medical migration - is there a need for regulation

7/31/2019 Medical Migration - Is There a Need for Regulation

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MEDICAL MIGRATION: IS THERE A NEED FOR REGULATION?

Gubat, Bennet A.

Professor Samuel Vera Cruz

Philosophy 199 (Senior Thesis)

22 May 2008


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TABLE OF CONTENTS

Introduction ......................................................................................................................... .............. ..... ...... 3

Defining Medical Migration ........................................................................................................ ..... ..... ......... 4

Other Forms of Migration ........................................................................................................................ ...... 6

Trends and Impacts of Medical Migration ............................................................................... ..... .............. ... 9

The Principle of Respect for Autonomy ................................................................................................... .... 12

The Concept of Autonomy ............................................................................................................... ..... .. 12

Kantian Autonomy ........................................................................................................................ .......... 13

Utilitarian Autonomy ................................................................................................................................ 14

Freedoms of Movement and Employment...............................................................................................15

Discussion ............................................................................................................................................ .. 15

The Principle of Distributive Justice ................................................................................................... ..... ....16

The Veil of Ignorance ..............................................................................................................................18

Discussion ............................................................................................................................................ .. 18

Implications on Policy ................................................................................................................................ .19

Conclusion .......................................................................................................................................... ..... .. 20

Notes .......................................................................................................................................................... 22

Works Cited ................................................................................................................................................ 22


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Introduction

As any proper philosophical essay should be, the mode of this paper will be normative rather than

empirical. That is, we will examine justificatory reasons on both sides of the issue to regulate medical

migration rather than the causes and effects of this global phenomenon. This is done with a view to

determine first of all, if the reasoning offered for each standpoint is sufficient and, second, if a reshaping of

international policy according to these perspectives is possible, or even necessary. We will not concern

ourselves with the problems of administration and enforcement, or even of the feasibility of proposing and

maintaining these policies as such acts are the purview of legislators and not philosophers. We are only

concerned with how it ought to be as dictated by reason.

To this effect we will begin by properly defining medical migration as it is taken in the context of this

paper. We will also distinguish how our definition of medical migration differs from (1) the contemporary

views on international migration and (2) from other perspectives on labor force migration. It is not my

intention to put forward a separation of medical migration from discussions on general migration, although

proposals have been made to treat it separately,1 but merely to remove overlap and ambiguity where they

may be found, sometimes to broaden the view where it is necessary, sometimes to delimit it.

The preconception that this is all the product of armchair intellectualizing will have to be done away

with however, as we cannot fully divorce the empirical from discussions of this sort. Empirical data will

provide us with a proper background on the issue and erase doubts as to whether there is an issue after all.

This will mostly be a review of related research and literature on the subject. Trends and statistics will be

stated briefly and then we will allow logic to carry us toward their ultimate possibility. It is to show that

indeed, a real problem exists and that we must take pains to equip ourselves morally in order that we may

know how to properly address it lest we be caught in our drawers when the problem smacks us full-blown.

There is a widely accepted view, or shall I say resignation, that data on international migration is

rather patchy and most often anecdotal (Stillwell 1; Carrington) based on limited databases and inconsistent

classification of education and skills. We will not let that stop us as general trends do emerge from some of

this research and the implications of those trends are clear if not prima facie visible. There are also

1 This is better explained in Alkire and Chen, p. 2


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research papers specific to geographical areas that may serve as baseline examples on the consequences

of medical migration for source countries. I am not saying however that push-pull conditions and

consequences are the same in all respects for source countries, merely that there are similarities and that

these similarities cannot be ignored when determining a global trend, or at the least a universal

consequence, for the outflow of skilled health personnel.

Central to my theme is the idea that medical migration ought to be regulated and that there are

good moral reasons to do so, the least of which are the socio-political implications unchecked medical

migration will bring. This certainly does not imply that regulation should be performed completely and

without qualification for we shall see, as the paper progresses, that there is a tension between two moral

issues underlying the entire discussion. It is my intention to lay bare this contention and determine how we

are to proceed without sacrificing the necessities imposed by morality. To do that requires a careful

examination of how these moral concepts relate to each other, and by what means can regulation strike a

balance between these opposing sides.

Defining Medical Migration

For our purposes I will be using a narrow definition of medical migration. This is not to say that my

definition should be the accepted one nor am I proposing qualifications out of the blue to make it easier for

the paper to flow. My intention is that by using a narrower version of the concept, we will be able to remove

ambiguity caused by the overlap of different concepts on migration and from this perform an analysis of the

different positions involved in justifying regulation. It will certainly be good if we were to move forward from

this narrow definition and use the justificatory reasons applicable to a broader sense but that will be a

matter for future essays.

For the record, it shall also be necessary to note that when we speak of migration, we are here not

looking at a localized, domestic context but are examining the concept from a global perspective. Although

we will speak of the consequences and implications at a domestic level, to formulate a proper ethical stand

we will be conceptualizing source and host countries and not take cases individually. Migration in itself is a

(1) global phenomenon and in recognizing that, there will be a sensitivity toward the similarities of push-pull


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factors and consequences across participating countries. -- expand

We will have a lot of initial preconceptions regarding medical migration upon hearing the term.

Chief among this would be that this is related or pertaining to migration or the movement of people from one

country to another. We are still maintaining that definition and furthermore, we are not concerning ourselves

whether this movement is out of one particular country, which is generally termed underemigration, nor

toward or into one particular country, which is then classified underimmigration. All we are concerned about

is the movement of people, specifically a labor force, and in this sense of migration, we are better able to

allow for the fact that the consequences of this movement are felt in both the source countries and the host

countries - the former are the countries where migrants generally come from while the latter are those that

generally accept these migrants. I say generallybecause it is certainly possible that during certain periods

or under certain circumstances, people may be migrating in the other direction. However, there exists a

general trend and that the established flow is in this way rather than the other. Medical migration then is the

(2) movement of healthcare professionals from one country to another.

There are many reasons for international migration such as to take up employment, to establish

residence or to seek refuge from persecution, either temporarily or permanently (Stillwell 2). Although these

reasons are valid, this leads us away from how we would like to distinguish medical migration from other

types of migration. We are examining the impact of medical migration on the healthcare systems of both

source and host countries therefore we will not concern ourselves with the effects ofbrain wastage, which is

the employment of professionals in a line of work different from their training, or even with people who have

migrated in order for families to be reunited. We will treat medical migration then conceptually, as the

migration of healthcare professionals with the (3) express purpose to practice their trade in the host country.

Whether temporary or permanent is something that does not concern us at the moment as there is very little

consistency in how countries define temporary (Stillwell 2). Furthermore, the impact to healthcare systems

can be felt as even with temporary migration as this type of migration would still have some effects on the

status quo that might change [the country's] tolerance for emigrants in the long run (Capones 5)

Another reason for this qualification is that in order to treat medical migration properly as a clear

issue, it must be stipulated that the purpose for migrating to another country is intentional, rather than

accidental; this purpose being that of healthcare practice in the host country. A doctor migrating to be


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reunited with her family may take filial piety into consideration. This same doctor may then, due to

complications in acquiring a practice in the destination country, serve as a governess for little kids instead

and continue to do so till the end of her life. We would be forced, in this case, to bring an entirely new moral

schema to bear, and would be taken into fields quite outside the range of discussion. I am not discounting

the fact that this type of movement also counts as part of the migration flow, nor the possibility that family

may also serve as part of the push-pull factors encouraging movement. I am only concerned with pointing

out that in cases such as this, the practice of healthcare may count as secondary only and what comes out

as a loss to one country's healthcare system may not necessarily come out as a gain to another. The

decision we are trying to examine here, all things being equal, is the healthcare practitioners decision to

either work at home or abroad, and the question we want to raise is, should the international community

intervene in this decision.

Combining these three properties, medical migration then is a (1) global phenomenon relating to

the (2) movement of healthcare professionals from one country to another (3) with the intention of practicing

their trade in the host country.

Other Forms of Migration

It is necessary to distinguish medical migration from other forms of international migration to further

clarify what we are talking about. Granted that the following concepts may not necessarily be mutually

exclusive, there still exists an overlap of ideas enough to cause ambiguity and to raise unnecessary

questions that may otherwise be prevented at this point.

There are two categories that emerge if we look at the current typology of migration. The first is a

classification of migration according to duration. This is descriptive of the migrants' length of stay in the host

country. Length of stay is defined loosely and standards vary with each country. This can be anywhere from

9 months to 10 years, depending on the country conditions (Stillwell, 2). Australia for example, defines

length of stay separately for different classes of migrants. Teachers are given 4 years and this permit is

renewable indefinitely. Business specialists range from 3 months to 4 years, while other migrants have a

stay limit of 2 years which is renewable once. The Netherlands and Germany both have max stays of 1


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year, renewable, while the United Kingdom can issue permits up to 4 years (OECD). While these facts

produce complications from a data-gathering perspective, it does not faze us in the least as (1) there are

alternate sources of information that can help us build an adequate picture of migration flows such as

population surveys, censuses, administrative registers and migrant visa statistics, the methodology of which

has been used in previous research. Furthermore, as stated earlier, (2) effects of medical migration are felt

regardless of duration.

The second category describes the act of migration as a response to factors external to the

individual, already implying that migration is not a wholly voluntary act. In these cases, migration is seen as

sometimes necessary in order to prevent present and future harm to one's person and family. Survival is of

the utmost consideration in these cases and they cannot be treated properly within our discussion as these

factors range across a broad spectrum and are not limited to the medical labor class. Furthermore, although

the International Convention on the Status of Refugees prohibits treatment that is less favorable than that

accorded to other aliens, there are still countries that adopt an obstructive stance towards refugees that limit

their opportunities in the host country, a violation that even convention signatories are guilty of propagating.2

This includes but is not limited to medical practice.

The following is a list and description of the widely accepted types of migration (Stillwell 2):

Indicative of Length of stay

Permanent settlers are legally admitted immigrants who are expected to settle in the country,

including persons admitted to reunite families.

Documented labour migrants include both temporary contract workers and temporary

professional transients.

o Temporary migrant workers are skilled, semiskilled or untrained workers who remain in

the receiving country for finite periods as set out in an individual work contract or

service contract made with an agency.

o Temporary professional transients are professional or skilled workers who move from

22 For a detailed discussion on this and other conditions affecting refugees especially movement,

employment, and acceptance into foreign countries, see examples in Iraqi Refugees. Also see Milner and

Loescher.


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one country to another, often with international firms.

Undocumented labour migrants are those who do not have a legal status in the receiving

country because of illegal entry or overstay.

Displaced Persons

Asylum seekers are those who appeal for refugee status because they fear persecution in their

country of origin.

Recognized refugees are those deemed at risk of persecution if they return to their own

country. Decisions on asylum status and refugee status are based on the 1951 United Nations

Convention Relating to the Status of Refugees.

Externally displaced persons are those not recognized as refugees but who have valid reasons

for fleeing their country of origin (such as famine or war).

There are other forms of migration phenomenon that are akin to medical migration and deserve

mention at this point, also in the interest of further qualifying the concept. These arebrain drain, brain gain,

brain waste and brain sharing.

Brain drain is the emigration, or outflow, of educated and professional people. It was originally

coined by the Royal Society of London to describe the outflow of scientists and technologists to the United

States and Canada but is now used to encompass all manner of human capital outflow. This term is usable

only in the context of source countries and is better used for describing the effects of human capital

depletion (Philippines sec. A; Industry sec. C). Medical migration is a more specific form of brain drain

signifying the outflow of doctors, nurses, medical technicians and the like. However, the term also includes

the class of migrant students who study abroad and do not return to their home country and as such cannot

be a clear signifier of the phenomenon we are trying to present.

There are also some critics who argue against the notion of brain drain, saying that its effects need

not be treated as negative. In fact, some economists state that brain drain may actually lead to positive

results, by applying an incentive to increase education and skills and induce investment in these systems. A

brain gain instead would be the result. When this domestic "brain gain" is greater than the "brain drain," the


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net impact on welfare and growth may well be positive (Sriskandarajah).

Brain waste is the phenomenon describing the loss of human capital from an educated and

technical sector of society in favor of menial or less skilled work. It is not restricted to migrant workers as it

can encompass movement within a domestic context. However, the term is generally used to denote skilled

and educated workers leaving their home country, but then [making] little use of their skills and education

in the host country (Mattoo 2). This may not be applicable to medical migrants as there is an increasing

demand for them, especially in the United States. Lucrative offers exist which may even serve as a pull

factor for medical practitioners in typical source countries like the Philippines and China. A shortage

exists due to aging baby boomers, people living longer with chronic conditions, rapid advances in

medical technology, and further medical specialization (Gearon).

Migrations effects need not be taken as a one-way street only. In fact, the concept of brain sharing

was coined to denote one of the positive effects of migration. There is research that shows a high

percentage of people who have studied abroad returning to their countries of origin. The people who stayed

kept in touch with their colleagues from the origin country resulting in a sharing of techniques, information

and vital knowledge in their line of work (Noxon). While this may be true in some instances and in other

fields, we have to disconnect this line of thought from our inquiry as our main concern is the labor pool.

Human resource is often considered a crucial factor as they are the active agents, who are inherently

responsible for the delivery of health care, the efficiency of the health systems, and the adequate use of the

other health care resources (Taskforce on Health Systems Research, Informed Choices). So while brain

and knowledge sharing can be adequate to compensate other fields like science, technology, engineering

and research, it is not so for the case of the medical sector as we will see below.

Trends and Impacts of Medical Migration

Recent research on general migration offers the conclusion that international migration is indeed

increasing (Alkire and Chen, 2; Buchan, 8; Stillwell, 3; World Health Organization, Migration of Skilled

Health, 5). Even though many authors report difficulties in acquiring accurate information due to incomplete

data and ambiguity in the definition of migrant flows, they were still able to piece together a picture of the


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migrant situation. Granted that only a small portion of the general migration flow is composed of medical

professionals, we will see below that this loss affects the capacity of the sending countries capacity to

dispense health care effectively.

Barbara Stillwell used a case study of the United Kingdom to illustrate the increase in the migration

flow. This was created with the proposition that it is easier to study migration trends via statistics from

recipient countries. The study then explored the impact of medical migration in sending countries, primarily

African countries as these are representative of the adverse effects that large scale medical migration has

on the healthcare system (Capones 6). The Philippines and India are found to be special cases as these

countries typically have a surplus of medical professionals and their economy is also traditionally dependent

on the exportation of this surplus human capital to more developed countries. The effects on less developed

countries, however, are different as (1) the educational cycle of preparation for health workers is long, and

response to loss of human capital from the health workforce is not usually fast or flexible. Furthermore (2)

Those health workers who remain in public health systems with inadequate numbers of health workers

experience added stress and greater workloads. Many of the remaining health workers are ill-motivated, not

only because of their workload, but also because they are poorly paid, poorly equipped, inadequately

supervised and informed and have limited career opportunities.

Joanna Capones and Ana Molina, in a research paper submitted to the University of the Philippines

School of Economics studied the effects of health worker migration on the healthcare system specifically to

healthcare quality and wages in the context of the Philippines. Their findings support theories that increased

medical migration leads to a decrease in healthcare quality by correlations in the numbers of mortality and

infant mortality, a decrease in life expectancy, and the increased length of time to receive medical service in

a study conducted in various hospitals in the Metro Manila area. They have also noted the fact that as the

migration trend continues the health workers left behind are those that are inept or inexperienced, therefore

contributing to the general decrease in healthcare quality.

The World Health Organization commissioned James Buchan et al. to study the trends in

international nurse mobility. His team concluded that the increase in medical migration is partially due to

some industrialized countries attempting to solve skill shortages by using overseas recruitment as a quick-

fix. Negative impacts include, but are not limited to, (1) there being not enough nurses to support delivery


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of health care; (2) a decreased capacity to deliver health services; (3) increased costs of recruitment and

retention; (4) possible compromises in the quality of care; (5) low consumer and staff morale. Buchan also

summarized the continuing debate on the correct assessment of impact on both destination and source

countries as there are both sides to each. Destination countries for example, enjoy the benefit of a

rejuvenated labor force due to the influx of migrants. However some commentators point out that wage

rates will become suppressed due to this influx. Jobs available to the native population will also reduce in

number. Source countries on the other hand benefit from brain sharing, increased remittances and the

return of migrant workers, while suffering the ill-effects mentioned above. This is not illustrated in the case

of source countries like the Caribbean, Ghana and South Africa. There is very little evidence that the

possible positive effects do happen. Instead, the information points to a direct negative impact on

remaining staff and on the quality of care provided.

The Philippines, once again, was highlighted as atypical due to its encouragement of emigration to

ensure remittance monies are returned to the country. This may indicate a surplus in the supply of medical

workers. In fact, Fely Lorenzo, in a report commissioned by the International Labor Organization found that

there is an oversupply of 139,083 nurses as opposed to the national demand for 193,223. The problem

however with this is that although the Philippines and other source countries may benefit from increased

remittances, such transfers do not necessarily go to the health system or to public coffers (Hamilton and

Yau).

These, and other comparable sources, indicate that there are indeed negative impacts associated

especially with the emigration of medical professionals. It is all the more significant in the case of source

countries as opposed to destination countries as the impact is directly on the health system rather than the

overall economy. In fact, there has been a call for medical exceptionalism in migration due to these

negative effects. In 2004, a plenary meeting of the World Health Assembly passed a resolution urging

member states to help mitigate the negative effects of medical migration (World Health Organization,

Eighth Plenary, 60). Our task then remains as philosophers, to examine both sides of the equation in the

worldwide regulation of medical migration.


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The Principle of Respect for Autonomy

At the very core of the medical migration phenomenon are the arguments for human rights and

dignity based primarily out of the concept of individual autonomy. In fact, various literatures on medical

migration state this as the main hindrance to implementing policy responses to the outflow and inflow of

health personnel. The following sections will examine the grounds of the concept of autonomy and how

these underlie the fundamental rights of humans as codified in the Universal Declaration of Human rights.

We shall in turn apply these concepts to medical migration and the idea of healthcare.

Afterwards, we will take a look at Rawls theory of distributive justice, based on the notion of his

original position. I will attempt to reformulate the original position in order to support a cosmopolitan theory

of justice, which will I hope supply grounds for the case of regulating medical migration.

The Concept of Autonomy

Autonomy can be defined simplistically as the ability to govern oneself, free from any coercion and

conditions that are external to ones authentic self (Christman, sec. 1). The autonomous person is able to

form decisions based upon ones own rationalization, ones desires, considerations and characteristics and

is able to absorb the responsibility and consequences of these decisions. It can be defined in many

contexts such as the moral, the individual and the political, but central to the concept is the idea of self-

governance and the capacity to apply same based on conditions that are authentic, ones own.

What concerns us here, of course, is individual autonomy which is a trait that individuals can

exhibit relative to any aspects of their lives contrasted from moral autonomy which refers to the capacity

to impose the moral law on oneself (Christman, sec 1.1). Recognition of this autonomy in persons is one of

the basic tenets of the liberal society, and in fact is essential to our identity as persons (Moon 4). My

decisions are my own and it is the duty of society to refrain from imposing restrictions on my ability to

implement these decisions. This imposes not just a negative obligation on society to refrain from restrictive

actions but also a positive obligation to act in order to maintain this autonomy.


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There exists many conceptual differences in the idea of autonomy, and it is even a question of how

autonomous agents can be recognized judging from notions of competency and the authenticity of the

deciding factors. These do not concern us here. What is important is that we are cognizant of this capacity

in others, regardless of their competence, and we are to accord the same value to their actions and

behavior as the products of autonomous decisions.

Kantian Autonomy

The idea of autonomy can be seen as central in Immanuel Kants moral philosophy. It springs from

his idea that the only true or proper barometer of correct and moral action is therational will. For Kant, the

willis the only thing that can be properly ascribed goodwithout limitation (Kant 49). A lot of other things can

be described as good on one hand, but are evil when viewed in another light or have drastically evil

consequences. In fact, he makes use of examples of understanding, wit and judgment or courage,

resolution and perseverance and states that these indeed can be harmful if the will which is to make use

of these gifts of nature, and whose distinctive constitution is therefore called character, is not good (Kant

49). To will according to reason is in effect to constitute the will as an end in itself, because rational nature

exists as an end in itself (Kant 79).

This also presents a cognizance of the capacity of others to make these same decisions. As

humans are rational beings, they therefore are capable of using reason and will actually serve as a limiting

factor in our treatment of moral questions and choices. His individuals therefore are ones capable of

exercising or making into effect moral laws that will bind humanity as a whole. In order to exercise this

capacity, the human will must be unfettered and thence comes his second formulation of the Categorical

Imperative:

Act in such a way that you treat humanity, whether in your own person or in the person of any

other, always at the same time as an end and never merely as a means (Kant 80).


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His second formulation can be interpreted thus, as moral actions do not only contain a principle but

also as an end, if we treat the individual human will as a subjective end, then the freedom to will is negated

and therefore results in a contradiction of the first formulation. In the case of a landowner and a slave, the

landowner utilizes the slave to achieve whatever ends he has in mind; prepare food for him to assuage

hunger, wash clothes that he may wear them clean, &c. In this case, the landowner limits the will of the

slave and is in violation of the categorical imperative.

Obstructing the flow of medical migration therefore, is to treat medical practitioners merely as

means to attain an end, that of the preservation of the current healthcare situation. It is thence immoral as

this would again constitute another violation of the Second Formulation.

Utilitarian Autonomy

John Stuart Mill in his works argues that freedom and autonomy is a basic requirement in order to

enjoy a quality life. It is in his view one of the elements of well-being (qtd. in Christman). A good human

life is one that exercises one's higher capacities (qtd. in Brink). A person's higher capacities include her

deliberative capacities, in particular, capacities to form, revise, assess, select, and implement her own plan

of life (Brink). To be able to select my own conditions for happiness is one of the prerequisites of happiness

in itself. It would therefore increase utility if the state were able to preserve conditions that do not limit this

individual freedom.

Also related to this view is that one must be sufficiently capable in order to exercise this autonomy.

The capacity to make informed and rational decisions rest on knowledge about the issue, skill in critical

reasoning and assessment of the consequences of the choices at hand, and a proper grasp of the social

and political responsibilities and effects of the following choices. This requires providence of the state by

instituting bodies that would serve to engender this competence in making autonomous decisions.

The principle of autonomy then in this case, not only refers to the negative obligation by which one

is to refrain from actions that supersede anothers autonomy, as is implied in the Kantian concept. It refers


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also to the positive obligation by which the state is required by the utilitarian principle to apply means and

measures by which this autonomy can be maintained.

Freedoms of Movement and Employment

Individual autonomy, with its grounding on the basis of human dignity, gives rise to certain

freedoms and rights that are inalienable if justice, freedom and peace are to be preserved. These rights are

codified in the Universal Declaration of Human Rights and are its direct corollaries. To wit:

- Freedom of Movement The human rightthat states that everyone has the right to

freedom of movement and residence within the borders of each Stateand that everyone

has the right to leave any country, including his own, and to return to his country.Art. 13

UDHR

- Freedom of Employment - everyone has the right to work, to free choice of employment,

to just and favourable conditions of work and to protection against unemployment.Art. 23

UDHR

The argument is that non-recognition of these rights has led to widespread oppression and has

resulted in barbarous acts which have outraged the conscience of mankind (UDHR, Preamble).

Moreover, as human dignity is founded on the capacity for rational thought and action, it is necessary to

maintain this dignity by instituting laws and policies that will preserve the freedom to make use of this

capacity, hence the Universal Declaration.

Discussion

As we can see above, respect for autonomy can be a sufficient principle to underlie the case for

unregulated medical migration. However, it is not such an overarching idea that it does not have its own


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limitations. To satisfy autonomy, certain preconditions must exist and it is these conditions that actually

underwrite the case for the positive obligations of this principle. One must possess sufficient knowledge and

skills in order to exercise autonomy and although in general, such as in cases of informed consent, there is

really no conflict, some cases present difficulties in determining the actual outcome when two autonomous

wills come clashing.

Take the case for example of medical migration. We are aware that doctors and nurses as rational

beings with the capacity for self-determination are autonomous agents. However, they are, due to their

chosen roles in society, also burdened with the duty to provide healthcare where it is needed, and where

they can. The negative obligation to affirm the medical practitioners autonomy then collides directly with the

positive obligation to provide healthcare in order for other individuals to be given the opportunity to exercise

their autonomy in other or future scenarios. How are we then to solve this dilemma?

Mill might be able to provide an answer which is actually derivative of his discussion on the liberty

of thought and speech. He was aware of the fact that in order to maintain this autonomy, some restrictions

on liberty must be imposed. This is due to the reason that, certainly, there are minimum conditions that

must be met in order to exercise this autonomy. For one, a person must needs be alive and functioning at

full capacity. This includes proper access to basic goods, including but not limited to healthcare, food and

shelter. Liberty and autonomy do not make sense when these conditions are absent, and it is therefore the

states duty, fulfilling the principle of utility, to provide these basic conditions.

Plant argues in his article that correct functioning as a human agent imposes a positive right to

resources which would increase the sphere of agency of the individual (59). Autonomy goes beyond the

case for being free from coercion. To be free from coercion is to be able to act autonomously. Inherent in

this statement is the concept of ability. If we are to provide value to the idea of liberty and autonomy, then,

by virtue of transitivity, we must also provide value to what makes an individual able to act autonomously.

This prepares the ground for establishing a case for welfare rights, and in our context, enables the

individual to claim at least a modicum or a minimal level of healthcare.

The Principle of Distributive Justice


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Distributive justice principles are normative doctrines concerning the proper, fair, and just allocation

of goods, materials, wealth and services. There are many distinctions in the concept itself, dependent on

the nature of the objects to be allocated, the nature of the subjects of distribution, and the basis for

determining the proper distribution of these goods. We will not be able to include all possible applications

and distinctions of the theory, and certainly not all their limitations but I hope from these examples that we

are able to form a picture of how this applies to the context of medical migration.

To begin however, we must properly address criticisms that may arise due to our treatment of

medical practitioners as means to an end. One recalls in the previous sections, that the efficiency of the

medical system is determined largely in part by the amount of human resource input. That, coupled with the

knowledge that medical practitioners go into service primarily to fulfill this need lends to the idea that they

have willingly engaged themselves to participate in the dynamics of the healthcare structure, on the

condition that they are aware of the social conditions and consequences of their choice. It is in fact an

affirmation of their autonomy by seeing them as adding to the benefit of the social institution to which they

attach themselves.

Additionally, on a forward looking note, if the practice of healthcare includes at the onset, a view to

the remuneration of society by providing service to the country of origin, even for a brief amount of time, it

would not be a violation of the categorical imperative for ends as these will be part of the idea of absorbing

the consequences of their actions. In fact, it would even be a contradiction in the context of the imperative

to universalize the act of migration. If a world was to be construed which makes it a universal law for

medical practitioners to migrate immediately after the completion of their education, which is largely

dependent on the healthcare system as a whole, the healthcare system would eventually collapse

prohibiting future training of medical practitioners. This is a self-defeating system and reason will be averse

to the creation of such a system.

Society even can justify a claim on medical practitioners by virtue of restitution. Medical education

and training are largely dependent on structures maintained and created by society for its benefit. It is only

logical in order to maintain balance and the proper functioning of these institutions to repay what is taken

out of it in terms of time, resources, and facilities by giving back service where it is needed. If this

knowledge is part of the process, as is demonstrated already in some universities in the Philippines, then it


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is incorrect to say that medical practitioners are treated as means as this knowledge will already form part of

their decision.

The Veil of Ignorance

As Mark Rowlands states in his article The Impartial Position, any proper moral theory must

satisfy the condition of equality and desert. In fact, he reformulates Rawls idea of the original position to put

not just economic status, race or gender, behind the veil of ignorance. He even includes species in this

determination and went to the point of applying the theories of justice to animals. We will not go that far

however, but confine ourselves in the context of peoples. Interestingly though, the reformulation of the

original position to a broader context will be grounded on the same arguments as Rowlands had used.

The veil of ignorance is a heuristic device put forward by John Rawls in presenting his theories on

distributive justice. To make equitable and just decisions on the allocation of resources, one must place

oneself in the original position, by which one is devoid of all knowledge about morally irrelevant

characteristics those that one has no control over - about oneself and others. Putting all of these arbitrary

characteristics behind a veil of ignorance forces one, out of their self-interest, to allocate goods and

services equitably for she does not know which one of constituents she would be in the receiving (III).

Although Rawls mainly puts forward his theories in the domestic context, one can see by closer

examination, that this restriction cannot hold. One does not have control over where she will be born. Since

the principle of desert states that the amount of received goods and services should not be changed by

virtue of circumstances over which one has no control, then any proper moral theory should be sensitive to

this idea. Partiality to nationality or domestic context is then morally illegitimate inside the realm of the

original position. One cannot know whether she is of this particular nationality or the other. It then makes

sense to ensure that a minimal level of allocating resources is applied in a global context order to prevent

scarcity where one may be placed.

Discussion


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Liberal political philosophy begins with the premise of moral egalitarianism. All human individuals,

simply in virtue of their status as human, are entitled to equal moral considerationhowever much

philosophers disagree about what such consideration entails. Allowing differences in the administration of

political justice to rest upon some morally arbitrary fact about persons is anathema to liberal theory. Nothing

which is a matter of luck can be allowed to serve as the basis for a distinction in equality of treatment

(Blake).

To adhere to this concept of justice then is to ensure that all humans are provided access to

medical resources, including the case of medical provision by healthcare workers. Nations have a duty to

compensate for the scarcity of medical resources in some areas by ensuring that migration flows do not

adversely impact the source countrys capacity to provide healthcare assistance.

In a more radical manner, it can be argued that this requires affluent nations to provide aid where it

is necessary. Singer actually provides premises that he thinks is un-controversially true. (1) Suffering from

lack of food, shelter, and medical care are bad. (2) If it is within our power to prevent something bad from

happening, without thereby sacrificing anything of comparable value, we ought, morally, to do it. (qtd. in

Blake). If one passes a child drowning in a lake, one is morally obligated by the principle of beneficence to

rescue the child. If one is able to prevent death by restricting migrants from medically impoverished areas,

there is sufficient moral reason to do so. We are not imposing any changes in the conditions of these

possible migrants, merely preserving the status quo and in doing so, are preventing future suffering and

deaths which are the certain result of medical workforce depletion.

Implications on Policy

Prima facie, we will be walking a very fine line in creating policy proposals that would govern the

flows of medical migration. On the one hand, is societys obligation to respect the autonomy of individuals

and not make any restrictions on movement and choice of employment. On the other is the duty to mitigate


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the adverse effects that un-regulated medical migration has on source countries by adhering to the

principles of global distributive justice and make direct intervention into migration flows. Any response seen

to be favoring one dimension over the other is likely to be met with extreme opposition.

It is necessary therefore to attain a balance by which the negative effects are alleviated but at the

same time caters to the need to maintain individual autonomy. In fact, this balance is the focus of current

responses, but even then, they are not immune to their specific brand of criticism. For example, it has been

suggested that compensation be given directly to the sending country. Critics argue that workers migrate

due to poor in-country opportunities for professional growth and remuneration. Governments, therefore,

should not be rewarded for this failure to provide meaningful employment for its citizens and for domestic

economic mismanagement (Hamilton).

A good precursor to any policy initiative must be to balance out the push and pull factors that lead

to medical migration. This presupposes further research on the identification of major push-pull factors and

ways in order to equalize them. Direct intervention into market dynamics may be necessary by regulating

wages and offers, and by making even conditions in both host and source countries. Whatever the case,

there are certainly many ways by which indirect pressure in some aspects of society may help divert or

even stem the flows of migration.

The problem with this approach is that it can take time for these changes to be seen, and medical

human resource depletion is already a continuing problem. What may be necessary therefore is to accept

as necessary the restrictions global justice may impose upon the individual and restrict recruitment from

countries with current health worker shortages. This way, even though we do not actively divert migration

flows to these countries, the status quo will be maintained and we will prevent future harm from being done.

A further consequence of global justice would require that we divert current resources and surplus medical

personnel to these countries with health worker shortages, thus improving working conditions and making

the choice of the individual to migrate based on remuneration a moot issue. Climate perhaps, but not

monetary compensation.

Conclusion


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There is a tremendous need for proper classification and research as regards medical migration, or

migration in general for that matter. Methods of classification, databases and qualitative marks should be

standardized in order to give a proper map of the trends and flows of international migration. This can

prevent duplication of quantitative analyses and in fact allow us to properly gauge the impact of migration

on health, the economy and the healthcare systems of countries in general.

Whatever difficulties quantitative researches have faced, it is determined that medical migration,

with very few exceptions, has very significant negative impacts on both host and source countries; these

impacts are felt more so in the case of source countries due to health worker depletion. The policymaker

therefore must recognize the need to regulate medical migration but is confronted with the need to balance

individual autonomy versus the interests of global justice. One may impose draconian measures restricting

the autonomy of certain individuals in order to further and preserve individual autonomy as a common good

and simultaneously provide restitution by upholding conditions wherein that autonomy may be exercised

without doing further damage to existing health systems.

On the whole, it is imperative that immediate action be taken and in the lack of proper international

accord and enforcement, the domestic policymaker should take charge of the situation. The important thing

is that medical migration not be left untrammeled.


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Notes

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War. February 2003. Human Rights Watch. 15 May 2006

Milner, James and Loescher, Gil. Home from Home? The Journey to a Better Refugee Policy. 18 June

2003. openDemocracy Ltd. 15 May 2006

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medical migration - is there a need for regulation

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