• International Migration of Health Professionals

Debating Brain Drain is an excellent book and I have learned much from both Gillian Brock's and Michael Blake's contributions.1 In this commentary, I will focus on Brock's contribution in part because I largely agree with Blake's position. But I also think that Blake neglects to emphasise some important epistemic considerations that weigh against Brock's argument.

Brock argues for the view that legitimate states can permissibly require skilled citizens to complete compulsory service before they can emigrate. One component of Brock's argument for compulsory service requirements is that these programmes would reduce deprivation. For example, many poor countries have few doctors, nurses and other health workers. If health workers emigrate from these countries, then the citizens of these countries may lack access to adequate medical care. Suppose though that states required health workers to complete compulsory service before they can emigrate. This policy might help alleviate the shortage of health workers in poor countries. Brock's argument for compulsory service has other facets as well. She argues that skilled citizens have moral responsibilities to remain in their countries for a period of time and states can therefore compel these citizens to stay. But Brock indicates that compulsory service programmes for skilled citizens would be unjustified if they failed to bring about good outcomes (pp.96–7, 100–1).

Liberals think that states need strong moral reasons to justify restricting valuable liberties, such as the freedom to emigrate. Brock seems to accept this presumption in favour of liberty (pp.250). But do the reasons in favour of compulsory service overcome this presumption? Unless we are absolutists about liberty, we should concede that restrictions on liberty are justified if these restrictions are necessary to bring about sufficiently good outcomes. However, to justify infringing on valuable liberties, we need compelling evidence that this infringement would actually bring about desirable consequences. And I am sceptical that we have compelling evidence that abridging the freedom to emigrate would have good results.

As both Brock and Blake observe, skilled migration can have positive and negative effects. Skilled migration can exacerbate shortage of workers who provide vital services, such as health workers, and can have other negative effects. But the emigration of skilled workers can also facilitate technology transfer, improve institutions, increase flows of remittances and encourage human capital formation. Brock concedes that skilled migration has ‘some positive, some negative, and some quite mixed results’ and that there is ‘much that we have yet to learn’ (pp.267). One reason for this uncertain state of affairs is that it is hard to isolate the direction of causation. Skilled migration sometimes correlates with bad development outcomes, but these bad outcomes may also cause skilled people in low/middle-income countries to emigrate. As a result, we are often unable to determine if skilled migration is the cause or merely the symptom of deprivation.2 This problem with causal identification helps explain why social scientists disagree about the effects of skilled immigration and why we can expect this disagreement to persist in the future. Yet, if social scientists are unable to reliably identify when skilled migration has bad effects on net, it is doubtful that public officials will be able to do so.

More importantly, we have almost no evidence that restricting freedom of movement would reduce deprivation. The economist Michael Clemens observes: ‘There is no real-world setting in which deterring skilled-worker migration of any kind has been shown sufficient to cause development by any measure’.2 Even if skilled emigration has negative effects, it does not follow that measures to prevent the emigration of skilled workers would have good effects. Suppose that a state implements Brock's proposal to compel skilled citizens, including citizens who attended private universities, to complete compulsory service for a year or two. This proposal might lower the returns to education even for citizens who have no intention of emigrating, which could cause fewer people to pursue higher education. Alternatively, people may decide to pursue higher education in another country in order to avoid these requirements. It is easy to imagine reasons why compulsory service requirements could fail to bring about the desired outcomes. But the more fundamental problem is that we may never know if compulsory service worked or not. Imagine that states enforce compulsory service and development indicators in these states improve. Can we be confident that compulsory service caused these good outcomes?ⁱ

Brock does briefly mention evidence of compulsory service requirements for doctors in order to argue that her proposal would have good effects (pp.98–9). As Brock notes, there is little rigorous evidence that these programmes improve health outcomes (Brock says that these programmes ameliorate loss of service, but it is seems to me that we should care about health outcomes rather than service per se). For instance, Brock cites a study of Ecuador, which requires the graduates of all medical, nursing and dental schools to perform a year of service in a rural area in order to obtain a licence to practice. But it is noteworthy that the authors of the study report that it is ‘highly unlikely’ that this programme improved health outcomes in part because doctors lacked adequate training and access to facilities.3 At any rate, even if compelling physicians to stay in a country has good results in some cases, we are unable to infer that prohibiting skilled citizens from emigrating would have good results in general.

So, I agree with Brock that it is in principle permissible to restrict freedom if this is necessary to significantly reduce deprivation. But public officials are often in a bad position to know if restricting emigration would have beneficial effects in any particular case. For this reason, poor states should err on the side of liberty and refrain from limiting emigration. States should instead pursue less-speculative measures to reduce deprivation.