Pediatric anesthesia outreach in low and middle-income countries: Models, motives, and moral misalignments.

BACKGROUND: A lack of anesthesia and surgical capacity leaves approximately 1.7 billion children per annum without access to surgical and anesthetic care. REVIEW: Over the past 50 years, the predominant strategy to address this lack of access has been to provide surgical capacity primarily from high-income countries (HICs) to low and middle-income countries (LMICs) in the form of short-term surgical missions. More recently, the international medical community has recognized the need to build sustainable surgical capacity in resource-constrained settings. This article reviews three models of surgical aid: the vertical model (short-term surgical missions); the horizontal model (system-wide capacity building); and the diagonal model, which is a hybrid of the first two. At their core, medical aid interventions exist on a spectrum ranging from providing surgical capacity to building surgical capacity. DISCUSSION: The skills, attitudes, and behaviors that drive success in providing medical capacity are fundamentally different from those that drive success in building medical capacity. The root cause of this difference is a shift in the moral duty of the visiting physician from a duty solely to the patient in front of them (based on the primacy of the doctor-patient relationship) to include a duty to the local physicians and the local medical system, and by extension to the next 10 000 patients in need of care. CONCLUSION: Failure to address the conflicts engendered by this fundamental moral shift risks undermining capacity-building efforts in all models of medical aid.

When International Humanitarian or Medical Missions Go Wrong: An Ethical Analysis.

Recent decades have seen a significant increase in physicians participating in international short-term missions to regions with limited or no access to health care by virtue of natural disaster or lack of resources. Recent publications in the ethics literature have explored the potential of these missions for unintentional harm to the intended beneficiaries. Less has been discussed about how to respond when harm actually occurs. The authors review the ethical issues raised by short-term medical and humanitarian missions and the literature on responding to unintended error to provide guidelines for avoiding harm to the intended beneficiaries of missions and an appropriate response when harm occurs. Two cases demonstrating an analysis and response to unintended harm are presented.

Ethics in humanitarian efforts: giving due credit to the local team.

BACKGROUND: It has become increasingly apparent that only the truly effective humanitarian work emphasises empowering local practitioners. One problem, though, is that we are often seen as the "experts" who have come to "save" the children. This perception may adversely affect the confidence in the country's own providers. METHODS: Non-profit organisations performing paediatric heart surgery in developing countries were identified from two sources: the CTSnet "volunteerism" web page and an Internet search using the term "Pediatric Heart Surgery Medical Mission." The website of each organisation was reviewed, seeking a "purpose" or "mission" statement or summary of the organisation's work. A separate Internet search of news articles was performed. The top five articles were analysed for each organisation, and the findings are then analysed using the Principlist and Utilitarian ethical systems. RESULTS: A total of 10 separate non-profit organisations were identified. The websites of eight (80%) placed significant emphasis on the educational aspects of their work and/or on interaction with local professionals. However, of 43 news articles reviewed, reporters mentioned education of, or interaction with, local professionals in only 14 (33%), and four out of 10 organisations studied had no mention of the local providers in any article. CONCLUSIONS: Although non-profit organisations emphasise the teaching and programme-building aspects of their efforts, media reports largely focus on simpler and more emotional stories such as patient successes or large donations. Acknowledgement of the clinical and financial contributions of the host countries is both a duty following from the principle of justice and an important factor in long-term programme building.

Affecting the Global Burden of Surgical Disease: Incorporating Surgical Training into International Missions: A Systematic Review.

The global burden of surgical disease is immense. Increasingly in the past several decades, international humanitarian medical missions have become more popular as a method of managing the sheer volume of patients requiring medical care worldwide. Medical education programmes have also had an increase in interest amongst medical students and surgical residents to participate in missions during training. The current review was planned to present the current body of literature on international experiences in residency training programmes. It comprised relevant literatur obtained from Medline (ubMed) using Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines. A total of 15 publications were reviewed with each falling into one of the threeidentified categories:programme design (goals/objectives), ethics, and post-experience analysis. The benefits of providing international missions opportunities for surgical trainees cannot be understated.

The ethical experiences of trainees on short-term international trips: a systematic qualitative synthesis.

BACKGROUND: Medical student and resident participation in short-term international trips for trainees (STINTTs) has increased in the past few decades. However, there has been no systematic review of trainees' actual ethical experiences. The authors sought to identify what ethical issues medical trainees encounter during STINTTs, as elicited by and reported in peer-reviewed, quantitative and qualitative research papers. METHODS: The authors systematically searched five academic databases finding 659 unique titles and abstracts. The authors applied inclusion and exclusion criteria to these titles and abstracts resulting in fourteen papers, which were analyzed using qualitative thematic synthesis. RESULTS: The qualitative analysis of the papers generated four themes: (1) Trainees' Concerns Over Perpetuating Medical Tourism; (2) Struggling to Identify and Balance the Benefits and Harms of STINTTs; (3) The Complicated Trainee Mens (mind); and (4) Ethical Situations Encountered by Trainees. The fourth theme, which was the largest, was further divided into (a) Navigating social and cultural dynamics, (b) Trainees' experiences related to the learner role, and (c) Ethical situations not qualifying for other catagories. Some of these issues reported in the empirical research papers are well represented in the broader literature on STINTTs, while others were less so-such as mistreatment of trainees. All included papers were published after 2010, and comprised a total of less than 170 medical trainees. CONCLUSIONS: Medical trainees report experiencing a wide range of ethical challenges during short-term international trips in which they engage in clinical or research activities. The authors call educators' attention to specific challenges that trainees face. The relevant literature covering US and Canadian STINTTs is relatively young and largely qualitative. The authors briefly sketch a program for expanding the research on this increasingly common educational experience.

Moral Agency in the Context of Global Volunteering.

Today there are many global volunteer opportunities for nurses and student nurses. While the intentions of volunteers may be good, the result may be harmful to the volunteer and/or the host, creating a situation of moral distress. An ethical code provides guidance and promotes moral agency. We discuss elements of the American Nurses Association Code of Ethics with Interpretive Statements and apply them to the experience of global volunteering through a case study approach.

Bribery and Its Ethical Implications for Aid Workers in the Developing World.

Bribery is a complicated, multi-dimensional issue. Upon first glance, most westerners would immediately condemn it as an underhanded, unfair means of gaining an advantage in a competitive or legal situation, and so it is in virtually every case in the westernized world. However, the issue becomes much more complicated in the international context, particularly in developing nations, where giving and accepting bribes is often normal and expected. This paper serves to inform ethical decision-making in situations where the "right choice" is unclear with regards to bribery, primarily for individuals performing aid work in foreign countries with corrupt officials and police officers. In such contexts, a simple offering of food, money, or a small trinket may make the difference between a person being able to accomplish meaningful, life-changing work for the local populace or having that work significantly slowed at best and being thrown out of the country, robbed, or imprisoned in worse cases. The larger scale bribery issues in international business and the laws pertaining to them are also discussed.

Motivations, barriers and ethical understandings of healthcare student volunteers on a medical service trip: a mixed methods study.

BACKGROUND: The motivation to volunteer on a medical service trip (MST) may involve more than a simple desire for philanthropy. Some volunteers may be motivated by an intrinsic interest in volunteering in which the context of the volunteer activity is less important. Others may volunteer because the context of their volunteering is more important than their intrinsic interest in volunteering. Furthermore, MSTs may pose a variety of ethical problems that volunteers should consider prior to engaging in a trip. This study evaluated the motivations and barriers for graduate health care students volunteering for an MST to either the Dominican Republic or Mississippi. Volunteers' understanding of some of the ethical issues associated with MSTs was also assessed. METHODS: Thirty-five graduate health professions students who volunteered on an MST were asked to complete an online survey. Students' motivations and barriers for volunteering were assessed using a 5-point Likert scale and Fisher's exact test. Ethical understanding of issues in volunteering was assessed using thematic analysis. RESULTS: Students' motivations for volunteering appeared to be related to the medical context of their service more than an inherent desire for volunteer work. Significant differences were seen in motivations and barriers for some student groups, especially those whose volunteer work had less opportunity for clinical service. Thematic analysis revealed two major themes and suggested that students had an empirical understanding that volunteer work could have both positive and negative effects. CONCLUSIONS: An understanding of students' motivations for volunteering on an MST may allow faculty to design trips with activities that effectively address student motivations. Although students had a basic understanding of some of the ethical issues involved, they had not considered the impact of a service group on the in-country partners they work with.

Ethics in global surgery.

Global surgery, while historically a small niche, is becoming a larger part of the global health enterprise. This article discusses the burden of global surgery, emphasizing the importance of addressing surgical needs in low- and middle-income countries. It describes the barriers to surgical care in the developing world, the ethical challenges that these barriers create, and strategies to overcome these barriers. It emphasizes the crucial role of preparation for global surgical interventions as a way to maximize benefits as well as minimize harms and ethical challenges. It ends with the cautionary statement that preparation does not eliminate ethical problems, so surgical volunteers must be prepared not only for the technical challenges of global surgery but also for the ethical challenges.

Building surgical capacity in low-resource countries: a qualitative analysis of task shifting from surgeon volunteers' perspectives.

INTRODUCTION: Surgical volunteer organizations (SVOs) focus considerable resources on addressing the backlog of cases in low-resource countries. This model of service may perpetuate dependency. Efforts should focus on models that establish independence in providing surgical care. Independence could be achieved through surgical capacity building. However, there has been scant discussion in literature on SVO involvement in surgical capacity building. METHODS: Using qualitative methods, we evaluated the perspectives of surgeons with extensive volunteer experience in low-resource countries. We collected data through in-depth interviews that centered on SVOs using task shifting as a tool for surgical capacity building. RESULTS: Some of the key themes from our analysis include the ethical ramifications of task shifting, the challenges of addressing technical and clinical education in capacity building for low-resource settings, and the allocation of limited volunteer resources toward surgical capacity building. CONCLUSION: These themes will be the foundation of subsequent studies that will focus on other stakeholders in surgical capacity building including host communities and SVO administrators.

Medical missions to Ghana: The ethics of choosing children for cardiac surgery.

The Hearts and Minds of Ghana project travels from Boston Children's Hospital for two weeks each year to provide cardiac surgery to children in Ghana. Of the hundreds of children in need, how to choose who will receive lifesaving surgery?

How do we choose?

The Hearts and Minds of Ghana project improves the lives of those who are less fortunate and have few resources. Providing clear goals for the mission, devising prior guidelines for patient selection and treatment, achieving a better understanding of local culture and expectations, and good team work, facilitate making better ethical decisions, but doesn't make them less difficult.

Ethical aspects of arranging local medical collaboration and care.

Yearly pediatric cardiac surgery missions to Ghana are of tremendous benefit to local children, but may create thorny ethical dilemmas for local clinicians who refer and screen children for the mission and who provide care to the children after the mission concludes for the year. This article presents the experiences and concerns of a pediatrician who is a local member of the Hearts and Minds of Ghana project.

Great need, scarce resources, and choice: reflections on ethical issues following a medical mission.

Medical missions to provide cardiac surgical procedures in developing and technologically less advanced countries is a great challenge. It is also immensely gratifying, personally and professionally. Such missions typically present significant ethical dilemmas, especially making difficult choices, given limited time and resources, and the inability to help all children in need of cardiac surgery. We describe some of these issues from our perspective as visiting cardiologists.

Epilogue: ethical goals for the future.

Based on the experiences of the Hearts and Minds of Ghana authors, I present possible approaches to the ethical questions that clinicians who participate in health missions and disaster relief programs often face.

Developing an ethical framework for short-term international dental and medical activities.

The popularity of volunteering to provide charity health care in third-world countries has increased dramatically in recent years. While there are advantages to both those being helped and to volunteers, there are also ethical issues that need to be addressed. A framework for analyzing the ethical impact of such service is presented which continues 27 principles that should be addressed.

A student's perspective on the ethics of international charity dental care.

A senior dental student describes the deep sense of personal satisfaction from participating in a weeklong charity dental care trips to the Dominican Republic. Care, primarily consisting of extractions, was provided to individuals living in conditions that encourage dental disease at the same time the availability of oral healthcare services are essentially nonexistent.

A look at international, short-term service trips: challenges from a dental ethical perspective.

Although professionals helping those in need in other countries is a noble endeavor, it is not without its ethical challenges. Those in the medical field are just beginning to explore these issues. In this paper, the five-principle structure of the ADA Code is used to explore some of the not-so-obvious problems that may come in the wake of charity care in international contexts. Issues surrounding respect for autonomy include informed consent, adequate health history, and cultural sensitivity. Sometimes the difficulty of working conditions increases the possibility of causing harm, and follow-up care may be lacking or inadequate. The duty for beneficence may have different meanings in other cultures than it does in the United States. Standards for justice or fairness may not be the same in other countries, and bringing American benefits to a segment of a local population may disrupt indigenous standards. Issues can also arise around veracity due to communication problems and alternative ways of counting benefits and harms.

Sustainability and the principle of respect for community as a means of enhancing healthcare equality.

Global short-term dental or medical volunteerism has grown significantly in recent years. Dental and medical schools, their faculty, and students, are becoming increasingly interested in the experience of providing care to individuals in low-resource communities around the world. A laudable goal of such care is to provide care to individuals in low-resource communities and to work to achieve equity in health for all people. These goals are consistent with the American Dental Association's ethical principles of justice, beneficence, and nonmaleficence. This paper will discuss ethical guidelines for conducting these volunteer experiences with an emphasis placed on sustainability--the provision of ongoing collaborative care, between the institution overseeing the experience and the local community, after the visiting group has departed. The ultimate goal, global health care equity, requires transforming these shortterm efforts into long-term sustainable solutions. This goal is based on an ethical principle entitled respect for communities. This ethic can be likened to a community-wide application of the ethic of respect for autonomy as routinely applied to individuals such as patients. A tripartite model is proposed as a means for transforming short-term efforts into long-term sustainable solutions.

Ethical considerations in targeted paediatric neurosurgery missions.

Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts.