Ethics and medical students abroad

This week's Lancet has a commentary that is very relevant to my posting yesterday.  The title is "Ethical coherency when medical students work abroad" and the author writes:

"Although benefits such as increased medical access in a developing nation and a positive experience for the students are incurred, risks are also associated with sending inexperienced medical trainees abroad.  Concerns such as physical hazard to the student and cultural insensitivity are important, but are secondary to the potential for harm to the patient.  In cases for which students are in a position to deliver care beyond their qualifications or without guidance, substantial room exists for malpractice and serious medical error... even well-intended efforts might result in inappropriate informed consent, unacceptable risk-benefit ratio, and unfair benefit distribution, thereby putting in jeopardy the fundamental medical principles of autonomy, non-maleficence, and justice."

Medical students (and doctors) can learn so much working in a resource-limited setting, including how to do a better physical exam without relying on expensive technology and opportunity to see conditions they will likely never see in their home country.  For example, Jon treated a patient with scrofula, a tuberculosis infection of the lymph nodes in the neck, a few weeks ago (he said he remembered learning about it as a medical student and thinking there was no way he would ever actually see a patient with it).

But, I do think there is a problem when medical students are providing care beyond their level of training in this kind of setting.  While medical students certainly learn from this experience, the vast majority end up practicing medicine in their home country.  Therefore, they are putting the patients in the developing country at risk but their patients in their home country are benefiting from their additional training.  I also think it's a somewhat arrogant assumption that the patients in the developing countries are always benefiting because "otherwise they wouldn't be getting any care."

In order to do research in a developing country, it needs to be approved by ethical review boards both locally and in the researchers home country if they are from outside the country.  This is to protect the research participants and to prevent researchers from exploiting people in developing countries by doing something they could never do in their home country.  No oversight currently exists for medical students in developing countries unless it is provided by the medical school sponsoring their rotation abroad.

I think international electives are extremely valuable (and I hope to do at least one when I go back to medical school) but I also agree with Dr. Bhat that the principles of medical ethics must be upheld no matter what part of the world we are working in.