Bioethical implications of global mobility.
Rome, Jan 24-26, 2003

The issues

Although a number of academic papers have been recently devoted to single ethical problems raised by the impact of globalization on health, until now very little research has been devoted to the general issue, and, to our knowledge, no study has been produced on the bioethical implications of global mobility. Advances in transport and communications are determining factors in the globalization process, and wider access to these technologies has increased the mobility of people, goods and services; these developments have affected health and health care.
Three main issues will be addressed in the meeting:

The meaning of mobility in the West

From Homer to Jack Kerouac, mobility has always been a special feature of western narrative. Both the Greek and Jewish cultures were “cultures on the move”, and western identity has been chiefly built on the metaphor of the traveller (it suffices to think of Odysseus and Abraham, the two “fathers” of western identity). Even the very idea of the west involves the idea of movement: “Inherent in the oldest recoverable meaning of the word West were the idea of movement toward or beyond the (western) horizon and the idea of sunset, evening, the fall of the night. The English word west, unchanged since Saxon times, and its identical cognates in German and Scandinavian was an adverb of direction, as in ‘to go west’. It derived from the Proto-Germanic westra, and it, in turn, from an Indo-European word, wes-tero, which was the comparative form of an adverb, wes-, meaning ‘down, away’. West thus originally meant ‘farther down, farther away’, then, by extension, ‘something farther down and farther away; the direction of something farther down and farther away’.” (D.Gress, From Plato to Nato. The idea of the west and its opponents”.” (D.Gress, From Plato to Nato. The idea of the west and its opponents””, New York:The Free Press, pp. 24-25). The western idea of voyage, which underlies both the myth of geographical discoveries and colonialism, has been challenged by new global mobility. Global mobility means a changed perception of space and time. Many issues are arising from a changed perception of the global space both at the level of international institutions and of national states and individual citizens. As part of this, the role of the individual will be examined, in particular the process of individualization within a global framework and its impact on traditional ethical issues such as respect for autonomy.

Health problems in mobile and other vulnerable populations

Once the concept of mobile populations chiefly included economic migrants and asylum seekers. Today mobile population is made up of very different people and groups that have in common only the fact that they all operate across borders. In recent years the world has seen violent ethnic wars for autonomy and secession. About 40 violent conflicts are currently active and nearly 1% of the people in the world are refugees or displaced persons. Thirty million people are estimated to be internally displaced and 23 million to be refugees (seeking refuge across international borders), the vast majority of whom are fleeing conflict zones. Over 80% of all refugees are found in developing countries, although 4 million have claimed asylum in Western Europe in the past decade. People may also be forced to leave for environmental reasons, such as major climate changes and natural disasters (for example, recent floods in Mozambique, India, and Bangladesh; Hurricane Mitch in Central America; drought in the Horn of Africa; and the volcanic eruption in Montserrat), or displaced by major civil engineering projects or expansionist landowners. People caught up in various emergency situations are often highly vulnerable and may have been severely abused. Mobile populations do not comprise only highly vulnerable groups but also international tourists, business men, traders, members of NGOs and other people involved in international cooperation. The degree of proximity in our world can be illustrated by the fact that the number of international travellers has tripled since 1980 - three million people now travel abroad every day. In addition, last year the traffic on international telephone switchboards topped 100 billion calls for the first time in history. Mobile populations are vital actors of globalisation processes. They also pose – at different levels – different ethical challenges in the health field: from prevention of transmitted diseases to sexual tourism, till to recent initiatives to establish ethical guidelines for medical research in populations affected by conflict.

Cross-border healthcare and illegal trade in the healthcare field

Cross-border health care and illegal trade in the healthcare field are other key issues. In Europe. cross-border healthcare is likely to increase when the European Union enlarges to take in up to 12 other countries from central and Eastern Europe. The enlargement might also precipitate a brain drain of health professionals from east to west. The migration of providers from lower-income to higher-income countries may be slowed down by increasing immigration restrictions and unemployment of indigenous health professionals. "Medical tourism", on the other hand, may increase as patients seek effective or less expensive care, especially if the Internet provides information on available facilities. The Australian government has introduced a "medical visa" for those from abroad seeking health care in Australia, and an excess of hospital beds in the USA has prompted major marketing campaigns to reach potential foreign patients. Finally, although increased economic exchanges bring benefits, international trade in illegal products and contaminated foodstuffs, inconsistent safety standards and the indiscriminate spread of medical technologies through the Internet may threaten public health. For instance, careful regulations on access to prescription drugs in one country may be subverted when its neighbour allows the unrestricted purchase of antibiotics, thereby stimulating the appearance of resistant microbes that show up in the first country. Ruling this very delicate issue promises to create new ethical and social challenges.