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I am very grateful to the five commentators for taking the time to respond to my article ‘The Active Recruitment of Health Workers: A Defense’.1 I have learned a great deal from each of their commentaries, and I am sorry to say that I will be unable to address all their important comments and criticisms in detail. In this response, I will focus on replying to the commentators’ major objections.
In my paper, I suggested that the emigration of health workers from poor countries might not have harmful effects on health outcomes in general, or may only have relatively small negative effects in a wide range of cases. Several commentators challenge my analysis. Carwyn Rhys Hooper suggests that it is prima facie plausible that the emigration of health workers causes harm, and that there is insufficient evidence to reject this claim.2 Gilian Brock3 and Iain Bassington4 argue that my paper failed to consider the full range of possible harms that the active recruitment of health workers brings about. These commentators are correct in that we need more evidence about the effects of migration, and that it may be too soon to arrive at the all-things-considered judgment that the emigration of health workers does not generally enable serious harm.
Nonetheless, I believe that the active recruitment of health workers is still permissible. For one thing, I am less confident than Brock that the empirical research on skilled migration clearly establishes that the migration of skilled professionals causes harm to sending countries. There is a sizable body of empirical research that is inconsistent with many of Brock's claims. It is not obvious that the emigration of skilled workers depletes human capital in the sending country.5 ,6 In fact, there is evidence that the opportunity to emigrate can, in certain circumstances, even raise the stock of educated people in sending countries by increasing people's incentives to invest in education.7 The emigration of skilled workers can also promote bilateral trade, foreign direct investment and technology transfer.8 Brock worries that the emigration of skilled workers damages institutional quality, but some recent empirical research indicates that emigration can actually enhance institutional quality.9–11 People who immigrate to democratic countries can help spread democratic norms to their home countries through return migration and diaspora networks. Once emigrants acquire experience with relatively good governance abroad, they may demand more accountability at home. Emigration might not damage institutional quality on balance.
Iain Bassington suggests that the emigration of health workers may enable harm in middle-income countries because these countries face higher opportunity costs associated with medical migration.4 This is possible, but we clearly need a great deal of empirical evidence in order to know one way or the other. There is also some reason to doubt whether emigration from middle-income countries is in fact harmful. A World Bank report observes that most skilled migrants to wealthy countries come from large middle-income countries like Brazil, and that ‘[m]igration prospects in these countries induce more human capital accumulation, increasing not only the number of skilled migrants but also the skills of the global workforce generally,’12 although it is of course possible that the emigration of health workers in particular may have different effects. It is also worth noting that the governments of some middle-income countries even encourage the emigration of skilled workers as part of their development strategies.13 So, the emigration of medical workers from middle-income countries could, in principle, have significant costs, but this emigration might not generally have net costs in practice. While I neglected to consider all the complex effects that emigration has on sending countries in my article, it is unclear whether a consideration of these other effects should lead me to alter my basic conclusions.
Even if the migration of health workers has costs for the citizens of sending countries, this does not yet show that it is impermissible for organisations to recruit and hire these workers. This is so because the recruitment of health workers from poor countries benefits the health workers who emigrate. Health workers earn much higher incomes in rich countries. For example, nurses’ wages in Australia and Canada are approximately 25 times their wages in Zambia, and physicians’ wages in the USA are about 22 times the physician wage in Ghana.14 Health workers who immigrate to rich countries benefit in many other ways too. Many health workers enjoy more security and better access to professional training in rich countries. Health workers migrate because they want to improve their lives and the lives of their families.
These benefits matter from a moral perspective. To show that the active recruitment of health workers is impermissible, we would also need to show that the moral reasons to refrain from enabling the relevant costs to people in sending countries outweigh the moral reasons to benefit health workers. If the activities of an organisation have both beneficial and harmful effects, these activities may, nonetheless, be permissible if the reasons to bring about the beneficial effects are undefeated by the moral reasons to avoid enabling the harmful effects. Organisations that recruit health workers from low-income countries directly benefit these workers in a significant way. These organisations might also indirectly enable costs to people in the sending countries, although it is often extremely difficult for an organisation to reliably determine whether their actions do, in fact, enable these costs. It seems to me that the moral reasons to directly confer substantial benefits on health workers can outweigh the moral reasons to refrain from indirectly enabling other costs, especially when the existence and magnitude of these costs are highly uncertain.
Alok Bhargava argues that I have misunderstood his research with Frédéric Docquier. Bhargava claims that this research indicates that the emigration of health workers causes poor health outcomes and that I have wrongly denied this claim. I am grateful to Bhargava for clarifying his research with Docquier15 and for pointing out problems with my presentation of their findings. While my discussion of Bhargava and Docquier's research in my article should have been clearer and more precise, I do not actually hold the view that Bhargava attacks in his commentary.16 I agree that Bhargava and Docquier's research give us some evidence the emigration of health workers is causally related to bad health outcomes, but this research does not provide us with sufficient evidence to justify the all-things-considered conclusion that medical emigration causes these harmful outcomes.
Other factors might largely explain both high rates of emigration and poor health outcomes. The economist Michel Clemens cites Bhargava and Docquier's study and writes: ‘[w]hile there is evidence of a correlation between physician emigration from sub-Saharan Africa and adult HIV-related deaths, there are many factors that could produce this correlation besides true causation of death by emigration…’.17 Clemens observes that Bhargava and Docquier's identification strategy ‘allows no way to check for weak instruments—a problem proven capable of generating spurious inference by several recent studies.’18 Moreover, the meaning of the dataset in this study is vague because this data mixes different measures of who counts as an African physician abroad.19 Clemens points out several other methodological problems with Bhargava and Docquier's study.18 I by no means intend to dismiss Bhargava and Docquier's research. My point here is merely that this research does not conclusively show that physician emigration is a major factor in explaining high mortality rates.i This is why I claimed in my article that it would be a mistake to immediately infer that the emigration of health workers causes harmful health outcomes on the basis of Bhargava and Docquier's findings.ii
Some commentators object to my analysis of the special obligations of health workers. Brock claims that I incorrectly conceive of government subsidies for medical training as a kind of gift. According to Brock, some governments clearly expect health workers to refrain from emigrating in return for receiving public subsidies for their training. Brock argues that we should conceive of these subsides as investments that ground a claim to a fair return. I disagree. The mere fact that governments expect people to perform certain actions does not generate obligations to perform these actions. At least, we lack obligations to conform to other people's expectations when making major decisions about how to live our lives. Consider an analogy. Suppose that an overbearing parent expects his daughter to become a doctor and pays for her undergraduate education with this expectation in mind. But, at a later date, the daughter discovers that she is more passionate about art than medicine, and she decides that she wants to become an artist instead. The fact that the parent has a certain expectation about her daughter does not seem to impose an obligation on the daughter to become a doctor. This is the case, I think, even if the daughter at one point accepted and cultivated the expectation that she would become a doctor. I believe that the point generalises: it is morally permissible to defy other people's expectations when making major decisions about how our lives should go. The decision to emigrate is a major life decision. Governments may expect health workers to remain in the country where they received their training. But this expectation is insufficient to ground obligations to remain.
It is also false that governments are entitled to any particular returns on their investments. When people make investments, they usually incur risks that their investments will fail. If these risks eventuate, it is typically the case that no one is obligated to compensate investors by ensuring that they receive a desired return. Why would the investments of governments be any different? I agree that health workers can acquire obligations to bear some of the costs of their medical training. But, in the absence of a contractual agreement, health workers lack obligations to provide specific services. It is, in general, implausible that the beneficiaries of public programmes must provide specific services in order to do their fair share. For example, suppose that my government constructs and maintains a system of public roads, and that this system of roads benefits me in important ways. Perhaps this benefit grounds a duty of reciprocity to pay a fair share of the costs of providing these roads. But I do not need to personally help construct public roads or provide any other particular services in order to satisfy my duty of reciprocity. This is the case even if I was a construction worker or engineer with specialised knowledge about how to build roads. The same goes for health workers. They may have obligations to bear some of the costs of their training, but these obligations do not generate a requirement to provide specific services on behalf of their compatriots or remain in the country where they received their training.
Several commentators, particularly Hooper and Sigrid Sterckx,20 criticise my paper for ignoring the unjust background conditions that cause medical migration, and for implying that the status quo is acceptable. Hooper claims that rich countries inflict injustices on poor countries, and that organisations that recruit health workers could exacerbate these background injustices. These commentators are wrong to suggest that I approve of the status quo, but my explanation of why the status quo is unjust might be different from Hooper and Sterckx's explanation. I have elsewhere defended the view that the global order is unjust in large part because rich states systematically restrict immigration from poor countries.21 ,22 Immigration restrictions interfere with important liberties, and perpetuate global poverty and inequality. There is strong evidence that rich states could dramatically reduce global poverty and inequality by removing their immigration restrictions.23 ,24 If the citizens of rich states actually wanted to benefit the global poor, they would eliminate their unjust immigration restrictions. The elimination of immigration restrictions would probably help alleviate some of the background factors that cause high rates of medical migration, such as severe poverty. It is, moreover, hypocritical in the extreme for rich states to interfere with the active recruitment of health workers in the name of benefiting the global poor while simultaneously maintaining their unjust immigration laws.
So, I agree that the status quo is unacceptable. But most of the organisations in rich countries that recruit health workers are not responsible for the unjust status quo. Recruiting organisations may even contribute to mitigating this background injustice. Health workers in poor countries should have the legal right to immigrate to rich countries as a matter of justice. But, in the actual world, these workers often must secure a job offer or employer sponsorship in order to obtain the legal permission to immigrate. Employers who recruit health workers help these workers to obtain this legal permission. So, recruiting organisations assist health workers in securing the rights that are owed to them as a matter of justice. Recruiting health workers from the developing world is, in this respect, an admirable thing to do from a moral perspective.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
↵i Bhargava also criticizes my parenthetical remark that his study with Docquier's finds that the emigration of physicians is sometimes negatively correlated with adult deaths. I am still unclear on why Bhargava believes that this remark is a misrepresentation. In his response, Bhargava writes that the net effect of medical brain drain on adult deaths due to AIDS was negative (−0.005) when computed at the start of the sample in 1991 when the sample mean of HIV prevalence rates was 2.98%. Michael Clemens notes: ‘Bhargava and Docquier find that the fraction of physicians abroad has …a negative and significant effect on AIDS deaths in countries where HIV prevalence is low.’18 I would be curious to know if Bhargava thinks that Clemens’ claim is mistaken.
↵ii An objector might argue that we are also unable to infer that the emigration of health workers does not cause harmful health outcomes from the other studies that I cite. After all, these studies have problems too. It is true that I am unable to rule out the possibility that the other studies that I cite are flawed. Nonetheless, it seems to me that the balance of evidence at least casts doubt on the claim that the emigration of health workers from low-income countries generally enables serious harm, even if these studies fail to conclusively establish this claim.