Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery

BACKGROUND

There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact.

METHODS

Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries.

RESULTS

The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas.

CONCLUSION

The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Could global surgery overcome a decline in surgical cases?

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There have been three distinct landmarks for the US surgical trainees leading to a decline in surgical volume and in open number of cases.

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Global surgery experiences have been adopted to expose trainees to surgical problems not routinely seen in the Global North.

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Global Surgery also exposes trainees to empathic and collaborative approaches.

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Benefits of global surgery to compensate for the decline in volume, variety and open surgical cases need to be studied through an academic, ethical, and economic lens.

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LMICs trainees could travel to HIC for research and clinical training in exchange for the skills and case volume that HIC trainees would obtain in LMICs.

Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study

BACKGROUND

French military doctors are currently deployed in the Sahel to support the armed forces of Operation Barkhane, in medical or surgical units. As well as supporting French soldiers, their other missions are diverse and complex: medical assistance to civilians and persons under control (PUC), advice to commanding officers. These tasks can create ethical dilemmas when decisions are forced upon doctors that may be in conflict with medical values or fundamental principles. Little is known about the specific dilemmas experienced by French military doctors in overseas operations. We therefore conducted a qualitative study among doctors and surgeons recently deployed to the Sahel to explore and better understand this question.

METHOD

Semi-structured, face-to-face interviews were conducted with 20 French military doctors or surgeons deployed since January 2016 in medical or surgical facilities in Mali and Chad.

RESULTS

All interviewed doctors reported having faced several ethical dilemmas during missions. All reported dilemmas involved the treatment of civilians (while delivering community medical assistance) or of PUC. The dilemmas involved choices as to which patients to treat, the use of care as a means to an end by military authorities, and the level of care attainable in the absence of any possible hospital follow-up. Questions of delivering care at the risk of their own safety or the mission's and of treating openly hostile patients were also brought up. Several dilemmas stemmed from the dual loyalty problem, namely the conflict between military doctors' duty of care to patients and to the military institution, but this was not the only factor involved. Contextual factors (restricted resources and security constraints) and psychological factors (especially hostility towards the enemy) were also associated with many of the reported dilemmas.

CONCLUSION

This is the first reported study focusing on the ethical dilemmas encountered by French military doctors in overseas operations. It provides unique insights into their ethical experiences and should prove useful in improving operational training for healthcare personnel deployed on overseas missions.

Teaching Human Rights in Surgical Curriculum

The relatively new academic discipline of health and human rights builds upon international efforts to support universal human rights education. I propose that teaching of human rights, both in domestic and international situations, could be part of a structured curriculum along with medical ethics, professionalism, role-modeling, and mentoring for surgeons in training. I suggest a pilot course of human rights be taught to global and humanitarian surgeons as an initial step before widespread inclusion for all surgeons.

Ethical considerations in global surgery: a scoping review

Introduction

An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge.

Methods

A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature.

Results

Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies.

Conclusion

The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.

Burn wound care of civilians in Sahel region by French military surgical teams: ethical challenges and future training requirements

The primary mission of the French military surgical teams deployed in external operations in the Sahel is to provide support for combatants. However, many of their activities and of the limited human and material resources allocated to them are devoted to providing free medical assistance to the local population. The French military surgical teams are very often expected to take care of serious burns for the benefit of civil populations because of the absence of dedicated civilian medical structures. Surgical teams are faced with a necessary triage of patients to be taken care of because of the discrepancy between the high demand for care and the means at their disposal. But the triage can lead to ethical dilemmas when the values that come into play in the decision contradict each other or when they run up against the quota of available human and material resources, as well as the interests of the military institution. The challenge is then to become aware of these dilemmas in this particular context. A discussion of these ethical dilemmas would help carers to avoid developing fatalistic attitudes or developing chronic pathologies due to unresolved or unconscious predicaments. Solutions are proposed that place ethical reflection at the heart of the practices during external operations by the French surgical teams. The ethics of discussion must bring together all players in care management and also the military authorities, before, during and after the missions. Training programmes for ethical reflection would benefit surgical teams and help them approach and become aware of the dilemmas they will necessarily face.