Ethical Guidance for Volunteer Medical Trips Issued by ACP

Marcia Frellick

March 26, 2018

A position paper from the American College of Physicians (ACP) says volunteer medical trips and other short-term experiences in global health (STEGHs) come with specific ethical responsibilities for physicians regarding the people and communities they serve.

Matthew De Camp, MD, PhD, from Johns Hopkins University, Berman Institute of Bioethics in Baltimore, Maryland, and colleagues outline these responsibilities in an article published online March 26 in the Annals of Internal Medicine.

ACP President Jack Ende, MD, told Medscape Medical News that these experiences "really are an opportunity to do something important for patients at an international level, but they have to be done in a way that respects local culture, respects local institutions, and really does more good than harm."

Ethics have evolved around similar complicated issues, Ende said, and ACP felt the timing was right to apply them to these common experiences.

"The idea that something is better than nothing is an outdated one," Ende said.

Carey Farquhar, MD, MPH, from the Department of Global Health at the University of Washington in Seattle, and colleagues write in an editorial that they applaud the work and note that until now, there have been few if any guidelines for practicing physicians and other providers engaging in these trips, but they say the paper raises some questions and concerns.

Core Advice

Among the guidance is that physicians' primary ethical obligation in such experiences is to improve the health and well-being of the people and regions they visit. The ACP notes that although this guidance is geared mostly toward practicing physicians, it also applies to other healthcare professionals and students.

"STEGHs must demonstrate real benefit to the local community, with a goal of sustainability," the guidelines authors write.

The guidelines also say that medical teams must partner with local leaders to minimize the burdens visiting teams place on host communities and consider limited resources. Burdens could include licensure, lodging, food, and protection, or asking local hosts to shift time and efforts, for instance.

"The full cost to local communities should be calculated and reimbursed," the authors write.

Volunteer work also must adhere to current ethical standards, the authors note. For instance, some question whether expired medicines may be used to stretch resources, but the World Health Organization usually prohibits such use. Some providers may want to practice outside their scope when a local entity has less regulation on those boundaries.

However, "[w]hen the need is urgent enough to raise consideration of exceeding one's scope, careful forethought and informed consent are required at a minimum," the authors explain.

Preparing for visitors' departure is an ethical obligation as well, the guidelines state. "It should incorporate preparation for logistical and ethical aspects of STEGHs, including the potential for ethical challenges and moral distress," the authors write.

Unanswered Questions, Editorialists Write

Meeting the ethical targets of these guidelines may not always be practical, say Farquhar and coauthors.

They offer an example of giving a patient curative surgery. People may get lifetime benefit from such surgery, but they may not receive appropriate postoperative care after the visiting surgeon leaves.

They also question what can reasonably be established in terms of sustainability in the short timeframe of some of these trips.

"[I]n the absence of relevant capacity-building activities, STEGHs rarely help host communities develop sustainable solutions that promote autonomy," the editorialists write.

The position paper says that physicians interested in these trips should choose organizations that sponsor ethical STEGHs, but the editorialists ask what criteria they would use to determine which groups meet ethical standards.

Ende says that although you won't find 2-star vs 5-star ratings for these organizations online, physicians have a duty to do their homework on the sponsor of the experience. They should consider a company's length of time in business; whether the mission is to support local infrastructure and whether it has a good system for debriefing, mentorship, and evaluation; and ideally even talk to someone who has completed the experience.

"I think doctors can be able to distinguish one from another," Ende said.

The editorialists also cite a lack of cultural diversity in the authorship of the guidelines.

"[W]e were perplexed and disappointed that no authors from low- and middle-income countries...were included and no input from in-country collaborators was acknowledged," they write.

Ende says the editorialists' point is important and said such input will be part of future developments surrounding these guidelines.

"We regard this paper as a first step," Ende said. "There will be opportunities to hear the voice of international physicians and the voice of local countries. I think that's very important."

DeCamp reports being a consultant for ACP and received an honorarium for work on the paper. A coauthor reports completing training internationally for HIV programs in several African countries with the following nonprofit organizations: International Training for HIV and Health Care (ITECH-University of Washington) and ICAP (Columbia University Mailman School). The remaining authors, Ende, and the editorialists have disclosed no relevant financial relationships.

Ann Intern Med. Published online March 26, 2018.

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