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Doctors Behind Borders: The Ethics of Skilled Worker Emigration
Linköping University, Department of Culture and Communication, Culture and Aesthetics. Linköping University, Faculty of Arts and Sciences.ORCID iD: 0000-0003-2867-1212
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This doctoral thesis within applied ethics consists of four articles together with a cover essay. All articles concern the ethics of skilled health worker emigration from under-served and resourcepoor regions, often referred to as ‘medical brain drain’. Methodologically, the thesis utilizes normative ethical theory to analyse the justifiability of temporary or long-term emigration restrictions, such as compulsory health service programmes, that are employed by developing countries with the aim of safeguarding their needs for health care provision. Such programmes restrict the mobility of individual health workers and give rise to conflicts between different types of rights and interests.

The ethics of skilled worker emigration warrants an exploration of the ethical implications of such restrictive programmes for different stakeholders, such as the under-served countries and health workers; and a clarification of the rights and duties of the concerned parties. This thesis provides a thorough analysis and clarification of such rights restrictions and offers theoretically and empirically grounded recommendations as to how they ought to be managed. Rights theory and accounts of individual responsibilities are employed to assess the acceptability of restrictive health service programmes.

In brief, the thesis (a) discusses the conditions under which individual health workers may have responsibilities to attend to the basic health needs of a population, (b) explicates the rights at stake such as the freedom of movement and the right to exit, (c) offers insight into what it means to restrict one’s right and its implications and (d) suggests ways for conflicting rights and interests to be balanced and resolved. Taken together, the thesis presents a nuanced approach towards individual responsibilities in under-served contexts and an improved understanding of the right to exit as well as the implications of restricting the right. The thesis also contributes to the ethics of skilled worker emigration with a discussion on the responsibilities of skilled workers when the other parties do not fulfil their fair share of responsibilities.

Abstract [sv]

Denna avhandling i tillämpad etik består av fyra artiklar jämte en längre introduktion. Samtliga artiklar behandlar etiska aspekter på emigrationen av högutbildad vårdpersonal från utvecklingsländer och resursfattiga regioner, ett fenomen som ofta beskrivs som medicinsk kunskapsflykt (Medical Brain Drain). Utifrån normativ etisk teori analyseras i vilken utsträckning, om alls, utvecklingsländers ansatser att säkerställa nationella vård- och omsorgsbehov med hjälp av begränsningar av vårdpersonals mobilitet kan anses vara etiskt försvarbara. I avhandlingen analyseras också olika intressenters skyldigheter och rättigheter utifrån teorier om ansvar och rättigheter. Det gäller bland annat frågan om sjukvårdspersonalens individuella ansvar att stanna i hemlandet för att tillgodose grundläggande vårdbehov hos befolkningen.

Avhandlingen bidrar med ett klargörande av (i) argument för och emot begränsningar av vårdpersonals rätt att lämna landet, (ii) relaterade rättighets- och intressekonflikters natur och (iii) teoretiskt förankrade rekommendationer för hur denna typ av konflikter bör hanteras. Avhandlingen synliggör etiskt relevanta följder av obligatoriska vårdprogram för olika intressegrupper (stakeholders) som stater, vårdgivare, vårdpersonal och vårdtagare, liksom vilka rättigheter och skyldigheter som står på spel, som exempelvis rätten att fritt lämna sitt land och rätten till grundläggande hälso- och sjukvård. Sammantaget bidrar avhandlingen med en grundlig analys av skäl för och emot begränsningar av den fundamentala men sparsamt analyserade mänskliga rättigheten att lämna det egna landet.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 69
Series
Linköping Studies in Arts and Sciences, ISSN 0282-9800 ; 767CTE, ISSN 1402-4152 ; 18
Keywords [en]
Brain drain, compulsory service, contracts, emigration, ethics, health workers, medical brain drain, skilled workers, responsibility, the right to exit, vulnerability, non-ideal theory
Keywords [sv]
Etik, kontrakt, kunskapsflykt, mänskliga rättigheter, migration, moraliskt ansvar, obligatoriska vårdprogram, rättighet, utsatta grupper, vårdpersonal
National Category
Ethics International Migration and Ethnic Relations Globalisation Studies
Identifiers
URN: urn:nbn:se:liu:diva-157076DOI: 10.3384/diss.diva-157076ISBN: 9789176850893 (print)OAI: oai:DiVA.org:liu-157076DiVA, id: diva2:1318267
Public defence
2019-06-14, KEY 1, Hus Key, Campus Valla, Linköping, 10:00 (English)
Opponent
Supervisors
Available from: 2019-05-27 Created: 2019-05-27 Last updated: 2019-11-01Bibliographically approved
List of papers
1. Health Without Care? Vulnerability, Medical Brain Drain, and Health Worker Responsibilities in Underserved Contexts
Open this publication in new window or tab >>Health Without Care? Vulnerability, Medical Brain Drain, and Health Worker Responsibilities in Underserved Contexts
2018 (English)In: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 26, no 1, p. 17-32Article in journal (Refereed) Published
Abstract [en]

There is a consensus that the effects of medical brain drain, especially in the Sub-Saharan African (SSA) countries, ought to be perceived as more than a simple misfortune. Temporary restrictions on the emigration of health workers from the region is one of the already existing policy measures to tackle the issue - while such a restrictive measure brings about the need for quite a justificatory work. A recent normative contribution to the debate by Gillian Brock provides a fruitful starting point. In the first step of her defence of emigration restrictions, Brock provides three reasons why skilled workers themselves would hold responsibilities to assist with respect to vital needs of their compatriots. These are fair reciprocity, duty to support vital institutions, and attending to the unintended harmful consequences of one's actions. While the first two are explained and also largely discussed in the literature, the third requires an explication on how and on which basis skilled workers would have a responsibility as such. In this article, I offer a vulnerability approach with its dependency aspect that may account for why the health workers in underserved contexts would have a responsibility to attend to the unintended side effects of their actions that may lead to a vital risk of harm for the population. I discuss HIV/AIDS care in Zimbabwe as a case in point in order to show that local health workers may have responsibilities to assist the population who are vulnerable to their mobility.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
medical brain drain, ethics, vulnerability, Zimbabwe, HIV/AIDS, health workers
National Category
Ethics Philosophy Medical Ethics International Migration and Ethnic Relations
Identifiers
urn:nbn:se:liu:diva-134570 (URN)10.1007/s10728-017-0342-x (DOI)000425320600002 ()28224293 (PubMedID)
Funder
Lars Hierta Memorial Foundation, FO2013-0484
Note

Funding agencies: Stiftelsen Lars Hiertas Minne [FO2013-0484]

Available from: 2017-02-16 Created: 2017-02-16 Last updated: 2019-05-27
2. How to Understand Limitations of the Right to Exit with Respect to Losses Associated with Health Worker Emigration: A Clarification
Open this publication in new window or tab >>How to Understand Limitations of the Right to Exit with Respect to Losses Associated with Health Worker Emigration: A Clarification
2018 (English)In: Etikk i praksis, ISSN 1890-3991, E-ISSN 1890-4009, Vol. 12, no 2, p. 69-86Article in journal (Refereed) Published
Abstract [en]

There is a recent interest in the ethics of high-skilled worker emigration through which the limitations of the right to exit are discussed. Insightful arguments have been made in favour of (or against) the emigration restrictions on skilled workers in order to tackle the deprivations in developing countries. However, there is still a need for clarification on how we can understand, discuss and implement limitations of a right from a normative perspective. Significantly, how we understand the limitation of a right might determine how we approach such limitations –both in terms ofthe process of assessing the limitations and in terms of their implications. In this paper, I identify two distinct ways to understand limitations of the right to exit with respect to losses associated with health worker emigration, while also pointing totheir implications for restrictive policies: (i) as a matter of scope, and (ii) as a matter of weight or emergency, which requires a compensatory scheme for the individual right holders. While the emergency restrictions seem to be a point of convergence in the literature, what defines an emergency and the nature of the compensation still warrant exploration. To that end, I also discuss from a normative perspective what might constitute a public emergency that would give states a prima facie prerogative to regulate temporary limitations on the exercise of the right to exit. In addition, I briefly introduce the implications of emergency restrictions, with a particular focus on compensatory schemes for individual right holders.

Place, publisher, year, edition, pages
Akademika forlag, 2018
Keywords
compensation, emergency, health worker emigration, right limitations, right to exit
National Category
Globalisation Studies Ethics Philosophy International Migration and Ethnic Relations
Identifiers
urn:nbn:se:liu:diva-152885 (URN)10.5324/eip.v12i2.2433 (DOI)000451375500006 ()
Available from: 2018-11-27 Created: 2018-11-27 Last updated: 2019-05-27Bibliographically approved
3. The Right to Exit and Skilled Labour Emigration: Ethical Considerations for Compulsory Health Service Programmes
Open this publication in new window or tab >>The Right to Exit and Skilled Labour Emigration: Ethical Considerations for Compulsory Health Service Programmes
2019 (English)In: Developing World Bioethics, ISSN 1471-8731, E-ISSN 1471-8847, Vol. 19, no 3, p. 169-179Article in journal (Refereed) Published
Abstract [en]

Compulsory (health) service contracts have recently received considerable attention in the normative literature. The service contracts are considered and offered as a permissible and liberal alternative to emigration restrictions if individuals relinquish their right to exit via contract in exchange for the state-funded tertiary education. To that end, the recent normative literature on the service programmes has particularly focused on discussing the circumstances or conditions in which the contracts should be signed, so that they are morally binding on the part of the skilled workers. However, little attention is devoted to the relevance of the right to exit for the debate on compulsory service programmes. In this paper, I argue that even if the service contracts are voluntary, and thus the would-be medical students voluntarily relinquish their right to exit, the reasons behind the right should be taken into account for the contracts to be morally valid. A clear understanding of the right to exit is a must in order not to breach its basic components and for the service contracts to be morally binding. To that end, I provide two accounts of the reasons to value the right to exit by presenting Patti Lenard’s discussion of the right and by reconstructing James Griffin’s account of human rights. I conclude by offering brief ethical considerations for compulsory health service programmes grounded in the reasons to value the right to exit.

Place, publisher, year, edition, pages
Wiley-Blackwell Publishing Inc., 2019
Keywords
compulsory service, ethics, right to exit, contract, health workers, migration
National Category
Ethics Philosophy Medical Ethics Political Science (excluding Public Administration Studies and Globalisation Studies) International Migration and Ethnic Relations
Identifiers
urn:nbn:se:liu:diva-152001 (URN)10.1111/dewb.12217 (DOI)000483705700007 ()30548442 (PubMedID)
Available from: 2018-12-12 Created: 2018-12-12 Last updated: 2019-09-23Bibliographically approved
4. Individual Responsibilities in Partial Compliance: Skilled Health Worker Emigration from Under-Served Regions
Open this publication in new window or tab >>Individual Responsibilities in Partial Compliance: Skilled Health Worker Emigration from Under-Served Regions
2019 (English)In: Public Health Ethics, ISSN 1754-9973, E-ISSN 1754-9981, p. 1-10, article id phz016Article in journal (Refereed) Published
Abstract [en]

One of the ways to address the effects of skilled worker emigration is to restrict the movement of skilled workers. However, even if skilled workers have responsibilities to assist their compatriots, what if other parties, such as affluent countries or source country governments, do not fulfil their fair share of responsibilities? This discussion raises an interesting problem about how to think of individual responsibilities under partial compliance where other agents (including affluent countries, developing states, or other individuals) do not fulfil their fair share of responsibilities. What is fair to expect from them? Taking health worker emigration as a case in point, I discuss whether the individual health workers’ fair share of responsibilities to address basic health care needs decreases or increases when the other parties do not fulfil their share. First, I review the responsibilities that different stakeholders may hold. Second, I argue that there are strong reasons against increasing or decreasing health workers’ fair share of responsibilities in a situation of partial compliance. I also argue that it is unfair for non-complier states to enforce health workers to fulfil their fair share or take up the slack.

Place, publisher, year, edition, pages
Oxford: Oxford University Press, 2019
National Category
International Migration and Ethnic Relations Ethics
Identifiers
urn:nbn:se:liu:diva-161454 (URN)10.1093/phe/phz016 (DOI)
Available from: 2019-11-01 Created: 2019-11-01 Last updated: 2019-11-01Bibliographically approved

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