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The literature on migration bioethics is not uniform; rather, it consists of a collection of overlapping but distinct debates. This entry contextualizes and describes a set of these debates, including those focused on the ethics of access to health-care by migrants, the ethics of providing health-care in a multi-cultural setting, and the ethics of public policies surrounding the “brain drain” of highly skilled workers from countries wherein they received their training – and in particular the migration of health-care workers.
Migration raises signiﬁcant and diverse ethical questions. For example, how does migration affect the vulnerabilities of migrants to illnesses? A migrant often experiences different barriers to health-care when they are abroad, but under what circumstances does this count as an injustice and how does it impact the migrant’s autonomy? When the migrants are themselves health-care workers, what determines their ethical responsibilities to people in their countries of origin and destination countries, and what responsibilities do those communities hold to the migrant health-care workers? Furthermore, what kinds of public policies regarding the recruitment of international health-care worker are most equitable? This entry does not seek to answer these and other relevant questions deﬁnitively; rather, it outlines background concepts that emerge in the bioethics literature on migration, and it surveys some of the main debates on this subject – many of which are ongoing.
History And Development
The UN has characterized migration as the deﬁning issue of today. Indeed, there are more migrants now than at any period in history. Even though this is at least partially an artifact of global population growth, migration is undoubtedly one of the three key demographic elements, along with birth and death rates (Skeldon 2013). Migration trends are relevant contributors to, or consequences of, signiﬁcant geopolitical events, and contemporary trends in migration raise signiﬁcant and diverse bioethical questions. This entry opens with deﬁnitions of several key concepts and terms in literature on the bioethics of migration, followed by a discussion of ethical issues raised by ﬁrst the impact of migration on the health of migrants and subsequently by the impact of migration by health-care workers.
In conjunction with fertility and death rates, migration patterns constitute a central factor determining demographic shifts within a population. Broadly speaking, migration occurs when people move from one region to live in another for extended periods. This movement can consist of a permanent relocation; however, it often involves temporary or cyclical relocations, such as when farm workers return to a country seasonally for harvests.
Although migration across country borders is the primary focus of this entry, migration within countries is also a signiﬁcant factor – for example, migration from rural to urban regions. Additionally, although migration activities can overlap with travel for tourism, migration is typically understood to be motivated by economic beneﬁts, political security, the desire to reunite families, or for other considerations that are not primarily leisure oriented. To reﬂect this common usage, this entry will focus on relocation activities that are not primarily motivated by leisure (thus, not tourism per se) and that are for longer periods (thus, not “business trips”).
There are several key terms used throughout this entry, as well as in the literature, that are useful to deﬁne up front for future reference. Country of origin will be used to refer to the country that is considered the initial home of the migrant – whether by birth, citizenship, or residence; destination country refers, conversely, to the country to which the migrant relocates. While these concepts do not apply cleanly in many cases – for example, when people move sequentially from one country to another in multiple steps – they are useful terms for framing important issues in the literature.
Economic factors are strong motivating factors in migration trends, such as the relocation of workers (skilled or unskilled) for employment, or the movement of retired people to countries where their pensions have greater purchasing power; however, other key motivations include (but are not limited to) political tensions or persecution, ecological devastation, and cultural factors such as linguistic similarity or religious afﬁliation. Push factors are traits attributable to migrants’ countries of origin that motivate their relocation, whereas pull factors are traits in the migrants’ destination countries that attract them abroad. An illustration of a push factor is when migrants are motivated to emigrate due to unstable political circumstances in their countries of origin, whereas a pull factor can be seen when a migrant’s move is motivated by a desire to reunite with family who have already moved abroad. Push and pull factors, however, are often integrally interrelated, such as when the economic opportunities in a destination country are good relative to those available in the country of origin.
Four aspects of migration receive special attention in the literature due to the roles they can play in understanding the causal and ethical implications of various migration trends: diaspora, remittances, brain drain, and migration chains. Diaspora refers to the dispersed peoples of a particular population, identiﬁed, for example, by ethno-cultural historical unity or by the nation of origin. Remittances refers to the funds that migrants earn while away from their home populations and which they send back to their countries or communities of origin – often to support family. These are important because remittances can comprise not only a signiﬁcant proportion of a family’s income but also of the gross domestic product of countries like Thailand or the Philippines where migration abroad for work is common.
Brain drain refers to the migration of skilled workers, and it is of particular interest to migration studies due to the role that this could play in undermining economic growth and development efforts in countries of origin. This leads to a fourth important consideration – migration chains. Traditionally, migration chains referred to observed migration patterns wherein family members from a particular country of origin follow one another to a new destination country, often to the same city and sometimes over many years, for example, thus making it signiﬁcant in understanding patterns in the global diaspora of various populations. Recently, however, this term has been used to refer to a cascading effect of brain drain, whereby skilled migrants from one destination country are replaced with skilled migrants from others, and so on; the main concern here being that the countries of origin at the ends of these chains are left without the ability to sustain the labor supply in the affected sectors. This is returned to shortly in discussion of the migration of health-care workers.
Health-Care Received By Migrants
As a means for keeping this entry focused on the bioethical issues raised by international migration, the following sections discuss how international migration can alleviate or exacerbate the vulnerabilities to which various parties are exposed with respect to their need for, their access to, and their provisioning of health-care.
Migration brings both opportunities and costs when it comes to health and medical care. Migrants often face greater challenges in obtaining proper health-care than the native-born citizens of their destination countries. For undocumented workers or migrants working in vulnerable temporary employment, the threat of potential job loss or deportation can be a powerful disincentive for seeking medical care for preventative or even acute conditions (Kuczewski 2012). Many migrants are in intrinsically vulnerable positions, having left behind possessions, professions, and family and community support networks, and they often face high degrees of uncertainty regarding the political status or protections that they might be able to access abroad.
This is especially problematic for those whose push factors are the most extreme – such as to evade the hardships of war or political or religious persecution – but it is also true for many economic migrants. Consequently, migrant groups are often more susceptible to diseases of poverty, to chronic diseases, and to illnesses associated with the vulnerable labor, which is often the only work available to them. It also leaves them vulnerable to exploitation by employers. Migrant sex workers, for example, are particularly vulnerable to health problems associated with sexually transmitted infections such as hepatitis and HIV/AIDS; in addition, it is difﬁcult to collect reliable data on this group due to the vulnerability of these workers to abuse and prosecution. From the perspective of justice and fairness, therefore, migrants are often at a disadvantage compared with native-born citizens in destination countries when it comes to health and health-care.
The threat of infectious diseases can also have a negative impact on migrant populations. Whether motivated by legitimate public health concerns or by unfounded public concerns regarding unlikely epidemics, infectious diseases such as SARS, HIV/AIDS, and Ebola come to be associated with particular countries or regions where the infections originate or where they are particularly virile, and by extension to socio-ethnic minority groups in destination countries. This can lead to further social stigmatization and xenophobia toward members of these groups.
Additionally, health-care workers in destination countries have been facing challenges in delivering medical care in the multicultural setting that results from migration events (Macklin 1998). For example, autonomy has become a pillar of bioethics in “Western” countries, and medical training of physicians and nurses emphasizes the importance of soliciting the opinions of, and respecting the wishes of, patients with respect to their treatment options. When patients are from other cultural settings, however, they can express a different valuation of autonomy – for example, some family members might assume decision-making in health matters over other family members – which can make it challenging for health-care workers to obtain from patients the level of informed consent prescribed by their training and institutions.
To illustrate, consider a hypothetical family that has emigrated from South Korea to the USA where the grandmother has been diagnosed with terminal cancer. The woman’s son and daughter in-law insist that the medical team not share news of the prognosis with the patient – a preference that is consistent with empirically studied attitudes of Korean Americans toward patient autonomy. This, however, runs contrary to the training of the medical team, for whom best practices dictate that the patient herself ought to be informed of her status so that she can make optimal decisions about her care that are based on her values and desires.
For another illustration, the modiﬁcation of genitals in female children is a practice that occurs in some African populations, although the nature and degree of modiﬁcation varies broadly. When families from these communities seek similar procedures after migrating to European or North American countries, however, they can face strong resistance from women’s rights groups, medical professionals, and political institutions – something that can seem at odds with the common acceptance of circumcision in male babies, of adult genital modiﬁcation, and of other forms of plastic surgery in those same destination countries.
While this section has focused primarily on the challenges facing migrants and their health-care providers, migration also offers positive opportunities and beneﬁts as well. For example, since wealthier countries often (though not always) have better equipped and serviced health-care systems than less wealthy countries, when people migrate to the latter from the former, they can beneﬁt from this; even if they have less access to medical goods and services and experience greater exposure to work-related harms, this can still be an improvement over the health-care related opportunities and risks they would experience in their countries of origin. Additionally, due to the family and community ties maintained by migrants to their countries of origin, migration can have positive cultural spillover effects – sometimes referred to as cultural remittances – for countries and communities of origin, such as enhancement of women’s autonomy (Skeldon 2013).
Furthermore, the citizens and health-care systems of destination countries can reap signiﬁcant beneﬁts when the migrants are themselves healthcare workers, such as physicians and nurses. The next section focuses exclusively on this phenomenon.
Health-Care Provided By Migrants
Some of the bioethical issues raised by migration are related to the impact of the migration of health-care workers. From a global perspective, the distribution of health-care workers such as doctors and nurses does not match the distribution of human populations; rather, richer countries tend to have a signiﬁcantly higher ratio of health-care workers to population size than less wealthy countries. This discrepancy is particularly stark when taking into account the fact that the less wealthy countries often have a much more acute set of public health-care priorities than wealthier countries.
Exacerbating this challenge is the phenomenon of health-care worker migration. Many countries are facing a brain drain in the health professions, with doctors and nurses who are trained domestically later deciding to move abroad (Crozier 2010). Pull factors can include higher remuneration and better working conditions, with common push factors involving lower pay in source countries and, ironically, stafﬁng shortages that can overload health-care workers if they choose to work in their countries of origin. The distribution of health-care workers within source countries also exacerbates this, with a similar shortage of physicians and nurses being observed in rural as opposed to urban areas.
One aspect of this phenomenon of health-care worker migration is the formation of “chains of care” whereby workers sequentially move from one country to an increasingly wealthy country – for example, from a sub-Saharan African country to an Eastern European country, to Canada, and then to the USA. Along the way, a nurse might, for example, upgrade his or her professional proﬁle through additional training and certiﬁcation or work experience, making him or her more marketable in the next country in the chain. The USA is often the ultimate destination country in these chains, with a seemingly bottomless need for health-care workers to service an increasingly aging and highly medicalized population.
Not only has this migration of health-care workers made it challenging for sufﬁcient basic medical care to be available to the citizens of source countries, in some cases it has also undermined the ability of these countries to renew their supply of health workers. In the Philippines, for example, the high demand for nurses abroad – and in particular the mostly highly skilled nurses who are best qualiﬁed to serve as educators – has left the country with a shortage of nurses capable of training further nurses. The demand is so high for nurses, in fact, that physicians are seeking to retrain as nurses – known as nurse medics – for the higher paying employment opportunities then available to them abroad.
This raises a variety of ethical questions: for the countries involved, for the workers, and for those employing or being cared for by them. For example, do destination countries for migrant health-care workers have a responsibility to curtail policies and practices that pull these workers abroad? Do health-care workers have a duty to stay within their countries of origin, if not permanently then at least until the investment that country has made into their education is paid off (Snyder 2009)? Does mainstream contemporary bioethics, with its emphasis on patient autonomy, have the right conceptual tools to properly evaluate the ethics of migration, or is it necessary to develop other conceptual lenses with a greater focus on solidarity (Eckenwiler et al. 2012), care (Crozier 2010), and social interconnectedness (Crozier 2009)?
The health-care workers themselves are often exposed to the same vulnerabilities as are faced by other migrant workers, but experience additional ones as well. For example, they are often overqualiﬁed for the positions they are able to obtain, they can ﬁnd themselves working in less professional settings: nurses might ﬁnd themselves working as home care aids in destination countries, under employment conditions that are less regularized, more isolated, and more vulnerable to employer abuse. If they become ill or pregnant, they can be forced to return to their countries of origin without an opportunity to recover and return to work. It is important to note the association between health-care worker migration and the feminization of migration whereby an increasing proportion of migrant workers are women. Many female migrant nurses, for example, become the primary wage earners in their families, but are required to leave their own families and growing children behind while they work abroad.
As this entry outlines, there are many ethical challenges raised by migration. It is important to note, however, that while it brings challenges to governments, migrants, health-care workers, and policy makers, it brings opportunities as well. For example, while health-care worker migration is often a burden for the countries of origin, this is a trend rather than a rule. Some countries have been able to take advantage of the global shortage of care workers by speciﬁcally training physicians and nurses to provide care abroad. Cuba, for example, has been training doctors from Cuba and elsewhere with the objective of bolstering public health-care in under-serviced communities domestically as well as abroad. On a different model, India has been positioning itself as an exporter of care workers to English-speaking countries such as England and the USA. Hospital twinning, rotational migration, and other mechanisms exist for increasing global ﬂow of care workers and transmission of expertise without permanently draining some countries of their health-care resources for the beneﬁt of other countries.
- Crozier, G. K. D. (2009). Agency and responsibility in health worker migration. American Journal of Bioethics, 9(3), 8–9.
- Crozier, G. K. D. (2010). Care workers in the global market: Appraising applications of feminist Ethics of Care. International Journal of Feminist Approaches to Bioethics, 3(1), 113–137.
- Eckenwiler, L., Straehle, C., & Chung, R. (2012). Global solidarity, migration and global health inequity. Bioethics, 26(7), 382–390.
- Kuczewski, M. (2012). Can medical repatriation be ethical?: Establishing best practices. American Journal of Bioethics, 12(9), 1–5.
- Macklin, R. (1998). Cultural relativism in a multicultural society. Kennedy Institute of Ethics Journal, 8(1), 1–22.
- Skeldon, R. (2013). Global migration: Demographic aspects and its relevance for development (Technical paper No. 2013/6). New York: United Nations, Department of Economic and Social Affairs, Population Division. Available at: http://www.un.org/esa/population/ migration/documents/EGM.Skeldon_17.12.2013.pdf. Accessed 11 Dec 2014.
- Snyder, J. (2009). Is health worker migration a case of poaching? American Journal of Bioethics, 9(3), 3–7.
- Daniels, N., & Ladin, K. (2014). Immigration and access to health care. In Routledge companion to bioethics (pp. 56–68). London: Routledge.
- Kaelin, L. (2010). A question of justice: Assessing nurse migration from a philosophical perspective. Developing World Bioethics, 11(1), 30–39.
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