On May 26, 2023, Ugandan President Yoweri Museveni signed legislation imposing steep criminal penalties on gays and lesbians, including life imprisonment for consensual sexual relations between same-sex partners and capital punishment for those convicted more than once; under the law, even the so-called “promotion of homosexuality” may result in up to twenty years of incarceration.Footnote 1 Although a number of nations in the world still criminalize same-sex relations, including thirty-one other African nations, many of these laws are nominally enforced. In contrast, Uganda appears serious regarding prosecution.Footnote 2 In addition to multiple arrests, the past year in Uganda has witnessed a dangerous rise in violence against the lesbian, gay, bisexual, and transgender (LGBT)+ community and an exodus of those LGBT+ Ugandans able to leave.Footnote 3 Although Uganda is a longstanding ally of the United States and many European Union nations, the country continues to be an authoritarian dictatorship with an abysmal human rights record.Footnote 4 These troublesome events are particularly relevant to U.S. medical education as Uganda remains a leading destination for American students and house officers conducting clinical fieldwork and research abroad.Footnote 5, Footnote 6 Uganda is not alone in this regard. Many developing nations to which American medical institutions send trainees are also among the world’s notorious human rights abusers. Unfortunately, Western institutions give far too little concern to the ethical implications of sending their trainees (i.e., students and house officers) to such countries. Using Uganda as a reference point, this paper explores this all too often neglected issue and argues that medical schools in the United States should weigh other ethical factors beyond merely the safety of their own trainees and the direct impact on foreign patients and research subjects when approving such ventures.
American medical trainees abroad
The history of U.S. medical trainees engaging in research and clinical apprenticeships abroad dates back to colonial times.Footnote 7 In the eighteenth century, aspiring American doctors generally supplemented their education with stints in Great Britain.Footnote 8 After 1815, France and then Germany became leading destinations. Writing in 1886, the renowned Albany neurologist Henry Hun noted that American medical students in “considerable number follow the good old German custom of supplementing their regular course of study (Lehrjahre) by a season of travel (Wanderjahre) for the purpose of seeing how people in other places perform the work which is to occupy the remainder of their lives.”Footnote 9 Starting in the 1960s, American medical students began to pursue postgraduation fellowships “for six months’ work in developing countries,” championed by the University of California at Berkeley’s William McCormack as “most useful” in that they allowed for “observation of situations that do not exist in the United States.”Footnote 10 Five decades later, more than one-third of American medical students reported participating in a “global health experience” and large numbers conducted research abroad either before matriculation or during medical school.Footnote 11 At the most prestigious medical schools, the numbers may run even higher. Indeed, such international endeavors have become staples of medical school and residency applications. At present, global health work for medical trainees most often occurs in the following contexts: either during college or a post-university “gap year”; through formal “global health” electives during medical school; at breaks in formal medical education, often during the summer interval between the first and second years of study or a “scholarly year” between the third and fourth; and during formalized research or clinical rotations in residency; or during short-term “breaks projects” and mission trips to provide care for brief intervals in the Global South. Although these ventures are administered by different authorities and their logistics vary considerably, for the ethical issues raised below, they implicate many of the same concerns—as the application of these concerns to specific cases may vary substantially. (Throughout this paper, the term “trainees” is used inclusively to encompass all of these individuals.) Needless to say, the suggestions raised below ought to be considered according to the particular nature and purpose of each specific program.
The arguments that favor global health experiences for future physicians focus on the benefits both for the American trainees themselves and for their host nations. By engaging abroad, trainees can gain exposure to “patients with diverse pathologies, improve physical exam skills by decreasing reliance on laboratory tests and imaging, enhance awareness of costs and resource allocation in resource-poor settings, and foster cultural sensitivity.”Footnote 12 At the same time, these trainees can serve as ambassadors of goodwill, foster intercultural cooperation, and, most importantly, provide healthcare services that might not otherwise be available. In addition, research conducted in developing nations “has helped answer many questions relevant to medical care in developed nations,” although this practice is not without its critics.Footnote 13, Footnote 14 From the perspective of medical school admission committees and residency program directors, global health endeavors may be perceived as demonstrating commitment to medicine and service, as well as crediting candidates with a distinctive attribute. The widespread belief among applicants that such efforts are highly regarded then creates a cycle of further engagement.
Student endeavors abroad do raise a number of complex ethical concerns.Footnote 15 For instance, Matthew DeCamp has enumerated a list of potential harms including that “medical outreach” might “contribute to a sense of false hope in Western medicine,” “play a role in the ‘brain drain’ of skilled workers,” “foster dependency on foreign aid,” or lead to “disenfranchisement with the local health system.”Footnote 16 At the extreme, Catholic priest and social critic Ivan Illich, in a widely quoted 1968 speech, “To Hell with Good Intentions,” objected to all such endeavors, famously declaring, “The damage which volunteers do willy-nilly is too high a price for the belated insight that they shouldn’t have been volunteers in the first place.”Footnote 17 However, the widespread acceptance of medical trainee forays abroad suggests that, in the context of appropriate review and safeguards, the American medical community largely views these endeavors favorably.
Human rights transgressors
One principal concern of schools and programs sending American medical trainees abroad is often the safety of these individuals.Footnote 18, Footnote 19 A range of reasons, including genuine interest in the well-being of those trainees under their auspices and fear of liability, prevent many such programs from dispatching students to war zones and to regions of significant geopolitical unrest. For instance, following the Russian invasion of Ukraine in 2022, many American medical schools suspended programs for their students in that country. Beyond its impact on the safety of American students abroad, the human rights environment of host nations does not appear to play a large role in determining whether to authorize or suspend such programs. Of note, this paper readily acknowledges that “human rights” are not easily defined—and may prove both culturally determined and subjective.Footnote 20 The Universal Declaration of Human Rights, adopted by that body’s General Assembly in 1948, offers one widely accepted, but far from universal, definition.Footnote 21 To a significant extent, years of data suggest that the American public shares a broad consensus regarding the fundamental parameters of such rights.Footnote 22 That being said, this paper does not seek to embrace one particular definition. Nor does this article intend to suggest that any nation, including the United States, cannot justly be criticized for human rights lapses. Western nations are far from immune to their own transgressions in the areas of civil liberties, civil rights, and healthcare justice. Rather, under the assumption that at least some consensus can be achieved within the United States regarding certain forms of conduct being incompatible with widespread perceptions of ethical behavior, this paper examines the issue of medical trainees—a broad term that includes applicants, medical students, and house officers—engaging in research and service in nations that consistently transgress these ethical benchmarks.
Two distinct sets of issues arise in relation to sending American trainees to nations with problematic human rights records. One set of concerns relates to the impact on the trainees themselves, whereas a second set of concerns implicates the status of human rights in the host nation and the welfare of potential victims of human rights abuses. Each of these issues is analyzed separately below, as each raises a distinct set of challenges.
Impact on students
Disparate impact
One major consideration in sending trainees to transgressor nations is that human rights abuses in host nations do not affect all potential visitors equally. Uganda offers an excellent example of this disparate impact in action. In that nation, LGBT+ students will face a wide range of dangers, from fears of arrest to the stress of concealing their sexual identities, that non-LGBT+ students will not face. As a result, for their own safety, LGBT+ students might reasonably be discouraged from pursuing such opportunities. History abounds with similar examples. African American medical students risked a range of distinctive de jure and de facto dangers had they sought to engage in fieldwork in Apartheid South Africa or the Republic of Rhodesia. Female Americans will confront both de jure and de facto restrictions in a number of Middle Eastern nations. Some countries still impose outright bans on visitors of certain ethnicities: Armenian Americans, for instance, are generally denied entry into Azerbaijan for any purpose. Other countries erect barriers for their own former citizens and those who share their ethnicity: Since Iran limits the ability of its nationals and their descendants to renounce their citizenship, male Persian Americans traveling to Iran may face military conscription upon arrival.
The extent and severity of such inequities vary among locales, a factor that might reasonably be considered by those organizations and institutions that post American trainees abroad. What cannot be ignored is the impact of sending some students to such environments on the welfare of others who cannot reasonably go. In essence, for this particular purpose, these excluded students are stamped with a proverbial badge of inferiority, one that may have equity implications far beyond this specific context. For instance, LGBT+ students might feel pressured to reveal their sexual identities to others at their home institutions in order to explain their unwillingness to join a project or rotation in Uganda. In situations where the same groups are likely to be targeted repeatedly by discrimination in various domains, what might appear to others as a minor inconvenience may actually prove part of a suffocating quilt of inequity.
Attenuation of indignation
A second significant consideration in sending trainees to transgressor nations is the message that these endeavors may send to these trainees, namely that human rights abuses are not a primary concern of medicine or that one may ethically look away when such abuses occur as long as one is engaged in other valuable work. The result may then be an attenuation of indignation through which these trainees come to accept such abuses as inevitable, or even routine, leading them to confound the familiar with the acceptable.
Under authoritarian regimes, the experiences of visiting trainees are often highly curated. For instance, most foreign trainees in Uganda are unlikely to witness the rampant physical and sexual torture that the nation’s authorities impose on perceived political opponents.Footnote 23 During the Apartheid era, South Africa made a point of curating the experiences of the small number of Black American visitors to shield them from the regime’s worst abuses. American volunteers to China are generally not permitted into Xinjiang/East Turkestan or Tibet—both sites of well-documented and ongoing human rights violations. The message that these trainees carry back to the United States from such experiences might, by design, render them unwitting apologists for transgressor regimes. Even those students for whom human rights abuses are merely normalized by what they do witness may transfer this resignation toward injustices to other aspects of their careers. To channel Ivan Illich, the damage done to the souls of volunteers, if their outrage at human rights abuses is attenuated, may be too high a price to pay for any tangible clinical or research benefits that result from their endeavors on the ground in certain nations.
Finally, one rarely discussed consideration is how these trainees may later suffer, either emotionally or through practical consequences, if international outrage toward a particular transgressor nation later increases. One can easily imagine a subsequent generation of physicians challenging a former trainee to justify engagement, even peripherally, with a particular abusive regime. The very act of such service in certain countries, whatever its intent, may ultimately tarnish the legacy of anyone involved. Predicting the impact of such “innocent” service early in one’s training may pose unanticipated negative consequences for one’s career far in the future. Yet trainees themselves may not fully appreciate this risk. As a result, it behooves institutions to consider such potential consequences as they choose to encourage or authorize certain endeavors.
Impact on host nations
American medical trainees provide value to transgressor nations that exceeds any particular contributions these visitors make to local economies or to the health of their citizens. Many of these host nations are engaged in the process of “white coat washing,” through which they use relationships with Western medical institutions to whitewash human rights abuses.Footnote 24 Such efforts are not unique to healthcare: For decades, authoritarian regimes from Pinochet’s Chile to Xi’s China have sought to host major international sporting events to gain acceptance on the global stage. Even medical ethical conferences have been targeted by such governments, an act condemned by van der Graaf and others as “ethics washing.”Footnote 25 Hosting American trainees as clinicians and researchers serves a similar purpose on a smaller scale—announcing to potential business partners and even to tourists that life in the host nation is “business as usual” and that reported human rights transgressions need not stand as barriers to other forms of engagement.
One can easily imagine the deleterious psychological and practical effects of such endeavors on human rights advocates and abuse victims within these nations. The message trainees may be inadvertently promoting is that America does value the welfare of these individuals or does not prioritize their concerns. When activists sought an international boycott of South Africa in the 1980s or of Israel in the 2000s, their goals were not primarily economic; rather, their objectives, rightly or wrongly, were to brand these nations as “pariah” states. Whether and when such boycotts are appropriate is well beyond the scope of this paper. Rather, the point here is that the engagement of the transgressor nation with the international community often undermines the interests of those who are challenging the legitimacy of particular governments. American medical trainees in nations like Uganda may be unwittingly complicit in “white coast washing” without even realizing the detrimental consequences of their presence.
Justifications
Having trainees engage in clinical and research interventions in transgressor nations is not without its justifications. As noted above, some critics reject the very notion that human rights can be defined or reject entirely the moral authority of the United States and its medical institutions to criticize the practices of other nations. In regard to American medical trainees abroad, however, by curtailing engagement, these institutions would be imposing consensus American values, to the degree they exist, upon Americans themselves. Holding one’s own trainees to one’s own standards, no matter how subjective these standards may be, is fundamentally different in kind from imposing these standards on foreign nationals elsewhere. Beyond these conceptual objections to raising human rights concerns in this context, two more concrete justifications might be offered in support of trainee engagement in transgressor nations.
First, these trainees often do valuable work: filling in gaps in care, educating host-nation practitioners, and obtaining data that may prove highly valuable in improving the health of local populations. Often, these good words are used to defend engagement. The flaw in this justification is that it suggests a false dichotomy: that either these students will fill voids that will otherwise go unmet or that their failure to do so will increase human suffering. In reality, countless locations around the globe that are not subject to human rights transgressions also experience grave deficiencies in care, gaps that these same students might be redeployed to fill. If no such gaps existed internationally, leaving students with the choice of serving in transgressor nations or not at all, a stronger case might be mustered for the benefits of such interventions excusing their harms. Under present circumstances, these trainees can easily mitigate as much or more human suffering elsewhere. This context also undermines the moral basis for the argument that any particular patients not helped by these trainees in transgressor nations will be denied this help through no fault of their own. After all, these individuals are rarely if ever responsible for the abuses of their authoritarian governments. Yet even if one believes medical trainees have an obligation to engage in service that fills unmet care needs abroad, it does not follow that these trainees have a particular moral obligation a priori to help any specific group of individuals rather than others in equal need elsewhere.
Second, one might contend that it is not the place of American medical institutions to impose their own values on applicants, students, and house officers. As autonomous beings, according to this reasoning, these trainees ought to be entitled to make their own choices regarding where to learn and volunteer. The difficulty with this argument is that no authority is preventing these trainees from studying or volunteering anywhere that they so choose; rather, these trainees are merely being denied recognition or credit in American medical institutions for such endeavors. In the field of medical training, such soft restrictions on autonomy are commonplace and widely accepted. For instance, if a medical school candidate chooses to watch television for ten hours daily rather than engage in social service, athletics, or the arts, he is welcome to document such an activity on his application; that does not mean that admission committees will or should reward him for doing so. In the same manner, admission committees—ideally with advance warning—might choose not to credit volunteer endeavors in transgressor nations. Similarly, most medical schools and residency training programs do not permit their charges to rotate abroad in any country of their choosing, but rather operate through established programs with select nations. That is a restriction on trainee autonomy, in a sense, but not one that generally faces opposition. Curating the list of nations for such rotations in light of one’s own institution’s values regarding human rights imposes hardly any greater burden on trainee autonomy.
Mitigation
The purpose of this paper is not to argue that trainees are never ethically justified in engaging with transgressor nations, nor that American institutions may not have defensible reasons for sponsoring such endeavors. These programs usually do convey benefits to both trainees and to vulnerable populations abroad—considerations that ought not be ignored. Rather, the hope is that trainees and institutions will incorporate concerns beyond the safety of students and the welfare of specific patients and research subjects abroad into any calculus before engaging in such endeavors. For example, the attitudes of human rights advocates, abuse victims, and local organizations in the potential host country toward such endeavors—if available—ought to be weighed heavily when contemplating engagement. Which individuals within the host nation will benefit from engagement might also be taken into consideration: For instance, if human rights transgressions target a specific population that is also systematically excluded from the intervention in which the trainee is involved, that injustice might weigh against participation. American trainees and institutions should also consider the impact on other American trainees, particularly those from vulnerable communities who are likely to be excluded from a range of international programs and opportunities. In that context, discrimination against LGBT+ students in Uganda might be weighted differently from a prohibition against Armenian American students working in Azerbaijan, as LGBT+ students will likely face numerous other stigmas both at home and abroad, whereas discrimination against Armenian American trainees outside this particular context at present is far rarer.
As important, in cases where such engagement may be justified, steps ought to be taken to mitigate any negative aspects of such endeavors. At a minimum, any institution permitting its trainees to serve in a transgressor nation must ascertain that such service is truly voluntary and that the participating trainee has been meaningfully educated regarding the transgressor nation’s problematic conduct so that the trainee may make an informed choice whether to engage. Trainees should also be asked to consider the impact of their choices on other American trainees and on the status of human rights advocates and abuse victims in the host nations as they decide for themselves whether the benefits justify the harm. Trainees and institutions might also engage in parallel efforts inside the United States to draw awareness to the transgressor nation’s problematic track record on human rights, decreasing the risk that their endeavors inside these host nations might be mistaken for an endorsement or used as a form of “white coat washing.” In short, every effort should be made to ensure that those governments and individuals engaged in abusive conduct do not benefit from the engagement of American trainees on their shores.
Conclusions
The range of ethical issues raised by the service of American applicants, medical students, and house officers abroad is varied and complex. No blanket rules can likely be established to address the many nuanced contexts and circumstances in which such engagement occurs. However, that does not mean that any individual or institution contemplating such service should be absolved from examining the ethical implications of such engagement from all angles. Factors beyond student safety and patient/subject welfare, which have been given short shrift for far too long, deserve to be given the serious consideration that they merit.
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On May 26, 2023, Ugandan President Yoweri Museveni signed legislation imposing steep criminal penalties on gays and lesbians, including life imprisonment for consensual sexual relations between same-sex partners and capital punishment for those convicted more than once; under the law, even the so-called “promotion of homosexuality” may result in up to twenty years of incarceration.Footnote 1 Although a number of nations in the world still criminalize same-sex relations, including thirty-one other African nations, many of these laws are nominally enforced. In contrast, Uganda appears serious regarding prosecution.Footnote 2 In addition to multiple arrests, the past year in Uganda has witnessed a dangerous rise in violence against the lesbian, gay, bisexual, and transgender (LGBT)+ community and an exodus of those LGBT+ Ugandans able to leave.Footnote 3 Although Uganda is a longstanding ally of the United States and many European Union nations, the country continues to be an authoritarian dictatorship with an abysmal human rights record.Footnote 4 These troublesome events are particularly relevant to U.S. medical education as Uganda remains a leading destination for American students and house officers conducting clinical fieldwork and research abroad.Footnote 5, Footnote 6 Uganda is not alone in this regard. Many developing nations to which American medical institutions send trainees are also among the world’s notorious human rights abusers. Unfortunately, Western institutions give far too little concern to the ethical implications of sending their trainees (i.e., students and house officers) to such countries. Using Uganda as a reference point, this paper explores this all too often neglected issue and argues that medical schools in the United States should weigh other ethical factors beyond merely the safety of their own trainees and the direct impact on foreign patients and research subjects when approving such ventures.
American medical trainees abroad
The history of U.S. medical trainees engaging in research and clinical apprenticeships abroad dates back to colonial times.Footnote 7 In the eighteenth century, aspiring American doctors generally supplemented their education with stints in Great Britain.Footnote 8 After 1815, France and then Germany became leading destinations. Writing in 1886, the renowned Albany neurologist Henry Hun noted that American medical students in “considerable number follow the good old German custom of supplementing their regular course of study (Lehrjahre) by a season of travel (Wanderjahre) for the purpose of seeing how people in other places perform the work which is to occupy the remainder of their lives.”Footnote 9 Starting in the 1960s, American medical students began to pursue postgraduation fellowships “for six months’ work in developing countries,” championed by the University of California at Berkeley’s William McCormack as “most useful” in that they allowed for “observation of situations that do not exist in the United States.”Footnote 10 Five decades later, more than one-third of American medical students reported participating in a “global health experience” and large numbers conducted research abroad either before matriculation or during medical school.Footnote 11 At the most prestigious medical schools, the numbers may run even higher. Indeed, such international endeavors have become staples of medical school and residency applications. At present, global health work for medical trainees most often occurs in the following contexts: either during college or a post-university “gap year”; through formal “global health” electives during medical school; at breaks in formal medical education, often during the summer interval between the first and second years of study or a “scholarly year” between the third and fourth; and during formalized research or clinical rotations in residency; or during short-term “breaks projects” and mission trips to provide care for brief intervals in the Global South. Although these ventures are administered by different authorities and their logistics vary considerably, for the ethical issues raised below, they implicate many of the same concerns—as the application of these concerns to specific cases may vary substantially. (Throughout this paper, the term “trainees” is used inclusively to encompass all of these individuals.) Needless to say, the suggestions raised below ought to be considered according to the particular nature and purpose of each specific program.
The arguments that favor global health experiences for future physicians focus on the benefits both for the American trainees themselves and for their host nations. By engaging abroad, trainees can gain exposure to “patients with diverse pathologies, improve physical exam skills by decreasing reliance on laboratory tests and imaging, enhance awareness of costs and resource allocation in resource-poor settings, and foster cultural sensitivity.”Footnote 12 At the same time, these trainees can serve as ambassadors of goodwill, foster intercultural cooperation, and, most importantly, provide healthcare services that might not otherwise be available. In addition, research conducted in developing nations “has helped answer many questions relevant to medical care in developed nations,” although this practice is not without its critics.Footnote 13, Footnote 14 From the perspective of medical school admission committees and residency program directors, global health endeavors may be perceived as demonstrating commitment to medicine and service, as well as crediting candidates with a distinctive attribute. The widespread belief among applicants that such efforts are highly regarded then creates a cycle of further engagement.
Student endeavors abroad do raise a number of complex ethical concerns.Footnote 15 For instance, Matthew DeCamp has enumerated a list of potential harms including that “medical outreach” might “contribute to a sense of false hope in Western medicine,” “play a role in the ‘brain drain’ of skilled workers,” “foster dependency on foreign aid,” or lead to “disenfranchisement with the local health system.”Footnote 16 At the extreme, Catholic priest and social critic Ivan Illich, in a widely quoted 1968 speech, “To Hell with Good Intentions,” objected to all such endeavors, famously declaring, “The damage which volunteers do willy-nilly is too high a price for the belated insight that they shouldn’t have been volunteers in the first place.”Footnote 17 However, the widespread acceptance of medical trainee forays abroad suggests that, in the context of appropriate review and safeguards, the American medical community largely views these endeavors favorably.
Human rights transgressors
One principal concern of schools and programs sending American medical trainees abroad is often the safety of these individuals.Footnote 18, Footnote 19 A range of reasons, including genuine interest in the well-being of those trainees under their auspices and fear of liability, prevent many such programs from dispatching students to war zones and to regions of significant geopolitical unrest. For instance, following the Russian invasion of Ukraine in 2022, many American medical schools suspended programs for their students in that country. Beyond its impact on the safety of American students abroad, the human rights environment of host nations does not appear to play a large role in determining whether to authorize or suspend such programs. Of note, this paper readily acknowledges that “human rights” are not easily defined—and may prove both culturally determined and subjective.Footnote 20 The Universal Declaration of Human Rights, adopted by that body’s General Assembly in 1948, offers one widely accepted, but far from universal, definition.Footnote 21 To a significant extent, years of data suggest that the American public shares a broad consensus regarding the fundamental parameters of such rights.Footnote 22 That being said, this paper does not seek to embrace one particular definition. Nor does this article intend to suggest that any nation, including the United States, cannot justly be criticized for human rights lapses. Western nations are far from immune to their own transgressions in the areas of civil liberties, civil rights, and healthcare justice. Rather, under the assumption that at least some consensus can be achieved within the United States regarding certain forms of conduct being incompatible with widespread perceptions of ethical behavior, this paper examines the issue of medical trainees—a broad term that includes applicants, medical students, and house officers—engaging in research and service in nations that consistently transgress these ethical benchmarks.
Two distinct sets of issues arise in relation to sending American trainees to nations with problematic human rights records. One set of concerns relates to the impact on the trainees themselves, whereas a second set of concerns implicates the status of human rights in the host nation and the welfare of potential victims of human rights abuses. Each of these issues is analyzed separately below, as each raises a distinct set of challenges.
Impact on students
Disparate impact
One major consideration in sending trainees to transgressor nations is that human rights abuses in host nations do not affect all potential visitors equally. Uganda offers an excellent example of this disparate impact in action. In that nation, LGBT+ students will face a wide range of dangers, from fears of arrest to the stress of concealing their sexual identities, that non-LGBT+ students will not face. As a result, for their own safety, LGBT+ students might reasonably be discouraged from pursuing such opportunities. History abounds with similar examples. African American medical students risked a range of distinctive de jure and de facto dangers had they sought to engage in fieldwork in Apartheid South Africa or the Republic of Rhodesia. Female Americans will confront both de jure and de facto restrictions in a number of Middle Eastern nations. Some countries still impose outright bans on visitors of certain ethnicities: Armenian Americans, for instance, are generally denied entry into Azerbaijan for any purpose. Other countries erect barriers for their own former citizens and those who share their ethnicity: Since Iran limits the ability of its nationals and their descendants to renounce their citizenship, male Persian Americans traveling to Iran may face military conscription upon arrival.
The extent and severity of such inequities vary among locales, a factor that might reasonably be considered by those organizations and institutions that post American trainees abroad. What cannot be ignored is the impact of sending some students to such environments on the welfare of others who cannot reasonably go. In essence, for this particular purpose, these excluded students are stamped with a proverbial badge of inferiority, one that may have equity implications far beyond this specific context. For instance, LGBT+ students might feel pressured to reveal their sexual identities to others at their home institutions in order to explain their unwillingness to join a project or rotation in Uganda. In situations where the same groups are likely to be targeted repeatedly by discrimination in various domains, what might appear to others as a minor inconvenience may actually prove part of a suffocating quilt of inequity.
Attenuation of indignation
A second significant consideration in sending trainees to transgressor nations is the message that these endeavors may send to these trainees, namely that human rights abuses are not a primary concern of medicine or that one may ethically look away when such abuses occur as long as one is engaged in other valuable work. The result may then be an attenuation of indignation through which these trainees come to accept such abuses as inevitable, or even routine, leading them to confound the familiar with the acceptable.
Under authoritarian regimes, the experiences of visiting trainees are often highly curated. For instance, most foreign trainees in Uganda are unlikely to witness the rampant physical and sexual torture that the nation’s authorities impose on perceived political opponents.Footnote 23 During the Apartheid era, South Africa made a point of curating the experiences of the small number of Black American visitors to shield them from the regime’s worst abuses. American volunteers to China are generally not permitted into Xinjiang/East Turkestan or Tibet—both sites of well-documented and ongoing human rights violations. The message that these trainees carry back to the United States from such experiences might, by design, render them unwitting apologists for transgressor regimes. Even those students for whom human rights abuses are merely normalized by what they do witness may transfer this resignation toward injustices to other aspects of their careers. To channel Ivan Illich, the damage done to the souls of volunteers, if their outrage at human rights abuses is attenuated, may be too high a price to pay for any tangible clinical or research benefits that result from their endeavors on the ground in certain nations.
Finally, one rarely discussed consideration is how these trainees may later suffer, either emotionally or through practical consequences, if international outrage toward a particular transgressor nation later increases. One can easily imagine a subsequent generation of physicians challenging a former trainee to justify engagement, even peripherally, with a particular abusive regime. The very act of such service in certain countries, whatever its intent, may ultimately tarnish the legacy of anyone involved. Predicting the impact of such “innocent” service early in one’s training may pose unanticipated negative consequences for one’s career far in the future. Yet trainees themselves may not fully appreciate this risk. As a result, it behooves institutions to consider such potential consequences as they choose to encourage or authorize certain endeavors.
Impact on host nations
American medical trainees provide value to transgressor nations that exceeds any particular contributions these visitors make to local economies or to the health of their citizens. Many of these host nations are engaged in the process of “white coat washing,” through which they use relationships with Western medical institutions to whitewash human rights abuses.Footnote 24 Such efforts are not unique to healthcare: For decades, authoritarian regimes from Pinochet’s Chile to Xi’s China have sought to host major international sporting events to gain acceptance on the global stage. Even medical ethical conferences have been targeted by such governments, an act condemned by van der Graaf and others as “ethics washing.”Footnote 25 Hosting American trainees as clinicians and researchers serves a similar purpose on a smaller scale—announcing to potential business partners and even to tourists that life in the host nation is “business as usual” and that reported human rights transgressions need not stand as barriers to other forms of engagement.
One can easily imagine the deleterious psychological and practical effects of such endeavors on human rights advocates and abuse victims within these nations. The message trainees may be inadvertently promoting is that America does value the welfare of these individuals or does not prioritize their concerns. When activists sought an international boycott of South Africa in the 1980s or of Israel in the 2000s, their goals were not primarily economic; rather, their objectives, rightly or wrongly, were to brand these nations as “pariah” states. Whether and when such boycotts are appropriate is well beyond the scope of this paper. Rather, the point here is that the engagement of the transgressor nation with the international community often undermines the interests of those who are challenging the legitimacy of particular governments. American medical trainees in nations like Uganda may be unwittingly complicit in “white coast washing” without even realizing the detrimental consequences of their presence.
Justifications
Having trainees engage in clinical and research interventions in transgressor nations is not without its justifications. As noted above, some critics reject the very notion that human rights can be defined or reject entirely the moral authority of the United States and its medical institutions to criticize the practices of other nations. In regard to American medical trainees abroad, however, by curtailing engagement, these institutions would be imposing consensus American values, to the degree they exist, upon Americans themselves. Holding one’s own trainees to one’s own standards, no matter how subjective these standards may be, is fundamentally different in kind from imposing these standards on foreign nationals elsewhere. Beyond these conceptual objections to raising human rights concerns in this context, two more concrete justifications might be offered in support of trainee engagement in transgressor nations.
First, these trainees often do valuable work: filling in gaps in care, educating host-nation practitioners, and obtaining data that may prove highly valuable in improving the health of local populations. Often, these good words are used to defend engagement. The flaw in this justification is that it suggests a false dichotomy: that either these students will fill voids that will otherwise go unmet or that their failure to do so will increase human suffering. In reality, countless locations around the globe that are not subject to human rights transgressions also experience grave deficiencies in care, gaps that these same students might be redeployed to fill. If no such gaps existed internationally, leaving students with the choice of serving in transgressor nations or not at all, a stronger case might be mustered for the benefits of such interventions excusing their harms. Under present circumstances, these trainees can easily mitigate as much or more human suffering elsewhere. This context also undermines the moral basis for the argument that any particular patients not helped by these trainees in transgressor nations will be denied this help through no fault of their own. After all, these individuals are rarely if ever responsible for the abuses of their authoritarian governments. Yet even if one believes medical trainees have an obligation to engage in service that fills unmet care needs abroad, it does not follow that these trainees have a particular moral obligation a priori to help any specific group of individuals rather than others in equal need elsewhere.
Second, one might contend that it is not the place of American medical institutions to impose their own values on applicants, students, and house officers. As autonomous beings, according to this reasoning, these trainees ought to be entitled to make their own choices regarding where to learn and volunteer. The difficulty with this argument is that no authority is preventing these trainees from studying or volunteering anywhere that they so choose; rather, these trainees are merely being denied recognition or credit in American medical institutions for such endeavors. In the field of medical training, such soft restrictions on autonomy are commonplace and widely accepted. For instance, if a medical school candidate chooses to watch television for ten hours daily rather than engage in social service, athletics, or the arts, he is welcome to document such an activity on his application; that does not mean that admission committees will or should reward him for doing so. In the same manner, admission committees—ideally with advance warning—might choose not to credit volunteer endeavors in transgressor nations. Similarly, most medical schools and residency training programs do not permit their charges to rotate abroad in any country of their choosing, but rather operate through established programs with select nations. That is a restriction on trainee autonomy, in a sense, but not one that generally faces opposition. Curating the list of nations for such rotations in light of one’s own institution’s values regarding human rights imposes hardly any greater burden on trainee autonomy.
Mitigation
The purpose of this paper is not to argue that trainees are never ethically justified in engaging with transgressor nations, nor that American institutions may not have defensible reasons for sponsoring such endeavors. These programs usually do convey benefits to both trainees and to vulnerable populations abroad—considerations that ought not be ignored. Rather, the hope is that trainees and institutions will incorporate concerns beyond the safety of students and the welfare of specific patients and research subjects abroad into any calculus before engaging in such endeavors. For example, the attitudes of human rights advocates, abuse victims, and local organizations in the potential host country toward such endeavors—if available—ought to be weighed heavily when contemplating engagement. Which individuals within the host nation will benefit from engagement might also be taken into consideration: For instance, if human rights transgressions target a specific population that is also systematically excluded from the intervention in which the trainee is involved, that injustice might weigh against participation. American trainees and institutions should also consider the impact on other American trainees, particularly those from vulnerable communities who are likely to be excluded from a range of international programs and opportunities. In that context, discrimination against LGBT+ students in Uganda might be weighted differently from a prohibition against Armenian American students working in Azerbaijan, as LGBT+ students will likely face numerous other stigmas both at home and abroad, whereas discrimination against Armenian American trainees outside this particular context at present is far rarer.
As important, in cases where such engagement may be justified, steps ought to be taken to mitigate any negative aspects of such endeavors. At a minimum, any institution permitting its trainees to serve in a transgressor nation must ascertain that such service is truly voluntary and that the participating trainee has been meaningfully educated regarding the transgressor nation’s problematic conduct so that the trainee may make an informed choice whether to engage. Trainees should also be asked to consider the impact of their choices on other American trainees and on the status of human rights advocates and abuse victims in the host nations as they decide for themselves whether the benefits justify the harm. Trainees and institutions might also engage in parallel efforts inside the United States to draw awareness to the transgressor nation’s problematic track record on human rights, decreasing the risk that their endeavors inside these host nations might be mistaken for an endorsement or used as a form of “white coat washing.” In short, every effort should be made to ensure that those governments and individuals engaged in abusive conduct do not benefit from the engagement of American trainees on their shores.
Conclusions
The range of ethical issues raised by the service of American applicants, medical students, and house officers abroad is varied and complex. No blanket rules can likely be established to address the many nuanced contexts and circumstances in which such engagement occurs. However, that does not mean that any individual or institution contemplating such service should be absolved from examining the ethical implications of such engagement from all angles. Factors beyond student safety and patient/subject welfare, which have been given short shrift for far too long, deserve to be given the serious consideration that they merit.