Jeremy Snyder

Many nations in the developing world invest scarce funding into training health workers. When these workers migrate to richer countries, particularly when this migration occurs before the source community can recoup the costs of training, the destination community realizes a net gain in resources by obtaining the workers' skills without having to pay for their training. This effect of health worker migration has frequently been condemned as 'poaching' or a case of theft. I assess the charge that the rich nations of the world poach the resources of the developing world through the active recruitment of migrants. I argue that the charge of poaching is misguided in these cases. The misuse of the term poaching is particularly troubling as it distracts attention away from the many actual moral wrongs taking place through the process of health worker migration and objectifies health workers.

Scholarship aiming to describe the wrongness of exploitation, especially when it is voluntary and mutually beneficial, has increased greatly in recent years. In this paper, I expand the scope of this discussion by highlighting a set of additional ethical concerns associated with many cases of mutually voluntary and beneficial exploitation. Specifically, I argue that the phenomenon of persons desperately seeking out and gratefully accepting exploitative interactions raises special moral concerns. The element of voluntariness is key to understanding how and why some exploitative interactions are degrading to exploitees. When an exploitative offer does not allow the exploitee sufficient progress toward a decent minimum of human functioning, these offers can create what I call a 'demeaning choice', where the exploitee may either accept the status quo or accept an offer that improves the exploitee's insufficiently. In these cases, the exploitee's participation in the interaction contributes to its demeaning quality, creating a form of `surface endorsement' of the treatment that she receives

Background: Medical tourism, thought of as patients seeking non-emergency medical care outside of their home countries, is a growing industry worldwide. Canadians are amongst those engaging in medical tourism, and many are helped in the process of accessing care abroad by medical tourism brokers - agents who specialize in making international medical care arrangements for patients. As a key source of information for these patients, brokers are likely to play an important role in communicating the risks and benefits of undergoing surgery or other procedures abroad to their clientele. This raises important ethical concerns regarding processes such as informed consent and the liability of brokers in the event that complications arise from procedures. The purpose of this article is to examine the language, information, and online marketing of Canadian medical tourism brokers' websites in light of such ethical concerns. Methods: An exhaustive online search using multiple search engines and keywords was performed to compile a comprehensive directory of English-language Canadian medical tourism brokerage websites. These websites were examined using thematic content analysis, which included identifying informational themes, generating frequency counts of these themes, and comparing trends in these counts to the established literature. Results: Seventeen websites were identified for inclusion in this study. It was found that Canadian medical tourism broker websites varied widely in scope, content, professionalism and depth of information. Three themes emerged from the thematic content analysis: training and accreditation, risk communication, and business dimensions. Third party accreditation bodies of debatable regulatory value were regularly mentioned on the reviewed websites, and discussion of surgical risk was absent on 47% of the websites reviewed, with limited discussion of risk on the remaining ones. Terminology describing brokers' roles was somewhat inconsistent across the websites. Finally, brokers' roles in follow up care, their prices, and the speed of surgery were the most commonly included business dimensions on the reviewed websites. Conclusion: Canadian medical tourism brokers currently lack a common standard of care and accreditation, and are widely lacking in providing adequate risk communication for potential medical tourists. This has implications for the informed consent and consequent safety of Canadian medical tourists

Medical tourists, persons that travel across international borders with the intention to access non-emergency medical care, may not be adequately informed of safety and ethical concerns related to the practice of medical tourism. Researchers indicate that the sources of information frequently used by medical tourists during their decision-making process may be biased and/or lack comprehensive information regarding individual safety and treatment outcomes, as well as potential impacts of the medical tourism industry on third parties. This paper explores the feedback from former Canadian medical tourists regarding the use of an information sheet to address this knowledge gap and raise awareness of the safety and ethical concerns related to medical tourism.

Medical tourism is a practice, whereby individuals travel across national borders with the intention of receiving medical care. Medical tourists are motivated to travel abroad by a number of factors, including the affordability of care abroad, access to treatments not available at home, and wait times for care at home. In this article, we share the findings of interviews conducted with 32 Canadian medical tourists with the aim of developing a better understanding of medical tourism, the ethical issues it raises for public health within Canada and other source countries for medical tourists, and to identify research gaps and policy responses to this practice. While patient and academic perspectives overlap in several regards, we suggest areas in which academic consideration of the ethical issues raised by medical tourism can be informed by patient perspectives

Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. For example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research.

Ballantyne correctly notes the need for clarification as to the standard of fairness that should guide nonexploitative international research on human subjects. When accounts of exploitation are applied to pharmaceutical development (as well as other areas), there is too often an uncritical acceptance that exploitation involves a form of unfairness. Moreover, these authors typically fail to produce an account of fairness by which exploitation should be identified. Ballantyne should be applauded for her attempt to inject greater clarity into these debates. Her preferred standard of fairness is problematic, however. Ballantyne fails to distinguish between at least two forms of exploitation, tied to two distinct forms of unfairness, that can take place in international research on human subjects. As I argue here, the first form of exploitation derives from transactional unfairness where researchers take special unfair advantage of research subjects. The second form of exploitation occurs when researchers take advantage of background injustices that disadvantage research subjects. As a result of this failure to differentiate between different forms of exploitation, Ballantyne misidentifies the requirements of fairness for engaging in nonexploitative international human subject research.

In this review, I survey theoretical accounts of exploitation in business, chiefly through the example of low wage or sweatshop labor. This labor is associated with wages that fall below a living wage standard and include long working hours. Labor of this kind is often described as self-evidently exploitative and immoral (Van Natta 1995). But for those who defend sweatshop labor as the first rung on a ladder toward greater economic development, the charge that sweatshop labor is self-evidently exploitative fails adequately to explain the nature of the alleged wrongdoing. While all sides might agree that poor working conditions are unfortunate and undesirable, defenders of sweatshop labor argue that they provide the best available employment alternative for some workers and the best chance at economic development for many low and middle income countries (LMICs). Some defenders of sweatshop labor even embrace the label of exploitation. <br><br>Unless there is a clear, widely understood account by which exploitation is a moral wrong, then charging a practice as exploitative will do little to advance debates over whether and why a practice is morally problematic. A considerable body of work has been developed applying a growing literature on exploitation to sweatshop labor. While many forms of moral wrong are associated with sweatshop labor, I will focus specifically on the worry that low wages allow relatively wealthy employers wrongfully to take advantage of or gain from relatively poor workers, especially in LMICs. In particular, I will focus on instances of alleged exploitation in employment relationships that are voluntary and mutually beneficial. I have two reasons for doing so. First, by restricting this review to voluntary and mutually beneficial instances of exploitation, I can isolate the moral wrong of exploitation from other moral wrongs, especially the wrongs of coercion and outright harms to workers. Second, the focus on mutually beneficial and voluntary relationships will allow for arguments that sweatshop labor is not only not exploitative, but is a morally praiseworthy means of helping to encourage economic growth in poor areas of the world and to provide jobs that pay better and are more stable than any existing alternatives.<br><br>In this review, I aim to accomplish three goals. First, I will provide an overview of the many different uses of the charge of exploitation in business practice through an examination of the uses of the term in the literature on sweatshop labor. While it is often not clear what kind of moral wrong is assumed to take place when the charge of exploitation is used, I will demonstrate that many distinct types of exploitation, connected to distinct moral wrongs, are used in the literature on sweatshop labor and elsewhere in business ethics. Specifically, I will identify two broad categories of exploitation—exploitation as unfairness and exploitation as the mere use of others—with subgroups under each main category of exploitation. Second, I will discuss which of these senses of exploitation are defensible as identifying clear moral wrongs that take place in the context of business and, specifically, sweatshop labor. As I will argue, not all uses of the charge of exploitation are capable of persuasively identifying clear moral wrongs. Moreover, there is not a single, clear type of exploitation that takes place in business but, rather, several distinct forms. Third, I will apply the lessons learned from my exploration of exploitation in sweatshop labor to other specific areas of business. As I will argue, there are multiple viable models of exploitation in the sweatshop literature that can illuminate exploitative practices of relatively well compensated employees, customers, suppliers, and entire communities. <br><br>While discussions of theories of exploitation tend to argue for a single, correct account of this moral wrong, my review of the literature on exploitation in sweatshop labor supports the conclusion that there are multiple defensible accounts of the moral wrong of exploitation. For this reason, those who would charge that a relationship is exploitative should specify the form of exploitation that they believe is taking place.

There is currently no international consensus around post-trial obligations toward research participants, community members, and host countries. This literature review investigates arguments and attitudes toward post-trial access. The literature review found that academic discussions focused on the rights of research participants, but offered few practical recommendations for addressing or improving current practices. Similarly, there are few regulations or legislation pertaining to post-trial access. If regulatory changes are necessary, we need to understand the current arguments, legislation, and attitudes towards post-trial access and participants and community members. Given that clinical trials conducted in low-income countries will likely continue, there is an urgent need for consideration of post-trial benefits for participants, communities, and citizens of host countries. While this issue may not be as pressing in countries where participants have access to healthcare and medicines through public schemes, it is particularly important in regions where this may not be available.

Medical tourism is the practice of traveling across international borders with the intention of accessing medical care, paid for out-of-pocket. This practice has implications for preferential access to medical care for Canadians both through inbound and outbound medical tourism. In this paper, we identify four patterns of medical tourism with implications for preferential access to care by Canadians: Inbound medical tourism to Canada’s public hospitals; Inbound medical tourism to a First Nations reserve; Canadian patients opting to go abroad for medical tourism; and Canadian patients traveling abroad with a Canadian surgeon. These patterns of medical tourism affect preferential access to health care by Canadians by circumventing domestic regulation of care, creating jurisdictional tensions over the provision of health care, and undermining solidarity with the Canadian health system.

The international migration of health workers, including long-term care workers for aging populations, contributes to a shortage of these workers in many parts of the world. In the Anglophone Caribbean, LCW shortages and the migration of nurses to take on LCW positions abroad threaten the health of local populations and widen global inequities in health. Many responses have been proposed to address the international migration of health workers generally, including making it more difficult for these workers to emigrate and increasing and improving local employment opportunities. In this article, we suggest an additional means of ethically reducing health worker migration, targeting the Anglophone Caribbean specifically. Countries in this region can take advantage of their warmer climate and well-trained work force to encourage aging populations in the global north to emigrate temporarily or permanently through international retirement migration. As a result, countries in the Anglophone Caribbean can not only decrease the international migration of trained health workers through the provision of well-paying, local jobs, but potentially reverse this flow by drawing on the international diaspora of their workers. International retirement migration, if carefully managed, can reduce global inequities in health while treating both retirees and LCWs ethically.

The concept of minimal risk has been used to regulate and limit participation by adolescents in clinical trials. It can be understood as setting an absolute standard of what risks are considered minimal or it can be interpreted as relative to the actual risks faced by members of the host community for the trial. While commentators have almost universally opposed a relative interpretation of the environmental risks faced by potential adolescent trial participants, we argue that the ethical concerns against the relative standard may not be as convincing as these commentators believe. Our aim is to present the case for a relative standard of environmental risk in order to open a debate on this subject. We conclude by discussing how a relative standard of environmental risk could be defended in the specific case of an HIV vaccine trial among adolescents in South Africa