AMA Journal of Ethics^®

The ethics of international research have been much discussed over the past decade in academic literature. These papers have primarily focused on the challenge of conducting ethically sound clinical trials. The related domain of medical education has also been affected by trends of globalization, but the literature addressing ethical issues in international medical education is insufficient.

Education and research are closely linked. Both are primary goals of higher academic institutions. Excellence in education requires some element of research, including the critical role of evaluation of program development. Thus, principles applied to research ethics should have some relevance to the field of education.

Globalization has affected medical education in numerous ways. One current trend is academic collaboration between educational institutions in high-income countries and those in low-income countries. Such partnerships are being entered into with much enthusiasm on the part of universities, faculty, and trainees. As institutions rush to build and boast of relationships in certain regions, some have described the phenomenon as a modern-day “Scramble for Africa.” Yet there has been little academic discourse about the ethical issues raised by such collaborative efforts.

An example is the Toronto Addis Ababa Academic Collaboration (TAAAC). The University of Toronto (U of T) has been involved in postgraduate medical training at Addis Ababa University (AAU) since 2003. It began with a partnership to train psychiatrists. Before then, Ethiopian physicians had to leave the country for specialty training. Many never returned, and as a result there were only 10 psychiatrists in a country of 77 million people. AAU was able to launch a residency in 2003 that U of T assisted by sending faculty and residents for monthlong on-site teaching blocks several times a year. U of T also provided on-site supervision, examination support, and evaluation-tool development. Since then, 27 new psychiatrists have been trained and four new departments of psychiatry have been established outside of Addis Ababa in Jimma, Harar, Makele, and Nazareth.

Recently, AAU has encouraged U of T to expand this model to postgraduate training for other specialties and subspecialties. By 2010, 11 departments of the Faculty of Medicine were part of the expansion. U of T contributes to faculty development and teaching to support the introduction of several new residency programs at AAU, including the possibility of a new specialty in family medicine.

Many other universities in high-income countries have similar commitments to assist with medical education in international sites. Such partnerships for building capacity may be highly effective and laudable, but they require ethical analysis and guidance to avoid doing more harm than good. In this paper I examine the ethical issues in academic collaboration by applying tests more common to the field of international research—informed consent; risks and benefits; exploitation; standard of care; and codes and guidelines. After applying these concepts to medical education, I offer some essential requirements for ethical engagement in international collaborations for medical education.

Informed Consent

Informed consent, founded on the ethical principle of respect for autonomy (or respect for persons), is arguably the most discussed concept in research ethics. Guidelines in the domain of research have enumerated requirements for informed consent that include: providing adequate information, assuring that the information is comprehended, and confidence that the subject’s participation is voluntary [1].

In the context of international research, the concept of informed consent requires some particular considerations. For example, language barriers can impact the successful provision and comprehension of information. The use of translators may allow a tendency to “camouflage, exaggerate or minimize information” [2]. Researchers have also described cultural differences in the location of decisional authority. One must bear in mind the role of community leaders in making consent decisions.

Ethical collaborations for medical education must similarly respect the principles that drive the notion of informed consent, beginning with the provision of information. If a visiting institution is offering educational assistance, the host institution must be adequately informed about what is being offered and given the opportunity to accept or decline the offer and the right to withdraw from the relationship.

In many cases, international universities have been invited to assist with education needs [3] but sometimes assistance is offered without a prior invitation. Clearly “collaboration” cannot be imposed on an institution. Consent to participate would require a full disclosure of risks and benefits for both host and visiting institutions. This is particularly important when an educational program such as postgraduate training in family medicine will be introduced in countries where it does not already exist. An outside university may offer support in launching such a program, but it should require documentation that the host facility has understood the offer, believes that the educational program is important and necessary in their location, and has voluntarily agreed to host it.

Risks and Benefits

In the context of international clinical trials, a second ethical theme that emerges is the balancing of risks and benefits. Some authors have helpfully categorized the potential risks associated with research trials as physical, psychological, social, and economic [4]. Others have clarified that the risks of participation include the costs of buildings, water, power, information technology, staff, administration, and hospitality [5]. An additional question or consideration is the risk to third parties who are indirectly affected by a clinical trial.

These kinds of evaluations should be applied to international collaborations for medical education. There may be a propensity to focus on the potential benefits of such partnerships, but ethical engagement demands a reasonable assessment of both risks and hoped-for benefits.

A host country that accepts international educational partners confronts a number of risks or costs: the additional time that it takes for communication, administration, and orientation of visiting faculty; host-site educators becoming distracted from other important tasks as they help to facilitate visitors; and educational priorities being determined by the expertise and interests of the visiting institution rather than by the needs of the local learners. There are also ongoing risks of cultural misunderstandings between institutions and their representatives and the likelihood that the standards of education of the partner institutions will differ.

Several recommendations for minimizing these risks can be drawn from the research ethics literature. Murff et al. have discussed systems factors in research centers and the importance of providing opportunities for participants to express their concerns about potential risks or faults in the research system [6]. Others have highlighted the importance of being willing to reinvent the design of the research [7]. This suggests that risks of adverse impact in educational collaborations could be minimized by an emphasis on obtaining adequate input from the host institution regarding curriculum, timelines, and educational priorities, input that might be enhanced through the development of a local advisory board.

One must determine whether the risks inherent in innovative educational collaboration are justified by studying how they are balanced by potential benefits. Advocates can readily point to potential benefits for the host site. In the case of medical education in low-income countries, there is hope that enhanced educational resources will increase the health workforce capacity. Historically, many countries have been obliged to send graduate physicians out of their home country for specialty training, an exigency that appears to have contributed to emigration of physicians. If international universities can increase postgraduate medical education in-country, local human resource capacity can be expected to improve. International institutions may be able to provide additional benefits such as access to electronic libraries.

A discussion of benefits must also acknowledge that visiting educators are also likely to benefit. Participation may result in career advancement and publications for some. An honest analysis would recognize that some visiting educators might be driven by a form of Orientalism—a desire for professional intrigue and expanded horizons to punctuate what may be an otherwise mundane career [8].

Finally it can be hoped that mutual educational benefits are to be had through global partnerships. The opportunities for learning should be recognized to be reciprocal. One of the most delightful theories of adult education is that of social constructivism. As medical learners intermingle with educators and learners from another setting, they share perspectives and observations. Through this social discourse, knowledge is analyzed and shaped into new knowledge, thereby benefiting all participants.

While realization of these expectations and hoped-for benefits remains to be documented, it is certain that an ethical educational collaboration must entail a just means of sharing both risks and benefits.

Exploitation

Benatar has remarked that “research, even under the best of circumstances, is potentially exploitative” [9]. International collaborations for education risk being imperialistic or driven by supremacist ideologies and similarly accused of exploitation. The risk derives from the possibility that, in some circumstances, international teachers may have more to gain than communities taught. Fitzgerald and Wasunna have defined exploitation as occurring “when one person or group uses another person or group to gain advantage” [10], and have stated that it is more likely to happen when there is a pre-existing unequal relationship by reason of wealth, class, education, gender or race. Whether or not exploitation takes place depends on some of the issues discussed previously about the distribution of risks and benefits.

In the context of research, exploitation occurs when subjects are used as means to the ends of researchers, when they derive minimal benefits, or when they are denied post-trial access to beneficial therapies [11]. It can result from the fact that research populations in low-income countries have less access to science education and limited experience in understanding and giving informed consent [12]. Local researchers may have limited familiarity with ethical and scientific review of research protocols, and they may be constrained by limitations of infrastructure, personnel, and technical capacity.

Collaborations in education would benefit from applying the same considerations to their design. Clearly any potential for exploitation must be minimized by assessing the program’s distribution of benefits and ensuring that power differentials are not abused. The parties involved must have a frank dialogue about their motivations for participation in the educational program. In the context of research ethics, Tangwa has elaborated on the Kantian concept that the moral value of particular actions must be determined from the perspective of the moral agent and not on the basis of outcomes [13]. Applying this to educational partnerships suggests that the moral value of the education should be determined from the intent of the visiting educator or institution. Tangwa goes on to warn about the “possibility of nicely dressing up self-interest or exploitation in the robes of moral acceptability or even those of altruism and philanthropy” [14].

Standard of Care/Standard of Education

The discourse in international research ethics has established the principle that appropriate standards of care should be observed regardless of where the research takes place. The same should apply to education—the standard of education should not depend on where the teaching occurs. This principle has a number of implications. Visiting educators have an obligation to teach what is in the best interest of the host country, and the curriculum should not be determined on the basis of the interests and expertise of expatriate teachers. In clinical teaching, there should also be an obligation to translate educational efforts into improved access to good health care in the host country.

It may be noted that, when medical education is provided in low-income countries, multiple standards of education exist. Again one may borrow from research ethics literature to note that the “inability to achieve immediate equity should not be an impediment to making improvements that could spread more widely with time and effort” [15]. In this way an international educational collaboration may begin with the reality of dual standards of education while striving progressively to improve medical education in each location by working together.

Codes and Guidelines

International research ethics has benefited in the past 60 years from the development of various codes and guidelines particularly related to scientific study of human subjects. No similar international codes exist to guide in the ethical participation of education collaborations. As such partnerships spring up in increasing numbers; it may be time to draft some guiding principles; some examples from research guidelines have application to education.

Paragraph 7 in the World Medical Association Declaration of Helsinki states that “Even the best current interventions must be evaluated continually through research for their safety, effectiveness, efficiency, accessibility and quality” [16]. Such a principle of continuous evaluation would equally apply to educational interventions.

Paragraph 9 of the same document states that “Some research populations are particularly vulnerable and need special protection. These include those who cannot give or refuse consent for themselves and those who may be vulnerable to coercion or undue influence” [16]. Some portions of this statement have relevance to educational relationships, cautioning that power differentials between institutions and other stakeholders not be abused.

Eriksson has proposed several questions that could be useful in the development of guidelines for educational partnerships [17]. What problem or problems are the guidelines meant to deal with? What ethical assumptions are the guidelines based on? What authority would they have? Who is expected to assume responsibility?

One might argue that the ethical issues in education are not as complex as those in clinical research. But even the simplest of relationships can benefit from statements that strive to ensure justice and autonomy for all participants. It is probably not too soon to establish guidelines for ethical collaboration in medical education.

Essentials for Ethical Engagement

I have argued that there are numerous ways in which the themes of international research ethics can be applied to the burgeoning field of international collaborations for medical education. Ultimately it is hoped that these educational collaborations will be of benefit to the health of the population where the education takes place. Educational efforts should take place in a context of fairness and respect for all stakeholders. Curriculum development as well as educational goals and strategies should be determined on the basis of an appropriate needs assessment and adequate consultation of all parties.

London’s “human development approach” should be applied to international collaborations for medical education [18]. London has pointed out the need to focus on broad issues of social justice and not routinely to be sidetracked by practical issues. His approach would advocate going beyond a minimalist view of educational objectives so that educators address the broadest social determinants of health.

As a synopsis, the helpful list of requirements for moral progress in international research [19] provides a starting framework that I have adapted to propose ethical guidelines in educational collaborations (see Table 1). Collaborations for medical education are now part of the global landscape. I have attempted to determine the principles that should undergird these efforts by borrowing from themes in international research ethics. Clearly, the principle of respect for autonomy must be observed to ensure the voluntary relationship with equitable input for all stakeholders. Additionally, the principle of justice must prevail so that burdens and benefits are fairly distributed.

Table 1