The “brain drain” problem: Migrating medical professionals and global health care
The global migration of physicians and nurses produces serious shortages in the developing world, exemplifying one of the ways that global capitalism sets up dynamics of surplus extraction from periphery to global wealth centers. This paper focuses specifically on the Ghanaian situation, and argues that an ethics of care framework offers a way of approaching the problem productively. Recognizing the various commitments and relationships that tie us together allows for a response that protects individual freedom while responding to the need to maintain adequate numbers of trained health-care workers.
Brain drain, the migration of skilled labor out of less-developed countries, is an especially acute problem in the medical sector. Countries in the global South face enormous shortages of health-care workers. The most direct solution, to train more doctors and nurses, does not solve the problem because so many of those who are trained move to the global North to take advantage of higher [End Page 1] salaries and an improved standard of living. Because we live in a world with porous boundaries and integrated economies, it is incumbent on us to think through questions that arise because of structural factors that benefit the already wealthy and developed economies at the expense of impoverished and struggling economies. Medical brain drain represents an enormous transfer of wealth from the global South to the North. Unfortunately, standard ways of framing a response to this issue tend to be relatively toothless, in part because they rely on a heavily individualistic, economic picture of human lives.
In this essay I set out the details of the situation briefly, noting the nature and extent of the problem as it arises in the particular context of Ghana. Ghana represents a relatively clear case of brain drain without the added complicating factors of civil unrest, war, or religious tension. When countries struggle with civil war for decades, or with intractable religious conflict, other questions generated by migration policy become more fraught. But Ghana is a country that, in many ways, is an African success story: it has been relatively stable politically since the 1980s, has a growing economy, is religiously tolerant and open, and has a functioning democratic political structure. In this context, issues such as the loss of medical professionals whose education has been underwritten by the citizens of Ghana as a whole take on weight. Ghanaian professionals are not leaving out of fear for their very survival, but purely for the sake of the better opportunities they can find elsewhere.
After noting the nature of the brain-drain problem, I examine the two main responses generally offered in the international context, which I characterize as the libertarian and the liberal approach. Neither of these has produced adequate solutions to the brain-drain problem to date, in part because each operates within the framework of a two-place ontology of the political that limits our analysis to the levels of state and individual. Because both work within a framework that pits individual interests against state legislative action, the policy proposals they have produced are limited in their effectiveness. Ghanaian society is marked, among other traits, by a deep and abiding concern for communal and social values, and if we begin with that perspective, working within a framework provided by an ethics of care, we can offer supplements to existing policies, or additional policy options, to increase the effectiveness of responses to brain drain.
An ethics of care has been extensively developed by feminist theorists, and in the interest of space I will not reiterate these accounts here.1 But I do want to note the two aspects of an ethics of care that I will be drawing on most heavily. The first is the notion of particularity, and of the need to be attentive to particular [End Page 2] circumstances and contexts. The notion of cultural particularity needs to be kept in the foreground within the context of international policies. When working at the policy level, one works within a framework that requires abstract-principles-style reasoning, which can obscure the relevance of particularity. Rules and principles are of vital importance in the international context—I am not arguing against them—but it is also vital to remember that cultural contexts are important and are not extraneous to our ethical deliberations. Particular cultural factors in Ghanaian society offer possibilities for addressing brain drain that would increase the effectiveness of some current policies.
The second feature of an ethics of care is the notion of attentiveness to relationships of care, and to the social structures that support and enable them. Again, when thinking about international issues, it is easy to see a need for structures of justice. But that focus on abstract justice can obscure the need for a concomitant focus on relationships of care. In the context of this topic, that revised focus helps us think outside some of the boxes that tend to constrain reflective deliberation.2 Relationships of care tend to be healthiest, all things considered, when power is diffuse and shared, rather than consolidated in a hierarchy of top-down authority, and this again suggests that policies addressing brain drain may need to incorporate alternatives to the current set of social structures that have given rise to the problem in the first place.
Before I turn to the question of how an ethics of care might help us think through the issues of brain drain, however, it is a good idea to get a sense of the magnitude of the problem as well as provide a brief overview of some proposed resolutions currently under consideration. I then turn to an ethics-of-care analysis, and finally conclude with general comments about care and the cosmopolitan tradition in political theory.
The brain-drain problem
It is estimated that slightly more than one-quarter of physicians in the United States are foreign trained; numbers are slightly higher for the United Kingdom and Ireland, and are slightly lower in Australia and Canada. The numbers have fluctuated slightly over the past few decades, reflecting general patterns of migration for highly skilled workers, but between 2001 and 2008 the trends were upward in all countries in the Organisation for Economic Co-operation and Development (OECD 2010, 2). The percentage of foreign-trained nurses is a bit lower, though it is as high as 47 percent in Ireland, and as low as 3 percent in Sweden. Globally, the trend has been upward for both doctors and nurses in [End Page 3] recent years, especially in countries with immigration policies that favor skilled over unskilled labor immigration (Brush, Sochalski, and Berger 2004).
Immigration of health-care professionals has been on the increase in part because of a combination of demographics (aging populations, in particular) and the limited numbers of physicians and nurses trained in any given year.3 Although both the United Kingdom and the United States are currently increasing available positions in medical and nursing schools, both countries are dealing with a decades-long policy of severe restrictions on positions, especially in medical schools, that have produced a net shortage of medical professionals (AAMC 2010). Wages are thus high and demand is strong, factors that increase the numbers of foreign-trained professionals working in these countries.
As long as we focus on the situation in countries that are relatively well-off, these statistics seem unproblematic. The United States, for example, has been able to deal, in the short run, with a shortage of physicians by implementing immigration policies that encourage migration, and this serves as a stopgap measure while medical schools gear up to expand their numbers. That is how global economic markets work, and it seems relatively unproblematic, especially since those immigrating do so because of attractive wages and lifestyle opportunities. Further, since the movement of medical professionals occurs as a result of individual freedom, it also seems a morally unproblematic exercise of personal choice.
The issue begins to look morally problematic only when we expand the range of our vision to include the countries of origin for migrating medical professionals. In some cases, those countries have a policy of training professionals in numbers greater than the expected demand, and the out-migrations do not result in shortages at home. The Philippines, for example, exports large numbers of nurses, but for many years had adequate numbers who stayed in the country. In recent years, however, even that country has seen such large numbers of nurses leaving to work elsewhere that the nation’s health-care system is at risk (Aiken et al. 2004; Prystay 2002; Lorenzo et al. 2007). The situation is far more dire in many sub-Saharan African countries (Buchan and Calman 2004). Although I am specifically considering the case of Ghana, similar situations (or worse) characterize many other African countries: Mozambique, Liberia, Sierra Leone, and Angola, as well as several of the francophone countries (Naicker et al. 2009).
Medical professionals are in short supply in Ghana. It is estimated that the country has about 13 practicing physicians and 92 nurses per 100,000 population (for a grand total of approximately 2,600 physicians in the entire country) (Mullan 2007, 441). By comparison, the United States averages 256 doctors and [End Page 4] 937 nurses per 100,000 population (US Census Bureau 2008). The United Kingdom and the United States together had just under 800 Ghanaian doctors in 2007—a number that represents only a miniscule percentage of the workforce for the wealthier countries, but close to a quarter of the physicians trained in Ghanaian medical schools (Mullan 2007, 440). The numbers for nurses are similar, though a larger percentage of them immigrate to Britain rather than the United States (Aiken et al. 2004).
Meanwhile, Ghana struggles with the provision of health care. Although it is a good deal more stable, both politically and economically, than many other sub-Saharan African nations, progress on basic health indicators in Ghana has been fitful. According to the World Health Organization, infant mortality rates were lowest in 2003 (64 per 1,000 live births) and have subsequently crept upward (71 in 2006). While Ghana has been instituting reforms aimed at increasing the wages of health-care professionals and extending coverage into rural areas, the system remains prone to corruption, bribery, and fraud (Lewis 2006, 24; ACCORD 2009, 17). Payments from the government remain unreliable, and even when treatments are available at no or low cost, the social stigma associated with certain diseases (TB and HIV/AIDS, for example) produces low compliance rates (ACCORD 2009, 8). Sanitation-related diseases remain one of the most significant areas of concern; one study noted that between 80 and 90 percent of the urban poor lack access to adequate sanitation, and rates are similar in rural areas (Freeman 2010, 48). In spite of these challenges, Ghana has moved to institute a National Health Insurance scheme, which has the potential to make basic care affordable for larger percentages of the population (Wahab 2008).
In the context of these numerous challenges, the flow of professionals from Ghana to higher-income countries poses a serious problem. Citing a report offered by Physicians for Human Rights (PHR), one researcher notes that “Ghana currently has only about half the nurses it had in the mid-1980s, when its population was only half of what it was in 2008.” “In 2002,” the report continues, “along with 70 physicians and 214 nurses, Ghana lost 77 pharmacists to other countries. The retail giant Wal-Mart is reported to be recruiting pharmacists from sub-Saharan Africa and India to work their Canadian stores” (Salisu and Prinz 2009, 23). In addition to the costs in terms of national health and lack of access to health care, countries like Ghana face heavy educational costs, provided at the country’s expense and then lost to out-migration. One study noted that between 1986 and 1996, Ghana lost an estimated U.S. $5,960,000 in tuition costs alone from graduates of just one medical school (Dovlo 2003, 5). These [End Page 5] numbers have not decreased since then, and it is heavily ironic that in a world in which most of us assume that financial assistance flows from countries like the United States to countries like Ghana, there are significant economic subsidies flowing in exactly the opposite direction (Hagopian et al. 2005, 1758).
Proposed solutions: A (very short) spectrum from liberals to libertarians
Most of the proposed solutions to the problem of brain drain can be categorized reasonably well into either a liberal or a libertarian framework. Liberal solutions tend to rely heavily on action by the state, either through increasing or decreasing the costs or benefits of particular actions in order to motivate individuals to act in desirable ways, or through changing legal policies to control individual behavior. Libertarian responses place a much heavier emphasis on preserving economic freedom and call for state noninterference in economic decisions, frequently focusing on the benefits such freedom offers.
The first and most obvious response to brain drain is to increase the number of seats in medical school. It seems straightforward that educating more physicians will result in larger numbers overall, even if the percentages of those leaving do not change. Along with other sub-Saharan countries, Ghana has also utilized Cuban medical corps to mitigate the shortfall of medial professionals (Hagopian et al. 2005, 1757). To this point, however, expanding training capacity has not been an effective solution. Given disparities in population sizes between a country such as the United States and one like Ghana, the size of the physician shortage, along with higher wages and better working conditions, represents too large a pull factor for an increase in numbers to effectively counter (Vujicic et al. 2004). Larger countries can attract Ghanaian doctors as quickly as they are trained. Further, training larger numbers increases the economic costs to Ghana, and may, in fact, exacerbate infrastructure problems if training larger numbers of students results in poorer quality overall (Dovlo 2003, 7). Other than pouring yet more water into an already leaky sieve, what other options are there for addressing the outflow of trained medical professionals?
Brain drain is usually analyzed in terms of push-and-pull factors—push refers to the conditions in the country of origin that drive individuals out (low wages, political instability, lack of access to adequate resources), whereas pull refers to conditions outside the country that attract immigration (higher wages, better working conditions). Most analyses of brain drain focus heavily on such [End Page 6] factors (for obvious reasons) and attempt to adjust them where possible to make retention in the country of origin more likely.
Solutions generally address either the “push” or the “pull” factors, and focus on either individual physicians or state-level policies. In the push category, countries like Ghana try to change the low levels of pay and heavy work schedules that make many doctors eager to leave. Unfortunately, even though Ghana has attempted to increase levels of pay for physicians, they remain extremely low, and attempts to increase total reimbursement by providing additional allowances to Ghanaian physicians have generated criticism from the IMF because they represent governmental intrusion into the market (IRIN 2003). Work levels are even more recalcitrant than pay levels, since the physician shortage produces huge demands on medical professionals, especially in rural areas. Until there are larger numbers of physicians, it will be almost impossible to lower the demands made on them for extremely long hours and heavy workloads (Martineau, Decker, and Bundred 2004).
An example of a pull factor is language. Medical education in many developing countries is carried out in a language that has global currency, such as English. Some countries faced with brain drain have switched the language in which they train professionals; Thailand, for example, saw rates of emigration diminish when it began teaching entirely in Thai (Dolvo 2003, 7). This would be more difficult to do in Ghana, however, since English is the official language. (There are a number of local languages, but there is no single language that most Ghanaians speak other than English. More than this, it would be politically difficult to choose one language over another for medical training.)
Other pull factors have been addressed in a variety of ways, usually by policies that can be categorized relatively straightforwardly as standard liberal responses. One proposed response to the pull of higher wages has been to impose a bond system or a compulsory service component to medical education. In the ideal case, compulsory service results in a significant number of professionals choosing to remain after their service time is completed. Including a financial penalty for professionals who leave also allows the origin country to recoup some of the costs of education. As an alternative to financial penalties, some countries delay licensure until the professional has served in the country for a specified period of time. These policies all target the incentives the individual has for remaining or migrating, with the expectation that rational individuals will adjust their behavior in response to these changes—an expression of classic liberal reasoning. [End Page 7]
Implementation of such a system in Ghana has not been successful, however, for a variety of reasons ranging from the difficulty of tracking debtors (especially in the context of a culture of corruption) (Dovlo and Nyonator 2003, 12), to the fact that bonding is not practiced with other advanced degrees, so imposing it in the case of medical degrees is considered unfair (Hagopian et al. 2005, 1757).
Another liberal policy proposal has been to create different licenses for different contexts in order to make emigration more difficult. Proposed changes include creating a separate medical degree that requires a shorter time of training, with heavy emphasis on generalist training, or authorizing health-care workers (usually nurses) to go beyond their normal range of tasks to take on jobs that are traditionally relegated to doctors. Analyses of these tactics again suggest that they have been less than successful, though the results vary from country to country (Bourgain, Pieretti, and Zhou 2009). Proposals for such licensing systems have met serious resistance in Ghana, in part because medical educators see the high percentages of their graduates who emigrate as a matter of prestige and in part because reduced training for Ghanaian medical professionals might imply that Ghana does not deserve the same level of medical care as other regions (Hagopian et al. 2005).
Finally, there have been occasional attempts to generate international agreements that would hamper migration; some countries have tried to generate treaties that would make work visas much harder to obtain for medical professionals. Not surprisingly, given the shortage of doctors and nurses in wealthier countries, these treaties have not been easy to negotiate, and, again, the effect has been relatively small. The most promising effort in this regard has occurred in the United Kingdom, with the development of the Commonwealth Code of Practice for International Recruitment of Health Workers. It prohibits recruitment of nurses from Africa by the NHS, but compliance by private firms is voluntary. The code places the responsibility for disclosing outstanding contracts on the individual wishing to emigrate. It affirms the responsibility of the receiving country to provide compensation to the sending country either by providing transfers of technology, skills, and technical assistance, or by enabling emigrants to return with enhanced skills and training. Again, however, compliance is voluntary. While the numbers of Ghanaian nurses entering the UK workforce have diminished somewhat since the adoption of the code (OECD 2010), in the words of one recent study, “the code has not adequately addressed the human resource gap caused by nurses migrating from Ghana” (Anarfi, Quartey, and Agyei 2010, 4). [End Page 8]
The solutions mentioned so far fit easily into a basic liberal framework of responses to political problems. They frame the issue as one that balances protection of individual rights and concerns about the general good, and attempts to resolve the problem of brain drain in ways that maintain individual freedom while modifying incentive structures or regulatory protocols in order to make it easier for the sending countries to keep doctors or diminish the pull of receiving countries. Both individual freedom and the public good are, of course, important considerations, but the solutions have been relatively ineffective so far, which suggests that we may need to expand the framework of our thought on this issue. One alternative to these standard liberal solutions is offered by libertarian thinkers, who argue that the problem is not brain drain, but rather the belief that emigration of health-care workers should be regulated.
Economic libertarians argue that countries like Ghana should not try to slow the movement of medical professionals (Easterly and Nyarko 2009; Record and Mohiddin 2006). Their argument depends on an analysis of the economic benefits generated by out-migration, and generally relies on the libertarian assumption that state intervention into economic systems is the problem, not the solution (Glavan 2008). Remittances account for a large component of Ghana’s national economy, as medical professionals practicing elsewhere send money back home to their families. Remittances to sub-Saharan African countries were estimated to be over $4 billion a year in 2003, a larger amount than global development aid. They are also a more stable source of income, providing a healthy annual growth rate of about 5 percent (Quartey 2006, 8).4 This flow of capital back into the economy generates both tax revenue (remittances that pass through banks are taxed on their way into the country) and a healthier economy overall, due to the increased available funds circulating in the economy.
In response to the language of brain drain, some libertarian economists have also proposed that a counterforce they call “brain gain” must be taken into account, in addition to the positive effects of remittances. Brain gain refers to the increase in expected return on education, raising the overall value of education sufficiently to offset brain-drain losses and produce an overall increase in welfare and growth in the sending country (Stark 2004). By making education more valuable, the argument goes, exporting skilled labor increases the motivation for (and willingness to invest in) education, which produces major benefits for the sending country that offset the costs of brain drain.
Both arguments that I call libertarian take as a given that brain drain will occur, though both also argue that there are hidden benefits (reminiscent of the [End Page 9] invisible hand) that generate sufficient overall good to outweigh the costs of brain drain. From a libertarian perspective, these are crucial arguments, since libertarians generally reject government intervention into individual economic decision making, and are committed to the claim that the rejection of intervention will ultimately generate optimal economic growth and distribution.
These examples of liberal and libertarian responses to medical brain drain both adopt similar assumptions about what values need to be protected and what trade-offs are possible for responding to brain drain. Both liberals and libertarians recognize the value of individual liberty and choice, and both recognize that public welfare matters. Obviously, they differ in how they evaluate the trade-offs involved in managing these values, and in their predictions about which policies produce the best outcomes, but the general agreement at the level of these values is clear.
In terms of policy solutions, on the liberal side there are attempts to restructure social and political structures to manage individual choices and steer them in the right direction. These arguments can easily take on a patronizing tone, as in debates about policies for changing licensure. This tone is not lost on the citizens of the sending countries who resist the notion that partially trained doctors are “good enough” for an African context (Hagopian et al. 2005, 1757). On the other side, in a libertarian mode, the emphasis is less on “managing” individual choice. Instead, libertarians focus on protecting individual freedom and argue that maximizing freedom will generate a corresponding maximization of social goods.
So both liberals and libertarians frame the issue of brain drain as one that involves some sort of relationship between individual liberty and the public good. They advocate opposing sets of policies because they adopt different sets of assumptions about how social structures work. Liberals advocate restructuring licensure or restricting entry visas for skilled workers into wealthy countries. These policies attempt to limit individual freedom in significant ways, and the limitation is one that is targeted—that is, it is directed at diminishing freedom and trying to force the individuals in question to conform to what the theorist wants them to do. From a liberal perspective, the assumption is that these limits on personal freedom are sufficiently small as to be outweighed by the overall benefits.
Libertarians, on the other hand, start with the assumptions that any diminishment of personal (economic) freedom is ethically unacceptable (though some restrictions may be justified to avoid harm to others) and that limitations on economic freedom will have detrimental effects on the common good over time. These assumptions lead libertarians to focus on the benefits that accrue [End Page 10] to remittances, which are important and vital. But they ignore the specific problems identified by the liberals: the problems of a hugely detrimental shortage of doctors and nurses that contributes to serious and intractable health problems in Ghana’s population. Remittances tend to be funneled through family connections, and the families of those who have gone to medical school or been licensed as nurses are statistically unlikely to be the rural poor (or the urban poor, for that matter). Remittances thus do enter the economy, and that is a good thing, but they hardly outweigh the serious effects of an inadequately staffed health-care system, nor do they outweigh the general drag on the economy caused when a significant percentage of a country’s highly educated classes choose to emigrate, and they certainly do not measure the imbalances created by the way remittances flow back primarily to those who are already the privileged in society (Clark, Stewart, and Clark 2006). Given their willingness to count remittances as morally valuable, the libertarians’ blindness to other countervailing costs is problematic, as is their unwillingness to consider issues of distribution, not just overall economic factors.
Thinking otherwise: Care and commitment
Modern ethical and political deliberation frequently frames questions in terms of abstract categories such as those of state and individual. Once such categories are set up, they take on a life of their own in our reasoning: state and individual, for example, are framed as oppositional and non-coextensive categories, so that one or the other acts in ways to respond, control, and/or limit the other. This makes us forget, of course, that the state is made up of individuals so that its flourishing cannot occur in isolation from the well-being of the individuals who make it up, and that the individual is a member of the state and has both economic and existential connections to it. But worse than this tendency to make binaries into exclusive categories is the tendency to erase all the mediating institutions that stretch between state and individual, from families and kinship groups, to communities of shared interests, to religious networks, to institutional structures, and so on. Mediating institutions of this sort play an enormous role in our lives in the real world, but tend to disappear off the radar screen when we think about public-policy matters.
One strength of an ethics-of-care analysis is that it redirects our attention to the particularities of a given situation (Raghuram 2008; Robinson 2006). Brain-drain issues involve more than just abstract individuals who are all substantially identical, rational egos making economic calculations about situations [End Page 11] impacted by costs and benefits imposed by abstract state institutions. Ghanaian medical students occupy different social situations than do, say, Thai medical students; networks of already migrated Ghanaian physicians play a different role in New York City than in Iowa, and so on. While it can be helpful to examine the situation at a very high level of analysis, it is also important to note that individual cases may exhibit specific features that make generalized solutions ineffective, as they have proven to be in this particular case.
While it is obviously impossible to resolve all of the complexities of the issues of migrating health-care workers in a brief analysis such as this, I believe that a number of features of care theory offer important resources for how we frame and debate the issues involved. Two considerations seem particularly salient: an ethic of care’s emphasis on particularity, and the need for an analysis that focuses on structures of care that are relevant to the issues at hand. Two possible polices start from a recognition of the particularities of Ghanaian culture and the social structures and relationships that might offer resources for changing the current situation.
Mediating institutions play an enormous role at both ends of the brain-drain pipeline. In Ghana, educational institutions, medical clinics, the families of students working toward their licenses, and a range of other institutions (extended kinship structures; churches, mosques, or other religious organizations, etc.) play a vital role in the decisions that individuals make about emigration (Hagopian et al. 2005; Akurang-Parry 2002). At the other end, countries such as the United States have systems of medical education structured to keep physician wages high (AAMC 2010), an aging population increasing the demand for medical services, insurance companies and government agencies trying to restrict cost increases, state and federal government agencies setting immigration policies, and so on (Maru 2008). These create very complicated webs of formal and informal relationships, some regulated by laws and policies, others generated by family relationships, and still others governed by informal (but still very rigid) traditions and historical practices.
It is worth considering how some of these mediating institutions play a role in the structure of the current situation. When individuals attend medical school and then emigrate, the financial benefits (in the form of remittances and the like) of their actions provide a very strong incentive for their families and close relatives to encourage them to remain abroad. While the costs of their education, like those of most medical professionals, are shared by society at large, the benefits are concentrated in certain families, often wealthy ones (deHaas 2007). [End Page 12]
One cannot address this issue without a more fine-grained analysis than most libertarian economic analysts are willing to give. It is not enough to note that wealth returns to a country via remittances; one also needs to note where that wealth enters the country, who has access to it and who doesn’t, and so on. Further, libertarian analyses tend to limit themselves exclusively to economic costs and benefits, as if these are the only factors that affect human motivation. But Ghana is a culture where one’s reputation, family connections, and social standing are at least as valuable as economic wealth (Hendricks 2000). In a relatively small country where people identify themselves by the village(s) their parents are from, and where they return every holiday, honor and the family name occupy a very different place than they do in a large, relatively anonymous country like the United States. These are also factors obscured by liberal assumptions about individuals functioning as isolated units, rather than as enmeshed subjects intricately connected to vital social networks. They are the sorts of features of a situation that appear when we begin to pay attention to the particularities of an individual context.
When we turn to the actual lives of people in the particular situation upon which we are focusing, it becomes apparent that since reputation matters, reputation might be an issue worth exploring in relation to brain drain. Wealthy families with members who attend medical school in Ghana but practice abroad could be held publicly accountable for their choices in any number of ways. Techniques that honor medical practitioners who remain in Ghana and that identify those who choose to leave might prove effective in slowing the flow of professionals out of the country. This is a particularly acute consideration, given that current cultural forces in medical schools in Ghana encourage a culture of medical migration, and medical school faculty are proud of their students who emigrate (Hagopian et al. 2005, 1755). Changing these cultural expectations requires framing exit as a problem rather than a practice to be celebrated.
In a Western context, a reader’s individualistic, privacy-oriented hackles are likely to be raised by the suggestion that public shaming techniques might be appropriate. Resistance to any publicity campaign or the use of shaming as a method for changing individual behavior is particularly strong in the Western medical context because of the strong ethos of confidentiality in health care. But paying attention to particular cultural contexts requires theorists to be reflective about their own cultural biases. Western patterns of privacy need not automatically be transferred to non-Western contexts; what is needed is careful thought about when and why shaming techniques are morally problematic. [End Page 13]
Western feminists have worked hard and long to fight against shaming techniques that are used to keep marginalized groups out of positions of power. The example of legally protecting rape victims from having their sexual histories become the subject of scrutiny in court is an obvious example; numerous other examples exist (Orenstein 1998). In their analyses, feminists have recognized that the standard dynamics of shaming often serve the purpose of maintaining power structures: less-powerful people are often shamed to reinforce power dynamics, while the powerful frequently are either protected from shaming or are treated as somehow not shameful when they engage in the same action that generates shame for the powerless.
Standard treatment of prostitution serves as an obvious example of this dynamic. Sex workers, generally a marginalized group, are considered shameful and problematic. Their clients, generally with more power, are often not prosecuted, and in some cultures are considered more manly for having purchased sex. This offers a classic case of shame functioning to maintain hierarchy. But shame can be used otherwise. Some communities have experimented with publishing the names of men who solicit sex workers, rather than focusing law-enforcement efforts on the sex workers themselves. No studies have demonstrated whether this is more or less effective than other techniques, but it seems less problematic from a feminist perspective simply because of the way it alters the power dynamics of the situation.5
Shaming, then, is not in and of itself absolutely morally wrong, but it seems reasonable to think that there is something about the situation in which it is used that makes it more or less problematic or acceptable. And surely both the cultural context within which it is used and the question of whether it exacerbates or lessens hierarchies of power are relevant to how it should be assessed. Using publicity to identify families and individuals who either contribute to or weaken the social fabric, it could be argued, has the potential to hold those in power accountable and so may be morally acceptable.6
Discussion of this issue also helps alert Western moral theorists to some of the ways in which our own cultural biases, good in their own context, may become blind spots when exported to another cultural context. Whether or not shaming techniques would work, and whether they would be morally acceptable, may be determined in large part by the cultural context within which they occur, and an automatic rejection of them might be indicative of cultural hegemony of an objectionable sort (Salles 2004). From either a libertarian or a liberal perspective, of course, one might find the use of shaming techniques acceptable, [End Page 14] so one might ask whether raising this issue really represents anything different that a care-ethics perspective might bring to the table. But what is striking in the literature on brain drain is the absence of such culturally situated responses. This does not indicate that a liberal theorist, for example, couldn’t endorse such a response, but it suggests that the framing assumptions within which liberal and libertarian theorists work may be prone to produce blind spots when it comes to such cultural particularity.
A care-ethics focus on particularity, then, calls our attention to the way that various practices might fit into specific cultures, especially ones that do not privilege an anonymous public sphere. But the development of some form of publicity or shaming response to brain drain addresses only the Ghanaian end of the issue, rather than noting that the social structures that fuel brain drain are global in nature. Care ethics calls our attention to the ways that social structures affect relationships of care. One set of social structures obviously relevant to brain drain is the structure of the delivery of medical care, both in Western countries and in the global South.
We can begin with Western medical care, and I will restrict my comments to the situation in the United States. For decades, the medical establishment has encouraged limiting enrollment in U.S. medical schools, as part of a policy of keeping physicians’ wages high. High wages make medical school attractive, and allow the schools to charge higher tuition, since students assume (generally correctly) that they’ll be able to pay off their loans after graduation with their high earnings. But physicians’ wages are not equal across specialties; as a general rule of thumb, the more specialized the area of study, the higher the wages, while the more general fields of medicine (general practitioners, internists, pediatricians) earn much lower salaries. Given the size of student loans, medical students show a decided preference for higher-paying specialties, leaving the United States with a serious shortage of primary care physicians. None of this is particularly startling, of course—critics have been noting this phenomenon for years (Perry 2009; Berlant 1975).
From a global perspective, however, we can now see that policy decisions about enrollment caps in medical schools do not just affect conditions in our own country; they also produce seriously detrimental effects in countries like Ghana. While libertarians have been critical of the licensing monopoly in American medicine, their concerns are generally focused on other U.S. medical practitioners whose practice is restricted by legislation that protects physicians and on the restrictions U.S. consumers face when looking for medical care (Blevin 1995). But analyses of health-care policies need to recognize that [End Page 15] economics do not stop at a country’s borders (Dwyer 2007); in this case, the policies function to extract resources from an already impoverished economy, and to exacerbate an already dire shortage of health-care workers.
I do not think that the situation is best addressed through attempting to resolve wage disparities and physician shortages by setting salaries at a national level or similar top-down techniques. But I do think that from an ethics-of-care perspective, it makes sense to propose policies that respond to professional misuse of power by diminishing the power professionals can wield. The shortage of physicians in the United States has resulted in much wider utilization of physicians’ assistants and nurse practitioners, midwives, and nurse anesthetists who have stepped in to meet some of the needs created by medical licensing policies, and it seems fully in keeping with an ethics of care to support a wide range of professional positions that can challenge the control currently exercised by physicians over health care (Dehn 2010). Democratization of power structures is generally a good thing, to be preferred over alternatives, unless there is good evidence it is harming the capacity to care for the vulnerable.
But what exactly does this have to do with brain drain in other countries? Two considerations, at least, follow from this observation. The first consideration concerns physician control of licensure and the delivery of care. Professional organizations (physicians’ groups, certainly, though the same charge could, of course, be leveled against academics) have traditionally argued for the moral right to determine policies precisely because they claim to use that power for the service of humanity (Cruess and Cruess 2004). When their policies are clearly at odds with the interests of those needing their services, and even more when they result in the exacerbation of already dire health situations in marginalized economies, their claim to be justified in acting as gatekeepers for licensure and providing care is seriously weakened.
In the case at hand, then, there are good reasons for arguing that the United States has a moral responsibility to increase the number of people educated as primary care physicians, and to make access to such an education more widely available. Such a policy would benefit both the United States and other countries. But physicians are not the only caregivers who can provide for people’s medical needs. A second consideration that the perspective of an ethics of care calls to our attention involves examining who else might be able to provide for people’s medical needs.
Utilizing a wide range of professionals offers a better model for provision of care in both the United States and Ghana. Nurse practitioners, midwives, and certified nutritionists all have important roles to play in the delivery of health [End Page 16] care, but to date their utilization has been limited because of the perceived need to have physician control and oversight of all care delivery. Today, however, we have the capacity to do basic evidence-based studies on which conditions need the specialized knowledge developed by physicians, and which conditions can be adequately cared for by practitioners with a much shorter, more accessible period of training; this should permit us to explore options for provision of health care that work outside the tired paradigm of physicians overseeing nurses.
The move to a broader range of professionals providing medical care is a different model of licensure than the technique mentioned earlier—that of changing licensure specifically to prevent professionals from moving easily across borders. As mentioned earlier, I find it unsurprising that those affected by such a policy find it patronizing. But broadening the range of licenses available, making them range from technician licenses that require only minimal schooling, to midwifery licenses that require a longer period of training, while maintaining traditional nursing and physician licensure, allows for more professionals and caregivers to be available without treating any of them with a lack of respect or recognition. This is not a matter of offering lesser care for certain countries; it is, instead, a matter of broadening the range of who can provide medical care, developing more programs that offer a diverse range of specializations, and generally developing diverse networks of care.
The advantage of moving in the direction of a far more diverse set of care providers is not just practical. From a libertarian perspective, such a policy increases consumer choice and limits the ability of any single part of the medical establishment to maintain a monopoly on delivery of medical care. From a liberal perspective, broadening the range of health-care professionals has the potential to increase availability and lower costs. And from the perspective of an ethics of care, such a policy addresses problematic power structures in productive ways. Any policy that can gain the support of a wide range of disparate theorists seems well worth supporting.
On cosmopolitan caring
Standard responses to policy-level questions in the international sphere adopt theoretical frameworks derived from the historically liberal tradition, whether or not they offer specific policies informed by liberal or libertarian sympathies. Because of this framework, the automatic assumption built into any response they offer is that the individual and the state are the two locations where changes can be made, and the interests of the two are inevitably at odds. [End Page 17] These framing assumptions limit our thinking about responses to problems, such as that of medical brain drain, that involve complex relational networks among the various agents involved.
I have argued in this paper that an ethics-of-care approach offers a different framework for addressing issues of this sort, a framework that calls our attention to potential responses that consider the particulars of the social contexts and the relational networks within which the problem arises and persists. The perspective provided by an ethics of care is vital to an adequate global response to the migration of both capital and professionals precisely because it provides a vantage point from which to see the importance of particular mediating structures. An ethics of care also foregrounds the social structures that support (or diminish) caring relationships, a crucial part of any analysis of the global health-care situation. This does not mean that other approaches should be dismissed; it seems much more likely that a range of policies is likely to be more effective used together. Shaming techniques, for example, might make bonding schemes more effective, while diversifying medical licensure could have beneficial effects both in Ghana and in the United States.
As care theorists from Joan Tronto to Virginia Held, Selma Sevenhuisjen to Anne Donchin have argued, the perspective offered by care theory provides an important vantage point from which to develop and critique policies. This is as true at the global level as at the national. Further, the concerns that care theory allows us to recognize and respond to are central to any social structure that aims at enabling people to live flourishing lives. As Margaret Walker puts it, “Care ethics affirms the dignity and profound importance of our efforts to meet human needs, [especially] those needs at stake in conditions of vulnerability that threaten survival or in relations of dependency on which survival and health depend” (Walker 2006, 149). An ethics of care pushes us toward a certain type of cosmopolitanism—a cosmopolitanism that focuses on the vulnerable and on the social structures that either enable or disable their capacity to care for themselves and for their dependents.
But while care pushes us toward cosmopolitanism, it also modifies our thinking about what an adequate cosmopolitanism would have to look like. Cosmopolitans are sometimes accused of being bloodless, uncaring, and distant, and of seeing the world, as it were, from a first-class seat on a transcontinental flight, high above all the day-to-day worries of the “little people.” If that is what cosmopolitanism means, of course, we’d be better off without it. But that isn’t what it has to be, any more than care ethics needs to be mushy emotionalism and sentimentality. Robust cosmopolitanism takes seriously the notion that we are citizens of the world and that our thinking and policy making need to take [End Page 18] that global responsibility into account (Dwyer 2007). But we cannot act responsibly unless we acquire knowledge rooted in particularity and specificity; cosmopolitanism forces us to return to something like an ethics of care with its account of how and why attentiveness to particularity is so vital.7
The problem of brain drain, like so many global health issues, is not one with easy solutions. We ought not take its intractable nature as a reason to ignore it, however. Both as caring human beings and as citizens of the world, we have a duty to argue for policies that mitigate the problem, to mobilize resources that address its causes, and to remain aware of the limits of any one answer to such a complex problem. But contemporary policies tend to exhibit a limited focus that screens out particularities and mediating structures. Care theory calls our attention to the particularities of specific cases of brain drain, and to work within the cultural and social context of individual social situations. Much of the policy making on such issues focuses on abstract individuals, but to address the issue more productively, we need to focus on situated individuals who live particular lives in particular places.
Likewise, our thinking about these issues is better if we pay attention to the social structures of care that play central roles in producing (or mitigating) the situation. Those of us who live in the global North need to be aware of how our own social structures may contribute to problems elsewhere in the world. Further, we also need to support policies that strengthen the capacity of those with fewer resources to meet their own needs. Rather than impose a model of medical care that centers on physicians to the exclusion of other caregivers, we should support the development of a broad range of medical professionals equipped to offer a variety of services and support. By broadening the range of professional licensure, we support wider access to care for people in our own country and around the globe, a goal that both cosmopolitans and care ethicists, and perhaps even liberals and libertarians, can surely agree upon.
Ruth Groenhout is a professor of philosophy at Calvin College, in Grand Rapids, Michigan. Her publications focus on a range of issues in bioethics and an ethics of care, and include Bioethics: A Reformed Look at Life and Death Choices, Connected Lives: Human Nature and an Ethics of Care, and Feminism, Faith, Philosophy, as well as a variety of journal articles on issues ranging from the ethics of public health research, to embodiment and the nurse–client encounter, to evolutionary psychology.
This paper has benefited enormously from careful reading and comments by two anonymous reviewers for IJFAB. My thanks to both for all the improvements they suggested.
1. See, for example, Virginia Held, The Ethics of Care: Personal, Political, and Global (Oxford: Oxford University Press, 2006); Ruth Groenhout, Connected Lives: Human Nature and an Ethics of Care (Lanham, MD: Rowman and Littlefield, [End Page 19] 2004); Eva Feder Kittay, Love’s Labor: Essays on Women, Equality, and Dependency (New York: Routledge, 1999); Eva Feder Kittay and Ellen K. Feder, The Subject of Care: Feminist Perspectives on Dependency (Lanham, MD: Rowman and Littlefield, 2002); Nel Noddings, Caring: A Feminine Approach to Ethics and Moral Education (Berkeley: University of California Press, 1984); Rosemarie Tong, Feminist Approaches to Bioethics: Theoretical Reflections and Practical Applications (Boulder, CO: Westview Press, 1997), and many others.
2. These considerations could certainly be accommodated by a theory that focuses on abstract principles. Almost any theory can be made to accommodate almost any set of considerations, given a sufficiently ingenious theorist. But any theoretical approach will tend to focus attention on certain parameters, while making others less central or salient. An ethics-of-care approach brings issues to our consideration that might otherwise be overlooked, and encourages the theorist to explore options that have not been considered by researchers working within alternative frameworks. Further, the constraints of justice, abstract principles that they are, should structure the parameters within which the policy should function; if the considerations raised by an ethics of care do not conflict with policies offered by a more abstract principles approach, that is a positive feature of the approach, all things considered. My argument is that an ethics of care brings alternative approaches to consideration, not that it generates policies that either cannot be accommodated or cannot be considered by a liberal theorist.
3. Analysts vary in their analysis of the reasons for the shortage. Some account for it on the basis of falling enrollment in medical schools and nursing programs, coupled with rising malpractice insurance rates (Clark, Stewart, and Clark 2006), others to the limits placed on doctors being trained in the 1980s and 1990s due to projections (at that time) of oversupply (Cauchon 2005). Data from the Association of American Medical Colleges indicate that enrollment in medical schools has remained largely steady, with recent increases since 2006 in response to concerns about shortages (AAMC 2010).
4. Other sources offer slightly different amounts for different years, but none less than the amounts cited; nearly all researchers note that remittances are one of the top five sources of foreign capital for Ghana.
5. From a feminist perspective, there are certainly other reasons for rejecting this as an appropriate social response to the sex trade. I offer it here merely as an example of how the use of shame varies on ethical modality depending on whether it serves the purposes of the powerful or the powerless.
6. One reviewer of an earlier version of this paper suggested that this account of power relationships implies that shaming techniques should be implemented [End Page 20] against Western physicians. There certainly may be cases where some form of public calls for accountability could be an appropriate response to brain-drain issues. Perhaps publicity about health-care systems that have explicit policies of recruitment in underserved countries would be appropriate, though it might also feed anti-immigrant feelings in the United States, and could have other complicated ramifications. It is worth noting, however, that publicity of this sort differs significantly from a policy that would specifically reflect the culture of family honor that exists in Ghana, because the United States lacks such a culture.
7. This discussion has relevance for debates within cosmopolitan theory about whether it is better to advocate a “rooted cosmopolitanism” or a transnational cosmopolitanism; that is, whether cosmopolitanism should accept the necessity of national boundaries and particularistic loyalties or should advocate a sort of global citizenship. See, for example, Pheng Cheah’s Inhuman Conditions: On Cosmopolitanism and Human Rights (Cambridge, MA: Harvard University Press, 2006) and the debates in Gillian Brock and Harry Brighouse’s The Political Philosophy of Cosmopolitanism (Cambridge: Cambridge University Press, 2005).