Managing skilled migration

This paper is part of the Special Issue: Book symposium on Debating Brain Drain: May Government Restrict Emigration? More papers from this issue can be found at http://www.ethicsandglobalpolitics.net

Substantial migration of people across borders, while it can bring wonderful benefits for migrants and locals alike, can sometimes also have serious costs. Perhaps, the clearest illustration of these costs arises when medical professionals trained in developing countries choose to emigrate en masse to more affluent countries. Even in this case, one must be cautious in drawing the conclusion that a particular instance of ‘brain drain’ is harmful on balance. Massive outflows of skilled professionals can in principle generate more than fully offsetting benefits, whether by way of remittance flows to poor relatives, reform pressures on governments, or any number of other, more indirect mechanisms. Moreover, when doctors and nurses manage to flee war, persecution and violence, this should be counted an unalloyed blessing.

And yet there are cases, as the World Health Organization tells us, where mass emigration by doctors and nurses from reasonably well-governed but poor countries adds to already debilitating shortages of trained health professionals in those countries.1 The shortages are said to be so severe as to preclude the delivery of even the most basic medical services to large numbers of poor people. In some of these countries, governments make what are arguably good faith efforts to train new doctors and nurses at great public expense, but then these new trainees, too, depart soon after graduation.2 Cases of this kind raise urgent questions about what responsible governments may do to manage migration by trained health workers and other categories of critical service professionals.

These questions are at the center of the dispute between Gillian Brock and Michael Blake in their book, Debating Brain Drain. Brock and Blake agree that the enduring flow of critical service professionals out of certain parts of the developing world is a serious problem.3 Yet, they defend starkly contrasting visions of what, if anything, may be done to address this problem. Whereas Brock believes that a range of policies that would place limits on the ability of professionals to emigrate are morally open to poor but responsible governments, Blake insists that professionals trained in the developing world should be understood to have more or less absolute rights to emigrate at will, and to renounce their wider civic and taxpayer obligations. Since both authors believe that the global community's ability to deal effectively with some of the worst consequences of international brain drain depend on whether poor countries can ever justify placing substantial restrictions on emigration, they end on contrasting notes of cautious ‘hope’ in the case of Brock, and ‘moral tragedy’, if not quite despair, by Blake.

In this essay, I argue that justifying effective coercive or basic-structural institutional responses to debilitating forms of international brain drain is both easier and more difficult than these authors claim. It is easier because the problem could be addressed by governments in wealthy societies choosing to prioritize the poorest and least skilled applicants for immigrant visas, giving them strict priority over their more advantaged compatriots with advanced skills and professional degrees. Alternatively, wealthy societies could choose to provide all applicants with the exact same prospects of admission by abolishing their skill-selective immigration policies and implementing a comprehensive immigrant visa lottery system. Choosing either of these responses to brain drain would undoubtedly limit the global freedom of movement that many health workers and other skilled professionals trained in developing countries currently enjoy. But it could hardly be condemned on the liberal egalitarian grounds that both Blake and Brock say they favor. By contrast, policies implemented in developing countries that make it temporarily impossible or even just prohibitively costly for a skilled professional to emigrate are much more difficult to justify than either Brock or Blake supposes. I will argue that, under certain circumstances, such policies could in principle be permissible as well, but any adequate explanation for the permission will require answering difficult, as yet-unanswered questions about the priority of basic liberal rights.

What options does the global community have for responding to severe and enduring cases of international brain drain? Michael Blake's answer to this question begins and ends with what he calls the ‘liberal orthodoxy’ on skilled migration.4 According to this doctrine, governments may offer financial and other incentives, but they must not prevent skilled workers from emigrating. The reason, ultimately, is that there is a universal human right to emigration.5 According to Blake, this right is ‘much like the right to be free from torture—a right that could only be suspended under truly exceptional circumstances’.6 Indeed, writes Blake, ‘the emergency would have to be of sufficient gravity that the kidnapping of outsiders would be similarly permissible. Given the comparative rarity of these circumstances, I will generally speak simply as if there were never any occasions when a state may legitimately prevent its own current residents from leaving’.7

What lies beneath this basic human right and the strict constraints it places on what even the most responsible governments may ever do to manage harmful migration? Blake writes that it is the fundamental ‘liberal’ and ultimately ‘Rawlsian’ principle that ‘[p]eople cannot be coerced simply because their being so coerced would be useful’.8 Indeed, the same principle is said to explain why a person must be free to quit his job at will, and to move wherever he likes, within a single country. Once we see the full force of this principle, the thought that people could ever permissibly be ‘made’ to do things for others, whether at home or abroad, becomes ‘fanciful’.9 The ultimate implications for ‘what can be done about brain drain … are not very hopeful. There are some things that can be justly done in response to the brain drain, but these responses will not adequately address the problem. In the end, … the brain drain represents a sort of moral tragedy; we have a truly unjust world, and there are no solutions that are simultaneously effective and just’.10

I would like to suggest that these conclusions are hasty. Blake is right to stress that ‘we do not have any particularly great stock of knowledge about how to make impoverished societies wealthy’.11 However, there is another policy response to debilitating health worker migration that is open to the global community, and which does not involve placing any restrictions on emigration. The policy is a concerted decision by rich countries, not to exclude skilled professionals with advanced training from immigrating, but instead to assign greater priority in immigration to the countless poor and unskilled individuals who are at least as desperate to move to the wealthy industrialized world.

This policy response would undoubtedly pare back the freedom of many skilled professionals trained in developing countries to relocate to wealthier countries.12 However, greater priority for the least advantaged in admissions is not a policy to which Blake (or other proponents of the liberal orthodoxy) could plausibly object on grounds of justice. After all, according to Blake, contemporary developed societies have no obligation to accept any and all comers, and may turn away at least some of the millions of people who would like to immigrate.13 If this is the view, however, then it is difficult to see why governments in developed countries could not simply choose to prioritize the least skilled and most vulnerable applicants for an immigrant visa, and to de-prioritize various in-demand, highly skilled professionals such as doctors and nurses. Alternatively, upon duly admitting asylum claimants and allowing for family reunifications, wealthy countries could choose to allocate the remaining immigrant visas by way of a simple ‘Green Card lottery’ system. In this way, wealthy countries could give exactly the same prospects of admissions to each and every person who would like to immigrate, while finally admitting only the limited number of foreigners that defenders of the orthodox view think would be morally optimal. Again, it is difficult to see what Blake and fellow travelers could find so unjust about this policy. If rich countries do not have an obligation to accept any and all comers, then why precisely are they morally obligated to accept highly trained and in-demand health professionals over, say, unemployed truck drivers who also wish to immigrate, not to mention illiterate teenaged slum dwellers?

By contrast, if rich countries are permitted to prioritize the most vulnerable classes of would-be immigrants, then a permissible change in the immigration policies of the destination developed countries could potentially help to slow debilitating health worker emigration without any restrictions on exit imposed in developing countries. For rich countries could simply stop issuing visas to any comparatively well-off doctors and nurses from countries with severe shortages, while at the same time issuing these very same entry visas to much more desperate would-be immigrants from the developing world. As I have already stressed, the same effect could be achieved by replacing existing skill-selective immigration policies with a procedurally fair immigrant visa lottery system. Indeed, some critics have suggested that existing skill-selective policies may be downright unjust and may well have to be abolished.14 Be that as it may, it is surely permissible for wealthy countries to replace such overt favoritism in immigrant admissions with a less biased visa lottery system. Assuming due allowance is made for claims to refugee status and family reunification, what could be the objection from the defenders of the orthodoxy on migration? Note that they could not reasonably object to the lottery proposal on the grounds that it would amount to an ‘education and skill penalty’.15 After all, the status quo in immigration can in the very same way be described as a penalty on being even more downcast, exploited, forgotten, destitute, and illiterate.

Let me explain why the forgoing observations, far from changing the subject, amount to genuine criticisms.16 It is true that Blake's immediate purpose in Debating Brain Drain is to address whether restrictions on emigration, not immigration, are ever permissible. However, Blake is ultimately concerned to press his argument into the service of a much wider thesis: the brain drain represents a moral tragedy because ‘there are no solutions that are simultaneously effective and just’. As I have argued, this wider thesis is false. A policy of favoring the global least advantaged in admissions to rich countries, whether directly or because of the introduction of a lottery system, would inevitably limit the existing global freedom of movement of many skilled health professionals. Yet, there can be no objection to such a policy by someone who affirms Blake's orthodox theory of migration.

Moreover, Blake's ultimate concern is, rightly, what the global community as a whole may do to address harmful brain drain. To that end, he does not hold the actions of wealthy governments fixed but is prepared to judge even their moral permissions. And yet, if wealthy governments acted in one of the ways that I have argued is permitted, then it would not be especially urgent to ask whether poor countries may restrict emigration in order to stem brain drain. As I shall now argue, this question becomes urgent only when, and because, rich countries are routinely failing to exercise their far more extensive capabilities.17

The medical brain drain is not a situation of moral tragedy since wealthy countries can permissibly do something about it. Nonetheless, we should be skeptical of the idea of limiting catastrophic emigration by medical workers exclusively through policies implemented in the rich countries. This is not because all such policies are bound to be ineffective. On the contrary, the surest means of slowing harmful brain drain would be for wealthy countries to train an adequate number of health professionals domestically. With an adequate workforce trained domestically, nurses and doctors from poor countries would no longer be needed to take up the slack. Wealthy countries would then presumably have even more reason to prioritize the poorest and least skilled applicants for immigrant visas.

The main reason to set aside this policy alternative is that there is little indication that wealthy countries will be prepared to adopt it. There are, to be sure, some notable exceptions. Norway has recently made it a priority to train an adequate health workforce domestically precisely to avoid the need to rely on recruitment from poor countries.18 Similarly, after years of recruiting actively in poor countries, the United Kingdom has introduced legislation requiring employers to favor European Economic Area medical graduates in hiring.19 However, other wealthy countries have failed to take these kinds of steps, and some are intent on exploring options to make it even easier for foreign medical workers to receive legal permission to work.20

The reason for these decades-old efforts is simple. By preferentially admitting thousands upon thousands of foreign-trained medical professionals,21 rich countries reap an enormous windfall of skilled human capital.22 The stream provides them with a powerful incentive to continue to underfund domestic higher education. Hence, it is unlikely that harmful medical brain drain will ever be stemmed through major reforms to staffing and recruitment in the rich countries. Instead, if the manpower needs of the health systems of the world's poorest countries are to be met, it seems clear that poor countries themselves will have to take the necessary steps.

In defending compulsory service, Gillian Brock's aim is to open up a broad range of policy tools for this purpose. She argues that: (1) When other options prove ineffective in ensuring the delivery of important services, poor but responsible governments that protect human rights may in principle expect skilled individuals such as doctors and nurses to work in underserved communities for a limited period of time—say, for 1 or 2 years. (2) Provided that fair warning is given to all would-be students in advance, governments may enforce this expectation by two means that may render it temporarily impossible or prohibitively costly for a skilled graduate to leave: withholding proof of educational credentials and diplomas, and accelerated collection on government-funded educational loans.23

Now, Brock and Blake agree that, when limited service obligations are accepted freely in exchange for generous educational loans or subsidies, this agreement renders the compulsory service permissible as long as the student had other reasonable options. Whereas Brock rests the permission in such cases largely on considerations of reciprocity,24 Blake puts a heavier stress on considerations of autonomy. At bottom, however, Brock and Blake are of one mind: under the right circumstances, ‘it is obviously permissible to bargain away our rights’.25

I would like to suggest that both authors are mistaken on this point. The first question to ask when evaluating compulsory service schemes like the ones endorsed by Brock is whether they materially restrict one or another of the truly basic liberties of citizenship. If they do, then ‘any agreement by citizens which waives or violates [this] basic liberty, however rational and voluntary this agreement may be, is void ab initio; that is, it has no legal force and does not affect any citizen's basic liberties’.26 However, compulsory service schemes, as practiced and envisaged, do restrict at least one of the basic liberties of citizenship – through the deliberate withholding of educational credentials, they make it effectively impossible for graduates from poor countries to move abroad: even if they choose to run from their debts, students without credentials can no longer count on foreign job offers, priority immigrant visas, and foreign work permits. Indeed, that is the whole point, as far as health policy makers are concerned!

Now, we must be careful in drawing inferences from this observation. The mere fact that a compulsory service scheme restricts one of the basic liberties of citizenship does not imply that the scheme is impermissible and has to be abolished. However, it does imply that the scheme cannot be justified in the particular manner that Brock and Blake think adequate. To illustrate, consider the following analogy. If you have a basic civil liberty to leave Massachusetts and move your person elsewhere, then any contractual agreement to keep you physically present in my house for the next 2 years is void ab initio. It makes no difference whatsoever that you signed the contract voluntarily, nor that at the time of the agreement you had plenty of other reasonable housing opportunities. The moment you wish to leave, you must be allowed to do so, unless there is some much more fundamental reason that justifies temporarily restricting your freedom of movement. The mere fact that you have contractually agreed to remain in my house could never provide an adequate justification for the police or anyone else enforcing my putative contractual ‘rights’. In particular, it is entirely irrelevant that at the time of the agreement you had other reasonable options and gave your free and informed consent. Because the agreement purported to waive one of the truly basic liberties to which you are entitled as a citizen, the agreement was void from the very beginning.

A similar analysis applies to medical students who enter familiar schemes of compulsory service. By credibly threatening to withhold educational credentials in the event of a contractual default, these schemes make it effectively impossible for participants to move abroad for a substantial period of time. For without diplomas in hand, medical students from poor countries will generally not be allowed to settle abroad, let alone be offered permission to work. On the correct analysis, then, standard compulsory service schemes make instrumental use of the coercive border policies of other states in conjunction with domestic rules and laws, as a means of enforcing a duty to stay and preventing medical graduates from moving abroad for a time. In this respect, they clearly restrict the freedom of movement as well as the right to emigrate, both of which clearly belong to the basic rights and liberties of citizenship.

Let me stress once again that this does not entail that all such schemes are impermissible and must therefore be abolished. What it means is that no such scheme could ever be justified merely by pointing to considerations of reciprocity, informed consent, and freedom of contract. In particular, it is not enough to observe that some medical students but not others have accepted costly educational loans and subsidies.27 To justify placing substantial burdens on liberties as basic as the right to emigrate and the freedom of movement, much more fundamental considerations are needed than merely the fact that some individuals have seen fit to give up these liberties.

But what sorts of considerations could ever be sufficient for this purpose? One such class of considerations derives from the importance of securing for everyone the basic liberties of citizenship. Neither Brock nor Blake singles out this special class of reasons, but it bears directly on what the state may reasonably ask of free and equal citizens.

To illustrate, consider a situation that is all too common in the developing world. Police forces regularly go understaffed for lack of adequate tax revenues to hire and train additional personnel. As a result, the basic freedom from assault of countless slum dwellers is continually insecure. Blake believes that local elites nonetheless have a right to renounce their taxpayer obligations at will and to move their wealth abroad, even if this means that poor countries will be less able to raise the revenues that better policing requires.28 However, this position cannot be defended on grounds that are both liberal and appropriately impartial.

On the contrary, the liberty of globally mobile elites to avoid taxation on their foreign-source incomes may indeed be restricted if necessary to secure the freedom from assault for each and every person. The fundamental reason is not the (merely supporting) consideration that individuals who have been privileged have duties of reciprocity. The reason is that everyone has an identical claim to the basic liberties of citizenship, and everyone's freedom from assault is more significant or basic than anyone's freedom to renounce his or her citizenship for the purposes of avoiding further taxation.29

In this way, the aim of securing for everyone the basic liberties of citizenship can sometimes justify placing substantial restrictions on the basic liberties of otherwise globally mobile citizens. The task becomes more difficult, however, when everyone's basic liberties are already more or less secure, and what poor people need now are simply the skillful services of some midwife, nurse, or doctor. This is the situation in poor countries that have managed to secure public order and a reasonable rule of law but lack the ability to extend universal health care because too many medical graduates (rather than, say, financiers) continue to move abroad.

Can we say in these circumstances that a poor but responsible government may take steps that curtail one of the basic liberties of recent graduates? May such a government make it temporarily impossible for recent graduates to move abroad and pursue more profitable employment opportunities? Given that everyone's basic liberties are already more or less secure, could we ever plausibly say these things on a ‘liberal’ view?

Brock clearly thinks that we could. It seems to me, however, that these sorts of conclusions—even if they are sometimes true—continue to elude adequate defense on a liberal philosophical view. After all, what is necessary is an account of why the basic liberty of one person should give way not to the basic liberty but to the naked need of another person—in circumstances when everyone already has the basic liberties to which he or she is entitled as a citizen.

Trying to remain faithful to liberal intuition, perhaps the most promising route would be to say the following. In addition to a claim to the basic liberties of citizenship, each person should be understood to have an even more basic claim to the social conditions that make any of one's liberties worth having. In this vein, Rawls once suggested that the principle that calls on societies to protect the basic liberties (including the freedom of movement) may have to be ‘preceded by a lexically prior principle requiring that basic needs be met, at least insofar as their being met is a necessary condition for citizens to understand and to be able fruitfully to exercise the basic rights and liberties’.30

With such a ‘prior principle’ of basic needs in hand, it would be no great mystery why a young nurse could be asked to delay her move abroad, if an educational system requiring such delays were necessary to deliver universal access to, say, immunization against some debilitating disease. But there are hard questions about how to understand and delimit the prior basic needs idea. After all, there are many sacrifices of liberty and bodily integrity that we are not prepared to allow our social institutions to make, even when such sacrifices are necessary to save innocent people from debilitating conditions or even death. Forcible kidney transplants come to mind (when people on a waitlist would otherwise die), or medical research that would hasten life-saving discoveries by dispensing with practices of informed consent. In each of these cases, people either lack or stand to lose the conditions that make any of one's liberties worth having, and assuring these conditions for everyone may require restricting truly basic liberties such as freedom from assault and rights to bodily integrity. Since these sorts of restrictions are presumably never justifiable on an appropriately liberal view, it is only reasonable to ask: What is the content and what are the limits of the prior ‘basic needs’ justification for restricting truly basic liberties of citizenship?

To be sure, it is important not to exaggerate the skepticism licensed by these questions. Brock is right to think that it can be permissible to ask medical students to perform a period of compulsory service in a medically underserved area as a condition of receiving their diplomas, even if this policy effectively prevents medical graduates from moving abroad for several years. And yet it is one thing to know that a policy is sometimes morally permissible, and quite another to have explained precisely why it is, when it is. Brock writes that a compulsory service scheme can be permissible if it does not impose any ‘unreasonable’ sacrifices on its participants.31 But what this condition amounts to is the very thing that requires a deeper explanation.

In this essay, I have argued that the permissibility of standard schemes of compulsory service cannot be explained by appealing primarily to considerations of reciprocity, informed consent, and freedom of contract. Nor can we provide a fully adequate explanation by pointing to the importance of securing for everyone the basic liberties of citizenship. Perhaps, the most promising route, on a broadly liberal philosophical view, is to appeal to the even greater moral urgency of satisfying everyone's basic needs, at least when these are understood as the social conditions that make any of our liberties worth having. However, if we take this route, we are bound to face difficult questions about the priority of many, truly basic, liberal rights. Since these questions have not been adequately addressed, and no other plausibly liberal principles are in the air, it is not yet clear why the schemes of compulsory service that Brock defends are permissible when they are.

Notes

This paper is part of the Special Issue: Book symposium on Debating Brain Drain: May Government Restrict Emigration? More papers from this issue can be found at http://www.ethicsandglobalpolitics.net

1 World Health Organization, World Health Report 2006: Working Together for Health (Geneva: World Health Organization, 2006), xvii.

2 ‘In 2000, for example, Ghana managed to train 250 new nurses—and lost 500 nurses to emigration’. Gillian Brock and Michael Blake, Debating Brain Drain: May Governments Restrict Emigration? (Oxford: Oxford University Press, 2015), 2.

3 In their separate contributions to this book, Blake and Brock are cautious not to claim that the emigration of skilled professionals out of developing countries is always a net loss to the communities they leave behind (see 36–45, 159–68). However, the authors agree that, in a range of actual cases, mass emigration by skilled professionals represents a grave social problem (11–12, 44–5, 210–11, 264–7). Indeed, for Blake, the problem in these cases rises to the level of a profound moral tragedy (224–8).

4 Brock and Blake, Debating Brain Drain, 287.

5 As Blake notes, Article 13 of the Universal Declaration of Human Rights proclaims that ‘everyone has the right to leave any country, including his own’.

6 Brock and Blake, Debating Brain Drain, 120.

7 Brock and Blake, Debating Brain Drain, 120–1.

8 Brock and Blake, Debating Brain Drain, 205ff.

9 Brock and Blake, Debating Brain Drain, 288: ‘the thought that I could be made, on threat of imprisonment, to deliver lectures on ethics to undergraduates is a bit fanciful. This image, though, is implicitly what is at stake in the debate surrounding brain drain. To “condition,” “manage,” or “delay” exit is, implicitly, to threaten with legal punishment those who seek to depart ahead of schedule … I think we do have the right to be free from this sort of coercion. The University of Washington does not have the right to coercively prevent me from being a cad. Neither, I believe, does any state have the right to prevent people from leaving, even if they would be most useful to the world by staying in their states of origin’.

10 Brock and Blake, Debating Brain Drain, 208 (my emphasis).

11 Brock and Blake, Debating Brain Drain, 225.

12 At least insofar as they did not qualify for family reunification or refugee status. For an argument that the criteria for refugee status should be expanded to include anyone fleeing not merely persecution but desperate poverty and generalized violence, see Andrew E. Shacknove, ‘Who Is a Refugee?’, Ethics 95 (1985): 274–84. See also Kieran Oberman, ‘Can Brain Drain Justify Immigration Restrictions?’, Ethics 123 (2013): 247–55, 454.

13 Brock and Blake, Debating Brain Drain, 113: ‘I will be assuming, most importantly, that states have a right to exclude unwanted would-be immigrants, and that this right is not morally indefensible’. See also Michael Blake, ‘Immigration, Jurisdiction, and Exclusion’, Philosophy & Public Affairs 41 (2013): 103–30.

14 For an argument that skill-selective immigration policies are unjust when such policies contribute to the failure of high-income countries to satisfy their duties of aid to the residents of low-income countries, see Douglas MacKay, ‘Are Skill-Selective Immigration Policies Unjust?’, Social Theory and Practice 42 (2016): 123–54, 147–51. For a more extended argument for a similar conclusion, see Peter Higgins, Immigration Justice (Edinburgh: Edinburgh University Press, 2013). For a critical response, see José Jorge Mendoza, ‘Does Cosmopolitan Ever Require Restrictions on Immigration?’, Public Affairs Quarterly 29 (2015): 175–86. See also the works cited in note 17 below.

15 Ari Z. Zivotofsky and Naomi Zivotofsky, ‘Are Healthcare Workers Chained to their Country of Origin?’, The American Journal of Bioethics 9 (2009): 16–18.

16 I would like to thank an anonymous reviewer for pressing me to clarify these points.

17 Kieran Oberman argues against using immigration restrictions to counteract brain drain (except ‘in a small minority of cases’) on the grounds that, for such a policy to be permissible, it would have to be shown that (1) every professional who stands to be subjected to it has a moral duty to stay in his home country and that (2) this duty can be legitimately enforced by the destination country. For two reasons, Oberman's analysis does not undermine the argument of this section. First, Oberman does not argue that completely open borders are required. But if some restrictions on immigration are permissible, then with due allowance for asylum and other special claims, states may implement a procedurally fair lottery system to allocate the remaining immigrant visas. Second, it is false that for an immigration policy to be permissible, everyone subject to it must have a personal ethical obligation to do what the policy requires. On the contrary, the justification of immigration laws—as with other parts of the basic structure—turns on how they enduringly impact important categories of interests for whole groups or classes of persons. Yet, the very possibility of such an analysis is foreclosed by Oberman's individualist ethical approach. After all, the emigration of a single skilled worker rarely if ever has any significant impact on human development outcomes. Therefore, it will almost never be true that a given individual has a self-standing ethical duty to remain; yet, this is no reason to conclude that persons cannot have duties that follow from—rather than precede—how the basic structure of societies ought to be arranged. For the priority of principles of justice for the basic structure over ethical principles for individuals, see John Rawls, A Theory of Justice, rev. ed. (Cambridge: Harvard University Press, 1999), 95. For an extended development of the second critical point in this note, see Peter Higgins, ‘The Ethics of Immigration and the Justice of Immigration Policies’, Public Affairs Quarterly 29 (2015): 155–74.

18 Otto Christian Rø, ‘Health Personnel Challenges in Norway,’ in Migration of Health Workers: WHO Code of Practice and the Global Economic Crisis, ed. Amani Siyam and Mario Roberto Dal Poz (Geneva: WHO Document Production Services, 2014), 57, cited in MacKay, ‘Are Skill-Selective Immigration Policies Unjust?’, 152–3.

19 Claire Blacklock, et al., ‘Effect of UK Policy on Medical Migration: A Time Series Analysis of Physician Registration’, Human Resources for Health 10 (2012), 5–6, also cited in MacKay, ‘Are Skill-Selective Immigration Policies Unjust?’, 152–3.

20 See Linda Rabben, Credential Recognition in the United States for Foreign Professionals (Washington, DC: Migration Policy Institute, 2013), 9, 12–14.

21 In the OECD countries, approximately 20% of practicing doctors are by now foreign-trained and foreign-born. The figure now exceeds one-quarter of all practicing doctors in the United States, and more than one-third of all practicing doctors in New Zealand. See WHO, World Health Report 2006, 98. See also Amy Hagopian et al., ‘The Migration of Physicians from sub-Saharan Africa to the United States of America: Measures of the African Brain Drain’, Human Resources for Health 2 (2004): 1–10; and Fitzhugh Mullan, ‘The Metrics of the Physician Brain Drain’, New England Journal of Medicine 353 (2005): 1810–18.

22 Recall that medical students in the United States graduate with an average of more than $175,000 in private debt. This figure represents only a fraction of the full social cost of training an American doctor, which has for decades been at least 10 times the GDP per capita. See Robert F. Jones and David Korn, ‘On the Cost of Educating a Medical Student’, Academic Medicine 72, no. 3 (1997): 200–10, 200. Very few studies have been done on the social cost of medical education outside of the United States. One such study found that in Vietnam, a low-income country, the social cost of educating a doctor in 1997 was approximately 32 times the GDP per capita. See William J. Bicknell et al., ‘Determining the Full Costs of Medical Education in Thai Binh, Vietnam: A Generalizable Model’, Health Policy and Planning 16, no. 4 (2001): 412–20, 416. These figures give some indication of the value, and cost, of the de facto subsidy represented by skilled health worker emigration to rich countries and poor countries, respectively.

23 Brock and Blake, Debating Brain Drain, 43–51, 72–80, 102–04.

24 Brock and Blake, Debating Brain Drain, 60–8.

25 Brock and Blake, Debating Brain Drain, 215.

26 John Rawls, Political Liberalism (New York: Columbia University Press, 1993), 365. For a helpful discussion of the contrast between liberal and non-liberal views of the basic rights and liberties of citizenship, see Samuel Freeman, ‘Illiberal Libertarians: Why Libertarianism Is not a Liberal View,’ Philosophy and Public Affairs 30 (2001): 105–151.

27 On the contrary, it can be objectionable when only those who are poor enough to need loans are effectively forced to stay to meet urgent social needs. After all, burdens on the truly basic liberties of citizenship should not be allowed to vary so dramatically by social class or prior family wealth. For further discussion, see Lucas Stanczyk, “Productive Justice,” Philosophy & Public Affairs 40 (2012): 144-64, 159-60.

28 Brock and Blake, Debating Brain Drain, 212–13. For Brock's contrasting view, see 104–6.

29 What makes the second liberty less significant or basic? I cannot defend my own view here, but here is the Rawlsian answer that Blake (who enlists Rawls) does not mention: the freedom to avoid further taxation by renouncing one's citizenship is normally less basic or ‘less significant’ than the freedom from assault because the former freedom is ‘less essentially involved in [and hence is] a less necessary institutional means to protect, the full and informed and effective exercise of [one's] two moral powers’ of rationality and reasonableness in judging the justice of the basic structure of society and in reasoning about what sort of life to live. See Rawls, Political Liberalism (New York: Columbia University Press, 1993), 335.

30 John Rawls, Justice as Fairness: A Restatement, ed. Erin Kelly (Cambridge: Harvard University Press, 2001), 44, n. 7.

31 Brock and Blake, Debating Brain Drain, 104.