Introduction

As discussed in the module Who are the Underserved? an individual is medically underserved when they have decreased access to quality healthcare. One way that medical students, physicians, and other health professionals have addressed the issue of access is by creating free health clinics to allow underserved patients access to healthcare they may not have otherwise been able to. These clinics are often “staffed” by volunteer students and volunteer providers.

While well-intentioned, it is important for those who are participating in medical volunteerism to be aware of the challenges that can arise. What are possible unintentional negative consequences for the patients? How can we evaluate the ethics of medical care provided by volunteers? What can students and physicians do, not only to avoid doing harm, but to sustainably benefit the communities and people they want to serve? How do we ensure that volunteer-run clinics do not simply reproduce the same systemic issues and oppressions we see in other healthcare systems?

Volunteer-run Clinics in the US

Many students will volunteer at a community free clinic at some point during their time in medical school, and many physicians will volunteer in medical settings later in their careers. While the motivations for volunteering are varied, there are many similarities in the critiques against volunteer-run clinics across the country and the ethics of their care for underserved patients. As a brief introduction to some of the issues that can arise, read Free Clinics: The Disparities That No One Are [sic] Talking About, written by medical student Azraa Chaudhury in 2022. Be sure to also read the comment that follows the article.

Obviously, some free care is thoroughly and thoughtfully planned, supported, funded, and executed. The Value of Medical Students in Free Clinics: Why Medical Students are Uniquely Positioned to Understand, Empower, and Serve offers a 2020 reflection by medical student Sofia Rojasova. In it, she notes,

"Several studies have compared student-run free clinics to comparable clinics or national measures and found no difference, whether in quality of diabetes care, mental health care, preventive care, ability of infrastructure to address chronic and acute complaints, or in high levels of patient satisfaction with care teams."[2,9-13]

Patient Outcomes from Student-Run Health Services: An Integrative Review (P. Broman, et. al, 2022), a paper not cited by the medical student above, utilized integrative review methodology to examine patient outcomes from student-run clinics (SRCs). Including 51 published and peer-reviewed articles, primarily from the US, the authors found generally positive health outcomes for patients.

However, other articles and evaluations of SRCs do not confidently demonstrate such benefits. One literature review, Measuring health outcomes, experience of care and cost of healthcare in student-led healthcare services: A literature review (L. Simmons, et. al, 2022) reviewed 14 published and peer-reviewed articles in evaluating patient impacts of student-run healthcare primarily in the US using the Triple Aim framework. The authors concluded that unfortunately, the evaluations of the services were not consistent enough to make confident observations about the benefits of the programs.

The bottom line is that while it’s not impossible to provide high-quality care in a student-run clinic, it takes a significant amount of intention, investment, resources, leadership, organization, and follow-up. More research is also needed to evaluate clinic outcomes.

The Four Principles of Medical Ethics

In the field of medical ethics, American philosophers Thomas Beauchamp and James Childress established the Four Principles in their 1979 textbook Principles of Biomedical Ethics. These principles are a widely accepted ethical framework in medicine. The principles are beneficence, nonmaleficence, autonomy, and justice:

Chart showing the four principles of medical ethics

Adapted from Burks, Douglas J. “Beauchamp and Childress The Four Principles”

Watch this quick video introducing these principles, keeping in mind how volunteer-run clinics in the US can carry out – or fail to carry out – these tenets.

https://youtu.be/1p8Z-K4LkxU

The Four Principles and Healthcare for the Underserved

Beneficence (doing good) is the foundational principle in healthcare and in efforts to provide care to the underserved, binding patient and provider in trust. As long-tenured, well-remembered UW bioethicist Thomas McCormick wrote, “This principle is at the very heart of health care implying that a suffering supplicant (the patient) can enter into a relationship with one whom society has licensed as competent to provide medical care, trusting that the physician’s chief objective is to help” (N.D.). When you care for patients who have barriers to healthcare access and non-stigmatized care, you are working to uphold the principle of justice (ensuring fairness or equity).

The ethical obligation for providers to give accurate and complete information to patients and the rights of patients to then make their own decisions regarding their healthcare (informed consent, or autonomy) is a relatively new priority within medicine. This is a departure from the tradition of medical paternalism in which doctors made decisions for their patients’ health without focusing on patient choice and the concept of patient-centered care and strategies of motivational interviewing support this shift. In underserved healthcare, patients lacking financial resources, facing stigma and discrimination, and enduring higher levels of stress and trauma may often feel less control over their own lives than their more privileged and resource-abundant counterparts. Therefore, it is even more important to give space for autonomy with your underserved patients.

When you graduate medical school, you’ll almost certainly take a version of the Hippocratic Oath. That promise is often associated with the phrase “first, do no harm.” Nonmaleficence (do no harm) might seem like an obvious or easy ethical principle, but is there a spectrum of harm, and are we always aware of harm that we cause? To be aware of potential harm, we need to be informed. As one doctor wrote, this principle “affirms the need for medical competence.” (McCormick, n.d.) Is it OK if a patient consents to harm? What about preventing a larger harm by employing a lesser harm? In the clinic, we can care for people who have experienced trauma by intentionally using trauma-informed care to avoid re-traumatizing them. Another way to uphold this principle is to respect privacy and confidentiality 100 percent of the time; imagine the kind of harm that could be inflicted on a family and community if you noted that your patient was undocumented in your charting and the word got to ICE? Nonmaleficence (do no harm) is “a reminder that doctors should neither overestimate their capacity to heal, nor underestimate their capacity to cause harm” (Shmerling, 2020).

When ethical dilemmas arise in healthcare, it is often because these four principles, or a subset of them, are in conflict with each other.

For example, while free clinics attempt to address issues related to healthcare access and equity (justice), patient preferences and choices (autonomy) are limited in where and how they can access care (e.g., due to lack of insurance or stigma they may experience in healthcare settings).

A conflict between the principles of nonmaleficence (do no harm) vs. beneficence (do good) comes into play when pre-licensure students are trying to provide care but do not have the skills and/or knowledge necessary to provide high-quality care.

Case Examples

You are an MS1 at an clinical outreach event at a shelter for women and children experiencing houselessness. It is a busy clinic day, with many children and parents coming for screening of upper respiratory infections. A mother of a four week-old baby comes for a visit and is concerned about her baby who has a fever of 100 and who she says is not breathing well. Your preceptor is seeing another family and asks you to do the initial intake and physical exam of the baby. You have never worked clinically with children of any age, and you have very little personal experience with such young babies. The mother seems rushed and tells you that she only has a few minutes before she needs to catch the bus to pick up her older child from daycare.

What is your initial reaction to this case example? Is there anything that makes you feel uncomfortable?
What ethical principles are involved in this scenario? (autonomy, justice, beneficence, nonmaleficence)
What would you do if you were in this scenario?
What kinds of barriers could there be to carrying out the right course of action?
What would help you to carry out the right course of action?

You are an MS2 participating in a Teeth and Toes clinic at a local Indigenous housing and human services agency. The medical student team is providing foot care services (cleaning and exams) for clients and the dental students are providing oral exams. A patient arrives with severe gangrene and two completely necrotic toes. Your medical preceptor has stepped away and only the dental faculty remain. You have been given clean socks and foot-washing instructions, but you have no other training in podiatry.

What is your initial reaction to this case example? Is there anything that makes you feel uncomfortable?
What ethical principles are involved in this scenario? (autonomy, justice, beneficence, non maleficence)
What would you do if you were in this scenario?
What kinds of barriers could there be to carrying out the right course of action?
What would help you to carry out the right course of action?

Photo: Student volunteer and preceptor at a student-run foot care clinic in Seattle.

You are volunteering at a busy clinic and when you pass through the waiting area, you overhear a conversation between two potential clients. One says to the other, “I hope I am not seen by any students today. I want care from a real doctor.” When you return to the clinic area you are unsure whether to tell the treating team about what you overheard.

What is your initial reaction to this case example? Is there anything that makes you feel uncomfortable?
What ethical principles are involved in this scenario? (autonomy, justice, beneficence, non maleficence)
What would you do if you were in this scenario?
What kinds of barriers could there be to carrying out the right course of action?
What would help you to carry out the right course of action?

You are an MS2 attending a fall quarter event organized by the local Latinx medical student group at a Catholic church with congregants who primarily speak Spanish (limited English) and are over 65 years old. The goal today is to administer as many flu vaccines as possible, and there’s a big line – the organizers expect to have at least 50 people today. Your role is to support the volunteer pharmacists and nurses that will be administering the vaccines. Most of the volunteers do not speak Spanish, but they’re distributing flyers about the potential adverse side effects of the vaccine (in English) and there are two Latinx medical students who are bilingual at the event. You also notice that there’s a physician volunteer who is taking photos at the event of people getting vaccinated.

What is your initial reaction to this case example? Is there anything that makes you feel uncomfortable?
What ethical principles are involved in this scenario? (autonomy, justice, beneficence, non maleficence)
What would you do if you were in this scenario?
What kinds of barriers could there be to carrying out the right course of action?
What would help you to carry out the right course of action?

Reflect, Evaluate, and Act to Manage Ethical Conflicts

Critically reflect on and question your motivations for doing clinical service learning work. Consider whether your volunteerism comes from a place of altruism (concern for the well-being of others, especially those “less fortunate”) or solidarity (unity of action, a shared vision, mutual aid). Often altruism shows up in these settings as a savior complex which reinforces power imbalances between patients and providers.

Pay attention to the balance between service and learning. The care you’re providing and your own learning goals can come into conflict. For example, you’ll benefit from more hands-on clinical experiences as an MS1, but will your patient benefit to the same degree? Could there even be unintentional harm done to the patient, be it obvious or through neglect? Will they be receiving the quality of care they deserve or would get if they were not underserved and could access a typical clinic or provider? Do we even perhaps have an ethical obligation to actually prioritize the service and the needs of vulnerable populations over student learning? How would this happen? What would it look like? Consider how you might elevate the people you serve over your own need or desire to learn/practice clinical skills. Follow the mantra of Give more than you take.

Critically evaluate your level of skill and always act within your scope of training and experience. Consider what you can realistically offer to the patients and make sure your expectations are in check. It might very well be that you don’t put your hands on a single patient, and that’s OK. Maybe you won’t have an appropriate opportunity to practice your clinical skills every time you show up to volunteer, and that’s OK.

Don’t be afraid to speak up if you're asked to perform a task and you don't feel comfortable with it or you feel that you don’t have the skill to do it well. Throughout medical school, you might become accustomed to doing things you're uncomfortable with and preceptors might assume you have more training or experience than you actually do. Service learning and medical volunteerism don’t have the same structure and oversight as clinical training does, so err on the side of caution and understand that it's appropriate for students to often do less rather than more! It’s imperative that you pay extra attention to your feelings and partake in honest self-evaluation of skills when dealing with underserved patients to ensure nonmaleficence (do no harm).

Students listening to foot care patient.

There is an enormous variety of ways for medical students to support the health and healthcare access of our most vulnerable neighbors. Read on for more concrete strategies for thinking about the clinics you lead and participate in, as well as many other ways to get involved.

Photo: Medical student volunteers at a student-run skin care clinic in Seattle, 2018

CHAP: a program based in community needs and agility

Students providing service aimed to improve the health of vulnerable communities is important. They are best developed with a stepping back from the desire to act as clinicians, using and practicing newly learned skills. It is equally important to realize and check that these communities are not being exploited by learners. Here are two good examples of needs-based service projects from the Community Health Advancement Program (CHAP) at UW Seattle:

CHAP Holly Park-1.jpg

Photo above: CHAP volunteers at Holly Park Clinic, circa 1980

The first CHAP project was the Saturday Clinic at Holly Park Clinic that opened in 1980. It was a model partnership and structure for a free student-run clinic. CHAP provided expanded hours to the clinic for sixteen years. CHAP’s services ended in May 1996 when the clinic initiated evening and weekend hours. CHAP was no longer meeting an unmet need, so students worked with the clinic staff to identify service gaps. A need for foot care and education for diabetic patients was identified, and CHAP’s foot care clinics were born. The project later expanded to a number of shelters working with people who are unhoused and today the foot care project lives on within UW School of Medicine Service Learning in Seattle and at other regional sites as well.

Students cooking for the Chicken Soup Brigade

In 1994, students at a CHAP retreat decided they wanted to serve the HIV-positive community delivering clinical care. They set out to develop a relationship with organizations who were serving this community. What evolved was collaborating with the Chicken Soup Brigade (CSB) and adding to their person-power fixing meals for people homebound with AIDS. Once a month they prepared 200-300 meals. Two years later, CSB was able to hire a full-time chef. No longer filling an unmet need, CHAP closed the project.

Photo right: CHAP student volunteers cooking for CSB, circa 1994

Promoting Ethical Care in Student-Run Clinics

Watch the following video from UWSOM Service Learning "Entering Communities Respectfully" and implement the practices that are outlined:
Practice cultural humility:

Do your research and learn about the communities you’ll work with. Maybe that means reading about systemic racism perpetrated against the patient population, learning about the political history of their home country, learning about their religious beliefs, or watching interviews with people experiencing homelessness talking about their daily experiences.
In addition, continue honing your cultural humility. As Ada Stewart writes in the Leader Voices Blog for the American Academy of Family Physicians article Cultural Humility Is Critical to Health Equity (n.d.),

"We must continue learning throughout our lives because we are ever-changing based on what is going on with us and with our patients. We must be humble about our level of knowledge regarding our patients' beliefs and values, aware of our own assumptions and prejudices, and active in redressing the imbalance of power inherent in the physician-patient relationship. Finally, we must recognize the importance of institutional accountability."

It is often much more efficient to become involved with an established clinic/program rather than create an entirely new one. Think of the positive impacts you can make by participating in and leading in a well-attended clinic and advocating for changes in policies and processes to make the patient care more ethical.
- - One option is to get involved as a student lead or general volunteer (see the UWSOM Service Learning page or the Underserved Pathway's list for some opportunities) and work to ensure policies and processes promote ethical care of underserved patients

Work together with other health sciences students and professionals (in the fields of social work, nutrition, and dentistry, to name a few) to provide the best care possible for medically complex patients. All providers and volunteers should be practiced in trauma-informed care.

Nine student volunteers are standing in a circle listening to the shelter manager speak before a foot care clinic.

Photo: Medical and nursing students meet with shelter managers before a student-run foot care clinic in Seattle, 2022

Starting a New Project

It’s imperative to seek leadership from and work collaboratively with a community partner, and ideally with community members themselves. Offer to incorporate community health assessments in the planning stages if the community partner hasn’t identified specific health needs. Once any unmet healthcare needs of the community are identified, candidly assess how your group can contribute in a sustainable, long-term way, and whether your group can ethically deliver care to help meet those needs. See the CDC's Community Health Assessment & Health Improvement Planning page and the below evaluation links for related resources.
Ensure that any clinic’s scope of care is comprehensively defined and documented and clearly communicated to all volunteers and patients well in advance of any patient care.
When starting a new project, ensure you have capacity for ongoing program efficacy monitoring and assessment. Work with your community partner and other stakeholders (e.g, those receiving health services, the healthcare providers, any entities providing funding) to set program goals and design evaluation for measuring progress toward those goals. Ensure adequate and accurate data collection and regularly report the results to stakeholders, improving the project as necessary based on key metrics. Program outcomes (these may include patient health outcomes and satisfaction with service, rates of actual follow-up care, cost per patient, or other measures) should at least be on par with comparable paid clinics. Some resources:
- - Start with these CDC resources: Types and Uses of Evaluation and Program Evaluation Framework
  - Nine Ways to Strengthen Program Evaluations by Centering Community Voice
  - Rural Health Information Hub's page on Evaluation Design in their Rural Community Health Toolkit
  - Encourage your community partner to work with the UW School of Public Health to find students to help with ongoing data collection and evaluation: sphpractice@uw.edu.
Ensure there are adequate numbers of licensed preceptors to supervise students and that they are regularly trained to carry out the goals of the clinic.
Ensure that it’s reasonable and realistic for patients to actually receive follow-up care and ensure they have supporting resources to help them achieve it. Consider working with community clinics to create a referral system to reduce barriers. Consider the physical, economic, and psychological roadblocks between your patient and that care. What good is learning that your blood pressure is high if it’s impossible to take the next steps to improve your health?
If patients and healthcare providers do not speak the same language, interpretation services must be available. Interpreters, volunteer or paid, should be held to the same standard as professional medical interpreters in the US. Any type of printed material (if that is culturally appropriate), such as health advice/education or medication labels, should be in the patient's first language.
Maintain patient privacy and confidentiality (including photos) just as you would in any paid clinic.
Below are example guidelines for medical schools developing programs for students to serve in domestic free clinics for immigrant populations:

Source: Shah, Sural, 2019

Other Ways to Get Involved

Another way to effect change at the population level aside from health policy work is good research on under-researched topics that affect underserved patients. You might be interested in UWSOM Family Medicine’s Research opportunities, for example, with ongoing research into rural health initiatives, opioid use disorder, and abortion access.
Real influence happens with long-term involvement as an advocate for policy change or systemic change (such as for Medicare For All or Doctors for America). Many professional medical organizations support students with advocacy toolkits. You can also get involved with a professional association related to your specialty and work to promote policies through the association. See the supplementary resources list at the end of the module for more resources.
Check out the UP modules Advocacy I: Physicians as Advocates and Advocacy II: Tools for the Physician Advocate for more tools and ideas.
Take an advocacy course if you’re on the Seattle Foundations campus or work with other students to develop one – see this integrated health policy and advocacy course within the University of New Mexico School of Medicine's Family Medicine clerkship or the two UWSOM courses listed below.
- - Seattle Foundations students have two non-clinical selective options as of Spring 2023:
    - UCONJ 646 - Interprofessional Advocacy for the Health Professions - meets weekly in the evening and focuses on advocacy at the local/city, state, and federal levels. Students work together on a group project that is presented at the end of the quarter.
    - UCONJ 624 - Health Equity and Community Organizing - a weekend workshop that talks about best practices in community organizing.

Serving Abroad: International Medical Volunteerism

While this module has focused on domestic medical volunteering, we recognize that many medical students will want to volunteer abroad. Perhaps you are in the Global Health Pathway and/or you will participate in or have participated in the Global Health Immersion Program (GHIP). These programs take place in low- and lower-middle-income countries, or LMICs (you may have heard the terms Third World, Developing World, or Global South – click here for an NPR article on the evolution of these labels).

Examine your motivations for wanting to go abroad for medical volunteering. Don’t be the satirical news article in the The Onion titled "6-Day Visit to Rural African Village Completely Changes Woman’s Facebook Profile Picture.” Again, consider your power and privilege, and whether yours is a calling to altruism or solidarity. Are you invested in changing the system, or is your volunteerism upholding the systems that created global disparities?

Take the time to delve into the histories of people in the country you’re interested in. How have people from upper income countries affected those in LMICs with the stated intent of “saving” or “helping” them? Read more at Tracing Historical Determinants of Health: Intersections of Colonialism, Neocolonialism & Global Health Policies & Practices. Consider the roles of power and privilege, and the history of extractive and/or settler colonialism in the country where you plan to volunteer. How have these histories shaped healthcare access? How do locals view visiting providers?

The bottom line is that every program that offers medical students experiences in global health is different. If you are considering doing global health work, make thoughtful and informed decisions based on the ethical framework presented at the beginning of this module when selecting and participating in your program. Throughout your participation, continue honest reflection on the ways in which your program upholds (or fails to uphold) the four principles of medical ethics. Use feedback channels and continued involvement to improve your program to prioritize the ethical care of the patients.

Quote about history as a determinant of health

More harm than good? The questionable ethics of medical volunteering and international student placements discusses the exploitative history of short-term international medical volunteer trips, specific concerns related to medical volunteers, and suggestions for better, collaborative approaches when working to improve healthcare around the world. Take a moment and read the 10-page paper (2017) here.

Source: Dumbaugh, M., et. al, 2021

One example of a positive partnership was the seven-year (beginning in 2012) Rwanda Human Resources for Health Program, a Rwanda Ministry of Health program to address shortages of healthcare professionals in Rwanda through the training of faculty. Faculty and students in the health sciences from the US went to Rwanda to collaborate with Rwandan counterparts in professional training, research, and care, and Rwandan faculty and students traveled to the US "to give lectures, participate in clinical clerkships, and pursue further training, while others have presented their work at … conferences" (C. Cancedda, et. al, 2018). The program used strategies based on many of the Six Principles of the Brocher Declaration, listed below.

Guiding Principles for Global Medical Volunteerism

Learn about the Six Principles of the Brocher Declaration from Advocacy for Global Health Partnerships (AGHP), a coalition of global health organizations, governments, and more. From Global Health Partnerships and the Brocher Declaration: Principles for Ethical Short-Term Engagements in Global Health (S. Prasad, et. al, 2022):

1. Mutual partnership with bidirectional input and learning
2. Empowered host country and community define needs and activities
3. Sustainable programs and capacity building
4. Compliance with applicable laws, ethical standards, and code of conduct
5. Humility, cultural sensitivity, and respect for all involved
6. Accountability for actions

The University of Minnesota offers a free web-based workshop for pre-licensed health sciences students called Global Ambassadors for Patient Safety. If you’re planning to participate in a global health experience or you’d just like to learn more, be sure to check out the free self-paced workshop here.

Continue to the next page to complete this module's assignment.

Supplementary Resources

Ethics and adjacent:
- Ethical Storytelling (video, 8 mins)
- Ethics in Medicine: an educational resource designed for clinicians in training hosted by the Department of Bioethics & Humanities at UWSOM.
Global health:
- Advice To Parachuting Docs: Think Before You Jump Into Poor Countries: a 2018 NPR article outlining some of the types of concerns presented in this module.
- Ethical Challenges in Short-Term Global Health Training by Stanford University Center for Global Health and the Johns Hopkins University Berman Institute of Bioethics: ten cases with multiple-choice responses that demonstrate and discuss ethical challenges.
- Hoping to Help: The Promises and Pitfalls of Global Health Volunteering by Judith Lasker (2016).
- Guidelines for short-term medical missions: perspectives from host countries. Global Health 18, 19 (2022) by Tracey, P., et. al.

Health equity research: In the domestic public health sphere, there’s been an uptick in researchers jumping into health equity research (and publication) without the necessary expertise, background, and long-term commitment to health justice and systemic change. Read more about the unintentional harm done by these researchers and how they can become community members and co-conspirators toward health justice in the 5-page paper from 2022, Health Equity Tourism: Ravaging the Justice Landscape.
- Policy and advocacy:

Health Equity Circle (has chapters on most UWSOM Foundations campuses)
National Rural Health Association: Student Constituency Group and Advocacy Campaigns pages

American Medical Association: Health Policy Action Committee & Team Advocacy Toolkit and articles: How medical students can be effective advocates on social media (2021), Medical student advocacy: 4 tips for effective lawmaker visits, (2021), How to get involved in advocacy work as a medical student (2019)

Works Cited

Broman P, Tokolahi E, Wilson OWA, Haggie M, Andersen P, Brownie S. (2022) Patient Outcomes from Student-Run Health Services: An Integrative Review. Journal of Multidisciplinary Healthcare. 2022 Mar 30;15:641-665. doi: 10.2147/JMDH.S348411. PMID: 35387392; PMCID: PMC8979421. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8979421/

Cancedda, C., Cotton, P., Shema, J., Rulisa, S., Riviello, R., Adams, L. V., Farmer, P. E., Kagwiza, J. N., Kyamanywa, P., Mukamana, D., Mumena, C., Tumusiime, D. K., Mukashyaka, L., Ndenga, E., Twagirumugabe, T., Mukara, K. B., Dusabejambo, V., Walker, T. D., Nkusi, E., Bazzett-Matabele, L., Butera, A., Rugwizangoga, B., Kabayiza, J. C., Kanyandekwe, S., Kalisa, L., Ntirenganya, F., Dixson, J., Rogo, T., McCall, N., Corden, M., Wong, R., Mukeshimana, M., Gatarayiha, A., Ntagungira, E. K., Yaman, A., Musabeyezu, J., Sliney, A., Nuthulaganti, T., Kiernan, M., Okwi, P., Rhatigan, J., Barrow, J., Wilson, K., Levine, A. C., Reece, R., Koster, M., Moresky, R. T., O’Flaherty, J. E., Palumbo, P. E., Ginwalla, R., Binanay, C. A., Thielman, N., Relf, M., Wright, R., Hill, M., Chyun, D., Klar, R. T., McCreary, L. L., Hughes, T. L., Moen, M., Meeks, V., Barrows, B., Durieux, M. E., McClain, C. D., Bunts, A., Calland, F. J., Hedt-Gauthier, B., Milner, D., Raviola, G., Smith, S. E., Tuteja, M., Magriples, U., Rastegar, A., Arnold, L., Magaziner, I., & Binagwaho, A. (2018). Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda. International Journal of Health Policy and Management, 7(11), 1024-1039. doi: 10.15171/ijhpm.2018.61 Retrieved from https://www.ijhpm.com/article_3524.html

DeGrazia, D., & Millum, J. (2021). Nonmaleficence and Negative Constraints. In A Theory of Bioethics (pp. 58-96). Cambridge: Cambridge University Press. doi:10.1017/9781009026710.004. Retrieved from https://www.cambridge.org/core/books/theory-of-bioethics/nonmaleficence-and-negative-constraints/2FBCD2D0E272CDE1D8E3AC6838BEA20C

Dumbaugh M, Hanneke R, Kalaitzi V, Kim S, Swatscheno J, Valencia A, Peters K. (2021). Public Health and Global Societies: A survey course in Global Health. Retrieved from https://pubh110.digital.uic.edu/

Kilbride MK, Joffe S. (2018). The New Age of Patient Autonomy: Implications for the Patient-Physician Relationship. JAMA. 2018 Nov 20;320(19):1973-1974. doi: 10.1001/jama.2018.14382. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988779/

Lett, E., Adekunle, D., McMurray, P. Ngozi Asabor, E., Irie, W., Simon, M., Hardeman, R., & McLemore, M. (2022). Health Equity Tourism: Ravaging the Justice Landscape. J Med Syst 46, 17 (2022). Retrieved from https://doi.org/10.1007/s10916-022-01803-5

McCormick, Thomas. (n.d.) Principles of Bioethics. University of Washington Department of Bioethics and Humanities. Retrieved from https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics

Prasad, S., Aldrink, M., Compton, B., Lasker, J., Donkor, P., Weakliam, D., Rowthorn, V., Mantey, E., Martin, K., Omaswa, F., Benzian, H., Calgua-Guerra, E., Maractho, E., Agyire-Tettey, K., Crisp, N., & Balasubramaniam, R. (2022). Global Health Partnerships and the Brocher Declaration: Principles for Ethical Short-Term Engagements in Global Health. Annals of Global Health. 2022; 88(1): 31, 1–9. Retrieved from https://doi.org/10.5334/aogh.3577

Rojasova, Sofia. (2020). The Value of Medical Students in Free Clinics: Why Medical Students are Uniquely Positioned to Understand, Empower, and Serve. Free Clinic Research Collective, 6(1). Retrieved from https://www.themspress.org/journal/index.php/freeclinic/article/view/476

Shah, Sural. (2019). How Should Academic Medical Centers Administer Students’ “Domestic Global Health” Experiences? AMA J Ethics. 2019;21(9):E778-787. doi: 10.1001/amajethics.2019.778. Retrieved from https://journalofethics.ama-assn.org/article/how-should-academic-medical-centers-administer-students-domestic-global-health-experiences/2019-09

Shmerling, Robert H. (2020). First, do no harm. Harvard Health Blog, Harvard Health Publishing, Harvard Medical School. Retrieved from https://www.health.harvard.edu/blog/first-do-no-harm-201510138421

Simmons, L. M., Emily, C., Barker, R., & Barnett, F. (2022). Measuring health outcomes, experience of care and cost of healthcare in student-led healthcare services: A literature review. Focus on Health Professional Education: A Multi-Professional Journal, 23(1), 37–64. Retrieved from https://doi.org/10.11157/fohpe.v23i1.389

Stewart, Ada. (n.d.) Cultural Humility Is Critical to Health Equity. Leader Voices Blog, American Academy of Family Physicians. Retrieved from https://www.aafp.org/news/blogs/leadervoices/entry/20190418lv-humility.html

Sullivan, Hannah. (2019). Voluntourism. AMA J Ethics. 2019;21(9):E815-822. doi: 10.1001/amajethics.2019.815. Retrieved from https://journalofethics.ama-assn.org/article/voluntourism/2019-09