University of Minnesota Medicine Global Health: So Much to Learn

Sometimes I think about the fact that I will never get to learn everything that I hoped to learn in this one lifetime. Even if I were to live in Thailand for another 5, 10, 20 years and get a Ph.D. in Thai studies there would still be much to learn. It is quite a humbling experience. Although I continue to study Thai language and try to learn about the culture and society there is still so much that I do not know and, as an outsider, likely never will.

One area of learning that has challenged and interested me a lot these last few weeks has been the topic of medical ethics in a global context. The faculty member that I am working with here expressed interest in the topic of medical ethics before I came to Thailand. After arriving in Thailand I learned that clinical ethics committees and ethics consultation services do not yet exist here, which I learned is the case in many areas of the world outside the US and Europe. But as medical technology continues to develop and globalization continues, there will be more and more ethical dilemmas encountered in clinical practice, especially related to end of life care.

During a recent palliative care conference at CMU (“Suandok Palliative Care Conference”), faculty from many hospitals in Thailand decided that one of the priorities going forward is to begin to develop clinical ethics committees in Thailand. My faculty mentor found an article that demonstrated a needs assessment for clinical ethics services in Tehran, Iran and we decided to design a similar survey here. I am fortunate to have the opportunity to do rounds with the ICU and palliative care teams in the mornings here which has helped me to gain a better understanding of the culture, especially end of life care issues, although as mentioned above I still have a great deal to learn.

In doing some of the background research for this project I learned that clinical ethics committees were first developed in the 1980s in response to the growing number of ethical dilemmas that resulted from the rise in medical technology, consumerism and healthcare costs. They are now a requirement in all hospitals in the U.S. but in many parts of the world they are just starting to develop. It is interesting to think about this in the global scheme of “development”. Many countries that were previously considered to be “low resource" now have more and more technology and infrastructure and so are facing new challenges, and this is likely to continue in other countries.

So the question arises, how do you create ethics committees to meet the needs of each specific country? Every country has a unique culture, language, history and set of religious traditions and as a result will need a unique approach to solving ethical dilemmas. I came across a number of interesting articles about this, some that specifically compared Thai and American approaches. This challenged me to reflect critically on the approach we take in the U.S. to medical ethics, specifically how narrow our approach can sometimes be.

In our medical schools, students are taught to analyze all ethical problems through the lens of four principles - beneficence, non-maleficence, autonomy and justice - but this is not the only way to approach ethics. Everyone has a unique ethical framework that is influenced by their culture, upbringing and religious background but unfortunately few medical trainees have the opportunity to discuss ethical dilemmas through their own lens. Given the incredible diversity in our culture I would argue it is important to allow trainees to explore other approaches to clinical ethics.

And of course as the discipline of clinical ethics develops in other countries around the world we need to make sure that we refrain from making “Western” ethical frameworks the only way to approach ethics. Much of the work that we do in global health puts us at risk of creating unequal partnerships with other countries given the often vast differences in resources. This can result in loss of local culture and values. In Thailand for instance, although the country was never formally “colonized”, many scholars argue that there was “semi-colonical” relationship with the Western countries that has resulted in significant external influence.

I think that before we travel abroad we should spend time learning about the culture and history of the country we plan to visit, especially the relationship that the U.S. has had with that country. We come from a very privileged place in the U.S. and unfortunately this can result in significant power differentials when we engage in cross-cultures collaboration. Rather than thinking about what we will bring to another country or how we will change the situation, we should start by asking ourselves what we can learn from the them and keep an open mind and heart in the process. I know that I have learned a great deal from Thailand over the years.