Global Health Ethics
By HVHF Member, Dr Selena Knight
What is global health ethics? The ethics I was taught at medical school focused on the doctor-patient relationship and the role I would play in this relationship both as a medical student and as a doctor in the future. Ethics and law teaching focused on consent, confidentiality, autonomy, non maleficence, beneficence, end-of-life care, resource allocation, and so on. But I have recently been considering what is global health ethics, and whether there are important ideas and principles that as a doctor I can learn from my recent exposure to this field working as an intern in the World Health Organisation’s Global Health Ethics Unit.
For one, global health ethics is about populations. There is a very different balance to be struck here, as often the balancing act is not between the potential harms and benefits to one person, but instead the harms or benefits to a whole community or population. But this population is made up of individuals with differing needs and values, so it may be the case that public benefit may cause harm (in many cases in the form of an infringement of autonomy) to some individuals. There are many areas where such ethical challenges arise in public and global health. Is it right to override the autonomy of individuals to make vaccinations compulsory for all eligible children, if doing so ensures herd immunity and provides benefit to the public? Is it right to carry out surveillance and population studies establishing HIV prevalence rates of populations, but not informing those who have participated of their HIV status? In the context of the current Ebola epidemic, is it ethically justified to expose individuals to potentially serious risks of untested vaccines or treatments in the hope of being able to provide others with a cure?
Global health ethics grapples with these challenges, and often has to take a pluralist approach combining utilitarian ethics (the right course of action being the one which produces the greatest good for the greatest number) with deontological ethics (that there are certain duties, or perhaps human rights, which may not be overridden or ignored irrespective of the consequences of such an action). This combined approach is fraught with challenges. Perhaps what is missing is a virtue ethics approach. What would be the required virtues of a global health worker (by which term I encompass clinicians, policy makers, researchers, surveillance teams, etc)? They would need to be be compassionate to the individual, respectful of human rights, be mindful of resource challenges, and show integrity and courage in their decision making (which is often difficult). Discernment is also an important virtue here.
So what can I as an NHS hospital doctor learn from global health ethics as a ‘subspeciality’ of ethics? I think that global health ethics encourages us to consider the wider perspective and the multiple stakeholders in our decision making. As a doctor my primary duty is towards the patient in front of me (the ‘index’ patient), but I need to be mindful that other parties will be affected by the decisions I make for that one patient. In the context of limited resources, this broader communitarian perspective, with patients viewed as inextricably connected to families and communities, is of greater value than the more individualistic Western perspective. Global health ethics also encourages us to consider wider issues – for example the public health implications when patients refuse to have their children vaccinated, when they travel abroad, or when a patient is an immigrant seeking care. With globalisation and the increasing ease of travel, we and our patients are living in a world that is becoming smaller and more interconnected. It no longer seems justifiable to see ourselves and our patients as if living in individual bubbles, sealed off from the rest of humanity and sheltered from the consequences of our actions.