"Ethical Obligations:
​How and Why We Are Able to Be Effective"

A Response to and Agreement with 
"Ethical Obligations Regarding Short-Term Global Health Clinical Experiences:
An American College of Physicians Position Paper"*

[LoveAIDS does a hybrid of short-term and longer-term work. This response to these five positions explains our ethical position on our short-term work, which also informs our longer-term work, and what enables us to be effective.] 

"Position 1: Physicians’ primary ethical obligation in Short-Term Global Health Care Experiences is to improve the health and well-being of the individuals and communities they visit."

At LoveAIDS, our goal is to be the feet and hands of Jesus as we meet the health care needs of HIV and AIDS patients in resource-limited countries. In doing so:

• We work with existing in-country systems in the countries we work with, to further strengthen them, coming alongside them to provide workers where there is a need. We do not work independently of existing in-country systems, which can lead to duplication of efforts, fragmentation of health care services, and the creation of a disproportionate management burden for local health care managers.
• We acknowledge and lament the reported errors of both secular organizations and “missions” organizations that host short-term global health experiences. LoveAIDS as an organization had much work to do to rebuild trust with the facilities we serve which was broken previously by the intentional and unintentional errors of other organizations. The cost was labor hours lost and decreased effectiveness. LoveAIDS heard complaints from facility leaders and the patients themselves about volunteers who were looking for a tourist experience or an opportunity to travel while doing some service work on the side. Complaints were shared about organizations making a profit for every worker they sent to the facilities while the facility themselves received little in funding from the organizations. Complaints were also shared about students seeking to volunteer for a couple weeks with the AIDS patients so that they could list their service experience on their medical school or medical residency applications. These observed actions did not communicate solidarity with the facilities nor the patients themselves. For these types of errors and others, best practice guidelines no longer identify short-term global health experiences as purely altruistic; they also now consider that the burden of proof is on organizers of such trips to show that the trips are both sustainable and bring true benefit to the receiving communities. LoveAIDS laments these reported errors and agrees that such trips must be both sustainable and bring true benefit to the receiving communities. It was with these commitments to sustainability and tangible benefit to our receiving communities that the work of LoveAIDS began.
• LoveAIDS confirms that the assistance we provide and the interventions we use are acceptable to the local communities receiving the assistance. We ask the facilities we serve what needs they have regarding licensed personnel and student volunteers, and then we fill those spots according to the resources we have. Each week and each day, LoveAIDS verifies what the objectives of the facility and for the designated patients are for that day, and LoveAIDS workers work under the leadership and approval of the facility’s in-house personnel. In doing so, as we as an organization through our workers seek to be the feet and hands of Jesus, we put in much effort daily so that our efforts daily benefit the patients, facilities, and communities we serve.
• Our licensed health care workers and volunteers do not overstep their scope of practice. Although regulations in the communities we serve may be more permissive, LoveAIDS workers work within their scope of licensure so that we are in compliance with both United States regulations as well as the regulations of the countries we serve. 

"Position 2: The ethical principle of justice requires partnering with local leaders to ensure that the potential burdens participants can place on local communities abroad are minimized. It also requires preparing our workers to expect to have limited material resources available." 

LoveAIDS has been committed to and continues to commit to logistically and practically minimizing any burden our workers might place on local communities we serve as we do our work.

• LoveAIDS acknowledges that health care resources may be drastically limited in the countries we serve compared to what is available in our home country.
• LoveAIDS supplies basic personal protective equipment but workers are also trained in advance to know they may not have access to the same resources in the countries we work as they would in their home country and to expect to need to make adjustments in the care they are able to provide.
• LoveAIDS acknowledges that financial responsibility for safety during travel for workers and for the provision of personal protective equipment lies with LoveAIDS. LoveAIDS workers are taught to be sensitive to the financial burdens they may unwillingly place on the local community or facilities we serve and to report any potential financial burden to LoveAIDS leadership. Examples of potential financial burdens includes food, transportation, and medical care, as well as directing the local facility’s staff time and energy away from their immediate work and onto the LoveAIDS team, which has labor costs associated with these efforts.
• In the case of limited resources, which can pose an ethical challenge, the decision as to how resources provided by LoveAIDS are used will be sought by involving all parties involved and with priority given to values of the local community we serve. 

"Position 3: The ethical principle of respect for persons, including being sensitive to and respectful of cultural differences, is essential to short-term global medical experiences." 

LoveAIDS has been committed to and continues to commit to maintaining respect of persons, respect of cultural differences, and cultural humility. This means:

• LoveAIDS commits to studying and understanding the culture of the countries we work in and to training LoveAIDS workers in the culture of the countries they work in. This includes communication styles, social etiquette, proper dress and presentation, culturally appropriate workplace behavior, and, specifically, behavior at the facilities we serve at. This also includes seeking to understand the cultural values and priorities of the communities we serve and to adjusting our delivery of services to make our partnership with these communities more seamless.
• LoveAIDS commits to meeting the same ethical standards of patient privacy, patient confidentiality, and patient choice that are required in our home country and holds all LoveAIDS workers to that standard. This includes not sharing any personally identifiable information regarding patients, including on social media platforms.
• LoveAIDS commits to maintaining cultural humility at all times, and as part of our deliberate attempt to do so, we commit to maintaining collaborative partnerships with the communities and facilities we serve. We seek to understand and prioritize each community’s values and self-identified needs as we come alongside each existing in-country health system to help strengthen it further in its delivery of health care services.
• As we seek to do so, LoveAIDS workers are not required to violate their own personal values, standards of medical ethics or care or to violate any laws. Possible areas of conflict are discussed in our worker onboarding before LoveAIDS workers travel to the communities we serve. For any potential areas of conflict that occur while workers are in the field, workers are to report concerns to LoveAIDS leadership and to the local community in seeking how best to respond. 

"Position 4: Pre-departure preparation is itself an ethical obligation. It should incorporate preparation for logistical and ethical aspects of [Short-Term Global Health Clinical Experiences,] including the potential for ethical challenges and moral distress." 

LoveAIDS provides pre-departure preparation to LoveAIDS workers. This includes:

• LoveAIDS requires all immunizations are current and medical screenings are complete. Workers must undergo a mental health evaluation as well as satisfy all background and reference checks, interview processes, and licensure verifications.
• We require all workers have travel insurance including emergency medical care and evacuation, any necessary prophylaxis if applicable, and personal safety needs (including personal protective equipment.)
• LoveAIDS educates our workers in the culture and history of the countries we work in as well as in the health systems and local health issues of the communities in which we work. In our cultural training we cover communication styles, proper dress and presentation, proper workplace behavior at the facilities we serve, as well as areas of cultural differences and potential misunderstandings. LoveAIDS also provides basic language training and ethics education.
• LoveAIDS also prepares our workers for the ethical challenges they will likely face and the possibility of moral distress, which can lead to burnout, a sense of powerlessness, a lowered quality of care, and lingering negative emotions. Moral resilience strategies are discussed and sources of support are established. 

"Position 5: Physicians should participate with organizations whose [Short-Term Global Health Clinical Experiences] are consistent with ethics and professionalism as exemplified in these positions." 

​LoveAIDS encourages health care professionals to choose to partner with organizations that facilitate ethical Short-Term Global Health Experiences in a high standard of medical professionalism:

• This allows workers to most effectively serve socioeconomically disadvantaged populations.
• This allows workers to best maintain and protect their professional integrity.
• This indirectly rewards and reinforces organizations which are striving to provide care at the highest ethical and professional standards.
• LoveAIDS believes that global health organizations which have developed long-term relationships with the countries, communities and in-country health systems which they support are recommended because of the sustainability, ongoing strategic investments involved, and the human capital of preexisting relationships. Exceptions do exist, such as situations of humanitarian crises or uncertain political climates, in which a short-term team can parachute in to serve. But even in those contexts, longer-standing partnerships merit being established as to help avoid a discontinuation of services to patients involved. In this regard, LoveAIDS encourages workers to seek out global health organizations which have developed or are developing long-term relationships with the communities in which they work.
• LoveAIDS believes global health organizations which are doing ethical work need to regularly evaluate the effectiveness of their work, including evaluating the effectiveness of their Short-Term Global Health Experiences and that these evaluations need to be determined and carried out by and with the local community the organization serves. LoveAIDS is committed to submitting itself to regular evaluations. By submitting to regular evaluations, a global health organization can verify the effectiveness of its work in the local community and make any needed changes to make sure it is most effectively meeting the community’s needs. And by verifying that an organization is indeed regularly receiving evaluations and making appropriate corrections, health care professionals can make sure that their efforts are being funneled into the organizations which will most ethically, effectively, and professionally utilize their skills and efforts. 

*"Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper"
by Matthew DeCamp, MD, PhD; Lisa Soleymani Lehmann, MD, PhD; Pooja Jaeel, MD; and Carrie Horwitch, MD, MPH for the ACP Ethics, Professionalism, and Human Rights Committee was published at Annals.org on March 27, 2018.