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Skip to 0 minutes and 7 secondsEthics can be thought of as the branch of knowledge that deals with moral principles. A dilemma is a situation in which a difficult choice has to be made. Therefore we could define an ethical dilemma as a situation in which moral principles come into conflict and a difficult choice has to be made. The BMA has a toolkit for facing ethical dilemmas as a medical student. However, ethical dilemmas on international elective could be very different to situations you have observed at home. This is because you'll be working with a different health system with different rules, regulations, and principles. You'll be working within a different culture with different values and ideas.

Skip to 0 minutes and 49 secondsYou may be working in a system with a different level of resource availability than what you are used to. Your role within this new health system is also different to your role in the one you have been training in. You are only a guest here for a short time. Your own support network will also be different within the system and so might your ability to access information to help you. Therefore the first step when you are faced with a difficult situation an international elective is to identify the situation as an ethical dilemma. Then consider what the relevant ethical or moral issues are in this situation. An ethical framework what could help you with this.

Skip to 1 minute and 27 secondsNext, consult a wide variety of reliable sources to support your decision. Finally, test your decision before you act. Play devil's advocate and challenge your ideas. Be prepared to justify your actions with sound arguments. For example, imagine that the hospital you are working in is running low on gloves and you have been told to only use gloves for certain procedures. However, you thought to bring a couple of boxes of gloves with you when you traveled. At first, you plan to keep them for yourself. But you end up donating them to the ward. Because of the short supply, no one is using gloves to examine patients, take bloods, or inset cannulas. This makes you very uncomfortable.

Skip to 2 minutes and 10 secondsFirst, identify whether there is an ethical dilemma within the situation. Arguably there are two. One, should you donate your spare gloves? And two, should you continue to examine patients, take blood, and insert cannulas without gloves? To help you answer these questions, you need to consider what the relevant ethical issues are. Ethical frameworks can help you to do this. The traditional ethical framework is the four pillars-- autonomy, beneficence, justice, and non-maleficence. You can use these four headings to list ideas about the situation. For example, under autonomy, consider ideas of self-government and self-determination. For the staff, do they have the right to refuse to work without protection?

Skip to 2 minutes and 59 secondsAnd for the patient, do they have the right to make the decision as to whether you use gloves or not? Under beneficence, consider the importance of doing good. You are duty bound to help patients. Are you doing more good by performing the procedure without gloves or by not doing the procedure? Does this answer change depending on whether you are examining the patient or taking blood? Under justice, consider the fairness of each outcome. Is it fair for you to keep the spare gloves for yourself? Does it matter that those gloves were yours? Does the background risk, ie, that staff here often work without gloves and you don't make any difference? Under non-maleficence, consider the importance of do no harm.

Skip to 3 minutes and 44 secondsWhat harm are you causing by using up gloves to learn? Is the potential harm greater if you work without gloves or if you refuse to perform the procedure? Does this depend on the procedure you are performing? An alternative ethical framework has been suggested for international electives. This framework considers humility, introspection, social justice, and solidarity. Using this framework, under humility, consider that you are part of a bigger picture. How does your decision fit into the longer term strategy of the team who were here long before you arrived and will still be here after you have left? Under introspection, consider what baggage you are bringing with you to the situation.

Skip to 4 minutes and 29 secondsHow does your background, training, and your reason for being here bias your decision? Are you here to help or to learn? Under social justice, consider whether you understand the realities of a resource poor health care setting. How high a priority is health and safety for the workforce? What is the broader context of your situation? Under solidarity, consider that you are part of the team while you are here. How important is it for you show your support to the team and the decisions they have made? After you have found the best system to consider the relevant issues, you next need to consult a wide variety of reliable sources to help support and inform your decision.

Skip to 5 minutes and 10 secondsFor example, what is your patient's opinion and why? What is the opinion of your local superiors and colleagues and why? Is there a professional guideline to help you, either local or international, such as the WHO? Is there any published or reliable safety advice from bodies, such as the WHO, UN, the BMA, Public Health England, the CDC, or a local authority? Finally, after you have identified, considered, and consulted, you need to test any conclusion you have formed before you act. Play devil's advocate and argue the opposite view. Does your original conclusion still hold? Can you list sound arguments in support of your decision? Could you justify your actions to someone?

Skip to 5 minutes and 56 secondsRemember, you are likely to face ethical dilemmas as part of your international elective. And they will probably be situations which you have not been faced with before. The BMA has a toolkit for helping medical students with ethical decisions. Ethical frameworks can also help you to make decisions. You need to consult reliable sources before you act. You need to test alternative opinions before you act. You need to identify, consider, consult, and test.

Applying ethical frameworks

When you are faced with a challenging ethical situation in clinical practice, it is advisable to use an established framework to help you analyse the case.

Many ethical frameworks have been published in the medical ethics literature. In this presentation, produced by KCL medical student Alice Hully, we draw on two frameworks that might contribute to the analysis of complex ethical situations, like the ‘scarcity of gloves’ scenario described in the previous step. One is the traditional framework that is taught in most medical schools - autonomy, beneficence, justice and non-malificence1 - and the second is an ethical framework developed specifically for electives - humility, introspection, solidarity and justice2.

We’ve also created a PDF reference sheet illustrating both ethical frameworks.


1 Beauchamp, T. L., & Childress, J. F. (2012). Principles of Biomedical Ethics. Oxford University Press.
2 Pinto, A. D., & Upshur R. E. (2009). Global Health Ethics for Students. Developing World Bioethics; 9:1-10

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This video is from the free online course:

Preparing for an International Health Elective: Exploring Global Health, Ethics and Safety

St George's, University of London

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