Revista Română de Bioetică, Vol. 13, Nr.1, January - March 2015
A VULNERABILITY/SOLIDARITY
FRAMEWORK FOR A GLOBAL ETHIC:
HISTORICAL & CONTEMPORARY
APPLICATIONS
Michael Olusegun Afolabi*
Abstract
Although bioethics seeks to address the basic problems of human flourishing, the articulation of
a consensus moral framework remains almost elusive due to charges including intellectual
hegemony, cultural domination and moral imperialism. This paper explores a phenomenological
approach in relation to developing a global ethical framework. It fashions a
vulnerability/solidarity framework drawing on trans-geographical narratives of domestic and
trans-Atlantic slavery in West Africa as well as the Euro-American evolution of the human rights
rhetoric and praxis. Applying this to the contemporary issue of medical brain drain, the paper
shows how such a framework may help engage the local and global dimensions of bioethical
issues.
Keywords: Brain drain, Global bioethics, Human rights, Phenomenology, Slavery, Solidarity,
Vulnerability
Corresponding author : Michael Olusegun Afolabi - [email protected]
* Center for Healthcare Ethics, Duquesne University, Pittsburgh, Pennsylvania USA
44
relation to the lifeworld is inexorable
and sheds useful narratives.4 On this
note, the paper uses two hypothetical
case scenarios to explore the
applicability of the VSF in relation to
the quandaries of autonomy, local and
global justice associated with medical
brain drain. Because the VSF uses
individual and social narratives drawn
from different cultural and historical
backgrounds, it side-steps the charge
of moral imperialism which is usually
levelled against a global ethic.
However, to ensure clarity it is
exigent that the notions of
vulnerability and solidarity are set in
their proper contexts.
1. Introduction & Background
Evolution in moral consciousness has
elicited varying degrees of social
responses geared towards fostering
human flourishing. While bioethics,
at its core, seeks to address the basic
problems of human flourishing,1 the
articulation of a consensus framework
remains almost elusive.2 In this
regards, it has been argued that a
global bioethical lens drawn from
Western origins and contexts can only
constitute a form of intellectual
hegemony, cultural domination and
moral imperialism.3 Drawing from
the anatomical concept of muscular
tonus, this paper argues that a
vulnerability/solidarity
framework
(VSF) has had a recurring pattern in
relation to morally problematic
human experiences and, as such,
constitutes a useful place to couch a
global or common ethic. Employing
the historical contexts of slavery and
the human rights movement, it shows
how issues of ethical concerns and
the
attendant
responses
have
transcended national and cultural
boundaries.
It
examines
the
contemporary issue of medical brain
drain, attempts a justification and
draws some attendant implications of
the VSF in relation to global
bioethics.
2.1.
The
Concepts
of
Vulnerability & Solidarity
Vulnerability has been described as
an ontological condition of humanity
which fosters susceptibility to
wounding and suffering from the
actions of others. Hence, it embeds
the need for reliance on the support of
others.5 This suggests the idea that
contextual
differences
between
individuals potentially creates a
vulnerable condition. In this vein, the
presence
of
diversities
–skin
pigmentation, educational prowess,
professional interests, technological
capacities,
health
conditions,
economic clout et cetera – creates
foundational
variances
between
persons in different locales, cultures
and nations; thus, producing an
inherently contextual vulnerability for
everyone. This echoes the view that
vulnerability is linked with the human
condition.6 Seen through this lens, the
contextual nature of vulnerability
implies moral obligation from person
A (who may be presently nonvulnerable) to person B (who may be
2. Methodology & Conceptual
Clarification
This paper employs the archival
method of scholarly research. Using
phenomenological narratives derived
from slavery in West Africa as well
as the human rights movement, the
paper forges a vulnerability/solidarity
framework. This approach mirrors the
Heideggerian
idea
that
the
relationship of the individual in
45
presently vulnerable). Such an
obligation also implies the need for
action towards helping the vulnerable
with a view to mitigating underlying
causes. In another sense, vulnerability
has been associated with conditions
that put certain categories of humans
in a state of ready manipulation,
coercion and/or deception facilitated
by background powerlessness or
disadvantaged
status.7
As
a
consequence of their vulnerable
condition, such categories of people
are ready prey to harm or threat by
others.8-9 This paper combines both
uses of vulnerability.
Solidarity
entails
collective
action. It implies the unity of a group
or a subgroup in terms of seeking
cooperative action. It has been
described as a naturalistic and
teleological impulse which joins one
human to another to foster
companionship
and
societal
interests.10 If solidarity is indeed
naturalistic and teleological, then it
does not necessarily have to involve
group or subgroup actions all the
time. In other words, solidarity may
be contextually expressed from an
individual to a group. Imagine a
university professor who observes a
group of students being unjustly
failed by another professor in the
same university.
Since this is
contrary to the spirit of academia, he
would probably act or express
solidarity by taking some courses of
actions to mitigate such a trend.
For some scholars, solidarity
embeds a moral feeling of indignation
against various forms of disrespect
which engenders specific actions. In
this vein, it may generate a rallying
point for members of movements in a
struggle.11
Elsewhere,
Wilde
conceptualizes solidarity as a feeling
of sympathy shared by people within
and across groups which impels
supportive action.12 Given that
solidarity is a social construct (or
social fact in Durkheimian terms), the
presence of different groups within
society implies the idea and
possibility that solidarity may
manifest in specific societal contexts
or segments. On the other hand, the
inherent nature of solidarity implies
that its manifestation will not be
limited by geographic time, place and
culture.
2.2. The Vulnerability/Solidarity
Framework
The idea that vulnerability and
solidarity
are
inherent
human
capacities has been underlined in the
preceding part of this section. That
both of these are teleological and
linked to human nature suggests the
possibility for a nexus of relationship,
especially since both are linked with
social action. On this note, this paper
advances
the
notion
that
a
vulnerability/solidarity
framework
constitutes a lens for engaging morally
problematic issues. In this regards, a
VSF may be likened to the flexorextensor system in muscular systems.
Here, the action of a flexor muscle acts
against an extensor muscle in an
agonist-antagonist manner to produce a
tonus which elicits movement.13
In
analogical terms, vulnerability may be
seen as the extensor upon which a
morally reprehensible stimulus (flexor)
acts to generate a corresponding tonus
or action (solidarity). On the other
hand, while the notions of vulnerability
and solidarity are Western constructs,
that they are inherent human capacities
connotes the plausibility that they –as
concept and praxis- may be found in
non-western geographies. For instance,
46
that the Newtonian idea that all bodies
of matter would remain at rest if left
undisturbed was phrased by Isaac
Newton does not imply that other
cultures were bereft of such an
intuitive understanding. Take the case
of an uneducated hunter in a remote
part of Papua New Guinea who has
downed a large game but realizes that
he is unable to transport it alone.
Without invoking Newton’s laws, he
probably knows that the game would
remain intact (provided it does not get
stolen) if he goes to seek help from
another hunter nearby. Similarly, that
the Arabian/Hindu-derived numerical
system has been adopted in
contemporary society14 does not mean
that non-Arab and non-Hindu cultures
were bereft of a numbering system
prior to that adoption. With this as a
conceptual foreground, the next section
of this paper elaborates the VSF via the
analysis of three historical events set in
different geographies and time periods.
subjugation of one individual to the
will of another single human being, or
to the will of several persons if the
ownership is multiple.15 This connotes
a sense of permanent powerlessness
and the absence of autonomous
capacities for people who become
slaves. Whereas what has been
described as domestic servitude in the
West African context falls short of this
conception, the “slavery” terminology
has persisted for want of a better
description. To be sure, there was
present a system of social oppression
such as serfdom, domestic servitude
and human chattel; yet, those caught
within it (through intertribal wars,
commerce, personal pledge to a King
etc.) had some measure of autonomy
such as rights to marry, own land, and
their children were not considered
slaves.16. In the Sokoto Caliphate,
slaves could acquire cash by working
on their own for an agreed time period
and pay a form of taxation (called
wuri) in return.17 In Ibadan, domestic
slaves were used for agricultural
production as well as manning
businesses owned by elites.18 In the
Akan and Adangme tribes of Ghana,
slaves were also used for agricultural
production as well as for household
chores and as porters.19
In spite of this indigenous
system of slavery, it seems that the
African notion of personhood which
encompassed an inherent moral worth
or human dignity20 was still applicable
to domestic slaves as evidenced by the
latitude of freedom and rights (though
in a restricted sense) such slaves had.
Indeed, some scholars have identified
some streak of egalitarianism in the
West African indigenous slavery
system.21 The Yoruba tribe, for
instance, treated slaves as part of the
family, eating from the same bowl,
3. Historical Contexts and the
Vulnerability/Solidarity Framework
In this section this paper attempts
to examine selected historical contexts
in which injustices to vulnerable sets
of people elicited responses of
solidarity.
3.1. Slavery in West Africa
Since the events associated with
slavery in West Africa were played out
in two distinct contexts of the
“domestic” and transatlantic phases, its
thematic examination is best pursued
along those lines.
3.1.1. Domestic Slavery in West
Africa
Slavery entails the complete
47
using the same dress in common so
much that slaves were (except at work)
indistinguishable from a free member
of the household.22
The case of Efunsetan Aniwura
exemplifies a historical context of
ethical intervention into the plight of
the vulnerable. Efunsetan was an elite
as well as a Minister of women affairs
in Ibadan in the mid-1850s who owned
more than two thousand slaves in her
lifetime. Following the death of her
only daughter, Efunsetan became cruel
to her slaves, limiting their hitherto
privileges, and prohibiting such
activities as the right to marry and bear
children. Death and gross physical
abuses were suffered by erring slaves.
But in spite of her social status, she
was sanctioned, lost her title and asked
to go on exile by the Ibadan ruling
Council. Rather than suffer such
shame, she committed suicide. The
Council thereafter set all her slaves
free.23 This incident may be interpreted
through the VSF. In this vein, the
inhuman actions of Efunsetan were
probably seen as morally reprehensible
as they placed her slaves in a
completely defenseless and vulnerable
state as opposed to the status quo. By
identifying
with
the
slaves’
vulnerability, the Council could act in
solidarity. In ethical terms, this
involved weighing and balancing the
interests of an autonomous slaveowner (Efunsetan) and vulnerable
people (the slaves) against the moral
standards of the community. This may
be better understood against the
backdrop of the indigenous ethical
concept of Ubuntu which entails a
sense of human interconnectedness and
dignity that one has towards others,
firstly in the cultural group to which
one belongs, and secondly to all other
human beings.24 In other words,
though the Council belonged to a
different echelon of societal strata,
they were morally obligated to act due
to their ubuntic duty to the slaves who
equally constituted part of the society.
3.1.2. Transatlantic Slavery in
West Africa
Whereas domestic slavery in West
Africa did not entail the absolute
subjugation of one individual to the
will of another, transatlantic slavery
did as it stripped the slaves in that
context of all forms of freedom.25
Indeed, transatlantic slavery foisted the
absolute power of life and death over
captured and/or bought persons.26
Falola notes that no other cases of
human trafficking compare with the
transatlantic slave trade in terms of
magnitude and impact.27 Although the
Euro-American
initiators
and
participants in the trans-Atlantic slave
trade appealed to the notion of res
nullius in describing the discovered
African territories and consequently
described the populations as barbaric;28
the West African victims of slavery
belonged to tribes with distinct
customs and ways of life. Their notion
of
personhood,
for
example,
encompassed an inherent moral worth
or human dignity as well as a high
sense of communal obligations.29 To
be sure, scholars like Small and
Walvin note that Africans endlessly
rebelled against the transatlantic
slavery and constantly affirmed their
humanity and asserted their dignity.30
Seen this way, and because slavery
entailed personal, and social disruption
of the dignity of living; it would be
expected that those on whom attempts
were made for capture as well as those
who were captured should find slavery
in the transatlantic context morally
48
good to foster cosmological balance.34
The antislavery abolition movement
also exudes some elements of the VSF.
Although Enlightenment writings as
well as the activities of Evangelical
Christians
and
Quaker-inspired
societies such as the British Society for
the Abolition of Slave Trade have been
pegged down as instrumental for the
success of the end of the transatlantic
slavery; the underlying basis for these
actions largely involved a sense of
sympathy and moral queasiness for the
slaves and the filth, disease, the
cruelties and mortality incident to the
capture and sale of Africans.35 In other
words, an increasing sense of
recognizing
captives
of
the
transatlantic slave trade as vulnerables
and the concomitant interpretation of
the whole process as morally
reprehensible was integral to the
solidarity which ultimately brought the
slave trade to an end. This again
echoes the VSF as well as how
competing interests (economic versus
moral concerns) needed to be balanced
via solidarity as a form of social
intervention.
reprehensible.
This idea clearly stands in stark
opposition to the standard narrative
that West African slaves accepted
bondage for four hundred years and
were
unhappy
with
abolition
movements of the nineteenth century.31
However, it offers a useful explication
for the attendant slave revolts which
characterized transatlantic slavery.
These revolts constituted attempts by
free Africans to rescue captured slaves
as well as the attempts of captured
slaves to revolt during embankment,
transportation on the Atlantic Ocean
and at the homes/plantations of slave
masters. In all, over four hundred
revolts have been documented; though
only the Amistad incident of 1839 has
received popular attention.32 This
foreground sheds some insights into
how West African peoples saw
transatlantic slavery as morally
reprehensible, and underscores how
slavery was forceful and fatal as well
as the fierce struggles for liberty and
freedom that characterized the
process.33 But it also points towards
the presence of an inherent capacity to
recognize loss of freedom as morally
repugnant, and the need to take action
on the cause(s) of such.
If the VSF is an inherent human
element, then it could be expected to
apply to the transatlantic slave context
as well and ultimately to the
antislavery movement. In this regard,
one could describe the pre-boarding
revolts as a form of solidarity from
free/uncaptured West Africans towards
the powerless and vulnerable captives.
Similarly, the post-boarding revolts
may be seen as representing solidarity
from the stronger captives towards the
common fate they shared with the
weaker ones, spurred by ubuntic duty
which embeds promoting common
3.2. Human Rights & Bioethics
Thought vis-à-vis the VSF
This section examines briefly the
evolution of the ideas and practices of
human rights and the bioethics
enterprise in relation to the VSF.
3.2.1. The Human
Rights
Rhetoric
The notion of human rights has
been conceived differently at different
times, in different climes and for
different segments of different
societies.36 By examining the social
and political evolution of the concept
and praxis of human rights in the
49
French and American revolutions till
the
United
Nations
Universal
Declaration of 1948, elements of the
VSF may be brought to the fore.
Waves of moral concerns expressed by
certain individuals over the morass of
human cruelty were foundational
impulses in the human rights
development. The Calas affair in
France, for instance, inspired Voltaire
to deplore the inhumane treatment. So
did punitive measures such as
branding, torture, quartering and
guillotining in England and America
inspire intellectuals of society to begin
applying rational principles to engage
and repudiate activities deemed
incompatible with natural rights or
human right (though the latter was
phrased latter). This moved from the
sphere of individual reflection to the
niche of social and collective solidarity
which engendered a call for more
lenient
punishments
for
social
wrongs.37 In other words, human
empathy towards vulnerable people
(victims of torture, guillotining
quartering etc.) by certain group of
individuals fostered action or solidarity
which partly obviated what was
considered morally objectionable and
wrong.
The solidarity or action
directed against acts deemed unjust or
inhuman needed a political structure
for larger scale success. In this vein,
the notion of natural law as an outcome
of natural rights38 was employed in the
American and French contexts as a
rallying point to channel displeasure
against extant political Sovereignty. It
may be argued that by recognizing its
vulnerable position via British colonial
domination, the American Revolution
constituted a kind of solidarity to
repudiate the clout of the British
Empire in 1776.39 A similar pattern
occurred in the French Revolution
which usurped the Monarchy system.
This same idea is echoed in part by the
Universal Declaration of 1948 aimed at
excising barbarous acts faced by
humnity.40
3.2.2. The Bioethics Enterprise
While Potter coined the term
“bioethics” broadly it caught on within
a narrow context.41 The contents of the
discipline may be traced partly to the
moral problems associated with
scientific research, clinical practice,
health policy etc. which fostered the
need for a framework for reflection
and action on these issues.42 Although
these issues were partly pivotal to the
birth of bioethics, human rights abuses
were an essential impetus. To be sure,
unpleasant
historical
events
exemplified by the role of scientists
and physicians involved in the use of
Jews for bizarre and extreme research
projects and their mass extermination
in the gas chambers of the Nazi
holocaust during the second world war
as well as the Tuskegee syphilis
research scandal brought to light the
need for some measure of control in
biomedical research.43 These inhuman
occurrences led to the creation of some
national and international codes
including the Nuremberg Code,
Helsinki Declaration and the Belmont
Report. Other Declarations have since
emerged such as the Universal
Declaration on Bioethics and Human
Rights aimed at upholding human
dignity and rights in clinical trials;
while some of the earlier ones have
undergone periodic modifications and
revisions.44
Elements of the VSF may be
teased out within these historical issues
and
developments.
The
harms
experienced by patients and research
50
diversity.48 It may also be supported by
the prevalence of the concepts of
respect for autonomy, beneficence,
non-malficence and justice as focal
principles drawn from the ethos of
moralism, meliorism and individualism
in American ethical thought in contrast
to principles such as liberty,
therapeutic wholeness, solidarity and
social subsidiarity employed by
European
ethicists.49
The
phenomenological nature of the VSF
however seems to mitigate the charge
of moral relativism vis-a-vis a global
ethic.
subjects clearly made them vulnerable.
At the same time, the epistemic
uncertainty engendered
by the
challenges
of
new
biomedical
technology equally made physicians
and scientists contextually vulnerable
qua human beings. Consequently, the
moral
outrage
and
queasiness
associated with these facilitated
increasing action or solidarity. For
instance, in the United States, social
deliberations such as the Mondale
hearings of 1968 and the Kennedy
hearings of 1973 may be seen as the
nexus of solidarity which ultimately
birthed avenues for concrete solutions
such as the National Commission for
the Protection of Human Subjects of
Biomedical and Behavioral Research
which became law in 1974.45 To be
sure, the Hastings Center, the Kennedy
Institute and the Society for Health and
Human Values may be described as
offshoots of the solidarity response to
the vulnerability issues that were
thrown up by the emerging bioethical
impetus.
The VSF partly echoes Potter’s
broad vision of bioethics as a general
normative ethic built on an increasing
feeling of solidarity between human
beings.46 Indeed, if the idea that the
VSF is a culture-free inherent feature
of humans is true, it again echoes
Potter’s thesis for the use of the
biological knowledge of man to foster
social good.47 Although this raises the
possibility for normative consensus,
the fact that contextualized social
ambiences have shaped the trajectories
of bioethical reflection and praxis is a
recurring drawback. Such position
leans towards ethical relativism, and
may be supported by the absence of
moral consensus after more than two
thousand years of philosophical
reflections on morality and moral
4. Global Bioethics & the
Vulnerability/Solidarity Framework
Although issues like abortion,
euthanasia,
transplantation
and
resource allocation constituted major
thematic foci of bioethics in the 60s
and 70s, this is no longer the case.
Perhaps, as an offshoot of the
globalizing and interconnected world
which unearths novel aspects to the
basic problems of human flourishing,50
a global ethic is emerging to establish a
liberal, social and democratic morality
geared towards the political realities
embedded in healthcare.51 This seeks
the cooperation of nations and multinational organizations relevant to
socio-political and economic contexts
to promote wellness, eliminate
avoidable diseases, prevent harm and
encourage courses of actions which are
amenable to this end.52This state of
affairs inevitably foists particularistic
as well as global dimensions on the
bioethical enterprise. Hence, the
validity of any global framework
would necessarily lie on its capacity to
deal with the local and global elements
of bioethical issues. Medical brain
drain (MDB) provides an example of a
51
bioethical theme with both local and
global dimensions. This section
therefore explores this theme in
relation to the VSF.
community and social investments.
This jeopardizes the benefits that nonmigrating members of society draw
from the staff-depleted healthcare
system. To be sure, acquiring
professional skills through public
resources and public institutions foists
some attendant social responsibilities
which, by implication, ought to limit or
restrain beneficiaries of such schemes
from engaging in MBD.58 Hence,
migrating to wealthier societies
following the
accumulation of
community and social goodwill is an
act that warrants moral repudiation.
But restricting the choice of migration
connotes a human right rhetoric.
While people as holders of certain
inalienable rights may choose to
remain in their countries of origins or
travel elsewhere, the moral currency
incurred in relation to getting an
education through public funds
demands that the rights to migrate
embed some contextual qualifications
or restrictions. Indeed, the right to
migrate for work in greener pastures
has the unintended consequence of
depriving home countries of essential
human capital. As such, core problems
facing
such
countries
remain
unattended, and as this scenario widens
existing inequalities between the South
and North, a vicious circle is an
aftermath.59 This raises the tendency
that local populations would hardly
have ample health professionals to
provide some of their basic health
needs. Seen through the lens of the
right to health rhetoric, MBD entails a
violation of human rights for since the
rights of one person or a small group
of individuals thwart the rights of a
larger group.60 Although this conflict
of rights may not necessarily occur
directly or intentionally, it brings about
an attendant issue of injustice
4.1. Medical Brain Drain vis-a-vis
the
Vulnerability/
Solidarity
Framework
Brain drain involves the transgeographical movement of educated
human capital for socially or
economically motivated reasons. It is
closely associated with migration of
health professionals, but may be used
in a wider scope to include
professionals in the academia and
research industry whose pattern of
migration also mirrors this. Although
the recruitment of Rene Descartes by
Queen Christina in 1649 for tutelage in
philosophy
shows
that
the
phenomenon is not entirely new,53 the
cascades of workers’ emigration in the
1960s from low to high-income
countries54 and as they have
particularly been played out in the
healthcare context raises several
ethical
issues.55
Against
this
background, this section explores some
of these issues in their local and global
dimensions.
4.1.1. Local Ethical Dimensions
Governments have the moral
responsibility to promote health and
foster social development.56 To this
end, wealthy and less wealthy nations
invest in the education of its citizens
through subsidies, research grants, tax
cuts, building hospitals and clinics and
making cadavers available for the
acquisition
of
clinical
skills.57
However, in the context of financially
struggling nations, MBD constitutes an
ethical issue as it entails the loss of
52
For
instance,
of
the
approximately five hundred physicians
that have been trained in Zambia, only
sixty currently practice there. In
Zimbabwe, only about three hundred
and sixty physicians were practicing in
2006 of the one thousand and two
hundred trained in 1991.61 The
emigration of health workers therefore
reeks of social injustice. Indeed, if
state institutions have a special
obligation to maintain an adequate
density of health workforce62 in order
to realize the availability of the special
and necessary “commodity” called
health; then brain drain shortchanges
the capacity of states to perform and
accomplish this critical obligation. On
that ground, brain drain becomes
unethical and warrants repudiation.
If social justice is conceived as
the
internal
arrangements
and
structures within a society,63 the
injustice embedded in health worker
migration is partly underscored when
social expectations are considered.
This has at least two dimensions. One,
by investing in the educational and
research trainings of health workers
government expects that they would
serve the populace in return, at least
for some part of their careers.
Although it may seem that by sending
some remittances to their home
countries64 émigré professionals offset
some of the social capital spent on
them, the net benefit generally does not
offset the massive financial and human
resource loss.65 Secondly, the public —
aware of the several health initiatives
of the government— expect that public
clinics and hospitals would have better
manpower to meet their minimal health
needs should they fall sick and need
public health services. Considering the
fact that a continent such as Africa
bears roughly 24% of the global
burdens of disease with only 3% of the
global
health
workforce,66
the
deprivation of health services via MBD
is doubly worrisome. Hence, MBD not
only constitutes social injustice to
government and populace but is also a
betrayal of social expectations and
trust.
4.1.2. Global Ethical Dimensions
The ethical issues associated with
MBD traverse beyond the local shores
of less wealthy nations or source
countries as they also apply to
wealthier or destination countries.
MBD thus embeds global dimensions.
Indeed, the capacity to offer better pay,
working conditions and job security
which readily lure health professionals
has been described as a stripping off of
critical resources to which source
countries are morally entitled.67 One of
such resources lost from the South to
the North is the huge financial
investments that have been incurred
through educational, research and
professional training to health workers.
Ghana, for instance, is estimated to
have lost about thirtyfive million
pound sterling of its training
investment due to brain drain.68
Roughly 20% of the health workforce
in the United States, New Zealand,
Australia, United Kingdom and
Canada are products of the process of
MBD.69 While destination countries
use MBD-recruited professionals to
augment their domestic healthcare
worker shortages,70 some often employ
active employment of professionals
from the South.71
Whereas medical brain drain
constitutes a brain gain, because the
health systems in destination countries
are already better off some scholars
have
argued
that
the
harms
53
experienced by the health sectors of
source countries and their populations
demands that the process be considered
unethical. In other words, the harmderived benefits of MBD are really no
benefits at all as they foster extant
inequalities between the North and
South.72 This again raises the question
of justice, though on a global scale.
Seen through a cosmopolitan lens,
migration restriction offers a means of
engaging the global justice aspects of
MBD. Although this would cause
some los to destination countries, the
consequent gains that would accrue to
source countries would be enormous,
and contribute towards addressing
extant disparities. In other words, the
right to emigrate needs to be balanced
against the social responsibilities that
health professionals have to their home
countries.73 This however, raises
questions on autonomy in relation to
freedom of travel for work.
Health professionals exercise
their autonomy when they choose to
accept job offers from rich destination
countries, though bad conditions in
their home countries may play a key
role in making refusal difficult.74 In
other words, individual health workers
decide to apply or not to for job
vacancies abroad, and when such
materialize they equally decide to go
or not to go. This entails a level of
premeditation which spans noneconomic dimensions. Indeed, working
abroad entails leaving behind friends,
close relations and a whole gamut of
other extant relationships. This
suggests that health professionals who
emigrate do so because that is what
they really want to do. Nevertheless, if
such decisions on aggregate exert
harmful consequences on vulnerable
populations and the health systems of
source countries, it calls for the need
for restriction. Indeed, the autonomous
decision to emigrate has been linked
with the attendant consequence that
each migration inspires about four
others.75 The ripple effects of this on
the healthcare systems of source
countries are potentially disastrous,
and worrisome. The question of
whether health-workers have a right to
freedom of professional movement or
whether this may be limited is
therefore a recurring ethical issue
underlying debates about brain drain.76
This derives largely from the moral
impasse of finding a balance around
autonomous migration, local and
global justice.
4.2. The Quandaries of MDB visà-vis the Vulnerability/Solidarity
Framework
This section examines the ethical
dilemmas or quandaries of MBD in
relation to how the VSF may help
engage these in source and destination
countries.
4.2.1. The Quandaries in Source
Countries
The VSF as elaborated in this paper
affirms the primacy of vulnerability in
setting off the chain of moral
repugnance from the sphere of
individual to sub-social and/or social
perception which gives rise to
solidarity that ultimately engages the
state of affairs. In applying the VSF to
the issue of MBD in source countries,
a prior task involves identifying who
amongst the actors including the
government, society and health
professionals constitute the vulnerable
group. This question will be addressed
drawing from how MDB typically
plays out in the sub-Saharan African
54
context.
scenario:
Consider the following
characterized by rational economic
choices.80 Similarly, Mr. Y’s overseas
study is not necessarily a form of brain
drain as it could have been borne out
of the absence of local expertise or
funding
opportunities.
This
is
consistent with the documented notion
that some African health researchers
emigrate in order to circumvent some
of the core challenges of their work or
career.81 The background conditions
around Nurse Y and Mr. Y thus foster
a contextual state of vulnerability.
On the other hand, the charge is
often levelled that the decision to
emigrate deprives home countries of
professional skills and services. Yet,
the presence of health professionals in
subSaharan Africa does not often
imply patronage by the populace.
Indeed,
there
a
number
of
underutilized hospitals and healthcare
centers abound, a situation fuelled
partly by cost considerations, mobility,
non-congeniality of services and
service-related chores such as queuing
for cards and long waiting periods.82
Since about 65% of African people
rely on traditional medicines for their
basic health needs;83 underutilization
of some health facilities may reflect
the fact that some people derive their
health needs through non-western
medicine. If this is true, emigration of
professionals employed in such
facilities does not necessarily leave the
local
population
contextually
vulnerable due to health deprivation.
To be sure, the local justice
polemic built on the health deprivation
logic assumes that there is a direct
correlation between the poor health
indices found in sources countries and
the migration actions of health
professionals. For instance, Dwyer
argues that the life expectancy
disparities between Canada and South
Mrs. Y. graduated from a
Bachelors of Nursing program in an
African university. All her educational
life, her parents have paid the bill,
sometimes having to sell personal
belongings. Her husband, a public
health expert, has just received a
scholarship for a doctoral study in
Canada. Since their marriage is only
six months old, they decide she has to
go with him. Incidentally, Canada is in
need of health workers; as such, Nurse
Y plans to work upon arriving Canada.
This
scenario
echoes
the
autonomous nature of professional
migration. It however highlights the
associated nuances. While Nurse Y has
decided to emigrate and has the
intention to offer her professional
services to the Government of Canada
who partly depends on such for
meeting Canadians’ health needs,77
that
decision is
not
entirely
autonomous per se. Specifically, the
dearness of her marriage and the
potential working opportunity which
would provide a means to repay some
of her obligations to her parents who
invested in her education would be
key. Here, it is important that to note
that Brassington’s analysis that parents
have only unidirectional moral
commitments to their children78 is not
consistent with the African worldview.
Specifically, the African nexus of
parent-child obligations is generally didirectional such that children are
obliged to show their appreciation of
the parental care they received early in
life when they become adults.79 The
case thus shows how MBD in the
African context is not always
55
Africa speaks against the drawing of
health personnel from the latter.84
Others have argued that such poor
indices result from failure of
governments to invest in the health
sector.85 The contributions of larger
socio-political factors such as years of
Apartheid and violence in South Africa
and the roles of externally imposed
schemes such as the Structural
Adjustment Program (SAP) in most
African countries are however hardly
engaged. Indeed, Loewenson remarks
that SAP was instrumental to rising illhealth, and decreasing access to health
care in the two-thirds of the population
of African countries.86 Scholars like
Akokpari have contended that SAP
with its attendant deceleration of
development facilitated MBD.87 These
observations show how background
external initiatives created conditions
which facilitated a contextual climate
of vulnerability that may enhance
professional migration. Lastly, the
nuanced nature of the quandary of
local justice is further highlighted by
the African order of relationships
which ubuntically ranks family
members above strangers. The nexus
of contextual vulnerability around
Nurse Y and Mr. Y in relation to their
family members would therefore
matter more compared to that which
may be foisted on society by their
departure. Indeed, if professionals who
receive public education incur greater
social responsibility88 then privately
educated ones could only at best have
supererogatory responsibilities. That is,
only the migration of state-sponsored
professionals leaves the state’s purse
exploited or contextually vulnerable in
relation to fulfilling its health
obligations to her citizens.
What
kinds of solidarity responses should the
sets of vulnerabilities incorporated in
these analyses provoke? Government
educational investment leads to huge
financial losses when professionals so
trained migrate. The solidarity
response to quell the contextual
vulnerability which society suffers
through the loss of skills acquired at
public expense may be realized in two
possible
ways.
Firstly,
the
implementation of formal contractual
arrangements that specify periods of
payback through service between
sponsoring governments and benefiting
professionals. In this regards, some
scholars have suggested that more
conditional subsidies and scholarships
on the part of government would help
slow down or reduce the prevalence of
MBD.89 If such agreements are signed
in a freely autonomous capacity it
would
imply
a
corresponding
responsibility90 and accountability on
the parts of signers in relation to
specified terms and conditions. Indeed,
this ethically eliminates the charge of
human rights violation vis-à-vis travel
restrictions. Secondly, the solidarity
response that MBD should provoke
involves the action of government
towards engaging the issues underlying
professional migration such as poor
working conditions and lack of
technological capacities.
The emigration of selfsponsored professionals is hardly
pleasing to governments in source
countries. But if privately-funded
health professionals who choose not to
practice (of which there are quite a few
in sub-Saharan Africa) 91 are not being
heckled, there can be no moral basis
for heckling those who choose to
emigrate upon self or family sponsored
education.
From
an
ubuntuan
perspective, the sets of people left
contextually vulnerable in this regards
are family members, friends and
56
relations. However, the decision of
non-publicly educated professionals
also renders the clientele of their
hospitals or students in their
universities contextually vulnerable.
While it is difficult to argue that
someone who chooses not to remain
employed in an institution have
obligations towards the clientele, the
emigration-induced
vulnerability
warrants
some
action,
albeit
supererogatory. Professionals engaged
in MBD may therefore show solidarity
through remittances. An average
Africa-trained physician in North
America is estimated to send about
US$6,500 per year to family, friends,
or charitable organizations in their
source countries.92 Also, the Diasporic
communities have been known to
engage in projects to uplift specific
sectors in their home countries. For
instance, The Ghana-Netherlands
Healthcare Project seeks to transfer
knowledge, skills and experiences
through short-term projects as well as
practical internships for Ghanaian
residents and specialists physicians.93
Lastly, the Ibadan College of Medicine
Alumni Association based in the
United states has as one its core goals
the development of the University
College. This is partly accomplished
through funding short-term scholar
exchanges and the provision of critical
technological and scientific equipment
to the College research staff. Gestures
of individual and group solidarity such
as these satisfy the ubuntic obligations
to relations and society.
nexus of vulnerability is also exigent in
terms of how the phenomenon
typically plays in this context.
Consider the following scenario:
Dr. M is a practicing physician and
metabolic researcher in a Ghanaian
University Teaching Hospital. In the
latest edition of the local medical
journal, he found a job advert by a
recruiting agency for endocrinologist
positions in New Zealand. Dr. M
decides to apply for one of the posts,
and believes that relocating would not
affect the family so much as their kids
are already away in the university
while his wife’s private business could
be managed in absentia.
This case highlights the active or
aggressive recruitment mechanism
through which destination countries
sometimes drain professionals from
source countries.94 Knowing that quite
a number of Africans grew up with the
fascination of living or travelling
abroad,95 such adverts for jobs abroad
as well as the socioeconomic realities
in most African states creates a climate
of contextual vulnerability that is
amenable to MDB. If Dr. M were a
self-sponsored
professional,
his
emigration decision poses little ethical
bottlenecks (as shown in the preceding
section). However, due to the extant
absence of contractual agreements
between public-funded professionals
and government, Dr. may (if he
belongs to this category) still decide to
emigrate. The solidarity responses
relevant to this scenario may involve
the need for source countries to place
travel restrictions on professionals who
have acquired educational training at
the expense of public funds and have
hitherto
signed
a
contractual
4.2.2.
The
Quandaries
in
Destination Countries
To understand and apply the VSF
to the issue of MBD in destination
countries, an identification of the
57
agreement. In this day and age of epassports, such restrictions can be
readily implemented. While such
restrictions will not preclude overseas
travel for conferences and short-term
scholar exchange programs, there is
still some possibility that some
professionals may still travel for shortvisits and thereafter fail to return to
their jobs. At the same time, the
corruption which is high amongst
government officials raises the
possibility that some public-funded
professionals may also bride their way
to emigrate.
On this note, destination
countries have at least two duties of
solidarity which can be realized
through international cooperation. This
echoes Article 24 of the UNESCO
Universal Declaration on Bioethics
and Human Rights which affirms the
promotion of solidarity towards
individuals and groups including
vulnerables and encourages bilateral
and multilateral agreements between
and amongst countries in the South and
North.96 In this vein, there is need for
the
recruitment
process
of
professionals from source countries to
take into account whether or not
shortlisted job candidates have existing
bonds for working in source countries.
As mentioned earlier, the e-passport
avenue
can
facilitate
easy
crosschecking. Those found to be on
such bonds would automatically not be
eligible for employment. Secondly, it
has been noted that in times of
economic distress, there often runs a
tendency for destination countries to
use immigrants as scapegoats in terms
of making them lose their jobs or
benefits associated with job loss before
citizens suffer similar fates. This has
been reported for countries like Saudi
Arabia and Malaysia.97 This springs
partly from the xenophobia associated
with economic policies in relation to
migration 98 but it creates a contextual
kind of vulnerability for self-sponsored
professionals who engage in MBD. In
this vein, there is need for UNESCO
member states to show solidarity
through
encouraging
destination
countries to have prior legally binding
agreements
with
MBD-recruited
professionals stipulating that in the
event of any economic crisis, they will
not be victimized.
With reference to the VSF, the
analyses in this section have
demonstrated how the contextual types
of vulnerabilities that accompany
MBD in both source and destination
countries may be mitigated via
context-specific kinds of solidarity. On
this note, the last section of this paper
examines how a VSF may be justified,
and some of its implications for global
bioethics.
5. Justification & Implications of
the VSF for Global Bioethics
Employing the ethical analyses of
MBD, this section draws possible
justification and some of the
implications
of
the
vulnerability/solidarity framework for
global bioethics.
5.1. Ethical Justification of the
VSF
Human flourishing remains a
strong core focus of societal telos
generally and the aim of the bioethical
enterprise
in
particular.
The
justification of an ethical framework
including the VSF may thus be
explored along these lines of thought.
58
how self-funded professionals ought to
be allowed to emigrate while the moral
quandary of public-funded ones may
be addressed by the implementation of
informed and autonomous contractual
agreements which go with travel
restriction. In this vein, it shows how
the expression of human rights though
free movement may warrant some
qualification.101
This echoes the notion of social
responsibility which constitutes article
14 of the UNESCO Declaration.102 In
other words, benefiting from public
purse implies reciprocal obligations to
society which in the spirit of fairness
should disallow the emigration of
benefiting individuals who have not
paid such social debts. In a world
where individuals hold fundamental
incompatible views,103 the VSF as a
phenomenological ethical lens fosters
human interests and offers a sphere of
analysis through which competing
interests may be weighed and balanced
on a scale of contextual vulnerability.
5.1.1. Human-centrism
If the VSF is indeed an inherent
phenomenological
flexor-extensor
system which enables a morally
problematic or repugnant scenario to
elicit an act of solidarity based on
contextual vulnerabilities, then its
goals should be tailored towards
fostering
human
good.
Phenomenologically, vulnerability as
an inherent human capacity which
varies according to contexts readily
latches on to solidarity due to the
teleological nature of the latter. Indeed,
solidarity as a feeling of individual,
group or subgroup sympathy which
gives rise to supportive action99
provides a phenomenological response
to ethical dilemmas which may be
shown to derive from the sphere of
contextual vulnerability.
The
analyses
of
the
phenomenon of brain drain reveal a
number of contextual vulnerabilities.
Addressing these via the solidarity
responses elaborated in the preceding
section suggests that while human
interests may conflict, the manner in
which these conflicts are mediated still
reflect, at its core, human interests. In
engaging the MBD, the VSF first
acknowledges the human agency of all
parties concerned. This reflects Article
3 of the UNESCO Declaration which
specifies the preponderance of
individual interests and welfare
without compromising the dignity of
the parties involved.100 The VSF
proceeds to balance conflicting
interests (e.g. of public-funded
individuals versus non-public-funded
individuals in relation to personal
choices and family nexus of
relationships),
highlighting
the
conflicts of rights involved. By
emphasizing the most vulnerable
amongst the moral agents, it shows
5.1.2. Ethical Flexibility
The translation of the rights
rhetoric into legally binding duties105 is
often morally problematic when
conflicts arise. The VSF may however
help engage some of such conflicts due
to its ethical flexibility. In the context
of MBD, the VSF shows how the
contextual vulnerabilities at source
countries may be engaged. However, it
equally unearths how those in
destination
countries
may
be
addressed. In other words, it highlights
how the application of a common
moral system may allow for some
variations
across
cultures
and
societies104 without losing sight of the
core ethical quandary and addressing
this.
59
South Africa’s Soobramoney case
provides another example where the
VSF may offer ethical flexibility. In
that case, a private
hospital
discontinued Soobramoney’s dialysis
sessions after he had run out of money
and accumulated a $25, 000 debt. He
thereafter sought to be placed on one
of the public hospitals but was refused
on resource allocation grounds. For hi,
this was contrary to the Constitutional
provision which recognized a right to
health and social security. He therefore
sought legal redress; however, the
court ruled in support of the
hospital.106 This incident sheds insights
into the vacuity of human rights
rhetoric in relation to providing
practical benefits when a nation is
incapacitated in following written
mandate. In relation to the VSF, it may
however
be
argued
that
Soobramoney’s
contextual
vulnerability or powerlessness outsized
the vulnerability that society would
experience if his dialysis were to have
been permitted at social expense. This
should therefore warrant solidarity and
not the injunction to deny him access
based on rationing. This again suggests
how the flexible lens of the VSF may
promote human dignity as an inherent
human capacity and foster human
flourishing.
5.2.1. Healthcare Context
In
the
healthcare
context,
vulnerability plays out in different
ways. A disparity in medical epistemic
power, for instance, features in the
professional-patient
interaction.
Regardless of the notion of patient
autonomy and informed consent,
patients thus remain potentially
vulnerable.107 Writing about the
American context of healthcare,
Brawley recently reports that the
internal quest for glory of the medical
establishment pushes physicians to
engage in over-treatment and heroic
surgeries in defiance of medical
epistemologies and at the expense of
patient’s full understanding of the pros
and cons, which is partly responsible
for the level of mistrust in the
system.108 Another but related view
holds that the necessary fallibility of
humans qua humans in the face of the
epistemic and technical complexities in
contemporary healthcare shows how
what
counts
as
professional
competence is increasingly altering,
and
how
inattention
to
this
development is fostering medical
errors with its attendant morbidity.109
These observations uncover a nexus of
vulnerability within healthcare that
demands attention.
On the other hand, BigPharma
research in Third World countries
where participants can hardly buy or
access drugs at the end of trials raises
another kind of vulnerability that has
not been adequately addressed.110
These instances thus emphasize how
patients and research subjects in
different geographical contexts remain
potentially open to harm, hence,
encounter
contextual
kinds
of
vulnerability. They also underscore the
need for health and public policy
reforms. By facilitating the ordering of
5.2. Some Implications of a VSF
for Global Bioethics
If the VSF promotes human
interests and offers an ethically flexible
lens for engaging morally problematic
issues, then it may be important to
understand some of its implications for
global bioethics. This may be explored
within the healthcare and nonhealthcare contexts.
60
the contextual vulnerabilities in
relation to competing interests, the
VSF has the capacity to identify the
relevant niche of solidarity. If this is
true, it offers a culture-free yet
nuanced approach to engaging the
local and global dimensions of
bioethical issues.
instruments
of
the
UNESCO
Declaration.111 It also shows that there
are global problems whose ethically
problematic nature may not be
resolvable without recourse to what
Drydyk describes as cross-border
cooperation.112 Finally, by adopting a
phenomenological rather than a
philosophical approach with its
restrictive
domain
of
moral
possibilities,113 the VSF echoes the
need for an expanded communitarian
niche for bioethical analysis. Such a
niche should situate moral agents, their
activities and the attendant moral
quandaries within one big moral
community.114
5.2.2. Non-healthcare Context
The contemporary Ebola crisis
demonstrates how local issues may
rapidly acquire global dimensions. It
also shows how a hitherto healthy
person may develop symptoms and
make those around them contextually
but fatally vulnerable. One only needs
to imagine the cyclical medical
calamity that such may bring about if it
occurs within a crowded public event.
Natural disasters, terrorism and
environmental pollution are another
class of events in which local ethical
issues may rapidly acquire global
dimensions. These clearly echo the
contextual
vulnerabilities
that
humanity living within a contemporary
globalized world increasingly face, and
the need for a viable bioethical
instrument. Engaging these issues via
the VSF warrants a clear understanding
of
the
different
contextual
vulnerabilities in relation to competing
interests.
Such an understanding
would consequently yield the nexus for
local or global solidarity.
The preceding analyses in this
section show how a VSF offers a
human-centric and ethically flexible
approach to engaging bioethical
dilemmas, and how the local and
global dimensions of a moral quandary
may be engaged using such a
framework. To be sure, the VSF
reflects a number of principles
incorporated within the normative
6. Concluding Remarks
This paper has argued that a
phenomenological approach such as a
vulnerability/solidarity
framework
offers a useful avenue through which a
global ethic may be couched. It shows
the tenability and the culture-neutrality
of the framework through historical
analyses of slavery in West Africa, the
abolition movement and the EuroAmerican evolution of human rights.
The paper applies the VSF to the
contemporary issue of medical brain
drain, and shows how it may help
engage the autonomy, local and global
justice ethical concerns embedded
therein. To be sure, the capacity of the
VSF to simultaneously engage the
local and global dimensions of ethical
issues (as illustrated in the context of
MBD) echoes Potter’s broad vision of
bioethics as a general normative ethic
built on an increasing feeling of
solidarity between human beings. It
also renders a humancentered and
culture-free approach to moral
quandaries by appealing to inherent
human capacities, again echoing
61
Potter’s thesis for the use of the
biological knowledge of man to shape
and foster social good via seeing the
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
individual as member of a community
of interdependent parts.115
Endnotes
_____________________
ten Have, “Potter’s Notion of Bioethics”, p.59.
Engelhardt, “The Search for a Global Morality”, pp. 18-30.
Petersen, The Politics of Bioethics, pp. 7, 17-18; Widdows, "Is Global Ethics Moral
NeoǦColonialism?” pp. 307312.
Heidegger, Being and Time, pp. 57-61, Lopez and Willis, “Descriptive and Interpretative
Phenomenology”, p. 729.
Mackenzie, Rogers and Dodds, Vulnerability pp. 1-4.
Neves, “Respect for Human Vulnerability and Personal Integrity” , pp. 158-159.
Afolabi, "Researching the vulnerables", p. 9; Sutton et al, "Recruiting vulnerable populations for
research”106-107.
Mackenzie, Rogers and Dodds, p. 5.
Forman and Nixon, “Human Rights Discourse within Global Health Ethics”, p. 48.
Mechtraud, “Durkheim’s Concept of Solidarity”, pp.23, 27.
Wilde, "The concept of solidarity”, p. 176.
Wilde, Global Solidarity, p. 1.
Wilder-Smith, The Drug Users, p. 236; Cailliet, The Illustrated Guide to Functional Anatomy of
the Musculoskeletal System, p. 15.
ten Have and Gordijn, “Travelling Bioethics”, p. 2.
Westermann, “Between Slavery and Freedom”, p. 214.
Rodney, “African Slavery and other Forms of Oppression in the Upper Guinea Coast in the
Context of the Atlantic Slave Trade”, 431-433, 440; Falola, “The End of Slavery among the
Yoruba”, p. 233.
Lovejoy, Slavery, Commerce and Production in the Sokoto Caliphate of West Africa, pp. 207211.
Salami, “Slaves in Agricultural Development of Ibadan”, p. 122-124.
Dumett, “The Work of Slaves in the Akan and Adangme Regions of Ghana in the Nineteenth
Century”, pp. 67-93.
Tangwa, "The traditional African perception of a person: some implications for bioethics", p.
303.
Baum, “Slaves without Rulers”, pp. 47-48.
Grace, Domestic Slavery in West Africa, p. 2.
Okunola and Ojo, “Socio-historical Crime Review of Efunsetan Aniwura, Bashorun Gaa and
Aare-Ago Ogunrinde Aje”, pp. 405-407; Awe, Nigerian Women, pp. 57-59; Adéè̳ kó̳ , The
Slave's Rebellion, p. 152.
Waghid and Smeyers, "Reconsidering Ubuntu”, p. 11.
Miers and Kopytof, Slavery in Africa, pp. 3-5.
Patterson, “Freedom, Slavery and the Modern Construction of Rights”, pp. 133-134.
Falola, The African Diaspora pp. 1-5.
Chemillier-Gendreau, “The Idea of the Common Heritage of Humankind and its Potential Uses”.
P. 377.
Tangwa, p. 39; Wiredu, “An Akan Perspective of Human Rights”, pp. 298
Small and Walvin, “African Resistance to Slavery”, p. 37.
Falola, p. 55.
62
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
Richardson, “Shipboard Revolts”, pp. 71-74; Falola, p. 53.
Falola, pp. 32, 59.
Mkhize, “Ubuntu and Harmony”, pp. 41-42.
Hunt, Inventing Human Rights, pp. 66, 205-206; Adams, “The Abolition of the Brazilian Slave
Trade”, pp. 608609; Page, "Rational Dissent, Enlightenment, and Abolition of the British Slave
Trade." pp. 741-742; Carrington, The Sugar Industry and the Abolition of the Slave Trade, pp.
202, 211.
Hunt, pp. 18,176.
Pogge, “How should human rights be conceived?”, pp. 187-189; Hunt, pp. 80-82, 96.
Pogge, pp. 190-191; Hunt, p. 117.
Hunt, pp. 119-122.
Hunt, pp. 204-205.
Potter, “Bioethics, the Science of Survival, pp. 126-133; Reich, The Word “Bioethics”, p. 320.
Jonsen, The Birth of Bioethics, pp. 15-100.
Ndebele, “Research Ethics”, pp. 306-308; Afolabi, “Researching the Vulnerables”, p. 8.
Ndebele, pp. 310-312; Annas and Grodin “The Nuremberg Code” pp. 136-139; Ashcroft, “The
Declaration of Helsinki”, pp. 141-143; Beauchamp, “The Belmont Report”, pp.151-152.
Jonsen, pp. 20-26.
Reich, “The Word “Bioethics”: the Struggle over its Earliest Meanings”, pp. 20-21; ten Have, p.
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Potter, p.152.
Engelhardt, pp. 18-19.
Jonsen, pp. 379-380, 390.
ten Have, p. 59, 67.
Engelhardt, p. 19.
Pinto et al, “The Context of Global Health”, pp. 8, 11.
Descartes, The philosophical writings of Descartes, p. xi.
List, “Justice and the Reversal of the Health Worker Brain Drain”, p. 10.
Snyder, "Is health worker migration a case of poaching?" p. 3.
Martinez-Palomo, “Social Responsibility and Health”, p. 219.
Dwyer, "What's wrong with the global migration of health care professionals?", p. 38.
Snyder, p. 8.
Brassington, "What's wrong with the brain drain (?)", pp. 113-114.
Eszter and Buyx, "Ethics and policy of medical brain drain”, p. 3.
Dwyer, p. 36; Taylor et al, "Stemming the brain drain—a WHO global code of practice on
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Eszter and Buyx, p. 4; List, p.10.
Dwyer, p. 39.
Hagopian et al “The flight of physicians from West Africa”, p. 1752; Eszter and Buyx, p. 4.\
Mackey and Liang, "Rebalancing brain drain: exploring resource reallocation to address health
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Taylor et al, "Stemming the brain drain—a WHO global code of practice on international
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Snyder. p. 19.
Connell et al,” Beyond the health worker migration crisis?", p. 1883.
Dwyer, pp. 36-37.
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Eszter and Buyx, p. 4.
Dwyer, pp. 40-42.
Snyder, p. 6.
63
75. Dwyer, pp. 39.
76. Eszter and Buyx, p. 4.
77. McIntouch et al., The ethical recruitment of internationally educated health professionals, pp. iii,
1.
78. Brassington, p. 118.
79. Arewa and Dundes, "Proverbs and the Ethnography of Speaking Folklore", p. 78; Ikuenobe,
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80. Brassington, p. 113.
81. Itiola, Drug Formulation, pp. 48, 50.
82. Mwabu et al, "Quality of medical care and choice of medical treatment in Kenya”, pp. 838-841;
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e13909; Erinosho, Health Sociology, pp. 7-18.
83. Kaya, "Indigenous knowledge (IK) and innovation systems for public health in Africa”, p. 103.
84. Dwyer, pp. 37.
85. Connell et al, p. 1876.
86. Loewenson, "Structural adjustment and health policy in Africa”, p. 717.
87. Akokpari, "Globalization, Migration, and the Challenges of Development in Africa”, p. 82.
88. Snyder, p. 5.
89. Docquier and Rapoport, “Quantifying the Impact of Highly Skilled Emigration on Developing
Countries”, pp. 278279.
90. Evans, “Autonomy and Individual Responsibility”, p. 111.
91. Ehlers, "Professional nurses' requests to remove their names from the South African Nursing
Council's register” , ;p. 70; Kombe et al, "New thinking in addressing the rising challenges of
human resources for health in sub Saharan Africa", pp. 83-87.
92. Hidalgo, "Why Restrictions on the Immigration of Health Workers Are Unjust”, p. 124.
93. Connell et al, p. 1888.
94. Muula, "Is there any solution to the “brain drain” of health professionals and knowledge from
Africa"
95. Holsey, Bayo "Transatlantic dreaming”, p. 172; 96. Diop, “International Cooperation”, pp. 309310.
97. Docquier and Rapoport, pp. 288-289.
98. Turner, Vulnerability and Human Rights, pp. 134-135.
99. Wilde, p. 258.
100.
ten Have and Jean, The UNESCO Universal declaration on bioethics and human
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102. Martinez-Palomo, Adolfa “Social Responsibility and Health”, pp. 219-223.
103. Taylor, “A World Consensus on Human Rights?”, p. 409.
104. Gert, “A Global Ethical Framework for Bioethics”, p. 13. 105. Forman and Nixon, pp. 47-48.
106. Rothman and Rothman, Trust is not Enough, pp. 139-145. 107. Neves, p. 162.
108. Brawley, How We do Harm pp. 27-40, 173-177.
109. Gawande, The Checklist Manifesto pp. 7-19.
110. Macklin, Double Standards in Medical Research in Developing Countries, pp. 4-15 111. ten
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113. Engelhardt, “Morality, Universality and Particularity”, pp. 21-22, 36.
114. ten Have, “Global Bioethics and Communitarianism”, p. 324.
115. Potter, Global Bioethics, p. 178.
64
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