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3 How toMaintain Ethical Standards ofGlobal Surgery Practice andPartnerships
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their engagements with LMIC surgery
programs.
It was Pelegrini that stated that surgery is a
moral practice, and every surgeon is therefore a
moral agent [8]. Ethical principles are universal,
but the specic details of the application of these
principles are inuenced by context, geography,
and personal experiences. Global surgery in difcult international terrain is intrinsically complex and invites subtle and overt moral
ambiguity– a literal “how to” manual effectively
over-simplies the compound reality. In addition,
most literature on global surgery ethics is intrinsically biased, as 80% is written exclusively by
authors from HICs [5]. Note that this is not a literal step-by-step “how to,” but a general guide
that must be put into action contextually, thoughtfully, and as guided by partners with whom readers will be engaging. We aim to advocate for the
recognition of ethical challenges and provide
principles that guide global surgeons to ethical
conclusions.
Ethical Challenges intheHistory
ofGlobal Surgery
Investigating the roots of global health and global
surgery is necessary if practitioners are to understand the original problematic frameworks that
guided the engagement of privileged surgical
health systems with less privileged ones. Traced
back to colonial and “tropical” medicine, which
was an attempt by colonial powers to protect
their troops and governing ofcials from infectious diseases rampant in colonized territories,
global health has evolved in nomenclature in an
attempt to distance itself from unwholesome historical ideologies and practices. Unfortunately,
the foundations of global health were not built on
equity. The colonized were second or third class
and were not the primary consideration in their
own countries– medications were prioritized in
favor of the colonizers, training of locals in
healthcare was limited, health systems were
neglected at basic levels by the colonizers, and
under-trained caregivers worked freely in lowincome settings [9].
As consciousness of the inappropriateness of
the approach to Tropical Medicine spread,
nomenclatures morphed to “Humanitarian
Medicine,” “International Health,” and then
“Global Health.” However, many things did not
change at the core, including the often prescriptive and exploitative nature of engagements with
struggling health systems. White privilege, white
supremacy, and systems of whiteness are still a
sad reality in global health today despite the independence gained by most LMICs with their own
budgetary systems. Global Surgery as a movement has inherited a number of these challenges
(Table3.1).
Humanitarian and faith-based surgical
missions are some of the earliest documented
global surgery efforts [10]. Ethical concerns
around motives, promotion, publicity,
photography, and funding of these organizations
have been raised. The International Committee of
the Red Cross, born of an epiphany in the 1859
Battle of Solferino, and Médicine Sans
Frontières inspired in 1971 are humanitarian
organizations that have contributed to global
surgery efforts. Ethical critique around neutrality
and impartiality versus a focus on patient’s rights
have been raised concerning these kinds of
platforms– for example, decisions not to speak
up in the face of grave violations of human rights
[9]. Plastic surgery- led short-term reconstructive
missions focused on cleft surgery, burns, and
cancrum oris (noma) followed, and came out of
HIC universities in the 1960s. The challenge with
many of these efforts is that they have historically
been extremely vertical and use a “hit and run”
model without adequate training of the local
providers. Many of these interventions did not
include health systems strengthening and it is
questionable that the primary focus of these
organizations was informed based on locally
dened priorities. Air, land, and sea-based selfcontained surgical platforms were introduced in
the 1970s, in part to circumvent the need for any
local resources during short-term missions.
Despite the convenience and efciency introduced
by this model, cost- effectiveness has been found
to be sacriced, local supply chains which are
underfunded and inadequate continue to being
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B. T. Alayande et al.
Table 3.1 Unethical global surgery motivations: few parallel lessons from history
S/n Motivations of historical colonialism Motivations of global surgery neocolonialism
1. Cheap raw materials Cheap research papers
2. Abundant raw materials Abundant data, patients and pathologies
3. Limited competition Limited academic competition
4. Limited regulation Less rigorous institutional review boards: Grant money solves it
all (subject to culture of bribery), permission from “higher
bodies” in leadership
5. Demand for raw materials in
colonizing countries
6. Need for stop-over ports, or
locations for sightseeing
7. Colonies as assets in the balance of
power
8. Inequitable exchange of goods for
slaves/workers
9. The prestige of conquest Pseudo-conquest (an LMIC author on the paper)
a
Table developed from original slides by Barnabas Alayande presented at the Consortium of Universities for Global
Health 2021 Global Surgery Satellite Session. Used with permission
b
In Nigeria’s Badagry port, 10 slaves were exchanged for a glass bottle of gin or a ceramic plate, 40 for an umbrella or
a Dane gun, 100 for a canon, while the number exchanged for a mirror was negotiable
b
undermined. Specialty mission hospitals were
later developed and have provided historical
Demand for publishing as a prerequisite for promotions; demand
to include LMIC partners by funders, the pictures are demanded
by funders and validate one on social media
Involve low- and middle-income countries whenever convenient
or usually invited for specialty knowledge
Low- and middle-income country connections are assets in
academic power although providing needed assistance and
teaching (by invitation)
Surgical donations that end up in hospital junkyards, pragmatic
over-emphasis by HIC funders on bringing in huge grant funding
into the LMIC setting
common good or community-centered public
health ethics [13].
a
contrasts in sustainability, local partnerships, and
training. Approval of global surgery electives in
2011 by the American Board of Surgery and the
Accreditation Council for Graduate Medical
Frameworks forGlobal Surgery
Ethics forPractice andPartnerships
Education has helped popularize existing and
new global surgery electives, fellowships, and
academic partnerships. This has heightened the
need for equity in partnerships, and the need to
focus deliberately on preventing paternalistic visits by educating both visiting and hosting organizations on equity in Global Surgery [9].
Western medical ethics though traceable to
religious foundations were formalized rather
reactively following Nazi war experimentation
and the Nuremberg trials, written in the
Nuremberg code, the Belmont report, the
Helsinki Declaration, the declaration of Geneva
[11]. Ethics specic to global surgery are also
elucidated as a result of missions gone wrong, or
in response to identied ethical challenges [12].
These western medical ethics focus on individual autonomy, as opposed to low-resource settings where the emphasis tends to be on the
Maintaining ethical standards of practice and
partnerships requires thinking within ethical
boundaries and frameworks, and not just “going
with the gut.” The enduring principles of benecence, nonmalecence, autonomy, and justice,
undergirded by integrity, truthfulness, dignity,
and honesty are important in considering global
surgery ethics [14]. Benecence demands that
global surgeons should act in the best interest of
others. Nonmalecence as a principle demands
that our work does not inict harm or the risk of
harm through negligence on others. It reects Sir
Robert Hutchison’s physician’s prayer, “From
inability to let well alone, from too much zeal for
the new and contempt for what is old, from putting knowledge before wisdom, science before
art and cleverness before common sense, from
treating patients as cases and from making the
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cure of the disease more grievous than the endurance of the same, good Lord deliver us” [15].
Autonomy speaks of self-determination based on
the conditions of liberty and agency. Justice as a
principle speaks to equitable distribution of limited healthcare resources, the perception of health
as a human right, and respect for the patient’s
rights.
A number of ethical frameworks exist from
the proverbial to the academically dened that
cover practice, partnerships, and educational
exchange. Five such useful frameworks are
briey described below.
The Ethical Fishing Principles
The often-used proverb in global health “Give a
man a sh and you would have fed him for a day”
versus “Teach a man to sh and you will feed him
for a lifetime” are only but part of the considerations in Global Surgery. We must ask the man
whether he wants to sh at all or would rather
hunt or pick fruit. Then if he chooses tosh as is
relevant to his context, we must shalongside
him with a non-arrogant accompaniment.
This anecdotal framework focuses on local
ownership and leadership of projects, relevance
of outputs and outcomes to local context, and
capacity building as core ethical principles of
global surgery engagement.
Projects– Guidelines forHIC
Surgeons onEstablishing Projects
inLow-Income Countries
A series of recommendations for HIC surgeons
seeking to establish projects in LICs were developed by Grimes and colleagues in collaboration
with the International Development Committee,
College of Surgeons of East, Central and Southern
Africa, International Federation of Surgical
Colleges, Association of Surgeons of Great
Britain and Ireland, West African College of
Surgeons and the Operation Hernia Foundation
[16]. Recommendations include appropriately
identifying partners, establishing local needs and
resources, training local surgical teams and
ensuring sustainability, using appropriate technology and skills, monitoring the quality of surgery, taking responsibility for and managing
post-operative complications, considering costs
and mitigating nancial impact on host institutions, and working with indigenous local and
regional training programs [16].
Partnerships– TheMonette
Principles Applicable toGlobal
Surgery
Monette et al. carried out a scoping review of
guiding principles informing “good” global
health research partnerships and identied an
ethical framework global surgeons would do well
to embrace [17]. Themes include mutual benet,
collective agenda setting, equity in partnerships,
accountability, and incorporation of capacity
building. Specic principles are shown in Box
3.1 [17].
Box 3.1 Monette Principles
Reciprocity
Benet
Mutual benets
Shared benets
Collective writing and publishing
Sharing of data and networks
Pooling of prots and merits
Focus
Setting baseline goals, objectives
Setting future milestones
Collective agenda setting
Equity
Responsiveness to causes of inequities
Proportionality
Accountability to partnership
Accountability to beneciaries
Development of national research capacity
Enhance capacities
Sustainability
Commitment to the future
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Investing in relationships
Sharing, assigning, and clarifying
responsibilities
Interacting with stakeholders
Broad consultative process
Understanding contextual values
Critically engaging context
Ensuring research inuences policy
Application of research results
Effective communication
Humility
Inclusivity and inclusion
Promotion of mutual learning
Social justice
Disclosure of nancial interests
Commitment to transparency
Authentic partnerships
Adapt and respond
Leadership
National ownership
Prevention of adverse impact
Promotion of common good
Relinquishing of power by the Northern
partner and acceptance of autonomy of
the Southern partner
Respect
Stewardship
Education– TheFair-Trade Learning
Rubric andPrinciples Applicable
toGlobal Surgery [18]
Hartman and colleagues published a rubric used
to generate discussion between partners and that
is relatable to fair trade exchange programs or
surgical visits between HICs and LMICs. Key
elements considered are.
1. Common purpose: The global surgery
exchange must be based on mutually established long-term goals.
2. Host community program leadership: The
programs should be locally led and host
community driven, with co-owned research.
3. Host community program participation:
Local communities must embrace and participate in the program.
B. T. Alayande et al.
4. Recognition and protection of rights of the
vulnerable: Rights of the most vulnerable
must be recognized and deliberately protected. LMICs, the poor, the uneducated,
women, children, and minorities must be
protected both as patients and care-providers
within the partnership.
5. Resourcing: Local sourcing of human and
material resources is key. The environmental and economic impact of any visits should
be discussed. The economic structure of the
programs should be discussed and shared.
6. Transparency: Financial budgets and grant
details should be available to all parties and
costs equitably shared.
7. Recruitment, publications, and social
media: Equal opportunities should undergird
recruitments, and remuneration should be
equitable. Decisions on whether to, who to,
where to, and how to publish should be jointly
taken and relevant to the context. Social
media use should be guided by principles of
condentiality, and respect for persons.
8. Clarity of commitment and evaluation of
partnership success: There should be clear
metrics prior to the engagement for what success looks like and all parties should show
tangible commitment to the partnership.
9. Appropriate communication: Lines of
communication and dissemination of partnered program results should be clear.
10. A focus on partnerships beyond a single
program: This implies a focus on system
strengthening. Timelines and commitments
should extend beyond a single “mission.”
11. Community and learners’ theory of
change: Motivations for the partnership and
the expected community outcomes are identied and welcomed by diverse community
stakeholders including any learners.
Practice– Mitigating the“Seven Sins
ofHumanitarian Medicine”
Framework [12]
Welling and colleagues provide a list of ethical
pitfalls applicable to global surgery that can serve
as a framework to challenge ethical engagement.
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Although it focuses on failures in humanitarian
(surgical) missions, it also presents the challenge
for improvement. Ethical pitfalls to note using this
lens include leaving a mess behind, failing to match
technology to local needs and abilities, competition
and failure of cooperation, failing to have a followup plan, politics over true service, going where one
is not needed or wanted, being poor guests and
doing the right thing for wrong reasons [12].
Ethical engagement in global surgery requires
careful planning based on local needs and priorities. There should be mutual benet, clarity in
terms of engagement, roles, and goals. Equity is
key, and these engagements must not create
dependence. An ethical emphasis is capacity
development – the aim is to literally “work yourself out of the job.” Institutional reections can
be carried out by using the Council on Health
Research for Development (COHRED), Research
Fairness Initiative Reporting Guide [19].
Practical Considerations
Ethical Considerations inTransBorder Global Surgical Care Delivery
Overview Teams must plan for long-term
follow- up and continuity of care. Ensure that local
human resources are not diverted from core needs
to surgical missions and that local material
resources are not exhausted or stretched by
diversion from basic use to less urgent, elective
missions [6, 12, 20]. Equity in patient choice and
procedure selection is key – avoid biased selection
of healthcare workers’ relatives, those that can
pay for services or have higher social capital. Also
mitigate corrupt practices that skew patient
selection. Always practice within your scope of
training, avoid compromising patient’s quality of
care, and avoid sub-standard approaches [5]. For
instance, an urologist performing an elective
thyroidectomy is performing surgery way out of
their scope of training. An extreme focus on taskshifting by engaging unqualied providers as part
of the “it is for Africa” syndrome should also be
avoided.
Consider that standards of care might be
variable in the LMIC context based on resources.
Be prepared for highest quality care in lowresource contexts; for instance, operating the
patient with suspected acute appendicitis without
an abdominal CT scan is not considered a
compromise of quality of care where it is not
available or is nancially prohibitive, but is a
recognized variation in standard of care. A
general surgeon performing a Dunhill’s
modication of a subtotal thyroidectomy, rather
than a total thyroidectomy for benign thyroid
disease, in a village where replacement
L-thyroxine is not available, follow- up is difcult,
health insurance cover is poor, and out-of-pocket
cost for medication is prohibitive can be
considered a variation in standard of care.
The waste of the global north in single-use
materials and overwhelming packaging of disposables should be avoided in all settings.
Reduce, reuse, recycle. Climate considerations
resulting from this waste are an often-neglected
ethical consideration. Safe cleaning and adequate
low-emission sterilization can allow reuse of
some (not all) disposables, and repurpose materials like diathermy pencils, tubes, monitors, etc.
To maintain contextual ethics for practice,
develop a rsthand cultural, religious, and social
awareness of the host community, and do not
transpose your own culture, biases, or assumptions. Be careful of linguistic peculiarities, and
within your capacity, learn at least the basics of
the communicating and medical language.
Review ethical informed consent for the environment – several African contexts for example view
consent as a family or communal decision.
Understand that condentiality for core family
members is extremely contextual. Deal with the
adult individual concerned but involve appropriately the social support system with consent and
by context. Do not undermine local healthcare
provision by innocent, but demeaning comparative comments to patients, health professionals,
or colleagues. This reduces the condence of
locals in their health systems and increases their
dependence on foreign missions and
interventions.
In sync with the Plan-Do-Study-Act
framework, ethics of global surgery can be
elaborated using a cycle that insists on continuous
improvement (Fig. 3.1). No partnership is
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4. Ethical adjustments
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3. Ethical quality
improvement evaluation
Surgical documentation
Organ donation and transplant
Negotiating limited critical care
Fig. 3.1 The ethics cycle of engagement in global surgical care delivery
and end of life care
Follow up.
Quality of care.
Negotiating informed Consent.
Licensing and adequacy of surgical expertise.
Appropriate donation.
B. T. Alayande et al.
1. Ethical engagement
and planning
2. Ethical execution of surgical
interventions and missions
Pre-departure training.
Arrival and acknowledgement of existing
social structures.
Respect for local infrastructure.
intrinsically “perfect”; the emphasis of this
framework is not as much on an ideal partnership,
as on the need for partners to bear in mind the
need for continuous review and improvement
throughout the cycle of their engagements and to
bring ethics into their quality improvement
processes. Ethical challenges encountered in
each phase are described below.
Ethical Engagement andPlanning
Parachute missions are a constant reality, with
funded HIC partners implementing global surgery projects and deciding priorities for LMIC
recipients. Many times, partners providing funding for these projects exercise the right to direct
them, and strings attached to resources create a
neocolonialist framework for control. The ethics,
value, goal, and outcome of the whole project
need to be agreed to by both parties prior to the
mission to avoid misunderstandings. They should
not permit the creation of a social structure or
power disparity in which there are debtors and
creditors. Approach these global surgery engagements as equal partners or as accepted and desired
mentors and mentees in an educational setting if
invited to do that.
“Buy-in” in global surgery does not refer to a
1- to 2-day workshop that can be included in your
nal report or write up [21]. It implies jointly
determining engagement priorities using frameworks, empowering partners to speak up, valuing
the culture and preferences of contextual partners, sharing leadership, and deferring program
leadership to LMIC partners. It also involves
agreeing before sending proposals to Institutional
Review Boards for review and before seeking
grant funding. We term this “The grave error of
sequence.” A number of such projects are actually dead-on-arrival. Many surgical groups are
already on a mission before they reach out to
local partners. Grant funding is already obtained
before contacting local partners [21]. This is
unacceptable – no matter how good the idea –
and leads to internal and external conict even if
LMIC institutions bend over backward to receive
this funding. Funding disparities are also an ethical concern, with HIC volunteers earning much
more in stipends from their HIC institutions than
LMIC partners do from their governments who
do more contextual work even when they reside
in the same context for the duration of the
project.
In planning, we must also avoid the “least
effort, greatest gain” syndrome, where we identify problems that are easy to tackle, and leave
the most difcult surgical challenges to the resident teams. It is best to encourage purchases
using the local supply chain, and be willing to
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improvise using local material, if it is available
and of sufcient quality to be acceptable for surgical interventions. We also need to make sure all
stakeholders that contribute to the project are
acknowledged.
Execution ofSurgical Interventions
andMissions
Stay within your certied scope of work, uphold
your responsibility to local collaborators and
community members, and identify, acknowledge,
and mitigate your intrinsic biases and power
dynamics.
Pre-Departure/Pre-Arrival Training
Inadequate pre-departure training sets up teams to
fail, and this in itself is unethical. Kalbarczyk and
colleagues identied culture, safety, projectspecic knowledge, ethics, travel medicine, language, mentorship, professionalism, emotional
wellness, language, and culture shock as minimal
domains that need to be covered in a rounded predeparture training. It is best that trainers are, at the
very least, in part, true indigenous contextual
experts, and that such training is evaluated [22] (see
Chap. 2). Trainings in cultural sensitivity, integration, and global health ethics are very important.
Arrival On Site, and Acknowledgement of
Existing Social Structures, and Community
Hierarchies
Much of western culture has lost its appreciation
for community hierarchy. This contrasts with
many LMIC settings, where elders, local
political leaders, religious leaders, chiefs, and
community heads have signicant inuences. The
inuences that senior doctors, nurses, lab techs,
administrators, and healthcare providers have
in hospitals– even if they are not related to the
specic project – should not be underestimated.
Local protocols should be adhered to, and
approvals must be ensured before moving in
for surgical missions or system strengthening
activities in any place. This should be regardless
of whether the recipient system is strong enough
to legislate and monitor this, or if such systems
are underdeveloped.
It is unethical and arrogant to perceive oneself
as the expert over a resident local professional
just because one has served as visitor in the same
setting for a few years [21].
Respect for Local Infrastructure
Many global surgery interventions use local
operating rooms, wards, clinics, and other facilities. An ethical challenge arises when elective
cleft repairs and hernia repairs, for instance, as
the focus of a mission, displaces emergency laparotomies, or when booked operating room space
is taken up by visiting surgeons, resulting in a
disruption of the surgical eco-system for local
patients and surgeons. These missions sometimes
result in a backlog of deprioritized patients.
Discussion with the local team and leadership is
mandatory to make these arrangements, and the
decisions must be left to the local administrator.
After all, the mission is his/her guest.
The Question of Adequacy of Surgical
Expertise
Surgical residents who have minimal or no
exposure in certain interventions in their HICs
often travel to LMICs to gain experience and
perform more cases. In some cases, medical
students who do not have appropriate licensing or
exposure scrub in on highly technical cases
during global surgery engagements. The ethics of
this is clearly challenging as sometimes in rural
and remote locations, such visitors are the only
available surgical provider who can attempt an
intervention. Dilemmas arise: “would you let this
patient die, or try out this emergency open
laparotomy, even though it is your rst?” General
guidance is to absolutely ensure appropriate local
licensure, and to operate within the connes of
the local license, all the time. Never operate
above your abilities or knowledge without due
supervision and avoid the assumption that local
expertise (even task sharers) cannot attempt what
you think you can exclusively do. Many issues
have arisen from blurring of these lines in the
name of compassion.
Appropriate Surgical Equipment Donations
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B. T. Alayande et al.
A large proportion (70–90%) of well-intended
donations from HICs end up in surgical junkyards
in the global south [23]. Very often, there is a disconnect between donors and the recipient context.
Inappropriate voltages, non-functional equipment, ambient temperature differences, old models of surgical gadgets for which there is no more
technical support, high-cost maintenance equipment, incompatible machines, absence of battery
backup for locations with inadequate electricity
supply, and lack of training of recipients on the
use of these donations are a few of the reasons for
these equipment waste sites. This applies to anything from syringes and vacutainers to anesthesia
machines, ultrasound, and CT scan machines. Up
to thirty-three frameworks have been suggested to
guide ethical medical donations in low-income
settings [23]. It is also not unusual to hear about
donations stuck in airports and ports just because
the local team does not have the necessary funds
to pay taxes and clearance fees or there are existing laws that prohibited entry of such equipment
and resources. Donations should rst start from
discussion with the local team as team as to what
is needed in the set up, what their priorities are.
Practical things such as checking the voltage of
donations against local power, including stepdown voltage transformers and stabilizers, ensuring maintenance, and discussing extensively with
Box 3.2 Ethical Donations Require
1. Pre-requisite agreement from the recipient
site on the need of the donated equipment.
2. Pre-import refurbishment certicates.
3. Alignment with the rules and regulations of
the country regarding import permits.
4. Presence of onsite capacity in human
resources to operate and maintain equipment.
5. Environmental considerations of adequate
space, water, electricity, low energy
consumption, and environmental safety.
6. Material resources like replacement parts and
supply chains.
7. Maintenance capacity through training and
sufcient nancing.
8. Educational resources and manuals for ongoing
training in equipment use, and interpretation of
output.
recipient sites prior to bringing donations can help
address this. Donated equipment should be discussed with the host staff and agreed on which is
wanted and on the best method of importing it to
avoid unnecessary costs, and mitigate against
delays in transport (Box 3.2).
Consent
Consent must be negotiated carefully and
respectfully particularly in the presence of a
language barrier. Mutilating surgeries such as
amputations, mastectomies, colostomies,
ileostomies, hysterectomies, tubal ligations, and
orchiectomies are particularly ethically
distressing given the often irreversible and
psychologically signicant nature of these
interventions. Local healthcare workers should
lead or help guide this process, and patient’s
families, caretakers, or an elder member of the
family should be involved in the decision (as per
the existing cultural norms). Independent
translators should be employed if they are
available.
Quality of Care
There is often a tension about the quality of
surgical care delivered at LMIC sites compared
to the home institution. Making a diagnosis of
acute appendicitis, without a CT scan, or
operating on a toxic goiter without a thyroid scan
for example, is rather a norm than unethical. The
pragmatic ethical standpoint will be to give the
best possible care, within the context of available
resources, while improving the quality of care as
you are able. Various diagnostic tests are not
available in many of these contexts, and emphasis
should be placed on visitor’s clinical acumen,
basic available investigations, and local
experience to make diagnoses. Given the above,
however, quality of care should not be
compromised.
Follow-Up of Surgical Patients
A very important ethical consideration is the
follow- up of operated patients. Some vertical
interventions focus more on the short-term
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outcomes than long-term results. Overtly, fewday short- term missions without provision for
follow-up may be dangerous since numerous
complications including surgical site infections
or hemorrhage are missed. The need for
re-operation is also a potential threat. To mitigate
this catastrophe, the local physicians must be
included as co-surgeons and trained to care for
the patients when the mission departs.
Covertly, surgeries with long-term, late-onset
complications are also missed when there is no
provision for longer term follow-up. This should
be done by trained local surgeons who preferably, if possible, participate in the original operation. These include cancer recurrences, long-term
complications such as adhesions after laparotomy
and hypothyroidism after thyroidectomy. All
global surgical engagements and local health
authorities should focus on strengthening systems that leave continuing care for native recipients of interventions.
Surgical Documentation
Many surgical missions done outside hospital
sites have the challenge of under-documentation.
Quite often, patients presenting in LMIC facilities following global surgical interventions have
little to no documentation of their surgeries or
surgical ndings. This can be challenging if
there is need for repeat surgeries or further evaluation. Records should never be extracted or
completely taken away by the visiting team. In
addition, patients must understand clearly, and
possibly have personal documentation of the
interventions in adequate detail for future reference. Documentation given to the patient should
best be not only a description of the procedure,
but include a simple drawing of the operation.
Given experts are involved in the treatment, plan
on further management would also be very
productive.
End of Life Care, Physician-Assisted Suicide,
and Limited Critical Care Ventilation
Although this remains a subject of debate in
Western countries, the ethics of the concept of
DALYs in favor of youth is perhaps contestable
in many African, Asian, or Middle Eastern cultures. Religious and socio-cultural beliefs many
times also do not approve the hastening of death,
and hold the sanctity of life over the quality of
life. We must ensure that a “western perspective”
of “death with dignity” versus “life prolongation
at any cost” of these ethics is not forced on nonwestern cultures. Decisions on end-of-life care
are best taken by a contextual expert, based on
contextual laws, taking full cognizance of autonomy, benecence, non-malecence, and justice.
Death is a personal experience, but some more
religious societies that believe in an afterlife are
more at rest with the non-nality of demise.
These cultures may be more accepting of death
and dying. Family decisions may also be more
nuanced, with decisions taken to stop treatment
when expenditure is catastrophic, and lands and
property have been sold with little or no improvements seen. Families may take decisions to
remove severely ill patients from orthodox medical care or hospital to traditional or spiritual healers or refuse disguring surgeries on behalf of
their patient.
Ethical dilemmas around critical care are
accentuated by a lack of resources. With 1 bed in
an ICU serving two million people, who gets the
bed following a mass casualty? The decision for
or against putting a patient on a ventilator or
using other limited critical care resources has
often been taken by default in low-resource countries. Where these are scarce, and expert intensivists are unavailable, those needing serious ICU
care are automatically not likely to live. This is an
inequity in and of itself, but the ethics around
who gets what is strongly locally driven by considerations of futility, patient’s wishes and sadly,
costs. The ethics in this sort of dilemma will need
to be formulated in the context of individual cultural, social, religious, socio-economic and legal
backgrounds, and is best left to a local expert in
context.
Organ Donation and Transplantation
All countries do not take the same approach to
organ donation. In Iran for example, a transplant
patient association controls the process of organ
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donation and allocation through the government
health authority. Teams must be aware of the
peculiar ethics behind this.
Issues of the “red/black” market also arise in
LMICs as many illegally harvested organs make
their way into the transplant market. The illegal
market knows no ethical boundaries [24].
Visiting surgeons should be careful to verify the
source of donated organs and the veracity of
consent by donors. “On-table” and under anesthesia donors should raise a red ag. Trace, and
avoid non- system- based purchases. Purchase of
organs from any living donor (even friends and
distant family members) is now forbidden by
both law and all Transplant Societies and
Agencies in almost all Western and Asian countries, even China now. The law is still sometimes
broken and punishable by imprisonment and by
large nes of doctors and donors, recipients, and
those who have been paid. As a foreigner that is
not as conversant with the intricacies of the local
organ donation system, private unethical sourcing, and black-market organs can nd its way to
your operating room when you work through
loose systems that need to be tightened. The
local hospitals that permit these illegal practices
should be exposed, penalized appropriately by
the regional and federal health authorities, and
reported to the International Transplantation
Society which can take appropriate actions to
limit and eliminate such practices.
Ethical Quality Improvement
Assessment
To close the loop of the ethics cycle of global
surgery engagement, evaluation of every intervention, visit, and mission is necessary.
Quantitative and qualitative methods should be
used to assess the local practitioner’s and host’s
perception of the ethics of the visitor’s practice
with a view to improvement [25]. There are suggestions that some hosts will hold back negative
information so as not to hinder subsequent
donations, funding, or visits, as a result of power
imbalance, or simply out of respect as these
partnerships are valued. Reports by visitors of
unethical or illegal practices of the host hospital
administrations and/or physicians should also
be reported to appropriate authorities, even at
the cost of not being allowed to return. Trust is
essential to permit open discussion that can be
used for ethical quality improvement.
Schoenbrunner et al. designed a useful tool to
review ethics of scope of practice and standard
of care (nonmalecence and benecence),
impact on local system (justice), informed consent and photography (autonomy) [25].
Ethical Adjustments
Utilizing feedback in an ethical manner is
important to improve global surgery practice.
Open and honest discussions should be held from
the place of vulnerability with a willingness to
apologize and correct unethical behavior going
forward. Partners should be able to safely and
constructively confront, ask forgiveness, and
change practice as appropriate.
Ethical Considerations inTransBorder Global Surgery Education
Visiting global surgeons should seek to include
an educational or training aspect to encounters
for clinical, research, or other skills transfer; but
also realize that this should be bidirectional [6].
Remember that even when not overtly expressed
by hosts, visitors might not be appropriately
qualied to teach, and content taught might be
inappropriate for the host’s curriculum. Ensure
that skills transferred are relevant to the LMIC
context. It is ethical to ensure that resources
required to implement knowledge or skills transferred are available, and that visiting trainees are
supervised appropriately both by their mentors
and by the local host surgeons based on their
level of training. Refuse assumptions that coming
from a HIC makes one a global expert. Visitors
should also resist the temptation to “lecture about
something” even when the content is not suitable
to the available audience.
Ensure that visiting trainees are conversant
with relevant contextual pathologies, presentations, and management and are taught appropriately by the host faculty. The saying that “when
you hear hooves, think horses, not zebras” can
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