Globalization of Healthcare Creates Evolving Ethical Dilemmas

Editor’s note: This article is based on the second-place winning entry in the 2022 History of Surgery Poster Competition, which occurred in conjunction with Clinical Congress. An article featuring the first-place entry appeared in the March issue of the Bulletin.

Global surgery, with the aim of relieving the surgical burden of disease for all people, involves the use of collaboration, education, and diplomacy to promote growth in quality surgical access and supporting policy.

What began as a clinical effort to advance the provision of safe, timely, and affordable surgical care to marginalized populations, particularly in resource-limited settings, has gained prominence within academia as well. With data gathered from surgical service delivery experience and introspective research, the field of global surgery has increasingly focused on evidenced-based interventions and conscientious health systems strengthening.

Surgical care often spans the fields of general surgery, anesthesia, obstetrics and gynecology, neurosurgery, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, otolaryngology, plastic surgery, urology, nursing, and rehabilitation.

A global surgeon has been defined as an individual who spends at least a portion of his or her time in person or virtually on activities aimed at improving surgical access in resource-limited settings, which may include participating in the delivery of surgical care, development of surgical capacity, education of local trainees, or enhancement of surgical systems.

Global surgery brings an added layer of complexity to the discussion of surgical ethics. To a certain extent, ethical standards for surgical care are bound by both culture and custom.

The globalization of healthcare, however, has resulted in the transcendence of medical care beyond regional and cultural borders and is associated with new ethical dilemmas. It is essential to understand the history of global surgery and its intimate relationship to surgical ethics.

This article reviews multiple phases of global surgery history and the specific ethical dilemmas that occurred during each phase, specifically regarding the principles of justice, autonomy, beneficence, and nonmaleficence, using a few selected examples.

Origins of Humanitarian Missions of Religious Groups

The history of global surgery begins in the mission work of religious organizations. The medical mission first originated in the 16th century and was developed by Jesuit Christians as part of their work to share their faith across different regions of the world.

Surgical care became an essential component of mission trips in the 18th century as invasive procedures gained legitimacy in the medical community.¹

In 1834, Peter Parker, MD, established an ophthalmic hospital as part of his mission work in Canton (now known as Guangzhou), China. There, he performed ophthalmic surgery, tumor excisions, lithotomies of the urinary tract, and trauma surgery.

In this context, Dr. Parker became an integral feature of the local community and took on Chinese pupils. Additionally, he founded the Medical Missionary Society in China that aimed to spread Western medicine and introduce Christianity to the region.²

Initially, these efforts were met with interest given the outcomes-oriented approach introduced by Western medicine.

However, tensions eventually developed as mission work became perceived as an insidious tool of imperialistic expansion when some of the public health interventions exclusively targeted disease processes that affected laborers’ productivity.³ This resulted in ethical challenges centered around the principles of autonomy and justice.

Specifically, violations of autonomy included:

• Suboptimal informed consent given significant linguistic and sociocultural barriers
• Inability of patients to choose care in the context of significant financial difficulties and medical disadvantages
• Pressure placed on patients for religious conversion when receiving medical care

Similarly, in terms of justice, the following dilemmas occurred:

• Introduction of novel surgical techniques in contexts with insufficient perioperative infrastructure
• Prioritization of healthcare that enhanced the workforce and neglected disease processes prioritized by the community
• Division between the local healthcare infrastructure and missionary healthcare system that resulted in systematic instability

Ultimately, there was no resolution to these ethical challenges as two historical revelations resulted in the withdrawal of medical missionaries from resource-limited settings:

• New emphasis on living a compassionate Christian life and a transition away from evangelism
• Conflict escalation in Europe causing mass casualties that required the reallocation of aid to the region³

World War I (WWI), which was characterized by large-scale warfare that crossed multiple sociopolitical regions, obviated the need for neutral medical entities to provide medical care during times of conflict. These neutral entities were intended to provide just and equitable care during eras of political strife.

This need led to the rise of secular organizations that provide medical care in resource-limited settings. It should be noted that faith-based organizations continue to have a presence in the global surgery community (e.g., Islamic Medical Association of North America, Pan-African Academy of Christian Surgeons).

Global Health Efforts Sponsored by Secular Organizations

The modern definition of humanitarian aid, which consists of the neutral provision of aid to those in immediate danger, arose in the 19th and 20th centuries.⁴

Secular organizations that provided surgical care subsequently developed in the 19th century, in part as a response to the geopolitical climate of the time that was characterized by significant conflict affecting multiple countries and regions.

These bodies included the International Committee of the Red Cross (ICRC), which was founded in 1863. The ICRC championed the first Geneva Convention in 1864, which defined the ethical parameters for the provision of medical care during conflict.⁵

Along with concepts like medical neutrality, the Geneva Convention introduced the concept of medical care as an apolitical service that must cross borders regardless of conflict or political tension.

WWI resulted from the culmination of European tensions. During this conflict, there were rapid advancements in surgical and anesthetic care. Laparotomies for penetrating abdominal injuries, surgical repair of fractures, craniotomies for intracranial hemorrhage, pedicled flap creation for facial injuries, and amputations for mangled extremities all became standard practice.⁶ The acceptance of these procedures was coupled with more targeted antibiotic use, wound debridement, and wound care.⁶

The massive number of casualties and significant disability among surviving soldiers led to the Treaty of Versailles, which outlined the need to assist recovering populations until their infrastructure was reestablished. The League of Nations Health Organization, later known as the World Health Organization (WHO), was established in 1920. This organization went on to direct global healthcare priorities and public health interventions.

In 1948, the United Nations (UN) ratified the Universal Declaration of Human Rights, and for the first time, established a precedent for intervention during both civil and international conflict.⁷

From the early 20th century, when medicine became a major feature of international collaboration, the focus was on establishing foundational ethical terms for engagement of healthcare workers, governments, and nongovernmental organizations (NGOs).

This era introduced the ethical principle of beneficence to global surgery. Specifically, it presented the concepts of:

• Surgical healthcare as a human right
• Prioritization of care over political conflict
• Need for ethical guidelines when employing novel surgical techniques on marginalized population
• Importance of investing and establishing surgical infrastructure to manage morbidity in a post-conflict era

Surgery-Specific Global Health Organizations

The period after World War II saw a significant blossoming in the number of NGOs with healthcare-based missions.

To provide an ethical framework for these organizations, the UN Code of Conduct was created. This document outlined the essential principles of humanity, neutrality, impartiality, and independence that must be observed by NGOs when providing medical care across borders.⁴ These efforts laid the foundation for the development of surgery-specific NGOs in the late 20th century.

Founded in 1969, Interplast was one of the first surgical NGOs and focused on the provision of cleft lip and palate care.

Interplast was instrumental in shaping the history of global surgery as it helped establish the “mission trip” paradigm for surgical NGOs. The organization sent surgeons from high-resource settings to resource-limited locations to perform cleft lip and cleft palate repairs for a predetermined week or on a month-long basis.

Similarly, Médecins Sans Frontières (MSF), which provides medical care in regions affected by conflict or disaster, started to provide surgical work in 1983. Often surgeons associated with MSF were deployed to regions in crisis to provide interim care in emergent settings until the healthcare infrastructure of that region was reestablished.

Additionally, credibility was given to the concept of global surgery efforts in 1980 when the director of the WHO, Halfdan T. Mahler, MD, urged the global health community to prioritize access to surgical care.

Subsequent research led to the gradual determination of global surgery efforts as financially feasible investments that have a significant impact on the health of a local population and improve disability-adjusted life years.⁸

With this information, the number of surgical NGOs continued to increase and, in 2016, there were 403 surgical NGOs operating in 139 countries.⁹ Concerns then were presented about the paradigm of care provided through surgical NGOs given the “mission trip” structure that was most often used in these programs.⁹

The ethics of short, service-based surgical trips were re-examined as longitudinal patterns were noticed. The ethical concerns raised about this structure of global surgery efforts included:

• An emphasis on the performance of cases without the appropriate postoperative plan may result in harm to the patient population.
• The expectation for surgeons to perform procedures not typically associated with their specialty may result in suboptimal operations.
• The inclusion of trainees in service-based trips may interfere with education of local students and residents as well as encourage them to attempt procedures outside their level of expertise.
• The absence of local provider and community engagement may result in agendas dictated by interests of visiting teams, missed opportunities to address critical health needs, and diversion of surgical resources from local providers to visiting teams.
• A lack of transparent financing may result in the misdirection of funding, unintended competition with local pharmacies and medical suppliers, and dead aid.
• An unfamiliarity with local languages and customs could create cultural misunderstandings that threaten partnerships and stagnate surgical efforts on a national scale.
• Performing complex surgical interventions within infrastructures that are not appropriate settings may hinder the management of subsequent complications. At their infancy, these organizations induced questions regarding the ethics of itinerant surgery.

In response to these ethical challenges, many surgical NGOs expanded their efforts in the early 2000s to include investment in surgical infrastructure, development of surgical capacity, support of local surgical workforces, and enhancement of surgical education structures.

Additionally, NGOs began to form that focused solely on surgical capacity building. The restructuring of global surgery NGOs was coupled with the development of global surgery advocacy groups and transnational collaborations. These organizations created a new emphasis on tracking surgical outcomes in resource-limited settings, enhancement of local educational paradigms, and development of local research infrastructure—all of which facilitated a natural transition to the academicization of global surgery.

Academic Institutions and the Impact on Ethics of Global Surgery Efforts

Since the early 2000s, academic medical institutions have attempted to formalize the field of global surgery through the creation of academic global surgery societies, centers for global surgery, global surgery research institutions, bidirectional academic partnerships, global surgery undergraduate and graduate medical education training programs, and global surgery research fellowships.

These efforts manifested in increased publications on global surgery, the inclusion of cases performed in resource-limited settings in the surgical academic promotion paradigm, and the movement to create international surgical accreditation systems.

The institutionalization of global surgery consisted of multiple, simultaneous efforts to incorporate global surgery activities into medical training and research.

In its initial form, modeling the surgery-specific mission trips, trainees and physicians participated in weeklong to monthlong medical trips that exposed them to global health efforts. In 2011, these exposures were formalized in surgery with the Accreditation Council for Graduate Medical Education’s (ACGME) support of incorporating international surgical rotations into general surgery training. This was a critical event as it stimulated the development of bidirectional partnerships between academic medical institutions.

In 2015, the World Bank published Essential Surgery, which includes a list of 44 surgical procedures that address substantial needs, are cost-effective, and are feasible to implement in low- and middle-income countries. This list of surgeries—from the fields of general surgery, obstetrics, ophthalmology, orthopaedics, oral and maxillofacial surgery, otolaryngology, neurosurgery, and plastic surgery—subsequently has served as the basis for the technical training of global surgeons.

The combination of all these actions described here helped establish long-term partnerships and enhanced global surgery research fellowships and clinical training programs.

During this time, seminal articles were published that discussed the cost-effectiveness of investing in surgical infrastructure,^8,10 the need for global-surgery-specific training programs, and the significant trainee and physician interest in pursuing global surgery efforts. This research further cemented the position of global surgery in academic medicine.

However, these developments resulted in multiple concerns about the ethics of global surgery on the programmatic, institutional, and international levels. Specifically, in certain lenses, academic global surgery may be perceived as a form of neocolonialism.

The parallels have included:

• Data mining from resource-limited settings as a form of resource extraction and depletion
• Presence of academic global surgeons creating mistrust and undermining of local healthcare infrastructures
• Use of global surgery partnerships to enhance the optics of academic institutions in resource-limited settings and facilitate programmatic expansion
• Deployment of trainees from high-income settings to resource-limited settings to gain experience, which may result in the disruption of the local healthcare biome
• Investment in pathologies that are a potential threat to high-income countries (e.g., Ebola, tuberculosis) instead of endemic surgical pathologies that enhance the health of the local population¹¹

To address these challenges, academic medical institutions have lobbied for special training permits to allow residents or students from resource-limited settings to meaningfully participate in surgical rotations in high-income countries.

Additionally, there are active discussions on the international level about creating more equitable research paradigms based in resource-limited settings. These conversations have included parameters for authorship and the importance of voices from low middle-income countries, grant and scholarship opportunities specific to individuals who reside in resource-limited settings, and hosting of scientific conferences, academic meetings, and advocacy summits in low middle-income countries.¹²

Moreover, there is increasing emphasis on the creation of global surgery efforts through equitable partnerships that are community-centered, needs-based, and collaborative with low- and middle-income countries.

Impending Ethical Dilemmas of Global Surgery

Global surgery is a dynamic field that continues to explore uncharted territory for the management of surgical pathologies in resource-limited settings and the development of surgical infrastructure (human resources, surgical care delivery systems, and so on).

The ecology of global surgery consists of faith-based organizations, surgical NGOs, surgical health policy groups, and academic global surgery programs. Each of these entities has contributed to the rapid enhancement of surgical accessibility.

The gradual removal of barriers to global surgery efforts will stir ethical challenges surrounding the development of international or regional surgical accreditation systems, the creation of equitable and comprehensive global surgery training programs, and the establishment of an international structure for ethical support. There are tremendous strides toward ensuring ethical global surgery activities by all key stakeholders.

However, the majority of surgical NGOs, academic global surgery societies, and global surgery centers are not based in resource-limited settings.⁹ Perhaps one of the most critical ethical tasks for global surgeons is creating room for the perspective of individuals who provide surgical care in resource-limited settings.

These voices must be included in the historical recording and assessment of global surgery.

As global surgery continues to evolve, clinicians will encounter new and nuanced ethical dilemmas. It is essential for practitioners to address these challenges in a conscientious, circumspect, and collaborative fashion to provide meaningful contribution to the field.

An intimate understanding of global surgery history and the ethical dilemmas presented during critical time periods is essential to advancing the ethical discourse in the field. Surgeons are, for better or worse, inextricably tied to the past. 

Acknowledgment

The authors would like to thank Lubna Khan for her support of this work.

Dr. Youmna Sherif is a general surgery resident in the global surgery track at the Baylor College of Medicine in Houston, TX.

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