This GUEST POST is written by Michael Clemens
This week, Professor Jonathan Wolff has warned the world that the United States “steals doctors from poorer countries” because it “simply does not train enough doctors to meet its voracious appetite for medical attention.” This is a strong accusation. Professor Wolff, a philosopher, should reconsider several dubious assumptions that his strong claim requires.
First, it is illegitimate to assume that it is possible for anyone to “steal” a human being. The very concept of such an act requires it to be possible for human beings to be owned by others. The notion that health workers may be owned—while presumably Professor Wolff would be offended if any person or group claimed ownership of him—is offensive. It is also illegal where Professor Wolff resides: the United Kingdom outlawed the ownership of people by other people in 1833. People, including health workers, who voluntarily leave their countries are not passive objects of others’ acts of “stealing”; they are active agents exercising a right guaranteed them by Article 13.2 of the United Nations Universal Declaration of Human Rights.
Second, it is incorrect to assume that the emigration of health workers from a poor country must cause a shortage of health workers at the origin. For decades, more nurses have left the Philippines to work abroad than leave any other country on earth. Yet in the Philippines today there are more Registered Nurses per capita than in the United Kingdom. This happened because so many Filipinos trained up as nurses to take advantage of opportunities abroad that this more than offset the departures. There is no such thing as a fixed stock of health workers in the world; they can be created, and wonderful career opportunities abroad are one of the forces that create them at home. The realities that shape the global health workforce are more complex than the simplistic picture that Professor Wolff paints.
Third, it is simply false for Professor Wolff to assert,
“If a doctor from Ghana is recruited to the US, not only does Ghana lose its doctor, it loses the money paid for the training. It may be that the doctor is likely to send a portion of earnings back home (known in the development business as ‘remittances’). But this is scant compensation.”
In fact, the average African-trained member of the American Medical Association left his or her country of training well over five years after earning the Medical Doctor degree—as I learned when I surveyed them. Thus an African country that has invested in the training of a typical emigrant doctor has already received several years of service from that doctor (without even accounting for care provided during medical school). So it is false to say that the investment in the training of those people is fully “lost”. Furthermore, African-trained members of the American Medical Association send home to Africa, on average, over $6,000 per year, even 20 years after arriving in the United States—including those who send no money. Far from being “scant compensation”, this means that the typical African-trained doctor coming to the United States has sent back much more than the cost of training another doctor in the country he or she came from.
Fourth, Professor Wolff’s argument requires the assumption that a proper policy goal of any country is that of zero immigration. Professor Wolff argues that the U.S. should train as many health workers as it needs. This, logically and inescapably, implies zero migration for health workers. (If every country did this, there logically could be no international movement of health workers as such—unless of course they gave up their professions and cleaned floors.) Zero migration of health workers means that the Ghanaian emigrant doctors Professor Wolff refers to must be forced to live in Ghana against their will—at a small fraction of the living standard of their colleagues in other countries, and of Professor Wolff’s living standard—or give up their profession to live elsewhere. “Self-sufficiency” in doctors at the destination would leave no other options for any of them. The ethical legitimacy of that state of affairs, and the consequent legitimacy of policies designed to bring it about, deserve more pondering than they have apparently received from philosophers. Taking actions that consign others to fates we would not accept for ourselves is something that we should do only with sad reluctance, based on great certainty and overwhelming evidence that directly harming health workers in this fashion will save lives. Professor Wolff has no such evidence.
Too much of the writing on health worker migration appears oblivious to the notion that health workers have agency or rights, and to the idea that the realization of health workers’ ambitions is an inherent good. I would expect philosophers to be the first concerned with such things, not the last. To anyone reading this post, I plead: If you ever say that health workers from poor countries are “stolen” or “poached”, please stop. That small change will mean that you begin to speak of them as human beings rather than owned property. Discussions of their movement must start from that premise, inside or outside our departments of philosophy.
In this paper I offer a non-technical summary of research on the above claims, and on related claims about the effects of skilled-worker migration on poor countries.