1 report a minimally invasive subaxillary approach to perform a bidirectional cavopulmonary anastomosis in a patient with single-ventricle physiology, and the commentary by Dodge-Khatami 2 suggests that avoiding an additional scar in 2-staged palliation would promote the patients' best interests. Although we understand Dodge-Khatami's concerns, we respectfully disagree with the assumption that the surgeons planned the surgical approach ''for their comfort,'' given the setting of this case report. The operation took place in the Dominican Republic (DR), which is a middle-income country with limited independent cardiac surgical services. The country relies on 5 local cardiac surgeons for a population of 10.8 million people, concurrently supported by visiting teams to operate on children with congenital heart defects (CHDs). 3 At a birth rate of 19.7 per 1000 people, more than 2000 children are estimated to be born with CHD in the DR annually, on top of the existing CHD burden, rheumatic heart disease prevalence, and growing ischemic heart disease incidence rates. 4 The rationale of a traditional sternotomy approach for the Glenn procedure, in addition to its ease and long-standing experience, aligns with the inevitable need for a resternotomy for final Fontan palliation. As Dodge-Khatami argues, this avoids the creation of 2 scars, which would occur when performing a subaxillary approach in the primary procedure, whereas the safety of resternotomy has improved significantly in recent years. Nevertheless, the setting of DR's limited economic and material resources requires trade-offs on a daily basis. The ethical principle of justice requires that the distribution of scarce resources benefit the entire population while respecting other principles as well: autonomy, manifested in the informed consent process, and beneficence and nonmaleficence, acting in the patient's best interest. Cost constraints may lead surgeons to avoid the use of