I was at Brighton Medical School recently, talking ethics to third years, and a lively and engaging bunch they were too. Among the many things we talked about were electives, particularly in resource poor countries. It is no surprise that students look forward to their electives. The travel appeals of course; the ability also to escape the tourist rat-runs, tourists having a terrible tendency to denature the places they tour. I certainly know from experience that there is nothing like a visit to a psychiatric hospital in sub-Saharan Africa to remind you that there is more to the world than you will find between the covers of a Lonely Planet guide. There will almost certainly be interesting clinical opportunities: the chance to see creative responses to extreme resource shortages. Depending on the location there will be conditions that you are unlikely to see at home. There may also be opportunities to learn from non-traditional carers. I have also heard it said they can be a good opportunity to take on more clinical responsibility than students are ordinarily given in the UK. And this is where things can get troubling. It was students who first alerted me to the problem. A few years ago, on returning from their elective, a group of students wrote to the BMJ describing the behaviour of a student colleague. Released from oversight he saw an opportunity effectively to practise on a captive population. He altered a prescription written by a local doctor; he photographed patients undergoing intimate procedures without consent, and he performed an unnecessary lumbar puncture because he fancied “having a go.” You would need to be deaf to history not to hear unsavoury echoes of colonialism in his behaviour: a western medical student practising techniques well beyond his competence on patients who thought him a western doctor. As the students wrote: “The local healthcare professionals sometimes perceived white skin to be synonymous with expertise, placing unprecedented levels of trust in us and allowing us to make decisions and perform procedures that would be unacceptable in the United Kingdom.” An extreme case no doubt but it points to a necessary moral: medical students are not qualified doctors and they have no greater licence abroad than at home. It should also be said that these students did precisely the right thing: when they saw unethical behaviour they confronted it and they spoke out. And not just locally. Writing to the BMJ on their return ensured the problem was given wider exposure.
Thinking about electives on the way back it struck me that greater thought needs also to be given to their underlying structure, to their justice. Whose interests do electives serve and what are their purposes? Do the benefits flow primarily to the under resourced hosts, do they flow mostly back to the UK or is there in each case some necessary and useful reciprocity? Students are seldom in a position to answer these questions, ones more for the institutions involved, but whatever the answers there are things that students can do. If students seek to gain personal educational benefits via an elective, then what can they offer their hosts in return? Thought should also be given in advance to ways of minimising burdens on the host country. If you don’t speak the language how effective will you be? Will you need a translator and if you do, who is going to provide one? Better presumably to choose a country where you know the language. Also a good idea, as far as possible, to familiarise yourself with the healthcare system and its major challenges before you go. Are there things that you can do beforehand to make you better equipped for your role when you arrive? And one final essential thing: find out about the culture, find out, in so far as you can, those cultural factors likely to have an impact on your relationships with patients and colleagues. It’ll likely make for a more successful elective. And besides, in the face of troubled history and deep and enduring global inequalities the least we can do is show respect.
(A link to the BMA’s student toolkit on ethics and medical electives in resource—poor countries is given here)
Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.