Médecins Sans Frontières (MSF), or Doctors Without Borders, offers physicians from wealthy countries the opportunity to utilize their medical expertise in poor areas. To do so, however, many physicians must forgo large salary earnings–sums that would likely save more lives if they were donated rather than sacrificed….
The starting yearly salary for a physician employed by MSF is currently under $20,000. By contrast, the mean 2009 salary for a general practitioner in the U.S. is $168,550. Clearly, there are more efficient uses of many doctors’ time and skills than to join MSF, even (or especially) if their main motivation is to save lives and treat the sick. Indeed, many U.S. physicians could easily donate enough to more than cover the salary of another doctor employed by MSF and pay for his/her medical supplies.
A similar issue arises in other professions.
The dilemma was posed by Prof. Christopher Olivola, Carnegie Mellon University
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Ethical Decisions 
Donating, rather than volunteering to practice medicine in a poor country, seems clearly utilitarian for a U.S. doctor. But it raises a question: if doctors donate rather than serve personally, who is left to practice medicine in poor countries? The utilitarian’s answer is based on marginal net benefit. Doctors with high salaries, who can create greater net benefit by donating, should do so. Doctors with low salaries can rationally work for MSF, and they presumably will meet local needs. The result is an equilibrium situation in which the doctors in low income countries are precisely those who can contribute more through service, and the reverse for those in high income countries, resulting in an optimal allocation of effort.
This is a beguiling argument, but there is a weakness in it. The allocation of effort in equilibrium may be individually optimal but not globally optimal. Even if no individual can increase utility by volunteering for MSF, a joint decision by many to volunteer may increase total utility.
Ethics does not necessarily require a global optimum, but it does require that the individual doctor’s decision be generalizable as well as utilitarian. One of the doctor’s reasons for donating rather than serving is that it will result in better medical care than now exists. But this calculation is based on the current medical infrastructure in poor countries, which relies on the efforts of many MSF doctors and other volunteers who could make more money elsewhere. For a donation to be generalizable, medical care must improve if all these volunteers made the same calculation. It is far from obvious that it would, since the medical infrastructure could collapse. There may simply be too few qualified personnel willing to work for $20,000 a year and maintain an infrastructure that can make use of donations.
A sufficiently large donation in lieu of service may be generalizable, but this must be investigated. Simply quoting the current tradeoff doesn’t settle this issue.
Volunteering for MSF is not necessarily generalizable, either, if it is done solely for the purpose of improving medical care. It may result in a shortage of doctors in affluent countries. In reality, career decisions are based on a number of factors, and the entire rationale must be checked for generalizability. Volunteering for MSF is more likely to be generalizable, for example, if the doctor’s reasons include a strong desire to help the less fortunate and a tolerance for a low standard of living. Volunteering in this case may not maximize net utility, but it is nonetheless ethical if donating (rather than volunteering) is not generalizable. The utilitarian principle only requires one to maximize utility subject to generalizability. On the other hand, donating is more likely to be generalizable (as well as utilitarian) for a wealthy doctor who has no particular drive to help the poor and can’t tolerate mosquitos and squat toilets.
A practical problem with donation in lieu of personal service is that one may not follow through. I have heard stories of people who justify their choice to work for a hedge fund with the intention to practice philanthropy after they get rich. They end up going into debt. The real estate around New York City is expensive, the kids deserve the best private schools, and the spouse has little interest in altruism.
This problem does not arise if one makes a contribution directly through one’s career rather than indirectly through philanthropy. There are many worthy careers besides practicing medicine in poor countries. An ethical career is one that maximizes one’s utilitarian contribution subject to generalizability, given one’s talents and inclinations.
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