Self-serving aspects

It is anathema, both in the general population and among surgeons, to suggest that clinicians are motivated by anything other than good will when conceiving, pursuing and performing surgical missions. By definition, surgeons are not remunerated for their efforts, and many use personal leave or vacation time to pursue benevolent activities to care for the global health community. Medicine and surgery are international skills and in many ways represent the very best interracial, intercultural and interreligious collaboration for improving the health of humanity (box 1). Nonetheless, there are clearly benefits for the visiting mission team. It is not uncommon at the mission's completion for visitors to state that ‘we have learned or benefited as much if not more than the people we helped’.

In addition to personal fulfilment, there are benefits not previously described in the literature that are amplified in the digital information age. First, medical universities and institutions inevitably publicise missions by members of their faculty and staff. Clearly, these philanthropic efforts should be lauded, yet the praise elicited by these missions intrinsically benefits the mission team and the institutions they represent and may, through publicity, yield material benefits for those parties as well. Although we do not dispute that this recognition is deserved, it is a fact that those who complete medical and surgical missions receive recognition and professional advantage from their efforts. In addition, as compelling images capture the attention of internet search engines and social media sites, surgical missions offer an opportunity for positive digital coverage that benefits the mission team. Missions, regardless of their intentions, must not offer more benefits, educational or otherwise, to the mission team than to those in the target community they intend to serve.5 ,6

Financial advantage

There is no anecdotal or published evidence that surgeons have been compensated for surgical missions. Often vacation time or personal time is used to participate in a mission. Considering that this time could be used for compensated clinical care at home, surgeons participating in missions are often at a net negative financially. At the individual level, it is unlikely that surgeons gain a financial advantage from these efforts. Nevertheless, since resources for international outreach are limited, we believe that there should be collective agreement that travel arrangements for surgical missions should be modest, comprised solely of economy airfare and hotel accommodations. Clearly, accommodations must be in safe regions of the cities visited, but they could be significantly less luxurious than the standard for pleasure travel, reflecting fiscal responsibility.

Issues can become more difficult when non-profit organisations coordinate and finance surgical outreach. While some organisations execute their mission without administrative costs, others have an administrative component that is used to attract donors for charitable fundraising. Each charity must be evaluated with the focus of successful and sustainable delivery of surgical care and presently no established criteria exist to serve as a barometer for this objective.2 ,7

Informed consent

The need for and use of informed consent is highly variable between different socioeconomic and geopolitical landscapes visited by surgical missions. Reports of successful international clinical trials indicate that informed consent can be effectively implemented in numerous healthcare scenarios and settings. Often surgical outreach requires a research component: it may be necessary to identify health needs to be met during a short-term intervention, assess effectiveness of those interventions and monitor long-term health gain.8 Currently, there is no published research demonstrating the use of advanced directives, informed consents or institutional review boards during short-term volunteerism either in medical or surgical missions. It is imperative that we not overlook the capacity of medically underserved populations to participate in fundamental elements of informing and consenting. This opinion is shared by the European Commission's directive, ‘Ethics in research and international cooperation’ cogently articulated as the following: ‘Independent of the cultural particularities that may require a slight modification of the standard procedures, the principle of Informed Consent — individual, comprehensible and fully documented — is fundamental. It must be adhered to in all circumstances without exposing the individual to discrimination or danger simply because the procedure does not fully comply with the local cultural settings. It is also important to ensure that the participants will not face any risk that relates to their refusal to participate in the planned study, and are offered actual alternative options’.9 It is important that citizens embrace the idea that, even when options are limited, their consent is fundamental to the process and they are the drivers of their medical care.10 ,11

Conflicts of interest

Healthcare workers and physicians who dedicate their lives or a portion of their work week to care for underserved populations in their resident country seldom exhibit ulterior motives in providing this care. Given the limited resources and competitive environment of developing a private practice, many doctors in America do not participate in the care of the underserved. The most common scenario that we have encountered in delivery of care to the poor in a host country is an academic surgeon who may work part of the week in a ‘government’ hospital and the remainder in a ‘private’ clinic. In this scenario, there exists an ethical hazard that the host team will use donated equipment and skills to benefit their private practices and not for the intended mission goals, namely, to benefit the underserved of the host country. There are, indeed, anecdotal reports of donated equipment being moved to private clinics after completion of targeted missions. The risk of this form of misappropriation, we feel, is minimised by repeated personal visits by mission members and diligent follow-up with the host team. If newly acquired operative skills (ie, those inculcated by the mission team's didactic outreach) lead to improvement in the ‘private’ element of a surgeon's practice, this in itself is not a conflict. Relocation of equipment intended for charity hospitals to private clinics is, however, unacceptable. Ultimately, the depth of dedication and commitment to the underserved is one that should be closely evaluated by inperson site evaluations by auditors prior to initiation of full-scale missions.

Futile and/or compromised care

Host teams usually have significantly limited resources. And, since most missions are charitable endeavours, discussion of optimal use of finite funds is necessary. However, integrating financial common sense with cost–benefit analysis of human life is a calculus not easily performed. Therein lies a major ethical consideration that applies to all members of the host and visiting teams. Both teams should have an understanding about the effective use of mission resources. Care should be appropriate to the needs of the community and not divert local resources inappropriately.4 ,12 No algorithmic approach can be devised to accomplish this since the healthcare ecosystem in each region is unique. Some basic principles can be stated but need to be personalised to each unique medical outreach context (box 2).

The desire for a ‘successful’ mission may create an environment where both the visiting and hosting teams feel pressured to demonstrate that a certain minimal number of operative cases can be performed. Indeed, for charitable organisations sponsoring the trips, the number of patients treated may be a component of their organisational fundraising strategies. Ultimately, these decisions lie with the surgeons involved and often significant teaching and logistical elements can be established leading to success in some of the varied didactic objectives within each mission. Case volume is not the only determinant of success. Poorly planned large volume missions can overwhelm local medical personnel.13 Overall, the strategy of performing cases that do not meet clear indications in order to achieve a certain case volume is not ethically aligned with the shared goals of the host and visiting teams.

A major limitation in clinical care delivered at international facilities is the lack of long-term follow-up. Since most significant numbers of treated patients will be lost to follow-up, this introduces major obstacles for discerning accurately the benefit of the surgical intervention and collaboration. Although this may be expected in some part based on the population that was served in a developing country, it does introduce potential error in declaring whether efforts were truly successful or not. Accordingly, the ‘success’ of surgical missions should be declared with caution and only after diligence.

Similarly, operative cases should be selected to be performed that are compatible with the resources possessed by patients to provide necessary postoperative care. For example, pituitary surgery that may leave the patient with panhypopituitarism postoperatively (whose treatment would require lifelong medication, the lack of which could lead to the patient's death) is not appropriate in a host country where such medications are not readily available. Poor health and advanced disease increase the risks and decrease potential benefits of some interventions, and one cannot assume that the outcomes of interventions in developing countries are identical to outcomes of the same intervention in developed countries.8 ,14 For example, in one case, described by Dupuis, two malnourished children died after cleft palate operations performed by medical volunteers from postoperative complications related to nutritional deficiencies.8 ,15 Thus, peri-operative evaluation and management are a critical element of surgical mission design and operative case selection.