11. Ethical Considerations in Global Health Engagement

Learning Objectives:

1. Know the definition and basic principles of ethics related to GHE
2. Be aware of the factors that influence our and our partners’ ethics and beliefs
3. Recognize how ethical considerations can influence GHE activities

Lecture:

The lecture provides an overview of ethical considerations in DOD Global Health Engagement activities, focusing heavily on situations where the direct provision of care is warranted. As you think about the four ethical principles presented in the lecture (beneficence, non-maleficence, justice, and autonomy) consider how these four ethical principles that are generally applied to patient care relate and/or conflict with the principles of public health ethics, which also likely inform post-DODI 2000.30 GHE activities.

Public health ethics relate specifically to community or population-level health interventions, which may apply to elements of partner nation military forces in DOD GHE, or even to partner nation civilian populations. It should not be surprising to students at this point in the GHE course (and the wider graduate certificate program) why close partnerships and coordination with partner nation government institutions such as the Ministry of Defense or Ministry of Health are so important in addressing and avoiding ethical issues during the selection, planning, and execution of DOD GHE activities.

Additionally, DOD GHE sits at a unique nexus of many overlapping fields with many overlapping ethical frameworks and principles. These fields include public health, global health, medical practice, international development, and potentially working with vulnerable populations, post-conflict societies, and unstable countries who will, have, or are experiencing conflict and/or war.

Because of the various overlapping fields that DOD GHE activities may touch, ethical issues can arise in many places or situations, and activities can case harm in many unique forms, including:

• Lack of sustainability, of both direct patient care and a U.S.-built capacity or capability
• Displacement of local providers or decreased local confidence in the quality of local providers
• Dependency on a U.S.-provided solution, causing harm to U.S. ability to maintain freedom of action within a theater and harm to the partner nation's ability to operate independently
• Lack of accountability to the partner nation, the U.S. government and public, and the wider global health community
• Reinforcement of harmful practices or beliefs that limit the enjoyment of human rights of women, minority communities, and other vulnerable populations
• Reduced physical security of populations directly or indirectly affected by DOD GHE activities
• Diplomatic harm to the U.S. government, U.S. military, or U.S. allies as credible actors in global health and security cooperation
• Harm to U.S. forces due to physical violence or disease
• Harm to the intrinsic security and national defense responsibilities of the U.S. military

Ethical dilemmas may arise in a variety of situations and during the full programmatic cycle of a GHE program, including:

• When treating patients
• When choosing who benefits from an activity or health intervention
• When a stakeholder may be harmed
• When communicating health issues
• When there is a cultural conflict

The above slide is provided as a framework for empowering GHE and other global health professionals to dissect and respond to an ethical dilemma. Other best practices are provided in the video lecture from Dr. Jim Fike.

Often, the greatest challenges to successfully navigating an ethical dilemma are identifying the core nature of the ethical issue (and what values are at stake) and identifying the relevant information necessary to make a decision, rather than coming to a conclusion on the decision and how to implement that decision.

Finally, please make sure that you read the section on Moral Injury (sometimes referred to as Ethical Distress) from chapter two of the Defense Health Board reading. Competently navigating ethical dilemmas in the context of DOD GHE is critical to avoiding and resolving Moral Injuries. Properly explaining the decision to those aware of the ethical dilemma, who may come to harm from decisions made, and who will be responsible for implementing the decision can be pivotal in promoting operational efficiency and maintaining morale of staff involved in DOD GHE activities.

Supplemental Materials:

1. Thorne, L. and Saunders, S.B. (2002). The Socio-Cultural Embeddedness of Individuals' Ethical Reasoning in Organizations. Journal of Business Ethics.

After You Watch/Read/Engage:

1. Visit the Sakai discussion forums.
2. Join the live VTC on Thursday.
3. Complete the Quiz before Wednesday at 2355 EST.

Looking Ahead:

1. There is no formal module next week.
2. The comprehensive final paper assignment (2000 words) is due May 13 at 2355 hours.