Avoiding Unethical Altruism in Global Health: Revisiting Ethics Guidelines for International Rotations for Medical Residents

Medical residents rotating abroad must be aware of how their presence can strain local resources. Residents impose an unavoidable burden on a local community, which is increased when they are underprepared.^10,14-16  Though host institutions may welcome visiting residents, they still sacrifice housing, time, and energy that could have been devoted to the local population. Physicians who supervise these medical guests often spend time orienting or teaching foreign residents instead of instructing local residents or caring for patients. International participants often require assistance with interpretation which siphons off local staff time. In places with limited access to water, food, or electricity, visiting residents can consume scarce resources.

Trainees are responsible for being prepared to minimize their burden on local resources. This includes reflecting on one's role prior to departure, attempting to learn some of the local language, and bringing key supplies. Residents must purchase travel insurance and establish a local contact to assist in navigating unforeseen circumstances. While stories of host communities banding together to assist a foreigner in times of need are admirable, they should not be considered the norm, and certainly ought not be expected or assumed.

It is imperative that rotating trainees acknowledge self-education as the primary goal of their international rotation. They should ask themselves why they want to spend their time rotating abroad instead of in the United States and whether their experience counts as mere medical tourism.

Global health opportunities are often shaped by secondary aims such as aiding a local community or participating in research, which make them susceptible to a unique set of ethical pitfalls. Residents abroad whose primary intention is to help provide medical care are often and naively thinking their US-based training has prepared them to provide better care than the local physicians. This naiveté may extend to assuming that they can fix chronic, systemic problems within the health infrastructure during their limited time abroad. Moreover, when undertaking a research project abroad, issues of human subject protection, collaboration and authorship, and privacy are common and sometimes shaped by local standards and customs. International research is rooted in a long history of ethical failures, exploitation, and discrimination against low- and middle-income country authors that persists in academic medicine.²⁶ 

Approaching an international rotation as a learning opportunity can mitigate behaviors likely to harm local communities. These educational opportunities include participating in the care of patients with a different spectrum of diseases than typically seen in the United States, learning how to function in a resource-limited setting, and learning the role of local beliefs and spiritual practices in health care. By expecting to learn, trainees can focus their energy on a limited but achievable set of goals and reduce the possibility of causing harm.

Rotating abroad requires trainees to acknowledge their own limitations. The professional and legal guidelines governing the clinical role of residents in the United States are often poorly defined or absent in other countries. It can be tempting to practice outside one's scope of training in contexts where there is both less oversight and a more urgent need for skills one has yet to develop. However, attempting interventions without competence in foreign communities demonstrates the unfortunate and misguided belief that other populations are not worthy of the vigorous standards to which trainees are held to in high-income countries.

Moreover, such interventions expose patients to unacceptable risks and harms. Exceeding one's level of training can have devastating consequences and produce irreversible adverse outcomes, regardless of the altruistic intentions behind such actions. While there will always be situations in which dire need surpasses the risk of practicing beyond one's scope of training, well-supervised and structured clinical environments can help reduce this risk, which further underscore the importance of predeparture planning.

Given the pervasiveness of social media, trainees sometimes photograph or publicly document their experiences abroad. When done humbly and with permission, this can be helpful for cross-cultural exchange, building awareness, and stimulating productive discussions. Nevertheless, patient privacy and confidentiality rights are regarded as universal and independent of any particular legislation.

It follows that permission needs to be obtained before any patients or community members are photographed—even if there is no intent to post or publish the images. As at home, any unique patient identifiers should be omitted from online publications or posts. Furthermore, using images or stories of individuals to garner monetary support, especially if not intended for the host institution, is a form of exploitation and therefore impermissible. Though the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule applies only in the United States, it should be followed by trainees abroad in the absence of stricter local rules.

Trainees are expected to practice cultural humility as opposed to cultural competence. Practicing cultural humility means acknowledging that culture is not something to study and perfect, but rather something to inquire and learn about with an open mind.²⁷  Being curious and nonjudgmental facilitates a more productive, reciprocal exchange of ideas in addition to allowing trainees to demonstrate respect for their host community.

Residents must remember that local physicians are trained to treat the local population and adhere to their own ministry of health's guidelines. These may differ from the US institutional guidelines that are often based on research studies conducted only in high-income countries. Respecting this difference allows residents to be more receptive to unfamiliar or novel approaches that may deviate from those of their home institutions.

Table 2 provides several possible mechanisms for adhering to the 5 ethical guidelines outlined above.

Though the burgeoning interest in global health is a welcome sign that medical residents are craving meaningful cross-cultural exchange, they must be aware of the ethical challenges that may arise abroad, particularly in low-resource settings. By adhering to these 5 guidelines, trainees can be better poised to undertake international rotations. The duty to act ethically abroad should not fall solely on residents' shoulders. Home institutions, accrediting organizations, and host sites all share responsibility for fostering good conduct and guiding best practices. Ideally, international rotations should be rooted within a structured educational program and in longitudinal, bidirectional partnerships between their home and host institutions. Even as these standards remain aspirational, these 5 principles—minimizing burden, aiming to learn, acknowledging limitations, respecting privacy and dignity, and practicing cultural humility—can empower individual medical residents to prepare for and improve their actions abroad.

The authors wish to thank Dr. Carmen Cobb, Dr. Ashti Doobay-Persaud, and Dr. Elizabeth Groothuis for their invaluable feedback on earlier versions of this paper.