a small physician supply, these countries are perceived to be in need of medical aid. In turn, students believe that they are able to provide that aid through participating in MSTs. Because MSTs are seen as charitable acts, their ethical implications are often left unexamined; a phenomenon known as “The Myth of Mere Charity.” However, many practices involved in MSTs directly oppose the principles of biomedical ethics, including autonomy (self-determination), beneficence (doing good), non-maleficence (avoiding harm), and justice (acting in fairness). Due to communication barriers and the inherent power imbalance between volunteers and patients, volunteers may compromise the autonomy of patients in HCs. Additionally, although volunteers intend to benefit patients, their lack of medical and cultural competence often leaves them incapable of doing so. Furthermore, the disruption to local healthcare systems by MSTs can harm the community. Finally, the short-term nature of many MSTs and the pressures they place on host countries reinforce barriers to global healthcare equity. This essay argues that MSTs deserve careful critique, as they have the potential to infringe on the autonomy of patients, cause undue harm, and promote global healthcare injustice.
It is argued that MSTs empower patients in low-income countries to become more autonomous through the exchange of information and the donation of goods and services. This purportedly allows patients to make informed decisions about their health — free of resource limitations. Additionally, students participating in MSTs claim that the response from HCs is overwhelmingly positive, suggesting that MSTs align with the wishes of the HCs. However, MSTs may also threaten the autonomy of HCs through improper communication and unfair collaboration. Because volunteers are unfamiliar with the language of their HC, obtaining informed consent from patients may be overlooked. On a broader scale, MSTs may undermine the autonomy of entire communities. Organizations executing MSTs often make decisions about the location and duration of the trip, the nature of care being provided, and the volunteers who attend the trip without consulting the community. This subverts its capacity to self-govern. For example, when asked about medical brigades, the Honduras Department of Health replied, “[W]e (only) know about those (teams) that apply for the permission but not for those that (do not and that) go only to small communities,” suggesting that the interests of MSTs are not always aligned with those of HCs.
Improving Local Care?
A common argument given in support of MSTs is that they promote beneficence by improving the health of HC residents. However, due to the limited time, training, and cultural competency of volunteers, they are not likely to provide continuous care to patients nor substantially improve the long-term health of HC residents. MSTs usually last less than one month and are comprised of short, one-time patient visits. Additionally, volunteers often have little background knowledge in the healthcare challenges of the country they are visiting, thus limiting their ability to provide care to patients. For example, a Canadian medical student participating in an MST may be able to identify a patient with severe dehydration and know that she requires a saline drip; however, due to his inexperience in inserting needles into collapsed veins (which is not commonly encountered in Canada), he is unable to help the patient and must call a local nurse to insert the needle. Finally, in addition to lacking technical skills, volunteers are often unversed in the culture of their host country, and are thus unable to provide culturally-relevant care to patients. For example, an American student may suggest that a patient use condoms or oral contraception as a means of family planning, without understanding that the use of contraceptives, while commonplace in the USA, may carry strong negative connotations in the patient’s culture.
At The Very Least, Harmless?
While MSTs may not produce substantial long-term benefits in HCs, many argue that they are, at the very least, also unlikely to result in harm. Proponents claim that communities targeted by MSTs often suffer from insufficient healthcare resources, and thus any effort to help these communities, even if provided by untrained volunteers, is likely to result in some positive net effect. However, MSTs can result in harm to communities by putting the health of patients at risk and disrupting the community’s healthcare system. During MSTs, volunteers are sometimes pressured to carry out procedures they are not trained to do. For example, a first-year medical student may be told to suture an incision following surgery without supervision by a surgeon, despite not having sufficient training in this procedure, potentially resulting in infection or scarring. Additionally, residents of HCs may avoid local healthcare providers in favour of volunteers, thereby disrupting the local healthcare system and resulting in delayed care. Local physicians in a Central-American HC have complained that some residents wait for the free care and medication provided by MSTs instead of seeking medical attention locally. Volunteers may also take away training opportunities from local students, leading to a shortage of healthcare providers, thus weakening local healthcare systems.
Decreasing Health Inequities?
Proponents of MSTs argue that these trips promote justice in healthcare by decreasing healthcare inequities and creating a cross-cultural network of information and resource exchange. Volunteers donate time and resources to improve the condition of the HC’s healthcare system, helping bridge the gap between healthcare in high and low-income countries. In many cases, however, MSTs may support structures of social injustice by implying that low-income communities are deserving of a lower quality of care. Care delivered by volunteers on MSTs is often well below the standard of care in the volunteers’ own country. MSTs may also cause a dependency on foreign aid in HCs by disrupting and destabilizing the existing healthcare system, resulting in the perpetuation of health injustice.
MSTs should not be considered inherently ethical simply because they are charitable acts. Rather, they deserve careful ethical critique, as they have the potential to infringe on the autonomy of patients, cause undue harm by promoting lower standards of care, and perpetuate global healthcare injustices — effects which directly oppose the principles of biomedical ethics. The manner in which many MSTs are currently conducted is unethical, and provisions should be put in place to counteract this. Many suggestions have been put forward to increase the ethicality of medical service trips, including providing pre-departure training to volunteers on the culture and language of HCs; setting strict guidelines to ensure that volunteers are not asked to perform tasks for which they are untrained; fostering fair partnerships with HCs to ensure that the trip is catered to their needs and will not negatively disrupt their healthcare system; collecting feedback from patients, local healthcare workers, and community members; and working with HCs to address and dismantle the systemic barriers to equitable healthcare access.
Written By Noor Hamideh
Reviewed By Nicola Gailits
References may be found in the journal.