The Ethics of Medical Practitioner Migration From Low-Resourced Countries to the Developed World: A Call for Action by Health Systems and Individual Doctors

Medical migration appears to be an increasing global phenomenon, with complex contributing factors. Although it is acknowledged that such movements are inevitable, given the current globalized economy, the movement of health professionals from their country of training raises questions about equity of access and quality of care. Concerns arise if migration occurs from low- and middle-income countries (LMICs) to high-income countries (HICs). The actions of HICs receiving medical practitioners from LMICs are examined through the global justice theories of John Rawls and Immanuel Kant. These theories were initially proposed by Pogge (1988) and Tan (1997) and, in this work, are extended to the issue of medical migration. Global justice theories propose that instead of looking at health needs and workforce issues within their national boundaries, HICs should be guided by principles of justice relevant to the needs of health systems on a global scale. Issues of individual justice are also considered within the framework of rights and social responsibilities of individual medical practitioners. Local and international policy changes are suggested based on both global justice theories and the ideals of individual justice.     

Poverty and Health Ethics in Developing Countries

Developing countries face difficulties of exploitation, dehumanisation and lack of ethical professionalism, to an extent that developed countries do not encounter. Poverty-related difficulties include lack of infrastructure, unreasonable dominance of defence-related expenses in the budget, lack of a sufficient number of health care providers, absence of accountability for serious medical malpractice, as well as exploitation of patients in pharmaceutical trials. This country report presents the case of Bangladesh, one of the poorest countries in the world and therefore a good example for the deplorable condition of the health sector in developing countries.     

From P-Values to Objective Probabilities in Assessing Medical Treatments

The assessment of the effectiveness of a treatment in a clinical trial, depends on calculating p-values. However, p-values are only indirect and partial indicators of a genuine effect. Particularly in situations where publication bias is very likely, assessment using a p-value of 0.05 may not be sufficiently cautious. In other situations it seems reasonable to believe that assessment based on p-values may be unduly conservative. Assessments could be improved by using prior information. This implies using a Bayesian approach to take account of prior probability. However, the use of prior information in the form of expert opinion can allow bias. A method is given here that applies to assessments already included or likely to be included in the Cochrane Collaboration, excluding those reviews concerning new drugs. This method uses prior information and a Bayesian approach, but the prior information comes not from expert opinion but simply from the distribution of effectiveness apparent in a random sample of summary statistics in the Cochrane Collaboration. The method takes certain types of summary statistics and their confidence intervals and with the help of a graph, translates this into probabilities that the treatments being trialled are effective.     

British Aid to Medical Schools in Developing Countries

If the British allocation for overseas aid is increased more generous agreements could be made with host universities and with expatriate staff. It would greatly stimulate overseas service by specialist trainees if the professional colleges and the universities agreed that they would be willing to substitute in their training programmes a year or two of service in an overseas medical school for one or more of their orthodox appointments. Consideration might be given by the councils for postgraduate education to ways of facilitating service overseas by specialist trainees and young consultants. The suggestion of the Royal Commission for the expansion of departmental staff establishments and training pools requires that the temporary expatriate occupying a supernumerary post is absorbed into the establishment on his return. While this may be done now in individual cases by personal arrangement a national agreement between universities and the N.H.S. would be necessary for these secondments to be made on the large scale commensurate to the need.For other returning young doctors not yet in specialist training schemes an assurance that applications for appointments by those who had worked in developing countries would receive favourable weighting, by both university and N.H.S. selection committees, would be very helpful.     

Methodological Problems in Evolutionary Biology. XII. Against Evolutionary Ethics

Evolutionary ethics has recently become popular again. Some of its representatives elaborate new attempts to derive ethics from evolutionary biology. The attempts, like previous ones, fail because they commit the naturalistic fallacy. Premises from evolutionary biology together with normative premises also do not justify ethical principles. Other representatives argue that evolutionary considerations imply that ethics cannot be justified at all. Their arguments presuppose an unacceptable form of foundationalism. In principle, evolutionary biology might explain some aspects of morality, but in practice explanations are hard to come by. All this does not imply that evolutionary theory is irrelevant in normative settings. To the contrary, it may help us devise guidelines in environmental policy and health care policy. It is to be hoped that evolutionary ethicists will divert their research efforts to the elaboration of such guidelines.