Ethical Guidance for Medical Schools and Medical Students in High-Income Countries for Clinical Electives in Low- and...

Academic interest in ethical guidance for medical students from High-Income Countries (HICs) undertaking clinical electives in Low- and Middle-Income Countries (LMICs) has increased. Earlier ethical frameworks laid important groundwork but predate contemporary debates on social justice in global health. This study reviews recent literature to assess how these debates shape and produce ethical guidance, distinguish between ethical student conduct and elective programs, and how such guidance is translated into practice.

A systematic review was conducted on ethical guidance for HIC medical schools and students regarding LMIC electives. Articles published between January 2018 and October 2023 were identified from PubMed, Embase, and Global Health. Thematic synthesis was combined with analysis of authorship (pose) and intended audience (gaze).

Of 711 articles, 24 met inclusion criteria. Five interconnecting themes emerged: humility, reflection, local embeddedness, equitable partnerships, and student health and well-being. While these align with existing frameworks, guidance remains largely conceptual, with limited attention to implementation and accountability across ethical student conduct and program design, with responsibility predominantly located at the level of HIC students. Pose and gaze analysis revealed epistemic imbalances in authorship and intended audiences. Most articles reflected HIC-based perspectives, with North American authors overrepresented and no solely LMIC-authored articles.

Ethical guidance remains dominated by HIC perspectives and focused on student conduct rather than program structures. By distinguishing between individual and institutional ethics, this study highlights the need for actionable, co-created frameworks that address accountability, equity, and sustainability in LMIC electives, including attention to institutional responsibility and LMIC perspectives.