Framework for ethical international academic partnerships in family medicine

Why partnerships are essential.

Partnerships are the foundation of family medicine. The Institute of Medicine defines primary care as

the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.¹

Given the scope of family medicine, there is no doubt that partnerships are essential.

Partnerships are also essential in a global context where the goal is to ensure healthier communities and more equitable health care systems. The Millennium Development Goals (agreed on in 2000)² acknowledge that virtually nothing in the sphere of international development happens without effective partnerships. There are also ethical reasons for partnership. Several scholars have shown that those particularly vulnerable to the choices of others and the outcomes of such choices deserve extra consideration to be measured.^3,4

There are many challenges in forming partnerships, such as financial constraints, sustaining commitment of the organizations, safety, and risk management. Other challenges are related to a moral shift to “learn to unlearn,” including being aware of Western cultural biases.⁵ Valuing differences, seeing strength in diversity, acknowledging power differences as well as sharing power, and stating expectations clearly are important factors to ensure that the partnership will enhance the mutual goals, the benefits, and the reciprocity that partners expect from it.⁶

The challenges of setting up partnerships call for the active contribution of key stakeholders.⁷ The World Health Organization has identified 5 principal partners: policy makers, health managers, health professionals, academic institutions, and communities. Although all have their strengths and constraints, they share a common set of values such as quality, equity, relevance, and cost-effectiveness, as well as a certain vision for future health services delivery. These common values make it possible to establish working relationships with the common aim of creating health services based on people’s needs and, finally, to anticipate “productive and mutually rewarding partnership[s].”⁷

Partnerships and ethical considerations.

Although partnership is seen as an interorganizational relationship, it most often occurs between leaders participating in a project. These people might take positions different from those of their institution or compensate for their lack of position. When 1 or more members risk adopting behaviour that cannot be justified in the light of shared values, ethical dilemmas might emerge. These situations can undermine the objectives and the achievement of the partnership’s mission.

Equitable partnership—ie, to be “impartial, just and fair to all parties as dictated by reason and conscience”—is often emphasized in partnership development.⁸ Measurable indicators for equitable partnerships have been identified, such as transparency, respect, solidarity, and equity.⁹ In their highest form these values are to be lived, not only in collective accomplishments but also in the way those accomplishments are achieved, including the implementation of partnership governance models. It is therefore important to be able to refer to a document that provides guidelines when managing and responding to complex situations or thorny problems. It is also important to have a reference guide that helps decision making in accordance with the rules, norms, and values promoted by the partnership in question.

Case description. You have just started a new international partnership as part of a primary care improvement project. The needs are great and the funding, although attractive, will probably not be enough to reach your goals completely. In parallel with this project, your partner is taking steps to develop a new specialized private clinic service in his environment and he would like to use the prestige of your university to obtain funding for this project. This new request will directly compete with the first project for limited time and resources. In addition, this new project does not meet the criteria of social responsibility, which is a key value of your university mission. You are uncomfortable with the request of your partner but you are thinking first and foremost that you do not want to interfere with the project already under way. You want to be sure you make the decision that ensures the objectives of the initial project are not compromised, which will have a direct effect on improving the health of the population. In such a context, how do you know or make the best ethical decision?

The importance of having an ethical framework.

Having an ethical framework for partnerships can be very useful, as disagreements can be real and important. Not every decision requires application of an ethical framework. In some situations, however, the right thing to do might be unclear or doing it difficult.¹⁰ For example,

• you might know the “right” thing to do in a situation, but encounter organizational or personal barriers, or you might encounter a situation where 2 equally important values seem to conflict;

• there might be conflict between members of a team around a challenging situation, often stemming from differing professional roles, beliefs, or worldviews; or

• there might be moral ambiguity—a situation characterized by uncertainty about the right thing to do either because it is novel or because it has unique features that make standards of practice difficult to apply.

An ethical framework can also help to overcome the limitations of conventions. The conclusion of a cooperation agreement does not mean that a number of underlying issues have been sufficiently explicit on both sides. Latent disagreements might remain that cannot be resolved over time by recourse to simple ethical rules, but which could have been resolved through previous discussions.

An ethical framework is therefore a complement to other resources to facilitate and strengthen partnerships among key stakeholders. It provides ethical guidance to those responsible for undertaking and overseeing partnership activities, given the challenges—and ethical considerations—inherent in linking cultures, goals, and processes across sectors. It also reassures members and the general public about the quality of services provided.

Ethical decision-making process.

As a hub of international collaboration advancing family medicine globally, the Besrour Centre welcomes new partnerships. The organization strives to ensure that partners with such responsibility do the “right thing” in order to establish better health for all. But without an evaluation framework, it cannot make such assessments. An explicit ethical framework can then have considerable practical usefulness that can improve support in the area of partnerships.

Principles underlying ethical decision making.

Principles for ethically sound international academic partnerships have been advanced as a response to the flawed nature of many North-South research partnerships.^11–14 Based upon the values of the Besrour Centre and those put forward during the 2 workshops dedicated to the development of this ethical framework, we suggest a set of 10 core principles that members of the Canadian global health community need to consider when they engage in partnerships. Together, these principles (see Figure 1 and the electronic supplementary material available from CFPlus^*) create a structured guide that stakeholders in partnerships might find helpful to identify potential ethical issues in interventions and actions, to reduce the creation of ethical tensions, and to assist in decision-making processes. These principles are complementary and interdependent; however, each principle in the framework should not be independently morally binding.^11,15 How they apply and the weight accorded to each will depend on the nature and context of the partnership being undertaken. There will be times when actions are approved despite 1 or more of the principles not being met.

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Figure 1.

Principles guiding the action of the stakeholders in the partnership

Frameworks for decision making.

Translating values into action requires a practised method for exploring and weighing the ethical aspects of a decision that should guide a course of action. Based on the principles here, using a framework to engage in ethical decision making regarding partnerships will help the members of the Canadian global health community and their partners to decide on the best approach for their situation and needs, whether at the initiation, maintenance, or reinforcement stage of a partnership.

Establishing partnerships: choosing ethical partners.

Over the course of the 2 workshops described above, the Besrour Centre facilitated a series of activities that fostered the framework development (Table 1).^13,16 It is most useful when implemented as early as possible in the collaborative process, before formulation of the partnership design.

Using this framework, potential partners can identify and address the most important issues in their collective capacity to establish a partnership. Such a framework does not indicate the level of determination to proceed with or abandon a partnership. A “go-no-go” strategy can help stakeholders assess the value, risks, and implications of a partnership so that they can confidently go ahead, know that more information or negotiation is required, or decide not to proceed. The Victorian Health Promotion Foundation in Australia has a Partnerships Analysis Tool available to organizations entering or working in a partnership to assess, monitor, and maximize the ongoing effectiveness of the partnership.¹⁷ This involves completing a checklist that rates 7 areas of a successful partnership, similar to those presented in Table 1. This checklist is useful for members of the Canadian global health community in their go-no-go decision for an ethically sound international academic partnership.

Managing partnerships: aligning with the ethical principles of the partner organizations.

Ethical issues of decision making in partnerships arise at every stage of the process. Ongoing collaboration throughout the partnership is essential for an ethical partnership, and partners should reach mutual decisions about every stage of the process from its design and implementation to its ending. Partner organizations should be aligned in their ethical principles. To that end, a reflective, deliberative process is essential, as each partner will have their own concerns and interests. There are a number of key steps that partners should consider to have ethically aligned relationships. This process can be seen in the electronic supplementary material available from CFPlus.^*

Case deliberation. After considering the principles guiding the action of the stakeholders in the partnership and following the steps of decision support, the best ethical decision would result from the following activities.

• Context: Review and define the social, economic, language, and cultural characteristics of the community that is expected to benefit from the partnership. Develop strategies that foster the involvement of stakeholders.

• Goals and expectations: Identify the goals and expectations of each potential partner. Discuss the pros and cons of working together, giving special attention to completed or ongoing joint projects. Define principles that promote transparency and mutual exchange of information.

• Logistics: Foster a critical understanding of each partner’s limitations in terms of contributing to the partnership, with particular attention paid to competing priorities. Work to elicit concerns about the collaborative process, giving careful attention to issues of partners’ readiness to participate.

• Remedies for problems: Create a mechanism for allowing modification when unanticipated events affect the partnership. Create a mechanism for monitoring partnership activities to ensure quality and to address problems as they arise.

Case resolution. After this reflection, you realize that you have extensively discussed with the partner your respective commitments and the values that support your involvement. You have already provided a mechanism to guide you in decision making or managing conflicts that are bound to arise. This approach has also allowed you to better know your partner, to share your respective visions, and to harmonize them while making sure that the project will be consistent with the values of each of your institutions. You had also completed a document that formalized the ethical framework of your partnership and mentioned that in any situation where one of the partners would consider making modifications to the initial agreement, this could only happen with the agreement of both partners, and that these changes should respect the original ethical framework. You rely on these documents to discuss the new proposal and soon you both come to the conclusion that this request could jeopardize the original project and would not contribute to achieving the goal of improving the health of the population in the spirit of health equity that is at the heart of the project. Your partnership continues on this basis, and a situation that could have generated tensions is solved without affecting the links that unite you.