To the Editor: We read with interest the qualitative study by Abedini et al1 investigating the meanings that 13 University of Michigan preclinical medical students attributed to participation in one-week international service–learning trips (ISLTs) in Central and South America and the Caribbean. We wish to underscore the authors’ call to ensure that “all parties’ interests are represented and met” and to suggest a broader way to frame the ethical issues involved in ISLTs.
First, a need exists to understand the benefits and burdens of ISLTs for others beyond students, including host institutions, host communities, and sending institutions. With this need in mind, in 2008 two of us identified a range of ethical considerations for short-term global health training experiences for all stakeholders.2 This led to the formation of the Working Group on Ethics Guidelines for Global Health Training (WEIGHT) that published guidelines in 2010.3 Second, it seems reasonable to view as ethical issues the various themes (e.g., explicit benefits) and subthemes (e.g., perceived positive outcomes for the community/individuals served) used by Abedini and colleagues. This more expansive view is reflected in a freely available introductory curriculum for trainees4 based on the WEIGHT guidelines.3 Third, while reflection on ethical issues after an ISLT is important, raising ethical awareness prior to the experience is itself a critical obligation likely to improve the experience for students, host institutions, and communities alike.
We commend the authors and call for more research on the benefits and burdens of ISLTs for all stakeholders. For example, whether shorter experiences involving more junior trainees compound burdens and ethical concerns, as many suspect, is an important question.2,3 An obligation, nonetheless, exists for programs to periodically review the benefits and burdens of ISLTs in consultation with all stakeholders.3 Such reviews might motivate restructuring existing programs and, when necessary, discontinuing harmful ones.2
John A. Crump, MB, ChB, DTM&H
McKinlay Professor of Global Health, Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; email@example.com.
Matthew DeCamp, MD, PhD
Postdoctoral fellow, Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University and School of Medicine, Baltimore, Maryland.
Michele Barry, MD
Senior associate dean for global health and director, Center for Innovation in Global Health, Stanford University and School of Medicine, Stanford, California.
Jeremy Sugarman, MD, MPH, MA
Harvey M. Meyerhoff Professor of Bioethics and Medicine, Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University and School of Medicine, Baltimore, Maryland.
1. Abedini NC, Gruppen LD, Kolars JC, Kumagai AK. Understanding the effects of short-term international service–learning trips on medical students. Acad Med. 2012;87:820–828
2. Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008;300:1456–1458
3. Crump JA, Sugarman JWorking Group on Ethics Guidelines for Global Health Training (WEIGHT).. Ethics and best practice guidelines for training experiences in globalhealth. Am J Trop Med Hyg. 2010;83:1178–1182
4. Stanford University Center for Global Health; Johns Hopkins University Berman Institute of Bioethics.. Ethical Challenges in Short-Term Global Health Training. 2012 www.ethicsandglobalhealth.org
.Accessed August 31