Designing a Global Surgery Ethics Course Outline: A Learners’ Proposal

Ethical principles in global surgery refer to the moral frameworks and guiding values that shape the planning, delivery, and evaluation of surgical care across international and cross-cultural settings, particularly in low- and middle-income countries [LMICs] [1]. They provide a foundation for ensuring that global surgical initiatives are conducted fairly, responsibly, and sustainably [2]. While access to equitable surgical healthcare is critical, ethical considerations and challenges in GS are often neglected in academic surgical training. This is perhaps understandable, as designing an ethics curriculum is a challenging task due to the evolving nature of ethical concepts. It also requires concerted effort from professionals of different experiences. An ethics curriculum requires in-depth understanding of theoretical frameworks, practical challenges, and decision frameworks.

Equity and ethics are closely related principles, such that fairness and justice in the distribution of resources, opportunities, and care are unachievable without ethical practice [2]. Ethics in global health discourse is guided by long-standing ethical principles such as autonomy, non-maleficence, beneficence, and justice. Consequently, global health practitioners have used these ethical guidelines to advance knowledge in ethical practice and equity [3–6].

The integration of ethics as a core component of global health education is gradual and promising. Prominent courses, such as the Global Health Ethics seminar at the University of Minnesota and Global Health Ethics at Duke University, integrate ethical frameworks and case-based discussions into broader curricula, exemplifying well-established approaches in global health. However, global surgery offers very few dedicated ethics courses. While standalone courses in global surgery ethics are virtually absent, UBC’s SURG 510: Surgical Care in International Health represents a course in which ethics is a central, integrated theme, covering clinical and research ethics, volunteerism, and advocacy alongside broader global surgery content [7]. Beyond this, ethics is typically embedded within broader programs rather than treated as a central focus. This highlights a critical gap in the literature and curriculum design for global surgery ethics.

Therefore, the ethical dimensions of global surgical endeavors are not well understood, and it remains unclear how they differ from ethical considerations within the broader global health discourse. The implementation of fundamental ethical principles in surgical care is complicated by existing challenges in LMICs. Lack of human resources, poor infrastructure, and scarce medical equipment make the provision of quality surgical care much more challenging. [8]. In turn, efforts to address the need for basic surgery in LMICs through collaboration with high-income countries (HICs) face ethical challenges that can lead to the exaggeration of inequities. 

Given the complexities and challenges inherent to the application of ethical principles to the real-world global surgical care environment, a standardized course outline on Ethics in Global Surgery is needed to guide interdisciplinary healthcare professionals and other actors in the field. Such a course outline should incorporate various viewpoints and lived experiences, including diverse representatives from both LMICs and HICs, to foster inclusive dialogue and a comprehensive understanding of the challenges and equitable solutions. The objective of this paper is to develop a basic course outline on ethics in GS, grounded in key ethical challenges in the field. It will explore the complexities surrounding major ethical dilemmas and argue for the integration of ethical training into global surgery education and practice. In addition, it will propose an academic course outline to provide a framework for addressing ethics in global surgery. This outline is intended to serve as a foundation for designing a more inclusive curriculum.

Research Design and Approach

To develop the Ethics in Global Surgery course plan, we used the Nominal Group Technique (NGT) through a four-step deliberative consensus-building process. We also carried out a process evaluation to track how the steps were implemented and how participants engaged at each stage [9] (Figure 2). The deliberative consensus-building approach is a participatory process that integrates diverse perspectives and achieves collective agreement based on the theoretical framework of collaborative governance [10]. Collaborative governance refers to a “collective and egalitarian process in that participants are endowed with substantive authority to make collective decisions, and each stakeholder possesses equal opportunity for their preferences to be reflected in the decision. [11]. This framework is characterized as a deliberative process with open sharing of knowledge and information, a consensus orientation rather than a majority rules approach, and mutually beneficial interactions. [10]. In parallel, a process evaluation was conducted to assess the dynamics of the consensus-building process, focusing on participation, decision-making mechanisms, and facilitation strategies (Figure 2).

Sampling Strategy and Participants

Participants were selected using a convenience sampling approach, in which all global surgery learners at the institution were chosen to allow for rapid collection of opinions from readily accessible individuals. The sample consisted of nine graduate-level students with diverse academic and professional experience ranging from 2 to 11 years (median: 4 years, IQR: 4–8). Together, they represented a total of 50 years of cumulative work experience in global health and surgery. This included three clinicians from Rwanda- a general practitioner with surgical interests, an orthopedic resident, and a dental surgeon; three physicians from Ethiopia with experience in leadership in national surgical quality improvement, inpatient surgical coordination, and private cardiac surgery; one Kenyan public health researcher and author with experience in anesthesia and simulation training; one surgical community health officer from Sierra Leone with extensive clinical experience in surgery via task shifting; and one clinical practitioner and public health officer from South Sudan.

Data collection method

Notes were taken in real time using a structured format to document key discussion points and areas of consensus. capturing key points of agreement and documenting agreed-upon ethical challenges that need to be included in the curriculum. After each session, written reflections were collected from participants. The reflections focused on the consensus-building process and their experience in the deliberation process.

Deliberative consensus-building approach

a. Immersive ethics in GS instructor-led session: In the first step of the process, participants were introduced to the subject matter through a one-week immersive ethics in GS instructor-led session. The instructor is an Assistant Professor and Center for Global Health Lead, with expertise in global surgery, maternal health, and health equity and ethics, holds a Master’s in Global Surgical Care, and leads multiple international capacity-building initiatives, including surgical training in rural Tanzania and South Sudan. The instructor leads global surgery ethics training in both a HIC and an LMIC institution. The session provided a structured exploration of ethics in global health and discussed the basics of ethics in GS, featured case-based discussion, and explored ethical dilemmas. This ensured a shared baseline understanding before participants centered consensus discussions.

b. Collective brainstorming: In the second step, participants were engaged in brainstorming sessions through structured small-group and large-group discussions facilitated by an instructor characterized by free information and experience sharing, and critical thinking. The process emphasized open dialogue and iterative refinement of ideas to reach a consensus on the key ethical challenges in GS and the proposal of potential curriculum content through the lens of African surgical healthcare providers. Participants presented their viewpoints on ethical challenges and advantages of learning these identified ethical challenges with learning objectives. Two instructors guided structured discussions while taking notes of the session.

c. Open discussion and initial rapid consensus building on key thematic areas: As the third step in the deliberative consensus-building approach, participants engaged in open discussion of identified ethical challenges in global surgery and outlined the importance of having structured guidelines for ethics in global surgery courses from the perspective of the LMICs, and identified key themes in implementation challenges that require attention. An agreement-seeking, a priori inclusive, participatory, and collaborative consensus decision-making process model was used to generate the final themes and the course outline document [Figure 3] [9]. The criterion for including any concept in the outline required unanimous agreement. Participants were encouraged to request clarifications, block consensus as needed, agree with stated reservations, or abstain with explanation. Iterative rounds of discussion were conducted to resolve disagreements through structured discussion, clarification of differing perspectives, and synthesis of ideas until consensus was reached, with the rationale documented in facilitator notes.

d. Collective prioritization and reprioritization: In a final step, challenges and components of a GS ethics course outline that address these challenges were prioritized and re-prioritized through further group feedback and dialogue. Participants iteratively reviewed the proposed themes and components of the ethics course outline. This allowed for reflection and refinement of a course plan, indicative content, and learning outcomes. The agreed-upon course plan was documented and reviewed by all participants for accuracy and completeness. In this final step, the group synthesized their discussions into a structured course outline, focusing on implementation challenges in GS ethics. Using a visual participatory review, line-by-line reading of the draft outline, and updates based on feedback from participants, was followed by unanimous consensus on the outline (Figure 3).

Process Evaluation Framework

To evaluate the consensus-building process, we applied a process evaluation framework focusing on three key dimensions. Participation, decision-making, and facilitation of group interaction [12]. This allowed us to evaluate the extent to which all participants/students contributed actively and equitably to the discussions; mechanisms through which consensus was achieved, such as negotiation, compromise, and reflection; and the role of facilitation in guiding discussions.

Data Analysis

The analysis followed a descriptive evaluation framework and focused on summarizing observations related to the process of consensus-building. Using elements of grounded theory, we analyzed facilitator notes from the deliberative discussions to identify key concepts and emerging themes. A rapid thematic review was conducted using a hybrid deductive–inductive coding approach, with an initial framework informed by study objectives and NGT domains. Codes were organized into thematic matrices and refined into higher-order themes through team discussion and consensus. Findings related to participation, decision-making, and facilitation were triangulated through comparative assessment across discussion phases and data sources, including facilitator notes and participant reflections.

Ethical Considerations

This study was part of routine educational practice, with minimal risk to participants as no personal data was collected and participation was voluntary. All participants are co-authors and actively involved in drafting and editing the manuscript. Given its educational nature and the absence of sensitive data, the study was considered exempt from full ethical review under (45 CFR 46.101[b] (Category 1)) [13].

Reflexivity

Our group represented five sub-Saharan African countries, bringing together diverse clinical and professional backgrounds with a balanced gender composition [Figure 1]. We met in Rwanda through the new MGHD Global Surgery track. Drawing on our shared experiences, we critically reflected on the challenges and opportunities within global surgery ethics. Nonetheless, we do not represent all of Africa or all possible professional views and are mostly early and mid-career practitioners immersed in African global surgery. Additionally, the instructor’s seniority might have introduced social desirability bias, potentially influencing participants to align their responses with perceived expectations. The authors proffered the following Global Surgery Ethics course outline that may guide and standardize such content for other programs. Such a course outline may be used for an array of actors in Global Surgical care, including but not limited to clinicians, academicians, policymakers, government, intergovernmental organizations, non-governmental organizations, and grassroots organizations. Given the diverse backgrounds of authors and our firsthand exposure to these real-world challenges, the proposed structure may serve as a starting point for designing a more inclusive curriculum.

The group of students reached a consensus on the three core ethical challenges in global surgery, as well as a set of special circumstances. Hence, the four key implementation challenges identified include (1) Equipment donation, (2) Short-term medical missions, (3) Global Research ethics, and (4) Special circumstances that require humanitarian responses, such as war, pandemics, and disaster response, which present unique ethical dilemmas.

Participants identified key ethical dilemmas through a process of group deliberation, in which each member drew from personal and professional experience in global health and surgery. Challenges were shortlisted based on repetition of occurrence in their clinical and training contexts, and relevance to real-world practice, particularly in resource-limited or cross-border surgical care. This consensus-driven prioritization yielded four central themes for ethical consideration.

1. Equipment Donation

Participants regarded equipment donation as a force for good, but with potential unintended consequences. Equipment donation, while intended to strengthen surgical capacity, often raises concerns regarding appropriateness, quality, and sustainability. Repair capacity, supply chains, and design incompatibility represent dilemmas in equipment donation that affect healthcare at the systems level, demanding attention.

Participants expressed that “ equipment use and infrastructure development are central to delivering safe surgical care, making these topics highly relevant for discussion in global surgery ethics.”

 Equipment donation poses a major ethical dilemma in LMICs, where up to 70%–80% of available medical equipment is donated [15]. In some cases, there is a mismatch between what is donated and what is needed by the recipient facility. Resource constraints, such as limited or incompatible infrastructure (e.g., voltage requirements) and biomedical support capacity, preclude the safe usage or essential maintenance and repair of donated equipment [16]. It was also mentioned that donated equipment is sometimes inappropriate for the context, leading to underutilization. A direct consequence is unusable medical equipment that occupies space and resources without tangible benefits to patient care, despite the existence of global guidelines to inform ethical donations. As the 2011 World Health Organization Guidelines on Medical Device Donations recommend, it is crucial to actively engage intended recipients and to treat medical donations with the same rigor applied to normal equipment procurement, in order to ensure that donations target identified needs, are appropriate for the hospital system, and are made within a plan for maintenance and ultimate disposal of the medical equipment [17].

2. Short-Term Medical Missions (STMM)

Short-term missions provide temporary relief and specialized services in otherwise hard-to-reach areas or backlogged institutions but carry risks related to continuity of care, accountability, and local capacity building. Concerns emerge when missions prioritize procedural volume or visibility over sustainable partnerships and long-term health system strengthening. Underserved regions in the global south are still dependent on these missions, necessitating discussions in Global Surgery Ethics.

Clinically, while these missions may provide immediate services to underserved communities, failure to follow ethical processes may affect both the patient and the existing healthcare system. The short-term nature of the mission with little to no clinical follow-up may lead to suboptimal care for patients undergoing complex procedures, leading to post-operative complications and challenges that burden the host team.  Instead of the traditional “parachute in, parachute out” model of medical missions, visiting surgical teams, participants agreed,  must plan for adequate clinical follow-up and ensure that such postoperative care issues do not fall squarely on the shoulders of the host team. The widespread use of telemedicine and virtual consultations permits such follow-up long after the visiting team has departed [20].

A comprehensive plan starts from a needs assessment that ensures alignment with host priorities while considering on-site resources to ensure the mission does not inadvertently siphon off scarce consumables, infrastructure, and human resources [21]. Pre-departure training for visiting staff is crucial and should also involve active participation from the host institution so that such training may be tailored to that specific facility and community. One cannot assume a one-size-fits-all approach to pre-departure training, and such sessions should include input from the host facility’s leadership to reflect the local context. This may be done virtually in the weeks leading up to the mission and would also provide the opportunity for the respective healthcare teams to meet.

In addition to pre-departure training, it was indicated that preliminary clinical consultations via telemedicine may also be considered. Local healthcare providers may present the cases of pre-selected patients, review medical history and complete investigations, and discuss the planned intervention with the visiting team [22]. Moreover, an innovative approach, in which, if logistics permit, the patient may also join the telemedicine consultation to meet the visiting and host teams and review the plan a priori.  As aforementioned, this method may also be used to arrange post-procedure visits. In doing so, this will equip the host provider with the necessary skills and technology to maintain continuity of care. Such collaborations may lay the groundwork for the medical mission’s success and the patient’s overall well-being.

National governments may also introduce policies to accredit the medical credentials of foreign health professionals and regulate STMMs. A participant mentioned that, in Kenya, for instance, the Medical Practitioners and Dentists Council introduced guidelines through a Parliamentary Act for medical camps. This Act requires temporary licensing of visiting health workers, a referral policy for patients, and professional indemnity[23]. Such regulations protect not only the patient but also ensure appropriate practice by foreign entities that align with national policies and priorities.

3. Global Research Ethics

Research ethics is a cross-cutting discipline that extends beyond global surgery. Recurrent subthemes identified from learners’ input include fair authorship practices, equitable sharing of benefits derived from research, and the conduct of externally driven studies that exclude meaningful local involvement. These issues directly influence partnerships and, in turn, shape the overall functioning of global surgery initiatives. On the deliberation process, Participants expressed concern that “Externally driven research conducted without sustained local collaboration undermines trust and equity in partnerships.”

Addressing authorship disparity between visiting researchers and local contributors is vital to fostering equitable and respectful research collaborations. A scoping review conducted by Grant et al., “Ethical considerations in global surgery”, showed the need to incorporate original research papers and perspectives from authors in LMICs [24]. This statement is supported by Ghani et al. (2020) who investigated authorship trends in LMICs and found nearly one-third of the publications reviewed that were conducted in this region did not list a local author from LMICs [25]. Authorship disparities reflect ethical issues that arise from inequitable partnerships between researchers [26]. Even with recent shifts towards authorship equity and inclusivity guidelines, the academic global surgery community must be mindful toavoid tokenism by relegating authors from LMICs to being simply middle authors on joint research manuscripts. Authentic and equitable research partnerships between HIC and LMIC authors are critical to producing thorough, locally relevant, and inclusive publications that honor and credit local contributions.

Ensuring that research benefits the local community, rather than exploiting it, is essential for ethical global surgery practices. “Ability to conduct foreign research is an opportunity and not a right,” as stated by Odeny and Bosurgi in their article titled “Time to end parachute science” [27]. Researchers from HICs often have greater access to funding, which enables them to set the research agenda in LMICs [27]. As a result, ethical concerns in research may arise even in the early stages of research question development, which may be misaligned with local priorities. This degrades the relevance and applicability of the research findings to impact the community for which the research is purportedly being done [27].  It is therefore essential to have the host team and community drive the research agenda while considering the local context to produce meaningful research with long-lasting real-world outcomes.

4. Special Circumstances Requiring Humanitarian Response

In humanitarian crises such as armed conflict, natural disasters, or mass displacement, ethical dilemmas emerge around triage, consent, allocation of scarce resources, and diversion of resources.

In such humanitarian surgical settings, the ethical challenges described by Welling et al. in the “Seven Sins of Humanitarian Medicine” are particularly relevant. Issues such as lack of follow-up care, inappropriate technology transfer, and competition among NGOs can be magnified in fragile health systems affected by war and disaster [28].

In such unique circumstances, prioritization of surgical resources could also be a difficult decision for professionals, raising questions of justice and equity in access to surgical interventions. For instance, the COVID-19 pandemic raised issues of resource allocation due to the unavailability of mechanical ventilators in the ICU, thereby compromising service delivery for surgical patients [29]. Similarly, the humanitarian response in disasters is prone to ethical dilemmas due to the urgency of response and the immense burden of need [30]. In conflict zones such as Gaza, healthcare workers face profound ethical challenges related to scarce resources, informed consent, and prioritization of care under extreme conditions of violence and infrastructure collapse, demonstrating the need for context‑specific ethical guidance in humanitarian medical practice. It is, therefore, important to understand the complexity of such scenarios and prepare professionals for decision-making [31].

Based on these four themes, the following course outline was proposed. The outline contains an introduction to the course, a discussion on the identified themes, and indicative content and learning outcomes. The summative exercise aims to provide a space for practical learning opportunities in which students can synthesize and apply core ideas.  This is summarized in the figure shown in Table 1.

The unique ethical issues that arise in global surgical practice remain insufficiently explored, leaving uncertainty regarding how they compare with ethical challenges encountered across global health more broadly. Existing literature has primarily emphasized clinical care, with comparatively limited attention to the ethical dimensions of transnational global surgery practice [14]. This gap shows the need for structured educational approaches that extend beyond bedside ethics and address system-level and cross-border challenges. [14].

In this paper, the authors identified common ethical dilemmas in global surgery practice, which were systematically organized into thematic domains to inform curriculum development. These ethical dilemmas were used to build a course structure grounded in real-world challenges. Unlike existing global surgery courses that emphasize international interventions and volunteerism, this proposed outline adopts an ethical challenge-based framework that is both inclusive and focused. Academic practice often shapes priorities in research and innovation; therefore, a curriculum anchored in empirically observed ethical challenges has the potential to guide future scholarship and responsible practice in global surgery. The discussion below elaborates on each theme and justifies its inclusion by examining associated dilemmas and mitigation strategies, while clarifying the scope and educational relevance of the proposed curriculum.

Equipment Donation

Equipment donation represents a significant ethical challenge in global surgery, particularly in LMIC settings. The prevalence of donated equipment and frequent mismatches between donated technologies and local capacity highlight systemic ethical risks [15, 16]. These challenges extend beyond inefficiency and directly affect patient safety, sustainability, and health system resilience. Despite the existence of international guidelines, inappropriate donations continue to occur, reflecting gaps in accountability and shared planning [17].

Given the critical role of medical equipment in global surgical care delivery, it is essential to include this as a standalone component in ethics curricula. This emphasis will enable students to grasp the complexities of equipment donations, including the challenges posed by dysfunctional medical equipment. It will also cover the ethical considerations involved in medical donations, helping students brainstorm potential regulatory mechanisms and deepen their understanding of the unintended harms of medical equipment donations.

Short-Term Medical Missions

The ethical complexity of short-term medical missions has been widely documented. Challenges related to scope of practice, sustainability, and cultural competence continue to raise concerns about the ethical integrity of these engagements ​[18]. While short-term missions may address immediate unmet needs, their structure can inadvertently compromise continuity of care and burden host system [19].

Educationally, these realities reinforce the need for ethics training that emphasizes host-led planning, accountability, and longitudinal responsibility. Incorporating case-based discussions on pre-departure preparation, telemedicine-supported follow-up, and regulatory frameworks allows learners to interrogate dominant mission models and explore ethically sound alternatives.  Such training shifts the focus from short terem service delivery to partnership-oriented, ethically grounded collaboration.

Global Research Ethics

Research ethics is also a challenging endeavor in the GS space. As identified in the literature, there are two key issues: authorship disparity between visiting researchers and local contributors, and ensuring research prioritizes local community benefit. Persistent disparities in authorship and agenda-setting reflect broader power imbalances within global research partnerships [25, 26]. Even as guidelines promoting inclusivity gain traction, the risk of tokenism and extractive research practices remains.

Integrating research ethics into the curriculum is therefore essential. Learners must be equipped to critically assess authorship practices, funding dynamics, and priority-setting processes. Emphasizing community-driven research agendas reinforces the ethical principle that global surgery research should generate meaningful, locally relevant impact rather than primarily advancing external academic interests [27].

Special Circumstances

Discussing the ethical dimensions of global surgery extends beyond the commonly addressed topics of equipment donation, research ethics, and short-term medical missions. Special circumstances such as war, pandemics, and disaster response present unique ethical dilemmas for healthcare professionals.

Accordingly, special circumstances should be addressed explicitly within global surgery ethics curricula. Preparing learners to navigate moral distress, triage decisions, and competing obligations in crisis settings strengthens ethical resilience and professional accountability. Including these scenarios as a distinct curricular objective ensures that future practitioners are better be prepared for the realities of humanitarian and conflict-affected surgical care.

Proposed Course Outline

Incorporating discussions of ethical challenges into the proposed course outline is crucial for preparing future healthcare leaders to navigate complex situations effectively. This course outline will include training on managing ethical dilemmas during emergencies, such as pandemics, war, and humanitarian disasters, which present unique challenges that necessitate independent consideration. By addressing these critical aspects of global surgery ethics, we aim to foster a comprehensive understanding of the responsibilities associated with providing surgical care in diverse contexts. Thus, these special circumstances should be included as a separate objective in the GS course outline (See Table 1).

The proposed course outline incorporates four key scenarios in global surgery ethics and applies a case-based approach, emphasizing challenges that are both frequent and impactful. The authors intentionally narrowed the scope to focus specifically on global surgery, acknowledging that this outline does not encompass all ethical dimensions within the field. Rather, it provides a focused framework that can serve as a foundation for developing a more comprehensive curriculum integrating broader aspects of ethics in both global surgery and global health. Furthermore, this course outline is intended to serve as a basis for future consensus-driven deliberations with experts to build a stronger and more inclusive curriculum.

Study Limitations

This study has several limitations. Although the participants provided diverse professional and geographical perspectives, nine participants from sub-Saharan Africa cannot be considered representative of the entire surgical workforce in the region. Similarly, the proposed outline does not represent a comprehensive curriculum, as it was not developed through a formal expert consensus process such as a modified Delphi study. Nonetheless, the diversity of participant backgrounds contributed valuable insights, and the exercise aimed to build a course structure that serves as a foundation for further discussion and refinement. As such, the proposed framework should be viewed as a starting point for broader discourse on ethics in global surgery, with the expectation that future efforts will incorporate wider expert engagement to strengthen and validate the curriculum.

Bridging the gap between theoretical ethics in GS and its practical implementation is crucial for achieving equity for patients, providers, and health systems in general. Real-world application is full of significant challenges, particularly around equipment donation, short-term medical missions, and research practices, which are further compounded by special circumstances such as pandemics, war, and humanitarian disasters. To address these challenges, a standardized GS ethics course outline for all stakeholders involved in surgical care is essential. By advocating for such a curriculum across all levels and settings, we can ensure that our efforts are ethically sound and equitable, ultimately minimizing inadvertent harm and promoting justice within global surgery.