AMA Journal of Ethics^®

Case

Dr. Wilson is the director of a family medicine residency program at a community hospital in North Dakota. In the last residency match process, she was unable to fill the available positions for incoming interns and is looking for one more qualified applicant for the 3-year program. At this point, the most promising applicants have all trained overseas, and the applicant she and her program wish to hire is from Ghana. Dr. Wilson is well aware that most foreign medical graduates tend to settle in the United States after residency, thereby depriving their home country of their expertise and the benefit of their training. In fact, the applicant from Ghana was educated at the state's expense with the expectation that the investment would be returned.

Commentary

This case presents a number of ethical and moral dilemmas, both for Dr. Wilson and for the applicant from Ghana. It also highlights a problem that many U.S. institutions will face in the next few years—a shortage of qualified doctors to fill positions at all levels of the health care delivery system. In fact, Cooper and colleagues have suggested that by 2020 the U.S. will be in need of 200,000 doctors [1]. Dr. Wilson is one of many medical administrators confronting the problem of how to fill physician vacancies when an insufficient number of qualified U.S. students apply. Her dilemma is whether she should fill the post with someone from a developing country or leave it vacant. If she chooses the former option she may indirectly damage the health of many Ghanaians who have significantly fewer doctors than their U.S. counterparts. If she chooses the latter she may not have the staff to run her service ideally and may compromise the health of patients attending her hospital. One way for Dr. Wilson to begin to resolve her dilemma is to evaluate which course of action would do greater harm. To do this she may examine some basic health and economic statistics for the two countries, shown in table 1.

Dr. Wilson will find that U.S. citizens have, at birth, a life expectancy 20 years longer than that of Ghanaians—children born in Ghana are 10 times more likely to die in the first year of life than their American counterparts—and that the maternal mortality rate in Ghana is 60 times that of the U.S. In 2006, a total of 540 women died during child birth and the puerperium in the U.S. compared to an estimated 4,000 women who died in Ghana, despite the fact that Ghana has less than 10 percent of the U.S. population. In the U.S. there are 250 doctors for every 100,000 people; Ghana has a mere 13. Finally, the average third-year medical resident's salary in the U.S. is 20 times that of the third-year medical resident in Ghana, highlighting the economic disparities between the countries [2-9].

Table 1. Basic health and economic statistics in the U.S. and Ghana

Once aware of this information, Dr. Wilson faces a difficult decision. In rural Ghana there is often only one doctor for every 40,000 people, and Dr. Wilson may think that removing the only doctor in the area is inequitable. Many of the health problems in Ghana have been shown to be directly related to a breakdown in the primary care or public health systems or a systematic problem in both. These problems are exacerbated by a lack of adequately trained physicians. Writing recently in the New England Journal of Medicine, Rosenfeld said of the high maternal mortality rate in sub-Saharan Africa, "deaths are only part of the tragedy. For every woman who dies at least thirty others are injured. Many of these injuries are disabling and, in the case of obstetrical fistula, they are socially devastating" [10]. This dire medical portrait may motivate Dr. Wilson to contemplate where the greater need for this doctor exists—in Ghana or in her community-based program in North Dakota.

The Ghanaian doctor also has much to ponder before accepting the offer of a residency in the U.S. On the one hand, she would be cognisant that her undergraduate training in Ghana cost the government a considerable amount, and she might believe that she owes it to her country to use her skills locally. On the other hand, she may feel that the 3 years she has spent working as an unspecialised medical officer in a rural hospital has repaid that debt. Almost certainly, that work was professionally difficult. Most likely she was the only medical officer on call in the hospital which, while it gave her the experience of caring for a population of more than a half-million people, could also have been daunting and overwhelming.

The financial incentive Dr. Wilson offers will be hard for the student to resist because the salary will be many times greater than what she currently earns. It will provide her with an opportunity to repay her family who have also invested in her education. If she decides to take the residency position she may repatriate a percentage of her salary each month to support her family. In a report published by the U.K. government in 2004, it was estimated that Ghanaians living abroad remitted $400 million ( U.S. ) annually, a substantial proportion of Ghana 's foreign exchange [11].

We can also imagine the student's wanting to work in the United States (or another location abroad) because of the lack of health care facilities and training available to her at home. A Nigerian doctor recently explained his desire to specialise abroad in these terms:

Today very few of my classmates remain in Nigeria. Most have gone to places like the US or the UK or Trinidad and Tobago. Anywhere but Nigeria. Here in Nigeria, everything is dilapidated. We don't have the basic infrastructure to do the job. Everyone wants to get out. All the time I am here, I am making plans to get out. It's not just about money. I want to specialise, I want to do medical research, I want proper training and I want to enhance my knowledge. I can't get any of that in Nigeria [12].

Articles about the American health care system published in Western medical journals are often sent to foreign hospitals by charity groups. Even the articles that are several years old confirm that the scope of medical practice in the U.S. is much broader and more advanced than what is available in Ghana.

At bottom, Dr. Wilson and the Ghanaian doctor are facing the same professional dilemma; namely, what is the doctors' responsibility to a wider society? Is medicine a moral enterprise or an occupation like any other? If medicine is inherently moral, it could be argued that the Ghanaian doctor should not be recruited away from the society that needs her services more.

Dr. Wilson and the Ghanaian doctor may wish to consider a creative solution. Could they arrange an exchange in which both doctors and technology could be shared between the two health systems? Opportunities for doctors from developed countries to spend a short period of their training in a developing country are increasing, and it seems that many find this popular elective to be a valuable experience. Both institutions may wish to examine ways of funding such exchanges. One subject that raises some concerns is the appropriateness of the training that the Ghanaian doctor would receive in the U.S. The Ghanaian system functions at a different level than that in developed countries. It would not surprise me to learn that physicians who return to developing countries following a period of training abroad find that they are unable to put into practice much of what they have learned. This would explain why doctors—even those with high ideals—remain in or return to the developed country where they received their graduate training.

As in so many ethical and moral dilemmas, there are no clearly right or wrong answers for Dr. Wilson and the Ghanaian physician. Very often the solution to such problems lies in a compromise. By setting up an exchange plan, Dr. Wilson and the Ghanaian physician could produce a win-win solution to what is a complex moral dilemma.