tutional decision-making culture and context are often shaped by the behaviour of local leaders. Accreditation bodies are increasingly emphasizing the importance of eth- ical accountability at the highest level of health organiza- tions, are giving increasing attention to defining the moral attributes and competencies of ethical leadership, and are developing standards to monitor and evaluate ethical per- formance of health organizations. What are key ethical issues in global health? Considerations of justice are central to global health. While access to good health may be thought to be a vitally impor- tant ethical principle, it remains unavailable to most peo- ple. Health in low-resource countries is often compromised by social determinants, such as poverty, malnutrition, poor education, unhealthy living conditions, and lack of access to health care, as well as by corruption in the public and private sectors. The global health care status quo reflects a collective failure of the international community to meet the most basic needs of most of the world's population. An urgent challenge in global health ethics is to specify the actions that wealthier countries should take, as a matter of global justice and solidarity, to promote global health equity. The problem of limited access to health care in resource-poor countries has been exacerbated by a "brain drain"." Health professionals trained in resource-poor countries are com- monly recruited to work in wealthier countries, resulting in a severe shortage of health care workers in the former. This raises questions about the ethical acceptability of such recruitment and the incentives that might be used to dis- courage emigration. This is another case of a moral con- flict between the freedom to relocate and associate freely and the need to improve the health of some of the most vulnerable people. B. Health ethics in practice: key issues and challenges 19 Another set of ethical issues in global health is related to cultural relativity. It is sometimes asked whether ethical standards are universal, given that different people in dif- ferent countries may hold different values or place different weights on common values. For example, some practices that are widely condemned by the international commu- nity, such as female genital mutilation, may still be carried out by certain social groups in accordance with specific religious or cultural beliefs. While some people may argue that condemning such practices as human rights violations constitutes a form of ethical imperialism, others strongly argue that we must stand up for the women and children who are at risk of being harmed. A third challenge in global health ethics concerns interna- tional research, especially where investigators from wealthy countries conduct research in impoverished settings where participants are especially vulnerable or where language and cultural barriers make informed consent difficult. One of the most hotly debated issues regarding international research ethics during the past two decades has been about standards of care: what level of care should be pro- vided to participants in the control arm of a clinical trial in settings where the usual standard of care is especially low? And what level of care or other benefits should be pro- vided to participants or participating communities at the conclusion of a trial?

tutional decision-making culture and context are often shaped by the behaviour of local leaders. Accreditation bodies are increasingly emphasizing the importance of eth- ical accountability at the highest level of health organiza- tions, are giving increasing attention to defining the moral attributes and competencies of ethical leadership, and are developing standards to monitor and evaluate ethical per- formance of health organizations. What are key ethical issues in global health? Considerations of justice are central to global health. While access to good health may be thought to be a vitally impor- tant ethical principle, it remains unavailable to most peo- ple. Health in low-resource countries is often compromised by social determinants, such as poverty, malnutrition, poor education, unhealthy living conditions, and lack of access to health care, as well as by corruption in the public and private sectors. The global health care status quo reflects a collective failure of the international community to meet the most basic needs of most of the world's population. An urgent challenge in global health ethics is to specify the actions that wealthier countries should take, as a matter of global justice and solidarity, to promote global health equity. The problem of limited access to health care in resource-poor countries has been exacerbated by a "brain drain"." Health professionals trained in resource-poor countries are com- monly recruited to work in wealthier countries, resulting in a severe shortage of health care workers in the former. This raises questions about the ethical acceptability of such recruitment and the incentives that might be used to dis- courage emigration. This is another case of a moral con- flict between the freedom to relocate and associate freely and the need to improve the health of some of the most vulnerable people. B. Health ethics in practice: key issues and challenges 19 Another set of ethical issues in global health is related to cultural relativity. It is sometimes asked whether ethical standards are universal, given that different people in dif- ferent countries may hold different values or place different weights on common values. For example, some practices that are widely condemned by the international commu- nity, such as female genital mutilation, may still be carried out by certain social groups in accordance with specific religious or cultural beliefs. While some people may argue that condemning such practices as human rights violations constitutes a form of ethical imperialism, others strongly argue that we must stand up for the women and children who are at risk of being harmed. A third challenge in global health ethics concerns interna- tional research, especially where investigators from wealthy countries conduct research in impoverished settings where participants are especially vulnerable or where language and cultural barriers make informed consent difficult. One of the most hotly debated issues regarding international research ethics during the past two decades has been about standards of care: what level of care should be pro- vided to participants in the control arm of a clinical trial in settings where the usual standard of care is especially low? And what level of care or other benefits should be pro- vided to participants or participating communities at the conclusion of a trial?