title: Ethical challenges in international surgical education, for visitors and hosts.
abstract: OBJECTIVE
  Contributing to medical practice in developing countries has become increasingly prevalent. Primary care and preventative health initiatives have been most visible, although attention has recently shifted to surgical disease, which represents a large burden in resource-poor settings. Typically dominated by individual efforts, there is now a more concerted approach, with surgical care being included in the comprehensive primary health care plan set by the World Health Organization. Although ethical dilemmas in international surgery have been discussed sporadically in the context of specific missions from the visiting surgeon/team perspective, we are missing a comprehensive evaluation of these issues in the literature. Here we have chosen to systematically categorize ethical issues confronted while teaching and operating in a developing country into 2 broad categories: venue (i.e., host) and visitor related.
  
  
  METHODS
  For each category, topics within follow an ordinal sequence that one might use when designing a surgical education mission. Illustrative examples are provided, as well as a depiction of the ethical principles or theories involved.
  
  
  CONCLUSIONS
  This article provides a discussion written from visiting and host surgeon perspectives on diverse ethical challenges for which there is limited literature, including location selection, unmet needs at home, role of sponsors, and personal gain. In addition to candid discussion and a solutions-focused approach, the reader is provided with an "ethical checklist" for international surgical education, akin to the World Health Organization surgical safety checklist, to serve as a framework for the design of surgical missions that avoid ethical pitfalls.
authors.affiliation: Global Health Education Institute, University of Toronto, Toronto, and Department of Surgery, McMaster University, Division of General Surgery, Hamilton, Ontario, Canada. Electronic address: kathryn.howe@utoronto.ca.
authors.forename: Kathryn L
authors.initials: KL
authors.lastname: Howe
authors.forename: Adefolarin O
authors.initials: AO
authors.lastname: Malomo
authors.forename: Mark A
authors.initials: MA
authors.lastname: Bernstein
mesh_terms: D001921:Brain / Q000601:surgery; D003399:Craniotomy; D003469:Culture; D003906:Developing Countries; D013502:General Surgery / Q000191:economics / Q000193:education* / Q000941:ethics*; D006301:Health Services Needs and Demand; D006801:Humans; D007258:Informed Consent; D009493:Neurosurgery / Q000193:education / Q000941:ethics; D009873:Operating Rooms; D010348:Patient Care Team; D011320:Primary Health Care / Q000191:economics / Q000941:ethics; D013523:Surgical Equipment
keywords: DALY; Disability adjusted life year; Education; Ethics; Surgery; WHO; World Health Organization; World health