Ethical Dilemmas in Global Plastic Surgery: Divergent Perspectives of Local and Visiting Surgeons

Abstract

Background: As more of the world’s resources are directed toward improving patient access to safe surgical and anesthesia care, there is a growing concern that volunteer surgeons’ “desire to help” has numerous unintended consequences. The purpose of this study was to ask in-country, local surgeons and visiting volunteer plastic surgeons about the frequency of ethical dilemmas for different types of global surgery collaborations and to assess their perception of compliance with the concepts of autonomy, beneficence, nonmaleficence, and justice. Methods: A cross-sectional email survey tool was sent to a representative sample of domestic American Society of Plastic Surgeons members, all international members of the American Society of Plastic Surgeons, and international partners of the Volunteers in Plastic Surgery committee of the Plastic Surgery Foundation. The survey response rate was 7.7 percent, with 356 respondents from 65 countries. Results: This survey data showed a statistically significant divergence of perspectives between local and visiting surgeons in regard to scope of practice, quality of patient care, impact on local health care systems, perception of the quality of care by local providers, the integrity of the informed consent process, and photography in global plastic surgery collaborations. Though the short-term mission trip model was particularly polarizing when comparing the responses of local and visiting surgeons, educational and research exchanges may also significantly interrupt local health care and incite ethical lapses. Conclusion: This survey provides quantitative insight into the impact of current global plastic surgery collaborations and highlights ethical areas of disagreement between local and visiting surgeons.

Discussion: Ethical Dilemmas in Global Plastic Surgery: Divergent Perspectives of Local and Visiting Surgeons

“…The authors put forth that “[a] possible solution to this tenuous ethical balance may lie in shifting focus away from direct provision of care by visiting surgeons and toward support of in-country capacity-building efforts.” 1 There is a great deal of support for this opinion as the historical colonial approach to providing care in low- and middle-income countries is increasingly viewed through the lens of the host country and its people, as was highlighted in this study. The mission model typically does little to build intrinsic capacity in low- and middle-income countries.…”

“…The authors of this study surveyed the perspectives of surgeons who had some experience with global surgical outreach trips or “missions.” 1 On these trips, surgeons from high-income countries traveled to low- and middle-income countries to provide clinical care, educational exchanges, or research. In this study, the authors surveyed the surgeons to determine whether they had experienced ethical dilemmas with respect to mission participants from high-income countries practicing outside their scope of practice, providing a lower standard of care, or creating interruptions in local care routines and whether they had seen ethical issues with the informed consent process or the use of photography.…”

“…Finally, it is not uncommon for surgeons on these trips to encounter patients with problems that they do not routinely care for in their practice. Frequently, they proceed with the surgery under the feeling that “doing something is better than nothing.” 1 This is not a sentiment that is universally shared. As pointed out by the authors, the Volunteers in Plastic Surgery “Guidelines for Providing Surgical Care for Children in the Less Developed World” states clearly that care provided on these trips and the expected outcomes should be comparable to those provided in the high-income countries from which the authors come.…”

Consent issues for vulnerable children in sub‐Saharan Africa and beyond

“…3 Educational and research exchanges may; however, still interrupt local health care andinciteethicallapses. 4 Concernsaboutthehandlingofthisreportbytheeditorialstaff ofthejournalhavealsobeenraised. 2 Whileanaccompanyingeditorial 5 highlightedissueswiththeuseofananesthesiatechniquethat did not conform to current optimal mission models that center on appropriateeducationandskillstraining,therewerealsoconcerns raisedaroundethicallapses.Thesepotentiallapsesdeservebetter…”

“…Collaborative research, quality improvement projects and education are best achieved where there is a commitment for such ongoing engagement with those in the local health care system 3 . Educational and research exchanges may; however, still interrupt local health care and incite ethical lapses 4 …”