The EIESL Project

On July 20th, 2009 we held our second student event: Kaholtik. There was much discussion and debate, which generated an extensive collection of ideas, questions and concerns about ethical behaviour during ISL experiences, as well as broader ideas about ethics and student engagement. All of this information will contribute to forming a picture of the current perspectives and culture of ISL at UBC. It will also be used to inform the upcoming awareness campaign and dialogue series.

The night began with a reading and discussion of an article: the Body Ritual of the Nacirema, by Horace Milner. The article was used as a warm up activity, to begin thinking about perceptions of self vs. other and normal vs. exotic.

We then moved into breakout groups to discuss four case studies. The previous four posts are the case studies used during Kaholtik, accompanied by a summary of the breakout group discussions.

Finally, we came together as a whole group to enjoy pizza, recap the case studies and discuss the broad issues affecting ISL at UBC. Below, you will find a summary of the final discussion.

General discussion notes:

Is it possible to build a consensus? Is it true consensus or community pressure being applied on the minority opinion?  There is a difference between the verbalization of consensus and reality.

Is consensus seen as sharing good things equally?  In Cuba there is a saying, “we share our poverty equally”. Perhaps consensus is best approach knowing that burdens and benefits must be taken into consideration.

When making decisions at a community level, is the majority always right? Is it possible to be the only one with a certain opinion, and to be ‘right’?

Within the field of ethics there is often a fear of subjectivity.  However, ethics change based on context.  For example, in some cultures, consensus is highly valued, in others, it is not.  This changes how decision-making should be approached. Ethics need to be fluid, elastic, and situated in the local context.

Self-awareness is critical in going abroad. It is essential to have a sense of personal needs so that when confronted with issues they can be resolved

Highly important/useful to reflect during and after your ISL experience.

What is the motivation for participating in ISL? Is there altruism? Is it for resume enhancement? It important to be aware of, and reflect on, personal motivation.

Can ethics successfully be taught as a mandatory undergraduate class?

• In a traditional classroom fashion? Experientially through community initiatives? Through case studies?
• Will ethics classes be enough to actually modify behaviour, or will they just become another hoop that students need to jump through before graduation?

Utilize diversity at UBC:

• Vast resource in the people that live, work, and study at UBC who have useful insights into ISL.
• Need to be careful when recruiting and selecting people to help advise ISL students – another whole set of ethical issues surrounding that idea.
• Isolating members of the UBC community because of different language or look is problematic.

Pre-departure preparation vs. Experiential learning

• Impossible to do everything in pre-departure training.
• Need to give students the tools to act ethically, a foundation. It would be impossible to teach a one-size-fits-all formula.

Josefa’s husband died of dengue fever three years ago, just weeks after the birth of his fourth daughter. Today, it is a struggle for Josefa to independently provide her children with adequate shelter, nutritious food, clean water, and clothing. Her only sources of income are her in-home laundry business and her small garden. Recently, upon a yearly check-up of her children, Josefa was told that her 3 year-old and 4½ year-old daughters are showing early effects of malnutrition. Her eldest daughter’s (9 years old) vision problem is also worsening. As Josefa was leaving the health clinic, a foreigner handed her a shiny pamphlet and told her about a new initiative in her neighbourhood. The initiative is sponsored by the Canadian “Education for our Daughters” NGO and her municipal government. The initiative aims to build a local school for girls in order to improve the quality of life through education.

What might Josefa’s reaction to this project be?

Discussion Summary

• Need to watch out for the assumption that foreigners have more knowledge than residents.
• Is there any community consultation taking place to determine the needs of the community? How is the consultation taking place?
• Josefa was approached at a vulnerable time. It is important to consider how this will affect the situation and the ethics of the project.
• Do the community needs differ from NGO objectives? Is the community divided over project?
• Are partnerships productive? How are partnerships formed and how does that affect ethics?
• The initiative is situated in Josefa’s community, and is partially sponsored by her local government. Why is a foreigner informing her about the program?
• A school may not be the most paramount need, is it something that is important to Josefa and her family?
• It is necessary to be aware of our own assumptions that this project is ill-planned and directed by the foreign organization. Perhaps the initiative is good and Josefa’s family’s situation is rare within the community. It is possible that most of the village would benefit from the project. The foreigner’s presence is not necessarily a bad thing. Maybe the foreigner adds visibility to a good initiative, a symbol of hope, etc.
• Community-based initiatives have more potential for reduced ethical dilemmas. It is better to have ethical problems surface from within a community than from without because a local framework exists to deal with the dilemmas.
• There is an assumption that education will improve quality of life in that community, but will it? Think about the type of education. Is education always good? What if this a for example a catholic school, and the community is not catholic.
• The underlying question is “how do we come up with these projects?” What is the process? UBC as a diverse campus but the diversity is not utilized to its fullest potential. UBC students from South Africa, for example, have not been approached to act as consultants for students who are going to South Africa.
• As a UBC student it is important to take note that it is difficult to answer all of the questions listed above. Each community is so nuanced that there are always special cases, it is important to dig for the back story.

You are working with a team of Canadian university students to build a school for a village in Cambodia. The team has spent the past year fundraising for the project and planning all the logistics. Now that you are in the community you are working as hard as ever to keep the project on schedule.

The team of students and hired locals usually work 8-hour days in the sticky tropical heat. Today was a particularly frustrating day because the price of bricks suddenly increased and you had a difficult time negotiating with the supplier in a foreign language.

After finishing work, you return to your homestay for dinner. You attempt to practice speaking Khmer with your homestay family, but after today’s setback all you want to do is take the night off to relax. Luckily some of your teammates are staying with families nearby, so you invite them to hang out at your place. One teammate brings over her laptop loaded with movies. Another takes the team’s rented motorcycle into a nearby market town to pick up beer and food. Everyone has a great time, and the group formulates a plan to go into town on the weekend for a proper night out.

Although you are enjoying your “asian adventure”, you are happy to momentarily escape the stress of cultural differences, communication barriers and strenuous manual labour. It feels good to just be yourself around other young Canadians.

Where do ethics come into play in this situation?

Discussion Summary

“What is ethics?” – this is an incredibly complex question. Yet, it is essential to understand the question before searching for answers. Several definitions were offered:

• Ethics equates to the acceptable thing to do. Ultimately, it is up to the individual to decide in a specific situation.
• Can be thought of in terms of harm reduction. In the case study, the situation essentially boils down to a question of politeness.

The group discussed initial reactions to the case study. Some thoughts and questions that emerged included:

• Does one necessarily need something familiar and comfortable in order to be able to relax? Isn’t it possible to unwind within the local surroundings?
• The student’s behaviour may be telling of their original motivations for participating in the project. Someone who is eager to immerse themselves in the local culture and learn as much as possible may be less likely to need an escape.
• Including the homestay family in the activities, and asking permission to bring other students into their home would have been a simple way to avoid being impolite.
• Looking at the situation objectively, you could judge the student for taking the easy way out. But thinking about being in the student’s position, you can understand the behaviour. It’s tough being a foreigner all the time.

The next phase of the conversation centered on how we can better prepare students to make ethical decisions during their ISL experience.

• By simply having empathy, the students can avoid many situations, like the one presented in the case study.
• The students need an opportunity for reflection and debriefing while they are in the field. Reflection and guided learning may help prevent frustration, and the associated behaviours.
• To what extent should students be free to explore and learn on their own, and to what extent it is beneficial to have guidance?
• The student’s motivation for being involved in an ISL project influences whether or not they will make ethical decisions. If they have a genuine dedication to learning and growing with the community, they will be more likely to make thoughtful decisions.
• When the project outcomes are in the forefront of the student’s mind, they can forget to take care of themselves and can neglect the relationships and interactions with community members. It is important for students to recognize the value of personal relationships within an ISL project.
• Coming into a project with high expectations for results can set up a student to feel a sense of failure, and increase the likelihood of unethical behaviour in order to achieve ‘successful’ project outcomes.
• Having a set of ground rules that the students are familiarized with beforehand would help prevent situations like the case study. Prevention, rather than firefighting, is key. However, in practical terms, how do you set ground rules that are appropriate and account for a wide range of circumstances?
• The framework approach doesn’t seem to be very useful because even if you learn a framework for decision-making, in the moment, you tend to forget what the approach is. Instead, it makes sense to identify the times and situations in which you feel most vulnerable. It is when your personal needs become paramount that you are most likely to make unethical decisions.
• Guidelines often make sense intellectually, but they need to be grounded in the real world. Perhaps it would be better to teach the philosophy behind the rules so that students develop a decision-making ability and learn the associated thinking process.

The language used in this case study was another a key topic of the discussion. Phrases such as “build a school for a community” can reinforce imbalances in power dynamics. Terminology such as “asian adventure” indicate that the subject of the case study may have less-than-ideal motivations for participating in the ISL project, and may have prejudices that need to be further explored. This language was purposefully built into the case study to highlight that our choice of vocabulary and form of communication can affect how we think about the issues.

It will be necessary to find a balance between students taking initiative to prepare themselves, and having a system that supports the students. From details emerging in our conversation, it is evident that the majority of the burden is currently placed on the student. Why aren’t we striving to build a system that supports ethics training?

Systems and organizations should supply/provide a supportive framework to share the burden of ethics.

The final topic of the discussion centered around why we are focusing on educating ISL students about ethics instead of recognizing that everyone could benefit from increased exposure to ethics. We need to make decisions in our day-to-day lives, thus we could surely gain from being more aware of ethical frameworks and having heightened decision-making abilities.

You are volunteering with a team for twelve weeks in a small suburb of a semi-arid country in the Third World. During your predeparture training, the Canadian NGO you work for emphasized their sustainability policy, which stresses local ownership and a low social footprint, both for specific projects and communities as a whole, in order to avoid building dependency relationships.

You have been working with youth at the local youth centre, helping the volunteer staff build their capacity and coordinate their activities. Over the last two months in-community, you have been learning the local language and have developed strong friendships with some of the youth.

Unexpectedly one day, the power goes out throughout the region, and the local government isn’t sure when it will be restored. The infrastructure in the region only supports piped water and there is a hand pump on the edge of the community, but the well soon runs dry.  Your contingency budget allows you to rent a small generator in order to pump water into the tank on the roof of your team’s rented house.  In order to keep a low profile, your team agrees it will only turn the generator on for a few hours at night, so you can write reports and conserve fuel.  To save water, you begin to bucket bathe rather than shower, and do so only once every three days.

A week later, you hear word that the power could be out for up to two months, well after your team has left.  The next morning, one of the youth comes to your gate with a jerry can, obviously humiliated, asking for water for his family.  You don’t want to set a precedent, as there is no way you can support the whole community, but you don’t want to turn away your friend either.

How do you approach making an ethical decision in this situation?

Discussion Summary

• How do you act in the short term vs. the long term? What are the immediate possibilities for providing people with water and solutions to their issues? Short-term band-aid or systematic change? Not ethical to support just one person because “everyone is equal”. But there is a problem, we don’t treat everyone the same. We cannot ignore our relationships. So what of equal treatment?
• What if you don’t know enough to make a decision like this? What if you haven’t been trained for this? Do you know enough to make a decision? This is bigger than the boy with the jerry can. You need to make a decision that preserves everybody’s integrity.
• Weaknesses of core theories – Utilitarianism vs. Deontology. We aren’t given a set of guidelines for addressing conflicts between ethical rules.
• Could do a community survey of need and help the families that are most vulnerable. However, the community must be involved in the process, ie. consult with their leaders. Should you draw international attention to the situation?
• What is your role as a volunteer? There are political problems with getting involved? You don’t necessarily know what’s already going on in a community if you’re on a short project.
• What if somebody from abroad showed up here in Canada during a crisis and tried to tell us what was best for us to do? How would that make us feel?
• Language is an issue. If you start treating people in a certain way, then they will likely start acting as such.
• Compromise? Are we doomed to an eternity of proliferation of new euphemistic terms in an attempt to be politically correct? Who is writing history?

A second year medical student elects to participate in an international service learning program based out of an urban center in Mexico. After receiving minimal cultural and practical pre-departure training, the volunteer arrives at the hospital eager to help. It quickly becomes clear that the hospital is severely understaffed and that many Mexicans are in (dire) need of (immediate) medical attention. The medical student begins assessing patients and recommending treatments to alleviate some of the burden placed on the few overstretched Mexican physicians. The wait times for Mexican patients are being greatly reduced as a result of the medical student’s services. The student feels a sense of personal satisfaction for helping an underserved population and accomplishment for translating their medical knowledge into clinical practice.

Did this medical student act ethically during their ISL experience?

Discussion Summary:

Medical student acted in a highly unethical fashion

• Not legally allowed to practice.
• The language barrier means that much critical information could be lost in translation (assuming student is not fluent in Spanish).
• Different climate = different ailments that student is likely unfamiliar with.
• Not a qualified physician, could do more harm than good.

Ethics change if treatment becomes a matter of life or death

• Ethical dilemma: a person should be treated by the most qualified person available, what if the most qualified person is a student?

Dependency relationships

• Mexican hospitals becoming reliant on foreign “experts” (often perceived this way by host communities).
• Even if the student is not an expert, will throw them into that situation because it has been done before. Cycle could be difficult to break considering the motivations (whether the be well-intentioned or other) of the students and position of the local community.
• Onus need not be placed on the community for dependency relationships.
• What about the long-term impacts on healthcare of developing this dependency relationship?

Is something better than nothing?

• Not always, with medical care one should always err on the side of quality over quantity. Look at the big picture to evaluate ethics.
• What’s the alternative?
• Do what you can with the resources at hand?
• Standards should not change just because you are in an underserviced country.

Varying degrees of severity

• Are students assisting with triage? (Something they would have likely already learned by year two).
• Are they going into operating rooms and performing surgeries? (Practicing far beyond the scope of their ability).

Ethics are affected by pragmatics

• Everyone deserves the best care available, but there are many barriers to implementation. Financial and logistical constraints may prevent optimal choices from being made.
• Best case scenarios not always feasible (eg. The type of treatment available for people living with HIV/AIDS).

Be conscious of the assumption that all underdeveloped countries are under-resourced

• Cuba has a good health care system and many good doctors.
• Trinidad has very well trained doctors, but still treats doctors from abroad as “experts” due to history of presence there/dependency.

Ethics are highly contextual

• For the purpose of discussion it’s good to have broad neutral presentations, but in reality there are so many other factors at play.
• Isolating situations is not necessarily fruitful, need to look at the bigger picture.
• More information needed to be able to inform a decision.
• Lots of grey area in the study of ethics.

What are the motivations of ISL volunteers?

• Are students acting unacceptably to brag to their friends, gather clinical experience and/or have a sense of personal accomplishment?

Learning about ethics is extremely important

• Not just for med students or ISL students. Any kind of work should have some form of ethics training.
• It is very important to grapple with difficult questions before you experience difficult situations.
• Case studies are an effective way to learn about ethics.