12 October 2020

Each year, more than 10,000 nurses leave the Philippines to work in other countries. They often do so under international agreements on labour migration. Such agreements cannot always be defended from an ethical point of view, and labour migration raises ethical questions for both the individual and the Filipino health and medical care systems. These are the conclusions of a new doctoral thesis presented at LiU.


Klein Fernandez travelled to the mountains of the Philippines as part of his master’s degree in medical anthropology. He intended to study the access of the indigenous population to medical care. He was, however, struck by one surprising fact – there were no nurses there.

“It was a paradox. The Philippines sends nurses to other countries, but medical care personnel are lacking in rural areas of their own country”, he says.

This is the background to Klein Fernandez’ doctoral project. His thesis in the field of applied ethics and public health discusses the ethical questions that are raised by labour migration within medical and social care in the Philippines, who has responsibility for these ethical questions, and how that responsibility can be distributed.

“The nurses themselves choose to emigrate, but labour migration is controlled by the government through bilateral agreements. These were used during the 1970s as a way to get people into employment and strengthen the economy. The state trained the nurses, sent them to other countries and received payment. This has continued to this day”, says Klein Fernandez. Klein Fernandez, PhD student in applied ethics.Klein Fernandez.

The Philippines has export agreements for nurses with around 15 countries, including Germany, Japan, Saudi Arabia, Kuwait and Bahrain.

Consequences of bilateral agreements

Klein Fernandez shows that the international contracts affect both individuals and the medical care system in the Philippines. 

The nurses who emigrate experience different conditions in the new country. It is not always the case that they are treated equally with their colleagues there, and they may not be always covered by insurance or pension benefits. They may suffer from a lack of human rights in certain countries.

The labour migration also affects the medical care system in the Philippines. There are not enough healthcare personnel for the needs of the population. Klein Fernandez describes this as a global crisis in medical care. Countries accept workers from outside in order to solve personnel deficiencies within their healthcare system, but this in turn causes deficiencies in the country that provides the workers.

The agreements – ethically defensible?

Klein Fernandez applies a theory of justice proposed by American philosopher John Rawls to analyse the conditions that should be satisfied in order for the agreements to be ethically defensible.

These conditions deal with such issues as principles of equal liberty, that everyone is to have access to social rights such as medical insurance and pensions, equal pay for equal work and that the receiving country takes political responsibility for the consequences that the migration has for the exporting country.

The results presented in the thesis show that the agreements of the Philippines with Japan and Germany are acceptable from an ethical perspective, but some problems arise during the implementation. The agreements with Saudi Arabia and Kuwait, in contrast, are not ethically defensible.
Klein Fernandez believes that possible solutions to the ethical questions are the use of standard agreements, and larger political responsibility.
“The differences are a result of policy decisions. What’s needed is work to ensure that the countries on both sides of an agreement take a larger responsibility. We have to ask, however, what political responsibility is. It may be, for example, that the country receiving the workers supports the country from which they come – in such areas as medical research, education and equipment”, he says.
Translated by George Farrants

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